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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Jason Shaun Kumar COR 2009 5767 Finding into death with inquest 14/07/2014 Coroner John Olle
    Mettaloka Malinda Halwala COR 2015 5857 Finding into death with inquest 10/05/2018 Coroner Rosemary Carlin
    Shida Li COR 2009 5959 Finding into death with inquest 20/04/2011 Coroner Heather Spooner
    Clarence Tuivaiese Nicholas Leo COR 2016 5542 Finding into death with inquest 09/11/2018 Deputy State Coroner Paresa Spanos
    Robert Humphreys COR 2015 4552 Finding into death with inquest 19/11/2018 Coroner Peter White
    Danielle Louise Meredith COR 2007 2127 Finding into death with inquest 21/10/2013 Coroner Dr Jane Hendtlass
    Ward Harker COR 2015 6083 Finding into death with inquest 31/01/2020 Coroner Darren Bracken

    Alfred Health was required to respond by 12 May 2020. The effects of COVID-19 have caused a delay, however a response is expected after August 2020.

    David Bardho COR 2016 0721 Finding into death with inquest 28/05/2020 State Coroner Judge John Cain
    Anthony Lansell Churches COR 2017 5543 Finding into death with inquest 21/10/2020 State Coroner Judge John Cain
    2017 Bourke Street Incident COR 2017 0325 Finding into death with inquest 19/11/2020 Coroner Jacqui Hawkins