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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
Kylie Jane Cay COR 2016 002831 Finding into death with inquest 06/09/2021 Deputy State Coroner Caitlin English
Robena May Lloyd COR 2009 003835 Finding into death with inquest 03/09/2021 Deputy State Coroner Caitlin English
Phillip John Sealey COR 2019 003297 Finding into death without inquest 01/09/2021 Coroner Leveasque Peterson
David John Main COR 2019 005601 Finding into death without inquest 31/08/2021 Coroner Sarah Gebert
'Child A' COR 2005 003607 Finding into death with inquest 31/08/2021 Coroner Phillip Byrne
Garry Mark Wise COR 2019 004128 Finding into death without inquest 26/08/2021 Coroner Katherine Lorenz
Mrs A COR 2017 2423 Finding into death without inquest 26/08/2021 State Coroner Judge John Cain

No response has been received to date from Family Safety Victoria.

David Perry COR 2019 000210 Finding into death with inquest 25/08/2021 Coroner Katherine Lorenz
Marilyn . COR 2019 005885 Finding into death with inquest 20/08/2021 Coroner Paresa Spanos
Valerie Lucy Jones COR 2020 003232 Finding into death without inquest 17/08/2021 Coroner Darren Bracken