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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
    Mark Andrew Spillane COR 2023 003142 Finding into death without inquest 15/04/2024 Deputy State Coroner Paresa Spanos
    Craig Geoffrey Rickard COR 2020 000270 Finding into death without inquest 15/04/2024 Deputy State Coroner Paresa Spanos
    Benjamin Suggate COR 2023 003486 Finding into death without inquest 12/04/2024 Deputy State Coroner Paresa Spanos
    Randal Robin Wilder COR 2024 001453 Finding into death without inquest 12/04/2024 Coroner David Ryan
    Irene Mary Donne COR 2020 002367 Finding into death with inquest 11/04/2024 State Coroner Judge John Cain
    Shirley Hill Jones COR 2021 005864 Finding into death without inquest 10/04/2024 Coroner Sarah Gebert
    Maurice Wayne Matthews COR 2021 003523 Finding into death without inquest 09/04/2024 Coroner Audrey Jamieson
    Terrence McCallion COR 2015 002134 Finding into death with inquest 05/04/2024 State Coroner Judge John Cain
    Joseph David Jones COR 2022 006991 Finding into death without inquest 02/04/2024 Coroner Ingrid Giles
    Caroline Harris Meallin COR 2023 004535 Finding into death without inquest 27/03/2024 Coroner John Olle