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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
    Gabriel Messo COR 2020 003809 Finding into death with inquest 01/12/2022 State Coroner Judge John Cain
    Alicia Maree Little COR 2017 006543 Finding into death with inquest 01/12/2022 State Coroner Judge John Cain
    Lucio Chiussi COR 2020 005107 Finding into death without inquest 28/11/2022 Coroner Leveasque Peterson
    Ms AA . COR 2019 001071 Finding into death without inquest 27/11/2022 State Coroner Judge John Cain
    Mr AS . COR 2020 002945 Finding into death without inquest 27/11/2022 State Coroner Judge John Cain
    Durdica Serbec COR 2016 000634 Finding into death with inquest 24/11/2022 Coroner Sarah Gebert
    Carl Robert Adler COR 2018 002604 Finding into death with inquest 24/11/2022 Coroner Audrey Jamieson
    Glenda Elaine Shapcott COR 2022 002650 Finding into death with inquest 23/11/2022 Coroner Paresa Spanos
    John Stuart Knox COR 2021 005272 Finding into death without inquest 23/11/2022 Deputy State Coroner Jacqui Hawkins
    G K COR 2019 004438 Finding into death without inquest 22/11/2022 Coroner Paresa Spanos