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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
A T COR 2024 007361 Finding into death without inquest 10/06/2026 Coroner Simon McGregor

The Minister for Police, Minister for Children, and the Deputy Secretary for Family Safety Victoria were invited to respond by 10 September 2026. Under the Coroners Act 2008 (Vic) (the Act), they are not required to respond. No response has been received to date.

Tracy Louise Walford COR 2025 008247 Finding into death without inquest 10/06/2026 Coroner Kate Despot
Amanda Joy Taylor COR 2025 006987 Finding into death without inquest 09/06/2026 Coroner Kate Despot
Patricia Anne Rickards COR 2026 001635 Finding into death without inquest 04/06/2026 Coroner David Ryan
Rowan David Tydell COR 2025 007902 Finding into death without inquest 03/06/2026 Coroner Kate Despot
John William Swiety COR 2024 005220 Finding into death without inquest 01/06/2026 Coroner David Ryan
A Q COR 2024 007465 Finding into death without inquest 01/06/2026 Deputy State Coroner Paresa Spanos
Baby R COR 2022 004878 Finding into death with inquest 29/05/2026 Coroner Dimitra Dubrow

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) was required to respond by 29 August 2026. No response has been received to date.

Phi Long Dang COR 2024 004480 Finding into death with inquest 28/05/2026 Coroner David Ryan
Stratos Ioannidis COR 2025 001682 Finding into death with inquest 27/05/2026 Coroner David Ryan