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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
    Michael Brian Sanders COR 2018 4194 Finding into death with inquest 03/03/2021 Coroner Audrey Jamieson
    Ian Fraser COR 2019 6921 Finding into death without inquest 26/02/2021 Deputy State Coroner Caitlin English
    Rosemary Gibson COR 2016 1676 Finding into death without inquest 25/02/2021 State Coroner Judge John Cain
    Shae Harry Paszkiewicz COR 2017 6235 Finding into death without inquest 24/02/2021 Coroner Jacqui Hawkins
    Mark Capovilla COR 2018 0287 Finding into death with inquest 24/02/2021 Deputy State Coroner Caitlin English
    Daniel Patrick Frawley COR 2019 4895 Finding into death without inquest 23/02/2021 Coroner Paresa Spanos
    MRWilson COR 2019 5502 Finding into death without inquest 10/02/2021 Coroner Audrey Jamieson
    Joyce Drummond COR 2019 3861 Finding into death without inquest 09/02/2021 Coroner Audrey Jamieson
    Carl David Waldon COR 2019 3878 Finding into death without inquest 05/02/2021 Coroner Audrey Jamieson
    Robert Gerard Dimattina COR 2019 4427 Finding into death without inquest 29/01/2021 Deputy State Coroner Caitlin English