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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 Sort descending Case type Date Coroner Related orders and rulings Responses to recommendations
    Timothy Jack Wood COR 2005 2539 Finding into death with inquest 08/12/2009 Deputy State Coroner Iain West
    Georgie Lopiccolo COR 2005 2579 Finding into death with inquest 20/02/2008 Deputy State Coroner Paresa Spanos
    Brian William Bottomley COR 2005 3694 Finding into death with inquest 31/12/2013 Coroner Dr Jane Hendtlass
    Dean Scott Westbrook COR 2005 4176 Finding into death with inquest 25/02/2010 State Coroner Judge Jennifer Coate
    Wingeel Plains Fire COR 2005 4668 Finding into fire with inquest 04/04/2011 Coroner Peter White
    Jennifer Gibbins COR 2005 4723 Finding into death with inquest 20/01/2010 Coroner John Martin Murphy
    Angelo Lombardo COR 2005 4746 Finding into death with inquest 07/06/2011 Coroner Audrey Jamieson
    Dallas Alister Anderson COR 2006 0101 Finding into death with inquest 13/03/2015 Coroner Audrey Jamieson
    Warwick Lorne Greville COR 2006 0220 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos
    George Panayiotis COR 2006 0221 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos