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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
    Ludmila Sezonenko COR 2021 003812 Finding into death without inquest 03/08/2022 Coroner Simon McGregor
    Master S COR 2017 003163 Finding into death without inquest 01/08/2022 Coroner Sarah Gebert
    Susan Mary Royals COR 2021 002666 Finding into death without inquest 29/07/2022 Coroner Simon McGregor
    Rosy Loomba COR 2020 006754 Finding into death without inquest 29/07/2022 Deputy State Coroner Jacqui Hawkins
    Mr EZT COR 2020 003629 Finding into death without inquest 29/07/2022 Coroner Simon McGregor
    Michael John Sim COR 2021 003685 Finding into death without inquest 28/07/2022 Coroner Simon McGregor
    Dominic Salvatore Mele COR 2020 006851 Finding into death without inquest 28/07/2022 Deputy State Coroner Jacqui Hawkins
    Noel Thomas COR 2017 003579 Finding into death with inquest 28/07/2022 Coroner Darren Bracken
    H C COR 2017 003973 Finding into death without inquest 28/07/2022 Coroner Leveasque Peterson
    Vasiliki Simopoulos COR 2019 000693 Finding into death without inquest 27/07/2022 Deputy State Coroner Jacqui Hawkins