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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
Child 1, Child 2, Child 3, Child 4 . COR 2015 004327 Finding into death with inquest 17/02/2025 State Coroner Judge John Cain
Jack Brownlee COR 2018 001357 Finding into death without inquest 14/02/2025 Coroner Leveasque Peterson
Charles Clarence Howkins COR 2018 001329 Finding into death without inquest 14/02/2025 Coroner Leveasque Peterson
Mathew Martin Farrell COR 2022 005430 Finding into death with inquest 14/02/2025 Coroner Paul Lawrie
Alexander Cameron COR 2023 001736 Finding into death without inquest 12/02/2025 Coroner Catherine Fitzgerald
Donald Walter Thoms COR 2023 006295 Finding into death without inquest 12/02/2025 Coroner John Olle
Kathleen Dawn Arnold COR 2023 005162 Finding into death without inquest 11/02/2025 Coroner Ingrid Giles
Daniel Francis McNeill COR 2023 001160 Finding into death without inquest 10/02/2025 Coroner Ingrid Giles
Baran Yalcin COR 2022 006644 Finding into death without inquest 10/02/2025 Coroner Ingrid Giles
Janelle Maree Lavery COR 2024 000935 Finding into death without inquest 06/02/2025 Coroner Ingrid Giles