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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
    HM COR 2015 6233 Finding into death without inquest 29/06/2021 Deputy State Coroner Paresa Spanos
    Maria Assunta Agius COR 2018 005700 Finding into death without inquest 29/06/2021 Coroner Jacqui Hawkins
    Hassan Khalif Shire Ali COR 2018 5663 Finding into death with inquest 28/06/2021 State Coroner Judge John Cain
    COR 2020 000929 Finding into death without inquest 28/06/2021 Coroner John Olle
    Tate Hobbs COR 2019 000686 Finding into death without inquest 25/06/2021 Coroner Darren Bracken

    The Victorian Health Minister was not required to respond and no response has been received to date.

    Julie-Anne Marie Kettle COR 2018 001044 Finding into death with inquest 25/06/2021 Coroner Katherine Lorenz
    PT COR 2018 3723 Finding into death without inquest 24/06/2021 Deputy State Coroner Paresa Spanos
    Mathew Duraid Jameel COR 2018 002777 Finding into death with inquest 17/06/2021 Coroner Jacqui Hawkins
    Christopher John Peter Dewhurst COR 2016 005972 Finding into death with inquest 09/06/2021 Coroner Audrey Jamieson
    John Reed COR 2015 003624 Finding into death without inquest 03/06/2021 State Coroner Judge John Cain