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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
Maryanne Gordon COR 2023 006743 Finding into death without inquest 25/01/2024 State Coroner Judge John Cain
Amelia Antonopoulos COR 2022 006149 Finding into death without inquest 25/01/2024 Coroner Leveasque Peterson
Elaine Pandilovski COR 2020 003777 Finding into death without inquest 23/01/2024 State Coroner Judge John Cain
Michael John O'connell COR 2023 002195 Finding into death without inquest 23/01/2024 Coroner Paul Lawrie
Kieran Joseph McGuinness COR 2022 005257 Finding into death without inquest 18/01/2024 Coroner David Ryan
Lily Grace Arbuckle COR 2021 003672 Finding into death without inquest 18/01/2024 State Coroner Judge John Cain
A J COR 2022 005920 Finding into death without inquest 11/01/2024 Deputy State Coroner Paresa Spanos
David Drowley COR 2022 003895 Finding into death without inquest 11/01/2024 Coroner Catherine Fitzgerald
Madeline Jane Howe COR 2019 002333 Finding into death without inquest 11/01/2024 State Coroner Judge John Cain
Michael Manuel Luno COR 2023 002545 Finding into death without inquest 11/01/2024 Coroner Sarah Gebert