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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.

    Findings list

    Name Case ID Case type Date Coroner Sort ascending Related orders and rulings Responses to recommendations
    Ms L COR 2015 4584 Finding into death without inquest 20/09/2019 Coroner Sarah Gebert
    Mr A COR 2016 4886 Finding into death without inquest 18/10/2019 Coroner Sarah Gebert
    Elizabeth Geiger COR 2017 3619 Finding into death without inquest 17/09/2019 Coroner Sarah Gebert
    Giuseppe Luci COR 2017 5518 Finding into death without inquest 29/10/2019 Coroner Sarah Gebert
    Nicole Maree Knox-Smith COR 2004 1311 Finding into death with inquest 21/07/2006 State Coroner Graeme Johnstone
    Rhys Andrew Rodger COR 2010 4518 Finding into death with inquest 04/07/2013 Coroner William P. Gibb
    Leonie Bedggood COR 2008 5666 Finding into death without inquest 22/06/2010 Coroner Tim McDonald
    Andrew Pollock COR 2011 2105 Finding into death with inquest 22/10/2012 Coroner Susan Jane Armour
    Lyle Somers Jeffery COR 2010 0681 Finding into death without inquest 27/03/2012 Coroner Susan Jane Armour
    Roderick Peter Oldfield COR 2010 3878 Finding into death without inquest 27/03/2012 Coroner Susan Jane Armour