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 Sort ascending | Coroner | Related orders and rulings | Responses to recommendations |
---|---|---|---|---|---|---|
Fiona Lebner | COR 2020 001105 | Finding into death without inquest | 05/10/2022 | Deputy State Coroner Paresa Spanos | ||
Stanley Stewart | COR 2021 000231 | Finding into death without inquest | 05/10/2022 | Deputy State Coroner Paresa Spanos | ||
Travis Jack Blows | COR 2018 001703 | Finding into death without inquest | 04/10/2022 | Coroner John Olle | ||
Christopher David French Hunter | COR 2015 003028 | Finding into death with inquest | 04/10/2022 | Deputy State Coroner Paresa Spanos | ||
Tom Owen Row | COR 2022 000939 | Finding into death without inquest | 03/10/2022 | Coroner Simon McGregor | ||
Neville Ernest Mills | COR 2021 003764 | Finding into death without inquest | 03/10/2022 | Coroner David Ryan | ||
Baby RMI | COR 2019 006834 | Finding into death without inquest | 30/09/2022 | Coroner Katherine Lorenz | ||
Gillian Patricia Johnston | COR 2020 007044 | Finding into death without inquest | 30/09/2022 | Coroner John Olle | ||
Y OA | COR 2022 000026 | Finding into death without inquest | 29/09/2022 | Coroner Simon McGregor | ||
Colleen Mary Chapman | COR 2020 000308 | Finding into death without inquest | 28/09/2022 | Coroner Paul Lawrie |