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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
    Tai Van Tran COR 2021 006035 Finding into death with inquest 22/02/2024 Coroner Catherine Fitzgerald
    Cheryl Balassopoulos COR 2023 002866 Finding into death without inquest 22/02/2024 Coroner Paul Lawrie
    John Robert Gregg COR 2021 001123 Finding into death without inquest 22/02/2024 Coroner Simon McGregor
    Child K COR 2022 005249 Finding into death without inquest 16/02/2024 Coroner Catherine Fitzgerald
    Jordan Riley Heyman COR 2022 005336 Finding into death without inquest 16/02/2024 Coroner Simon McGregor
    Maahi Tukapua COR 2021 004522 Finding into death without inquest 14/02/2024 Coroner Catherine Fitzgerald
    Miranda Louise Lynch COR 2023 002141 Finding into death without inquest 14/02/2024 Coroner Catherine Fitzgerald
    Elizabeth Helen Barber COR 2021 003111 Finding into death without inquest 13/02/2024 Coroner Audrey Jamieson
    Baby ZCZ COR 2022 000609 Finding into death without inquest 13/02/2024 Coroner Sarah Gebert
    Ms KSI COR 2018 000588 Finding into death without inquest 05/02/2024 State Coroner Judge John Cain