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 |
---|---|---|---|---|---|---|
DQ | COR 2018 4614 | Finding into death without inquest | 29/05/2019 | Coroner Rosemary Carlin | ||
Thi Ha Do | COR 2016 3862 | Finding into death without inquest | 17/05/2019 | Coroner Simon McGregor | ||
Mabel Grace Ellen Pritchard | COR 2018 0680 | Finding into death without inquest | 17/05/2019 | Coroner Audrey Jamieson | ||
Desmond John Watson | COR 2017 2478 | Finding into death without inquest | 15/05/2019 | Coroner Jacqui Hawkins | Kneeboard Surfing Victoria were required to respond by 26 August 2019. No response has been received to date. |
|
Simon Smith | COR 2016 2572 | Finding into death without inquest | 10/05/2019 | Coroner Rosemary Carlin | ||
Darren Templeton | COR 2017 3850 | Finding into death without inquest | 09/05/2019 | Coroner John Olle | ||
William Willms | COR 2017 5202 | Finding into death with inquest | 29/04/2019 | Coroner Audrey Jamieson | ||
Dennis John Wright | COR 2018 0488 | Finding into death without inquest | 24/04/2019 | Coroner Audrey Jamieson | ||
Nick Falos (formerly known as Nikolaos Falieros) | COR 2018 5977 | Finding into death with inquest | 15/04/2019 | Coroner Phillip Byrne | ||
Hannah Rachel Charles | COR 2010 1382 | Finding into death with inquest | 08/04/2019 | Deputy State Coroner Iain West |