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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
Linda Joy Bridle COR 2024 004438 Finding into death without inquest 17/07/2026 Deputy State Coroner Paresa Spanos
Guy Edwin Gellibrand COR 2025 007600 Finding into death without inquest 15/07/2026 Coroner Sarah Gebert
Adam James Southern COR 2024 005245 Finding into death without inquest 15/07/2026 Coroner Simon McGregor
Danielle Jade Pezzutti COR 2024 004039 Finding into death without inquest 14/07/2026 Coroner Paul Lawrie
Philip Charles Arnott COR 2023 004344 Finding into death with inquest 14/07/2026 Coroner Paul Lawrie
GRA GRA COR 2024 004704 Finding into death without inquest 13/07/2026 Deputy State Coroner Paresa Spanos
W Q COR 2024 007582 Finding into death without inquest 13/07/2026 Coroner Therese McCarthy
Loi Ngoc Pham COR 2024 006672 Finding into death without inquest 13/07/2026 Coroner Paul Lawrie
Grant Douglas Griffiths COR 2024 004003 Finding into death without inquest 13/07/2026 Coroner Therese McCarthy
Mark Wesley Tyson COR 2025 004669 Finding into death without inquest 10/07/2026 Coroner Sarah Gebert