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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
    Boe Luke Memery COR 2019 002530 Finding into death without inquest 31/08/2022 Deputy State Coroner Jacqui Hawkins
    Jaymii Leslie Mott (Green) COR 2019 002875 Finding into death without inquest 31/08/2022 Deputy State Coroner Jacqui Hawkins
    B L COR 2019 001574 Finding into death without inquest 31/08/2022 Coroner John Olle
    COR 2020 006798 Finding into death without inquest 31/08/2022 Coroner John Olle
    Jessica Higgins COR 2017 002579 Finding into death without inquest 30/08/2022 Coroner Simon McGregor
    David Patrick Hardisty COR 2019 000165 Finding into death with inquest 30/08/2022 Coroner John Olle
    Mr GFE COR 2020 004255 Finding into death without inquest 30/08/2022 Coroner Simon McGregor
    X Y COR 2020 002838 Finding into death with inquest 25/08/2022 State Coroner Judge John Cain
    M D COR 2019 001926 Finding into death without inquest 23/08/2022 Coroner John Olle

    The Minister for Agriculture was invited to respond by 24/11/2022. They were not required to respond and no response has been received to date.

    Ruth Ann McKenna COR 2018 000823 Finding into death without inquest 22/08/2022 Coroner Leveasque Peterson