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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
    Baby M COR 2019 2669 Finding into death without inquest 08/10/2020 Coroner Phillip Byrne
    Mrs FS COR 2017 2423 Finding into death without inquest 07/10/2020 State Coroner Judge John Cain
    Jennifer Joyce Coomber COR 2018 3559 Finding into death without inquest 30/09/2020 Coroner Jacqui Hawkins
    Nicola Deleo COR 2018 6153 Finding into death without inquest 29/09/2020 Coroner Sarah Gebert
    Swee Chuan Ho COR 2019 0762 Finding into death without inquest 28/09/2020 Coroner Audrey Jamieson
    Graham William Summerfield COR 2018 5660 Finding into death without inquest 28/09/2020 Coroner Audrey Jamieson
    Mary Veronica Payne COR 2019 0145 Finding into death without inquest 28/09/2020 Coroner Audrey Jamieson
    Harley Robert Larking COR 2016 2137 Finding into death with inquest 18/09/2020 Deputy State Coroner Caitlin English
    Mr ST COR 2019 6974 Finding into death without inquest 18/09/2020 Deputy State Coroner Caitlin English
    Michael James McBain COR 2019 0199 Finding into death without inquest 18/09/2020 Deputy State Coroner Caitlin English