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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
Matteo Geminian COR 2017 4491 Finding into death without inquest 16/03/2020 Coroner Darren Bracken
PATIENT A COR 2017 5208 Finding into death with inquest 13/03/2020 Coroner John Olle
James Daniel Bankin COR 2019 4768 Finding into death without inquest 06/03/2020 Coroner Simon McGregor
Robert Louis Gerrard COR2019 4930 Finding into death without inquest 02/03/2020 Coroner Simon McGregor
Robb Thomas Lawson COR 2017 6361 Finding into death with inquest 28/02/2020 Deputy State Coroner Paresa Spanos
Keith Walter Sharp COR 2017 2583 Finding into death without inquest 28/02/2020 Coroner Simon McGregor
James John Wilson COR 2019 2262 Finding into death without inquest 26/02/2020 Coroner Simon McGregor
Laurie Henry Cartledge COR 2017 3211 Finding into death without inquest 25/02/2020 Deputy State Coroner Paresa Spanos
Zakiya Crystal Lisa Thomas COR 2015 2417 Finding into death without inquest 24/02/2020 Coroner Darren Bracken
Stephen James Johnston COR 2016 5821 Finding into death with inquest 12/02/2020 Coroner Simon McGregor