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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
Gwenyth Evelyn Miles COR 2019 002142 Finding into death without inquest 11/05/2022 Coroner Darren Bracken
Marlene Sako COR 2015 006072 Finding into death without inquest 05/05/2022 State Coroner Judge John Cain
PX O COR 2020 001502 Finding into death without inquest 05/05/2022 Coroner Simon McGregor
Stuart Brant Garten COR 2014 000918 Finding into death with inquest 05/05/2022 State Coroner Judge John Cain
Carol Austin COR 2018 004283 Finding into death without inquest 03/05/2022 Coroner Leveasque Peterson
Hunter Patrick Boyle COR 2020 004420 Finding into death without inquest 03/05/2022 State Coroner Judge John Cain
Mr S COR 2020 003434 Finding into death without inquest 29/04/2022 Coroner Sarah Gebert
Leonardo Antonio Biancofiore COR 2019 003577 Finding into death without inquest 27/04/2022 State Coroner Judge John Cain
John Kennard COR 2019 001704 Finding into death with inquest 20/04/2022 Coroner Simon McGregor
Mr BB COR 2020 005578 Finding into death without inquest 19/04/2022 State Coroner Judge John Cain