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.
Title & TASCD number | Coroner | Date | Keyword |
---|---|---|---|
Street, Audrey (PDF File, 383.1 KB) 2021 TASCD 115 |
Olivia McTaggart | 05-03-2021 | Aged care, falls, older persons, physical health, closed traumatic head injury, Bishop Davies Court, Extended Care Assistant, enrolled nurse, Franklin Unit, nightly checks, delayed care. |
Lattimer, Joseph Aaron (PDF File, 455.5 KB) 2021 TASCD 62 |
Olivia McTaggart | 05-02-2021 | Inquest, intentional self-harm, asphyxia, hypoxic encephalopathy, mental illness & health, Royal Hobart Hospital Emergency Department, recommendations, government, Psychiatric Emergency Nurses (PENs), mental health services reforms |
Townsend, David Lester.pdf (PDF File, 132.8 KB) 2021 TASCD 24 |
Olivia McTaggart | 25-01-2021 | Intentional self-harm, mental illness & health, suicidal ideation, weapon, partial contact range gunshot wound of the head, psychiatrist, Department of Psychiatry, Guardianship and Administration Board, Firearms Act 1996. |
Buhler, Finn Ruben Leo (PDF File, 106.6 KB) 2021 TASCD 20 |
Olivia McTaggart | 22-01-2021 | Transport & traffic related, single motor vehicle collision, car crash, Glenfern, Derwent Valley Council, recommendations |
Kettle, Terrence Michael (AMK) Web.pdf (PDF File, 304.9 KB) 2020 TASCD 712 |
Andrew McKee | 17-12-2020 | Coronial, death in care, guardianship order, held in care, asphyxia, choking, food, Roy Fagan Centre, Inquest, |
Oakley, Joseph Richard.(AMK) Web.pdf (PDF File, 307.3 KB) 2020 TASCD 711 |
Andrew McKee | 17-12-2020 | Coronial, held in care, guardianship order, inquest, person in care, Roy Fagan Centre, atherosclerotic, hypertensive cardiovascular disease. |
Mitsakis, Stavros (PDF File, 114.3 KB) 2020 TASCD 713 |
Olivia McTaggart | 17-12-2020 | Domestic incident, falls, older persons, fall from a ladder, home maintenance, recommendations |
Brewer, Ruby and Shanzel (PDF File, 164.5 KB) 707 & 708 TASCD 2020 |
Simon Cooper | 14-12-2020 | Coronial, House Fire, Smoke Alarm, Smoke inhalation, asphyxia, heating, flames, smoke, heating, electrical work. |
Palmer, Wade (PDF File, 118.4 KB) 2020 TASCD 701 |
Andrew McKee | 27-11-2020 | Transport & traffic related, motorcycle crash, single vehicle crash, high speed, multiple trauma |
Kelly, Brian John (PDF File, 94.7 KB) 2020 TASCD 657 |
Simon Cooper | 26-11-2020 | Accidental drug overdose, palliative care, end stage mesothelioma, hydromorphone toxicity, North West Regional Hospital, Emergency Department, Burnie, medical negligence, medical certificate of death, Coroner's comments, |
Ridgeon Beryl Jean (PDF File, 135.0 KB) 2020 TASCD 651 |
Simon Cooper | 23-11-2020 | Older persons, physical health, Mersey Community Hospital, gastroenteritis, ECG, myocardial infarction, haemopericardium, Root Cause Analysis, coroner's comment. |
Golding, Laura Rebecca (PDF File, 127.5 KB) 2020 TASCD 652 |
Olivia McTaggart | 23-11-2020 | Mental illness & health, water related, drowning, Copper Alley Bay, Lymington, dinghy, police response, psychotic episode, rescue, aerial search. |
Woolley, Dale Robert (PDF File, 374.2 KB) 2020 TASCD 644 |
Andrew McKee | 19-11-2020 | Inquest, transport & traffic related, work related, Ten Mile Creek Farm, tractor rollover, not wearing a seatbelt, blunt trauma of the head, neck & chest, WorkSafe Tasmania, Riverdale Dairies Pty Ltd, recommendation |
Spencer, Melissa Mary - web.pdf (PDF File, 122.9 KB) 2020 TASCD 615 |
Simon Cooper | 09-11-2020 | Drugs & alcohol, accidental overdose, prescription drugs, mixed drug toxicity, prescribing, Pharmaceutical Services Branch, Poisons Act 1971, Poisons Regulations 2018, schedule 8 substances, central nervous system depressants. |
Marshall, Eric Craig (PDF File, 843.8 KB) 2020 TASCD 603 |
Andrew McKee | 05-11-2020 | Inquest, work related, forklift rollover, farm, not wearing a seat belt, workplace, Work Health and Safety Act, guilty,Burnie |
Mikl, Petr (PDF File, 126.3 KB) 2020 TASCD 590 |
Olivia McTaggart | 02-11-2020 | Law enforcement, mental illness & health, death in custody, secure mental health unit, Wilfred Lopes Centre, inquest, natural cause of death |
Besgrove, Trevor Scott (PDF File, 101.7 KB) 2020 TASCD 591 |
Olivia McTaggart | 02-11-2020 | undetermined cause of death, Bicheno |
Wilson, Kerry Paul (PDF File, 109.9 KB) 2020 TASCD 592 |
Simon Cooper | 02-11-2020 | Transport & traffic related, motor vehicle crash, truck, collision, incorrect side of the road, Black River |
Espie, James William (PDF File, 100.2 KB) 2020 TASCD 583 |
Olivia McTaggart | 28-10-2020 | Transport & traffic related, motor vehicle crash, Iveco prime mover, Freighter trailer, truck, speed, work related, employment, workplace, request by senior next of kin not to hold inquest pursuant to s26A(2) of the Coroners Act 1995 |
Mansell, Robert Charles (PDF File, 488.0 KB) 2020 TASCD 576 |
Olivia McTaggart | 27-10-2020 | undetermined cause of death, missing person, suspicious circumstances, Flinders Island, North East River, Salmon Rock, fishing, Joshua Kennedy, Stephanie Riggall |
Nicolle, Paula Elizabeth (PDF File, 111.1 KB) 2020 TASCD 563 |
Simon Cooper | 12-10-2020 | Transport & traffic related, motor vehicle crash, multiple blunt traumatic injuries, instantaneous death, Kimberley Road, Railton, crash scene investigation. |
Bond, Johnathon Lee.pdf (PDF File, 122.0 KB) 2020 TASCD 543 |
Simon Cooper | 06-10-2020 | intentional self harm, suicide, mental health and illness, mixed prescription drug toxicity, amisulpride, diazepam, mirtazapine, Tasmania Ambulance Service, delay in dispatch of ambulance |
Boyle, John Patrick (PDF File, 140.6 KB) 2020 TASCD 542 |
Simon Cooper | 05-10-2020 | Geographic, leisure activity, caverneering, Tasmanian Caverneering Club, Mount Anne, North East Ridge, exploration, disappearance, undetermined cause of death. |
Fish, Winston William - Web version.pdf (PDF File, 112.1 KB) 2020 TASCD 036 |
Olivia McTaggart | 02-10-2020 | coronial, organ failure, multiple snake bites, tiger snake, neuropathy, coagulopathy, farm |
Oliver, Colin Jamie.pdf (PDF File, 124.3 KB) 2020 TASCD 537 |
Simon Cooper | 01-10-2020 | coronial, mountain bike, collision, head injury, blunt force, |
Lockley, Rodney Dennis (PDF File, 107.8 KB) 2020 TASCD 535 |
Olivia McTaggart | 29-09-2020 | Transport & traffic related, four wheeled all-terrain vehicle, ATV, quad bike, drink driving, alcohol, excessive speed, speeding, Bruny Island |
Pears, Phyllis (AMK) signed 11.09.20.pdf (PDF File, 437.3 KB) 2020 TASCD 518 |
Andrew McKee | 11-09-2020 | coronial, Wheat Pack, House Fire, Incineration, Flame, Heating, Thermal Mechanism |
Breen, Kylie Anne (PDF File, 126.0 KB) 2020 TASCD 504 |
Olivia McTaggart | 02-09-2020 | Hypoxic brain and lung injury, drug toxicity and gas inhalation, suicide, euthanasia, multiple scleorosis, Advance Care Directive, Goals of Care Plan, Launceston General Hospital, Coroner's recommendation |
Murray, Geoffrey Raymond (PDF File, 107.1 KB) 2020 TASCD 495 |
Olivia McTaggart | 27-08-2020 | Older person, natural cause death, acute myocardial ischaemia, Launceston General Hospital, Emergency Department, triaged patients, assessment and treatment, monitoring of whereabouts, documentation of significant interactions, recommendations. |
Harmon, Trinton John (PDF File, 586.4 KB) 2020 TASCD 491 |
Olivia McTaggart | 26-08-2020 | South Arm Highway, transport and traffic related, single vehicle, misadventure, pedestrian walking on road, struck from behind, multiple traumatic injuries, failure to stop and render assistance, alcohol and drugs, DPP, Department of Public Prosecution, driving with suspended licence, Simone Bridges |
Wright, Maria Rebekah (PDF File, 148.8 KB) 2020 TASCD 473 |
Olivia McTaggart | 13-08-2020 | intentional self harm, mental illness and health, drowning, Howrah, Mental Health Act 2013, Protective Custody Order, involuntary admission, Royal Hobart Hospital, Tasmanian Health Service |
Wellington, Timothy John (PDF File, 298.7 KB) 2020 TASCD 474 |
Olivia McTaggart | 13-08-2020 | alcohol and drugs, accidental death, intravenous injection of prescription medications, injection of crushed tablets intended for oral ingestion, methadone, quetiapine, diazepam, mirtazapine, cannabis, Tasmanian Opiod Pharmacotherapy Program |
Maynard, Grant Godfrey (PDF File, 100.7 KB) 2020 TASCD 470 |
Simon Cooper | 12-08-2020 | Transport & traffic related, motor vehicle accident, car crash, multi-organ failure, North West Regional Hospital, failure to properly diagnose |
Howe, Rowland Michael Chilton (PDF File, 118.7 KB) 2020 TASCD 467 |
Simon Cooper | 11-08-2020 | Domestic incident, tree felling accident, hypothermia and rhabdomyolysis, traumatic crush injuries, chainsaws, lack of training, deficient falling techniques, recommendations. |
Howard, Noeline Dawn (PDF File, 124.1 KB) 2020 TASCD 469 |
Simon Cooper | 11-08-2020 | adverse medical effects, failure to diagnose, misdiagnosis, Hobart Private Hospital, carcinomatosis, failure to report death to Coroner, medical, hospital. |
Williamson, Colin George (PDF File, 114.5 KB) 2020 TASCD 463 |
Olivia McTaggart | 10-08-2020 | Tree felling accident, chainsaw, Tasmanian Forest Industries Training Board, expired Forest Works Licence, non-compliant helmet, Coroner's recommendations |
Delios, Voula 2020 TASCD 458 (PDF File, 541.5 KB) 2020 TASCD 458 |
Simon Cooper | 07-08-2020 | Homicide and assault, mental illness and health, weapon, Tasmanian Prison Service, Wilfred Lopes Centre, Risdon Prison, North Hobart, Daryl Royston Wayne Cook, Section 24 Criminal Justice Mental Impairment Act 1999, remissions of sentence, mental health services, coroner's comments |
Thompson, Michael Robert (PDF File, 134.3 KB) 2020 TASCD 437 |
Olivia McTaggart | 29-07-2020 | Transport & traffic related, work related, single vehicle crash, concrete truck, Tea Tree Road, speed, no seatbelt |
McNeair, Jacqueline (PDF File, 116.0 KB) 2020 TASCD 427 |
Coroner Olivia McTaggart | 27-07-2020 | Older persons, physical health, subdural haematoma, mechanical fall with head strike, Launceston General Hospital, George Town Hospital. |
Deuchar, Susan Ann (PDF File, 110.8 KB) 2020 TASCD 430 |
Olivia McTaggart | 27-07-2020 | Transport & traffic related, older persons, physical health, car accident, environmental heat & cold exposure, dehydration, missing person, Tullah |
Borchi, Alessandro (PDF File, 105.7 KB) 2020 TASCD 414 |
Andrew McKee | 20-07-2020 | Transport & traffic related, motor vehicle crash, car accident, speed, alcohol, illicit drugs, criminal prosecution, causing death by dangerous driving, Huonville |
Crowden, Jeffrey Donald (PDF File, 276.7 KB) 2020 TASCD 398 |
Simon Cooper | 17-07-2020 | Long term missing person, deckhand, work related, water related, weather related, boating, dinghy |
Thompson, Paul Christopher (PDF File, 544.7 KB) 2020 TASCD 397 |
Olivia McTaggart | 17-07-2020 | Inquest, acute subdural haematoma, drugs & alcohol, assault, Coroner's comments |
Lyons, Matthew Clayton - web.pdf (PDF File, 133.8 KB) 2020 TASCD 408 |
Coroner Simon Cooper | 17-07-2020 | Drugs & alcohol, mental illness & health, mixed prescription drug toxicity, Royal Hobart Hospital, Department of Emergency Medicine, Liverpool Street. |
Alsop, Olaf Paul (PDF File, 92.5 KB) 2020 TASCD 393 |
Olivia McTaggart | 16-07-2020 | intentional self harm, suicide, hanging, mental illness and health, prescribing, drug seeking, pain medication |
Lomas, Corey Ronald (PDF File, 99.7 KB) 2020 TASCD 384 |
Olivia McTaggart | 14-07-2020 | transport and traffic related, alcohol and drugs, single motorcycle crash, unlicenced, learner rider, speeding, riding at excessive speed, methamphetamine, unregistered, riding over blood alcohol limit, loss of control |
Stone, Corrie Collean (PDF File, 85.4 KB) 2020 TASCD 391 |
Olivia McTaggart | 14-07-2020 | Transport & traffic related, motor vehicle crash, Lebrina, speeding, death by negligent driving, charged and convicted |
Cashion, Dale John (PDF File, 315.6 KB) 2020 TASCD 389 |
Coroner Simon Cooper | 13-07-2020 | Transport & traffic related, mental Illness & health, motor vehicle, multiple severe crushing injuries, Davey Street, emergency services, Royal Hobart Hospital, crash investigation. |
Neubert, Olga (PDF File, 327.3 KB) 2020 TASCD 374 |
Simon Cooper | 02-07-2020 | Domestic incident, homicide & assault, weapon, rifle, gunshot wound, murder, Klaus Neubert, estranged husband, Tasmania Police, family law |
Hinley, David John (PDF File, 116.6 KB) 2020 TASCD 347 |
Olivia McTaggart | 30-06-2020 | alcohol and drug related, mixed prescription drug toxicity (codeine, paracetamol, mirtazapine, promethazine, diazepam), accidental overdose, appropriate prescribing regime, stockpiling medication |
Shrimpton, Dallas Brooks (PDF File, 137.5 KB) 2020 TASCD 350 |
Olivia McTaggart | 30-06-2020 | Drugs & alcohol, intentional self-harm, mental illness & health, transport & traffic related, suicide, carbon monoxide inhalation, asphyxia, Launceston General Hostpial, Royal Hobart Hospital, Emergency Department, Inpatient Withdrawal Unit, Coroner's comments |
Konstantinidis, Agis (PDF File, 124.6 KB) 2020 TASCD 317 |
Coroner Simon Cooper | 19-06-2020 | Inquest, older person, person held in care, Guilford Young Grove, Roy Fagan Centre, emergency guardianship order, mental health, aspiration pneumonia, dementia |
Crawford, Jacob Raymond (PDF File, 126.8 KB) 2020 TASCD 314 |
Simon Cooper | 15-06-2020 | Quad bike roll-over, accident, head injury, drugs & alcohol, pillion passenger, dam, coroner's comment |
Bishop, Laurence (PDF File, 121.4 KB) 2020 TASCD 303 |
Coroner Simon Cooper | 12-06-2020 | Inquest, person in care, older person, Bishop Davies Nursing Home, Roy Fagan Centre, aspiration pneumonia, advanced dementia. |
Arnold, Derek William (PDF File, 116.8 KB) 2020 TASCD 309 |
Simon Cooper | 12-06-2020 | Acute methadone toxicity, prescription drug overdose, Pharmaceutical Services Branch, breach of Poisons Act 1971, Coroner's comment |
Dickinson, Mary Marguerite (PDF File, 485.6 KB) 2020 TASCD 291 |
Olivia McTaggart | 05-06-2020 | Inquest, person held in care, Roy Fagan Centre, comments, recommendations, pneumonia, Guardianship Order, Public Guardian, Guardianship and Administration Board, fall |
Tonner, Justin Michael (PDF File, 104.0 KB) 2020 TASCD 282 |
Olivia McTaggart | 01-06-2020 | Homicide and assault, weapon, drugs and alcohol, hypovolemic shock, multiple stab wounds, popliteal artery, manslaughter, Robert Michael Allen, coroner's comments |
Steer, Marianne (PDF File, 111.0 KB) 2020 TASCD 250 |
Olivia McTaggart | 19-05-2020 | Drugs & alcohol, mental illness & health, methadone, methadone program, take-away doses, Tasmanian Opioid Pharmacotherapy Program, drug toxicity |
Adams, Christopher Neil (PDF File, 98.7 KB) 2020 TASCD 253 |
Olivia McTaggart | 19-05-2020 | Drugs & alcohol, mental illness & health, methadone, methadone program, take-away doses, Tasmanian Opioid Pharmacotherapy Program, drug toxicity |
Baby I (PDF File, 106.9 KB) 2020 TASCD 251 |
Simon Cooper | 19-05-2020 | Child & infant death, baby, co-sleeping, bed sharing, suffocation, avoidable |
McCarthy, Blake John (PDF File, 109.9 KB) 2020 TASCD 254 |
Andrew McKee | 19-05-2020 | Transport & traffic related, motorbike, motorcycle, dirt bike, unroadworthy, crash, accident, speed, illicit drugs, erratic, unlicensed, unregistered |
Barber, Gavin John (PDF File, 90.1 KB) 2020 TASCD 273 |
Olivia McTaggart | 18-05-2020 | Single motorcycle crash, transport & traffic related, head injury, existing injuries, Harley Davidson, drugs, THC, cannabis |
Griffin, James Geoffrey (PDF File, 101.4 KB) 2020 TASCD 246 |
Simon Cooper | 18-05-2020 | Intentional self-harm, mixed drug toxicity, overdose of prescription medication, criminal sexual misconduct, criminal charges, toxicological analysis, Launceston General Hospital. |
Baby E (PDF File, 103.5 KB) 2020 TASCD 243 |
Simon Cooper | 18-05-2020 | Child & infant death, baby, co-sleeping, bed sharing, suffocation, avoidable |
Dennis, Wayne Phillip (PDF File, 104.9 KB) 2020 TASCD 240 |
Andrew McKee | 15-05-2020 | transport and traffic related, single vehicle motor accident, car crash, Port Sorell, failure to wear seat belt, drink driving, blood alcohol of 0.261 g/100ml, driving in excess of speed limit, 120km/h in a 80km/h zone |
Hunter, Feryne Gaylene (PDF File, 137.7 KB) 2020 TASCD 241 |
Coroner Olivia McTaggart | 15-05-2020 | Adverse medical effects, older person, permanent tracheostomy, aspiration, airway obstruction, Hobart District Nursing Service, Ambulance Tasmania, Refusal of Treatment and Transport Policy, Coroner's recommendation. |
Cashion, Brett Matthew (PDF File, 293.9 KB) 2020 TASCD 238 |
Olivia McTaggart | 14-05-2020 | Mental illness & health, drugs & alcohol, accidental prescription medication overdose, morphine, doctor shopping |
Riley, Shane Patrick (PDF File, 375.3 KB) 2020 TASCD 227 |
Andrew McKee | 12-05-2020 | house fire, fire related, Latrobe, charging battery, combustible materials near charger, accidental |
McLean, James Hugh (PDF File, 117.8 KB) 2020 TASCD 213 |
Simon Cooper | 08-05-2020 | long term missing person, missing bushwalker, undetermined cause of death, South West National Park, Huon Track, ill-equipped, bushwalking, no personal locator beacon, PLB, Coroner's comments |
Tonks, Russell Rodney (PDF File, 100.7 KB) 2020 TASCD 204 |
Simon Cooper | 05-05-2020 | Transport & traffic related, motor vehicle accident, pneumonia, Royal Hobart Hospital, reminder to medical practitioners |
Ferguson, Roy Waldren Trevor (PDF File, 117.5 KB) 2020 TASCD 198/20 |
Coroner A McKee | 29-04-2020 | Motor vehicle crash, Nunamara, campervan, drink driving, inattention, incorrect side of the roadway, head-on collision, prime mover |
Jones, Bradley James (PDF File, 124.8 KB) 2020 TASCD 194 |
Andrew McKee | 28-04-2020 | transport and traffic related, motorcycle crash, multiple trauma, collision with stationary prime mover, Mayfield, unroadworthy, unregistered, unlicensed, failure to wear helmet, alcohol and drugs, cannabis, methylamphetamine |
Hayward, Vanessa Claire (PDF File, 113.8 KB) 2020 TASCD 187 |
Coroner S Cooper | 23-04-2020 | Transport and traffic related, motor vehicle crash, speed, alcohol, drugs, New Town, unroadworthy, reckless driving, manslaughter, death by dangerous driving, imprisonment |
Hyde, Zachary Tyler (PDF File, 98.3 KB) 2020 TASCD 190 |
Olivia McTaggart | 23-04-2020 | homicide, manslaughter, assault, consequences of stab injury, hypoxic brain injury, exsanguination, cardiac arrest, Deejay Feil, sentencing comments, Supreme Court of Tasmania |
Tudor, Adrian David (PDF File, 95.3 KB) 2020 TASCD 183 |
Olivia McTaggart | 21-04-2020 | transport and traffic related, motor vehicle accident, Launceston, Wellington and Frederick Streets, manslaughter, ran red light, driving in excess of speed limit, driving whilst disqualified, decamped from scene, Dylan Lee, sentenced to imprisonment |
Petterwood, Michael Lewis (PDF File, 115.5 KB) 2020 TASCD 182 |
Olivia McTaggart | 20-04-2020 | natural cause death, atherosclerotic coronary vascular disease, Nyrstar Hobart Pty Ltd, Lutana, zinc works, factory, death at work place, Work Safe Tasmania |
Godfrey, Dale Eric (PDF File, 95.2 KB) 2020 TASCD 179 |
Coroner Simon Cooper | 20-04-2020 | Undetermined Circumstances, Undetermined Cause of Death, Mount Wellington Park, East-West Fire Trail, Mental Health, DNA Analysis |
Chequer, Ellen Marie (PDF File, 98.2 KB) 2020 TASCD 176 |
Coroner Olivia McTaggart | 17-04-2020 | Transport & Traffic Related, Motor Vehicle Crash, Traumatic Injuries, Crash Investigation, East Tamar Highway, Inattention, Wire Rope Barrier. |
Connell, Jay (PDF File, 84.9 KB) 2020 TASCD 160 |
Coroner O McTaggart | 15-04-2020 | Transport and traffic related, weather related, motor vehicle accident, truck, speed, wet weather, improved roadway, advisory signage, Glengarry |
Southwell, Sandra (PDF File, 158.7 KB) 2020 TASCD 166 |
Simon Cooper | 15-04-2020 | Leisure activity, transport & traffic related, weather related, aircraft crash, private airfield, windsock, coroner's comment & recommendation, |
Emery, Judith Anne (PDF File, 121.3 KB) 2020 TASCD 158 |
Olivia McTaggart | 08-04-2020 | aged care, older persons, fall from cliff, possible drowning, Derwent Waters, retirement village, Claremont, undetermined circumstances |
Pettersson, Jan Axel (PDF File, 85.2 KB) 2020 TASCD 153 |
Coroner S Cooper | 07-04-2020 | Falls, leisure activity, older persons, Mersey Community Hospital, infection, avoidable, Root Cause Analysis, misdiagnosed |
Hargraves, Audrey Doreen (PDF File, 113.7 KB) 2020 TASCD 151 |
Coroner Olivia McTaggart | 03-04-2020 | Adverse medical effects, older persons, reversal of Hartmann's procedure, post-operative complications, electrocardiogram, long QT syndrome, St Luke's Hospital, Launceston General Hospital, recommendation |
Pears, William Ernest (PDF File, 123.3 KB) 2020 TASCD 149 |
Coroner S Cooper | 03-04-2020 | Adverse medical effects, Coroner's comment, operation, George Town Hospital, Launceston General Hospital, St. Vincent's Public Hospital, surgery, laparoscopic cholecystectomy |
Button, Shirley Gwendoline (PDF File, 116.0 KB) 2020 TASCD 142 |
Coroner S Cooper | 01-04-2020 | Adverse medical effects, falls, leisure activity, older persons, Launceston General Hospital, LGH |
Standaloft, Cora Gwendoline (PDF File, 100.4 KB) 2020 TASCD 141 |
Coroner S Cooper | 01-04-2020 | Aged care, falls, older persons, Coroner's comment, bed alarms |
Szemes, Kim Leonie Maree (PDF File, 104.5 KB) 2020 TASCD 128 |
Simon Cooper | 23-03-2020 | undetermined cause of death, mental health and illness, Ambulance Tasmania, Mental Health Services |
Shepperd, Stephen Charles (PDF File, 92.5 KB) 2020 TASCD 124 |
Andrew McKee | 20-03-2020 | transport and traffic related, single motor vehicle crash, multiple chest injuries, failure to wear seatbelt, intoxicated, drink driving, drugs and alcohol, coroner's comments |
Wood, Glenn Thomas (PDF File, 86.0 KB) 2020 TASCD 105 |
Coroner O McTaggart | 11-03-2020 | Drowning, leisure activity, fishing, water related, weather related, winter, alcohol related |
MH (PDF File, 144.6 KB) 2020 TASCD 99 |
Olivia McTaggart | 09-03-2020 | child and infant death, sudden unexpected death in infancy (SUDI), co-sleeping with parents, potential overlay whilst sleeping, sleeping in adult bed, smoking, unsafe sleeping environment, bronchopneumonia, Child Safety Services, Child Protection Services, Child and Youth Services |
Wilton, Melissa Joan (PDF File, 135.3 KB) 2020 TASCD 094 |
Coroner A McKee | 05-03-2020 | Drugs & Alcohol, Transport & Traffic Related, Motor Vehicle Accident, Speeding, Collision, Distraction, Orford, Learner Licence |
Kiley, Jordan Jackson (PDF File, 89.7 KB) 2020 TASCD 86 |
Olivia McTaggart | 02-03-2020 | Traffic and transport related, youth, single vehicle motorcycle crash, blunt injuries of head, neck and chest, loss of control, sweeping turn, Strathaven Drive Rosetta |
Lawrence, Timothy Michael (PDF File, 137.5 KB) 2020 TASCD 92 |
Simon Cooper | 02-03-2020 | water related, multiple injuries, personal water craft (PWC), jet ski, Chinaman's Bay, Dunalley, alcohol and drugs, operating a PWC whilst intoxicated, collision with stationary object |
Reid, Lena Kathleen (PDF File, 116.0 KB) 2020 TASCD 84 |
Andrew McKee | 28-02-2020 | transport and traffic related, motor vehicle crash, Longford, Illawarra Road, methylamphetamine, cannabis, driving under influence of illicit substances |
Evans, Conor Maclaren (PDF File, 98.2 KB) 2020 TASCD 74 |
Olivia McTaggart | 18-02-2020 | Drugs and alcohol, mental illness and health, mixed drug toxicity, respiratory arrest, methadone, diazepam, coroner's finding, coroner's comment |
Dawkins, Kelvin John (PDF File, 85.6 KB) 2020 TASCD 72 |
Olivia McTaggart | 17-02-2020 | Transport & traffic related, car crash, older persons |
Whitney, Margaret Ann (PDF File, 100.6 KB) 2020 TASCD 64 |
Olivia McTaggart | 14-02-2020 | Aged care, nursing home, fall, older persons, dementia, person held in care, Royal Hobart Hospital, Roy Fagan Centre, Public Guardian, guardianship order, medical review, Coroner's comments |
Procter, Wilfred Pearson (PDF File, 118.3 KB) 2020 TASCD 046 |
Simon Cooper | 03-02-2020 | Missing person, LTMP, unknown cause of death, bones, Launceston |
Potts, Robert James (PDF File, 110.6 KB) 2020 TASCD 44 |
Simon Cooper | 28-01-2020 | Transport & traffic related, motorcycle crash, blunt force trauma, crash investigation, speed, unroadworthy |
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 |
Bell, Graeme Clem (PDF File, 78.5 KB) 2020 TASCD 16 |
Olivia McTaggart | 16-01-2020 | Natural cause death, location, West Tamar Highway, Lanena, older persons, physical health, The Public Trustee |
Combes, Margot Janeece (PDF File, 89.6 KB) 2020 TASCD 3 |
Olivia McTaggart | 03-01-2020 | Fall, work related, pulmonary thromboembolus, left medial malleolar fracture, anti-coagulation, risk of DVT and PE, coroner's finding, 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 |
Mole, Andrew Robert (PDF File, 368.7 KB) 2019 TASCD 410 |
Olivia McTaggart | 11-10-2019 | transport and traffic related, motor vehicle collusion, two vehicle crash, failure to take care when overtaking, prime mover, sedan, Bass Highway, Deloraine, multiple injuries |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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, |
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 |
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, |
DS (PDF File, 302.2 KB) 2019 TASCD 17 |
Olivia McTaggart | 21-01-2019 | Coroner's findings, drugs, alcohol |
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 |
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 |
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 |
Richardson, Margaret Rita.(Web).pdf (PDF File, 406.9 KB) |
01-01-2016 | coronial, artery dissection, ischaemic heart disease, renal scarring, emphysema |