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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. Anyone 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. The Court does not provide a copy of a response to a recommendation to any person unless they have advised the Principal Registrar in writing that they have an interest in the subject of the recommendations.

    Findings list

    Name Case ID Case type Date Sort ascending Coroner Related orders and rulings Responses to recommendations
    Elizabeth Geiger COR 2017 3619 Finding into death without inquest 17/09/2019 Coroner Sarah Gebert
    David John Farlech COR 2018 5510 Finding into death without inquest 06/09/2019 Coroner John Olle
    Rodney Wayne Weise COR 2019 1771 Finding into death without inquest 03/09/2019 Coroner Simon McGregor
    Matt Robert Crampton COR 2016 0678 Finding into death with inquest 03/09/2019 Coroner Darren Bracken
    Agostino Cutugno COR 2017 4222 Finding into death without inquest 30/08/2019 Coroner Simon McGregor
    John Reimers COR 2016 5983 Finding into death with inquest 23/08/2019 Coroner Audrey Jamieson
    John Reimers COR 2016 5983 Finding into death with inquest 23/08/2019 Coroner Audrey Jamieson
    Traci O'Sullivan COR 2015 0642 Finding into death with inquest 22/08/2019 Coroner Simon McGregor
    Leslie Hawkins COR 2018 5253 Finding into death with inquest 21/08/2019 Coroner Caitlin English
    Jovan Kozarov COR 2015 0614 Finding into death without inquest 15/08/2019 Coroner Caitlin English