Skip to main content Skip to home page

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.

    Findings list

    Name Case ID Case type Date Sort ascending Coroner Related orders and rulings Responses to recommendations
    Sommer Bethany Warren COR 2014 5137 Finding into death with inquest 18/03/2020 Coroner Audrey Jamieson
    PATIENT A COR 2017 5208 Finding into death with inquest 13/03/2020 Coroner John Olle
    James Daniel Bankin COR 2019 4768 Finding into death without inquest 06/03/2020 Coroner Simon McGregor
    Robert Louis Gerrard COR2019 4930 Finding into death without inquest 02/03/2020 Coroner Simon McGregor
    Robb Thomas Lawson COR 2017 6361 Finding into death with inquest 28/02/2020 Coroner Paresa Spanos
    James John Wilson COR 2019 2262 Finding into death without inquest 26/02/2020 Coroner Simon McGregor
    Zakiya Crystal Lisa Thomas COR 2015 2417 Finding into death without inquest 24/02/2020 Coroner Darren Bracken
    Stephen James Johnston COR 2016 5821 Finding into death with inquest 12/02/2020 Coroner Simon McGregor
    Dianne Bradley COR 2016 0418 Finding into death with inquest 11/02/2020 Coroner Audrey Jamieson
    Ian Chamberlain COR 2016 0419 Finding into death with inquest 11/02/2020 Coroner Audrey Jamieson