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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 ascending Date Coroner Related orders and rulings Responses to recommendations
    COR 2020 000929 Finding into death without inquest 28/06/2021 Coroner John Olle
    V T COR 2016 001876 Finding into death without inquest 06/08/2021 State Coroner Judge John Cain
    Phillip John Sealey COR 2019 003297 Finding into death without inquest 01/09/2021 Coroner Leveasque Peterson
    MR XH COR 2019 001998 Finding into death without inquest 28/10/2021 Deputy State Coroner Caitlin English
    Maxine Joyce Manwaring COR 2020 006348 Finding into death without inquest 09/02/2022 Coroner Sarah Gebert
    Mark Clinton Edwards COR 2020 006721 Finding into death without inquest 16/12/2021 Deputy State Coroner Caitlin English
    H J COR 2021 003048 Finding into death without inquest 17/11/2021 Coroner David Ryan
    Raylene Barbara Armstrong COR 2019 0657 Finding into death without inquest 25/11/2021 Coroner David Ryan
    Andrew William Staker COR 2021 002157 Finding into death without inquest 16/03/2022 Coroner David Ryan
    Leonardo Antonio Biancofiore COR 2019 003577 Finding into death without inquest 27/04/2022 State Coroner Judge John Cain