Coronial findings (decisions) 2022-2023

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
Williams, Stewart.pdf (PDF File, 202.1 KB)
2023 TASCD 743
Olivia McTaggart 17-11-2023 Manslaughter, RHH
Bennetts, Adam Ian (PDF File, 93.8 KB)
2023 TASCD 686
Simon Cooper 31-10-2023 Alcohol, Motor Vehicle Accident
Gesler, Rick Keith (PDF File, 94.5 KB)
2023 TASCD 685
Simon Cooper 30-10-2023 Alcohol, Motor Vehicle Accident
Conley, Graham Rex.pdf (PDF File, 82.9 KB)
2023 TASCD 678
Simon Cooper 25-10-2023 Motor Vehicle Crash, Seatbelt, Coroners Comment
de-identified IY.pdf (PDF File, 118.8 KB)
2023 TASCD 677
Robert Webster 25-10-2023 Coroner's Recommendation, Spray Painting
Greenwood, David Raymond.pdf (PDF File, 120.7 KB)
2023 TASCD 679
Robert Webster 25-10-2023 Pedestrian. Struck by Car
Thogersen Aron.pdf (PDF File, 84.4 KB)
2023 TASCD 675
Olivia McTaggart 24-10-2023 Speed, Alcohol, Motor Vehicle Accident
Tweedie, Valma Ann (PDF File, 543.6 KB)
2023 TASCD 668
Simon Cooper 23-10-2023 Inquest
de-identified FG.pdf (PDF File, 83.0 KB)
2023 TASCD 664
Olivia McTaggart 19-10-2023 Co-sleeping, Infant Death
de-identified HN.pdf (PDF File, 88.6 KB)
2023 TASCD 654
Olivia McTaggart 16-10-2023 Motor Vehicle Accident, Coroner's Recommendation
Jones, Emily Margaret Rose.pdf (PDF File, 140.4 KB)
2023 TASCD 649
Robert Webster 11-10-2023 Fall, Coroner's Commentws
Rouse, Wayne Victor.pdf (PDF File, 113.8 KB)
2023 TASCD 640
Robert Webster 10-10-2023 CPR, Older Persons, Coroners Recommendation
East, Robert William.pdf (PDF File, 106.2 KB)
2023 TASCD 632
Olivia McTaggart 04-10-2023 Older Person, Tasmanian Taxi Council, Wheelchair accessible taxis
Czerniejewski, Roswitha.pdf (PDF File, 172.9 KB)
2023 TASCD 627
Robert Webster 01-10-2023 Older Person, NWRH, MCH
Phillips Geraldine May.pdf (PDF File, 80.2 KB)
2023 TASCD 618
Simon Cooper 25-09-2023 Motor Vehicle Accident, Fatality
Stein, Emily Catherine (PDF File, 97.8 KB)
2023 TASCD 613
Simon Cooper 22-09-2023 Drowning, Physical Health, Cataract Gorge
Kremmer, Bradley (PDF File, 97.2 KB)
2023 TASCD 600
Olivia McTaggart 18-09-2023 Motor Cycle Crash, Alcohol and Drugs, Speed
RA - deidentified (PDF File, 127.6 KB)
2023 TASCD 606
Robert Webster 18-09-2023 Homicide, Youth
Gee, Pamela Bernice (PDF File, 137.8 KB)
2023 TASCD 598
Robert Webster 15-09-2023 Pedestrian, Motor Vehicle Accident, Cause death by Negligent Driving
Briggs, Phillippa Helene (PDF File, 123.1 KB)
2023 TASCD 597
Robert Webster 15-09-2023 Motor Vehicle Accident
Harris, Peter Blackwell (PDF File, 697.3 KB)
2023 TASCD 589
Robert Webster 12-09-2023 Fall, Royal Hobart Hospital
Weldon, Dayle Patricia (PDF File, 437.0 KB)
2023 TASCD 579
Olivia McTaggart 06-09-2023 Inquest, Aged Care, Falls, Mental Illness & Health, Older Person
Hunt, Paul George; Reynolds, Paul James; Darke, Simon Graham; Cooke, Robert Anthony (PDF File, 1.9 MB)
2023 TASCD 561
Simon Cooper 01-09-2023 Dugs & Alcohol, Intentional Self-Harm, Law Enforcement, Mental Illness & Health, Weapon, Work Related
Douglas, Jethro Wolf (PDF File, 206.8 KB)
2023 TASCD 560
Robert Webster 31-08-2023 Motor Vehicle Accident, Excessive Speed, Alcohol
Nicholson, Dale Waverley.pdf (PDF File, 76.9 KB)
2021 TASCD 648
Simon Cooper 25-08-2023 Drowning, Derwent River
Gudge, Gian George.pdf (PDF File, 97.2 KB)
2023 TASCD 554
Robert Webster 25-08-2023 Motorcycle Crash, Alcohol
Taylor, Carter Jim (PDF File, 101.4 KB)
2023 TASCD 533
Simon Cooper 18-08-2023 Falls, Clifton Beach
Lukacevich, Anton.pdf (PDF File, 80.1 KB)
2023 TASCD 53
Simon Cooper 18-08-2023 Ambulance Tasmania, Coroners Comments
de-identified EJ.pdf (PDF File, 120.6 KB)
2023 TASCD 518
Robert Webster 15-08-2023 Motorcycle Crash, Alcohol and Speed
Cooper, Nelson Keith Cyril (PDF File, 119.8 KB)
2023 TASCD 512
Robert Webster 14-08-2023 Transport & Traffic Related, Alcohol
Dobson, Barbara Maree.pdf (PDF File, 178.6 KB)
2023 TASCD 510
Robert Webster 11-08-2023 Mixed Drug Toxicity, Tasmania Police, Family Violence
de-identified GN.pdf (PDF File, 113.3 KB)
2023 TASCD 507
Robert Webster 09-08-2023 Shed Fire, Child, Coroners Recommendations
Bell, Elizabeth Robertson.pdf (PDF File, 114.9 KB)
2023 TASCD 501
Robert Webster 08-08-2023 RACF, Fall, Older Persons, Movement Sensor
Colpo, Dario (PDF File, 141.8 KB)
2023 TASCD 579
Robert Webster 07-08-2023 Aged Care, Falls, Older Person, Recommendations
de-identified LD.pdf (PDF File, 127.0 KB)
2023 TASCD 492
Simon Cooper 02-08-2023 Infant Death, Asphyxia, RHH
Nalder Michael Graeme.pdf (PDF File, 112.9 KB)
2023 TASCD 497
Robert Webster 02-08-2023 Medical Treatment, RHH, Older Persons
Slatter, Ronald Reginald.pdf (PDF File, 85.4 KB)
2023 TASCD 494
Simon Cooper 02-08-2023 Alzheimer's Dementia, Fall, Older Persons, Coroners Comments
Murfet, Eileen and Stones, Lachlan James.pdf (PDF File, 94.0 KB)
2023 TASCD 487
Olivia McTaggart 31-07-2023 Motor Vehicle Accident, Tasmanian Helicopters Double Fatality
de-identified BK.pdf (PDF File, 97.9 KB)
2023 TASCD 483
Olivia McTaggart 31-07-2023 Tasman Bridge, Suicide, Mental Illness
Ainsley, Reginald.pdf (PDF File, 105.6 KB)
2023 TASCD 481
Simon Cooper 28-07-2023 Long Term Missing Person, Boat Harbour, 1969
de-identified FR.pdf (PDF File, 124.9 KB)
2023 TASCD 467
Simon Cooper 24-07-2023 Suicide, Carbon Monoxide Intoxication, Mental Illness,
QD de-identified (PDF File, 86.9 KB)
2023 TASCD 470
Simon Cooper 24-07-2023 Alcohol and Drugs, Coroners Comments
Hayes, Joy.pdf (PDF File, 79.0 KB)
2023 TASCD 466
Simon Cooper 21-07-2023 Older Persons, Quad Bike, Speed
Turner, Andrew Quentin.pdf (PDF File, 122.3 KB)
2023 TASCD 464
Robert Webster 20-07-2023 Motorcycle Accident, Speed, Alcohol, Drugs
Mohr, Wolfgang.pdf (PDF File, 88.4 KB)
2023 TASCD 439
Olivia McTaggart 06-07-2023 Pearl, Boating. drowning
Crump, Damian Michael (PDF File, 1.9 MB)
2023 TASCD 437
Olivia McTaggart 05-07-2023 Inquest, Drugs & Alcohol, Intentional Self-Harm, Work Related
Barron Rickie Underwood - SJC.pdf (PDF File, 245.8 KB)
2023 TASCD 431
Simon Cooper 30-06-2023 Inquest, HMP, Coroners Recommendations
Guy, Peter Joseph.pdf (PDF File, 88.6 KB)
2023 TASCD 421
Simon Cooper 27-06-2023 Older Persons, Fall, Coroners Comments
Anderson-Brettner, Jake Daniel.pdf (PDF File, 115.1 KB)
2023 TASCD 425
Robert Webster 27-06-2023 Homicide, Gunshot
Tucker, Harrison.pdf (PDF File, 85.5 KB)
2023 TASCD 420
Simon Cooper 26-06-2023 Motorcycle collision, Disqualified Driver, Speed, Drugs
Riley, Judith and Donald.pdf (PDF File, 125.8 KB)
2023 TASCD 524
Robert Webster 26-06-2023 Motor Accident, Double Fatality,

Response received from Department of State Growth, State Roads Division 2 October 2023

I note the record of investigation and findings, handed down on 26 June 2023, with respect to the deaths of Judith Anne Riley and Donald Roy Riley. A copy was provided to the Department by your office on 15 September 2023.

The record of investigation noted a report from the Department of State Growth that indicated that slippery when wet signs were to be provided as an interim measure on this section of the West Tamar Highway, with resealing works to occur at a later date.

I can confirm that the Department completed resealing works at this location in February 2022 as part of its annual maintenance program, improving skid resistance of the road surface. A skid resistance survey will also be conducted to confirm the effectiveness of this treatment.

Zhang, Jingai.pdf (PDF File, 104.5 KB)
2023 TASCD 427
Robert Webster 23-06-2023 Strangulation. Supreme Court
Dawson, Andrew.pdf (PDF File, 90.1 KB)
2023 TASCD 401
Olivia McTaggart 18-06-2023 Mental Illness, Methamphetamine toxicity, Tasmania Police
HN de-identified.pdf (PDF File, 85.1 KB)
2023 TASCD 385
Simon Cooper 13-06-2023 Older Persons, LGH, Coroner's Comments
Richardson Rebecca Eileen.pdf (PDF File, 145.3 KB)
2023 TASCD 364
Robert Webster 31-05-2023 NWRH, LGH, Coroners Recommendation,
Clayton, Danielle Alisha (PDF File, 97.3 KB)
2023 TASCD 365
Olivia McTaggart 31-05-2023 Motor Vehicle Accident, Excessive Speed, Drugs
Murphy, Scott Paul.pdf (PDF File, 83.0 KB)
2023 TASCD 358
Simon Cooper 29-05-2023 Suicide, Mental Illness
CE de-identified.pdf (PDF File, 99.6 KB)
2023 TASCD 355
Olivia McTaggart 25-05-2023 Alcohol Toxicity, Mental Illness, Coroners Recommendation
Vanderfeen, Jacinta.pdf (PDF File, 83.0 KB)
2023 TASCD 352
Olivia McTaggart 23-05-2023 Falling Tree, Blunt Trauma
Courtney, Wesley Paton.pdf (PDF File, 117.3 KB)
2023 TASCD 349
Robert Webster 22-05-2023 Fall, Older Person
Hyde-Wyatt, Michael Phillip.pdf (PDF File, 114.2 KB)
2023 TASCD 346
Olivia McTaggart 22-05-2023 Hydrocephalus, Nexus Inc
Kirkwood, Jordan Thomas.pdf (PDF File, 270.7 KB)
2023 TASCD 337
Robert Webster 19-05-2023 Hanging, RHH, Coroners Recommendations, Comments, Mental Illness
Barwick, Ian John.pdf (PDF File, 143.2 KB)
2023 TASCD 333
Olivia McTaggart 19-05-2023 Tractor Accident, Coroner's Recommendations
Dodd, Christopher Darren.pdf (PDF File, 99.0 KB)
2023 TASCD 321
Simon Cooper 16-05-2023 Motorcycle Crash, Speed, Alcohol and Drugs
Ross, Shaun and Willams, Nicholas (PDF File, 101.8 KB)
2023 TASCD 312-313
Olivia McTaggart 15-05-2023 Motor Accident, Double Fatality, Alcohol
PQ de-identified (PDF File, 209.0 KB)
2023 TASCD 298
Olivia McTaggart 10-05-2023 Suicide, Alcohol, Firearms
Badcock, Alexander.pdf (PDF File, 124.6 KB)
2023 TASCD 296
Robert Webster 09-05-2023 Motorcycle Crash, Speed
McKenna, Andrew Shaun.pdf (PDF File, 96.6 KB)
2023 TASCD 284
Simon Cooper 08-05-2023 Motor Cycle Crash, Alcohol and Drugs
Johns, Ross Alexander (PDF File, 312.1 KB)
2023 TASCD 288
Olivia McTaggart 08-05-2023 Drugs & Alcohol, Intentional Self-Harm, Mental Illness & Health, Inquest
Pedler, Anne Helen.pdf (PDF File, 137.1 KB)
2023 TASCD 272
Robert Webster 05-05-2023 Launceston General Hospital, Older Person
Mayes, Luke Callum.pdf (PDF File, 93.4 KB)
2023 TASCD 281
Simon Cooper 05-05-2023 Wheelchair, Asphyxia
Chuah Soo Lan.pdf (PDF File, 113.4 KB)
2023 TASCD 271
Robert Webster 04-05-2023 Cause of death not determined, Immigrant.
Xu and Davies Decision.pdf (PDF File, 707.0 KB)
2023 TASMC
Robert Webster 03-05-2023 Reasons for Decision, Inquest into the deaths of Bo Xu and Jarrod Davies, Scope of Inquest
Flight, Anthony John.pdf (PDF File, 94.7 KB)
2023 TASCD 171
Simon Cooper 03-05-2023 Motor Vehicle Accident, Causing the Death of another person
Koeter, Jacqueline Francis.pdf (PDF File, 106.1 KB)
2023 TASCD 248
Olivia McTaggart 01-05-2023 Schedule 8 Drug, Mixed Drug Toxicity
Clark, Michael John.pdf (PDF File, 98.5 KB)
2023 TASCD 231
Olivia McTaggart 26-04-2023 Motor Vehicle Accident, Negligent Driving
Young, Luke Trevor.pdf (PDF File, 114.9 KB)
2023 TASCD 219
Olivia McTaggart 20-04-2023 Mental and Physical Health Conditions, Drug and Alcohol
Taylor, Irene Barbara.pdf (PDF File, 92.4 KB)
2023 TASCD 210
Olivia McTaggart 14-04-2023 Fall, Older Persons, Coroners Recommendation
Hardie, Nathan John.pdf (PDF File, 129.0 KB)
2023 TASCD 180
Robert Webster 14-04-2023 Motorised Bicycle Accident, North Caroline Street East Devonport
Leader, Andrew (PDF File, 288.4 KB)
2023 TASCD 212
Olivia McTaggart 13-04-2023 Adverse Medical Effects, Location, Mental Illness & Health, Physical Health
Dishman, Stephen.pdf (PDF File, 97.9 KB)
2023 TASCD 202
Olivia McTaggart 05-04-2023 Motorcycle Rally, Motorcycle Accident
Litchfield, Claire Louise.pdf (PDF File, 101.1 KB)
2023 TASCD 273
Olivia McTaggart 05-04-2023 Pedestrian Accident, Criminal Charges
RS - de-identified.pdf (PDF File, 87.9 KB)
2022 TASCD 589
Simon Cooper 03-04-2023 RHH, LGH, Child Death
Catto, Simon Anthony.pdf (PDF File, 92.6 KB)
2023 TASCD 181
Simon Cooper 03-04-2023 Single Vehicle Accident, Speed, Drugs
Hazell, Nancy.pdf (PDF File, 93.0 KB)
2023 TASCD 173
Olivia McTaggart 03-04-2023 Uniting AgeWell Queenborough, Fall, Coroners Recommendation

Response received from Queenborough Rise 16 August 2023

Following the death of Mrs Hazell we developed a tool within our clinical care system to prompt staff to conduct regular safety checks of all chair sensors within the facility. This tool reminds staff to conduct a safety check every shift. This observation is then documented within our clinical care system.

Correspondingly, the ‘Purposeful Rounding Chart’ was reviewed and now includes the following check: “Check if the resident has a bed sensor, chair sensor calls bell and/or pendant-functioning and or near the resident before leaving the room”. This chart contains a list of actions that must be undertaken for each resident every hour.

As well, every six months scheduled testing of the nurse call bell system is competed by an external provider. The chair sensor mats work through this system. The scheduled testing was last completed in May 2023.

Other measures we have taken include

  • The Coroner’s findings were discussed at our local site quality meeting and the actions were documented in our Continuous Improvement Plan.
  • The Coroner’s findings were discussed at the Regional Executive Team meeting. This meeting is attended by all senior clinical managers from around the state. As a result all sites now closely monitor the use of motion chair sensors
  • The Coroner’s findings were also discussed in the Senior Executive Team meeting.
De-identified HJ.pdf (PDF File, 128.2 KB)
2023 TASCD 172
Simon Cooper 03-04-2023 Starvation, Older Persons
Laing, Gary John.pdf (PDF File, 125.4 KB)
2023 TASCD 170
Robert Webster 31-03-2023 Fire, Older Persons, Smoke Inhalation
IO de-identified.pdf (PDF File, 181.7 KB)
2023 TASCD 209
Olivia McTaggart 17-03-2023 Misadventure, Alcohol and Drugs
Culic, Jana (PDF File, 300.4 KB)
2023 TASCD 140
Olivia McTaggart 07-03-2023 Inquest, Intentional Self-Harm, Falls, Mental Illness & Health, Water Related, Location
Oates, Adam Grant.pdf (PDF File, 126.1 KB)
2023 TASCD 138
Robert Webster 06-03-2023 Single Vehicle Crash, Coroners Recommendation

Response received from Clarence City Council 16 August 2023.

In the report published, there was reference to a heavy indentation known as a rut on the gravel road edge approximately 50 metres from the crash site. As noted in the report, the rutting in the road edge is triggered by road users cutting through the shoulder of the road. The report states that the rut was not identified as a contributing factor to the crash.

The recommendation of the report was made for Clarence City Council to ‘assess this rut and repair it if the assessment deems it necessary’. This was reported in the Mercury newspaper article of 20 June 2023 titled ‘Snapchat posts 12min before fatal ute crash’. Council was not consulted before the publication of the report or article.

In reference to the Coroner’s recommendation to council, I can confirm the gravel road edge is part of council’s ongoing road maintenance program and repair of the rut was undertaken between 19 August and 19 September 2021, within weeks of the death of Mr Oates. Since this time the road has been re-edged as part of regular maintenance in the area, most recently in early 2023. Council acknowledges the rutting is prone to regression given the practice of road users cutting the corner and driving on the gravel edge.

Council is committed to maintaining council roads to providing safe roads for all users. The rut is on council’s maintenance schedule and will continue to be maintained as part of council’s road maintenance program.

Bell Mary and David.pdf (PDF File, 146.1 KB)
2023 TASCD 136
Robert Webster 05-03-2023 Motor Vehicle Accident, Double Fatality
Cash, Robert.pdf (PDF File, 91.4 KB)
2023 TASCD 86
Olivia McTaggart 22-02-2023 Older Persons, Fall, Coroner's Recommendations
Phillips, Lawrence William.pdf (PDF File, 133.8 KB)
2023 TASCD 90
Simon Cooper 22-02-2023 Tree Felling Accident, Coronial Recommendation
Barham, Timothy.pdf (PDF File, 108.9 KB)
2023 TASCD 85
Robert Webster 21-02-2023 Motor Vehicle Accident, Excessive Speed
Calabrese Vincenzo.pdf (PDF File, 256.3 KB)
2023 TASCD 165
Olivia McTaggart 20-02-2023 Workplace Death, Heart Disease
de-identified RI.pdf (PDF File, 134.1 KB)
2023 TASCD 77
Robert Webster 20-02-2023 Pneumonia, Alcohol Abuse
Tribolet, John Wesley.pdf (PDF File, 111.0 KB)
2023 TASCD 72
Simon Cooper 17-02-2023 ATV, Coroner's Recommendation
Campbell, Anthony Robert.pdf (PDF File, 92.8 KB)
2023 TASCD 74
Simon Cooper 17-02-2023 Pedestrian, Motor Vehicle
Hanslow, Rodney James.pdf (PDF File, 134.2 KB)
2023 TASCD 75
Simon Cooper 17-02-2023 Fall, Older Persons, Calvary Hospital
Balsley, Peter Donald.pdf (PDF File, 425.9 KB)
2023 TASCD 59
Olivia McTaggart 09-02-2023 Alcohol, Sorell Council, Asphyxia
Johnson, Sarah Catherine.pdf (PDF File, 92.9 KB)
2023 TASCD 52
Simon Cooper 06-02-2023 Pedestrian, Motor Vehicle, Alcohol and Drugs
Peters, Joan.pdf (PDF File, 98.2 KB)
2023 TASCD 51
Olivia McTaggart 01-02-2023 Motor Cycle,, Multiple Injuries, Older Person
Munnings, Barry.pdf (PDF File, 81.5 KB)
2023 TASCD 47
Olivia McTaggart 30-01-2023 Older Persons, Fall, Recommendations, Corumbene Nursing Home

Response from Corumbene received 3 May 2023

Corumbene has taken the following actions since receiving the Coroner’s recommendations:

* Reviewed policy and procedure concerning falls, risk assessments and associated matters.

* Initiated a staff education and display reminder on the importance of Falls Risk Assessment Tool (FRAT) assessments.

* Completed a spot check audit on individual residents’ suitability of FRAT risk.

* Reviewed and increased contracted physiotherapist services and implemented and enablement and falls risk component to the service.

* Implemented a physiotherapist post fall review process.

* Executed annual, or as needed, allied-health functional assessments, including exercise programs and equipment prescription.

* Increased clinical oversite with the recruitment of two (2) care managers and regular senior clinical care meetings which focus on specific clinical care  needs of high-risk residents.

* Implemented a falls committee meeting bi-monthly.

* Improved clinical incident response and investigation governance oversight.

Howse, John Neville.pdf (PDF File, 127.3 KB)
2023 TASCD 32
Robert Webster 20-01-2023 Fall, Residential Aged Care Facility
Creely, Colin Wayne.pdf (PDF File, 202.6 KB)
2022 TASCD 693
Robert Webster 21-12-2022 Fall, Mountain Bike, St Helens
Procter, Sheelagh Patricia.pdf (PDF File, 116.6 KB)
2022 TASCD 692
Robert Webster 21-12-2022 Fall, THS, Older Persons
Wildman, Benjamen (PDF File, 1.2 MB)
2022 TASCD 656
Robert Webster 15-12-2022 Coronial, finding, inquest, self-inflicted stab wound to the chest, a person held in custody
Mather, Robert Andrew (PDF File, 803.8 KB)
2022 TASCD 657
Robert Webster 15-12-2022 Inquest, Coroners Recommendations, Aged Care, Falls
Triffett, Brendan (PDF File, 370.3 KB)
2022 TASCD 653
Olivia McTaggart 07-12-2022 Cardiac arrhythmia caused by heart disease, Kingston Pool
Wood, Margaret.pdf (PDF File, 106.9 KB)
2022 TASCD 646
Robert Webster 02-12-2022 Older Persons, Decompensated Frailty Syndrome
Hughes, Ellis Newton.pdf (PDF File, 165.1 KB)
2022 TASCD 645
Robert Webster 30-11-2022 Aspiration Pneumonia, Ambulance Tasmania, Older Persons
Gurr, Phillip Leslie.pdf (PDF File, 202.0 KB)
2022 TASCD 660
Robert Webster 30-11-2022 Transport & Traffic Related, Alcohol
Tongs, Janetta Ann.pdf (PDF File, 125.1 KB)
2022 TASCD 650
Robert Webster 30-11-2022 Self-Inflicted, Mental Illness
Donnelly, Christopher Ronald.pdf (PDF File, 114.3 KB)
2022 TASCD 649
Robert Webster 30-11-2022 Sudden Unexpected Death in Epilepsy, Natural Causes
TR (PDF File, 568.8 KB)
2022 TASCD 642
Robert Webster 29-11-2022 Motor Vehicle Accident, Multiple Injuries
Young, Andrew Robert.pdf (PDF File, 125.1 KB)
2022 TASCD 644
Robert Webster 29-11-2022 Hanging, Mental Illness
Godwin, Chantal Maree.pdf (PDF File, 112.1 KB)
2022 TASCD 636
Robert Webster 28-11-2022 Sudden Unexpected Death in Epilepsy (SUDEP), Mental Illness
Dare, Daniel Wayne.pdf (PDF File, 116.8 KB)
2022 TASCD 637
Robert Webster 28-11-2022 Mixed Prescription Toxicity, Accidental Overdose
Stevens, Cynthia (PDF File, 355.0 KB)
2022 TASCD 630
Olivia McTaggart 22-11-2022 Coronial, inquest, wheelchair, fall
Phillips, William Garnett.pdf (PDF File, 121.2 KB)
2022 TASCD 618
Robert Webster 16-11-2022 Elderly Persons, Natural Causes
Hall, Robert John.pdf (PDF File, 96.4 KB)
2022 TASCD 609
Simon Cooper 15-11-2022 Motor Vehicle Crash, Multiple Injuries,
KL .pdf (PDF File, 110.4 KB)
2022 TASCD 603
Robert Webster 11-11-2022 Global Hypoxic Brain Injury, Positional Asphyxia, Epileptic Seizure
Revell, Dianne Judith.pdf (PDF File, 110.8 KB)
2022 TASCD 601
Robert Webster 11-11-2022 Liver Failure, Fall, RHH
UR de-identified.pdf (PDF File, 139.9 KB)
2022 TASCD 602
Robert Webster 11-11-2022 Drowning, Spear Fishing, Lighthouse Bay
Tate, Barry Ronald.pdf (PDF File, 124.3 KB)
2022 TASCD 599
Robert Webster 09-11-2022 Bronchopneumonia, Fall
Kerr,Anthony Neville.pdf (PDF File, 98.5 KB)
2022 TASCD 59
Olivia McTaggart 08-11-2022 Toosey Aged and Community Care Nursing Home, Elderly, Falls Risk
Oates, Janet Patricia.pdf (PDF File, 120.8 KB)
2022 TASCD 596
Olivia McTaggart 08-11-2022 Fall, Mobility Hoist, Coroner's Recommendations

Response from Respect received 23 August 2023.

In response to the first recommendation, I recommend that all facilities using mobility hoists review their maintenance schedules to ensure that they are serviced at intervals which are appropriate to detect and prevent failure of the components, the following has occurred:
 Review of policy and process.
 Review of the preventative maintenance process indicated that monitoring of schedules could be improved, thus improvement has been facilitated by the introduction of an electronic recording and monitoring system, replacing the previous paper-based system.
Following trial, this system is being rolled out throughout the organisation.

In response to the second recommendation, I recommend that technicians responsible for servicing mobility hoists use thread locking adhesive (such as Loctite) and/or split pins to provide additional. security to critical, load-bearing nuts and bolts, the following has occurred:
 Respect have consolidated service agreements for preventatve maintenance of hoists to have two service providers over three states. Discussions with service providers has indicated that technicians are unwilling to make any changes to the manufactured structure of hoists given that they may be accountable for liability of any failure. Additionally, warranties would be voided.
 To mitigate the risk of further incidents in addition to regular external annual service and checks the internal Respect maintenance staff undertake monthly checks of all hoists with particular attention to nuts and bolts.
 Servicing of hoists continues to be undertaken as per the manufacturer’s recommendations..

Lampkin, Christopher Maxwell.pdf (PDF File, 112.5 KB)
2022 TASCD 585
Robert Webster 31-10-2022 Intentional Self-Harm, Alcohol, Mental Illness & Health
Tunks, John Harold.pdf (PDF File, 102.6 KB)
2022 TASCD 586
Robert Webster 31-10-2022 Atherosclerotic Vascular Disease, Fall
O'Shea, Amie Maree.pdf (PDF File, 126.0 KB)
2022 TASCD 581
Robert Webster 28-10-2022 Mixed Prescription Drug Toxicity, Lymphoedema, Prescription Drugs, Mental Illness
Carroll, Terence John.pdf (PDF File, 167.5 KB)
2022 TASCD 564
Robert Webster 26-10-2022 Sepsis/Mediastinal Empyema, RCA, THS,
GW de-identified.pdf (PDF File, 118.2 KB)
2022 TASCD 634
Olivia McTaggart 25-10-2022 Alcohol, Mental Illness & Health, Weapon, Coroners Recommendations
Meyer, Glenn Sturley.pdf (PDF File, 142.5 KB)
2022 TASCD 563
Robert Webster 25-10-2022 Mixed Drug Toxicity, Sleep Apnoea, Mental Health
Woldemichael, Nazrawi.pdf (PDF File, 148.1 KB)
2022 TASCD 562
Simon Cooper 24-10-2022 Unable to determine cause of death, State of Tasmania
EL de-identified.pdf (PDF File, 153.0 KB)
2022 TASCD 560
Robert Webster 19-10-2022 Workplace Accident, Blast Injuries, Safe Working Practices
Krushka, Robert.pdf (PDF File, 83.1 KB)
2022 TASCD 556
Olivia McTaggart 13-10-2022 Fairway Rise, Dementia, Older Persons, Urinary Catheters
Willetts, Ernest Charles (PDF File, 374.6 KB)
2022 TASCD 548
Simon Cooper 07-10-2022 Aspiration pneumonia, re-opened case, adverse medical effects
Mundy, Gilbert Raymond.pdf (PDF File, 81.2 KB)
2022 TASCD 544
Olivia McTaggart 04-10-2022 Snug Village, Older Persons, Falls Risk
Eirth, Rebecca Jayne.pdf (PDF File, 173.5 KB)
2022 TASCD 532
Olivia McTaggart 29-09-2022 Combined Drug Toxicity, Unintentional
Borton Jessica Rose-Aida.pdf (PDF File, 97.5 KB)
2022 TASCD 528
Simon Cooper 27-09-2022 Hypoxic Brain Injury, VTE, Coroner's Comments
Brown, Sandra Anne.pdf (PDF File, 118.3 KB)
2022 TASCD 516
Robert Webster 21-09-2022 Hypothermia, Drug Toxicity
Henrich, Peter.pdf (PDF File, 97.9 KB)
2022 TASCD 508
Simon Cooper 20-09-2022 Missing Person, Patina, Tasmania
Infant F - De-identified.pdf (PDF File, 138.9 KB)
2022 TASCD 517
Robert Webster 20-09-2022 SUDI, Rhinovirus, Fluoxetine
Hill, Sandra Germaine.pdf (PDF File, 133.4 KB)
2022 TASCD 514
Robert Webster 20-09-2022 Mixed Drug Toxicity, Depression, Overdose
Tommerup, Daniel James.pdf (PDF File, 98.2 KB)
2022 TASCD 507
Simon Cooper 19-09-2022 Thermal Burns, Homeless, Accident
Tedmanson, Wayne Douglas.pdf (PDF File, 114.7 KB)
2022 TASCD 504
Robert Webster 16-09-2022 Hyperglcaemic Hyperosmolar syndrome (HHS), Natural Death
Walker, Gary Wayne.pdf (PDF File, 131.9 KB)
2022 TASCD 489
Robert Webster 08-09-2022 Motor Vehicle Accident, Asphyxia, Seatbelt
Parr, Tristram Craig.pdf (PDF File, 128.2 KB)
2022 TASCD 481
Robert Webster 06-09-2022 Pedestrian., Motor Vehicle, Alcohol
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
Daw Rodney Keith.pdf (PDF File, 158.3 KB)
2022 TASCD 480
Robert Webster 18-08-2022 Acute Blood Loss, Mental Health, Advanced Care Directive
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,
Mann, David.pdf (PDF File, 78.6 KB)
2022 TASCD 408
Olivia McTaggart 09-08-2022 Asbestos, Mesothelioma, Ruling
David Cecil Mann Ruling (PDF File, 148.8 KB)
2022 TASCD 408
Olivia McTaggart 09-08-2022 Ruling on Mesothelioma
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

Response from Veterinary Board of Tasmania received 4 September 2023

The VBT recently declared revised veterinary service standards and guidelines.

On page 42 the Guidelines state the following with respect to storage of Pentobarbital:


Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (Regulation) lists Schedule 4 substances (prescription-only medicines) that have common therapeutic uses, but are also liable to abuse, misuse and diversion, warranting more stringent controls on possession and supply. These substances are commonly referred to as Schedule 4 Appendix D (S4D) medicines. S4D substances must be stored in a locked container and kept securely when not in immediate use. The Board expects that Pentobarbital be stored in an S8 safe to prevent unauthorised access.

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.
Fraser, Stella Joan.pdf (PDF File, 157.0 KB)
2022 TASCD 377
Olivia McTaggart 22-07-2022 Ouse, Pedestrian Bridge, Drowning, River Bank,
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
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
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
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
Oates, Nigel.pdf (PDF File, 99.3 KB)
2022 TASCD 316
Olivia McTaggart 30-06-2022 Transport and traffic related, No seatbelt
MX De-identified.pdf (PDF File, 162.0 KB)
2022 TASCD 317
Robert Webster 30-06-2022 USID, CatholicCare Housing Connect Support (CCHCS), CSS
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
TS de-identified (PDF File, 139.6 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
Bogdanova, Rimma.pdf (PDF File, 92.6 KB)
2022 TASCD 237
Simon Cooper 23-05-2022 Pedestrian, Cause death by Negligent Driving
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,
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.
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.
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.
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
Mackey, Lois Winifred.pdf (PDF File, 122.0 KB)
2022 TASCD 153
Robert Webster 21-03-2022 Decompensated Heart Failure, Elderly Persons, THS,
Rouse, Rex (PDF File, 496.9 KB)
2022TASCD 152
Robert Webster 21-03-2022 Coronial, Findings, Deep Vein Thrombosis, Pulmonary Embolism
Shields, Sandra Mary.pdf (PDF File, 288.9 KB)
2022 TASCD 151
Olivia McTaggart 18-03-2022 Older Persons, 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
Campbell, Nancy.pdf (PDF File, 293.3 KB)
2022 TASCD 149
Olivia McTaggart 18-03-2022 Older Person, 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
BR - deidentified.pdf (PDF File, 111.5 KB)
2022 TASCD 100
Olivia McTaggart 23-02-2022 SUDI, Risks of Co-Sleeping, Infant Death
Attwood, Maurice.pdf (PDF File, 111.7 KB)
2022 TASCD 96
Robert Webster 23-02-2022 Hospital acquired pneumonia, Fall, Calvary Hospital, Older Person
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
Bruinewoud, Brieley Joyce.pdf (PDF File, 97.4 KB)
2022 TASCD 79
Olivia McTaggart 08-02-2022 Alcohol, Rookery Road
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
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
Mitchell, Gordon Arthur David.pdf (PDF File, 101.9 KB)
2022 TASCD 59
Simon Cooper 28-01-2022 LGH, Acute Myocardial Infarction, Coroners Comments
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.
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
Johns, Ross Alexander (PDF File, 312.0 KB)