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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
Nicholas Lopes COR 2020 000831 Finding into death with inquest 24/11/2021 Coroner Katherine Lorenz
Mr W COR 2018 006154 Finding into death without inquest 24/11/2021 Coroner Sarah Gebert
Mark Leslie Missen COR 2016 001154 Finding into death without inquest 24/11/2021 State Coroner Judge John Cain
Pippa May Griffiths COR 2018 001812 Finding into death without inquest 23/11/2021 Coroner Audrey Jamieson
Peta Hickey COR 2019 2336 Finding into death with inquest 22/11/2021 Coroner Simon McGregor
Nathan James Thomas COR 2020 000850 Finding into death without inquest 22/11/2021 Coroner Paresa Spanos
Ratko CRNIC COR 2020 006517 Finding into death with inquest 18/11/2021 Coroner Phillip Byrne
COR 2021 3048 Finding into death without inquest 17/11/2021 Coroner David Ryan
Michael Anderson COR 2017 1795 Finding into death with inquest 12/11/2021 Coroner Audrey Jamieson
Baby MNL COR 2017 004991 Finding into death without inquest 12/11/2021 Deputy State Coroner Caitlin English