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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
    Matthew Robert Frandsen COR 2011 2198 Finding into death with inquest 12/06/2013 Coroner John Olle
    Findings Adang Akot COR 2012 4496 Finding into death with inquest 12/06/2013 Coroner John Olle
    Naomi Eva-May Hall COR 2009 5565 Finding into death with inquest 12/06/2013 Coroner John Olle
    Bendigo Maiden Gully Bushfires COR 2009 1497 Finding into fire without inquest 07/06/2013 State Coroner Judge Ian L Gray
    John Christopher Hender COR 2006 0950 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass
    Hayden Marcel Curtis COR 2003 1838 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass
    Leigh Ronald Bellingham COR 2008 2734 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass
    Stephen William Summers COR 2006 0650 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass
    Samuel Hender COR 2006 0953 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass
    Lenin McLarty COR 2007 4671 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass