Findings and upcoming inquests - Coroners Court

Inquest findings (since 2004) as well as non-inquest public interest matters (since 2012) are available below.

Findings are published on this website when an inquest was held or a coroner otherwise orders they be published in the public interest.

A finding is the document handed down by a coroner at the end of an investigation into a death. If possible, the finding will include:

  • who the deceased person is
  • how the person died
  • when the person died
  • where the person died.

If an inquest was held, the findings may include comments or recommendations made by the coroner relating to public health and safety, the administration of justice or ways to prevent similar deaths.

WARNING - content in these findings may be distressing to readers. Aboriginal and Torres Strait Islander peoples are warned, findings contain the names of deceased persons.

An Inquest sittings list for the Coroners Court is posted online at the end of every month (note: the list is subject to change).

Search or sort for the relevant findings below. You can also read more about findings including what to do if you disagree with findings or would like an inquest reopened.

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38 results found…  Search by keyword

2021

Name/event Findings delivered Government response
Hyde, Enid Cecilia and Hyde, Norman Reeve (PDF, 317KB) Reopening of 1973 coronial investigation and inquest, deaths at sea 100 metres off False Cape, Yarrabah. 14/10/2021 by Wilson Queensland Government response not required
Drier, Logan (PDF, 633KB) Queensland Police Service, pursuit, pursuit policy, communications centre, dangerous driving, urgent duty driving, primary pursuit vehicle, radio communications. 14/10/2021 by Bentley
Christensen, Corey James and Davy, Thomas Ian (PDF, 502KB)

Stabbing, double fatality, police investigation, police response, QAS response, decision to charge.

07/10/2021 by Bentley
Harris, John Edward (PDF, 316KB) Suicide, death in custody, hanging, life prisoner, hanging points. 20/09/2021 by Ryan Queensland Government response not required
Ely-Smith, Zamia (PDF, 2MB) Baby, neonate, home birth, midwife, Neopuff, resuscitation, falsification of medical records. 17/09/2021 by Bentley
Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings (PDF, 439KB) Domestic and family violence, domestic abuse, mental health, protection orders, health care providers, service system contact. 10/09/2021 by Bentley Queensland Government response not required
Batalha, Benjamin John (PDF, 378KB) Death in custody, cause of death not determined, availability and misuse of prescribed and non-prescribed medication in custody, information sharing, polypharmacy. 02/09/2021 by Ryan Queensland Government response not required
Dower, Sarahjane - Non-inquest findings (PDF, 459KB)

Intimate partner violence, private Domestic Violence application, service of Domestic Violence application and Order/s, dismissal of Domestic Violence application, parenting orders, stabbing, fatal injuries, set vehicle to fire, interfering with corpse, military service, Australian Defence Force, psychological care, Veteran’s Counselling Service, private psychologist, termination of therapeutic relationship, failure to disclose intention to harm.

20/08/2021 by Wilson Queensland Government response not required
Caramin, Olivier Max - Non-inquest findings (PDF, 219KB)

Overseas national, working holiday visa, farm work, labour hire, pumpkin picking, death as a result of heat stroke, failure to implement adequate controls, Work Health and Safety Act 2011, Magistrates Court prosecution, Safe Work Australia, managing risks of working in heat, employer obligations to workers and foreign nationals, Harvest Trail Inquiry Report.

20/08/2021 by Wilson Queensland Government response not required
Saunders, Cary James (PDF, 248KB) Death in custody, natural causes, infective endocarditis leading to cerebral haemorrhage. 26/07/2021 by Ryan Queensland Government response not required
Cunningham, Luke (PDF, 393KB) Suicide, death in custody, young remand prisoner, shared cell, hanging points. 26/07/2021 by Ryan Queensland Government response not required
Palmer, Tiahleigh Alyssa-Rose (PDF, 451KB) Child Safety, foster care, missing children, murder, rape, incest, Thorburn. 18/06/2021 by Bentley Queensland Government response not required
Cunningham, Martin Sydney - Non-inquest findings (PDF, 2MB) Collision at sea, fishing vessel (FV) Cygnet Lass and tugboat Svitzer Nana, Bowen Harbour, crossing vessel, give way vessel, stand on vessel, overtaking vessel, collision course, failure to maintain a proper lookout, rescue and recovery, Convention on the International Regulations for Preventing Collisions at Sea (COLREGs), delisted inquest, published non-inquest findings. 16/06/2021 by Wilson Queensland Government response not required
Bradford, Teresa and Bradford, David - Non-inquest findings (PDF, 578KB) Domestic Abuse, Domestic and Family Violence, Choking, Strangulation, Queensland Police Service, Specialist Services. 15/06/2021 by Bentley Queensland Government response not required
Wust, Phillip John (PDF, 244KB) Death in custody, natural causes. 11/06/2021 by Ryan Queensland Government response not required
McCoy, Damon Edward (PDF, 959KB) Re-open findings, motor vehicle collision, identity of driver. 10/06/2021 by Wilson Queensland Government response not required
McLoughlin, Kirra-Lea (PDF, 364KB) Domestic abuse, domestic and family violence, choking, strangulation. 07/06/2021 by Bentley Queensland Government response not required
Scorsese, Liam Cooper (PDF, 423KB) Death in custody, police shooting, edged weapon, tasers, body-worn cameras, information sharing, mental health support for parolees. 28/05/2021 by Ryan
SVE (PDF, 355KB)

Suicide, death in custody, remand prisoner, risk assessment, hanging points.

24/05/2021 by Ryan
Ahquee, Dylon James (PDF, 380KB) Death in custody, suicide of young prisoner, transition from youth justice to adult prison, information sharing, hanging, whether death was suspicious, risk assessment. 24/05/2021 by Ryan Queensland Government response not required
Cahill, Margaret Ann (PDF, 466KB) 60mgs intramuscular morphine injection prescribed by general practitioner, morphine interaction with tapentadol and other central nervous system suppressants, mixed drug toxicity, medical management by general practitioner, doctor / patient relationship, post intra-muscular morphine observations by general practitioner and caregiver husband, delayed emergency response. 14/05/2021 by Wilson Queensland Government response not required
Baby J - Non-inquest findings (PDF, 285KB) Co-sleeping, risk factors, Department of Communities, Child Safety and Disability Services, child tracking register. 13/05/2021 by Bentley Queensland Government response not required
Penno-Thompsett, Jayden Joseph (PDF, 428KB) Missing person, road trip Newcastle to Charters Towers, consumption of illicit drugs, MDMA, ice, ecstasy, pingers, fatigue, dehydration, 40 degree temperatures, isolated location, delay to report missing, police investigation and search, death by exposure to the elements. 07/05/2021 by Wilson Queensland Government response not required
Hambly, Scott (PDF, 349KB) Death in custody, natural causes, life prisoner lost to follow-up. 04/05/2021 by Ryan Queensland Government response not required
Bigie, Allan Maka; Mooka, Donald; Gaidan-Banu, Gina Laiana Precilla; Mooka, Claude; Mooka, Telcy Patricia Elizabeth (Illyzaveth) Mooka – Non inquest findings (PDF, 262KB) (The ‘PANA BOY’) 30/04/2021 by Wilson Queensland Government response not required
Ms D - Non-inquest findings (PDF, 237KB)

Licence holder, medical fitness to drive, assessing fitness to drive, insulin dependent diabetes, diabetes mellitus, obligations of medical and general practitioners, Transport and Main Roads, motor vehicle accident, recommendations.

16/04/2021 by McDougall Queensland Government response not required
Burrett, Constance Ann (PDF, 224KB) Heroin, methylamphetamine, injecting another. 06/04/2021 by Bentley Queensland Government response not required
Horne, Ashley Thomas (PDF, 377KB) Death in custody, self-inflicted stab wound, police dog, Taser, first aid response. 09/03/2021 by Ryan Queensland Government response not required
Damjanovic, Anna (PDF, 214KB) Pedestrian hit by car, difficult intersection, S46 comments from inquest, accident, weather conditions. 25/02/2021 by Clements
Petzler, Dennis Michael (PDF, 257KB) Death in custody, natural causes. 24/02/2021 by Ryan Queensland Government response not required
Fullerton, Robert Martin (PDF, 264KB) Death in custody, natural causes 24/02/2021 by Ryan Queensland Government response not required
Springer, Daniel Geoffrey (PDF, 2MB) Mining accident, BHP Billiton Mitsubishi Alliance Coal Operations, Goonyella Mine, excavator bucket, external steel vertical wear plate package, indentions, build up of stored energy, air carbon arc gouging, 1.150 metre spring-back event, fatal injuries to head due to industrial accident, death of qualified boilermarker, no prior industry knowledge regarding magnitude of spring-back. 23/02/2021 by Wilson
T, an eight week old infant - Non-inquest findings (PDF, 296KB) SIDS, co-sleeping, risk factors, parental drug use, child protection, Qld Child Death Case Review, Department of Communities, Queensland Health, information exchange 17/02/2021 by Bentley Queensland Government response not required
B, an eleven week old infant - Non-inquest findings (PDF, 182KB) Sudden infant death syndrome, SIDS, co-sleeping, overlay, risk factors, parental drug use, child protection. 17/02/2021 by Bentley Queensland Government response not required
Brown, Tara Matekino - Non-inquest findings (PDF, 336KB) Domestic and Family Violence, Domestic Violence Protection Orders, Domestic and Family Violence Protection Act 2021, murder, Lionel Patea, Queensland Police Service, High Risk Teams, Queensland Health. 27/01/2021 by Bentley Queensland Government response not required
Miller, Cindy Leigh (PDF, 409KB) Death in custody, police watchhouse, mixed drug toxicity, assessment and monitoring of prisoner health, police CPR skills and training, investigation of police related deaths. 22/01/2021 by Ryan
Cobb, Tyrell - Non-inquest findings (PDF, 207KB) Failure to obtain medical attention, failure to provide necessities of life, murder, unlawful killing, manslaughter, child abuse. 22/01/2021 by Bentley Queensland Government response not required
Palhares, Fabiana - Non-inquest findings (PDF, 350KB) Domestic and Family Violence, DVConnect, Queensland Police Service, High Risk Teams. 20/01/2021 by Bentley Queensland Government response not required