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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
    Mr P COR 2019 003365 Finding into death without inquest 18/11/2022 Coroner Darren Bracken
    Aleksander Kojic COR 2018 001290 Finding into death without inquest 24/01/2023 Coroner Kate Despot
    Cody Morrella Watson COR 2019 005247 Finding into death without inquest 23/02/2023 Deputy State Coroner Paresa Spanos
    Christopher William Hanson COR 2022 006260 Finding into death without inquest 28/03/2023 Coroner Simon McGregor
    Christopher James Wrigglesworth COR 2020 004724 Finding into death without inquest 13/07/2023 Coroner Leveasque Peterson
    Shannon Troy Calvert COR 2022 001895 Finding into death without inquest 09/08/2023 Coroner John Olle
    Dianne Christine Hobbs COR 2023 000692 Finding into death without inquest 30/08/2023 Coroner David Ryan
    Doriano Valenti COR 2023 000277 Finding into death without inquest 17/10/2023 Deputy State Coroner Paresa Spanos
    Renato Ettore Poletti COR 2021 002292 Finding into death without inquest 06/11/2023 Coroner Audrey Jamieson
    RW C COR 2020 000709 Finding into death without inquest 31/01/2024 Coroner Ingrid Giles