Coronial findings (decisions) 2022

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
Walker, Gary Wayne.pdf (PDF File, 131.9 KB)
2022 TASCD 489
Robert Webster 08-09-2022 Motor Vehicle Accident, Asphyxia, Seatbelt
Glanville, Scott Roderick (PDF File, 744.7 KB)
2022 TASCD 478
Simon Cooper 02-09-2022 Road Accident, Frankford Road, Harford, Northern Tasmania
Walker, Nikita (PDF File, 1.5 MB)
2022 TASCD 452
Simon Cooper 25-08-2022 Coronial, aircraft, Flight, weather, multiple blunt injuries, incineration, western Arthur Range, Southwest Nation Park,
ZM De-identified.pdf (PDF File, 130.3 KB)
2022 TASCD 457
Robert Webster 24-08-2022 Motorcycle Collision, Speeding, Helmet, Alcohol, Interfering with Crash Scenes
Bentley, Ena Ann.pdf (PDF File, 98.8 KB)
2022 TASCD 443
Olivia McTaggart 19-08-2022 Elderly Person, Multicap Tasmania, Natural Causes
Meades Michelle Louise.pdf (PDF File, 207.5 KB)
2022 TASCD 415
Olivia McTaggart 12-08-2022 Drug and Alcohol Services, Drug Addiction, Manslaughter
Woolley, Jillian (PDF File, 1.7 MB)
2022 TASCD 421
Olivia McTaggart 12-08-2022 Coronial, Inquest, aspiration pneumonia, palliative care, pallative practice,
Dora, Bogdan.pdf (PDF File, 151.5 KB)
2022 TASCD 412
Robert Webster 11-08-2022 Aspiration, Death in Care, Falls, Roy Fagan Centre
Youd, Diane Maree.pdf (PDF File, 110.0 KB)
2022 TASCD 411
Robert Webster 11-08-2022 Death cannot be determined, Major Depression, Mental Health
Paynter, Pamela.pdf (PDF File, 80.0 KB)
2022 TASCD 409
Olivia McTaggart 10-08-2022 Queen Victoria Care, Falls Risk, Elderly Person,
David Cecil Mann Ruling (PDF File, 148.8 KB)
2022 TASCD 408
Olivia McTaggart 09-08-2022 Ruling on Mesothelioma
Mann, David.pdf (PDF File, 78.6 KB)
2022 TASCD 408
Olivia McTaggart 09-08-2022 Asbestos, Mesothelioma, Ruling
Joyce. Kaye Maree.pdf (PDF File, 136.4 KB)
2022 TASCD 378
Olivia McTaggart 04-08-2022 Thermal Burns, Heat Pump, RCD
Linklater, Brian Gary.pdf (PDF File, 114.5 KB)
2022 TASCD 396
Simon Cooper 03-08-2022 Mixed Drug and Alcohol Toxicity, Alcohol, Coroner's Recommendations
Chamberlain, Pamela Jacqueline.pdf (PDF File, 117.8 KB)
2022 TASCD 390
Olivia McTaggart 29-07-2022 Asphyxia, Mental Health, Common Ground
Hayes, Gary John -SJC.pdf (PDF File, 323.7 KB)
2022 TASCD 378
Simon Cooper 22-07-2022 Transport and traffic related, multiple injuries.
Brown, Elizabeth Mary.pdf (PDF File, 97.3 KB)
2022 TASCD 379
Olivia McTaggart 22-07-2022 Lynch Street Strahan, Motor Vehicle Accident, Older Person, No Seatbelt
Moran, Kayla Maree.pdf (PDF File, 152.1 KB)
2022 TASCD 376
Robert Webster 21-07-2022 Hanging, Mental Health, Workplace Incident, YFCC
Rapana, Dean Moses.pdf (PDF File, 93.9 KB)
2022 TASCD 373
Simon Cooper 20-07-2022 Single Motor Vehicle Collision, Passenger, King Island, Seatbelt
Summers, Nicholas John (PDF File, 461.4 KB)
2022 TASCD 384
Andrew McKee 15-07-2022 Coronial, Inquest, Kidney Disease, Transplant Operation, Scab on the aneurysm on the Fistula
AB de-identified.pdf (PDF File, 152.7 KB)
2022 TASCD 344
Olivia McTaggart 08-07-2022 Single Motor Vehicle Accident, Boat Harbour, Criminal Charges
Davis, Patricia Jane.pdf (PDF File, 77.7 KB)
2022 TASCD 343
Olivia McTaggart 07-07-2022 Reclusive, Unable to Determine Cause of Death, Natural Causes
Healey, Peter Andrew.pdf (PDF File, 76.1 KB)
2022 TASCD 22
Simon Cooper 07-07-2022 Single Motor Vehicle Crash, Unlicensed, Drugs, Blunt Trauma of Head
McKillop, John Andrew.pdf (PDF File, 98.7 KB)
2022 TASCD 331
Olivia McTaggart 06-07-2022 Betsy Island, Canoeing, Drowning, Cardiac Event
Wallace., Vivienne Lorraine.pdf (PDF File, 144.4 KB)
2021 TASCD 567
Robert Webster 04-07-2022 Coronary Vascular Disease, Elderly Persons, Flecainide,
CL de-identified.pdf (PDF File, 180.0 KB)
2022 TASCD 318
Robert Webster 01-07-2022 Hanging, Mental Health, Coroner's Recommendations, RCA
MX De-identified.pdf (PDF File, 162.0 KB)
2022 TASCD 317
Robert Webster 30-06-2022 USID, CatholicCare Housing Connect Support (CCHCS), CSS
Oates, Nigel.pdf (PDF File, 99.3 KB)
2022 TASCD 316
Olivia McTaggart 30-06-2022 Transport and traffic related, No seatbelt
Mansell, Sean Erwin.pdf (PDF File, 113.7 KB)
2022 TASCD 309
Robert Webster 28-06-2022 Death cannot be determined, Centre Care, Assault, Alcohol Dependence, SUDEP
Williams, Julie Gaye.pdf (PDF File, 227.1 KB)
2022 TASCD 288
Robert Webster 20-06-2022 Drugs and Alcohol, Mental Health, Unintentional
De Vries, Truus.pdf (PDF File, 94.8 KB)
2022 TASCD 289
Olivia McTaggart 17-06-2022 Traumatic Brain Injury, Driver error, Accident
Duggan, Philip Craig (PDF File, 342.2 KB)
2022 TASCD 285
Simon Cooper 15-06-2022 Self-inflicted gunshot wound to the head, Death in Custody, Family Violence, Firearm.
Baker, Christopher John.pdf (PDF File, 110.8 KB)
2022 TASCD 284
Olivia McTaggart 13-06-2022 Drowning, Deviot, Boating Accident,
Geertsema, Darlene Avis (PDF File, 491.0 KB)
2022 TASCD 280
Simon Cooper 10-06-2022 Long Term Missing Person
Leighton, Garth Mcdonald.pdf (PDF File, 115.4 KB)
2022 TASCD 323
Simon Cooper 04-06-2022 Motor Cycle Accident, CIS, Hollow Tree Road, Coroners Recommendations
Borishkewich, Katherine.pdf (PDF File, 139.7 KB)
2022 TASCD 255
Robert Webster 27-05-2022 Traumatic Closed Head Injury, Unwitnessed Falls,
LP - deidentified.pdf (PDF File, 92.0 KB)
2022 TASCD 245
Simon Cooper 26-05-2022 Bicycle Accident, Worksafe Tasmania, Garbage Truck
QG - Deidentified.pdf (PDF File, 92.7 KB)
2022 TASCD 241
Olivia McTaggart 24-05-2022 Drug use, methamphetamine, cardiac damage
David, Nathaniel and Cheryl.pdf (PDF File, 95.4 KB)
2022 TASCD 236
Simon Cooper 23-05-2022 Two Vehicle Crash, Bass Highway near Exton,
Bogdanova, Rimma.pdf (PDF File, 92.6 KB)
2022 TASCD 237
Simon Cooper 23-05-2022 Pedestrian, Cause death by Negligent Driving
Dillon, Kelly John-RBW signed 19.05.22.pdf (PDF File, 654.6 KB)
2022 TASCD 238
Robert Webster 19-05-2022 Pulmonary Thromboembolus, NOSS, Natural Causes
Masters, Shane Anthony (PDF File, 551.2 KB)
2022 TASCD 229
Olivia McTaggart 18-05-2022 SUDEP, Sudden Unexpected Death in Epilepsy, Aprin Transport Pty Ltd, Workplace Health and Safety Act 1995, Workplace Health and Safety Regulations 1998, WorkSafe Tasmania, reportable death, workplace injury.
Lavoipierre, Andre Marc (PDF File, 298.6 KB)
2022 TASCD 216
Simon Cooper 29-04-2022 Exsanguination, hypovolemic shock complicating acute blood loss, Richmond Fellowship, Mental Health Act 2013, person held in care.
Mawer, Stephen Charles (PDF File, 422.4 KB)
2022 TASCD 217
Olivia McTaggart 29-04-2022 Self-inflicted burns, person held in custody, Crisis Assessment and Treatment Team, cordon.
Gardiner, Timmothy Matthew (PDF File, 216.5 KB)
2022 TASCD 92
Robert Webster 22-04-2022 Gunshot, chest wound, accidental discharge, home-made firearm
Beesley, Nathaniel Owen (PDF File, 2.6 MB)
2022 TASCD 208
Simon Cooper 21-04-2022 Savage River Mine, West Coast, Grange Resources Tasmania, SRG Global Mining (Australia) Pty Ltd, crush injuries, IRATA, WorkSafe Tasmania, manual scaling
PL (PDF File, 253.4 KB)
2022 TASCD 147
Robert Webster 14-04-2022 Prosser River, head injury, ski biscuit, kill switch, Tahwalhi, Marine and Safety Tasmania (MAST), Fatal Accidents Act 1934, Hanlon v Hanlon [2006] TASSC 1, Marine and Safety (Motorboats and Licences) By-laws 2013, Marine and Safety Authority Act 1997, Harbour Master Marine Board Hobart, 5 knots, minimum age, towing poll..
Kirk, Rodney (PDF File, 160.3 KB)
2022 TASCD 198
Olivia McTaggart 13-04-2022 Guardianship Administration Board, Mental health Act, dementia, person held in care
Callinan, Damian Francis (PDF File, 167.5 KB)
2022 TASCD 199
Olivia McTaggart 13-04-2022 Guardianship and Administration Act, Mental Health Act, frontal glioblastoma multiforme, person held in care
Sykes, Andrew Philip.pdf (PDF File, 95.8 KB)
2022 TASCD 192
Olivia McTaggart 08-04-2022 Seatbelt, Motor Vehicle Accident, Memana
Reardon, Michael Wayne.pdf (PDF File, 103.2 KB)
2022 TASCD 192
Simon Cooper 08-04-2022 Diabetes Mellitus, Schizophrenia, Care Arrangements
Williams, John Michael.pdf (PDF File, 104.3 KB)
2022 TASCD 180
Robert Webster 30-03-2022 Death cannot be determined, Shorewell Park Burnie
Nguyen, Hanh Thi My and Dang, David Quan Hien SJC.pdf (PDF File, 98.2 KB)
2022 TASCD 168
Simon Cooper 25-03-2022 Motor Vehicle Collision, Midlands Highway, Methylamphetamine
Stephens, Vicki Lavinia.pdf (PDF File, 85.6 KB)
2022 TASCD 161
Robert Webster 23-03-2022 Klebsiella Pneumonia Sepsis, Fall, Objection to Post-Mortem, RHH
Rouse, Rex (PDF File, 496.9 KB)
2022TASCD 152
Robert Webster 21-03-2022 Coronial, Findings, Deep Vein Thrombosis, Pulmonary Embolism
Mackey, Lois Winifred.pdf (PDF File, 122.0 KB)
2022 TASCD 153
Robert Webster 21-03-2022 Decompensated Heart Failure, Elderly Persons, THS,
Shields, Sandra Mary.pdf (PDF File, 288.9 KB)
2022 TASCD 151
Olivia McTaggart 18-03-2022 Older Persons, Mental Health Act, Treatment Order
Campbell, Nancy.pdf (PDF File, 293.3 KB)
2022 TASCD 149
Olivia McTaggart 18-03-2022 Older Person, Mental Health Act, Treatment Order
Collis, Mary.pdf (PDF File, 278.9 KB)
2022 TASCD 150
Olivia McTaggart 18-03-2022 Older Persons, Mental Health Act, Treatment Order
Stokie, Stephen Wayne.pdf (PDF File, 92.7 KB)
2022 TASCD 146
Simon Cooper 14-03-2022 Motorcycle accident, West Tamar Highway
Cooper, Joanne Dulcie.pdf (PDF File, 102.2 KB)
2022 TASCD 136
Simon Cooper 10-03-2022 Tea Tree Road, Motor Vehicle Accident
AZ, CY and DX de-identified.pdf (PDF File, 122.5 KB)
2022 TASCD 139
Simon Cooper 10-03-2022 Drugs and Alcohol, Transport and Traffic Related, Ross
Salter, Lyndsay Kenneth.pdf (PDF File, 121.8 KB)
2022 TASCD 235
Robert Webster 09-03-2022 Motor Vehicle Crash, Pulmonary Fat Embolism, Ralton & Mersey Main Road Junction
FL de-identified.pdf (PDF File, 113.9 KB)
2022 TASCD 133
Simon Cooper 07-03-2022 Hypoxic Brain Damage, Gastroschisis, Short Bowel Syndrome,
Gaiswinkler, Anthony Adolf James.pdf (PDF File, 98.2 KB)
2022 TASCD 131
Simon Cooper 03-03-2022 Drowning, Derwent River
Gray, Alan Maurice.pdf (PDF File, 99.2 KB)
2022 TASCD 120
Olivia McTaggart 01-03-2022 Traumatic closed head injury, Older Persons, Fall, Ambulance Tasmania
Hassanloo, Saeed (PDF File, 546.5 KB)
2022 TASCD 105
Olivia McTaggart 28-02-2022 Suicide, Tasman Bridge, drowning, asylum seeker
Homan, Geoffrey Brian.pdf (PDF File, 109.3 KB)
2022 TASCD 101
Olivia McTaggart 24-02-2022 Older Persons, Community Housing Limited, Recluse
Scott, Paul Stephen.pdf (PDF File, 193.9 KB)
2022 TASCD 98
Robert Webster 24-02-2022 Intentional Self-Harm, Mental Illness and Health, Spencer Unit
Attwood, Maurice.pdf (PDF File, 111.7 KB)
2022 TASCD 96
Robert Webster 23-02-2022 Hospital acquired pneumonia, Fall, Calvary Hospital, Older Person
BR - deidentified.pdf (PDF File, 111.5 KB)
2022 TASCD 100
Olivia McTaggart 23-02-2022 SUDI, Risks of Co-Sleeping, Infant Death
BL de-identified.pdf (PDF File, 100.9 KB)
2022 TASCD 95
Olivia McTaggart 22-02-2022 Mental Health Plan, Extensive Burns
XY - deidentified.pdf (PDF File, 123.6 KB)
2022 TASCD 91
Robert Webster 18-02-2022 Morphine, Older Persons,
Berechree, Shelbi and Cooper-Rozynski, Isaack.pdf (PDF File, 129.6 KB)
2022 TASCD 82
Olivia McTaggart 10-02-2022 Motor Vehicle Accident, Arthur Highway, Double Fatality
Streets, Steven (PDF File, 427.8 KB)
2022 TASCD 81
Simon Cooper 08-02-2022 Coroner, motorcycle, rider, crash, lower limb, chest injuries, compound fractures, right leg bones, left pneumothorax, rib fractures
Bruinewoud, Brieley Joyce.pdf (PDF File, 97.4 KB)
2022 TASCD 79
Olivia McTaggart 08-02-2022 Alcohol, Rookery Road
KN - deidentified.pdf (PDF File, 105.6 KB)
2022 TASCD 80
Simon Cooper 08-02-2022 LGH, Hypoxic Brain Injury,
Hosking, Leigh Mathew.pdf (PDF File, 76.1 KB)
2022 TASCD 73
Simon Cooper 05-02-2022 Alcohol and Drugs, Single Motor Vehicle Crash, Huon Highway
Cupit, Leon Gordon.pdf (PDF File, 92.1 KB)
2022 TASCD 72
Simon Cooper 04-02-2022 Colebrook Road, Barton Vale Road Campania, Motorcycle accident
Whitehouse, Kieren Jamie Wesley.pdf (PDF File, 94.5 KB)
2022 TASCD 70
Simon Cooper 04-02-2022 Speed and Alcohol
Wood, Stanley (PDF File, 100.3 KB)
2022 TASCD 68
Simon Cooper 03-02-2022 Coronial, unable to determine cause of death, vessel, fell, waters, bass strait.
Reed, Ian William McDonald.pdf (PDF File, 94.9 KB)
2022 TASCD 65
Simon Cooper 03-02-2022 AstraZeneca, Intracerebral Haemorrhage,
Griffiths, Deborah Renee (PDF File, 293.0 KB)
2022 TASCD 63
Simon Cooper 01-02-2022 coronial, passenger, two vehicle collison, multiple injuries, left side of body, chest or abdomen, arm and leg
Chugg, Ethan.pdf (PDF File, 102.9 KB)
2022 TASCD 61
Olivia McTaggart 31-01-2022 Motor Vehicle Crash, Alcohol, Seat Belt
AZ 2022 TASCD 60.pdf (PDF File, 467.1 KB)
2022 TASCD 60
Kenneth Stanton 28-01-2022 Mental Health Plan, Wyndham Clinic Private Hospital, Albert Road Clinic (ARC), Alum Cliffs.
Mitchell, Gordon Arthur David.pdf (PDF File, 101.9 KB)
2022 TASCD 59
Simon Cooper 28-01-2022 LGH, Acute Myocardial Infarction, Coroners Comments
Waters, Billy Ray.pdf (PDF File, 76.3 KB)
2022 TASCD 44
Simon Cooper 24-01-2022 Murder, Mayfield.
Freeman, Stuart Clyde Dew.pdf (PDF File, 91.7 KB)
2022 TASCD 40
Simon Cooper 21-01-2022 Motor Vehicle Crash, Alcohol,
de Wit, Pauline Catherine Marie.pdf (PDF File, 145.3 KB)
2022 TASCD 38
Robert Webster 21-01-2022 Motor Vehicle Crash, Midland Highway, Coroners Recommendations
Hay, Geoffrey Robert.pdf (PDF File, 96.9 KB)
2022 TASCD 8
Simon Cooper 05-01-2022 Long Term Missing Person, Missing Persons Week
Forrest, Allan Leslie.pdf (PDF File, 96.6 KB)
2022 TASCD 7
Olivia McTaggart 05-01-2022 Medical Episode, Loss of Control
Pettigrew John Douglas.pdf (PDF File, 151.5 KB)
2022 TASCD 4
Robert Webster 04-01-2022 Motor Vehicle Crash, Mood Food Service Station Kempton, Coroner's Recommendation
Chilvers, Peter Michael.pdf (PDF File, 98.6 KB)
2021 TASCD 638
Olivia McTaggart 16-11-2021 Mt Geryon, Knot, Fall, Abseiling