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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
H D COR 2023 004809 Finding into death without inquest 14/03/2025 Deputy State Coroner Paresa Spanos
Heather Joan Moody COR 2024 005100 Finding into death without inquest 14/03/2025 Coroner Kate Despot
Paul Francis McHugh COR 2022 007035 Finding into death without inquest 14/03/2025 Coroner Ingrid Giles
Maria Grazia Nardiello COR 2022 001018 Finding into death with inquest 14/03/2025 Coroner Simon McGregor
Aaron Matthew Forte COR 2023 004845 Finding into death without inquest 14/03/2025 Coroner Sarah Gebert
Robin Albert Banks COR 2020 000256 Finding into death without inquest 13/03/2025 Deputy State Coroner Paresa Spanos
Stephen Peter O'Brien COR 2023 000213 Finding into death without inquest 12/03/2025 State Coroner Judge John Cain
Anne-Maree Tammy Carr COR 2024 005889 Finding into death without inquest 12/03/2025 Coroner Leveasque Peterson
Dianne Elizabeth Harper COR 2022 001581 Finding into death without inquest 11/03/2025 Coroner Ingrid Giles
Steven John Parlby COR 2023 005449 Finding into death without inquest 06/03/2025 Coroner Audrey Jamieson