What are findings?

Following an investigation in the majority of cases the coroner must make written findings where possible about the identity of the deceased; when, where and how they died; and what caused them to die.

If an inquest is held the coroner may also make recommendations about broader issues connected with the death and to prevent similar deaths in the future. For example, the coroner may recommend improving hospital procedures, safety standards or road signage.

What the coroner can and can’t do

The coroner can’t make any finding that a person is guilty of an offence or civilly liable. Additionally, their findings and recommendations can’t be used as evidence in any court or tribunal because the focus (of the Coroners Act 2003) is helping prevent further deaths in similar circumstances.

However, the coroner can refer a matter to the Director of Public Prosecutions or a disciplinary body for consideration and possible action (i.e. Office of the Health Ombudsman).

Where findings are published

Findings are provided to the family and other relevant parties determined by the coroner.

If an inquest has been held, the findings must be posted on the Queensland Courts website unless the coroner orders otherwise. If recommendations are made, they’re sent to the responsible government department for response.

A coroner can also publish non-inquest findings  on the website if it’s in the public interest (though they must consult with the family before doing so). Often these findings can be de-identified to remove any reference to the deceased person.

Reopening investigations and inquests

A coronial investigation is finalised once a coroner has made their findings. However the coroner may reopen an investigation or inquest in rare cases where new evidence has been found or the circumstances of the death require more investigation.

Disagreeing with findings

Inquest findings

If you are dissatisfied with inquest findings, you can apply to the investigating coroner and provide reasoning.

You can also apply to the state coroner or District Court to have the findings set aside.

To apply to the state coroner - submit Form 21 - Application to the State Coroner to set aside a finding (PDF, 68.1 KB) or (DOC, 55.0 KB)

The state coroner or the District Court have the powers to set aside the finding and direct that the inquest be reopened or a new inquest held.

The state coroner may set aside a finding if new evidence casts doubt on the findings or they weren’t recorded correctly.

A person may apply to the District Court which has wider jurisdiction and may set aside a finding if:

  • new evidence casts doubt on the findings
  • the findings were not recorded correctly
  • there was no evidence to support the finding
  • the evidence couldn’t reasonably support the finding.

A person can not apply to the state coroner if an unsuccessful application based on the same grounds has already been made to the District Court.

Non-Inquest Findings

Where a person does not agree with the findings and would like an inquest held they can refer to the ‘Requesting an inquest’  section for further information.

In addition, you can apply to the State Coroner to set aside the findings, as outlined above.