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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
Erica Hubai COR 2017 006528 Finding into death with inquest 16/03/2022 Coroner Phillip Byrne
PFS COR 2017 006328 Finding into death without inquest 14/03/2022 Coroner Darren Bracken
Joanne Callahan COR 2018 5516 Finding into death with inquest 10/03/2022 Coroner Katherine Lorenz
SMW COR 2020 001571 Finding into death without inquest 10/03/2022 Coroner Darren Bracken
Dylan James Charlton-Smith COR 2018 006064 Finding into death with inquest 09/03/2022 Coroner Katherine Lorenz
Daniel McQuilken COR 2021 002741 Finding into death without inquest 09/03/2022 Coroner David Ryan
David Charles Shaw COR 2020 003566 Finding into death without inquest 08/03/2022 Coroner Darren Bracken
Michael Domenic Colosimo-Minniti COR 2019 001899 Finding into death without inquest 07/03/2022 Coroner Darren Bracken
A B COR 2021 004607 Finding into death without inquest 25/02/2022 Coroner Darren Bracken
Peter Trimbos COR 2020 5276 Finding into death without inquest 24/02/2022 Deputy State Coroner Caitlin English