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 ascending | Date | Coroner | Related orders and rulings | Responses to recommendations |
---|---|---|---|---|---|---|
Van Thanh Thi Do | COR 2013 3177 | Finding into death without inquest | 28/04/2015 | Coroner Caitlin English | ||
Richard Powell | COR 2017 000126 | Finding into death without inquest | 20/07/2021 | State Coroner Judge John Cain | ||
M J | COR 2016 006105 | Finding into death without inquest | 12/08/2021 | State Coroner Judge John Cain | ||
James Owen Lynch | COR 2020 006194 | Finding into death without inquest | 30/09/2021 | Coroner John Olle | ||
John Crabtree | COR 2016 002356 | Finding into death without inquest | 08/11/2021 | Deputy State Coroner Paresa Spanos | ||
Eden Herbert-Allan | COR 2018 003944 | Finding into death without inquest | 06/12/2021 | Coroner Audrey Jamieson | ||
Ronald Jelbert | COR 2019 007112 | Finding into death without inquest | 16/12/2021 | Coroner Audrey Jamieson | ||
Leeanne Matheson | COR 2019 001967 | Finding into death without inquest | 03/02/2022 | Deputy State Coroner Caitlin English | ||
Margaret Rose Ryan | COR 2018 5164 | Finding into death without inquest | 28/01/2022 | Coroner David Ryan | ||
Joseph Cardona | COR 2017 002729 | Finding into death without inquest | 17/03/2022 | Deputy State Coroner Paresa Spanos |