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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 Sort ascending Case type Date Coroner Related orders and rulings Responses to recommendations
    Brian Neil Smith COR 2021 006040 Finding into death without inquest 04/12/2023 Coroner Simon McGregor
    Tai Van Tran COR 2021 006035 Finding into death with inquest 22/02/2024 Coroner Catherine Fitzgerald
    John Disley COR 2021 005950 Finding into death without inquest 17/08/2022 Coroner Simon McGregor
    Robert Arthur Selby Lowe COR 2021 005913 Finding into death without inquest 14/06/2023 Deputy State Coroner Paresa Spanos
    Patricia Backhurst COR 2021 005893 Finding into death with inquest 15/12/2022 Coroner Paul Lawrie
    Shirley Hill Jones COR 2021 005864 Finding into death without inquest 10/04/2024 Coroner Sarah Gebert
    P L COR 2021 005809 Finding into death without inquest 29/02/2024 Coroner Katherine Lorenz
    Reece John Pullen COR 2021 005749 Finding into death with inquest 04/12/2022 Coroner David Ryan
    Ruby-Lee Gold COR 2021 005748 Finding into death with inquest 05/10/2023 Coroner David Ryan
    Nickolaos Vlahos COR 2021 005736 Finding into death without inquest 16/05/2023 Coroner David Ryan