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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 Coroner Sort ascending Related orders and rulings Responses to recommendations
    Child K COR 2022 005249 Finding into death without inquest 16/02/2024 Coroner Catherine Fitzgerald
    Tai Van Tran COR 2021 006035 Finding into death with inquest 22/02/2024 Coroner Catherine Fitzgerald
    H J COR 2021 003048 Finding into death without inquest 17/11/2021 Coroner David Ryan
    Raylene Barbara Armstrong COR 2019 0657 Finding into death without inquest 25/11/2021 Coroner David Ryan
    Andrew William Staker COR 2021 002157 Finding into death without inquest 16/03/2022 Coroner David Ryan
    Amanda Jane Stapledon COR 2022 000357 Finding into death without inquest 06/07/2023 Coroner David Ryan
    Margaret Rose Ryan COR 2018 5164 Finding into death without inquest 28/01/2022 Coroner David Ryan
    Charles Earl Swanson COR 2021 001719 Finding into death without inquest 27/04/2023 Coroner David Ryan
    Mariza Beretta COR 2020 000493 Finding into death without inquest 12/08/2021 Coroner David Ryan
    Matthew Lee Dongelmans COR 2020 001763 Finding into death with inquest 22/02/2022 Coroner David Ryan