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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
Pamela Mary Bell COR 2018 005588 Finding into death without inquest 21/07/2021 Coroner Simon McGregor
Gela Anne Vigor-Newitt COR 2020 005460 Finding into death without inquest 21/07/2021 Coroner Jacqui Hawkins
Richard Powell COR 2017 000126 Finding into death without inquest 20/07/2021 State Coroner Judge John Cain
Simone Grigg COR 2017 005939 Finding into death without inquest 13/07/2021 Coroner Jacqui Hawkins
Simone Leslie Quinlan COR 2015 004974 Finding into death without inquest 12/07/2021 State Coroner Judge John Cain
Lorraine Simmons COR 2019 001474 Finding into death without inquest 05/07/2021 Coroner Phillip Byrne
Kathryn O'Rourke COR 2018 002296 Finding into death with inquest 30/06/2021 Coroner Sarah Gebert
Eoghan Jerome Arnold COR 2018 005766 Finding into death without inquest 30/06/2021 Deputy State Coroner Caitlin English
ED COR 2019 3580 Finding into death with inquest 30/06/2021 Coroner Phillip Byrne
Kyle James Shepherd COR 2020 003638 Finding into death without inquest 30/06/2021 Deputy State Coroner Caitlin English