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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
    Bradley Scott Liefvoort COR 2021 002849 Finding into death without inquest 25/05/2023 Coroner Audrey Jamieson
    O S COR 2022 000569 Finding into death without inquest 22/05/2023 Coroner Paresa Spanos
    COR 2022 003072 Finding into death without inquest 19/05/2023 Deputy State Coroner Jacqui Hawkins
    P A COR 2021 004832 Finding into death without inquest 18/05/2023 Coroner Paresa Spanos
    Dianne Linford COR 2018 003161 Finding into death with inquest 17/05/2023 Coroner John Olle
    Nickolaos Vlahos COR 2021 005736 Finding into death without inquest 16/05/2023 Coroner David Ryan
    Ian Keith Beissel COR 2022 3072 Finding into death without inquest 16/05/2023 Deputy State Coroner Jacqui Hawkins
    Mathew James Luttrell COR 2018 005721 Finding into death with inquest 16/05/2023 Coroner Audrey Jamieson
    Jennifer Mary Thomas COR 2021 003381 Finding into death with inquest 15/05/2023 Coroner David Ryan
    John Edward Hadland (Millar) COR 2021 004640 Finding into death with inquest 11/05/2023 Coroner Paul Lawrie