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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. Anyone 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. The Court does not provide a copy of a response to a recommendation to any person unless they have advised the Principal Registrar in writing that they have an interest in the subject of the recommendations.

    Findings list

    Name Case ID Case type Date Sort ascending Coroner Related orders and rulings Responses to recommendations
    Johannes Gerhardus Jansen COR 2019 1081 Finding into death without inquest 13/08/2019 Coroner Phillip Byrne
    Traci O'Sullivan COR 2015 0642 Finding into death with inquest 12/08/2019 Coroner Simon McGregor
    Bartosz Zgadzaj COR 2017 5993 Finding into death with inquest 07/08/2019 Coroner Audrey Jamieson
    Leon Edward Balshaw COR 2018 0521 Finding into death without inquest 01/08/2019 Coroner Audrey Jamieson
    Tyla Jade Hovenbitzer COR 2016 1992 Finding into death without inquest 01/08/2019 Coroner Paresa Spanos
    Hong Tay COR 2016 5110 Finding into death without inquest 31/07/2019 Coroner Caitlin English
    G W COR 2017 4821 Finding into death without inquest 30/07/2019 Coroner Paresa Spanos
    I M COR 2018 1222 Finding into death without inquest 29/07/2019 Coroner Caitlin English
    Leigh James Carr Price COR 2017 3598 Finding into death without inquest 25/07/2019 Coroner Audrey Jamieson
    Christopher George COR 2018 5884 Finding into death with inquest 18/07/2019 Coroner Jacqui Hawkins