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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
Erol Elmas COR 2022 006863 Finding into death with inquest 30/09/2024 Coroner Paul Lawrie
Jessica Nyla Louis COR 2023 002788 Finding into death without inquest 30/09/2024 Coroner Simon McGregor
Gerard Richard Bailey COR 2023 007023 Finding into death without inquest 26/09/2024 Coroner Kate Despot
Abraham Sleiman Transcendo COR 2023 000988 Finding into death without inquest 25/09/2024 Coroner Catherine Fitzgerald
Carl Edward Medlyn COR 2022 004394 Finding into death without inquest 25/09/2024 Coroner Paul Lawrie
Frank Mellia COR 2023 000310 Finding into death without inquest 25/09/2024 Coroner Paul Lawrie
B K COR 2022 006852 Finding into death without inquest 24/09/2024 Deputy State Coroner Paresa Spanos
Silvio Rolfo COR 2023 003818 Finding into death without inquest 23/09/2024 Coroner Simon McGregor
L M COR 2022 004069 Finding into death without inquest 20/09/2024 Coroner David Ryan
George Diamond COR 2019 000968 Finding into death with inquest 19/09/2024 State Coroner Judge John Cain