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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
    Colleen Mary South COR 2022 004478 Finding into death with inquest 15/03/2024 Coroner David Ryan
    Kathleen Mary Savage COR 2017 005806 Finding into death without inquest 15/03/2024 Coroner Audrey Jamieson
    Claire Louise Carroll COR 2021 002625 Finding into death without inquest 14/03/2024 Deputy State Coroner Paresa Spanos
    S L COR 2022 006970 Finding into death without inquest 13/03/2024 Coroner Ingrid Giles
    Baby F COR 2022 002599 Finding into death without inquest 13/03/2024 Coroner Audrey Jamieson
    K M COR 2023 002206 Finding into death without inquest 13/03/2024 Coroner Simon McGregor
    Zoha Khan COR 2021 004464 Finding into death without inquest 13/03/2024 Coroner Audrey Jamieson
    Wayne Thomas Jamieson COR 2023 005725 Finding into death without inquest 12/03/2024 Coroner Leveasque Peterson
    Frank Allen Hall-Bentick COR 2023 002776 Finding into death without inquest 05/03/2024 Coroner Simon McGregor
    P L COR 2021 005809 Finding into death without inquest 29/02/2024 Coroner Katherine Lorenz