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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 Sort ascending Case type Date Coroner Related orders and rulings Responses to recommendations
    John Salemme COR 2022 002890 Finding into death without inquest 30/06/2023 Deputy State Coroner Paresa Spanos
    Yukako Fukuhara COR 2022 002657 Finding into death without inquest 21/07/2023 Deputy State Coroner Jacqui Hawkins
    Glenda Elaine Shapcott COR 2022 002650 Finding into death with inquest 23/11/2022 Deputy State Coroner Paresa Spanos
    Baby F COR 2022 002599 Finding into death without inquest 13/03/2024 Coroner Audrey Jamieson
    Bria Kathleen Joyce COR 2022 001937 Finding into death without inquest 14/03/2023 Coroner John Olle
    Shannon Troy Calvert COR 2022 001895 Finding into death without inquest 09/08/2023 Coroner John Olle
    Edward Michael Schutz COR 2022 001727 Finding into death without inquest 13/09/2023 Coroner David Ryan
    Joyce Elizabeth Tyndall COR 2022 001661 Finding into death without inquest 11/12/2023 Coroner David Ryan
    Jasmine Sara Thomas COR 2022 001606 Finding into death without inquest 23/04/2024 State Coroner Judge John Cain
    Evlyn Kay James COR 2022 001605 Finding into death with inquest 23/04/2024 State Coroner Judge John Cain