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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 in the last 365 days 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.

    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
    Ernest Hyde COR 2018 4519 Finding into death with inquest 11/06/2019 Coroner Rosemary Carlin
    Mabel Grace Ellen Pritchard COR 2018 0680 Finding into death without inquest 17/05/2019 Coroner Audrey Jamieson
    Thi Ha Do COR 2016 3862 Finding into death without inquest 17/05/2019 Coroner Simon McGregor
    Desmond John Watson COR 2017 2478 Finding into death without inquest 15/05/2019 Coroner Jacqui Hawkins
    William Willms COR 2017 5202 Finding into death with inquest 29/04/2019 Coroner Audrey Jamieson
    Dennis John Wright COR 2018 0488 Finding into death without inquest 24/04/2019 Coroner Audrey Jamieson
    Nick Falos (formerly known as Nikolaos Falieros) COR 2018 5977 Finding into death with inquest 15/04/2019 Coroner Phillip Byrne
    Hannah Rachel Charles COR 2010 1382 Finding into death with inquest 08/04/2019 Deputy State Coroner Iain West
    Richard Alan Jones COR 2018 6510 Finding into death without inquest 05/04/2019 Coroner Phillip Byrne
    Isabella Estelle Rees COR 2015 0592 Finding into death with inquest 04/04/2019 Coroner Caitlin English