Coronial findings (decisions) 2015 - 2017

Earlier findings

Specific findings can be located by entering information in the search box below. Please enter a keyword, name or year of the coronial finding you are looking for.

Please note that the below table contains less than 10% of coronial findings. Publication of findings on the internet is at the discretion of the coroner and in consultation with the wishes of family members.

If you are unable to locate the findings you are looking for, please contact the Coroners’ Office

Please consider that it may be upsetting to read details about a death in an inquest finding.

Title & TASCD number Coroner Date Keyword
Smith, Molly Jessie (PDF File, 761.7 KB)
2017 TASCD 444
Olivia McTaggart 17-11-2017 death in care, Roy Fagan Centre, mental illness and health, GP Assist, misdiagnosis, pneumonia, pyelonephritis.
Allie, Sue Denise (PDF File, 382.0 KB)
2017 TASCD 415
Olivia McTaggart 12-10-2017 Undetermined cause, Munchausen Syndrome, factitious disorder, superwarfarin (brodifacoum) toxicity
Hedrick, Gary John (PDF File, 264.3 KB)
2017 TASCD 388
Olivia McTaggart 25-09-2017 Water related, drowning, alcohol, intoxication
Willox, Brian William (PDF File, 162.0 KB)
2017 TASCD 408
Duncan Fairley 25-09-2017 fracture neck, fall standing height,
Freestone-Barks, Rosalind MacDonald Maxwell (PDF File, 449.7 KB)
2017 TASCD 387
Duncan Fairley 25-09-2017 Motor bike accident, coronial, multiple injuries
Pel, Tracie Ann and Pel, Michael Geraddus (PDF File, 371.1 KB)
2017 TASCD 393 & 394
Rod Chandler 18-09-2017 motorcycle, passenger, neck injuries, chest injuries, abdominal injuries, round bale
Falvey, Theresa Mary (PDF File, 378.0 KB)
2017 TASCD 373
Duncan Fairley 11-09-2017 Neck Injury, Single motor vehicle collison
Tabor, Pamela Lois and Belinda Ann (PDF File, 163.0 KB)
2017 TASCD 403
Duncan Fairley 11-09-2017 motor vehicle, car crash, head injuries, chest injuries, multiple fatality
Holmes, David Scott (PDF File, 228.4 KB)
2017 TASCD 379
Olivia McTaggart 08-09-2017 Transport & Traffic Related, Work Related, motor vehicle crash, truck crash, truck rollover, prime mover truck, cardiac arrhythmia, heart attack, physical health.
Quad bike related deaths of Heather Dawn Richardson, Jan Severin Jensen, Kendall Russell Bonney, Vicki Mavis Percy, Jay Randall Forsyth, Jabob Graham Green and Roger Maxwell Larner (PDF File, 658.9 KB)
2017 TASCD 329 330 331 332 333 334 and 335
Simon Cooper 25-08-2017 quad bikes, ATV, Leisure Activity, Transport & Traffic Related, quad bike safety, quad bike crash, quad bike accident, quad bike rollover, crushing, brain injury, WorkSafe Tasmania, quad bike fatality, quad bike deaths.
AH (PDF File, 465.3 KB)
2017 TASCD 405
Rod Chandler 22-08-2017 Mental illness & health, intentional self harm, suicide, depression, Royal Hobart Hospital, Crisis Assessment and Treatment Team
Dransfield, Brian (PDF File, 241.2 KB)
2017 TASCD 323
18-08-2017 Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Hyland, Tobias Joseph (PDF File, 241.0 KB)
2017 TASCD 325
Simon Cooper 11-08-2017 Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Young, Dylan Broderick Ernest (PDF File, 247.2 KB)
2017 TASCD 328
Simon Cooper 11-08-2017 Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Spanney, Kenneth David (PDF File, 242.0 KB)
2017 TASCD 327
Simon Cooper 11-08-2017 Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Howard, Lawrence Alan (PDF File, 242.6 KB)
2017 TASCD 324
Simon Cooper 11-08-2017 Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Mitchell, Kenneth Hudson (PDF File, 243.4 KB)
2017 TASCD 326
Simon Cooper 11-08-2017 Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Barker, Richard Carl (PDF File, 255.0 KB)
2017 TASCD 302
Andrew McKee 28-07-2017 Work Related, work place death, industrial accident, work place accident, crushing, crush by metal plate, BIS Industries, ATH Engineering and Maintenance, work site accident, work place safety, safety harness, safety rails.
Langford, Samuel Peter and Jones, Timothy Peter (PDF File, 306.3 KB)
2017 TASCD 316 and 317
Simon Cooper 21-07-2017 plane crash, Cape Raoul, Par Avion, Airline of Tasmania, Storm Bay, aircraft crash, Sydney to Hobart, photographing from plane, plane crash into sea, flying too low, fly at low height, low level flying, Civil Aviation Regulations, pilot error, Transport and Traffic Related.
Monson, Troy Colin; Michael, Robin and Mitchell, Scott Clifford (PDF File, 922.8 KB)
2017 TASCD 253, 254 and 255
Simon Cooper 30-06-2017 Deaths in Custody, death in custody, hanging, prison, Risdon Prison, prison van, seatbelt, Tasmania Police, Prison Health Care, prison systems, suicide, jail, gaol, Law Enforcement, prison cell, prisoner escort van, mental health.
Tate, Magella Luisa Faye (PDF File, 160.6 KB)
2017 TASCD 250
Duncan Fairley 26-06-2017 Transport & Traffic Related, motor vehicle crash, motor vehicle accident, provisional licence, P1 licence, fail to negotiate bend, lost control of vehicle, gravel, over corrected, crash into tree, loss of traction in gravel, inexperienced driver, car crash.
Johnstone, BJay (PDF File, 938.6 KB)
2017 TASCD 248
Olivia McTaggart 23-06-2017 infant, ill-treat child, child death, infant death, child protection, Child & Infant Death, Homicide & Assault, family violence, assault child,
Crosswell, Wendy (PDF File, 162.7 KB)
TASCD 247
Simon Cooper 20-06-2017 Adverse Medical Effects, Hospital, PEG tube, percutaneous endoscopic gastrostomy tube; RHH, Royal Hobart Hospital, pyelonephritis, nasogastric feeding tube, misdiagnosis, unacceptable standard of care, inadequate care, recommendations regarding PEG tubes, recommendation to hospitals.
Nancarrow, Maurice Cecil (PDF File, 242.3 KB)
2017 TASCD 241
Rod Chandler 19-06-2017 RHH, Hospital, Royal Hobart Hobart, misdiagnosis, complication of medical care, aspiration pneumonia, ileus, aspiration of gastric contents, failure to diagnose, renal failure, large bladder, bladder neck obstruction,
Baldock, Andrea Eileen (PDF File, 256.4 KB)
2017 TASCD 313
Rod Chandler 16-06-2017 sleeve gastrectomy, weight reduction surgery, gastroparesis, aspiration pneumonia, adverse medical effects, Launceston General Hospital, coroner's recommendations
Paino, Sarah (PDF File, 169.8 KB)
2017 TASCD 321
Simon Cooper 12-06-2017 Sarah Paino, Transport & Traffic Related, motor vehicle crash, Davey Street motor vehicle crash, fatal crash, stolen car, youth driver, unborn baby saved, car crash, manslaughter,
Bugg, Margaret Evalina (PDF File, 334.6 KB)
2017 TASCD 225
Rod Chandler 12-06-2017 North West Regional Hospital, Yaraandoo Nursing Home, fall, stand up lifter, coroners recommendations
Flockhart, Alexander Michael & Pauly, Damian Kenneth (PDF File, 320.1 KB)
2017 TASCD 204 & 205
Olivia McTaggart 31-05-2017 Coronial, violent, homicide, gunshot wounds, stab wound, firearms,
Harrison, John Joseph & Viney, Danny Leonard.pdf (PDF File, 111.9 KB)
2017 TASCD 208; 2017 TASCD 209
Duncan Fairley 27-05-2017 Water related, drowning, recreational boating, Waterhouse Point, PFD, not wearing a life-jacket, Marine & Safety Tasmania, boat insufficiently equipped
Smith, James Maurice (PDF File, 320.5 KB)
2017 TASCD 202
Rod Chandler 19-05-2017 Hospital, haemopericardium, pericardial tamponade, aortic dissection, incorrect diagnosis, misdiagnosis, poor medical practice, inadequate diagnosis, inadequate hospital care, ischaemia, surgical delay, cardiac arrest,
Woulleman-Jarvis, Anne Maree 2017 TASCD 188.pdf (PDF File, 349.4 KB)
2017 TASCD 188
Rod Chandler 17-05-2017 hospital, head injury, CT scan, fall, standing height, subacute subdural haematoma, closed head injury,
Fellows, Peter Leslie (PDF File, 235.2 KB)
2017 TASCD 185
Rod Chandler 15-05-2017 congestive cardiac failure, coronary artery disease, cardiac failure, dilated poorly contracting heart, acute myocardial infarct, atherosclerotic coronary vascular disease, cardiogenic shock, LGH, Launceston General Hospital, beta blockers, adverse medical effects,
McCall, Pamela (PDF File, 318.8 KB)
2017 TASCD 173
Simon Cooper 08-05-2017 prescription medication, overdose, prescribing, panadeine forte, mixed drug and alcohol toxicity, paracentamol, propranolol, mental health issue.
Handasyde, Robert Neil (PDF File, 232.2 KB)
2017 TASCD 187
Rod Chandler 08-05-2017 medical care, older person, North West Regional Hospital, sepsis, septic shock, urinary tract infection, pyelonephritis
Harris, Stephen Russell (PDF File, 271.6 KB)
2017 TASCD 172
Duncan Fairley 04-05-2017 Death in care, cardiac arrhythmia, North West Regional Hospital, Spencer Clinic, Mental Health order, Paliperidone
Higgins, Elizabeth Ann (PDF File, 728.7 KB)
2017 TASCD 160
Glenn Hay 04-05-2017 Drowning, water related, Little Howrah Beach
Jin, Kang (PDF File, 242.3 KB)
2017 TASCD 150
Olivia McTaggart 28-04-2017 Hypothermia, exposure, Overland Track, Cradle Mountain, Parks and Wildlife Service, tourist, unprepared bushwalker, search and rescue, coronial recommendations
Wright, Mark Norman (PDF File, 272.7 KB)
2017 TASCD 145
Olivia McTaggart 28-04-2017 Transport & Traffic related, motor vehicle crash, Drugs & Alcohol
Plowright, Ben Wara 2017 TASCD 159 (PDF File, 171.4 KB)
2017 TASCD 159
Duncan Fairley 24-04-2017 Drowning, water, river, threat to breathing,
Roberts-Burton, Blaze Christian (PDF File, 180.5 KB)
2017 TASCD 130
Olivia McTaggart 20-04-2017 alcohol, drugs, intoxication, run over by truck, body on highway, diazepam, temazepam, alprazolam, methylamphetamine,
Fisher, Melissa (PDF File, 160.2 KB)
2017 TASCD 129
Simon Cooper 20-04-2017 fall, bush walking, Southwest National Park, fall from height, fall from Federation Peak,
Sheedy, Barbara (PDF File, 166.9 KB)
2017 TASCD 182
Duncan Fairley 19-04-2017 Launceston General Hospital, fall, subdural haemorrhage, uncal herniation
Graham, Dylan Rhys (PDF File, 211.3 KB)
2017 TASCD 123
Olivia McTaggart 10-04-2017 Elizabeth Street Pier, Salamanca, undetermined cause of death
Hoskinson, Neville Robert (PDF File, 325.8 KB)
2017 TASCD 107
Rod Chandler 31-03-2017 cardiac tamponade, proximal aortic dissection, hypertension, Launceston General Hospital, angiogram, radiology, transthoracic echocardiogram, delayed diagnosis, adverse medical effects
Mr JC 105 TASAD 2017.pdf (PDF File, 172.4 KB)
2017 TASCD 105
Olivia McTaggart 27-03-2017 Thermal burns, single motorbike accident,
Whittle, Marion Olive 2017 TASCD 114 (PDF File, 167.0 KB)
2017 TASCD 114
Olivia McTaggart 27-03-2017 motor vehicle crash, cardiogenic shock, tricuspid regurgitation, Royal Hobart Hospital, corolla Sedan, traumatic papillary muscle laceration, blunt force, transport, vehicle occupant
Bird, Heather Mary (PDF File, 243.3 KB)
2017 TASCD 126
Rod Chandler 20-03-2017 Physical health, Royal Hobart Hospital, intensive care unit, ICU, Medical Emergency Team, inadequate care, retroperitoneal haemorrhage, anticoagulation, cerebrovascular infarct, intra-arterial cannulation, pneumonia, sub-acute stroke, haemorrhagic shock
HE (PDF File, 118.2 KB)
2017 TASCD 181
Simon Cooper 16-03-2017 echovirus type 9, myocarditis and pneumonitis, infant death, natural causes, St Mary's Community Hospital
Noble, Murray (PDF File, 168.7 KB)
2017 TASCD 89
Olivia McTaggart 13-03-2017 house fire, combustion, asphyxia, smoke inhalation, inhalation of products of combustion,
Greer, Rita (PDF File, 422.0 KB)
2017 TASCD 059
Olivia McTaggart 23-02-2017 self-inflicted stabbing, suicide, mental health, schizophrenia, section 58, re-open, re-investigation, Barbara Etter,
Free, Maxwell John (PDF File, 233.3 KB)
2017 TASCD 066
Rod Chandler 22-02-2017 paracetamol, paracetamol overdose, drug overdose, paracetamol toxicity, organ failure, Royal Hobart Hospital.
Scheffer, Yolande (PDF File, 87.7 KB)
2017 TASCD 62
Duncan Fairley 20-02-2017 Water related, drowning, Somerset beach, swimming, surf life saving, NWRH
Slabkowski,_Mary.pdf (PDF File, 82.7 KB)
2017 TASCD 64
Duncan Fairley 20-02-2017 Older person, fall, subarachnoid haemorrhage, closed head injury, in-home care, LGH, Anglicare Tasmania
DF (PDF File, 166.7 KB)
2017 TASCD 069
Simon Cooper 09-02-2017 newborn death, infant death, premature baby, extreme prematurity, acute chorioamnionitis, 23 weeks gestation.
Mordha, Debra Christine (PDF File, 162.8 KB)
2017 TASCD 017
Duncan Fairley 23-01-2017 drug toxicity, overdose, prescription medication, tramadol, amitriptyline, venlafaxine, diazepam.
Hosking, Jason Mathew Henry (PDF File, 364.2 KB)
2017 TASCD 380
Simon Cooper 22-01-2017 Royal Hobart Hospital, RHH, misdiagnosis, decision to discharge, discharge from hospital, Staphylococcus Aureus, sepsis, endocarditis,
Cooper, David Wade Archer (PDF File, 166.1 KB)
2016 TASCD 432
Olivia McTaggart 19-12-2016 Transport & Traffic Related, Motor Vehicle Crash, motorcycle, East Derwent Highway, Geilston Bay, Grass Tree Hill, Pipers Road, Youth, learner, provisional, death by negligent driving, fail to give way, inadequate lookout
Cobham, David Alexander (PDF File, 316.1 KB)
2016 TASCD 429
Rod Chandler 19-12-2016 Royal Hobart Hospital, RHH, rhabdomyolysis, aspiration pneumonia, Vaucluse Gardens, Bupa Care, entrapment, towel rail, nursing home, care facility, elderly, injury in care, death in care, care plan.
Harrison, Jason Keith (PDF File, 313.9 KB)
2016 TASCD 430
Rod Chandler 16-12-2016 NWRH, WCDH, small bowel infarct, sepsis, mesenteric hernia, regional hospital
Johnson, Damian (PDF File, 187.6 KB)
2016 TASCD 417
Olivia McTaggart 06-12-2016 Mercury Passage, Triabunna, Water Related, Leisure Related, Animal, great white shark, diver, scallops, Tasmania Police, Tas Maritime Radio
Deaths from a Public Place (PDF File, 509.2 KB)
2016 TASCD 385 386 387 388 389 390
Olivia McTaggart 28-11-2016 Tasman Bridge, Intentional Self-Harm, Mental Illness & Health, Tasmanian Suicide Prevention Strategy, drowning, jump, fall, surveillance, telephones, signage, barrier .
Mr S.pdf (PDF File, 162.7 KB)
2016 TASCD 377
Simon Cooper 21-11-2016 suicide, hanging, asphyxia, mental health, depression, mental health ward, Royal Hobart Hospital
Hingston, Nicolle Clare (PDF File, 230.2 KB)
2016 TASCD 374
Rod Chandler 17-11-2016 cardiorespiratory arrest, pulmonary hypertension, cor pulmonale, congenital heart disease, ventricular septal defect, North West Regional Hospital, blood transfusion, premature discharge from hospital
Mr D (PDF File, 209.7 KB)
2016 TASCD 372
Olivia McTaggart 11-11-2016 Drugs & Alcohol, methylamphetamine
Hickman, Peter (PDF File, 257.6 KB)
2016 TASCD 371
Olivia McTaggart 10-11-2016 Transport & Traffic Related, Motor Vehicle Crash, Drugs & Alcohol, methylamphetamine, West Tamar Highway, Rosevears, single vehicle, oxycontin, amphetamine, alprazolam, methadone, Traffic Act, section 41A, bail
Richardson, Kenneth Charles (PDF File, 228.8 KB)
2016 TASCD 369
Rod Chandler 10-11-2016 Physical Health, Older Persons, Adverse Medical Effects, Drug Overdose, Royal Hobart Hospital, digoxin toxicity, Digibind, heart disease, renal disease, congestive cardiac failure, mitral regurgitation, atrial fibrillation, blood testing, monitoring
Hanlon, Louise Kamarnia May (PDF File, 175.0 KB)
2016 TASCD 347
Olivia McTaggart 02-11-2016 motor vehicle crash, car crash, motor accident, South Arm Road, provisional licence, P1.
Powell, Arthur John (PDF File, 164.3 KB)
2016 TASCD 370
Simon Coooper 31-10-2016 Adverse Medical Effects, Physical Health, Older Persons, Aged Care, Hobart Private Hospital, Royal Hobart Hospital, sepsis, parotid gland, perforated diverticulum, wound infection, discharge, inadequate care
McConnon, Desmond Keith (PDF File, 159.6 KB)
2016 TASCD 406
Simon Cooper 31-10-2016 Domestic Incident, Older Persons, fall, tree, trimming branches, safety equipment, harness, gardener
Bishop, Sarah Victoria (PDF File, 164.4 KB)
2016 TASCD 346
Simon Cooper 17-10-2016 Transport & Traffic Related, Motor Vehicle Crash, Channel Highway, Cygnet, dextromethorphan, robitussin, warnings, over the counter
Weily, Richard Maurice (PDF File, 322.5 KB)
2016 TASCD 323
Rod Chandler 07-10-2016 Older Persons, Physical Health, Aged Care, Death in Care, Mental Illness & Health, Huon Eldercare, Roy Fagan Centre, Fall, pneumonia, hip fracture, heart disease, dementia, Parkinson's disease, inadequate care, falls assessment, haloperidol, quetiapine, amiodarone
Hewitt, Robert Ian (PDF File, 166.2 KB)
2016 TASCD 345
Olivia McTaggart 07-10-2016 Transport & Traffic Related, Older Persons, Motor Vehicle Crash, Channel Highway, Oyster Cove, driver error
Mr B (PDF File, 180.5 KB)
2016 TASCD 320
Simon Cooper 03-10-2016 Drowning, Drugs & Alcohol, Mental Illness & Health, Intentional Self-Harm, Suicide, bath, quetiapine, diazepam, St Helen’s Private Hospital
Bone, Christine Sylvia (PDF File, 270.7 KB)
2016 TASCD 294
Duncan Fairley 12-09-2016 motor vehicle collision, coronial, abdominal injuries, chest injuries
Broomhall, Tyler John (PDF File, 240.7 KB)
2016 TASCD 313
Olivia McTaggart 12-09-2016 Drugs & Alcohol, Leisure Activity, Physical Health, football, sport, methylamphetamine, intra-cerebral haemorrhage, delay in diagnosis, North West Regional Hospital
White, Paul Marcus (PDF File, 230.0 KB)
2016 TASCD 312
Olivia McTaggart 12-09-2016 Drugs & Alcohol, Leisure Activity, football, methylamphetamine intoxication, heart disease, intravenous drug use
Westcott, Barbara (PDF File, 611.4 KB)
2016 TASCD 286
Olivia McTaggart 01-09-2016 Aged Care, Older Persons, inadequate care, Vaucluse Gardens, entrapment, first aid training, bed pole, KA524, records, Department of Health and Ageing, checks
Pasinski, Alexander (PDF File, 273.0 KB)
2016 TASCD 285
Rod Chandler 16-08-2016 Mental Illness & Health, Death in Care, Launceston General Hospital, asphyxia, choking, Amitriptyline, Paliperidone, Chlorpromazine, Magill forceps, soft diet, schizophrenia
Teressa Beswick (PDF File, 340.1 KB)
2016 TASCD 261
Rod Chandler 08-08-2016 Adverse Medical Effects, Mersey Community Hospital, terminal cervical cancer, pneumonia, pain management, morphine overdose
Reardon, Jean May (PDF File, 299.1 KB)
2016 TASCD 253
Olivia McTaggart 01-08-2016 Older persons, Physical Health, Royal Hobart Hospital, sepsis, pressure ulcer, bedridden
Margaret Nicol Foran (PDF File, 214.0 KB)
2016 TASCD 248
Olivia McTaggart 01-08-2016 Older Persons, Homicide & Assault, Mental Illness & Health, strangulation, smothering, asphyxia, schizophrenia, psychotic, mother
Kupsch, Jessica Ann (PDF File, 256.3 KB)
2016 TASCD 217
Simon Cooper 25-07-2016 Homicide & Assault, domestic violence, Penny Royal Hotel, family violence order, Launceston Police, drug treatment order, plea bargain
ADT (PDF File, 226.7 KB)
2016 TASCD 299
Duncan Fairley 22-07-2016 Child & Infant Death, Homicide & Assault, shaken baby, feeding, ill-treatment of a child
Henriksen, Wendy Margaret (PDF File, 503.3 KB)
2016 TASCD 219
Rod Chandler 18-07-2016 Coronial, hospital, sepsis, chemotherapy, Emergency Department,
Bedford, Sidney (PDF File, 226.3 KB)
2016 TASCD 209
Rod Chandler 14-07-2016 Falls, Older Persons, Launceston General Hospital, Physical Health, subdural haemorrhage, CT scan, misdiagnosis
Blackaby, Kobie (PDF File, 210.2 KB)
2016 TASCD 210
Olivia McTaggart 12-07-2016 Child & Infant Death, Water Related, Drowning, inflatable pool, fence, supervision
Slater, Timothy Guy (PDF File, 261.5 KB)
2015 TASCD 349
Simon Cooper 09-07-2016 Undetermined, missing person, Fern Tree, Mental Illness & Health, Drugs & Alcohol, bushwalker
James, Damien Aron Web (PDF File, 167.8 KB)
2016 TASCD 212
Olivia McTaggart 30-06-2016 Motor Vehicle Crash, Transport & Traffic Related, single vehicle, driver, Powranna, Midland Highway, fatigue, fell asleep, driver licence testing
Ball, Jeremy Dacre (PDF File, 189.5 KB)
2016 TASCD 196
Simon Cooper 30-06-2016 motor vehicle crash, suicide, semi-trailer, mental health, deliberate crash, prime mover, drive into prime mover, suicide by motor vehicle crash.
McDougall, Kirsten Web (PDF File, 168.4 KB)
2016 TASCD 211
Olivia McTaggart 29-06-2016 Transport & Traffic Related, Motor Vehicle Crash, passenger, single vehicle, traumatic brain injury, aspiration pneumonia, Midland Highway, fatigue, fell asleep
Brook, Jason Mark (PDF File, 184.9 KB)
2016 TASCD 194
Olivia McTaggart 27-06-2016 Physical Health, Transport & Traffic Related, Motor Vehicle Crash, Mersey Community Hospital, North West Regional Hospital, motorcycle, surgery, deep vein thrombosis, pulmonary embolism, anticoagulation, immobilisation, inadequate care
Grey, Andrew Amos (PDF File, 192.2 KB)
2016 TASCD 224
Simon Cooper 27-06-2016 Drowning, Leisure Related, Water Related, Weather Related, Burns Bay, St Helens, lobster, Stormy Seas PFD, service
Mr P (PDF File, 91.3 KB)
2016 TASCD 254
Simon Cooper 27-06-2016 Adverse Medical Effects, Physical Health, Royal Hobart Hospital, small bowel obstruction, adhesions, misdiagnosis, inadequate care
Moylan, Mark David (PDF File, 222.0 KB)
2016 TASCD 195
Simon Cooper 24-06-2016 Water Related, Leisure Activity, Marine Fatality, Drowning, Drugs & Alcohol, Mental Illness & Health, prescription, Tamar River, Gravelly Beach marina, dinghy, diazepam, missing person, PFD
Gordon, Mark Alexander (PDF File, 235.7 KB)
2016 TASCD 282
Rod Chandler 20-06-2016 Physical Health, Royal Hobart Hospital, misdiagnosis, inadequate care, cardiac arrest, heart disease, pericardial tamponade, aortic dissection, hypertension, diabetes, obesity, hepatic steatosis, thyroiditis, CT scan
Jackson, Christopher George (PDF File, 203.4 KB)
2016 TASCD 183
Simon Cooper 31-05-2016 Youth, Water Related, Drugs & Alcohol, Drowning, boating, long term missing person, Derwent River, Kangaroo Bay
Barnes, Deearne Joan (PDF File, 354.2 KB)
2016 TASCD 179
Stephen Carey 25-05-2016 Physical Health, Mental Illness & Health, Drugs and Alcohol, Overdose, mixed drug toxicity, prescription medication, venlafaxine, methadone, amitriptyline, quetiapine, diazepam, chronic opioid therapy
Mr F (PDF File, 154.0 KB)
2016 TASCD 149
Simon Cooper 13-05-2016 scooter accident, skate park, laceration of heart,
Butterworth, Lucille (PDF File, 503.2 KB)
2016 TASCD 096
Simon Cooper 02-05-2016 Homicide & Assault, long term missing person, bus stop, Claremont, Box Hill Road, Geoffrey Hunt
McDermott, Janice Faye (PDF File, 165.3 KB)
2016 TASCD 124
Olivia McTaggart 26-04-2016 Transport & Traffic Related, train, level crossing, pedestrian, Box Hill Road, Claremont
Hoskinson, Christopher & Hoskinson, Elaine (PDF File, 186.1 KB)
2016 TASCD 142, 143
Stephen Carey 25-04-2016 Transport & Traffic Related, Motor Vehicle Crash, Midlands Highway, Ross, mobile phone, log truck
Stacey, Leanne Maree (PDF File, 162.5 KB)
2016 TASCD 044
Stephen Carey 25-04-2016 Drugs & Alcohol, Physical Health, Misadventure, heart disease, mixed drug toxicity, morphine, benzodiazepine, dothiepin, intravenous drug use
Newett, Margaret Wynne (PDF File, 313.5 KB)
2016 TASCD 150
Rod Chandler 21-04-2016 Ischaemic heart disease, calcific aortic valve sclerosis, hospital death, unsatisfactory treatment.
Harper, Marlene Jean (PDF File, 230.3 KB)
2016 TASCD 100
Rod Chandler 20-04-2016 Older Persons, Physical Health, deep vein thrombosis, chronic lymphocytic leukaemia, atherosclerotic vascular disease, duplex ultrasound, anticoagulant, misdiagnosis
Dawson, Aidan Andrew (PDF File, 395.5 KB)
2016 TASCD 091
Olivia McTaggart 06-04-2016 Homicide & Assault, Drugs & Alcohol, domestic violence, stabbing, self-defence, Police Family Violence Order, Safe at Home
Thorpe, Gloria Theresa (PDF File, 205.9 KB)
2016 TASCD 099
Olivia McTaggart 25-03-2016 Motor Vehicle Accident, Bass Highway, Rocky Cape, Multiple blunt traumatic injuries
Beuckelaers, Elfride Elisabeth (PDF File, 174.9 KB)
2016 TASCD 090
Olivia McTaggart 25-03-2016 Motor Vehicle Crash, Older Persons, driver, fail to give way, Bass Highway, Christmas Hills Road, Elizabeth Town
Zimmerman, Manfred (PDF File, 172.9 KB)
2016 TASCD 091
Olivia McTaggart 25-03-2016 Transport & Traffic Related, Motor Vehicle Crash, driver, sole occupant, Royal Hobart Hospital, palliative, terminal lung cancer, emphysema
Nettlefold, Carmel (PDF File, 164.3 KB)
2016 TASCD 084
Simon Cooper 24-03-2016 Older Person, Homicide & Assault, head injury, stranger, manslaughter, New Town Road
Bradshaw, Luke (PDF File, 274.2 KB)
2016 TASCD 083
Olivia McTaggart 21-03-2016 Water Related, Drugs & Alcohol, Drowning, Marine Fatality, Derwent River, Prince of Wales Bay, jetty
Kulla, Daniel and Macleod, Malcolm (PDF File, 237.6 KB)
2016 TASCD 077, 078
Simon Cooper 18-03-2016 Mental Illness & Health, Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Death in Care, abscond, citalopram, olanzapine, cannabis, unregistered, unroadworthy, unlicensed, speed, helmet
Williams, Leigh John (PDF File, 160.9 KB)
2016 TASCD 065
Olivia McTaggart 03-03-2016 Transport & Traffic Related, Motor Vehicle Crash, single vehicle, driver, sole occupant, alcohol, speed, mobile phone
Macdonald, Shauna Maree (PDF File, 161.6 KB)
2017 TASCD 063
Duncan Fairley 20-02-2016 drug toxicity, pentobarbital, drug use, drug overdose.
Mr D (PDF File, 372.3 KB)
2016 TASCD 009
Stephen Carey 29-01-2016 Mental Illness & Health, stress, fall, anti-depressant, noncompliant, self-reporting, Launceston General Hospital, Crisis Team
Goss Brittany Kate (PDF File, 187.0 KB)
2016 TASCD 011
Stephen Carey 29-01-2016 Youth, Transport & Traffic Related, Motor Vehicle Crash, Weather Related, bus stop, pedestrian, rural, Collins Lane, West Tamar Highway, Sidmouth
Ordonez, Genaro Lotero (PDF File, 178.1 KB)
2016 TASCD 041
Stephen Carey 29-01-2016 Water Related, Leisure Activity, Drowning, Swimcart Beach, Binalong Bay, tourist, swim, rip, head injury, signs
Smart, Joshua David (PDF File, 197.7 KB)
2016 TASCD 038
01-01-2016 exsaunguination/ hypovolaemic arrest, bleed from severed artery
Delaney, Maxwell (PDF File, 208.9 KB)
2016 TASCD 071
Stephen Carey 28-01-2016 Aged Care, Eliza Purton Care Home, North West Regional Hospital, Falls, outdoor area, plastic chair, monitoring, fracture, pneumonia
Atkinson, James Robert (PDF File, 272.4 KB)
2016 TASCD 090
Stephen Carey 28-01-2016 Older Person, Falls, head injury, walking frame
Marshall, Donald Joseph (PDF File, 180.8 KB)
2016 TASCD 047
Simon Cooper 21-01-2016 Water Related, Older Persons, Intentional Self-Harm, Geographic, Badger Island, Bass Strait, EPIRB, coordination, search
Mansell John Ernest (PDF File, 400.4 KB)
2016 TASCD 001
Simon Cooper 20-01-2016 Leisure Activity, Motor Vehicle Crash, Targa, Porters Bridge Road, Deloraine, competitive sport, driver, racing, rally, CAMS, inexperience, Tarmac Rally Standing Regulations, breathalyse, HANS device, pace note, chicane, beginners briefing
Mr K (PDF File, 173.1 KB)
2016 TASCD 006
Simon Cooper 04-01-2016 Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Youth, learner, inexperience, pillion passenger
Summerfeldt; Ian Patrick.pdf (PDF File, 243.7 KB)
2017 TASCD 002
Rod Chandler 03-01-2016 hospital, renal failure, perforated gastric ulcer, sepsis, stomach pain,
Youth Suicide (PDF File, 819.6 KB)
2015 TASCD 298,299,300,301,302,303
01-01-2016
Field, Jayden Craig (PDF File, 555.6 KB)
2015 TASCD 373
Olivia McTaggart 23-12-2015 Misadventure, Drugs & Alcohol, Youth, taxi, fare evasion, head injury, CCTV, taxi camera, police investigation
McManus, Pamela (PDF File, 208.1 KB)
2015 TASCD 427
Rod Chandler 27-11-2015 Older Persons, Physical Health, Royal Hobart Hospital, John Street Medical Centre, Adverse Medical Effects, colon cancer, bowel, large volume aspiration, right hemicolectomy, misdiagnosis, anaemia, inadequate care
Tetley, Andrew Jason (PDF File, 166.2 KB)
2015 TASCD 371
Simon Cooper 24-11-2015 Water Related, Drowning, Marine Fatality, missing person, disappearance, fisherman, fishing, Falmouth, PFD, lifejacket, dinghy, fall, boarding, dark
Henri, Paul Lucien (PDF File, 237.7 KB)
2015 TASCD 367
Rod Chandler 12-11-2015 Older Persons, Aged Care, Physical Health, Royal Hobart Hospital, Huon Eldercare Nursing Home, pain, anxiety, drug management, morphine, MS Contin, starting dose, opiate naïve, cross tolerance, monitoring, observation, heart disease, aspiration pneumonia, Parkinson’s disease, sleep apnoea, cerebral infarction, hypoxic brain damage, Tramadol, quetiapine, CPAP, sedation, blood samples
Holmes, Michael John (PDF File, 211.8 KB)
2015 TASCD 333
Simon Cooper 11-11-2015 Undetermined, Drugs & Alcohol, Mental Illness & Health, missing person, suicide attempts, unemployment, isolation
CK (PDF File, 176.9 KB)
2015 TASCD 420
Simon Cooper 02-11-2015 Child & Infant Death, Transport & Traffic Related, Motor Vehicle Crash, bystander, four-wheel drive, Trial Harbour
Mr S (PDF File, 261.4 KB)
2015 TASCD 242
Simon Cooper 30-10-2015 Intentional Self-Harm, Suicide, Transport & Traffic Related, Motor Vehicle Crash, driver, single occupant, tree, Powranna
Mr B (PDF File, 171.1 KB)
2015 TASCD 327
Simon Cooper 26-10-2015 Work Related, crush, mechanic, trolley jack, jack stands
Hay, Katrina Maree (PDF File, 182.4 KB)
2015 TASCD 319
Stephen Carey 09-10-2015 Misadventure, Drugs & Alcohol, intravenous drug use, crushed tablet, heart failure, pregnant, fetal death, pulmonary hypertension, cardiac arrest, microcrystalline cellulose, granulomas, granulomatous inflammatory reaction
Mundy, Kaylene Louise (PDF File, 182.9 KB)
2015 TASCD 306
Stephen Carey 08-10-2015 Drugs & Alcohol, Misadventure, Alprazolam, Xanax, crushed tablets, intravenous drug use, heart failure, Tasmanian Alcohol & Drug Service
Kokholm, Dan (PDF File, 183.1 KB)
2015 TASCD 324
Simon Cooper 02-10-2015 Leisure Activity, Geographic, Mount Ossa, Cradle Mountain, Lake St Clair, national park, bushwalking, mountaineering, climbing, missing person, disappearance, soldier, army, Vietnam, logbook, hut
G Ms (PDF File, 165.4 KB)
2015 TASCD 423
Stephen Carey 02-10-2015 Intentional Self-Harm, Drugs & Alcohol, Mental Illness & Health, Suicide, bereavement, financial pressure, unemployment, outpatient support, addiction
Mattathyahu, Judah (PDF File, 415.7 KB)
2015 TASCD 286
Simon Cooper 02-10-2015 Homicide & Assault, missing person, affair,
Muller Shar Marie (PDF File, 168.0 KB)
2015 TASCD 304
Olivia McTaggart 01-10-2015 Intentional Self-Harm, Suicide, missing person, Tasman Bridge, Mental Illness & Health
J (PDF File, 173.6 KB)
2015 TASCD 259
Simon Cooper 01-10-2015 Child & Infant Death, drowning, solar dome pool cover, fencing
Adamson, Darryl (PDF File, 166.9 KB)
2015 TASCD 289
Stephen Carey 01-10-2015 Transport & Traffic Related, tractor, slasher, seizures, heart disease, orchard, cut-off switch, traumatic amputation
Mr R (PDF File, 356.3 KB)
2015 TASCD 422
Stephen Carey 30-09-2015 Drugs & Alcohol, doxepin, mianserin, fluoxetine, combined drug intoxication, self-medication, depression, hypertensive heart disease
Mrs W (PDF File, 163.2 KB)
2015 TASCD 318/15
Simon Cooper 25-09-2015 Weather Related, Domestic Incident, falling tree, wind
Pearn Natalia (PDF File, 254.9 KB)
2015 TASCD 264
Olivia McTaggart 11-09-2015 Motor Vehicle Crash, Transport & Traffic Related, negligent driving, safety barrier, Midland Highway, Tim Ellis
Weir, Mary (PDF File, 165.3 KB)
2015 TASCD 368
Simon Cooper 07-09-2015 Adverse Medical Effects, Falls, Older Persons, Calvary Hospital, head injury, bathroom, walking frame, subdural haematoma, high risk falls prevention plan, chronic heart failure, cellulitis, swollen legs, unwitnessed fall, seizures, CT scan, aspirin, clopidogrel, Clexane, anticoagulant, presumed stroke, error, unsound medical practice, misdiagnosis
Leemhuis, Leah Maree (PDF File, 177.5 KB)
2015 TASCD 243
Stephen Carey 01-08-2015 Motor Vehicle Crash, Transport & Traffic Related, Drugs & Alcohol, prescription medication, Diazepam, Sertralin, cannabis, fatigue, fell asleep, Bass Highway, Carrick, Astra sedan, seatbelt defect, airbag defect
Mr J (PDF File, 181.0 KB)
2015 TASCD 323
Stephen Carey 29-07-2015 Intentional Self-Harm, Older Persons, Physical Health, Mental Illness & Health, Suicide, independence, disability pension, heart disease, refusal of treatment, self-diagnosis, bowel cancer, nursing home, firearms licence, unregistered firearm
Hovington, Byron Russell (PDF File, 167.9 KB)
2015 TASCD 322
Stephen Carey 29-07-2015 Drugs & Alcohol, Misadventure, Drug Overdose, Royal Hobart Hospital, methylamphetamine toxicity, hypoxic encephalopathy, cardiac arrest, intravenous drug use, jaw pain
Drew, Malcolm (PDF File, 165.3 KB)
2015 TASCD 369
Stephen Carey 29-07-2015 Transport & Traffic Related, Motor Vehicle Crash, Driver, single vehicle, tree, tourist, Lyell Highway, head injuries, fatigue, fell asleep, tired, wet
Rivelli, Andrea (PDF File, 214.1 KB)
2015 TASCD 372
Stephen Carey 29-07-2015 Intentional Self-Harm, Mental Illness & Health, Suicide, tourist, traveller, meditation
Wilton, Meagan & Eyles, Benjamin (PDF File, 187.4 KB)
2015 TASCD 436, 437
Stephen Carey 29-07-2015 Homicide & Assault, Intentional Self-Harm, domestic violence, breakup, access to child, firearm seizure, unsafe storage of weapons, police intervention
Dortkamp, John Andrew (PDF File, 220.7 KB)
2015 TASCD 237
Simon Cooper 17-07-2015 Death in Care, Millbrook Rise Centre, schizophrenia, emphysema, hypertrophy of the heart, treatment order, Physical Health, Mental Illness & Health
Pedersen, Jonas Havskov (PDF File, 235.0 KB)
2015 TASCD 239
Olivia McTaggart 03-07-2015 Misadventure, Drugs & Alcohol, poppy tea, morphine intoxication, poppy fields, opium poppies
Mr C (PDF File, 163.8 KB)
2015 TASCD 187
Simon Cooper 01-07-2015 Domestic Incident, crushed, trolley jack, vehicle, ramp, chocking
Smith, Kimberley Dale (PDF File, 172.6 KB)
2015 TASCD 217
Simon Cooper 01-07-2015 Water Related, Drowning, Marine Fatality, dinghy, missing person, hypothermia, Chasm Creek, Heybridge, Blythe River
Stephenson, Jason Scott (PDF File, 292.0 KB)
2015 TASCD 225
Stephen Carey 30-06-2015 Leisure Activity, Water Related, Physical Health, Drowning, Marine Fatality, scuba diving, diving equipment, age, fitness, obesity, breathlessness, Eddystone Point, cardiac
Mr B (PDF File, 235.2 KB)
2015 TASCD 186
Stephen Carey 19-06-2015 Water Related, Drowning, Marine Fatality, Older Persons, Derwent River, fishing, defective PFD, cardiac event, cold water immersion
Clarke, Joshua (PDF File, 179.0 KB)
2015 TASCD 106
Olivia McTaggart 16-06-2015 Motor Vehicle Crash, Transport & Traffic Related, Drugs & Alcohol, York Plains Road, Lemont, seat belt, unroadworthy
Sansom, Ann Margaret (PDF File, 224.0 KB)
2015 TASCD 224
Rod Chandler 16-06-2015 Adverse Medical Effects, Physical Health, Royal Hobart Hospital, subarachnoid haemorrhage, perforation, aneurysm, endovascular coiling, complication, diabetes, cirrhosis
Mr A (PDF File, 33.3 KB)
2015 TASCD 173
Simon Cooper 05-06-2015 Misadventure, Drugs & Alcohol, Ritalin, methylphenidate, microcrystalline cellulose, intravenous injection, crushing pills, psychostimulant, foreign body granulomas of the lung, heart failure
Pearce, Jasmine Rose (PDF File, 264.6 KB)
2015 TASCD 75
Olivia McTaggart 27-05-2015 Child & Infant Death, Drugs & Alcohol, safe sleeping, bed sharing, suffocation, CPS, family violence, cumulative harm, Gateway Services, police
Jones, Thomas Elvet
2015 TASCD 058
Simon Cooper 30-04-2015 Transport & Traffic Related, Water Related, Fall, Location, Motor Vehicle Crash, Tasman Bridge collapse
O'Day, Dennis James
2015 TASCD 109
Simon Cooper 30-04-2015 Suicide, Intentional Self-Harm, Youth, Tasman Bridge, missing person, relationship breakdown
McCallum, William
2015 TASCD 085
01-01-2016 death, drowning, dover, hypothermia, kayak, immersion
Aherne, Benjamin Mark & Clements, John William (PDF File, 108.4 KB)
2015 TASCD 032, 033
Michael Brett 22-04-2015 Homicide & Assault, Intentional Self-Harm, Suicide, firearm, family violence, sexual dysfunction
Rogers, Maureen Ann (PDF File, 241.7 KB)
2015 TASCD 190
Rod Chandler 22-04-2015 Older Persons, Physical Health, Launceston General Hospital, misdiagnosis, gastritis, aortic dissection, cardiac tamponade, CT scan
Leary, Leslie John (PDF File, 183.1 KB)
2015 TASCD 083
Stephen Carey 15-04-2015 Drowning, Water Related, Weather Related, rock lobster, dinghy, PFD, certificate of competency
Mr T
2015 TASCD 090
Simon Cooper 06-04-2015 Domestic Incident, Domestic Accident, mechanic, car, motor vehicle, trolley jack, support stands, jack stands, car stands
Ms D (PDF File, 179.0 KB)
2015 TASCD 211
Stephen Carey 06-04-2015 Drugs & Alcohol, mixed drug toxicity, amitriptyline, chlorpheniramine, diazepam, codeine, biventricular hypertrophy, antihistamines, opiates
McCauley, Terence Bernard (PDF File, 173.0 KB)
2015 TASCD 321
Olivia McTaggart 03-04-2015 Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, negligent driving causing death, overtaking, following distance, lookout, head-on collision, Arthur Highway, Copping
Lane, Andrew Brian
2015 TASCD 034
Stephen Carey 25-03-2015 Water Related, Weather Related, Leisure Activity, Geographic, Drowning, safety, fishing, dinghy, boat size, forecast, EPRIB, PFD, cold water immersion, Tooms Lake, Oatlands
Mr D
2015 TASCD 069
01-01-2016 suicide, exhaust fumes, Tasmania death
Sterling, William John (PDF File, 227.3 KB)
2015 TASCD 182
Stephen Carey 20-03-2015 Physical Health, Natural Cause Death, lung disease, intravenous drug use, hypertension, cardiovascular disease, hepatitis
Balmer, Rosemary Joy (PDF File, 166.2 KB)
2015 TASCD 181
Stephen Carey 20-03-2015 Drugs & Alcohol, Misadventure, mixed prescription drug toxicity, oxycodone, amitriptyline, diazepam, diphenhydramine, paracetamol, chronic pain
Davis, Ross James (PDF File, 209.7 KB)
2015 TASCD 178
Stephen Carey 20-03-2015 Drugs & Alcohol, Misadventure, intravenous drug use, injecting opiates, crushed pills, opiate analgesia, chronic pain, pulmonary disease, respiratory disease, morphine
Norris Freda Kate (PDF File, 167.0 KB)
2015 TASCD 223
Stephen Carey 18-03-2015 Undetermined, Missing Person,
Thompson, Geoffrey Ross Sydney (PDF File, 168.5 KB)
2015 TASCD 180
Stephen Carey 18-03-2015 Drugs & Alcohol, prescription, promethazine, citalopram, ethanol, mixed drug toxicity
Bronson, Connan Taiaroa (PDF File, 170.2 KB)
2015 TASCD 179
Stephen Carey 18-03-2015 Intentional Self-harm, Mental Illness & Health, Drugs & Alcohol, Suicide, cliff, itinerate
Clarke, Donald John (MS Word Document, 235.0 KB)
2015 TASCD 003
Rod Chandler 10-03-2015 Physical Health, Adverse Medical Effects, Calvary St Luke's Hospital, Launceston General Hospital, cervical spine surgery, aspiration pneumonia, radiology, obesity, oxycodone, midazolam, tracheomalacia, endone
Mr J (PDF File, 221.3 KB)
2015 TASCD 077
Olivia McTaggart 06-03-2015 Adverse Medical Effects, prostatectomy, deep vein thrombosis, multiple pulmonary thromboemboli, prostate carcinoma, prostate cancer, TED stockings, sequential compression device, Calvary Hospital, blood clots, VTE, DVT, clexane, anticoagulation
Swift, John McGregor
2015 TASCD 035
Olivia McTaggart 02-03-2015 Transport & Traffic Related, Older Persons, Physical Health, Motor Vehicle Crash, driver, sole occupant, heart disease, cardiac event
Lucas, Troy Dale (PDF File, 193.2 KB)
2015 TASCD 120
Olivia McTaggart 20-02-2015 Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Brooke Street, East Devonport, negligent driving causing death, sun, inattention, head-on collision
Payton, Robert John (PDF File, 179.5 KB)
2015 TASCD 76
Olivia McTaggart 09-02-2015 Transport & Traffic Related, Motor Vehicle Crash, Bass Highway, Wiltshire, motor scooter, head-on, negligent driving, overtaking, proper lookout
Mr G
2015 TASCD 031
Simon Cooper 06-02-2015 Mental Illness & Health, Death in Care, Royal Hobart Hospital, treatment order, schizophrenia, chest pain, cardiovascular disease, cardiac arrest
Rock, Scott
2015 TASCD 002
Simon Cooper 03-02-2015 Homicide & Assault, Drugs & Alcohol, head injuries
Mr S (PDF File, 169.6 KB)
2015 TASCD 216
Stephen Carey 27-01-2015 Mental Illness & Health, Work Related, Drug Overdose, tramadol, opiate pain relief, chronic pain, Mt Lyall Mine, colleagues, anti-depressant, workplace deaths
Carr, Dennis Robert
2015 TASCD 001
Simon Cooper 23-01-2015 Law Enforcement, Physical Health, Natural Cause Death, Death in Custody, Risdon Prison, Royal Hobart Hospital, Palliative Care Plan, cirrhosis of the liver, hepato-renal syndrome