Coronial findings (decisions) 2019 -

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) 2019 -
Title & TASCD number Coroner Date Keyword
Clark, Guy Redman (PDF File, 513.8 KB)
2020 TASCD 22
Simon Cooper 21-01-2020 Electrocution, work related, Residual Current Devices, portable defibrillator, Coroner's finding, Coroner's recommendation, Coroner's comment
White, Janelle Lee (PDF File, 105.4 KB)
2019 TASCD 556
Andrew McKee 18-12-2019 Ladder fall, traumatic closed head injuries, working at height, training, home building site, recommendations, Workplace Health and Safety Act 2012
Woodward, Ernest Henry (PDF File, 111.9 KB)
2019 TASCD 550
Simon Cooper 13-12-2019 Missing person, water related, recreational fishing, suspected death, disappearance
Arundel-Clarke, Catherine Clara (PDF File, 99.6 KB)
2019 TASCD 551
Olivia McTaggart 13-12-2019 Transport & traffic related, single vehicle crash, learner's licence, unlicenced, unroadworthy, wet conditions, speed, child survived, crash investigation, Coroner's comments
Woolley, Zedric Basil (PDF File, 118.2 KB)
2019 TASCD 534
Simon Cooper 09-12-2019 undetermined cause of death, missing person, Glen Huon
McInerney, Robert Edward (PDF File, 617.6 KB)
2019 TASCD 531
Olivia McTaggart 06-12-2019 Coroner's finding, coroner's recommendations, gunshot wound, law enforcement, mental illness & health, weapon, police provoked shooting, Tasmania Police
Paton, Benjamin Luke (PDF File, 89.0 KB)
2019 TASCD 515
Olivia McTaggart 28-11-2019 Transport & traffic related, alcohol, drink driving, excessive speed, speeding, mobile phone usage, texting, single vehicle crash, unroadworthy, asphyxia, Turners Marsh, failure to wear seat belt, coroner's comments
Martin, Jack Hedley (PDF File, 374.5 KB)
2019 TASCD 502
Simon Cooper 21-11-2019 adverse medical effects, hospital death, Mersey Community Hospital, sepsis, failure to remove intravenous cannula
Rice, Luke Jesse (PDF File, 420.9 KB)
2019 TASCD 491
Simon Cooper 18-11-2019 Coroner's finding, water related, transport & traffic related, blunt force trauma with brain injury, leisure activity, misadventure, PWC, unlicensed and inexperienced PWC operators, Lake Trevallyn Dam, Tasmanian Jet Sport Boating Club
Mason, Alison Henderson (PDF File, 369.9 KB)
2019 TASCD 485
Simon Cooper 15-11-2019 Coroner's finding, long-term missing person, older person, undetermined cause of death, body not located, North-West Tasmania
Nunn, Peter John (PDF File, 360.1 KB)
2019 TASCD 479
Olivia McTaggart 12-11-2019 transport and traffic related, single motor vehicle crash, excessive speed, driving over speed limit, Lilydale
Maxwell, Benjamin Murray (PDF File, 86.9 KB)
2019 TASCD 497
Simon Cooper 11-11-2019 Homicide, murder, assault, stabbing, Devonport
Holmes, Julie Anne (PDF File, 403.5 KB)
2019 TASCD 464
Simon Cooper 29-10-2019 Transport & traffic related, motor vehicle accident, pneumonia, older person, undiagnosed cervical spine fracture, guidelines, Royal Hobart Hospital
Stewart, Keith Thomas (PDF File, 367.0 KB)
2019 TASCD 460
Simon Cooper 28-10-2019 transport and traffic related, mobility scooter crash, single vehicle crash, no helmet, loss of control
McKenzie, Heather Patricia Dale (PDF File, 383.5 KB)
2019 TASCD 430
Simon Cooper 17-10-2019 alcohol and drugs, mixed alcohol and drug toxicity, unintentional, Amlodipine, drug interaction, Burnie, Silver Whisper cruise ship
Davies, Eva Fay (PDF File, 365.9 KB)
2019 TASCD 428
Simon Cooper 17-10-2019 Falls, older persons, closed head injury, left frontal/temporal subdural haematoma, anticoagulation, reverse anticoagulation protocol, Coroner's finding, Coroner's recommendation
Powell, Stephen Maxwell (PDF File, 309.1 KB)
2019 TASCD 417
Simon Cooper 16-10-2019 Intentional self-harm, Mental illness & health, older persons, Mental Health Act 2013 (Tas), Mental Health Treatment Order, person held in care, community services
Roberts, Anna Jane and Stanley, Brett John (PDF File, 378.5 KB)
2019 TASCD 439 and 440
Olivia McTaggart 15-10-2019 transport and traffic related, motor vehicle accident, two vehicle crash, multiple traumatic injuries, drugs and alcohol, alcohol intoxication, blood alcohol over legal limit, cannabis, Lauderdale
Fillisch, Eric (PDF File, 424.2 KB)
2019 TASCD 413
Olivia McTaggart 14-10-2019 water related, drowning, scuba diving, rebreather, rebreather apparatus, displacement of mouthpiece, Visscher Island
Benneworth, Anthony John (PDF File, 414.5 KB)
2019 TASCD 419
Olivia McTaggart 11-10-2019 Drowning, water related, Ansons Bay, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety
Long, Anthony Edward (PDF File, 412.9 KB)
2019 TASCD 418
Olivia McTaggart 11-10-2019 Drowning, water related, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety
Frith, Aaron Douglas (PDF File, 363.8 KB)
2019 TASCD 398
Simon Cooper 30-09-2019 Adverse medical effects, physical health, pulmonary embolism, deep vein thrombosis, prophylactic anticoagulant, Achilles tendon rupture, coroner's finding, coroner's comment
Sulman, Murray Matthew (PDF File, 373.0 KB)
2019 TASCD 396
Olivia McTaggart 27-09-2019 motor vehicle crash, transport and traffic related, Mornington, South Arm Highway, excessive speed, negligent driving, Traffic Act 1925
Peck, Edward Paisley (PDF File, 825.8 KB)
2019 TASCD 386
Olivia McTaggart 26-09-2019 intentional self harm, mental illness and health, death in a public place, Tasman Bridge, Royal Hobart Hospital, Mental Health Act 2013 (Tas), decision not to involuntarily detain
Smith, Barry (PDF File, 378.0 KB)
2019 TASCD 381
Olivia McTaggart 20-09-2019 Transport and traffic related, physical health, heart disease, positional asphyxia, workplace, coroner's finding, coroner's comments
O'Brien, Mark Andrew (PDF File, 369.6 KB)
2019 TASCD 380
Olivia McTaggart 17-09-2019 transport and traffic related, motor vehicle accident, motorcycle accident, loss of control, traumatic injuries of head and chest, Kalang Avenue
Swan, Daniel Peter (PDF File, 363.4 KB)
2019 TASCD 373
Simon Cooper 12-09-2019 Transport and traffic related, multiple blunt traumatic injuries, two-vehicle collision, West Tamar Highway, coroner's finding
Clark, Darren Stuart (PDF File, 410.5 KB)
2019 TASCD 374
Simon Cooper 11-09-2019 transport and traffic related, single motor vehicle accident, motorsport, rally car, Scottsdale Classic Rally, Confederation of Australian Motor Sport Ltd, breach of National Rally Code
Smith, Jordan Marcellus (PDF File, 380.9 KB)
2019 TASCD 370
Andrew McKee 11-09-2019 Transport and traffic related, motorcycle and motor vehicle crash, head-on collision, incorrect lane, multiple traumatic injuries, alcohol, coroner's finding
Mwarabu, Alice (PDF File, 414.7 KB)
2019 TASCD 376
Simon Cooper 10-09-2019 Transport and traffic related, motor vehicle crash, Domain Highway, multiple blunt injuries
Picken, Jason Scott (PDF File, 362.0 KB)
2019 TASCD 369
Olivia McTaggart 10-09-2019 manslaughter, assault, subarachnoid haemorrhage, comments on passing sentence, Criminal Code
Bowerman, Graeme Anthony (PDF File, 415.1 KB)
2019 TASCD 368
Olivia McTaggart 10-09-2019 drowning, capsize of boat, Marion Bay, Narrows channel, MAST, marine safety, water related, transport related
Wilson, Jacob Leigh (PDF File, 380.7 KB)
2019 TASCD 399
Olivia McTaggart 09-09-2019 Transport and traffic related, single motorcycle crash, loss of control, chest and abdominal injuries, drugs and alcohol, unroadworthy, coroner's finding
Jenkins, Mark Andrew (PDF File, 376.9 KB)
2019 TASCD 364
Andrew McKee 09-09-2019 Transport and traffic related, motorcycle crash, multiple traumatic injuries, drugs and alcohol, lost control, speed, unregistered and unlicensed, rear brake lock, coroner's finding
Davies, Luke; Drobnjak, Aleksander; Ritter, Magnus; Roche, Anthony (PDF File, 839.6 KB)
2019 TASCD 348
Simon Cooper 30-08-2019 Drowning, Frederick Henry Bay, transport & traffic related, water related, PFD, boat licence, second hand boat inspection, Coroner's finding, Coroner's recommendation, Coroner's comments
Golus, Peter (PDF File, 104.2 KB)
2019 TASCD 331
Simon Cooper 21-08-2019 Adverse medical effects, escherichia coli urosepsis, sepsis, kidney stone surgery, launceston
Stanley, Christopher Stephen (PDF File, 372.6 KB)
2019 TASCD 333
Olivia McTaggart 20-08-2019 transport and traffic related, single motorcycle crash, Smithton, school zone, excessive speed, un-roadworthy vehicle, drug and alcohol, methamphetamine
McLean, Michael William (PDF File, 260.2 KB)
2019 TASCD 338
Olivia McTaggart 19-08-2019 Transport and traffic related, motorcycle and vehicle crash, chest injuries, incorrect side of road, cornering technique, crosswinds, high risk of death, coroner's finding
Saltmarsh, Aidan Denis (PDF File, 384.2 KB)
2019 TASCD 332
Olivia McTaggart 19-08-2019 transport and traffic related, single vehicle crash, motorcycle crash, multiple injuries, loss of control of vehicle, alcohol and drugs, blood alcohol level over legal limit, cannabis (THC), excessive speed
Halson, Gary Peter (PDF File, 367.5 KB)
2019 TASCD 334
Olivia McTaggart 19-08-2019 Transport and traffic related, motorcycle and vehicle crash, blunt traumatic injuries, overtaking, following too closely, poor riding, coroner's finding
Mollross, Daniel (PDF File, 392.1 KB)
2019 TASCD 335
Simon Cooper 19-08-2019 Transport and traffic related, motorcycle and motor vehicle crash, speed and alcohol, diffuse head injury, unroadworthy, coroner's finding, coroner's comment
Jeffrey, Angela Joy (PDF File, 517.6 KB)
2019 TASCD 322
Simon Cooper 13-08-2019 missing person, suspected intentional self harm, undetermined cause of death, body not located, Bakers Beach, northern Tasmania, coroner's comments
Mead, Liam - Ruling on Evidence (PDF File, 147.9 KB)
Ken Stanton 02-08-2019 ruling on evidence, whether evidence within scope of inquest, adolescent mental health, Tasmania, Liam Mead inquest, Coroners Act 1995 (Tas)
Horcicka, Josef Vratislav (PDF File, 488.4 KB)
2019 TASCD 298
Simon Cooper 25-07-2019 adverse medical effects, hospital related death, Calvary St Luke's Hospital Launceston, reportable death, failure to report death, no post mortem performed, undetermined cause of death
Eaton, Jodi Michelle (PDF File, 460.4 KB)
2019 TASCD 257
Olivia McTaggart 03-07-2019 homicide, assault, asphyxia, Bridgewater, Darren Dobson, strangulation/choking, coroner's recommendations, recommendation of enactment of indictable offence of choking, suffocation or strangulation
Hughes, Joan May (PDF File, 1.2 MB)
2019 TASCD 241
Simon Cooper 28-06-2019 Aspiration of gastric contents following vomiting, aged care, mental illness and health, older person, coroner's finding, inquest
Smith, David Alan (PDF File, 403.1 KB)
2019 TASCD 255
Simon Cooper 28-06-2019 Two vehicle collision, transport and traffic related, multiple injuries, coroner's finding
Lukendlay, Charlotte (OM) Findings.pdf (PDF File, 751.2 KB)
2019 TASCD 234
Coroner Olivia McTaggart 26-06-2019 child and infant death, global hypoxic brain injury, cessation of breathing, family violence context, non-accidental injury, rib fractures
DI (PDF File, 419.2 KB)
2019 TASCD 226
Olivia McTaggart 16-06-2019 transport and traffic related, intentional self harm, head injuries, mental health and illness, driver, intentionally driving into path of oncoming vehicle, Latrobe
Hardy, Dion Ronald (PDF File, 403.0 KB)
2019 TASCD 204
Simon Cooper 03-06-2019 Transport & traffic related, motorcycle and car collision, alcohol & drugs, Brooker Highway
BK (PDF File, 405.0 KB)
2019 TASCD 202
Simon Cooper 23-05-2019 Hanging, intentional self-harm, mental illness and health, drugs and alcohol, Coroner's finding
Tolputt, Trevor (PDF File, 825.1 KB)
2019 TASCD 175
Olivia McTaggart 21-05-2019 hypothermia, Overland Track, Lake St Clair, Parks and Wildlife Service, coroner's recommendations, bushwalker, winter inadequately equipped
Nichols, James Raymond (PDF File, 397.8 KB)
2019 TASCD 169
Simon Cooper 17-05-2019 transport and traffic related, single motor vehicle crash, Bass Highway, failure to wear seatbelt, alcohol, drink driving, driving over the limit, blood alcohol level of 0.157, speeding, failure to drive at speed limit, coroner's comments
MA (PDF File, 401.7 KB)
2019 TASCD 153
Simon Cooper 13-05-2019 Coroner's finding, transport & traffic related, motorcycle crash, multiple injuries
Russell, Allan Geoffrey (PDF File, 873.4 KB)
2019 TASCD 152
Simon Cooper 10-05-2019 Drowning, water related, coroner's finding, fishing vessel, dinghy capsize
Evans, Wendy Anne (PDF File, 407.4 KB)
2019 TASCD 147
Simon Cooper 03-05-2019 Coroner's finding, coroner's recommendation, head and chest injuries, Metro, pedestrian struck by bus, transport & traffic related
Porteous, Shayne Edward (PDF File, 490.3 KB)
2019 TASCD 143
Olivia McTaggart 24-04-2019 Mixed drug toxicity, serotonin syndrome, sertraline, tramadol, SSRIs, drugs & alcohol, coroner's finding
Kranz, Lothar Wolfgang (PDF File, 501.6 KB)
2018 TASCD 174
Rod Chandler 24-04-2019 hospital death, abdominal aortic aneurysm (AAA), Royal Hobart Hospital, chimney vascular repair procedure, advanced coronary artery and peripheral vascular disease complicating repair
Davis, Catherine Joy (PDF File, 484.0 KB)
2019 TASCD 138
Rod Chandler 18-04-2019 Urosepsis, pyelonephritis, lissencephaly, Royal Hobart Hospital, UTI, incorrect diagnosis, coroner's finding, coroner's recommendation
Kenney, Margaret Patricia (PDF File, 510.8 KB)
2019 TASCD 142
Rod Chandler 18-04-2019 Coroner's finding, coroner's recommendations, adverse medical effects, PPI, gastrointestinal bleed, death review
Fulham, Julianne (PDF File, 493.8 KB)
2019 TASCD 183
Rod Chandler 18-04-2019 hospital related death, adverse medical affects, Smithton District Hospital, ischaemic small bowel, bowel obstruction, Crohn's disease
Ham, Roderick David Charles (PDF File, 487.1 KB)
2019 TASCD 136
Rod Chandler 16-04-2019 Pulmonary thromboemboli, deep vein thrombosis, hip replacement, physical health, Coroner's finding
Hill, Phillip John (PDF File, 323.5 KB)
2019 TASCD 135
Rod Chandler 16-04-2019 hospital death, Royal Hobart Hospital, Hobart Private Hospital, colonic cancer, hemicolectomy, sepsis, delayed diagnosis
Best, Christopher Mark (PDF File, 497.5 KB)
2019 TASCD 128
Olivia McTaggart 29-03-2019 workplace death, work related, transport related, farming property, motorcycle crash, use of motorcycles on private property, single vehicle crash, unroadworthy and unsafe vehicle, no working brakes, neurocardiogenic syncope whilst driving
Finding Brendan Smith (Web) pdf.pdf (PDF File, 780.6 KB)
2019 TASCD 120
Olivia McTaggart 27-03-2019 vehicle accident, tree, head injury, car crushed by falling tree, transport,
Close, Terrence Findings Web.pdf (PDF File, 943.2 KB)
2019 TASCD 119
Simon Cooper 27-03-2019 Industrial accident, blunt force, blunt trauma, pedestrian, hit by utility vehicle, chest and abdomen
Burns, Brendan Craig (PDF File, 324.4 KB)
2019 TASCD 130
Simon Cooper 26-03-2019 Coronial, Suicide, Asphyxia, Smoke inhalation, Caravan, Fire,
Morris, Jason Simon (PDF File, 122.1 KB)
2019 TASCD 110
Olivia McTaggart 22-03-2019 natural cause death, death in custody, Coroners Act 1995, Risdon Prison, Royal Hobart Hospital, Whittle Ward, metastatic squamous cell carcinoma of the lung
Glover, Gerald Samual (PDF File, 125.7 KB)
2019 TASCD 109
Olivia McTaggart 22-03-2019 natural cause death, death in custody, Coroners Act 1995, Risdon Prison, dilated cardiomyopathy, emphysema, Correctional Primary Health
Steshic, John Norman -web .pdf (PDF File, 495.7 KB)
2019 TASCD 103
Rod Chandler 18-03-2019 coronial, hospital, heart disease, ischaemic heart disease, single vessel atherosclerosis
FW (PDF File, 398.6 KB)
2019 TASCD 105
Olivia McTaggart 15-03-2019 Drowning, intentional self-harm, coroner's finding, coroner's recommendations
Paraskevas, Odissefs (PDF File, 396.0 KB)
2019 TASCD 95
Rod Chandler 08-03-2019 Pulmonary thromboembolism, deep vein thrombosis, D-dimer, Wells score, PERC, Coroner's recommendation
Novaski, John James (PDF File, 394.5 KB)
2019 TASCD 083
Rod Chandler 01-03-2019 Coronial, atherosclerotic, hypertensive, cardiovascular disease, hospital, Launceston General Hospital, obesity, hypertension, complications of health care, missed or incorrect diagnosis
Lore, Margaret (PDF File, 499.9 KB)
2019 TASCD 79
Olivia McTaggart 26-02-2019 Head injury, cliff fall, hazardous area, Blackmans Bay blowhole, safety, public area, Coroner's recommendations
Nowitzki-Eisenburg, Heike (PDF File, 493.2 KB)
2019 TASCD 75
Olivia McTaggart 25-02-2019 transport and traffic related, motor vehicle accident, two vehicle crash, Lilydale Road, adverse weather conditions, poor condition of road, excessive speed for conditions
Mansfield, Doreen (PDF File, 842.3 KB)
2019 TASCD 69
Simon Cooper 22-02-2019 Coronial, Findings, Inquest, death in care, Royal Hobart Hospital, fall from standing position/ height, complication of left femur fracture
Beltz, Sarah Rose -(Web).pdf (PDF File, 469.7 KB)
2019 TASCD 68
Simon cooper 19-02-2019 Coronial, Findings, Meningococcal, immunisation, disease, A, C,Y, W and B Strain, Neisseria meningitides, bacterial sepsis, hospital
Lewtas, Georgia Amy (PDF File, 350.4 KB)
2019 TASCD 52
Olivia McTaggart 12-02-2019 drowning, water related, Mersey Bluff, Devonport, youth, Surf Life Saving, coroner's recommendation, surf rescue, swimming, leisure activity
Kugel, Karen (PDF File, 484.8 KB)
2019 TASCD 53
Olivia McTaggart 11-02-2019 Homicide & assault, murder, stabbing, coroner's finding, restraint order
Cowen, Craig -web.pdf (PDF File, 411.8 KB)
2019 TASCD 037
Olivia McTaggart 04-02-2019 coronial, drowning, wharf, fall, alcohol, intoxication, water
Killer, Debbie Dubravka (PDF File, 411.5 KB)
2019 TASCD 42
Simon Cooper 31-01-2019 undetermined cause of death, undetermined circumstances of death, Tasmania Police, incomplete investigation, Tasmania Police Manual, Forensic Services, forensic evidence, coroner's comments
Skrepetos, Stavroula (PDF File, 478.6 KB)
2019 TASCD 34
Olivia McTaggart 31-01-2019 older persons, abdominal aortic aneurysm (AAA), haemoperitoneum/retroperitoneal haematoma, Royal Hobart Hospital Emergency Department, falls
DS (PDF File, 302.2 KB)
2019 TASCD 17
Olivia McTaggart 21-01-2019 Coroner's findings, drugs, alcohol
Brown, Tony David .pdf (PDF File, 595.0 KB)
2019 TASCD 022
Simon Cooper 21-01-2019 traumatic brain injury, homicide, Mitchell Clay Dowling, Jay David Blazely, one punch death, assault,
Stefaniw, Gerard Ernest (PDF File, 738.2 KB)
2019 TASCD 8
Simon Cooper 18-01-2019 death in care, order under the Guardianship and Administration Act 1995, Guardianship and Administration Board, intentional self harm, mental illness and health, Roy Fagan Centre
Dunster, Kenneth Francis (PDF File, 743.5 KB)
2019 TASCD 5
Simon Cooper 11-01-2019 death in care, Mental Health Act 2013, mental health order, Millbrook Rise Centre, asphyxia, choking on food, supervision of meals
Roberts, Nigel Douglas (PDF File, 734.5 KB)
2019 TASCD 9
Rod Chandler 04-01-2019 death in care, Mental Health Act 2013, mixed prescription drug sedation, clozapine, olanzapine, Spencer Clinic, Burnie, North West Regional Hospital, Karingal Nursing Home, mental illness and health, coroner's recommendations
Elias, Nebras (PDF File, 496.5 KB)
2019 TASCD 1
Rod Chandler 04-01-2019 transport and traffic related, motor vehicle accident, two vehicle crash, Lebrina
Richardson, Margaret Rita.(Web).pdf (PDF File, 406.9 KB)
01-01-2016 coronial, artery dissection, ischaemic heart disease, renal scarring, emphysema