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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
Eugene Mahauariki COR 2017 001861 Finding into death with inquest 24/11/2023 Coroner Sarah Gebert
Geelong Youth Suicide Cluster Finding COR 2020 0958, 2020 1106, 2020 2250, 2020 2877 * 2020 3158 Finding into death without inquest 24/11/2023 Coroner Leveasque Peterson
Ahedah Hamed COR 2021 000269 Finding into death without inquest 23/11/2023 Coroner Audrey Jamieson
Unknown Remains COR 2018 000183 Finding into death with inquest 22/11/2023 Coroner Kate Despot
K S COR 2021 000292 Finding into death without inquest 21/11/2023 Coroner Audrey Jamieson
Caitlin Mary O'Brien COR 2019 003251 Finding into death without inquest 20/11/2023 State Coroner Judge John Cain
Jon Gorr COR 2021 005158 Finding into death without inquest 20/11/2023 Coroner David Ryan
K K COR 2021 004419 Finding into death without inquest 14/11/2023 Deputy State Coroner Paresa Spanos
Ryan Govind Chisholm COR 2020 006085 Finding into death without inquest 13/11/2023 Coroner Audrey Jamieson
Abdurahman Faid COR 2018 006558 Finding into death with inquest 10/11/2023 Coroner Leveasque Peterson