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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
    Craig Vincent Douthie COR 2018 0717 Finding into death with inquest 02/07/2020 Coroner Audrey Jamieson
    Cai Wheeler-Trow COR 2017 5946 Finding into death without inquest 02/07/2020 Coroner Jacqui Hawkins
    Baby M COR 2018 5489 Finding into death without inquest 01/07/2020 Coroner Simon McGregor
    Vladimir Mark Makovnik COR 2017 1356 Finding into death without inquest 30/06/2020 Coroner Audrey Jamieson
    Colleen Elizabeth Fermanian COR 2017 1400 Finding into death with inquest 29/06/2020 State Coroner Judge John Cain
    Babby AA COR 2018 3542 Finding into death without inquest 29/06/2020 Coroner Jacqui Hawkins
    Bernice Edna Northover COR 2019 1003 Finding into death without inquest 29/06/2020 Coroner Darren Bracken
    Gregory Mark Hulands COR 2019 2161 Finding into death without inquest 24/06/2020 Coroner Darren Bracken
    Scott Andrew Fewson COR 2017 4397 Finding into death without inquest 23/06/2020 Coroner Darren Bracken
    Karen Elda Belej COR 2016 1958 Finding into death without inquest 23/06/2020 State Coroner Judge John Cain