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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
Errol Leslie Solly COR 2021 003110 Finding into death without inquest 06/05/2024 Coroner Audrey Jamieson
Rodney Norman Galvin COR 2021 006135 Finding into death with inquest 03/05/2024 Coroner Audrey Jamieson
KLH KLH COR 2022 005245 Finding into death without inquest 03/05/2024 Coroner David Ryan
Jean Meyer COR 2023 003306 Finding into death with inquest 01/05/2024 Coroner Katherine Lorenz
Adelaide Wilson COR 2022 000978 Finding into death without inquest 01/05/2024 Coroner Simon McGregor

National Pathology Accreditation Advisory Council (NPAAC) was required to respond by 1 August 2024. No response has been received to date.

Colac Area Health was required to respond by 15 July 2024. No response has been received to date.

Robert Norman Spencer COR 2022 000929 Finding into death without inquest 30/04/2024 Coroner Simon McGregor
Claudette Marie Daw COR 2023 000834 Finding into death without inquest 29/04/2024 Coroner Simon McGregor
Allison Leah Randall COR 2020 002716 Finding into death with inquest 26/04/2024 Coroner Sarah Gebert

The Chief Psychiatrist was required to respond by 2 August 2024. No response has been received to date.

Michael Molony COR 2021 002006 Finding into death with inquest 23/04/2024 Deputy State Coroner Paresa Spanos
Jasmine Sara Thomas COR 2022 001606 Finding into death without inquest 23/04/2024 State Coroner Judge John Cain