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Findings

A written finding is a formal document handed down by a coroner following an investigation into a death or fire and is generally the final step in the coronial investigation process. A written finding is made regardless of whether an inquest is held or not.

A written finding following an investigation into a death will usually, if possible, include:

  • the identity of the person who died
  • the time, date, and location where the death occurred
  • a summary of the evidence relating to the circumstances of the death, in some cases
  • comments or recommendations made by the coroner aimed at preventing similar deaths, in some cases.

Findings are published when:

  • an inquest was held
  • recommendations have been made
  • a coroner otherwise orders they be published.

Findings handed down and published are available below.

Search older findings on the Australasian Legal Information Institute database (AustLII).

Please consider that it may be upsetting to read details about a death or fire in an inquest finding. Some information may be graphic or distressing.

Use the search field above to locate a finding. You can search for a name, a case number, type of death or location of death.

Any person may apply for some or all of a finding to be reviewed and/or appealed.

    Recommendations

    The Coroners Act 2008 allows a coroner to make recommendations as part of their finding following an investigation into a death or fire.

    Recommendations can be made to any Minister, public statutory authority or entity that may help prevent similar deaths. A public statutory authority or entity who receives a recommendation from a coroner must respond, in writing, within three months stating what action, if any, has or will be taken.

    The Court will publish inquest findings with recommendations and the subsequent responses below.

    Findings list

    Name Case ID Case type Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Daylon John Roeton COR 2020 001531 Finding into death with inquest 15/09/2023 Coroner Kate Despot
    Catherine Mary Reid COR 2020 007017 Finding into death with inquest 30/11/2023 Coroner Sarah Gebert
    Lena Divola COR 2008 0028 Finding into death with inquest 20/05/2011 Coroner Peter White
    Raelene Jean Syddall COR 2011 0085 Finding into death with inquest 22/02/2013 Coroner John Olle
    Sarolta Elesits COR 2009 0139 Finding into death with inquest 26/08/2013 Coroner Phillip Byrne
    SF COR 2006 0276 Finding into death with inquest 19/06/2014 Coroner Rosemary Carlin
    Trevor James Day COR 2006 0303 Finding into death with inquest 27/04/2010 Coroner Audrey Jamieson
    James Thomas Smith COR 2008 0359 Finding into death with inquest 02/11/2011 State Coroner Judge Jennifer Coate
    Kay Alexandra Stanley COR 2008 0417 Finding into death with inquest 23/08/2012 Coroner Jacinta Heffey
    Lilian Olive Blanche McClurkin COR 2007 0547 Finding into death with inquest 29/05/2014 Coroner Jacqui Hawkins