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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
    Russell Langford Munsch COR 2017 000876 Finding into death with inquest 10/11/2022 Coroner Darren Bracken
    John Washburn COR 2017 000875 Finding into death with inquest 10/11/2022 Coroner Darren Bracken
    Greg Reynolds De Haven COR 2017 000873 Finding into death with inquest 10/11/2022 Coroner Darren Bracken
    Sotirios Temopoulos COR 2020 004482 Finding into death without inquest 03/11/2022 Coroner Simon McGregor
    Steven William Judge COR 2019 001360 Finding into death with inquest 02/11/2022 Deputy State Coroner Jacqui Hawkins
    Master S COR 2019 006224 Finding into death without inquest 31/10/2022 Coroner Sarah Gebert
    Mark Skidmore COR 2017 000753 Finding into death with inquest 31/10/2022 Coroner Darren Bracken
    Ronald Allen Cunnington COR 2022 003945 Finding into death without inquest 30/10/2022 Deputy State Coroner Jacqui Hawkins
    Vasileios Avtsidis COR 2021 003483 Finding into death without inquest 28/10/2022 Coroner Paresa Spanos
    Elizabeth Judith Robyn Wilms COR 2016 003075 Finding into death with inquest 27/10/2022 State Coroner Judge John Cain