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 |
---|---|---|---|---|---|---|
Nickolaos Vlahos | COR 2021 005736 | Finding into death without inquest | 16/05/2023 | Coroner David Ryan | ||
Mathew David West | COR 2021 005650 | Finding into death without inquest | 30/08/2023 | Coroner David Ryan | The Commonwealth Department of Infrastructure, Transport, Regional Development, Communications and the Arts was required to respond by 30 November 2023. No response has been received to date. |
|
Miss YBT | COR 2021 005404 | Finding into death without inquest | 15/08/2022 | Coroner Simon McGregor | ||
Paul Henry Green | COR 2021 005288 | Finding into death without inquest | 20/10/2022 | Deputy State Coroner Jacqui Hawkins | ||
John Stuart Knox | COR 2021 005272 | Finding into death without inquest | 23/11/2022 | Deputy State Coroner Jacqui Hawkins | ||
Ngoc Bao Vy Tran | COR 2021 005189 | Finding into death without inquest | 19/06/2023 | State Coroner Judge John Cain | ||
Jon Gorr | COR 2021 005158 | Finding into death without inquest | 20/11/2023 | Coroner David Ryan | ||
Vikki Michelle Prenc | COR 2021 005024 | Finding into death without inquest | 28/11/2023 | Deputy State Coroner Paresa Spanos | ||
Neville Reginald Want | COR 2021 004978 | Finding into death without inquest | 25/01/2023 | Coroner David Ryan | ||
Paul Kenneth Wright | COR 2021 004932 | Finding into death with inquest | 06/12/2022 | Coroner Simon McGregor |