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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
Thomas James Brigham COR 2004 2347 Finding into death with inquest 20/06/2013 Deputy State Coroner Iain West
Paul Allan Skinner COR 2010 4610 Finding into death with inquest 18/06/2013 Coroner John Olle
Trevor Edward Hammond COR 2011 2037 Finding into death without inquest 17/06/2013 Coroner Audrey Jamieson
Matthew Robert Frandsen COR 2011 2198 Finding into death with inquest 12/06/2013 Coroner John Olle
Colin Frederick Toogood COR 2012 4513 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
Findings Adang Akot COR 2012 4496 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
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