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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
    Veronica Nelson COR 2020 0021 Finding into death with inquest 30/01/2023 Coroner Simon McGregor
    Neville Reginald Want COR 2021 004978 Finding into death without inquest 25/01/2023 Coroner David Ryan
    Nina Barake COR 2021 003026 Finding into death without inquest 25/01/2023 Coroner David Ryan
    Heather Amy Robertson COR 2022 004213 Finding into death without inquest 25/01/2023 Coroner David Ryan
    Garry Nicholls COR 2022 006667 Finding into death without inquest 25/01/2023 State Coroner Judge John Cain
    Periklis Papadopoulos COR 2021 003736 Finding into death without inquest 24/01/2023 Coroner David Ryan
    Aleksander Kojic COR 2018 001290 Finding into death without inquest 24/01/2023 Coroner Kate Despot
    Lorraine Earl COR 2019 004931 Finding into death without inquest 23/01/2023 Coroner Paul Lawrie
    Gabriel Messo COR 2020 003809 Finding into death with inquest 19/01/2023 State Coroner Judge John Cain
    Danny Lee O'Brien COR 2016 005829 Finding into death without inquest 19/01/2023 State Coroner Judge John Cain