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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. 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
    Christina Maree Chamberlain COR 2018 3423 Finding into death without inquest 22/05/2020 Coroner Audrey Jamieson
    Harlow Eden Laderman COR 2017 4078 Finding into death without inquest 21/05/2020 Coroner Audrey Jamieson
    Jolanta Boyd COR 2018 2910 Finding into death without inquest 11/05/2020 Coroner Audrey Jamieson
    Penelope Thelma Jane Hill COR 2018 2909 Finding into death without inquest 11/05/2020 Coroner Jacqui Hawkins
    Mark Beames COR 2017 1659 Finding into death without inquest 07/05/2020 Coroner Simon McGregor
    Richard Neil Gaudion COR 2018 3966 Finding into death without inquest 05/05/2020 Coroner Audrey Jamieson
    John Hayle COR 2017 5173 Finding into death without inquest 05/05/2020 Coroner Audrey Jamieson
    Jane Nola Rolph COR 2018 5078 Finding into death without inquest 04/05/2020 Coroner Audrey Jamieson
    Joelene Therese Dowden COR 2017 3353 Finding into death with inquest 01/05/2020 State Coroner Judge John Cain
    Justin Dance COR 2018 5724 Finding into death without inquest 28/04/2020 Coroner Audrey Jamieson