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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 ascending Related orders and rulings Responses to recommendations
    Ruby-Lee Gold COR 2021 005748 Finding into death with inquest 05/10/2023 Coroner David Ryan
    Denise Lucina Roberts COR 2023 002843 Finding into death without inquest 16/05/2024 Coroner David Ryan
    LKV LKV COR 2019 000738 Finding into death without inquest 26/07/2022 Coroner David Ryan
    K W COR 2020 006780 Finding into death without inquest 24/01/2022 Coroner David Ryan
    Periklis Papadopoulos COR 2021 003736 Finding into death without inquest 24/01/2023 Coroner David Ryan
    Mathew David West COR 2021 005650 Finding into death without inquest 30/08/2023 Coroner David Ryan

    The Commonwealth Department of Infrastructure, Transport, Regional Development, Communications and the Arts was required to respond by 30 November 2023. No response has been received to date.

    Darren Ricky Culleton COR 2021 0740 Finding into death with inquest 18/09/2023 Coroner David Ryan
    Robert Leonard Morris COR 2022 000536 Finding into death without inquest 16/05/2024 Coroner David Ryan
    Lorinda Stacey Ruff COR 2019 005416 Finding into death without inquest 22/07/2021 Coroner David Ryan
    Child C COR 2020 004720 Finding into death without inquest 16/09/2022 Coroner David Ryan