Coronial findings (decisions) 2015 - 2018

Coronial Findings 2019 -

Pre-2015 findings

The Magistrates Court (Coronial Division) publishes a small but important amount of records of investigations and findings.

The decision to make these findings available has been made by the Chief Magistrate, or their delegate, or the coroner presiding over the particular investigation, under Coroners Rules 2006.

Publishing a finding is decided on an individual basis, but the coroner may take into account a number of factors:

  • the work of the courts being available to public scrutiny
  • the death prevention role of the coroner
  • family privacy
  • sensitivity of the findings
  • possible harm from making an investigation publically available

In general, authorised findings for publication will include:

  • all public inquest findings
  • motor vehicle crashes
  • long-term missing persons cases
  • homicides after the criminal process has been completed
  • any other death which has been reasonably widely reported in the news media for clarification of the factual findings
  • any death where health and safety recommendations can result in improvements and death prevention (for example, child protection systems issues, deaths in medical settings with recommendations for improvement)
  • any other matter which the coroner believes is in the public interest

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.

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.

Table: Coronial findings (decisions) 2015 - 2018
Title & TASCD number Coroner Date Keyword Responses to Coronial Recommendations
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
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

Response from StateGrowth  20 February 2020

Since the Coroner made her recommendations, the Department of State Growth has undertaken work to improve the safety of taxi users, including taxi drivers.  The Department recognises that taxis are an important mode of transportation and Tasmanians should be able to be confident that taxi services are reputable, safe, reliable and convenient.

Concurrently there has been significant change to the Tasmanian taxi industry which led to the Department commencing a review of the regulatory framework for the taxi and hire vehicle industries in 2016.  The review recognises that taxi industries across Australia and overseas are undergoing rapid change led by new service models.

The review is to ensure the sector and the community are well positioned to meet the challenges and seize the opportunities arising from new business models and emerging technologies relating to on-demand passenger transport.  A proposed framework for the industries is currently subject to external consultation with the intention that a new package of legislative reform will be considered by Parliament in the first half of this year.

The regulations which support the industries were rolled over in 2018, pending an outcome of the review.  These regulations have a sunset clause of three years (September 2021), with the view that a holistic review of the regulations, including those provisions relating to security cameras in taxis, would be done in line with the new framework.

In respect of the Coroner's recommendation relating to the review of the operation of taxi security systems, there has been significant change which has reduced the risk profile associated with non-compliant taxi-security camera systems.

  1. The introduction of ride-sourcing platforms (in particular, Uber) has significantly changed the landscape of the taxi industry.  The personal safety mechanism to identify and confirm the identity of the driver and passenger using ride-source platforms is by way of technical validations built into the relevant 'app'.  The technical validations negate the need to install security camera systems into ride sourcing vehicles, as has been accepted by Australian regulators.  To remain competitive, the taxi industry is beginning to invest in technology by way of 'apps' to confirm the identity of taxi users and record travel details.
  2. The new security camera system equipment which is now available in the market has far superior functionality than the functionality which existed at the time the Coroner made her recommendations. The functionality means that footage is stored for longer periods and captures wider images, and is increasingly becoming cloud-based.  As this technology emerges and superseded systems are replaced, the need to routinely test security camera systems and taxi camera images to be downloaded is set to diminish.
  3. The compliance activity relating to the taxi regulatory framework undertaken by the Department is now much more effective.  This includes desk-top and on-road enforcement which can detect non-compliances to the taxi security camera systems' regulatory framework with the appropriate administrative or infringement action taken.

Tasmania remains a very small jurisdiction with minimal demand for the installation of taxi security camera systems.  From a practical and cost perspective it is unrealistic for Tasmanian to independently develop its own minimum specifications before a taxi camera system can be used in Tasmania.  The larger jurisdictions are in the preferred position to develop the minimum functionality.  The flow-on effect is that as new taxi camera systems enter Tasmania, the functionality will continue to improve.

With regard to the recommendation to requirement prepayment of fares for late night services, there has been significant discussion with the taxi industry on this subject.  The industry acknowledges that there is existing regulation which allows a driver to require a passenger to prepay the fare at any time of day.  However, industry representatives advise that drivers will not utilise this mechanism.  It is difficult to understand how a similar regulation limited to only certain hours of operation could give drivers confidence to require prepayment.

With the emergence of ride sourcing using apps, a significant portion of on-demand travel is now effectively prepaid as payment is managed electronically through the passenger account at the time of booking.  In responding to this new competitive force in the market, some taxi dispatch networks have opted to create similar apps for booking and payment.  Accordingly, the sector of the market which is likely to operate without electronic payment is the rank market.  However, in these instances, drivers continue to have the capacity to require the passenger to prepay before commencing the journey and regulations permit a driver to refuse a fare at the rank should they have concern for their safety or the safe operation of the taxi.

Updated response from StateGrowth 7 October 2022

Legislative reforms proposed affecting on-demand transport to which I referred to in my previous letter were passed by the parliament in November 2020.  Implementation is currently progressing.  Two tranches of the new legislation have commenced.  A third tranche is expected to commence in coming months.  Given the substantial changes to regulations that are required to align with the new provisions, the review of legislation intended to occur by September 2021 was deferred until September 2023.  That review has recently commenced.

The Transport Commission is currently finalising a review of specifications for taxi security camera systems with the aim of modernisng the requirements and aligning substantially with other Australian jurisdictions.  This is intended to result in new taxi security cameras having built in self-testing capability amount other features.  The key to implementing new specifications will be in establishing suitable transition arrangements including an appropriate period of time in which any older cameras must be replaced.  This will require careful consultation with industry given the current challenges in the operating environment and viability concerns.

Notwithstanding that this work is still underway, I would note that all cameras recently approved by the Transport Commission for the Tasmanian market are models that reflect the higher specifications in use in other jurisdictions.

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, Coroners Recommendations

Updated response provided by THS South 14 October 2022

DHHS and hospitals have reviewed.  High levels of medical suspicion of a drug cause for situation will result in samples being kept.

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
Mattathyahu, Judah (PDF File, 415.7 KB)
2015 TASCD 286
Simon Cooper 02-10-2015 Homicide & Assault, missing person, affair,
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
Ms G de-identified (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
J (PDF File, 173.6 KB)
2015 TASCD 259
Simon Cooper 01-10-2015 Child & Infant Death, drowning, solar dome pool cover, fencing
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
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

Response from Motors (Names redacted) 23 August 2019

  1. TR was our Workshop Forman at Motors Launceston at the time of the incident.
  2. What took place was rather informal at the time. Transport inspectors came in with various modules from the vehicle & asked as a favour if TR could pull diagnostic information from the air bag module
  3. TR wired the modules up on the workbench for them & was able to pull codes, but was unable to provide meaningful information
  4. They then took a statement from TR at their office
  5. No formal process was used & no records were made/kept
  6. TR felt he was simply doing the transport guys a favour.
  7. TR resigned from Motors on 28th February 2019.
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
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
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
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
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
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

Response received from Australian Competition & Consumer Commission (ACCC) 15 August 2019

The Australian Competition and Consumer Commission (ACCC) promotes competition and fair trading in markets to benefit consumers, businesses and the Australian community. Our primary responsibility is to ensure that individuals and businesses comply with the Competition and Consumer Act 2010 (the CCA) which includes the Australian Consumer Law (the ACL).

The focus of the ACCC’s product safety role is on the safe supply and use of consumer products – which are those products used or likely to be used for personal, domestic or household use. The ACCC monitors and investigates complaints about consumer products connected with accidents and injuries, administers voluntary recalls and mandatory injury reports submitted by suppliers and undertakes surveillance and monitoring to ensure compliance of regulated consumer products that are subject to safety standards, information standards and bans.

Trolley jacks, vehicle jacks, vehicle support stands and portable ramps are all subject to mandatory safety standards under the ACL. These standards were reviewed in 2017 to improve requirements for warning labelling and weight bearing performance. The ACCC regularly performs market surveillance and testing of these products to ensure their compliance with mandatory safety standards, administers voluntary recalls to retrieve unsafe or non-compliant products from users, promotes the voluntary recalls via social media and the Product Safety Australia website and communicates with consumers about safe ways to undertake vehicle maintenance.

In June 2019 the ACCC developed a media campaign about the safety risks of DIY vehicle repairs. The campaign included release of two videos to renew and promote safety messaging targeting people attempting DIY tasks on motor vehicles, a media release, social media campaign on Twitter and Facebook, digital advertising via YouTube, and a Product Safety Matters newsletter. Evaluation in July 2019 indicated that media coverage alone had a potential reach of 7.35 million people in the period 20-26 June

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

Response received from Marine and Safety Tasmania (MAST)  16 July 2019

  • MAST TV with Dr David Smart, Boatwise articles, Facebook, work with Uni Dive Club
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

Response provided by Marine and Safety Tasmania (MAST)

  • Servicing inflatables has also been a major part of MAST work over the 15 years. Including Boatsafe Education nights, numerous Boatwise articles, PR campaigns, Facebook, School programs, Inland anglers talks, MAST TV, Newspaper articles,  numerous TV interviews, newspaper articles, Boatsafe Partners; MAST currently instrumental into a review of the Australian Standard in relation to inflatable life jackets including but not limited to servicing inflatables and also addressing loose CO 2 cylinders
  • Cold water immersion extensively covered in various Boatwise articles, inland lake and Boatsafe education nights, MAST TV , website, Boatsafe Partners, IFS, school education programs
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
Mr A De-identified
2015 TASCD 173
Simon Cooper 05-06-2015

Response received from PSB updated and received 21 December 2022

  • The Department has undertaken consultation with health professional stakeholders with the aim to publish updated guidelines for the legal prescribing of Schedule 8 psychostimulants to children and adults in Tasmania. Further consultation and final publication of updated guidelines is planned for 2023.
  • Since 2015, Departmental section 59E delegates have implemented and consistently applied a more rigorous approach to assessing applications to prescribe Schedule 8 psychostimulants for adults and children in Tasmania. This improved process includes:
    • Requests for urine drug screening and examination for stigmata of injecting drug use where indicated.
    • Assessment of Departmental records for both patients and carers to determine any source of risk including history of overdose, injecting drug use, unsanctioned drug use, or drug diversion.
    • Increased communication and collaboration with treating medical practitioners where high risk behaviours are identified, ensuring the medical practitioner is aware of identified risks and has conducted a risk benefit assessment regarding treatment with Schedule 8 psychostimulants and implemented appropriate mitigation and / or monitoring strategies.
  • The Department has continued to engage with Tasmania Police where appropriate. If there are Departmental concerns of unlawful activity such as drug diversion or trafficking by a patient or known associate, Use and Disclosure provisions included in Schedule 1 of the Personal Information Protection Act 2004 are applicable and information can be shared between the Department and Tasmania Police in order to either prevent patient and/or public harm, or for the purposes of an investigation.
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
O'Day, Dennis James
2015 TASCD 109
Simon Cooper 30-04-2015 Suicide, Intentional Self-Harm, Youth, Tasman Bridge, missing person, relationship breakdown
Jones, Thomas Elvet
2015 TASCD 058
Simon Cooper 30-04-2015 Transport & Traffic Related, Water Related, Fall, Location, Motor Vehicle Crash, Tasman Bridge collapse
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

No response provided

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

Response received from Marine and Safety Tasmania (MAST)  16 July 2019

  • Extensive campaigns into the legalities and benefits of wearing a life jacket, MAST TV , website, Boatwise education nights, School education programs, AGFEST displays, IFS open days, website, Boatsafe Partners
  • First jurisdiction in the world to make life jackets compulsory on any vessel 6m and under
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

Response received from Australian Competition & Consumer Commission (ACCC)

The Australian Competition and Consumer Commission (ACCC) promotes competition and fair trading in markets to benefit consumers, businesses and the Australian community. Our primary responsibility is to ensure that individuals and businesses comply with the Competition and Consumer Act 2010 (the CCA) which includes the Australian Consumer Law (the ACL).

The focus of the ACCC’s product safety role is on the safe supply and use of consumer products – which are those products used or likely to be used for personal, domestic or household use. The ACCC monitors and investigates complaints about consumer products connected with accidents and injuries, administers voluntary recalls and mandatory injury reports submitted by suppliers and undertakes surveillance and monitoring to ensure compliance of regulated consumer products that are subject to safety standards, information standards and bans.

Trolley jacksvehicle jacksvehicle support stands and portable ramps are all subject to mandatory safety standards under the ACL. These standards were reviewed in 2017 to improve requirements for warning labelling and weight bearing performance. The ACCC regularly performs market surveillance and testing of these products to ensure their compliance with mandatory safety standards, administers voluntary recalls to retrieve unsafe or non-compliant products from users, promotes the voluntary recalls via social media and the Product Safety Australia website and communicates with consumers about safe ways to undertake vehicle maintenance.

In June 2019 the ACCC developed a media campaign about the safety risks of DIY vehicle repairs. The campaign included release of two videos to renew and promote safety messaging targeting people attempting DIY tasks on motor vehicles, a media release, social media campaign on Twitter and Facebook, digital advertising via YouTube, and a Product Safety Matters newsletter. Evaluation in July 2019 indicated that media coverage alone had a potential reach of 7.35 million people in the period 20-26 June

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

Response from Marine and Safety Tasmania (MAST)  16 July 2019

  • Articles in Boatwise and on Facebook  regarding boat usage. Covered in Buoyancy programs in Boatsafe education nights and MAST TV
  • Part of trip planning component in licence course and articles in Boatwise advising to tell people your destination and return. In safe boating handbook and part of Boatsafe Education nights, school education programs
  • MAST weather service promoted over many years, articles in Boatwise, Website,- and Facebook regarding obtaining weather forecasts from BOM, always covered at Boatwise Education nights and MAST TV, school education programs
  • Accessibility of safety gear covered at Boatsafe Education nights, Facebook and in Boatwise and at ramp checks, MAST TV, school education programs, Boatsafe Partners (working with retailers and marine businesses)
  • Cold water immersion extensively covered in various Boatwise articles, inland lake and Boatsafe education nights, MAST TV , website, Boatsafe Partners, IFS, school education programs
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
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
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
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
Norris Freda Kate (PDF File, 167.0 KB)
2015 TASCD 223
Stephen Carey 18-03-2015 Undetermined, Missing Person,
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

No response received

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
Tetley, Barry Lindsay.pdf (PDF File, 253.8 KB)
2014 TASCD 246
Rod Chandler 19-09-2014 Sepsis, ED, Coroner's Recommendations
Wagg, Christopher.pdf (PDF File, 1.3 MB)
2014 TASCD 199
Olivia McTaggart 23-05-2014 Inquest Findings, Workplace, Factory Plant, Zinc Works, Brain Damage, Mechanical Asphyxia, Cherry Picker, Coroner's Recommendations