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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
    Felicity Ruth Loveday COR 2021 0282 Finding into death with inquest 29/11/2021 Coroner Audrey Jamieson
    Adrian Christian Victor Meneveau COR 2021 0279 Finding into death with inquest 29/11/2021 Coroner Audrey Jamieson
    Meeram Bano COR 2021 007009 Finding into death without inquest 21/09/2023 Coroner Audrey Jamieson
    BCT . COR 2021 006991 Finding into death with inquest 31/10/2023 Coroner Katherine Lorenz
    Samuel Kenneth Elsom COR 2021 006934 Finding into death with inquest 02/06/2023 Coroner Paul Lawrie
    Sean David Scott COR 2021 006933 Finding into death with inquest 02/06/2023 Coroner Paul Lawrie
    RT W COR 2021 006801 Finding into death without inquest 31/01/2024 Coroner Ingrid Giles
    Phyllis Joan Porter COR 2021 006663 Finding into death without inquest 30/01/2024 Coroner Paul Lawrie
    Stuart John Noble COR 2021 006598 Finding into death without inquest 28/06/2023 Coroner Audrey Jamieson
    Ms K COR 2021 006401 Finding into death without inquest 02/08/2023 Coroner Sarah Gebert