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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
    Baby RMI COR 2019 006834 Finding into death without inquest 30/09/2022 Coroner Katherine Lorenz
    Y OA COR 2022 000026 Finding into death without inquest 29/09/2022 Coroner Simon McGregor
    Colleen Mary Chapman COR 2020 000308 Finding into death without inquest 28/09/2022 Coroner Paul Lawrie
    Mrs A COR 2019 006390 Finding into death without inquest 26/09/2022 State Coroner Judge John Cain
    Colin Snooks COR 2017 005508 Finding into death without inquest 21/09/2022 State Coroner Judge John Cain
    Ms W COR 2020 002142 Finding into death without inquest 21/09/2022 Coroner Sarah Gebert
    John Jacob Beirouti COR 2021 000462 Finding into death with inquest 19/09/2022 Coroner Simon McGregor
    Child C COR 2020 004720 Finding into death without inquest 16/09/2022 Coroner David Ryan
    Mr AB COR 2020 002109 Finding into death without inquest 15/09/2022 Coroner Darren Bracken
    John Llewellyn Williams COR 2020 006653 Finding into death without inquest 15/09/2022 Coroner Darren Bracken