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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
    HM Q COR 2022 003101 Finding into death without inquest 31/01/2024 Coroner Ingrid Giles
    Phyllis Joan Porter COR 2021 006663 Finding into death without inquest 30/01/2024 Coroner Paul Lawrie
    Baby T S COR 2022 005413 Finding into death without inquest 30/01/2024 Coroner Sarah Gebert
    David Sean Takwalai COR 2022 003588 Finding into death without inquest 30/01/2024 Coroner Kate Despot
    Lachlan John Howe COR 2018 002344 Finding into death without inquest 29/01/2024 State Coroner Judge John Cain
    Maryanne Gordon COR 2023 006743 Finding into death without inquest 25/01/2024 State Coroner Judge John Cain
    Melissa Jan Hadland COR 2022 006064 Finding into death without inquest 25/01/2024 Coroner Leveasque Peterson
    Amelia Antonopoulos COR 2022 006149 Finding into death without inquest 25/01/2024 Coroner Leveasque Peterson
    Michael John O'connell COR 2023 002195 Finding into death without inquest 23/01/2024 Coroner Paul Lawrie
    Elaine Pandilovski COR 2020 003777 Finding into death without inquest 23/01/2024 State Coroner Judge John Cain