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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 ascending Case type Date Coroner Related orders and rulings Responses to recommendations
    Master L COR 2022 001102 Finding into death without inquest 07/12/2023 Coroner Sarah Gebert
    Adelaide Wilson COR 2022 000978 Finding into death without inquest 01/05/2024 Coroner Simon McGregor
    Tom Owen Row COR 2022 000939 Finding into death without inquest 03/10/2022 Coroner Simon McGregor
    Robert Norman Spencer COR 2022 000929 Finding into death without inquest 30/04/2024 Coroner Simon McGregor
    Simon Peter Scarff COR 2022 000829 Finding into death without inquest 31/10/2023 Coroner Paul Lawrie
    Mr C COR 2022 000827 Finding into death without inquest 03/05/2023 Coroner Sarah Gebert
    Antonios Myrianthopoulos COR 2022 000658 Finding into death without inquest 22/03/2024 Coroner Katherine Lorenz
    Baby ZCZ COR 2022 000609 Finding into death without inquest 13/02/2024 Coroner Sarah Gebert
    O S COR 2022 000569 Finding into death without inquest 22/05/2023 Deputy State Coroner Paresa Spanos
    John Sloots COR 2022 000559 Finding into death without inquest 12/12/2022 Deputy State Coroner Paresa Spanos