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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
Catherine Claudia Thomas COR 2020 006426 Finding into death with inquest 21/10/2021 State Coroner Judge John Cain
Catherine Thomas COR 2020 6426 Finding into death with inquest 21/10/2021 State Coroner Judge John Cain
Raymond John Cassar COR 2018 002939 Finding into death without inquest 18/10/2021 Coroner Darren Bracken
A H COR 2017 002931 Finding into death without inquest 15/10/2021 Coroner Sarah Gebert
Nikita Chawla COR 2015 0145 Finding into death without inquest 15/10/2021 State Coroner Judge John Cain
Mr A COR 2019 1858 Finding into death without inquest 12/10/2021 Coroner Audrey Jamieson
Stuart Anthony Wills COR 2014 002618 Finding into death with inquest 08/10/2021 Coroner Darren Bracken
Carlene Margaret Salveson COR 2018 005744 Finding into death without inquest 01/10/2021 Coroner Audrey Jamieson
James Owen Lynch COR 2020 006194 Finding into death without inquest 30/09/2021 Coroner John Olle
Abigail Louise Cooke-Mitchell COR 2015 000363 Finding into death without inquest 29/09/2021 State Coroner Judge John Cain