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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
    Rodney Charles Collins COR 2018 2196 Finding into death without inquest 07/01/2019 Coroner Phillip Byrne
    Vicki Evelyn Webster COR 2017 0893 Finding into death without inquest 20/12/2018 Coroner Darren Bracken
    LF M COR 2015 4992 Finding into death without inquest 18/12/2018 Deputy State Coroner Paresa Spanos
    COR 2015 4992 Finding into death without inquest 18/12/2018 Deputy State Coroner Paresa Spanos

    The Secretary, Department of Economic Development, Jobs, Transport and Resources was required to respond by 17 April 2019. No response has been received to date

    VicRoads were required to respond by 17 April 2019. No response has been received to date

    Anthony Sean Jenkins COR 2017 4333 Finding into death without inquest 14/12/2018 Coroner Darren Bracken
    Yucel Arslan COR 2016 0855 Finding into death with inquest 14/12/2018 Coroner Audrey Jamieson
    Doris Clare Spratling COR 2016 3726 Finding into death without inquest 10/12/2018 Coroner Caitlin English
    Jean Elizabeth Tants COR 2018 2068 Finding into death without inquest 07/12/2018 Coroner Michelle Hodgson
    Wayne Brown COR 2016 2614 Finding into death without inquest 07/12/2018 Deputy State Coroner Iain West
    Bede Levi Davies COR 2017 6605 Finding into death without inquest 07/12/2018 Coroner Phillip Byrne