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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
Peter A Keating COR 2024 004841 Finding into death without inquest 20/12/2024 State Coroner Judge John Cain
Sonya Marshman COR 2024 004825 Finding into death without inquest 20/12/2024 State Coroner Judge John Cain
Peter Christofidis COR 2023 005188 Finding into death with inquest 20/12/2024 Coroner Dimitra Dubrow
Paul Munt COR 2024 004846 Finding into death without inquest 20/12/2024 State Coroner Judge John Cain
Baby S COR 2023 001846 Finding into death without inquest 18/12/2024 Coroner Catherine Fitzgerald
BCA BCA COR 2023 005224 Finding into death without inquest 17/12/2024 Coroner Kate Despot
Geoffrey Paul McConachy COR 2023 005213 Finding into death without inquest 17/12/2024 Coroner Simon McGregor
Gretchen Heidi Anastasia Van Lunenburg COR 2023 005934 Finding into death without inquest 17/12/2024 Coroner Kate Despot
C L COR 2023 005124 Finding into death without inquest 16/12/2024 Coroner David Ryan
Caroline Monique Hall COR 2021 002438 Finding into death with inquest 16/12/2024 Deputy State Coroner Paresa Spanos