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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 Coroner Sort ascending Related orders and rulings Responses to recommendations
    Phillip John Pierson COR 2020 001612 Finding into death with inquest 18/08/2023 Deputy State Coroner Jacqui Hawkins
    Gregory Paul Sedgman COR 2018 004920 Finding into death with inquest 09/09/2022 Deputy State Coroner Jacqui Hawkins
    Steven William Judge COR 2019 001360 Finding into death with inquest 02/11/2022 Deputy State Coroner Jacqui Hawkins
    COR 2022 003072 Finding into death without inquest 19/05/2023 Deputy State Coroner Jacqui Hawkins
    Benjamin Peter Madex COR 2021 000399 Finding into death with inquest 21/08/2023 Deputy State Coroner Jacqui Hawkins
    Ian Keith Beissel COR 2022 3072 Finding into death without inquest 16/05/2023 Deputy State Coroner Jacqui Hawkins
    Paul Henry Green COR 2021 005288 Finding into death without inquest 20/10/2022 Deputy State Coroner Jacqui Hawkins
    Arthur Peter Andrianakis COR 2021 004554 Finding into death without inquest 19/12/2022 Deputy State Coroner Jacqui Hawkins
    Vasiliki Simopoulos COR 2019 000693 Finding into death without inquest 27/07/2022 Deputy State Coroner Jacqui Hawkins
    Cindy Jane Martin COR 2020 003618 Finding into death without inquest 31/08/2022 Deputy State Coroner Jacqui Hawkins