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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
Joseph John Janes COR 2019 1115 Finding into death without inquest 16/08/2021 Coroner Sarah Gebert
Mark Marian Milewski COR 2020 000671 Finding into death without inquest 16/08/2021 Coroner Sarah Gebert
Sestilio Malaspina COR 2018 005661 Finding into death with inquest 13/08/2021 State Coroner Judge John Cain
M J COR 2016 006105 Finding into death without inquest 12/08/2021 State Coroner Judge John Cain
Mariza Beretta COR 2020 000493 Finding into death without inquest 12/08/2021 Coroner David Ryan
V T COR 2016 001876 Finding into death without inquest 06/08/2021 State Coroner Judge John Cain
NB COR 2016 6080 Finding into death with inquest 04/08/2021 Deputy State Coroner Caitlin English
Peter George Starkie COR 2020 005113 Finding into death without inquest 04/08/2021 Deputy State Coroner Caitlin English
Ashley Wayne Phillips COR 2017 2477 Finding into death without inquest 03/08/2021 State Coroner Judge John Cain
Gregory John Bennett COR 2018 005412 Finding into death without inquest 03/08/2021 Coroner Sarah Gebert