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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 Date Sort ascending Coroner Related orders and rulings Responses to recommendations
George Scott Boyens COR 2025 003431 Finding into death without inquest 20/03/2026 Coroner Simon McGregor
Richard Watson COR 2024 002635 Finding into death without inquest 20/03/2026 Coroner Paul Lawrie
Aisha Natasha Khan COR 2023 005102 Finding into death without inquest 20/03/2026 Coroner Ingrid Giles
Catherine Alison Lynch COR 2022 003659 Finding into death without inquest 20/03/2026 Coroner Ingrid Giles
HD S COR 2022 000793 Finding into death without inquest 20/03/2026 State Coroner Judge Liberty Sanger
Rhiannon Charlotte Drake COR 2023 002868 Finding into death without inquest 19/03/2026 Coroner Ingrid Giles
NJC COR 2021 006530 Finding into death with inquest 18/03/2026 Coroner Audrey Jamieson
Anthony Joseph Moore COR 2025 004868 Finding into death without inquest 17/03/2026 Coroner David Ryan
Michelle Anne Leiper COR 2025 001347 Finding into death without inquest 17/03/2026 Coroner Ingrid Giles
Mark Andrew Harvey COR 2024 004847 Finding into death without inquest 16/03/2026 State Coroner Judge John Cain