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 Sort ascending Case type Date Coroner Related orders and rulings Responses to recommendations
    Gary William Kennedy COR 2022 004708 Finding into death without inquest 27/10/2022 Coroner Simon McGregor
    Deborah Leona Smith COR 2022 004607 Finding into death with inquest 03/04/2023 Coroner Simon McGregor
    Colleen Mary South COR 2022 004478 Finding into death with inquest 15/03/2024 Coroner David Ryan
    Angelo Anthony Gioscio COR 2022 004453 Finding into death with inquest 08/09/2023 Deputy State Coroner Jacqui Hawkins
    Gillian Burgess COR 2022 004369 Finding into death without inquest 01/06/2023 Deputy State Coroner Jacqui Hawkins
    Heather Amy Robertson COR 2022 004213 Finding into death without inquest 25/01/2023 Coroner David Ryan
    Angela Cuthbert COR 2022 004129 Finding into death with inquest 19/07/2023 Coroner Simon McGregor
    Ya (Cindy) Zhao COR 2022 004111 Finding into death without inquest 09/01/2024 Coroner Simon McGregor
    Travis John Cashmore COR 2022 004092 Finding into death with inquest 24/10/2023 Coroner Katherine Lorenz
    Benjamin Paul Ray COR 2022 004086 Finding into death with inquest 24/10/2023 Coroner Katherine Lorenz