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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 ascending Date Coroner Related orders and rulings Responses to recommendations
    Hunter Patrick Boyle COR 2020 004420 Finding into death without inquest 03/05/2022 State Coroner Judge John Cain
    Mr Y COR 2020 002571 Finding into death without inquest 30/06/2022 Coroner Sarah Gebert
    Michael John Sim COR 2021 003685 Finding into death without inquest 28/07/2022 Coroner Simon McGregor
    Ruth Ann McKenna COR 2018 000823 Finding into death without inquest 22/08/2022 Coroner Leveasque Peterson
    Mr H COR 2021 000138 Finding into death without inquest 13/10/2022 Coroner Sarah Gebert
    Charles Frederick Norton COR 2020 001163 Finding into death without inquest 03/01/2023 Coroner Audrey Jamieson
    Master T COR 2019 006467 Finding into death without inquest 25/01/2023 Coroner Sarah Gebert
    Charles Earl Swanson COR 2021 001719 Finding into death without inquest 27/04/2023 Coroner David Ryan
    P A COR 2021 004832 Finding into death without inquest 18/05/2023 Deputy State Coroner Paresa Spanos
    Emma Gertrude Weidemann COR 2019 006767 Finding into death without inquest 06/06/2023 Deputy State Coroner Paresa Spanos