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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
Daniel Joseph Herbert COR 2018 005440 Finding into death without inquest 02/08/2021 Coroner Audrey Jamieson
GAMcM COR 2017 3739 Finding into death without inquest 30/07/2021 Coroner Darren Bracken
G H COR 2020 003007 Finding into death without inquest 30/07/2021 Coroner Sarah Gebert
Edward Michael Espino COR 2016 000456 Finding into death without inquest 29/07/2021 Coroner Darren Bracken
Barry Brown COR 2013 001298 Finding into death with inquest 29/07/2021 Coroner Darren Bracken
JM COR 2019 000350 Finding into death without inquest 29/07/2021 Coroner Leveasque Peterson
Adam Laufer COR 2016 005581 Finding into death with inquest 29/07/2021 State Coroner Judge John Cain
Lioubov Manouilenko COR 2021 002728 Finding into death without inquest 23/07/2021 Coroner Jacqui Hawkins
Christian Joy COR 2019 005322 Finding into death without inquest 23/07/2021 Coroner Katherine Lorenz
Lorinda Stacey Ruff COR 2019 005416 Finding into death without inquest 22/07/2021 Coroner David Ryan