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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
    Yosuke Kanno COR 2017 0328 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins
    Bhavita Patel COR 2017 0465 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins
    Matthew Poh Chuan Si COR 2017 0325 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins
    Jess Mudie COR 2017 0329 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins
    (Si, M) (Hakin, T) (Kanno, Y) (Mudie, J) (Matthew Bryant, Z) (Patel, B) COR 2017 0325 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins
    Thalia Hakin COR 2017 0327 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins
    Zachary Matthew Bryant COR 2017 0343 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins
    Hilton Davis COR 2018 1882 Finding into death without inquest 16/11/2020 Coroner Audrey Jamieson
    Mr BT COR 2018 4185 Finding into death without inquest 10/11/2020 Coroner Audrey Jamieson
    Robert Thomas Love COR 2015 0833 Finding into death with inquest 06/11/2020 Coroner Audrey Jamieson