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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 Date Sort ascending Coroner Related orders and rulings Responses to recommendations
John Crabtree COR 2016 002356 Finding into death without inquest 08/11/2021 Coroner Paresa Spanos
Esri Lederberger COR 2019 000601 Finding into death without inquest 03/11/2021 Coroner Simon McGregor
Arzu Karakoc COR 2017 001148 Finding into death with inquest 03/11/2021 Deputy State Coroner Caitlin English
Yunjie Zhang COR 2020 004299 Finding into death without inquest 29/10/2021 Deputy State Coroner Caitlin English
Joshua Brown COR 2017 001877 Finding into death without inquest 28/10/2021 Coroner Paresa Spanos
MR XH COR 2019 001998 Finding into death without inquest 28/10/2021 Deputy State Coroner Caitlin English
Michelle Lorraine Duque COR 2020 005818 Finding into death without inquest 27/10/2021 Deputy State Coroner Caitlin English
James Dimitrios Komninakis COR 2020 000206 Finding into death without inquest 26/10/2021 Coroner Simon McGregor
Vasil Lazarevski COR 2021 004649 Finding into death without inquest 24/10/2021 Coroner David Ryan
Catherine Claudia Thomas COR 2020 006426 Finding into death with inquest 21/10/2021 State Coroner Judge John Cain