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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 Date Sort ascending Coroner Related orders and rulings Responses to recommendations
Joseph Michael Romano COR 2024 000115 Finding into death with inquest 06/05/2026 Deputy State Coroner Paresa Spanos
Cornelia Groot COR 2025 001943 Finding into death without inquest 06/05/2026 Coroner Leveasque Peterson
Baby E COR 2024 003398 Finding into death without inquest 05/05/2026 Coroner Dimitra Dubrow
Elizabeth Susan Edwina Ferris COR 2022 006797 Finding into death without inquest 04/05/2026 Coroner Simon McGregor
TBL . COR 2023 003101 Finding into death without inquest 04/05/2026 State Coroner Judge Liberty Sanger
Graham Peter Moore COR 2025 008484 Finding into death without inquest 01/05/2026 Coroner David Ryan
Sandra Susan Black COR 2023 006774 Finding into death without inquest 30/04/2026 Coroner Catherine Fitzgerald
Nick Panagiotopoulos COR 2021 005523 Finding into death with inquest 30/04/2026 Coroner Catherine Fitzgerald
Saba Pietropaolo COR 2024 007400 Finding into death without inquest 29/04/2026 Coroner Simon McGregor
Ronald William Beaumont COR 2023 006364 Finding into death without inquest 29/04/2026 Coroner Paul Lawrie