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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 Sort ascending Date Coroner Related orders and rulings Responses to recommendations
    Liana Pickup COR 2018 0747 Finding into death without inquest 10/10/2019 Coroner John Olle
    Ms C COR 2017 5367 Finding into death without inquest 29/10/2019 Deputy State Coroner Paresa Spanos
    Sarah Rose Crimmins COR 2017 5717 Finding into death without inquest 09/12/2019 Coroner Simon McGregor
    Janet Foster COR 2016 2544 Finding into death without inquest 05/02/2020 Coroner Darren Bracken
    Karen Frazer COR 2018 5070 Finding into death without inquest 17/04/2020 Coroner Jacqui Hawkins
    John Alexander King COR 2017 4664 Finding into death without inquest 23/04/2020 Deputy State Coroner Paresa Spanos
    Baby M COR 2016 5077 Finding into death without inquest 28/04/2020 Deputy State Coroner Caitlin English
    Phillip Harry Parker COR 2017 5085 Finding into death without inquest 22/10/2020 Coroner Audrey Jamieson
    Mitchell James Dowling COR 2018 3490 Finding into death without inquest 20/01/2021 Coroner Darren Bracken
    Sharon Brown COR 2020 5942 Finding into death without inquest 10/02/2021 Coroner Phillip Byrne