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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
    Giovanni Castillo Garbanzos COR 2021 004666 Finding into death without inquest 14/06/2024 State Coroner Judge John Cain
    Russell James Aldridge COR 2023 005470 Finding into death without inquest 14/06/2024 Coroner Catherine Fitzgerald
    Jennifer Rowallan Turnbull COR 2022 006316 Finding into death without inquest 13/06/2024 Coroner David Ryan
    Martin Page COR 2022 005163 Finding into death with inquest 12/06/2024 Coroner Catherine Fitzgerald
    Stephen John Lunson COR 2021 006612 Finding into death without inquest 11/06/2024 Coroner Audrey Jamieson
    Sebastian D'Imperio COR 2017 006321 Finding into death with inquest 11/06/2024 Deputy State Coroner Paresa Spanos
    Gwyn Pugh COR 2022 006158 Finding into death without inquest 06/06/2024 Coroner Leveasque Peterson
    Nihal Singh Hundal COR 2023 001485 Finding into death without inquest 30/05/2024 Coroner Sarah Gebert
    Trevor Lindsay Jones COR 2023 001947 Finding into death without inquest 30/05/2024 Coroner Ingrid Giles
    Murray Noel Haggar COR 2023 006025 Finding into death without inquest 27/05/2024 State Coroner Judge John Cain