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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
Mr AS . COR 2020 002945 Finding into death without inquest 27/11/2022 State Coroner Judge John Cain
B JF COR 2021 003127 Finding into death without inquest 25/11/2022 Coroner Simon McGregor
Carl Robert Adler COR 2018 002604 Finding into death with inquest 24/11/2022 Coroner Audrey Jamieson
Durdica Serbec COR 2016 000634 Finding into death with inquest 24/11/2022 Coroner Sarah Gebert
Glenda Elaine Shapcott COR 2022 002650 Finding into death with inquest 23/11/2022 Deputy State Coroner Paresa Spanos
John Stuart Knox COR 2021 005272 Finding into death without inquest 23/11/2022 Deputy State Coroner Jacqui Hawkins
G K COR 2019 004438 Finding into death without inquest 22/11/2022 Deputy State Coroner Paresa Spanos
Vlado Tomislav Micetic COR 2013 003776 Finding into death with inquest 22/11/2022 Coroner Audrey Jamieson
Douglas Earnest Stott COR 2021 000130 Finding into death without inquest 21/11/2022 Deputy State Coroner Paresa Spanos
Mr P COR 2019 003365 Finding into death without inquest 18/11/2022 Coroner Darren Bracken