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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 ascending Case type Date Coroner Related orders and rulings Responses to recommendations
    Jean Meyer COR 2023 003306 Finding into death with inquest 01/05/2024 Coroner Katherine Lorenz
    Mark Andrew Spillane COR 2023 003142 Finding into death without inquest 15/04/2024 Deputy State Coroner Paresa Spanos
    Cheryl Balassopoulos COR 2023 002866 Finding into death without inquest 22/02/2024 Coroner Paul Lawrie
    Frank Allen Hall-Bentick COR 2023 002776 Finding into death without inquest 05/03/2024 Coroner Simon McGregor
    Michael Manuel Luno COR 2023 002545 Finding into death without inquest 11/01/2024 Coroner Sarah Gebert
    K M COR 2023 002206 Finding into death without inquest 13/03/2024 Coroner Simon McGregor
    Michael John O'connell COR 2023 002195 Finding into death without inquest 23/01/2024 Coroner Paul Lawrie
    Miranda Louise Lynch COR 2023 002141 Finding into death without inquest 14/02/2024 Coroner Catherine Fitzgerald
    Vincenzo Mario Chiarello COR 2023 001764 Finding into death without inquest 01/12/2023 State Coroner Judge John Cain
    C J COR 2023 001580 Finding into death without inquest 26/03/2024 Deputy State Coroner Paresa Spanos