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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 Sort descending Case type Date Coroner Related orders and rulings Responses to recommendations
Peter Allen Bain 2018 5611 Finding into death without inquest 30/10/2019 Coroner Darren Bracken
MrsL 2018 5623 Finding into death without inquest 28/01/2021 Coroner Sarah Gebert
Maxwell Rowllings COR 18 4752 Finding into death without inquest 05/08/2020 Coroner Audrey Jamieson
Barbara Dawson COR 1980 3469 Finding into death with inquest 16/04/2021 Coroner Audrey Jamieson
Margaret Penny and Claire Acocks COR 1991 1444 Finding into death with inquest 30/06/2017 Coroner Jacqui Hawkins
Louis Gerard Le Boeuf COR 1992 3557 Finding into death with inquest 07/05/2015 State Coroner Judge Ian L Gray
Frederick Goggin COR 1996 3530 Finding into death with inquest 01/02/2011 Coroner Kim M. W. Parkinson
George Marcus COR 1997 1148 Finding into death without inquest 08/09/2011 State Coroner Judge Jennifer Coate
Kathleen Gladwyn Downes COR 1997 3954 Finding into death with inquest 27/03/2015 State Coroner Judge Ian L Gray
Gianni (John) Furlan COR 1998 2331 Finding into death with inquest 31/08/2017 State Coroner Judge Sara Hinchey