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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
Mukesh Jayantilal Sanghavi COR 2024 001880 Finding into death with inquest 05/12/2024 Coroner Dimitra Dubrow
Alison Debra Johns COR 2022 007408 Finding into death without inquest 05/12/2024 Coroner Ingrid Giles
Robert Lisle Nelson COR 2024 004843 Finding into death without inquest 05/12/2024 State Coroner Judge John Cain
Joseph Hatzaw COR 2023 5452 Finding into death without inquest 04/12/2024 Coroner Audrey Jamieson
Baby M COR 2023 1072 Finding into death without inquest 04/12/2024 Coroner Audrey Jamieson
David Waples COR 2024 004864 Finding into death without inquest 03/12/2024 State Coroner Judge John Cain
XY XY COR 2022 003816 Finding into death without inquest 03/12/2024 Coroner Catherine Fitzgerald
Child 1, Child 2, Child 3, Child 4 . COR 2015 004327 Finding into death with inquest 03/12/2024 State Coroner Judge John Cain
Baby Patel COR 2020 003004 Finding into death without inquest 03/12/2024 Coroner Ingrid Giles
Giulia Nesci COR 2024 004861 Finding into death without inquest 02/12/2024 State Coroner Judge John Cain