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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
Laurence Maxwell Attwood COR 2021 003498 Finding into death without inquest 29/07/2024 Coroner Audrey Jamieson
Shane Anthony Pappas COR 2021 003492 Finding into death with inquest 29/07/2024 Coroner Audrey Jamieson
Nathan Ruan Roy Greenwood COR 2021 004938 Finding into death without inquest 29/07/2024 State Coroner Judge John Cain
Philip Sopikiotis COR 2022 006349 Finding into death without inquest 26/07/2024 Coroner David Ryan
Mr KE COR 2020 005777 Finding into death without inquest 26/07/2024 Coroner Ingrid Giles
Peter Fiorakis COR 2022 006312 Finding into death without inquest 26/07/2024 Coroner David Ryan
Ryleigh James Pallot COR 2021 007031 Finding into death without inquest 22/07/2024 Coroner Catherine Fitzgerald
Rohan Patrick Cosgriff COR 2022 004182 Finding into death without inquest 16/07/2024 Coroner Audrey Jamieson
Wayne Duncan Miller COR 2023 003890 Finding into death without inquest 12/07/2024 Coroner Sarah Gebert
Lilian Isabella Lister COR 2021 002241 Finding into death without inquest 11/07/2024 Coroner Leveasque Peterson