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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 Sort ascending Case type Date Coroner Related orders and rulings Responses to recommendations
    Keanne Liza Whittam COR 2022 000539 Finding into death without inquest 27/03/2023 Deputy State Coroner Paresa Spanos
    Martin William Sheahan COR 2022 000532 Finding into death with inquest 26/04/2023 Coroner Sarah Gebert

    The Minister for Police was invited to respond by 26 July 2023. Under the Coroners Act 2008 (Vic) (the Act), the Minister is not required to respond. No response has been received to date.

    Matthew Richard Thomas Biggin COR 2022 000459 Finding into death without inquest 28/03/2023 Deputy State Coroner Paresa Spanos
    Amanda Jane Stapledon COR 2022 000357 Finding into death without inquest 06/07/2023 Coroner David Ryan
    Y OA COR 2022 000026 Finding into death without inquest 29/09/2022 Coroner Simon McGregor
    Mary Veronica Morrow COR 2021 3682 Finding into death without inquest 10/10/2023 Coroner Leveasque Peterson
    Michael John Hanratty COR 2021 1241 Finding into death without inquest 12/07/2022 Coroner Audrey Jamieson
    Darren Ricky Culleton COR 2021 0740 Finding into death with inquest 18/09/2023 Coroner David Ryan
    David Andrew Coulter COR 2021 0452 Finding into death without inquest 12/07/2022 Coroner Audrey Jamieson
    Terry John Chandler COR 2021 0372 Finding into death without inquest 12/07/2022 Coroner Audrey Jamieson