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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
    Shane Michael Tuck COR 2020 003895 Finding into death with inquest 11/12/2023 State Coroner Judge John Cain
    Ricky James Broughton COR 2018 002064 Finding into death with inquest 08/12/2023 Deputy State Coroner Paresa Spanos
    Danielle Elizabeth Peters COR 2022 005649 Finding into death without inquest 07/12/2023 Coroner Paul Lawrie
    Master L COR 2022 001102 Finding into death without inquest 07/12/2023 Coroner Sarah Gebert
    J ZA COR 2017 002564 Finding into death with inquest 06/12/2023 Coroner Leveasque Peterson
    Brian Neil Smith COR 2021 006040 Finding into death without inquest 04/12/2023 Coroner Simon McGregor
    Vincenzo Mario Chiarello COR 2023 001764 Finding into death without inquest 01/12/2023 State Coroner Judge John Cain
    JCS COR 2020 4767 Finding into death with inquest 01/12/2023 Coroner Leveasque Peterson
    COR 2020 4767 Finding into death with inquest 01/12/2023 Coroner Leveasque Peterson
    Catherine Mary Reid COR 2020 007017 Finding into death with inquest 30/11/2023 Coroner Sarah Gebert