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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 descending Date Coroner Related orders and rulings Responses to recommendations
    Mohamed Omar COR 2017 3010 Finding into death with inquest 28/04/2021 Deputy State Coroner Paresa Spanos
    William Maxwell COR 2018 1430 Finding into death with inquest 21/05/2021 Coroner Jacqui Hawkins
    Christopher John Peter Dewhurst COR 2016 005972 Finding into death with inquest 09/06/2021 Coroner Audrey Jamieson
    Ruth Ridley COR 2020 001530 Finding into death with inquest 22/09/2021 State Coroner Judge John Cain
    Deva Rebecca Frijlink COR 2018 006518 Finding into death with inquest 30/03/2022 Coroner Phillip Byrne
    Christopher Polden COR 2020 1401 Finding into death with inquest 26/05/2022 Coroner Leveasque Peterson
    Brent Andrew Newman COR 2020 001323 Finding into death with inquest 17/06/2022 Coroner Simon McGregor
    Jonas Lew Montealegre COR 2020 000676 Finding into death with inquest 30/06/2022 Coroner Audrey Jamieson
    Wiki Raymond Lowe COR 2017 001114 Finding into death with inquest 25/07/2022 Coroner Darren Bracken
    John Lester Costello COR 2018 001413 Finding into death with inquest 18/08/2022 Coroner Audrey Jamieson