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
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