Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Christopher P Webster Coroner, having investigated the death of

James Peter Church

Circumstances Surrounding the Death:

James Peter Church (Mr Church) arrived in Australia at the age of 7 years and was later granted permanent residency.  He married and had two children however that relationship ended.  He then lived with Ms Gayle Clark for 24 years and had a further eight children.  During his working life Mr Church had been employed as a disability carer for a number of years but had recently become ill himself and was in receipt of a disability pension at the time of his death.

On the morning of 15 May 2012 Mr Church was home alone and working on the internal fittings of an extension to their house at Lady Bay Road, Sisters Bay.  At some time during the day he has fallen between 2.8 and 4.0 metres when a board on which he was sitting/standing collapsed. The board was part of  ‘home-made’ scaffolding located over an internal stairway and broke due to the presence of a knot in the fibre of the timber.  Mr Church was discovered by several of his children when they returned from school at about 5.30pm.  At the time he was vomiting, bleeding from the ear and mostly unresponsive to their questions.  With the arrival of an older child at about 7.00pm Ambulance Tasmania were called and Mr Church was evacuated to the Royal Hobart Hospital.  He was admitted to the ICU with a decompressed head injury but failed to respond to treatment and passed away on 6 June 2012, 3 weeks after the fall.

A post mortem examination conducted on the morning of 7 June 2013 determined that Mr Church’s cause of death was a head injury following a fall from height.

I Find That:

a) Mr Church died on 6 June 2012 at Royal Hobart Hospital, Liverpool Street, Hobart. 

b) Mr Church was born at Scunthorpe in the United Kingdom on 9 May 1951 and was aged 61 years at the time of his death

c) Mr Church was in a defacto relationship and was a disability pensioner at the date of death.

d) Mr Church died as a result of a head injury following a fall from height.

e) At the time of Mr Church’s death he was being treated by a medical practitioner.

Comments and Recommendations:

I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity of Mr Church, the time, place, relevant circumstances concerning how his death occurred, and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act 1999.  I do not consider that the holding of a public inquest hearing would elicit any important information further to that disclosed by the investigations conducted by me.

I am satisfied that a thorough and complete investigation into this matter has been conducted and that Mr Church died in circumstances created without the knowledge or intervention of any other person.

Before I conclude this matter, I wish to convey my sincere condolences to the family of Mr Church.

This matter is now concluded.


Dated:  The 12 June  2013 at Hobart in the state of Tasmania.

Christopher P Webster