Coronial findings (decisions) 2019 - 2021

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 Responses to Coronial Recommendations
O'Donnell, Margaret Joy.pdf (PDF File, 135.6 KB)
2021 TASCD 720
Olivia McTaggart 21-12-2021 Death cannot be determined, Schedule 8 substances
Donohue, Tracey Lee.pdf (PDF File, 103.1 KB)
2021 TASCD 718
Olivia McTaggart 20-12-2021 LGH, Natural Causes, Heart Disease,
Tilley, Jennifer May.pdf (PDF File, 117.4 KB)
2021 TASCD 717
Olivia McTaggart 17-12-2021 Death is undetermined, Schedule 8 substances
McCoy, Mathew (PDF File, 308.8 KB)
2021 TASCD 701
Olivia McTaggart 10-12-2021 Undetermined death, Mental Illness & Health, Health Treatment Order, GAB Order
Wells, Peter Williams.pdf (PDF File, 100.9 KB)
2021 TASCD 692
Simon Cooper 06-12-2021 Quad Bike, Sandy Cape Track, Coroner's Recommendation

Response from Tasmania Parks and Wildlife Service  11 August 2022

  • Signage has been installed at the entrance to Sandy Cape Track (Temma) and the Arthur Beach Track (Gardiner Point, Arthur River): Sand Flags Recommended.
  • Quick release adaptors for sand flags were attached to all operational vehicles in the Field Centre likely to operate on the track.
  • Sand flags are stored for easy access/attachment when field centre vehicles are accessing the tracks.
  • The PWS Arthur River Visitor Centre is trialling selling sand flags to the public.
  • The APCA Recreational Driving Guide, available to all Recreational Driver Pass holders, already contained advice to install sand flags under Vehicle Checklist (page 7, point 7).
Summers, Damian 2021 TASCD 691 (PDF File, 1.7 MB)
2021 TASCD 691
Olivia McTaggart 03-12-2021 Intentional self-harm, Statewide Mental Health Services, mental illness and health, Root Cause Analysis Report, Mental Health Act 2013, mental health facility rural or remote area, Coroner's recommendations
Lowe, Paul 2021 TASCD 684.pdf (PDF File, 1.1 MB)
2021 TASCD 684
Simon Cooper 02-12-2021 Drugs and alcohol, mental illness and health, physical health, epilepsy, Mental Health Act 2013, person held in care, methadone intoxication, Pharmaceutical Services Branch, methadone program, Alcohol and Drug Service, TOPP guidelines
Helen Mary Badcock (PDF File, 453.6 KB)
2021 TASCD 674
Simon Cooper 29-11-2021 Launceston General Hospital, Older Persons
Bennett, Anthony George.pdf (PDF File, 114.0 KB)
2021 TASCD 681
Robert Webster 29-11-2021 Ischaemic heart disease, pulmonary disease, Royal Hobart Hospital
Roberts Henry Arthur.pdf (PDF File, 112.3 KB)
2021 TASCD 670
Olivia McTaggart 26-11-2021 Industrial Accident, Crash Investigation
Breward, Bradley Wade.pdf (PDF File, 78.7 KB)
2021 TASCD 672
Simon Cooper 26-11-2021 Homicide, Lake Eugenana,
Nicholson, Dale Waverley.pdf (PDF File, 104.2 KB)
2021 TASCD 648
Simon Cooper 25-11-2021 Missing Person
Larkins, Pamela Judith.pdf (PDF File, 96.7 KB)
2021 TASCD 642
Simon Cooper 22-11-2021 Motor Vehicle Accident, South Arm Road
Lindburg, Jason Richard.pdf (PDF File, 105.5 KB)
2021 TASCD 641
Olivia McTaggart 18-11-2021 Mental Illness, Mental Health Act,
Wheldon, Jamie Damien.pdf (PDF File, 106.0 KB)
2021 TASCD 639
Olivia McTaggart 18-11-2021 Drugs, Bridge Program, Missiondale,
Chilvers, Peter Michael.pdf (PDF File, 98.6 KB)
2021 TASCD 638
Olivia McTaggart 16-11-2021 Mt Geryon, Knot, Fall, Abseiling
Pearce, Jayden John.pdf (PDF File, 103.1 KB)
2021 TASCD 637
Olivia McTaggart 15-11-2021 Drugs, Criminal Charges, Motor Vehicle Accident
Pereira, Thomas.pdf (PDF File, 95.6 KB)
2021 TASCD 636
Simon Cooper 12-11-2021 Coroner's Comments, Seasonal Worker, Alcohol, Seat-Belt
Rosendale, Dwayne Edward (PDF File, 376.1 KB)
2021 TASCD 631
Simon Cooper 04-11-2021 Mental illness and health, physical health, person held in care, schizophrenia, morbid obesity, cardiac enlargement, Forensic Mental Health Service, Anglicare, Royal Hobart Hospital, coroner's recommendations
Bester, Valentine Eric Neal (PDF File, 130.9 KB)
2021 TASCD 582
Simon Cooper 01-11-2021 Coronial, findings, drowning, Frederick Henry Bay, Tasmania, Paddle, Kayak, Rochus Beach, Lime Bay, PFD, Wetsuit, Weather Forecast, Paddle Safe Guidelines, MAST Surf Life Saving Tasmania
Lane, Christopher Mark.pdf (PDF File, 97.2 KB)
2021 TASCD 621
Simon Cooper 01-11-2021 Motorcycle Crash, Annual St Helens to Strahan Off Road Motorcycle ride,
Hume, Rosemary Josephine.pdf (PDF File, 112.6 KB)
2021 TASCD 619
Andrew McKee 28-10-2021 Motorcycle Crash, Bass Highway
Lacroix, Adrian.pdf (PDF File, 108.6 KB)
2021 TASCD 600
Olivia McTaggart 15-10-2021 Alcohol, Intentional Self-Harm, Mental Illness, Transport and Traffic Related
Parsons, Anna Maree.pdf (PDF File, 402.4 KB)
2021 TASCD 587
Olivia McTaggart 11-10-2021 Mixed Drug toxicity, Mental Health Plan, Schedule 8 substances,
Reaks, Karen Tracey.pdf (PDF File, 98.7 KB)
2021 TASCD 585
Olivia McTaggart 08-10-2021 Drug Intoxication, Borderline Personality Disorder, Anxiety Disorder
Suter, Nigel Douglas.pdf (PDF File, 98.0 KB)
2021 TASCD 547
Simon Cooper 20-09-2021 Transport and traffic related, St Helens,
Infant Deaths (PDF File, 8.0 MB)
2021 TASCD 551, 552, 553, 554, 555, 556, 557
Olivia McTaggart 17-09-2021 Coroner's finding, joint inquest, child and infant death, youth, transport and traffic related, Child Safety Services, Department of Communities, Tasmania, child protection systems, Sudden Unexpected Death in Infancy, co-sleeping, drowning, motor vehicle crash, exposure to risk
King, Nicholas Brian.pdf (PDF File, 99.7 KB)
2021 TASCD 539
Olivia McTaggart 10-09-2021 mixed drug toxicity, long term drug use
Sterling, Barbara Lynette.pdf (PDF File, 103.5 KB)
2021 TASCD 510
Simon Cooper 02-09-2021 Drowning, River Derwent, Mental Illness and Health
PY.pdf (PDF File, 107.3 KB)
2021 TASCD 496
Simon Cooper 26-08-2021 Child and Infant Death, Sepsis, Royal Hobart Hospital
Quirk, Stewart James (PDF File, 99.0 KB)
2021 TASCD 497
Simon Cooper 26-08-2021 motor vehicle accident, transport and traffic related, epilepsy, suspended licence, medically unfit to drive, driving unlicenced, Risdon Road
Lockley, Shane Reginald.pdf (PDF File, 113.1 KB)
2021 TASCD 487
Simon Cooper 25-08-2021 Guardianship Order, Alcohol, Dementia
Price, Charles (PDF File, 94.8 KB)
2021 TASCD 479
Simon Cooper 23-08-2021 Long Term Missing Person, D'Entrecasteaux Channel, Probable Drowning, Water Related,
Groves, Justin Thomas (PDF File, 117.3 KB)
Andrew McKee 23-08-2021 Coroner's, Coronial, Motor vehicle Crash, Blunt Traumas Injury to the head, lost control, seat belt
Cooper, Melanie Sarah 2021 TASCD 475.pdf (PDF File, 121.9 KB)
2021 TASCD 475
Olivia McTaggart 23-08-2021 Drug Use, Addiction, Embolic Strokes
LA.pdf (PDF File, 109.4 KB)
2021 TASCD 473
Simon Cooper 20-08-2021 Adverse Medical Effects, Acute Gastrointestinal, Hobart Private Hospital, Royal Hobart Hospital
EJ.pdf (PDF File, 93.4 KB)
2021 TASCD 472
Simon Cooper 20-08-2021 Child & Infant Death, Falls, Geographic, Leisure Activity, Conservation Area
Mrs M.pdf (PDF File, 107.4 KB)
2021 TASCD 458
Simon Cooper 13-08-2021 Surgical Complications, Royal Hobart Hospital, Calvary Hospital.
Midson, Gilbert Arthur.pdf (PDF File, 111.4 KB)
2021 TASCD 456
Simon Cooper 13-08-2021 Long Term Missing Person, Reportable Death, DNA,
Negga, Retbe Chide (PDF File, 319.7 KB)
2021 TASCD 435
Simon Cooper 09-08-2021 Inquest, work related, employment, accident, Derwent Valley, cherry orchard, trailer, SD Reid Holdings Pty Ltd, Reid Fruits, WorkSafe Tasmania
Williamson, Shane Elliott; Rowe, Rodney Leo; and Robertson, Adam David (PDF File, 141.8 KB)
389/21, 390/21; 391/21
Andrew McKee 06-08-2021 motor vehicle accident, two vehicle crash, Bass Highway, Carrick, drugs and alcohol, methamphetamine, incorrect side of roadway, Coroner's comment
Haigh, Kevin Bruce (PDF File, 117.2 KB)
Simon Cooper 04-08-2021 Coronial, drowning, boat, Maria Island, Rock Lobster, FV Yimbala, Life Jackets
Fitz-gerald, Peter John (PDF File, 106.1 KB)
Simon Cooper 30-07-2021 Coronial, injuries, head injuries, aspiration, head and facial, acute alcohol intoxication
Selby, Robert Norman (PDF File, 731.0 KB)
2021 TASCD 404
Andrew McKee 27-07-2021 Coronial, coroner, Crash injuries, Chest and pelvis, Tractor crash
Hildyard, Nicholas William (PDF File, 112.0 KB)
Simon Cooper 27-07-2021 Coronial, traumatic closed head injuries, motor vehicle crash,
Menzies, Mervyn Roy (PDF File, 109.0 KB)
2021 TASCD 405
Simon Cooper 27-07-2021 decision not to hold inquest, supervision order, Criminal Justice (Mental Impairment) Act 1995, Royal Hobart Hospital, aspiration pneumonia
Sowden, James Robert (PDF File, 597.0 KB)
2021 TASCD 393
Andrew McKee 26-07-2021 coronial, coroner, suicide, stab wounds, neck and incised wounds to wrists
Cano, Carmen (PDF File, 92.6 KB)
2021 TASCD 380
Olivia McTaggart 14-07-2021 Older Persons, Falls, Aged Care, Medical Certificate Cause of Death, Coroner's Finding, Physical Health
Woolley, Byron Balfour (PDF File, 77.1 KB)
2021 TASCD 352
Simon Cooper 05-07-2021 long term missing person, undetermined cause of death, Knocklofty Reserve
HB (PDF File, 145.8 KB)
2021 TASCD 350
Simon Cooper 02-07-2021 child death, asthma, North West Regional Hospital, misdiagnosis, incorrect diagnosis, substandard medical treatment, Tasmanian Health Service, medico legal, Coroner's comments, Asthma Australia
Carver, Todd Andrew (PDF File, 2.5 MB)
2021 TASCD 347
Olivia McTaggart 02-07-2021 Inquest, re-investigation, work related, transport & traffic related, truck driver, De Bruyn’s, prime mover, laden fish tanker, fish run, Esperance Coast Road, rollover, crash, training, frame rise, air suspension, recommendations

Response from  De Bruyn's Transport 23 July 2022

Recommendation 1: Rollover Awareness and Training

De Bruyn’s Transport continues to utilise the VicRoads Heavy Vehicle Rollover Prevention Program and, specifically, its dynamic load elements as the cornerstone of our induction training for all employees and not just those involved in harvest fish operations. The reason for this is quite straightforward and that is that every employee has some role to play in reducing the likelihood of rollovers and incidents more broadly. We then focus on specific rollover awareness factors during both our mentoring as well as our refresh programs. We have also engaged the service of a Driver Trainer to provide additional coaching to all our drivers. This includes a combination of in cab assistance, review/follow-up of telematic data and ongoing focus on travel times for higher risk activities.

Recommendation 2: SOP Guidance

Our Safe Operating Procedure for this specific task along with our Risk Register and our weather related guidance were all updated some time ago. These updates then influence our mentoring and internal checking efforts, especially when it comes to conducting safety observations and reviewing travel times and probation.

Recommendation 3: Probationary Review

Safety assessments of driver performance not only occur at the end of probation but are undertaken on an ongoing basis. We often utilise telematic data for this process as well as timesheet reviews, camera evidence and even road user and customer anecdotal feedback. We already have a mentoring process for new drivers as well as those undertaking new tasks and, as mentioned above, we plan to use our recently employed Driver Trainer to provide even further coaching and safety feedback to our drivers.

Recommendation 4: Refresh Training

Our three yearly refresh program already includes specific rollover awareness elements. Our intention now is to broaden this process by utilising our recently recruited Driver Trainer to provide programmed in cab refresh sessions and assessments (similar, in many respects, to what pilots undertake now).

Hunn, Janine Mona (PDF File, 96.0 KB)
2021 TASCD 333
Olivia McTaggart 24-06-2021 hypoxic brain injury, epilepsy, seizure, Royal Hobart Hospital, Nexus supported living
Meerman, Michael (PDF File, 376.2 KB)
2021 TASCD 329
Andrew McKee 23-06-2021 Coronial, treatment order, ischaemic heart disease
Gleeson, Craig; Lucas, Alistair & Welsh, Michael (PDF File, 892.1 KB)
2021 TASCD 316
Simon Cooper 18-06-2021 Work related, Copper Mines of Tasmania, Mount Lyell Mine, Queenstown, chest injuries, fall from height, asphyxia, mud rush, temporary work platforms, fall arrest equipment, WorkSafe Tasmania, hazard management, Coroners comments & recommendations.
Bryers, Wallace Edgar (PDF File, 398.7 KB)
318 TASCD 2021
Andrew McKee 18-06-2021 Inquest, bee sting, bee venom, anaphylactic reaction, anaphylaxis, Tasiliquid Gold, bee apiary, beehives, Coroner's recommendations
Carnes, Wendy Maree.pdf (PDF File, 110.5 KB)
2021 TASCD 315
Simon Cooper 17-06-2021 transport and traffic related, motor vehicle accident, two vehicle accident, Melton Mowbray, Highland Lakes Road, Midlands Highway, prescription medication, tramadol, diazepam
Beames, Michael James (PDF File, 117.6 KB)
2021 TASCD 309
Olivia McTaggart 15-06-2021 Leisure activity, misadventure, sports related, water related, personal water craft, PWC, Jet Ski, drowning, could not swim, no personal floatation device, PFD, alcohol, no licence, inexperienced
Wells, Kenneth James (PDF File, 98.1 KB)
2021 TASCD 305
Simon Cooper 10-06-2021 hypothermia, Launceston, Summerhill
RA (PDF File, 107.9 KB)
2021 TASCD 304
Simon Cooper 07-06-2021 misadventure, fall from height, head injury, adolescent, youth, Penguin Primary School, Royal Hobart Hospital, North West Regional Hospital, Coroner's comment
Marshall, David Basil (PDF File, 94.9 KB)
2021 TASCD 287
Olivia McTaggart 26-05-2021 undetermined cause of death, Penguin, natural causes
Johnson, Rowyn Jake (PDF File, 131.7 KB)
2021 TASCD 266
Andrew McKee 24-05-2021 motorcycle crash, transport and traffic related, motor vehicle accident, Launceston, unlicenced rider, rider at fault, drugs and alcohol, exceeding speed limit, disobey road rules, exceed alcohol limit, riding unlawfully, Coroner's comment, incompetent rider, ride unsafely, multiple severe trauma
Wade, Neville Ernest (PDF File, 100.0 KB)
2021 TASCD 268
Simon Cooper 24-05-2021 Older persons, acute myocardial ischaemia, coronary atherosclerosis, North West Regional Hospital, MET call, ECG results, Coroner's comment
Lumley, Barry Alyn (PDF File, 107.5 KB)
2021 TASCD 267
Simon Cooper 24-05-2021 Falls, older persons, Meadow Mews Plaza, acute subdural haematoma, Launceston General Hospital Emergency Department, no CT scan, Canadian CT scan rule
Hayes, Emma Frances (PDF File, 93.9 KB)
2021 TASCD 260
Simon Cooper 21-05-2021 Drugs & alcohol, transport & traffic related, motor vehicle collision, Bass Highway, methamphetamine, MDMA, mobile phone
Jones, Nathan John (PDF File, 108.2 KB)
2021 TASCD 261
Olivia McTaggart 20-05-2021 alcohol and drugs, illicit drugs, injection of methamphetamine, multiple organ failure, hypoxic encephalopathy due to cardiac arrest, misadventure
Hanson, Sungwaan (PDF File, 414.2 KB)
2021 TASCD 232
Andrew McKee 12-05-2021 Death in Care,Guardianship Order, IVB metastatic adenocarcinoma of the rectum, schizophrenia
Ghanbarzadeh, Masoud (PDF File, 120.1 KB)
2021 TASCD 243
Simon Cooper 12-05-2021 transport and traffic, motor vehicle crash, Brooker Highway, blunt traumatic injuries, alcohol and drug related, prescription medication, diazepam, oxazepam, tramadol, olanzapine, cannabis, THC, impaired driving
Porthouse, David John (PDF File, 294.6 KB)
2021 TASCD 254
Andrew McKee 12-05-2021 Royal Hobart Hospital, Whittle Ward, hospital, palliation, Guardianship Order, Guardianship and Administration Board, inquest
Bester, Alec Laurence (PDF File, 294.3 KB)
2021 TASCD 233
Andrew McKee 12-05-2021 Death in care, Roy Fagan, Guardianship Order, aspiration pneumonia complicating advanced multifactorial dementia. chronic alcoholism and emphysema
Stocks, Michelle Jayne (PDF File, 121.3 KB)
2021 TASCD 234
Olivia McTaggart 10-05-2021 Mixed prescription drug toxicity, accidental overdose, drugs & alcohol, central nervous system depressants, lung disease, physical health, pharmaceutical services branch, Poisons Act 1971, schedule 8 narcotic substances
Sun, Lindi (PDF File, 96.0 KB)
2021 TASCD 228
Simon Cooper 10-05-2021 Drowning, rock fishing, not wearing a personal floatation device, PFD, Boltons Beach, Triabunna, Coroner's comment, Coroner's recommendation
Steffen, William Francis (PDF File, 82.6 KB)
2021 TASCD 220
Simon Cooper 04-05-2021 Long term missing person, 1985, cause of death unknown, circumstances unknown, Tasmania Police Missing Persons Unit, Queensland
Bowerman, Valerie Joy (PDF File, 399.8 KB)
2021 TASCD 213
Olivia McTaggart 28-04-2021 Inquest, falls, domestic incident, older persons, Ambulance Tasmania, paramedic, transport not required, transport refused, subdural heamatoma, Royal Hobart Hospital, recommendations
Young, Jeremy Dean (PDF File, 354.2 KB)
2021 TASCD 192
Olivia McTaggart 20-04-2021 Inquest, drugs & alcohol, misadventure, water related, drowning and intoxication with methamphetamine and other substances, Little Howrah Beach
Davis, Graeme Charles (PDF File, 122.6 KB)
2021 TASCD 176
Simon Cooper 12-04-2021 Launceston General Hospital, sepsis, Medical Certificate of Death, Office of the Health Complaints Commissioner, poor medical treatment, entirely avoidable death
Fowler, Alice Mary (PDF File, 435.4 KB)
2021 TASCD 175
Simon Cooper 12-04-2021 Inquest, falls, older persons, elderly persons, Royal Hobart Hospital, application pursuant to section 58 of the Coroners Act 1995, investigation re-opened, Coroner's comment, high falls risk
Rubenach, Timothy Luke (PDF File, 141.1 KB)
2021 TASCD 179
Simon Cooper 12-04-2021 aspiration pneumonia, National Disability Insurance Scheme, NDIS, palliative care, epilepsy, brain injury
Daly, Raymond Albert.pdf (PDF File, 268.2 KB)
2021 TASCD 146
Simon Cooper 25-03-2021 Older persons, physical health, Roy Fagan Centre, Guardianship and Administration Order, Public Guardian, care, treatment and supervision, dementia, aspiration pneumonia.
Gibson, Roger Alan (PDF File, 267.5 KB)
2021 TASCD 147
Simon Cooper 25-03-2021 Older persons, physical health, Roy Fagan Centre, Emergency Guardianship Order, care, treatment and supervision, Alzheimer's disease, aspiration pneumonia.
Clark, Philip Patrick (PDF File, 252.7 KB)
2021 TASCD 148
Simon Cooper 25-03-2021 Older persons, physical health, Roy Fagan Centre, Emergency Guardianship and Administration Order, care, treatment and supervision, advanced dementia.
Master T (PDF File, 280.9 KB)
2021 TASCD 139
Simon Cooper 19-03-2021 Inquest, child & infant death, person held in care, Care and Protection Order, Children, Young Persons and their Families Act 1997, multi-systemic disabilities, hypoxic brain injury secondary to a cardiorespiratory arrest
Hyatt, Saxon George (PDF File, 273.9 KB)
2021 TASCD 138
Simon Cooper 19-03-2021 Inquest, intentional self-harm, law enforcement, mental illness & health, person held in custody, Risdon Prison, HMP Risdon
Dale, Colin Rex (PDF File, 105.3 KB)
2021 TASCD 127
Simon Cooper 12-03-2021 Water related, long term missing person, suspected death, undetermined cause of death, disappearance, intoxication, Fisherman's Wharf, Strahan.
Fischer, Rodney James (PDF File, 101.4 KB)
2021 TASCD 116
Simon Cooper 09-03-2021 Coronial, single motor vehicle crash, multiple injuries, Toyota HiLux Utility, paddock, blunt trauma to the head, neck, thorax and arms, skull fractures, brusing of both lungs
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

Update provided by THS South 14 October 2022

Since the Coroner’s recommendation a Mental Health Short Stay Unit has been implemented to improve flow for mental health patients out of the ED.
With the ED redevelopment, planning is underway to include a secure high acuity area for mental health patients as well as a calming, private area for lower acuity patients where they are able to wait for their assessment separate from non-mental health patients.

Greene, Yvonne Beverley (PDF File, 86.2 KB)
2021 TASCD 65
Olivia McTaggart 05-02-2021 Coronial, stairs, step, fall, head injuries, blunt force,
Boon Alison Kim (PDF File, 108.2 KB)
2021 TASCD 52
Simon Cooper 03-02-2021 Coronial, peritoneal sepsis, multiple organ failure, bowel, perforation of the bowel.
ST (PDF File, 96.1 KB)
2021 TASCD 45
Andrew McKee 01-02-2021 Motorcycle crash, motorbike, youth, de-identified, transport & traffic related, fence post, avid motocross & enduro competitor, well-maintained & appropriate safety equipment, abdominal trauma, reminder of supervision
Clark-Robertson, Tyson Timothy (PDF File, 117.7 KB)
2020 TASCD 37
Andrew McKee 29-01-2021 Homicide & assault, missing person, murder, failing to report killing, accessory after the fact, hammer, Ian Rosewall, Renae Donald, Robert Broad, imprisonment
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

Response from  Derwent Valley Council 30 August 2022

Following is report of actions taken by the Derwent Valley Council to reduce risks to motorists on the gravel section of Glenfern Road.

Council’s Operations Manager, a qualified engineer, was charged with investigating improvements to the road.  He developed a scope of works and issued a Request for Quotation to civil contractors in December 2020 with the following overview of works required:

The unsealed section of Glenfern Road has a higher than average incidence of casualty crashes including a fatality in recent years. Derwent Valley Council has identified a number of sections at which sight distance could be improved via vegetation reduction and sight benching / reducing the slope of cut batters.  The extent of works is over a length of approximately 2.1km of Glenfern Road.  There are six sections, each of approximately 50m long identified for sight benching on the eastern side of the road. There are also a series of sections totalling approx. 600m that require vegetation removal.

A grant from the Department of State Growth Safer Rural Road Program was secured on 23 March 2021 for:

Vegetation reduction, site benching works, installation of guard rails and signage at Glenfern Road.

Works were completed and reported to the grant program on 30 June 2021.

All proposed sight benching, vegetation reduction and guard rail was successfully achieved as per application submission except for the length of guard rail marked in location below. This was attempted but unfortunately was not achievable due to presence of shallow rock.

With the reduced scale of the guard rail installation and favourable rates for the benching and vegetation reduction, the total cost requested from the grantor is $80,086.42

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
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,
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,
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.
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.
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
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
Besgrove, Trevor Scott (PDF File, 101.7 KB)
2020 TASCD 591
Olivia McTaggart 02-11-2020 undetermined cause of death, Bicheno
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.
Le Roy, Carole Ann (PDF File, 115.3 KB)
2020 TASCD 556
Simon Cooper 09-10-2020 Intentional self-harm, mental illness & health, Royal Hobart Hospital, Clarence and Eastern Districts Adult Community Mental Health Service, Statewide Mental Health Services, Department of Psychiatry Open Unit, suicidal ideation, suicidal crisis, K Block, anti-ligature amenities
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
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.
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
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
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
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
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 E (PDF File, 103.5 KB)
2020 TASCD 243
Simon Cooper 18-05-2020 Child & infant death, baby, co-sleeping, bed sharing, suffocation, avoidable
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.
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.
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
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.
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,
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
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
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
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
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
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
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
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
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
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
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

Updated response provided by THS South 14 October 2022

The THS Adult Anticoagulation statewide guideline includes when and how to reverse anticoagulation.  This includes rapid reversal requirements and perioperative management.

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
Powell, Stephen Maxwell (PDF File, 309.1 KB)
2019 TASCD 417
Simon Cooper 16-10-2019 Intentional self-harm, Mental illness & health, older persons, Mental Health Act 2013 (Tas), Mental Health Treatment Order, person held in care, community services
Roberts, Anna Jane and Stanley, Brett John (PDF File, 378.5 KB)
2019 TASCD 439 and 440
Olivia McTaggart 15-10-2019 transport and traffic related, motor vehicle accident, two vehicle crash, multiple traumatic injuries, drugs and alcohol, alcohol intoxication, blood alcohol over legal limit, cannabis, Lauderdale
Fillisch, Eric (PDF File, 424.2 KB)
2019 TASCD 413
Olivia McTaggart 14-10-2019 water related, drowning, scuba diving, rebreather, rebreather apparatus, displacement of mouthpiece, Visscher Island
Benneworth, Anthony John (PDF File, 414.5 KB)
2019 TASCD 419
Olivia McTaggart 11-10-2019 Drowning, water related, Ansons Bay, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety
Long, Anthony Edward (PDF File, 412.9 KB)
2019 TASCD 418
Olivia McTaggart 11-10-2019 Drowning, water related, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety
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
Frith, Aaron Douglas (PDF File, 363.8 KB)
2019 TASCD 398
Simon Cooper 30-09-2019 Adverse medical effects, physical health, pulmonary embolism, deep vein thrombosis, prophylactic anticoagulant, Achilles tendon rupture, coroner's finding, coroner's comment
Sulman, Murray Matthew (PDF File, 373.0 KB)
2019 TASCD 396
Olivia McTaggart 27-09-2019 motor vehicle crash, transport and traffic related, Mornington, South Arm Highway, excessive speed, negligent driving, Traffic Act 1925
Peck, Edward Paisley (PDF File, 825.8 KB)
2019 TASCD 386
Olivia McTaggart 26-09-2019 intentional self harm, mental illness and health, death in a public place, Tasman Bridge, Royal Hobart Hospital, Mental Health Act 2013 (Tas), decision not to involuntarily detain
Smith, Barry (PDF File, 378.0 KB)
2019 TASCD 381
Olivia McTaggart 20-09-2019 Transport and traffic related, physical health, heart disease, positional asphyxia, workplace, coroner's finding, coroner's comments
O'Brien, Mark Andrew (PDF File, 369.6 KB)
2019 TASCD 380
Olivia McTaggart 17-09-2019 transport and traffic related, motor vehicle accident, motorcycle accident, loss of control, traumatic injuries of head and chest, Kalang Avenue
Swan, Daniel Peter (PDF File, 363.4 KB)
2019 TASCD 373
Simon Cooper 12-09-2019 Transport and traffic related, multiple blunt traumatic injuries, two-vehicle collision, West Tamar Highway, coroner's finding
Clark, Darren Stuart (PDF File, 410.5 KB)
2019 TASCD 374
Simon Cooper 11-09-2019 transport and traffic related, single motor vehicle accident, motorsport, rally car, Scottsdale Classic Rally, Confederation of Australian Motor Sport Ltd, breach of National Rally Code
Smith, Jordan Marcellus (PDF File, 380.9 KB)
2019 TASCD 370
Andrew McKee 11-09-2019 Transport and traffic related, motorcycle and motor vehicle crash, head-on collision, incorrect lane, multiple traumatic injuries, alcohol, coroner's finding
Mwarabu, Alice (PDF File, 414.7 KB)
2019 TASCD 376
Simon Cooper 10-09-2019 Transport and traffic related, motor vehicle crash, Domain Highway, multiple blunt injuries
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
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
McLean, Michael William (PDF File, 260.2 KB)
2019 TASCD 338
Olivia McTaggart 19-08-2019 Transport and traffic related, motorcycle and vehicle crash, chest injuries, incorrect side of road, cornering technique, crosswinds, high risk of death, coroner's finding
Saltmarsh, Aidan Denis (PDF File, 384.2 KB)
2019 TASCD 332
Olivia McTaggart 19-08-2019 transport and traffic related, single vehicle crash, motorcycle crash, multiple injuries, loss of control of vehicle, alcohol and drugs, blood alcohol level over legal limit, cannabis (THC), excessive speed
Mollross, Daniel (PDF File, 392.1 KB)
2019 TASCD 335
Simon Cooper 19-08-2019 Transport and traffic related, motorcycle and motor vehicle crash, speed and alcohol, diffuse head injury, unroadworthy, coroner's finding, coroner's comment
Jeffrey, Angela Joy (PDF File, 517.6 KB)
2019 TASCD 322
Simon Cooper 13-08-2019 missing person, suspected intentional self harm, undetermined cause of death, body not located, Bakers Beach, northern Tasmania, coroner's comments
Mead, Liam - Ruling on Evidence (PDF File, 147.9 KB)
Ken Stanton 02-08-2019 ruling on evidence, whether evidence within scope of inquest, adolescent mental health, Tasmania, Liam Mead inquest, Coroners Act 1995 (Tas)
Horcicka, Josef Vratislav (PDF File, 488.4 KB)
2019 TASCD 298
Simon Cooper 25-07-2019 adverse medical effects, hospital related death, Calvary St Luke's Hospital Launceston, reportable death, failure to report death, no post mortem performed, undetermined cause of death
Eaton, Jodi Michelle (PDF File, 460.4 KB)
2019 TASCD 257
Olivia McTaggart 03-07-2019 homicide, assault, asphyxia, Bridgewater, Darren Dobson, strangulation/choking, coroner's recommendations, recommendation of enactment of indictable offence of choking, suffocation or strangulation
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
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
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

Updated response provided by THS South 14 October 2022

In response to the following;

The RHH carry out an investigation of the delays to administration of antibiotics on this occasion with a view to implementing steps to avoid their repetition.

Report provided in June 2019

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
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
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,
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
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
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

Updated response provided by THS - South 14 October 2022

RHH complies with the state record policy with regard to retention of records

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
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
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
DS (PDF File, 302.2 KB)
2019 TASCD 17
Olivia McTaggart 21-01-2019 Coroner's findings, drugs, alcohol
Brown, Tony David .pdf (PDF File, 595.0 KB)
2019 TASCD 022
Simon Cooper 21-01-2019 traumatic brain injury, homicide, Mitchell Clay Dowling, Jay David Blazely, one punch death, assault,
Stefaniw, Gerard Ernest (PDF File, 738.2 KB)
2019 TASCD 8
Simon Cooper 18-01-2019 death in care, order under the Guardianship and Administration Act 1995, Guardianship and Administration Board, intentional self harm, mental illness and health, Roy Fagan Centre
Dunster, Kenneth Francis (PDF File, 743.5 KB)
2019 TASCD 5
Simon Cooper 11-01-2019 death in care, Mental Health Act 2013, mental health order, Millbrook Rise Centre, asphyxia, choking on food, supervision of meals
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
Westbrook, Eden Jayde (PDF File, 314.2 KB)
2016 TASCD 318
Olivia McTaggart 30-09-2016 Intentional self-harm, mental illness & health, youth, St Helens District High School, asphyxia, police investigation.
Rallings, Geoffrey (PDF File, 253.3 KB)
2001 TASCD 14
Ian Matterson 01-01-2016 Coronial Missing Person
Richardson, Margaret Rita.(Web).pdf (PDF File, 406.9 KB)
01-01-2016 coronial, artery dissection, ischaemic heart disease, renal scarring, emphysema