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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
    Yukako Fukuhara COR 2022 002657 Finding into death without inquest 21/07/2023 Deputy State Coroner Jacqui Hawkins
    Reginald Desmond Benham COR 2019 004552 Finding into death without inquest 19/07/2023 Coroner Audrey Jamieson
    Angela Cuthbert COR 2022 004129 Finding into death with inquest 19/07/2023 Coroner Simon McGregor
    Daryl William Nioa COR 2019 006741 Finding into death without inquest 19/07/2023 Coroner Audrey Jamieson
    Sasha . COR 2019 004069 Finding into death with inquest 18/07/2023 Coroner Paul Lawrie
    Mayumi Spencer COR 2015 000271 Finding into death with inquest 18/07/2023 State Coroner Judge John Cain
    Christopher James Wrigglesworth COR 2020 004724 Finding into death without inquest 13/07/2023 Coroner Leveasque Peterson
    Carl Anthony Van Der Kaay COR 2019 003747 Finding into death without inquest 12/07/2023 Coroner John Olle
    Amanda Jane Stapledon COR 2022 000357 Finding into death without inquest 06/07/2023 Coroner David Ryan
    Jeffrey Marsden COR 2019 000142 Finding into death without inquest 06/07/2023 Coroner Audrey Jamieson