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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
David Sheppard COR 2017 2291 Finding into death without inquest 02/10/2019 Deputy State Coroner Paresa Spanos
Mark Richard Mennie COR 2015 6105 Finding into death with inquest 26/09/2019 Coroner Simon McGregor
Tangimama Tavai COR 2016 6008 Finding into death without inquest 26/09/2019 Coroner Simon McGregor
Ross Bennett COR 2019 4329 Finding into death without inquest 25/09/2019 Coroner Phillip Byrne
Leslie Roberts COR 2018 3201 Finding into death without inquest 23/09/2019 Coroner Simon McGregor
Ms L COR 2015 4584 Finding into death without inquest 20/09/2019 Coroner Sarah Gebert
Vanna Vassallo COR 2017 2313 Finding into death with inquest 19/09/2019 Coroner Simon McGregor
Lucia Grace Sefton (Bowlen) COR 2015 3928 Finding into death without inquest 18/09/2019 Coroner Caitlin English
Marco Angelo Virgona COR 2017 2418 Finding into death with inquest 18/09/2019 Coroner Michelle Hodgson
Elizabeth Geiger COR 2017 3619 Finding into death without inquest 17/09/2019 Coroner Sarah Gebert