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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Arsinoi Karamoskos COR 2020 003121 Finding into death with inquest 04/04/2022 Coroner Phillip Byrne
    Mohammed Ismael Ibrahim COR 2020 001403 Finding into death with inquest 26/05/2022 Coroner Leveasque Peterson
    Noel Thomas COR 2017 003579 Finding into death with inquest 28/07/2022 Coroner Darren Bracken
    Gregory Paul Sedgman COR 2018 004920 Finding into death with inquest 09/09/2022 Deputy State Coroner Jacqui Hawkins
    Christopher David French Hunter COR 2015 003028 Finding into death with inquest 04/10/2022 Deputy State Coroner Paresa Spanos
    Steven William Judge COR 2019 001360 Finding into death with inquest 02/11/2022 Deputy State Coroner Jacqui Hawkins
    Durdica Serbec COR 2016 000634 Finding into death with inquest 24/11/2022 Coroner Sarah Gebert
    Scott Adam Brown COR 2019 004846 Finding into death with inquest 12/12/2022 Coroner Katherine Lorenz
    M S COR 2010 2851 Finding into death with inquest 29/06/2017 State Coroner Judge Sara Hinchey
    Cameron Douglas Boyes COR 2019 001516 Finding into death with inquest 30/03/2023 Coroner Leveasque Peterson