Skip to main content Skip to home page

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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Jackson David Eales COR 2016 006147 Finding into death with inquest 18/08/2023 Deputy State Coroner Jacqui Hawkins
    COR 2020 4767 Finding into death with inquest 01/12/2023 Coroner Leveasque Peterson
    Tai Van Tran COR 2021 006035 Finding into death with inquest 22/02/2024 Coroner Catherine Fitzgerald
    Norton Beal-Guilfoyle COR 2009 0004 Finding into death with inquest 16/01/2013 Coroner Audrey Jamieson
    Matthew Patrick James Maher COR 2011 0100 Finding into death with inquest 06/03/2014 State Coroner Judge Ian L Gray
    John Raynox Jansen COR 2013 0160 Finding into death with inquest 11/11/2016 Coroner Caitlin English
    Llona Elizabeth Doolan COR 2012 0220 Finding into death with inquest 11/09/2014 Coroner John Olle
    Mathew Lister COR 2010 0258 Finding into death with inquest 21/12/2012 Coroner Heather Spooner
    COR 2011 0293 Finding into death with inquest 10/07/2014 Coroner Rosemary Carlin
    Kara Lennah Compton COR 2006 0441 Finding into death with inquest 12/11/2010 Coroner John Olle