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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Alan Joseph Wilson COR 2021 000551 Finding into death with inquest 02/09/2022 Coroner Simon McGregor
    Carl Robert Adler COR 2018 002604 Finding into death with inquest 24/11/2022 Coroner Audrey Jamieson
    Ahmet Gezer COR 2019 006597 Finding into death with inquest 07/12/2022 State Coroner Judge John Cain
    B K COR 2011 0702 Finding into death with inquest 12/12/2012 Coroner Heather Spooner
    Thelma Katherine Holt COR 2009 1577 Finding into death with inquest 13/08/2013 Coroner Dr Jane Hendtlass
    Phillip John Pierson COR 2020 001612 Finding into death with inquest 18/08/2023 Deputy State Coroner Jacqui Hawkins
    BCT . COR 2021 006991 Finding into death with inquest 31/10/2023 Coroner Katherine Lorenz
    John Doe COR 2018 004573 Finding into death with inquest 27/11/2023 Coroner Leveasque Peterson
    Allison Naomi Eagle COR 2021 002131 Finding into death with inquest 19/04/2024 Coroner Paul Lawrie
    Claire Kathleen Fogarty COR 2011 0004 Finding into death with inquest 25/01/2012 Deputy State Coroner Iain West