A coroner may make recommendations following an investigation that relate to public health and safety to help prevent similar deaths in the future.

Fatal facts is a unique NCIS service providing access to coronial recommendations from across all Australian states and territories.

Fatal facts contains cases closed by a coroner from 2000. The NCIS Unit is currently preparing cases closed from 2021 onwards.

New Zealand cases are not included in Fatal facts search from April 2013 onwards, or in PDF editions from 37 onwards. New Zealand coronial recommendations are published by Coronial Services of New Zealand.

Fatal facts is based on information available in the NCIS at the time of reporting.

Category tags are assigned by the NCIS Unit to each Fatal facts case based on the case circumstances and recommendations made.

Category tag Description
Adverse medical effects Adverse effects from medical or surgical treatment, failure to comply with medical advice
Aged care Incidents that occurred in an aged care or assisted living facility or residence, including a retirement village
Animal Incidents where an animal was involved in the death
Child and infant death Any case involving a child or infant
Domestic incident Incidents as a result of a domestic injury or event
Drugs and alcohol Deaths where drugs or alcohol or both made a primary or secondary contribution
Electrocution Cases where electrocution contributed to death
Falls Incidents where a fall was involved in the circumstances or cause of death
Fire related Incidents where a fire was involved in the circumstances or cause of death
Geographic Cases where the geographic region is significant to the death, such as a remote location
Homicide and assault Deaths due to interpersonal violence
Indigenous Cases where the indigenous status of a person was relevant to the circumstances of death
Intentional self-harm Deaths determined by a coroner to be due to intentional self-harm
Law enforcement Includes police pursuits, deaths in custody, legal or court issues and coronial investigation or police procedures
Leisure activity Any leisure activity that directly influenced the circumstances of death
Location Cases where the location type of either the incident or the discovery of the body is of significance. Does not refer to geographic location
Mental illness and health Cases where mental health issues or their management were relevant to the death, whether diagnosed or anecdotal
Misadventure Risk-taking behaviour such as train surfing
Natural cause death Cases where the death was due to natural causes
Older persons Cases where the agedness of a person was a factor in the death
Physical health Cases where the existing physical health of the person contributed but was not necessarily the cause of death
Sports related Cases where a sporting incident contributed to death
Transport and traffic related Cases involving road, water and air vehicle incidents, motorised or naturally powered. Includes cases of pedestrians impacted by transport vehicles
Water related Includes swimming, scuba, snorkelling, boating, fishing and all water-based activities in either a recreational or commercial context
Weather related Cases where the environmental conditions such as heatwave or storm conditions contributed to death
Work related Cases where a work incident is related to the death
Weapon Cases where the involvement of a weapon is significant
Youth Cases where the youth of a person was a factor in the death

Fatal facts search

Fatal facts search is a tool to help you find coronial recommendations.


Fatal facts editions

Fatal facts editions contain summaries of cases with coronial recommendations made by an Australian state or territory coroner within a three-month period.

The following special editions contain coronial recommendations relating to specific topics of interest where the case was closed by a coroner between 2008 and 2010.

Edition 24: Deaths of children in care/children identified at risk

Published May 2014

Edition 23: Deaths in police presence and mental health services

Published February 2013

Edition 22: Deaths in police custody or during police pursuit

Published May 2012

Edition 21: Deaths related to quad bikes

Published March 2011

Edition 20: Deaths in custody

Published March 2009

Earlier editions are available upon request.