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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 Date Sort ascending Coroner Related orders and rulings Responses to recommendations
    Michael Molony COR 2021 002006 Finding into death with inquest 23/04/2024 Deputy State Coroner Paresa Spanos
    Evlyn Kay James COR 2022 001605 Finding into death with inquest 23/04/2024 State Coroner Judge John Cain
    Caroline Anne Willis COR 2018 002451 Finding into death without inquest 23/04/2024 State Coroner Judge John Cain
    Jasmine Sara Thomas COR 2022 001606 Finding into death without inquest 23/04/2024 State Coroner Judge John Cain
    Timothy Michael Funder COR 2022 006220 Finding into death without inquest 23/04/2024 Coroner Paul Lawrie
    Carolyn Mary James COR 2022 001604 Finding into death with inquest 23/04/2024 State Coroner Judge John Cain
    Baby B COR 2020 006592 Finding into death without inquest 22/04/2024 Coroner Audrey Jamieson
    HM I COR 2019 000188 Finding into death without inquest 22/04/2024 Coroner Ingrid Giles
    Patrick Anthony Barry COR 2023 003324 Finding into death without inquest 19/04/2024 Deputy State Coroner Paresa Spanos
    Allison Naomi Eagle COR 2021 002131 Finding into death with inquest 19/04/2024 Coroner Paul Lawrie