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 | Coroner Sort ascending | Related orders and rulings | Responses to recommendations |
---|---|---|---|---|---|---|
Boe Luke Memery | COR 2019 002530 | Finding into death without inquest | 31/08/2022 | Deputy State Coroner Jacqui Hawkins | Mallee District Aboriginal Services were required to respond by 01 December 2022. No response has been received to date. |
|
Dominic Salvatore Mele | COR 2020 006851 | Finding into death without inquest | 28/07/2022 | Deputy State Coroner Jacqui Hawkins | ||
Jaymii Leslie Mott (Green) | COR 2019 002875 | Finding into death without inquest | 31/08/2022 | Deputy State Coroner Jacqui Hawkins | ||
Robert Albert Burns | COR 2018 003819 | Finding into death without inquest | 07/06/2022 | Deputy State Coroner Jacqui Hawkins | ||
Rosy Loomba | COR 2020 006754 | Finding into death without inquest | 29/07/2022 | Deputy State Coroner Jacqui Hawkins | ||
Paul Turner | COR 2018 003864 | Finding into death without inquest | 07/06/2022 | Deputy State Coroner Jacqui Hawkins | ||
Gillian Burgess | COR 2022 004369 | Finding into death without inquest | 01/06/2023 | Deputy State Coroner Jacqui Hawkins | ||
John Stuart Knox | COR 2021 005272 | Finding into death without inquest | 23/11/2022 | Deputy State Coroner Jacqui Hawkins | ||
Yukako Fukuhara | COR 2022 002657 | Finding into death without inquest | 21/07/2023 | Deputy State Coroner Jacqui Hawkins | ||
Angelo Anthony Gioscio | COR 2022 004453 | Finding into death with inquest | 08/09/2023 | Deputy State Coroner Jacqui Hawkins |