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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
    Hugh Neville Monroe COR 2010 0117 Finding into death without inquest 06/08/2015 Coroner Audrey Jamieson
    WJ COR 2012 1503 Finding into death without inquest 06/08/2015 Coroner Rosemary Carlin
    Terence Bernard and Christine Elizabeth Hodson COR 2004 1710 Finding into death with inquest 31/07/2015 State Coroner Judge Ian L Gray
    Martin Robert Beaty COR 2014 3640 Finding into death without inquest 31/07/2015 Coroner Audrey Jamieson
    Bradley Charles Finegan COR 2013 2666 Finding into death without inquest 30/07/2015 Coroner Caitlin English
    Casey and Cardinia Suicide Cluster COR 2012 0760 Finding into death with inquest 30/07/2015 Coroner Audrey Jamieson
    Jeffrey John McCarty COR 2012 0567 Finding into death with inquest 29/07/2015 Coroner Caitlin English
    Beatrix Dammers COR 2007 2281 Finding into death with inquest 29/07/2015 Deputy State Coroner Iain West
    Michael John Jonson COR 2007 1339 Finding into death with inquest 27/07/2015 Coroner Audrey Jamieson
    James Stewart Dougan COR 2010 4459 Finding into death without inquest 24/07/2015 Coroner John Olle