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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
    Robert Gerard Dimattina COR 2019 4427 Finding into death without inquest 29/01/2021 Deputy State Coroner Caitlin English

    The Royal Australian College of Surgeons were required to respond by May 2021. No response has been received to date.

    Steven Christopher Stewart COR 2019 0442 Finding into death without inquest 29/01/2021 Coroner John Olle
    David Musicka COR 2018 1952 Finding into death without inquest 29/01/2021 Deputy State Coroner Caitlin English
    Diane Maria Hillgrove COR 2018 3264 Finding into death without inquest 28/01/2021 Coroner Darren Bracken
    MrsL 2018 5623 Finding into death without inquest 28/01/2021 Coroner Sarah Gebert
    Seth James Haddow COR 2019 0504 Finding into death without inquest 28/01/2021 Coroner Darren Bracken
    MrR COR 2019 1727 Finding into death without inquest 28/01/2021 Coroner Sarah Gebert
    Mr LY COR 2017 1055 Finding into death with inquest 22/01/2021 Coroner Phillip Byrne
    Mitchell James Dowling COR 2018 3490 Finding into death without inquest 20/01/2021 Coroner Darren Bracken
    Julie Ann Lindsay COR 2016 2346 Finding into death without inquest 19/01/2021 Deputy State Coroner Paresa Spanos