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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 descending Date Coroner Related orders and rulings Responses to recommendations
    Erica Hubai COR 2017 006528 Finding into death with inquest 16/03/2022 Coroner Phillip Byrne
    Joanne Callahan COR 2018 5516 Finding into death with inquest 10/03/2022 Coroner Katherine Lorenz
    John Kennard COR 2019 001704 Finding into death with inquest 20/04/2022 Coroner Simon McGregor
    Sally-Anne Wills COR 2020 1402 Finding into death with inquest 26/05/2022 Coroner Leveasque Peterson
    Vaatoa Moli Chang COR 2020 000677 Finding into death with inquest 30/06/2022 Coroner Audrey Jamieson
    Kim Rebecca Lynch COR 2016 000778 Finding into death with inquest 07/09/2022 State Coroner Judge John Cain
    Paul Kenneth Wright COR 2021 004932 Finding into death with inquest 06/12/2022 Coroner Simon McGregor
    Antoinette O'Brien COR 2017 004055 Finding into death with inquest 07/03/2023 State Coroner Judge John Cain
    Dianne Linford COR 2018 003161 Finding into death with inquest 06/06/2023 Coroner John Olle
    Dung Tri Pham COR 2015 001474 Finding into death with inquest 28/06/2023 State Coroner Judge John Cain