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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
Matt Byrne COR 2021 001636 Finding into death with inquest 29/08/2024 Coroner Ingrid Giles
Mount Disappointment Helicopter Accident COR 2022 001771 Finding into death without inquest 29/08/2024 Coroner David Ryan
A S COR 2021 002415 Finding into death with inquest 29/08/2024 Coroner Ingrid Giles
Bridget Flack COR 2020 006727 Finding into death with inquest 29/08/2024 Coroner Ingrid Giles
Siya Yogin Patel COR 2020 005070 Finding into death without inquest 28/08/2024 Coroner Katherine Lorenz

The Hon. Mark Butler, Minister for Health and Aged Care was invited to respond by 28 November 2024. Under the Coroners Act 2008 (Vic) (the Act), the Minister is not required to respond. No response has been received to date.

Heather Maree Smith COR 2022 007425 Finding into death without inquest 28/08/2024 Coroner Catherine Fitzgerald
Georgios Stamkos COR 2023 000259 Finding into death with inquest 23/08/2024 Deputy State Coroner Paresa Spanos
Hayley Michelle Impey COR 2023 002798 Finding into death without inquest 21/08/2024 Coroner David Ryan
Con Kostantinou COR 2024 001822 Finding into death without inquest 20/08/2024 Coroner David Ryan
Yong Li COR 2023 002255 Finding into death without inquest 16/08/2024 Coroner Simon McGregor