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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 Coroner Sort ascending 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
    Peter John Evans COR 2020 003449 Finding into death without inquest 27/05/2022 Coroner Catherine Fitzgerald
    Adam Richard Greaves COR 2022 006285 Finding into death without inquest 03/11/2023 Coroner Catherine Fitzgerald
    Trevor James Bayldon COR 2022 007435 Finding into death without inquest 04/10/2023 Coroner Catherine Fitzgerald
    Peter Henry Scerri COR 2021 002905 Finding into death with inquest 15/06/2023 Coroner Catherine Fitzgerald
    David Drowley COR 2022 003895 Finding into death without inquest 11/01/2024 Coroner Catherine Fitzgerald
    Craig Harvey COR 2019 002141 Finding into death with inquest 11/05/2023 Coroner Catherine Fitzgerald
    Maahi Tukapua COR 2021 004522 Finding into death without inquest 14/02/2024 Coroner Catherine Fitzgerald
    Baby A COR 2020 007018 Finding into death with inquest 28/02/2023 Coroner Catherine Fitzgerald
    Miranda Louise Lynch COR 2023 002141 Finding into death without inquest 14/02/2024 Coroner Catherine Fitzgerald