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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
    Catherine Myee Drinkwater COR 2022 6129 Finding into death without inquest 12/09/2023 Coroner Leveasque Peterson
    Student HBI COR 2020 001263 Finding into death without inquest 03/10/2023 Coroner Simon McGregor
    Brian Neil Smith COR 2021 006040 Finding into death without inquest 04/12/2023 Coroner Simon McGregor
    Mr E COR 2022 005384 Finding into death without inquest 18/10/2023 Coroner Sarah Gebert
    Melissa Jan Hadland COR 2022 006064 Finding into death without inquest 25/01/2024 Coroner Leveasque Peterson
    Cheryl Balassopoulos COR 2023 002866 Finding into death without inquest 22/02/2024 Coroner Paul Lawrie
    Grethe Larsen COR 2022 007430 Finding into death without inquest 21/03/2024 Coroner Leveasque Peterson
    Cathy Mary McPhee COR 2013 0054 Finding into death without inquest 05/09/2016 Coroner Audrey Jamieson
    WJ COR 2014 0169 Finding into death without inquest 21/09/2015 Deputy State Coroner Paresa Spanos
    Daniel John Woodburn COR 2011 0260 Finding into death without inquest 01/06/2016 Coroner Audrey Jamieson