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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
Arsinoi Karamoskos COR 2020 003121 Finding into death with inquest 04/04/2022 Coroner Phillip Byrne
Charles Bertram Squires COR 2017 000481 Finding into death with inquest 31/03/2022 Deputy State Coroner Caitlin English

The Department of Justice and Community Safety was required to respond by 30 June 2022. No response has been received to date.

FJ L COR 2021 000475 Finding into death without inquest 31/03/2022 Coroner Simon McGregor
Maria James COR 1980 1820 Finding into death with inquest 31/03/2022 Deputy State Coroner Caitlin English
Tessa Michelle Ballam COR 2015 004117 Finding into death with inquest 31/03/2022 Coroner Phillip Byrne
Ms L COR 2021 001095 Finding into death without inquest 31/03/2022 Coroner Sarah Gebert
Ms WJ COR 2019 002653 Finding into death without inquest 30/03/2022 Coroner Paresa Spanos
Deva Rebecca Frijlink COR 2018 006518 Finding into death with inquest 30/03/2022 Coroner Phillip Byrne
Nilofer Nezami COR 2019 000200 Finding into death without inquest 29/03/2022 Deputy State Coroner Caitlin English
Nalaka Mudiyanselage Wijeratne COR 2020 006052 Finding into death without inquest 28/03/2022 Coroner Katherine Lorenz