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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. Anyone 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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Omar Jamil Moujalled COR 2016 5533 Finding into death with inquest 09/11/2018 Coroner Paresa Spanos
    Jaesok Lee COR 2007 2126 Finding into death with inquest 21/10/2013 Coroner Dr Jane Hendtlass
    John Reimers COR 2016 5983 Finding into death with inquest 23/08/2019 Coroner Audrey Jamieson
    Sonya Szala COR 2016 4755 Finding into death with inquest 28/11/2019 Coroner Phillip Byrne
    Travis Lee Fernandez COR 2014 5936 Finding into death with inquest 14/01/2020 Coroner Paresa Spanos
    Stephen James Johnston COR 2016 5821 Finding into death with inquest 12/02/2020 Coroner Simon McGregor
    Carl Ranthe COR 2009 0013 Finding into death with inquest 28/02/2011 Coroner John Olle
    Dallas Alister Anderson COR 2006 0101 Finding into death with inquest 13/03/2015 Coroner Audrey Jamieson
    John Raynox Jansen COR 2013 0160 Finding into death with inquest 11/11/2016 Coroner Caitlin English
    Llona Elizabeth Doolan COR 2012 0220 Finding into death with inquest 11/09/2014 Coroner John Olle