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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
    John Rose COR 2022 005643 Finding into death without inquest 30/11/2023 Coroner Paul Lawrie
    Catherine Mary Reid COR 2020 007017 Finding into death with inquest 30/11/2023 Coroner Sarah Gebert
    Greg John Howarth COR 2022 007325 Finding into death without inquest 30/11/2023 Coroner Sarah Gebert
    Rebecca Jayne May COR 2022 006572 Finding into death without inquest 29/11/2023 State Coroner Judge John Cain
    Vikki Michelle Prenc COR 2021 005024 Finding into death without inquest 28/11/2023 Deputy State Coroner Paresa Spanos
    John Doe COR 2018 004573 Finding into death with inquest 27/11/2023 Coroner Leveasque Peterson
    Timothy Rhys Cheshire COR 2019 001375 Finding into death without inquest 26/11/2023 Coroner Simon McGregor
    Melissa Louise Arbuckle COR 2023 000171 Finding into death without inquest 26/11/2023 State Coroner Judge John Cain
    Daryl Scott Perkins COR 2019 001376 Finding into death without inquest 26/11/2023 Coroner Simon McGregor
    Geelong Youth Suicide Cluster Finding COR 2020 0958, 2020 1106, 2020 2250, 2020 2877 * 2020 3158 Finding into death without inquest 24/11/2023 Coroner Leveasque Peterson