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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
Heather Ash COR 2022 000157 Finding into death with inquest 03/10/2025 Coroner Leveasque Peterson
Alicia Jade Montebello COR 2023 002819 Finding into death without inquest 03/10/2025 Coroner David Ryan
Richard Mark Ellis COR 2023 004191 Finding into death with inquest 02/10/2025 Coroner Audrey Jamieson
Robert Thoai Dao COR 2023 002785 Finding into death without inquest 02/10/2025 Coroner Simon McGregor
Viet Quy Dinh COR 2024 000175 Finding into death without inquest 02/10/2025 Coroner Paul Lawrie
Baby M COR 2022 006477 Finding into death without inquest 30/09/2025 Coroner Sarah Gebert
Dio Miranda Katiana Kemp COR 2019 006537 Finding into death with inquest 29/09/2025 Deputy State Coroner Paresa Spanos
Frederick William Boyle COR 2023 003716 Finding into death without inquest 25/09/2025 Coroner Dimitra Dubrow
Bryan Pham COR 2020 002930 Finding into death without inquest 25/09/2025 Coroner Simon McGregor
Jay Joseph Harrison COR 2023 006521 Finding into death without inquest 25/09/2025 Coroner Simon McGregor