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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
    Student HBI COR 2020 001263 Finding into death without inquest 03/10/2023 Coroner Simon McGregor
    Student FSB COR 2020 001132 Finding into death without inquest 02/10/2023 Coroner Simon McGregor
    Student KCM COR 2020 003894 Finding into death without inquest 02/10/2023 Coroner Simon McGregor
    Meeram Bano COR 2021 007009 Finding into death without inquest 21/09/2023 Coroner Audrey Jamieson
    Refan Abdulrhman M Al Moarfeg COR 2021 003519 Finding into death without inquest 21/09/2023 Coroner Audrey Jamieson
    Simaile Masila-Liutolo COR 2022 002896 Finding into death with inquest 21/09/2023 Coroner David Ryan
    Andrew James Lack COR 2019 001679 Finding into death without inquest 20/09/2023 Coroner Simon McGregor
    Ju Zhang COR 2021 001047 Finding into death without inquest 18/09/2023 State Coroner Judge John Cain
    Darren Ricky Culleton COR 2021 0740 Finding into death with inquest 18/09/2023 Coroner David Ryan
    Daylon John Roeton COR 2020 001531 Finding into death with inquest 15/09/2023 Coroner Kate Despot