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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 Coroner Sort descending Related orders and rulings Responses to recommendations
    Drew Dax COR 2015 0188 Finding into death without inquest 12/12/2016 State Coroner Judge Sara Hinchey
    Charbel Atallah COR 2007 1374 Finding into death with inquest 08/12/2016 State Coroner Judge Sara Hinchey
    Rosario Pezzano COR 2010 1494 Finding into death with inquest 23/02/2017 State Coroner Judge Sara Hinchey
    Stuart Rattle COR 2013 5647 Finding into death without inquest 16/12/2016 State Coroner Judge Sara Hinchey
    Zane Bradbury COR 2014 2384 Finding into death without inquest 28/10/2016 State Coroner Judge Sara Hinchey
    Luis Lopez COR 2015 0710 Finding into death with inquest 13/09/2017 State Coroner Judge Sara Hinchey
    Robert Andrew Brewster COR 2012 0748 Finding into death without inquest 22/06/2017 State Coroner Judge Sara Hinchey
    Mark Jordan-Hill COR 2016 5253 Finding into death without inquest 08/01/2018 State Coroner Judge Sara Hinchey
    Alexander David Jones COR 2013 1338 Finding into death without inquest 04/06/2018 State Coroner Judge Sara Hinchey
    Wye River and Separation Creek, Victoria COR 2016 0308 Finding into fire without inquest 23/05/2018 State Coroner Judge Sara Hinchey