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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 Coroner Sort descending Related orders and rulings Responses to recommendations
    Louise Litis COR 2007 4970 Finding into death without inquest 16/09/2010 Deputy State Coroner Iain West
    Bella Jayde Lawrence COR 2015 4738 Finding into death without inquest 24/01/2019 Deputy State Coroner Iain West
    Jacinta OBrien COR 2012 2330 Finding into death with inquest 21/01/2014 Deputy State Coroner Iain West
    Junichi Yoshimura COR 2017 4024 Finding into death without inquest 05/04/2018 Deputy State Coroner Iain West
    Nicholas Raymond Lobo COR 2008 4896 Finding into death with inquest 01/12/2009 Deputy State Coroner Iain West
    Unknown Bones COR 2009 0924 Finding into death with inquest 30/08/2010 Deputy State Coroner Iain West
    Joshua Peter Jensen COR 2012 1243 Finding into death with inquest 31/05/2016 Deputy State Coroner Iain West
    Nigel Delaney COR 2010 1380 Finding into death with inquest 20/04/2011 Deputy State Coroner Iain West
    Beatrix Dammers COR 2007 2281 Finding into death with inquest 29/07/2015 Deputy State Coroner Iain West
    Patrica June Andrew COR 2010 4317 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West