Coronial findings (decisions) 2015 - 2018
The Magistrates Court (Coronial Division) publishes a small but important amount of records of investigations and findings.
The decision to make these findings available has been made by the Chief Magistrate, or their delegate, or the coroner presiding over the particular investigation, under Coroners Rules 2006.
Publishing a finding is decided on an individual basis, but the coroner may take into account a number of factors:
- the work of the courts being available to public scrutiny
- the death prevention role of the coroner
- family privacy
- sensitivity of the findings
- possible harm from making an investigation publically available
In general, authorised findings for publication will include:
- all public inquest findings
- motor vehicle crashes
- long-term missing persons cases
- homicides after the criminal process has been completed
- any other death which has been reasonably widely reported in the news media for clarification of the factual findings
- any death where health and safety recommendations can result in improvements and death prevention (for example, child protection systems issues, deaths in medical settings with recommendations for improvement)
- any other matter which the coroner believes is in the public interest
Specific findings can be located by entering information in the search box below. Please enter a keyword, name or year of the coronial finding you are looking for.
If you are unable to locate the findings you are looking for, please contact the Coroners’ Office
Please consider that it may be upsetting to read details about a death in an inquest finding.
Title & TASCD number | Coroner | Date | Keyword | Responses to Coronial Recommendations |
---|---|---|---|---|
Wicks, Benjamin (PDF File, 639.6 KB) 2018 TASCD 491 |
Rod Chandler | 17-12-2018 | Work Related, workplace death, pile driving, recommendations for safe work practices, piling industry, risk assessment, fail to undertake risk assessment, unsafe workplace practices, crushing by steel beam, crush. | |
Pitchford, Rhiannon Pearl Vanessa (PDF File, 397.7 KB) 2018 TASCD 511 |
Olivia McTaggart | 17-12-2018 | child & infant death, undetermined cause, SUDI, sudden infant death whilst bed sharing, co-sleeping, unsafe sleeping environment, Child Protection Services (now Child Safety Services), Child and Youth Services, unborn baby notification, Child Protection response and reforms, coroner's recommendations | |
McKenzie, Alan John (PDF File, 538.9 KB) 2018 TASCD 499 |
Rod Chandler | 10-12-2018 | Coronial, Coroner, heart failure secondary to ischaemic heart disease, arrhythmia, fall, cervical neck fractures, nursing home | |
Webb, Shanelle Jean (PDF File, 497.5 KB) 2018 TASCD 493 |
Rod Chandler | 05-12-2018 | SUDEP, Sudden unexpected death in epilepsy, night-time epileptic seizure, Oak Possability. | |
Suckling, James William (PDF File, 523.8 KB) 2018 TASCD 509 |
Rod Chandler | 05-12-2018 | North West Regional Hospital, hypovolemic shock, complication following surgery, incorrect diagnosis, | |
Palmer, Ian George (PDF File, 404.1 KB) 2018 TASCD 492 |
Simon Cooper | 03-12-2018 | transport and traffic related, motor vehicle crash, pedestrian struck, Launceston CBD, death by negligent driving | |
Taylor, Michael John (PDF File, 342.3 KB) 2018 TASCD 488 |
Olivia McTaggart | 30-11-2018 | drugs and alcohol, combined drug intoxication, prescription medications, methadone, alprazolam, injecting medications intended to be taken orally, coroner's recommendations, misuse of prescription medication, Pharmaceutical Services Branch | |
Stewart, Eileen Adeline (PDF File, 284.7 KB) 2017 TASCD 553 |
Simon Cooper | 28-11-2018 | long term missing person, | |
Williams, Michael David (PDF File, 399.0 KB) 2018 TASCD 475 |
Simon Cooper | 19-11-2018 | homicide, murder, assault, head injury, Stainforth Court, Cornelian Bay | |
Duff, Jayde Kaylam (PDF File, 479.9 KB) 2018 TASCD 457 |
Rod Chandler | 09-11-2018 | transport and traffic related, motorcycle accident, drug and alcohol, methylamphetamine, cannabis, excessive speed, Meander Valley Road | |
Van Galen, Esther Grace (PDF File, 470.1 KB) 2018 TASCD 460 |
Rod Chandler | 09-11-2018 | Child & Infant Death, baby death, overlay, bed sharing, SIDS, sudden infant death, | |
Fenton, Timothy John (PDF File, 409.2 KB) 2018 TASCD 462 |
Simon Cooper | 08-11-2018 | adverse medical affects, inadequate treatment as a patient, Royal Hobart Hospital, ileus, aspiration pneumonia, sepsis, multiple organ failure, nasogastric tube | |
Unwin, David Paul (PDF File, 409.3 KB) 2018 TASCD 466 |
Rod Chandler | 05-11-2018 | Coroner's finding, coroner's recommendation, sepsis, kidney transplant, polycystic kidney disease, adverse medical effects, physical health | |
Cohen, Yvonne Dawn (PDF File, 397.9 KB) 2018 TASCD 467 |
Simon Cooper | 05-11-2018 | pneumonia, undiagnosed, North West Regional Hospital, standard of care, medical care | |
Blazely, Corey Benjamin Maverick (PDF File, 379.0 KB) 2018 TASCD 465 |
Simon Cooper | 05-11-2018 | transport and traffic related, pedestrian struck by motor vehicle, Southern Outlet | |
Dent, Freda Lillian Florence (PDF File, 384.0 KB) 2018 TASCD 450 |
Olivia McTaggart | 30-10-2018 | ischaemic heart disease, Freemasons, inadequate care, nursing home. | |
Bowden, Frederick Rocky (PDF File, 560.3 KB) 2018 TASCD 433 |
Simon Cooper | 19-10-2018 | death in care, death in custody, mental illness and health, Roy Fagan Centre, schizophrenia, pneumonia, renal failure. | |
Sheehan, Leon Dennis (PDF File, 371.6 KB) 2018 TASCD 444 |
Simon Cooper | 19-10-2018 | motor vehicle crash, transport and traffic related, positional asphyxia, drink driving, driving whilst alcohol in body, exceed 0.05, driving affected by alcohol. | |
Dufty, David Richard (PDF File, 552.6 KB) 2018 TASCD 434 |
Simon Cooper | 19-10-2018 | death in custody, death in care, mental illness and health, Royal Hobart Hospital, metastatic carcinoma, schizophrenia | |
Walsh, Chloe Michelle (PDF File, 399.4 KB) 2018 TASCD 439 |
Simon Cooper | 18-10-2018 | motor vehicle accident, single vehicle crash, transport and traffic related, Strahan, alcohol and drugs, cannabis, failure to wear a seatbelt, unroadworthy vehicle, learner driver, passenger, dangerous driving, section 167A Criminal Code Act 1924 (Tas) | |
MacQueen, Tyrone Frederick (PDF File, 513.1 KB) 2018 TASCD 441 |
Simon Cooper | 18-10-2018 | long term missing person, 1994, Ravenswood, northern Tasmania, mental illness and health, undetermined circumstances of death, undetermined cause of death | |
Jones, Tristan Adam (PDF File, 522.4 KB) 2018 TASCD 425 |
Rod Chandler | 17-10-2018 | subarachnoid haemorrhage, middle cerebral artery rupture, hospital policies, hospital transfers. | |
MacKinnon, Ian (PDF File, 393.3 KB) 2018 TASCD 423 |
Simon Cooper | 17-10-2018 | Work Related, tractor, agricultural machine, rock picker, crush by machine, crush by rock picker, farming, farm accident. | |
McTye, Wilma (PDF File, 399.3 KB) 2018 TASCD 417 |
Olivia McTaggart | 15-10-2018 | older persons, falls, subdural haematoma, Lewy Body Dementia, aged care, Strathaven Aged Care Facility | |
Roberts, Theressa Mae (PDF File, 398.2 KB) 2018 TASCD 412 |
Rod Chandler | 04-10-2018 | Transport & traffic related, coroner's finding, pedestrian fatality | |
Davis, Alby Fox (PDF File, 399.9 KB) 2018 TASCD 378 |
Simon Cooper | 02-10-2018 | Coronial, Hypoxic Brain Injury, Bouncy Ball, Throat | |
Patrick, Robert David (PDF File, 368.9 KB) 2018 TASCD 398 |
Rod Chandler | 21-09-2018 | West Coast District Hospital, medical related, abdominal aortic aneurysm | |
Hill, Trent Terrence (PDF File, 400.3 KB) 2018 TASCD 395 |
Rod Chandler | 20-09-2018 | Finding, motor vehicle accident, alcohol, transport and traffic related | |
NN (PDF File, 397.9 KB) 2018 TASCD 274 |
Olivia McTaggart | 20-09-2018 | Alcohol-induced central nervous system depression, alcohol-related heart disease, hypothermia, location, physical health | |
Smith, Nicky Glenn (PDF File, 437.8 KB) 2018 TASCD 396 |
Rod Chandler | 20-09-2018 | traffic and transport related, motor vehicle crash, single vehicle crash, alcohol and drugs, drink driving, intoxication, failure to wear seatbelt, unroadworthy vehicle, Lake Leake Highway | |
Steer, Michael Allan (PDF File, 289.1 KB) 2018 TASCD 316 |
Olivia McTaggart | 20-09-2018 | Drugs & Alcohol, mixed drug toxicity, drug seeking, schedule 8 drugs, doctor shopping, quetiapine, codeine, diazepam, fluoxetine, central nervous system depression, prescription medication, drug overdose, Pharmaceutical Services Branch, recommendations schedule 4 drugs, recommendations Poisons Act, | |
Jones, Gweneth Elsie (PDF File, 373.1 KB) 2018 TASCD 399 |
Rod Chandler | 20-09-2018 | Coronial, findings, blunt force, accidental fall, unwitnessed fall, lung bronchopneumonia, small dilstal pulmonary emboli, | |
Peart, Alexander Alfred and Ruby Rose (PDF File, 395.5 KB) 2018 TASCD 390 and 391 |
Olivia McTaggart | 19-09-2018 | transport and traffic related, motor vehicle accident, child and infant death, Sorell causeway | |
Ronald Grundy, Aaron Jeffrey and Ian Smith.pdf (PDF File, 490.8 KB) 2018 TASCD 375 376 377 |
Simon Cooper | 14-09-2018 | Law Enforcement, death in custody, death in care, natural causes death, Wilfred Lopes Centre, Risdon Prison, Section 28(5) Coroners Act. | |
Dick, Braiden Taylor (PDF File, 437.5 KB) 2018 TASCD 372 |
Rod Chandler | 07-09-2018 | intentional self harm, suicide, youth, Child and Adolescent Mental Health Services, mental illness and health, Spencer Clinic | |
Hamill, Tracey Fay (PDF File, 407.5 KB) 2018 TASCD 359 |
Simon Cooper | 03-09-2018 | transport and traffic related, motor vehicle accident, mental health and illness, depression, Penquite Road, Launceston | |
Green, Paul William (PDF File, 457.7 KB) 2018 TASCD 336 |
Olivia McTaggart | 31-08-2018 | carbon monoxide poisoning, exhaust gas, lawn mower exhaust, Mental Illness & Health, prevention of suicide, older persons, suicide prevention. | |
Oosterloo, Jane (PDF File, 371.8 KB) 2018 TASCD 364 |
Rod Chandler | 31-08-2018 | hospital, medical, haemopericardium, surgical, Launceston General Hospital | |
Cross, Adrian John.pdf (PDF File, 372.2 KB) 2018 TASCD 349 |
Simon Cooper | 29-08-2018 | cyclist hit truck, transport and traffic related, bicycle rides into truck. | |
Horsham, Gordon James (PDF File, 371.7 KB) 2018 TASCD 327 |
Simon Cooper | 27-08-2018 | Transport and Traffic Related, motor vehicle crash, motor vehicle accident, seatbelt, not wearing seatbelt, seatbelt fastened incorrectly, | |
Hall, Alexander (PDF File, 381.2 KB) 2018 TASCD 324 |
Simon Cooper | 24-08-2018 | tractor accident, tractor crash, transport and traffic related, seatbelts, seatbelts in tractors | |
Bruinger, Stephen Guy (PDF File, 364.8 KB) 2018 TASCD 350 |
Rod Chandler | 17-08-2018 | medical related death, Royal Hobart Hospital, Emergency Department, overcrowding | |
Gorrie, Kurt Joshua (PDF File, 568.9 KB) 2018 TASCD 309 |
Simon Cooper | 03-08-2018 | work related, work place death, fall from height, King Island airport, failure to wear safety harness, Coroner's recommendations, Work Health and Safety Act 2012 | |
Miller, Melinda Shirley (PDF File, 561.9 KB) 2018 TASCD 298 |
Simon Cooper | 27-07-2018 | Mental Illness and Health, Clozapine, Olanzapine, Community Treatment Order, Mental Health Act, Natural Cause Death, Coroner's Recommendations | Update provided by THS South 14 October 2022 In relation to recommendation 1 - Rejected (1) This recommendation seeks to avoid the problem of post mortem redistribution by taking multiple blood samples immediately following and for 72 hours after death. The mortuary service only operates 7.30am to 4.00pm. It would require a coronial order to draw PM blood prior to the autopsy implementation is not practical at this stage. Furthermore, there is a long standing issue in relation to retention of ante mortem admission blood samples in overdoses that die. Blood samples tend to be discarded at around day 7-10. If an overdose case dies after that time then there are no samples for toxicology to analyse. |
Fletcher, Braidon Lewis (PDF File, 284.8 KB) 2018 TASCD 300 |
Simon Cooper | 26-07-2018 | chainsaw, tree felling, crush by tree, domestic accident, chainsaw accident, tree felling accident, jammed chainsaw, pull tree down with ute, unsafe chainsaw use, chainsaw recommendations, chainsaw training. | |
Greaves, Brett Jason (PDF File, 375.3 KB) 2018 TASCD 299 |
Simon Cooper | 26-07-2018 | transport and traffic related, motorcycle accident, coroner's recommendations | |
Orton-Tracey, Jim (PDF File, 399.8 KB) 2018 TASCD 311 |
Olivia McTaggart | 26-07-2018 | pulmonary embolism, immobilised lower leg, 'moon boot', anticoagulation | |
Weber, Kevin Howard (PDF File, 365.1 KB) 2018 TASCD 306 |
Olivia McTaggart | 26-07-2018 | falls, leisure activity, fall striking head, subdural haematoma, hand rail, fall from steps. | |
KW (PDF File, 371.9 KB) 2018 TASCD 297 |
Olivia McTaggart | 25-07-2018 | Drugs & Alcohol, Leisure Activity, Misadventure, exposure to sun, mixed drug toxicity, excessive consumption of alcohol, preventing protective responses to dangerous environmental conditions | |
Lee, Lester William (PDF File, 407.0 KB) 2018 TASCD 286 |
Simon Cooper | 19-07-2018 | long-term missing person, undetermined cause of death, Devonport | |
Mackozdi, Janet Lois (PDF File, 795.0 KB) 2018 TASCD 274 |
Olivia McTaggart | 13-07-2018 | older persons, elderly, elder abuse, hypothermia, dementia, coroner's recommendations, domestic incident, Mt Llyod | |
Godley, David Geoffrey (PDF File, 674.7 KB) 2018 TASCD 273 |
Olivia McTaggart | 06-07-2018 | intentional self-harm, mental health and illness, psychosis, self-inflicted stabbing, weapon, drugs and alcohol, ice, cannabis, methamphetamine | |
MB (PDF File, 458.8 KB) 2018 TASCD 241 |
Olivia McTaggart | 20-06-2018 | drug overdose, tramadol, alprazolam, drugs & alcohol, mental illness & health, drug toxicity, sharing prescription drugs, supply prescription drug to another, drug interaction, sharing restricted medications. | |
Shayler-Appleton, Gemma Louise (PDF File, 371.5 KB) 2018 TASCD 239 |
Simon Cooper | 20-06-2018 | transport and traffic related, motor vehicle accident, pedestrian | |
Baxter, Joyce Kathleen (PDF File, 291.9 KB) 2018 TASCD 236 |
Simon Cooper | 13-06-2018 | Long term missing person, missing person, disappearance 1955, bones, Organ Pipes, Mt Wellington, human remains, DNA profiling, undetermined cause of death. | |
Morris, Audrey Anne (PDF File, 374.9 KB) 2018 TASCD 237 |
Simon Cooper | 13-06-2018 | fire related, house fire, wood heater, smoke inhalation | |
Burkhardt, Wesley Ian (PDF File, 372.1 KB) 2018 TASCD 231 |
Simon Cooper | 12-06-2018 | transport & traffic related, motorcycle crash, motor vehicle crash, motorbike, methyl amphetamine, driving motorcycle under influence of drug, drug driving, motorcycle collides with truck. | |
Osborn, James Lee (PDF File, 379.8 KB) 2018 TASCD 230 |
Olivia McTaggart | 12-06-2018 | Mental Illness & Health, Intentional Self-Harm, drowning, jump off jetty with weight, false report of missing person. | |
Campbell, Kenneth Arthur (PDF File, 371.8 KB) 2018 TASCD 225 |
Simon Cooper | 08-06-2018 | ischaemic heart disease, atrial fibrillation, mitral valve regurgitation, congestive cardia failure, heart attack while driving, natural cause death, Transport & Traffic Related. | |
Hayes, Teegan Rose Dana (PDF File, 443.6 KB) 2018 TASCD 208 |
Olivia McTaggart | 31-05-2018 | child & infant death, co-sleeping, bed sharing, SIDS, Sids and Kids, Red Nose, suffocation, Child Protection Services, alcohol, brain damage, safe sleeping practices, neglect, Tasmanian Government Response to Coroner's Recommendations, Vulnerable Infants and Babies Strategy, Child and Youth Services. | |
Forward, Trudi Maree (PDF File, 630.4 KB) 2018 TASCD 197 |
Rod Chandler | 30-05-2018 | Royal Hobart Hospital, RHH, thrombus, delay in diagnosis, misdiagnosis, medical failures, failure to diagnose, sepsis, multiple organ failure, infarct, necrosis, small bowel, superior mesenteric artery, | Updated response provided by THS South 14 October 2022 A statewide Inter-Hospital Transfer policy along with a time critical patient transfer policy has been implemented to support necessary system changes. |
Simmons, Lawrence John (PDF File, 278.8 KB) 2018 TASCD 212 |
Simon Cooper | 29-05-2018 | undetermined cause of death, disappearance, long term missing person, | |
Jarman, Andrew John (PDF File, 379.1 KB) 2018 TASCD 209 |
Simon Cooper | 28-05-2018 | missing person, Drugs & Alcohol, Mental Illness & Health, human remains, Warrawee Reserve, asphyxia. | |
Fletcher, Thomas Charles and Priest, Leonard Roger (PDF File, 331.3 KB) 2018 TASCD 195 and 196 |
Olivia McTaggart | 24-05-2018 | Leisure Activity, older persons, sports related, water related, weather related, boating, drowning, Park Beach Tasmania, capsize, life jackets. | |
Knight, Milfred Keith (PDF File, 449.5 KB) 2018 TASCD 192 |
Simon Cooper | 21-05-2018 | aircraft crash, light aircraft, Devonport Airport, transport and traffic related, leisure activity | |
Jackson, Margaret Joan (PDF File, 381.9 KB) 2018 TASCD 101 |
Olivia McTaggart | 19-05-2018 | Transport & Traffic Related, motor vehicle crash, Interlaken Road, gravel road, drive without due care, inexperienced driver, speed limit. | |
Cuthbertson, Kevin Ross (PDF File, 384.4 KB) 2018 TASCD 187 |
Rod Chandler | 15-05-2018 | Transport & Traffic Related, crush by campervan, home mechanics, crushed working under vehicle, crushed working under campervan. | |
Daniels, Scott Allen (PDF File, 280.1 KB) 2018 TASCD 174 |
Simon Cooper | 07-05-2018 | Drugs & Alcohol, Mental Illness & Health, Misadventure, positional asphyxia, clozapine, antipsychotic, cannabis, THC, marijuana. | |
Kerry Michael (PDF File, 374.1 KB) 2018 TASCD 168 |
Simon Cooper | 03-05-2018 | homicide, murder, weapon, location, homicide and assault, Mount Roland, struck by rock. | |
Broomhall, Callum Dane (PDF File, 274.1 KB) 2018 TASCD 127 |
Olivia McTaggart | 24-04-2018 | transport and traffic related, single vehicle crash, drink-driving, alcohol and drug related, failure to wear a seat-belt | |
Weedon, Jackson Nate John Daniel (PDF File, 467.0 KB) 2018 TASCD 153 |
Rod Chandler | 23-04-2018 | transport and traffic related, motorbike crash, motorcycle crash, single vehicle crash, speeding | |
Williams, Brett (PDF File, 573.5 KB) 2018 TASCD 143 |
Simon Cooper | 20-04-2018 | murder, homicide, stabbing, Eggs and Bacon Bay, | |
Brown, Maddison Ann (PDF File, 363.8 KB) 2018 TASCD 145 |
Simon Cooper | 16-04-2018 | Transport & Traffic Related, motor vehicle crash, Murchison Highway, mobile phone while driving. | |
GW (PDF File, 355.9 KB) 2018 TASCD 148 |
Olivia McTaggart | 09-04-2018 | Alcohol & Drugs, alcohol intoxication, acute alcohol toxicity, acute ethanol toxicity, 0.524g/100ml, fatal alcohol level, aspiration pneumonia, chronic alcohol abuse, alcoholic, Mental Illness and Health. | |
Scott, Douglas Ian (PDF File, 368.8 KB) 2018 TASCD 132 |
Simon Cooper | 03-04-2018 | smoking, emphysema, oxygen concentrator, oxygen tubes, smoking using oxygen concentrator, oxygen deprivation, carbon dioxide toxicity, ignite oxygen, recommendation regarding medical oxygen concentrators. | |
Baby B (PDF File, 345.2 KB) 2018 TASCD 131 |
Simon Cooper | 02-04-2018 | SUDI, SIDS, child & infant death, sudden unexpected death in infancy, co-sleeping, coroner's recommendations | |
Britton, Eamon (PDF File, 274.3 KB) 2018 TASCD 121 |
Simon Cooper | 28-03-2018 | Long term missing person, missing person, human leg, DNA profiling, Forensic Science Service Tasmania, exhumation, bones, leg in Tamar River, | |
Pinner, Liam Christopher (PDF File, 370.0 KB) 2018 TASCD 126 |
Simon Cooper | 27-03-2018 | motor vehicle crash, motorcycle crash, loss control of motorcycle, motorbike crash, | |
Russell; Patricia Joy RC signed 26-3-18.pdf (PDF File, 380.3 KB) 2018 TASCD 141 |
Rod Chandler | 26-03-2018 | Health care, hospital, empyema, sepsis, complicating oesophageal perforation, diabetes, obesity, atherosclerotic coronary vascular disease | |
Hamlyn, Michael William (PDF File, 369.1 KB) 2018 TASCD 104 |
Simon Cooper | 19-03-2018 | Intentional self harm | |
MC (PDF File, 363.0 KB) 2018 TASCD 108 |
Simon Cooper | 19-03-2018 | Drugs & Alcohol, Misadventure, combined drug intoxication, drug overdose, self-medicate, Mental Illness & Health, doctor shopping, opioid medication, drug-seeking behaviour, schedule 8 drugs, U-$7700, mixed drug toxicity. | |
Bessell, Lynne - finding web.pdf (PDF File, 475.3 KB) 2018 TASCD 107 |
Rod Chandler | 19-03-2018 | coronial, metastatic carcinoma of colon, emphysema, acute bronchopneumonia, | |
Vince, Brock (PDF File, 275.4 KB) 2018 TASCD 99 |
Christopher Webster | 15-03-2018 | intentional self harm, St Helens Private Hospital, seroquel, quetiapine, drowning, bath, drugs & alcohol, re-examined findings | |
Little, Neita Jean (PDF File, 642.8 KB) 2018 TASCD 97 |
Rod Chandler | 14-03-2018 | North West Regional Hospital, Older Persons, death after surgery, complications from surgery, Adverse Medical Effects, aspiration pneumonia, small bowel obstruction, gall bladder surgery, haematoma, blood clot. cardiovascular disease, morbid obesity, inadequate care. | |
Bunn, Lauren Elizabeth (PDF File, 375.6 KB) 2018 TASCD 094 |
Simon Cooper | 05-03-2018 | Drugs and Alcohol, mixed drug toxicity, mental illness, self-harm, Police Radio Dispatch Service, RDS, prescription drugs, review RDS policies, review police policy, ambulance dispatch. | |
Patmore, Jason (PDF File, 378.0 KB) 2018 TASCD 088 |
Olivia McTaggart | 28-02-2018 | haemorrhagic stroke complicating anticoagulation, intravenous antibiotic therapy, deep vein thrombus, hospital, traumatic brain injury, bicycle crash, | |
Evans, Jillian and John (PDF File, 342.2 KB) 2018 TASCD 81 and 82 |
Olivia McTaggart | 28-02-2018 | homicide, suicide, murder, murder suicide, violence, assault, domestic violence, delusions, bipolar, mental health, | |
King, David John (PDF File, 449.0 KB) 2018 TASCD 091 |
Simon Cooper | 26-02-2018 | Royal Hobart Hospital, RHH, aspiration pneumonia, acquired brain injury, unwitnessed fall, group home, alcohol, alcohol via Percutaneous Endoscopic Gastrostomy, Drugs & Alcohol, Falls, Physical Health. | |
Fitzgerald, Oswyn Leigh (PDF File, 272.7 KB) 2018 TASCD 89 |
Olivia McTaggart | 23-02-2018 | transport and traffic related, single vehicle accident, Baskerville Raceway, cardiac arrhythmia | |
Thompson, Ian Graham (PDF File, 608.4 KB) 2018 TASCD 73 |
Simon Cooper | 16-02-2018 | work related, workplace death, Tassal, fishing vessel, Efishent, Worksafe Tasmania, capstan, accident | |
Reaney, Leigh Anthony (PDF File, 432.9 KB) 2018 TASCD 071 |
Simon Brown | 13-02-2018 | blunt force, ground, fall, balcony, roof | |
Towns, Martin John (PDF File, 212.4 KB) 2018 TASCD 59 |
Duncan Fairley | 05-02-2018 | drugs and alcohol, fall, subdural haematoma | |
Mrs F de-identified (PDF File, 379.1 KB) 2018 TASCD 62 |
Rod Chandler | 05-02-2018 | Hospital, Aged Care, Falls, Mental Illness and Health, Older Persons, Physical Health, fracture of neck of femur, nursing home, RHH, Royal Hobart Hospital, death in medical setting, Coroners Recommendations | Updated response provided by THS South 14 October 2022 Recommendation (1) The RHH has switched from using the FRAT to the Falls Assessment and Management Plan (FAMP). The rollout of the Falls Assessment and Management Plan (FAMP) to other areas within the THS has continued with the roll out and implementation within the RHH, Repatriation Centre inpatient units, community nursing services and district hospitals. This has extended to a Statewide rollout which has commenced in the north and northwest of the State. The rollout is supported by the senior nursing staff in the areas, allied health and Clinical Nurse Educators. The completion of the charts within the areas is monitored by the staff on the units through monthly' point of care' audits and monthly review of their data. This data is available to the senior executives and the Falls Minimisation Action Group as part of ongoing quality improvement and patient safety monitoring which includes falls rates and severity of injuries. The Falls Minimisation Action Group has also introduced a post fall safety huddle where the team and the patient discuss their recent fall and review strategies in place and recommend new actions if required to prevent further falls. Post fall monitoring of the patient through a post fall clinical pathway has also been adopted across Hospitals South to ensure patients that have had a fall receive medical and nursing clinical review of their condition with frequent observations, and CT scan if a head strike has occurred. The observations and standard of care required post a fall is standardised and any deterioration or review required is provided in a timely manner. Patient and family education is included to prevent falls on the wards and information is provided to the patient during their stay on admission and on discharge. Recommendation (2) Direct observation of patients at risk of falling is one strategy in the prevention of falls. The FAMP identifies patients at risk of falling through risk factors such as history of previous fall, unsteady gait, visually impaired, on 4 or more medications and confusion for example. The actions to alleviate or reduce these risks are listed beside the risk identified, and the nurse needs to date and sign that the action has occurred. On the back of the form is a management plan for the patient with communication, environmental, equipment and other care strategies listed. If implemented these need to be signed and dated. Observation is one strategy, and this can be frequent rounding and surveillance by nursing staff every 15 - 30 minutes for example, supervision during toileting and hygiene, mobilisation, or patient safety observers if the nurse's clinical judgement is that they need 1:1 supervision for a period of time, till they are stablised. Bed/ chair check alarms are put in place if the patient is impulsive, confused or cognitively impaired and is unable to use a call bell for assistance. The Falls Minimisation Action Group has encouraged units where able to incorporate the bed/ chair check alarm into the call bell system. Beds with inbuilt bed alarms are also being reviewed for future purchase in some areas following evaluation of their use. Other strategies mentioned in 2019 have continued with close supervision by moving patients close to the nurse's station, referral to Allied Health for review. Recommendation (3) As outlined above audits occur monthly on the inpatient units, with the units that do not meet the target on the audit rating supported by CNEs and other senior staff within Q&PS to undertake quality improvement projects to improve their practice. These results are available to the Hospitals South stream executives for further support if required to meet the accepted standard. The Falls Action Group reviews the overall Hospitals South results monthly at their meeting and if these are low new initiatives are discussed and where appropriate may be developed to improve practice to meet the Australian Commission of Safety and Quality in Health Care Standards. These strategies are outlined in a Hospitals South- Preventing Falls and Harm from Falls Protocol. Recommendation (4) The FAMP tool has been rolled out with education and tools for staff. There is a Falls Prevention and Management Plan developed for each patient as part of the FAMP tool. This is individualised for all patients and their risk factors. Prior to this, only those patients identified as high risk had individualised plans. The FAMP is also one tool in the Comprehensive Assessment of patients within RHH and will be incorporated into an overall Comprehensive Care Plan for all patients following a recent trial. Patients that are identified at risk of falls - an Falls Alert can be placed on their file that is current for their present and future admissions if required. There is now only one Falls Alert rather than the two previous versions. This alerts staff to those patients at risk of falling in all care settings. As mentioned earlier the Post Fall Clinical Pathway, Post Fall safety Huddle and regular auditing of charts have been introduced to provide appropriate patient strategies for the patient to prevent falls and serious harm from falls. Serious falls that cause head injuries or fractures or other serious harm are then investigated either by London Protocol or Root Cause analysis so that any recommendations for improvement can be implemented to prevent further incidents. Recommmendation (5) All requests from the Coroner need to come through the RHH Medico-Legal office with endeavours to meet the Coroner's requested timelines |
Dunk, Michael & Johnson, Elishka (PDF File, 213.3 KB) 2018 TASCD 60; 2018 TASCD 61 |
Duncan Fairley | 05-02-2018 | homicide & assault, weapon, firearm, intentional self harm, mental illness & health | |
Ruling and Reasons on Objection to Admissibility of Evidence - Gleeson, Lucas and Welsh (PDF File, 371.6 KB) |
Simon Cooper | 01-02-2018 | Copper Mines Tasmania, Barminco, mine deaths, ruling on admissibility of evidence, Mount Lyell mine, Queenstown mine, work place deaths, work related, location, | |
Marriott, Molli Margaret Anne (PDF File, 374.2 KB) 2018 TASCD 42 |
Olivia McTaggart | 31-01-2018 | Motor vehicle accident, traffic and transport related, child unrestrained, drugs and alcohol, learner driver | |
Stewart, Justin Blade (PDF File, 370.9 KB) 2018 TASCD 029 |
Duncan Fairley | 29-01-2018 | mixed drug toxicity, drugs and alcohol, schizophrenia, mental illness and health, Oxazepam, Quetiapine, Temazepam, Alprazolam, accidental overdose, antipsychotic drugs, | |
Bryan, Timothy David (PDF File, 438.9 KB) 2018 TASCD 87 |
Simon Cooper | 29-01-2018 | motor vehicle accident, transport and traffic related, drugs and alcohol, failure to wear a seat belt, drink driving | |
Mr M (PDF File, 404.6 KB) 2018 TASCD 025 |
Rod Chandler | 29-01-2018 | Adverse Medical Effects, Royal Hobart Hospital, RHH, thrombotic stroke, thrombus, hypertensive cardiovascular disease, emphysema, Launceston General Hospital, LGH, mistreatment, misdiagnosis, North West Regional Hospital, standard of care, recommendations for hospitals. | |
Ball, Betty Irene. (web) pdf.pdf (PDF File, 494.0 KB) 2018 TASCD 56 |
Rod Chandler | 29-01-2018 | spinocerebellar ataxia, hospital, St Luke's Calvary, Aged Care, inadequate care, constipation, Presbyterian Care, Older persons, physical health, bowel obstruction. | |
Lockwood, Shane (PDF File, 406.3 KB) 2018 TASCD 52 |
Rod Chandler | 25-01-2018 | Mental health & illness, intentional self harm, Clozapine, Risperidone, Mental Health Order | |
Woolley, Paul James (PDF File, 497.0 KB) 2018 TASCD 40 |
Rod Chandler | 24-01-2018 | Royal Hobart Hospital, RHH, hospital death, deep vein thrombus, heparin-induced thrombocytopenia, HITS, sleep apnoea, complications of medical care, adverse medical affects, physical health, CPAP machine, failure in care. | |
Edmonds, Ashley Samantha (PDF File, 377.3 KB) 2018 TASCD 44 |
Duncan Fairley | 01-01-2018 | motor vehicle crash, transport and traffic related, Bradley Chaplin, school bus, inappropriate driving, driving offences. | |
Ross, Ronald Charles (PDF File, 273.6 KB) 2017 TASCD 535 |
Olivia McTaggart | 13-12-2017 | Undetermined cause of death | |
Allen, Vincent (PDF File, 366.6 KB) 2017 TASCD 530 |
Olivia McTaggart | 11-12-2017 | transport and traffic related, motor vehicle accident, drug and alcohol, dangerous driving | |
Lehmann, Matthias (PDF File, 444.1 KB) 2017 TASCD 538 |
Simon Cooper | 11-12-2017 | missing person, possible drowning, Spirit of Tasmania, possible suicide | |
Woods, Brian Oakley (PDF File, 276.7 KB) 2017 TASCD 521 |
Olivia McTaggart | 08-12-2017 | motorcycle crash, motorbike crash, transport and traffic related, speeding, Black Charlie's Opening, Tasman Highway, excessive spped, double white lines, blind corner. | |
Burling, Gregory (PDF File, 373.5 KB) 2017 TASCD 531 |
Simon Cooper | 07-12-2017 | carbon monoxide intoxication, inhalation of exhaust, petrol generator, boat, boating accident, Water Related, exhaust gas, carbon monoxide detector, | Response from Marine and Safety Tasmania (MAST) 16 July 2019
|
Daley, Brian Owen (PDF File, 374.1 KB) 2017 TASCD 532 |
Simon Cooper | 07-12-2017 | carbon monoxide intoxication, inhalation of exhaust, petrol generator, boat, boating accident, Water Related, exhaust gas, carbon monoxide detector, | Response from Marine and Safety Tasmania (MAST) 16 July 2019
|
Simpson, Peter Lawrence (PDF File, 359.8 KB) 2017 TASCD 514 |
Olivia McTaggart | 07-12-2017 | drugs & alcohol, mixed prescription drug toxicity, methadone, diazepam, promethazine | |
Plummer, Samuel Anthony (PDF File, 348.4 KB) 2017 TASCD 469 |
Duncan Fairley | 29-11-2017 | sudden unexpected death in a person with epilepsy (SUDEP) | |
Smith, Molly Jessie (PDF File, 761.7 KB) 2017 TASCD 444 |
Olivia McTaggart | 17-11-2017 | death in care, Roy Fagan Centre, mental illness and health, GP Assist, misdiagnosis, pneumonia, pyelonephritis. | |
Patmore, Jason - Decision as to Inquest.pdf (PDF File, 417.9 KB) |
Olivia McTaggart | 17-11-2017 | decision not to inquest, | |
Rushton, Ethan Charles & Kearnes, Christopher Peter (PDF File, 131.0 KB) 2017 TASCD 440 and 441 |
Duncan Fairley | 06-11-2017 | Transport & Traffic related, motorcycle accident, speeding, drug & alcohol related | |
French, Steven John (PDF File, 500.6 KB) 2017 TASCD 445 |
Rod Chandler | 01-11-2017 | Adverse Medical Effects, Hospital death, stroke, Royal Hobart Hospital, North West Regional Hospital, misdiagnosis, shortcomings in care, inadequate care, failure to diagnose. | |
Kingston, Neil Robert (PDF File, 142.9 KB) 2017 TASCD 439 |
Simon Cooper | 23-10-2017 | Tree felling, chainsaw, domestic accident, no helmet, Coroner's recommendations | |
Wang, Yu Qian (PDF File, 262.9 KB) 2017 TASCD 548 |
Simon Cooper | 23-10-2017 | motor vehicle crash, transport and traffic related, lost control of vehicle, overtaking, collision with tree, inexperienced driver, driver inexperience, seatbelt, failure to wear seatbelt, incorrectly fastened seatbelt. | |
Trent Walliker (PDF File, 282.3 KB) 2017 TASCD 420 Trent Walliker |
Olivia McTaggart | 23-10-2017 | blunt force trauma, lower chest area, single vehicle accident, motorcycle accident | |
Allie, Sue Denise (PDF File, 382.0 KB) 2017 TASCD 415 |
Olivia McTaggart | 12-10-2017 | Undetermined cause, Munchausen Syndrome, factitious disorder, superwarfarin (brodifacoum) toxicity | |
Freestone-Barks, Rosalind MacDonald Maxwell (PDF File, 449.7 KB) 2017 TASCD 387 |
Duncan Fairley | 25-09-2017 | Motor bike accident, coronial, multiple injuries | |
Jock, Chuak John (PDF File, 275.1 KB) 2017 TASCD 546 |
Olivia McTaggart | 25-09-2017 | Transport and Traffic Related, motor vehicle crash, motor vehicle accident, bald tyres, Channel Highway, driver error, loss of control, damp road, wet road, gravel verge. | |
Willox, Brian William (PDF File, 162.0 KB) 2017 TASCD 408 |
Duncan Fairley | 25-09-2017 | fracture neck, fall standing height, | |
Hedrick, Gary John (PDF File, 264.3 KB) 2017 TASCD 388 |
Olivia McTaggart | 25-09-2017 | Water related, drowning, alcohol, intoxication | |
Pel, Tracie Ann and Pel, Michael Geraddus (PDF File, 371.1 KB) 2017 TASCD 393 & 394 |
Rod Chandler | 18-09-2017 | motorcycle, passenger, neck injuries, chest injuries, abdominal injuries, round bale | |
Tabor, Pamela Lois and Belinda Ann (PDF File, 163.0 KB) 2017 TASCD 403 |
Duncan Fairley | 11-09-2017 | motor vehicle, car crash, head injuries, chest injuries, multiple fatality | |
Falvey, Theresa Mary (PDF File, 378.0 KB) 2017 TASCD 373 |
Duncan Fairley | 11-09-2017 | Neck Injury, Single motor vehicle collison | |
Holmes, David Scott (PDF File, 228.4 KB) 2017 TASCD 379 |
Olivia McTaggart | 08-09-2017 | Transport & Traffic Related, Work Related, motor vehicle crash, truck crash, truck rollover, prime mover truck, cardiac arrhythmia, heart attack, physical health. | |
Quad bike related deaths of Heather Dawn Richardson, Jan Severin Jensen, Kendall Russell Bonney, Vicki Mavis Percy, Jay Randall Forsyth, Jabob Graham Green and Roger Maxwell Larner (PDF File, 3.9 MB) 2017 TASCD 329 330 331 332 333 334 and 335 |
Simon Cooper | 25-08-2017 | quad bikes, ATV, Leisure Activity, Transport & Traffic Related, quad bike safety, quad bike crash, quad bike accident, quad bike rollover, crushing, brain injury, WorkSafe Tasmania, quad bike fatality, quad bike deaths. | |
AH - de-identified (PDF File, 465.3 KB) 2017 TASCD 405 |
Rod Chandler | 22-08-2017 | Mental illness & health, intentional self harm, suicide, depression, Royal Hobart Hospital, Crisis Assessment and Treatment Team | Update response provided by THS South 14 October 2022 Recommendation 1 Transfer of Care processes have been ratified and uploaded into SDMS. Recommendation 2 The Statewide Separation Summary Policy has been adopted. All separation summaries are sent electronically by encrypted transmission or by Fax. Separation summaries are also sent to the My Health Record where one exists. The KPI is 48 hours. GP Liaison Officer receives and logs complaints where handover is inadequate. |
Dransfield, Brian (PDF File, 241.2 KB) 2017 TASCD 323 |
18-08-2017 | Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws | ||
Howard, Lawrence Alan (PDF File, 242.6 KB) 2017 TASCD 324 |
Simon Cooper | 11-08-2017 | Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws | |
Mitchell, Kenneth Hudson (PDF File, 243.4 KB) 2017 TASCD 326 |
Simon Cooper | 11-08-2017 | Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws | |
Spanney, Kenneth David (PDF File, 242.0 KB) 2017 TASCD 327 |
Simon Cooper | 11-08-2017 | Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws | |
Hyland, Tobias Joseph (PDF File, 241.0 KB) 2017 TASCD 325 |
Simon Cooper | 11-08-2017 | Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws | |
Young, Dylan Broderick Ernest (PDF File, 247.2 KB) 2017 TASCD 328 |
Simon Cooper | 11-08-2017 | Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws | |
Barker, Richard Carl (PDF File, 255.0 KB) 2017 TASCD 302 |
Andrew McKee | 28-07-2017 | Work Related, work place death, industrial accident, work place accident, crushing, crush by metal plate, BIS Industries, ATH Engineering and Maintenance, work site accident, work place safety, safety harness, safety rails. | |
Langford, Samuel Peter and Jones, Timothy Peter (PDF File, 306.3 KB) 2017 TASCD 316 and 317 |
Simon Cooper | 21-07-2017 | plane crash, Cape Raoul, Par Avion, Airline of Tasmania, Storm Bay, aircraft crash, Sydney to Hobart, photographing from plane, plane crash into sea, flying too low, fly at low height, low level flying, Civil Aviation Regulations, pilot error, Transport and Traffic Related. | |
Simpson, Bryan Thomas (PDF File, 369.3 KB) 2018 TASCD 282 |
Simon Cooper | 17-07-2017 | transport and traffic related, motor cycle crash, recommended speed, advisory speed sign. | |
Monson, Troy Colin; Michael, Robin and Mitchell, Scott Clifford (PDF File, 922.8 KB) 2017 TASCD 253, 254 and 255 |
Simon Cooper | 30-06-2017 | Deaths in Custody, death in custody, hanging, prison, Risdon Prison, prison van, seatbelt, Tasmania Police, Prison Health Care, prison systems, suicide, jail, gaol, Law Enforcement, prison cell, prisoner escort van, mental health. | |
Tate, Magella Luisa Faye (PDF File, 160.6 KB) 2017 TASCD 250 |
Duncan Fairley | 26-06-2017 | Transport & Traffic Related, motor vehicle crash, motor vehicle accident, provisional licence, P1 licence, fail to negotiate bend, lost control of vehicle, gravel, over corrected, crash into tree, loss of traction in gravel, inexperienced driver, car crash. | |
Johnstone, BJay (PDF File, 938.6 KB) 2017 TASCD 248 |
Olivia McTaggart | 23-06-2017 | infant, ill-treat child, child death, infant death, child protection, Child & Infant Death, Homicide & Assault, family violence, assault child, | |
Crosswell, Wendy (PDF File, 162.7 KB) TASCD 247 |
Simon Cooper | 20-06-2017 | Adverse Medical Effects, Hospital, PEG tube, Percutaneous Endoscopic gastrostomy tube; Royal Hobart Hospital, pyelonephritis, Misdiagnosis, Coroners Recommendations | Updated response provided by THS South 14 October 2022 Feedback is provided through existing case review within Medical Imaging |
Nancarrow, Maurice Cecil (PDF File, 242.3 KB) 2017 TASCD 241 |
Rod Chandler | 19-06-2017 | RHH, Hospital, Royal Hobart Hobart, misdiagnosis, complication of medical care, aspiration pneumonia, ileus, aspiration of gastric contents, failure to diagnose, renal failure, large bladder, bladder neck obstruction, | |
Baldock, Andrea Eileen (PDF File, 256.4 KB) 2017 TASCD 313 |
Rod Chandler | 16-06-2017 | sleeve gastrectomy, weight reduction surgery, gastroparesis, aspiration pneumonia, adverse medical effects, Launceston General Hospital, coroner's recommendations | |
Paino, Sarah (PDF File, 169.8 KB) 2017 TASCD 321 |
Simon Cooper | 12-06-2017 | Sarah Paino, Transport & Traffic Related, motor vehicle crash, Davey Street motor vehicle crash, fatal crash, stolen car, youth driver, unborn baby saved, car crash, manslaughter, | |
Bugg, Margaret Evalina (PDF File, 334.6 KB) 2017 TASCD 225 |
Rod Chandler | 12-06-2017 | North West Regional Hospital, Yaraandoo Nursing Home, fall, stand up lifter, coroners recommendations | |
Flockhart, Alexander Michael & Pauly, Damian Kenneth (PDF File, 320.1 KB) 2017 TASCD 204 & 205 |
Olivia McTaggart | 31-05-2017 | Coronial, violent, homicide, gunshot wounds, stab wound, firearms, | |
Harrison, John Joseph & Viney, Danny Leonard.pdf (PDF File, 111.9 KB) 2017 TASCD 208; 2017 TASCD 209 |
Duncan Fairley | 27-05-2017 | Water related, drowning, recreational boating, Waterhouse Point, PFD, not wearing a life-jacket, Marine & Safety Tasmania, boat insufficiently equipped | |
Smith, James Maurice (PDF File, 320.5 KB) 2017 TASCD 202 |
Rod Chandler | 19-05-2017 | Hospital, haemopericardium, pericardial tamponade, aortic dissection, incorrect diagnosis, misdiagnosis, poor medical practice, inadequate diagnosis, inadequate hospital care, ischaemia, surgical delay, cardiac arrest, | |
Woulleman-Jarvis, Anne Maree 2017 TASCD 188.pdf (PDF File, 349.4 KB) 2017 TASCD 188 |
Rod Chandler | 17-05-2017 | hospital, head injury, CT scan, fall, standing height, subacute subdural haematoma, closed head injury, | |
Fellows, Peter Leslie (PDF File, 235.2 KB) 2017 TASCD 185 |
Rod Chandler | 15-05-2017 | congestive cardiac failure, coronary artery disease, cardiac failure, dilated poorly contracting heart, acute myocardial infarct, atherosclerotic coronary vascular disease, cardiogenic shock, LGH, Launceston General Hospital, beta blockers, adverse medical effects, | |
Handasyde, Robert Neil (PDF File, 232.2 KB) 2017 TASCD 187 |
Rod Chandler | 08-05-2017 | medical care, older person, North West Regional Hospital, sepsis, septic shock, urinary tract infection, pyelonephritis | |
McCall, Pamela (PDF File, 318.8 KB) 2017 TASCD 173 |
Simon Cooper | 08-05-2017 | prescription medication, overdose, prescribing, panadeine forte, mixed drug and alcohol toxicity, paracentamol, propranolol, mental health issue. | |
Harris, Stephen Russell (PDF File, 271.6 KB) 2017 TASCD 172 |
Duncan Fairley | 04-05-2017 | Death in care, cardiac arrhythmia, North West Regional Hospital, Spencer Clinic, Mental Health order, Paliperidone | |
Higgins, Elizabeth Ann (PDF File, 728.7 KB) 2017 TASCD 160 |
Glenn Hay | 04-05-2017 | Drowning, water related, Little Howrah Beach | |
Jin, Kang (PDF File, 242.3 KB) 2017 TASCD 150 |
Olivia McTaggart | 28-04-2017 | Hypothermia, exposure, Overland Track, Cradle Mountain, Parks and Wildlife Service, tourist, unprepared bushwalker, search and rescue, coronial recommendations | |
Wright, Mark Norman (PDF File, 272.7 KB) 2017 TASCD 145 |
Olivia McTaggart | 28-04-2017 | Transport & Traffic related, motor vehicle crash, Drugs & Alcohol | |
Plowright, Ben Wara 2017 TASCD 159 (PDF File, 171.4 KB) 2017 TASCD 159 |
Duncan Fairley | 24-04-2017 | Drowning, water, river, threat to breathing, | |
Fisher, Melissa (PDF File, 160.2 KB) 2017 TASCD 129 |
Simon Cooper | 20-04-2017 | fall, bush walking, Southwest National Park, fall from height, fall from Federation Peak, | |
Roberts-Burton, Blaze Christian (PDF File, 180.5 KB) 2017 TASCD 130 |
Olivia McTaggart | 20-04-2017 | alcohol, drugs, intoxication, run over by truck, body on highway, diazepam, temazepam, alprazolam, methylamphetamine, | |
Sheedy, Barbara (PDF File, 166.9 KB) 2017 TASCD 182 |
Duncan Fairley | 19-04-2017 | Launceston General Hospital, fall, subdural haemorrhage, uncal herniation | |
Graham, Dylan Rhys (PDF File, 211.3 KB) 2017 TASCD 123 |
Olivia McTaggart | 10-04-2017 | Elizabeth Street Pier, Salamanca, undetermined cause of death | |
Hoskinson, Neville Robert (PDF File, 325.8 KB) 2017 TASCD 107 |
Rod Chandler | 31-03-2017 | cardiac tamponade, proximal aortic dissection, hypertension, Launceston General Hospital, angiogram, radiology, transthoracic echocardiogram, delayed diagnosis, adverse medical effects | |
Mr JC 105 TASAD 2017.pdf (PDF File, 172.4 KB) 2017 TASCD 105 |
Olivia McTaggart | 27-03-2017 | Thermal burns, single motorbike accident, | |
Whittle, Marion Olive 2017 TASCD 114 (PDF File, 167.0 KB) 2017 TASCD 114 |
Olivia McTaggart | 27-03-2017 | motor vehicle crash, cardiogenic shock, tricuspid regurgitation, Royal Hobart Hospital, corolla Sedan, traumatic papillary muscle laceration, blunt force, transport, vehicle occupant | |
Bird, Heather Mary (PDF File, 243.3 KB) 2017 TASCD 126 |
Rod Chandler | 20-03-2017 | Physical health, Royal Hobart Hospital, intensive care unit, ICU, Medical Emergency Team, inadequate care, retroperitoneal haemorrhage, anticoagulation, cerebrovascular infarct, intra-arterial cannulation, pneumonia, sub-acute stroke, haemorrhagic shock | Response provided by THS South 14 October 2022 Immediately following this event, Royal Hobart Hospital Medical Emergency Response (MET and Code Blue) Protocol was updated to include the following: |
HE (PDF File, 118.2 KB) 2017 TASCD 181 |
Simon Cooper | 16-03-2017 | echovirus type 9, myocarditis and pneumonitis, infant death, natural causes, St Mary's Community Hospital | |
Noble, Murray (PDF File, 168.7 KB) 2017 TASCD 89 |
Olivia McTaggart | 13-03-2017 | house fire, combustion, asphyxia, smoke inhalation, inhalation of products of combustion, | |
Greer, Rita (PDF File, 422.0 KB) 2017 TASCD 059 |
Olivia McTaggart | 23-02-2017 | self-inflicted stabbing, suicide, mental health, schizophrenia, section 58, re-open, re-investigation, Barbara Etter, | |
Free, Maxwell John (PDF File, 233.3 KB) 2017 TASCD 066 |
Rod Chandler | 22-02-2017 | paracetamol, paracetamol overdose, drug overdose, paracetamol toxicity, organ failure, Royal Hobart Hospital. | |
Slabkowski,_Mary.pdf (PDF File, 82.7 KB) 2017 TASCD 64 |
Duncan Fairley | 20-02-2017 | Older person, fall, subarachnoid haemorrhage, closed head injury, in-home care, LGH, Anglicare Tasmania | |
Scheffer, Yolande (PDF File, 87.7 KB) 2017 TASCD 62 |
Duncan Fairley | 20-02-2017 | Water related, drowning, Somerset beach, swimming, surf life saving, NWRH | |
DF (PDF File, 166.7 KB) 2017 TASCD 069 |
Simon Cooper | 09-02-2017 | newborn death, infant death, premature baby, extreme prematurity, acute chorioamnionitis, 23 weeks gestation. | |
Mordha, Debra Christine (PDF File, 162.8 KB) 2017 TASCD 017 |
Duncan Fairley | 23-01-2017 | drug toxicity, overdose, prescription medication, tramadol, amitriptyline, venlafaxine, diazepam. | |
Hosking, Jason Mathew Henry (PDF File, 364.2 KB) 2017 TASCD 380 |
Simon Cooper | 22-01-2017 | Royal Hobart Hospital, RHH, Misdiagnosis, Staphylococcus Aureus, Sepsis, Endocarditis Coroners Recommendation | Updated response provided by THS South 14 October 2022 (a) Microbiology Telephone Protocol developed and implemented requiring positive staph results to be phoned through directly to relevant clinician. Time, date and person receiving call is recorded. (b) The Statewide Separation Summary Policy has been adopted. All separation summaries are sent electronically by encrypted transmission or by Fax. Separation summaries are also sent to the My Health Record where one exists. The KPI is 48 hours. GP Liaison Officer receives and logs complaints where handover is inadequate. (c) There has been a significant increase in FTE to match increased activity in ED and EMU. EMU has a dedicated Consultant who rounds a number of times each day to facilitate appropriate discharges. |
Cobham, David Alexander (PDF File, 316.1 KB) 2016 TASCD 429 |
Rod Chandler | 19-12-2016 | Royal Hobart Hospital, RHH, rhabdomyolysis, aspiration pneumonia, Vaucluse Gardens, Bupa Care, entrapment, towel rail, nursing home, care facility, elderly, injury in care, death in care, care plan. | |
Cooper, David Wade Archer (PDF File, 166.1 KB) 2016 TASCD 432 |
Olivia McTaggart | 19-12-2016 | Transport & Traffic Related, Motor Vehicle Crash, motorcycle, East Derwent Highway, Geilston Bay, Grass Tree Hill, Pipers Road, Youth, learner, provisional, death by negligent driving, fail to give way, inadequate lookout | |
Harrison, Jason Keith (PDF File, 313.9 KB) 2016 TASCD 430 |
Rod Chandler | 16-12-2016 | NWRH, WCDH, small bowel infarct, sepsis, mesenteric hernia, regional hospital | |
Johnson, Damian (PDF File, 187.6 KB) 2016 TASCD 417 |
Olivia McTaggart | 06-12-2016 | Mercury Passage, Triabunna, Water Related, Leisure Related, Animal, great white shark, diver, scallops, Tasmania Police, Tas Maritime Radio | |
Lunson, Nathan (PDF File, 356.8 KB) 2016 TASCD 407 |
Olivia McTaggart | 05-12-2016 | Drugs and alcohol, prescription drug toxicity, mental illness and health | |
Deaths from a Public Place (PDF File, 509.2 KB) 2016 TASCD 385 386 387 388 389 390 |
Olivia McTaggart | 28-11-2016 | Tasman Bridge, Intentional Self-Harm, Mental Illness & Health, Tasmanian Suicide Prevention Strategy, drowning, jump, fall, surveillance, telephones, signage, barrier . | |
Mr S.pdf (PDF File, 162.7 KB) 2016 TASCD 377 |
Simon Cooper | 21-11-2016 | suicide, hanging, asphyxia, mental health, depression, mental health ward, Royal Hobart Hospital | |
Mr D (PDF File, 209.7 KB) 2016 TASCD 372 |
Olivia McTaggart | 11-11-2016 | Drugs & Alcohol, methylamphetamine | |
Richardson, Kenneth Charles (PDF File, 228.8 KB) 2016 TASCD 369 |
Rod Chandler | 10-11-2016 | Physical Health, Older Persons, Adverse Medical Effects, Drug Overdose, Royal Hobart Hospital, Coroners Recommendations | Updated response provided by THS South 14 October 2022 Nil recommendations for THS |
Hickman, Peter (PDF File, 257.6 KB) 2016 TASCD 371 |
Olivia McTaggart | 10-11-2016 | Transport & Traffic Related, Motor Vehicle Crash, Drugs & Alcohol, methylamphetamine, West Tamar Highway, Rosevears, single vehicle, oxycontin, amphetamine, alprazolam, methadone, Traffic Act, section 41A, bail | |
Hanlon, Louise Kamarnia May (PDF File, 175.0 KB) 2016 TASCD 347 |
Olivia McTaggart | 02-11-2016 | motor vehicle crash, car crash, motor accident, South Arm Road, provisional licence, P1. | |
Powell, Arthur John (PDF File, 164.3 KB) 2016 TASCD 370 |
Simon Coooper | 31-10-2016 | Adverse Medical Effects, Physical Health, Older Persons, Aged Care, Hobart Private Hospital, Royal Hobart Hospital, sepsis, parotid gland, perforated diverticulum, wound infection, discharge, inadequate care | |
McConnon, Desmond Keith (PDF File, 159.6 KB) 2016 TASCD 406 |
Simon Cooper | 31-10-2016 | Domestic Incident, Older Persons, fall, tree, trimming branches, safety equipment, harness, gardener | |
Bishop, Sarah Victoria (PDF File, 164.4 KB) 2016 TASCD 346 |
Simon Cooper | 17-10-2016 | Transport & Traffic Related, Motor Vehicle Crash, Channel Highway, Cygnet, dextromethorphan, robitussin, warnings, over the counter | |
Weily, Richard Maurice (PDF File, 322.5 KB) 2016 TASCD 323 |
Rod Chandler | 07-10-2016 | Older Persons, Physical Health, Aged Care, Death in Care, Mental Illness & Health, Huon Eldercare, Roy Fagan Centre, Fall, pneumonia, hip fracture, heart disease, dementia, Parkinson's disease, inadequate care, falls assessment, haloperidol, quetiapine, amiodarone | |
Hewitt, Robert Ian (PDF File, 166.2 KB) 2016 TASCD 345 |
Olivia McTaggart | 07-10-2016 | Transport & Traffic Related, Older Persons, Motor Vehicle Crash, Channel Highway, Oyster Cove, driver error | |
White, Paul Marcus (PDF File, 230.0 KB) 2016 TASCD 312 |
Olivia McTaggart | 12-09-2016 | Drugs & Alcohol, Leisure Activity, football, methylamphetamine intoxication, heart disease, intravenous drug use | |
Broomhall, Tyler John (PDF File, 240.7 KB) 2016 TASCD 313 |
Olivia McTaggart | 12-09-2016 | Drugs & Alcohol, Leisure Activity, Physical Health, football, sport, methylamphetamine, intra-cerebral haemorrhage, delay in diagnosis, North West Regional Hospital | |
Bone, Christine Sylvia (PDF File, 270.7 KB) 2016 TASCD 294 |
Duncan Fairley | 12-09-2016 | motor vehicle collision, coronial, abdominal injuries, chest injuries | |
Westcott, Barbara (PDF File, 611.4 KB) 2016 TASCD 286 |
Olivia McTaggart | 01-09-2016 | Aged Care, Older Persons, inadequate care, Vaucluse Gardens, entrapment, first aid training, bed pole, KA524, records, Department of Health and Ageing, checks | |
Pasinski, Alexander (PDF File, 273.0 KB) 2016 TASCD 285 |
Rod Chandler | 16-08-2016 | Mental Illness & Health, Death in Care, Launceston General Hospital, asphyxia, choking, Amitriptyline, Paliperidone, Chlorpromazine, Magill forceps, soft diet, schizophrenia | |
Teressa Beswick (PDF File, 340.1 KB) 2016 TASCD 261 |
Rod Chandler | 08-08-2016 | Adverse Medical Effects, Mersey Community Hospital, terminal cervical cancer, pneumonia, pain management, morphine overdose | |
Reardon, Jean May (PDF File, 299.1 KB) 2016 TASCD 253 |
Olivia McTaggart | 01-08-2016 | Older persons, Physical Health, Royal Hobart Hospital, sepsis, pressure ulcer, bedridden | |
Margaret Nicol Foran (PDF File, 214.0 KB) 2016 TASCD 248 |
Olivia McTaggart | 01-08-2016 | Older Persons, Homicide & Assault, Mental Illness & Health, strangulation, smothering, asphyxia, schizophrenia, psychotic, mother | |
Kupsch, Jessica Ann (PDF File, 256.3 KB) 2016 TASCD 217 |
Simon Cooper | 25-07-2016 | Homicide & Assault, domestic violence, Penny Royal Hotel, family violence order, Launceston Police, drug treatment order, plea bargain | |
ADT (PDF File, 226.7 KB) 2016 TASCD 299 |
Duncan Fairley | 22-07-2016 | Child & Infant Death, Homicide & Assault, shaken baby, feeding, ill-treatment of a child | |
Henriksen, Wendy Margaret (PDF File, 503.3 KB) 2016 TASCD 219 |
Rod Chandler | 18-07-2016 | Coronial, hospital, sepsis, chemotherapy, Emergency Department, | |
Bedford, Sidney (PDF File, 226.3 KB) 2016 TASCD 209 |
Rod Chandler | 14-07-2016 | Falls, Older Persons, Launceston General Hospital, Physical Health, subdural haemorrhage, CT scan, misdiagnosis | |
Blackaby, Kobie (PDF File, 210.2 KB) 2016 TASCD 210 |
Olivia McTaggart | 12-07-2016 | Child & Infant Death, Water Related, Drowning, inflatable pool, fence, supervision | |
James, Damien Aron Web (PDF File, 167.8 KB) 2016 TASCD 212 |
Olivia McTaggart | 30-06-2016 | Motor Vehicle Crash, Transport & Traffic Related, single vehicle, driver, Powranna, Midland Highway, fatigue, fell asleep, driver licence testing | Response provided by StateGrowth 14 August 2019 Response: Young drivers are at greatest risk of a crash in their first year of driving on their provisional licence. A proven measure to reduce the crash risk for young drivers is through an effective Graduated Licensing System (GLS). All Australian jurisdictions have some form of GLS in place. At the centre of a GLS is the recognition that new drivers need time and attention to develop safe driving skills. In 2014, the Australian Graduated Licensing Scheme Policy Framework (national policy framework, Attachment 1) was developed. It stipulates a three tiered best-practice GLS model informed by evidence that should be applied in Australian jurisdictions. In line with a commitment made by all state and territory transport Ministers under the National Road Safety Strategy 2011-2020, most jurisdictions have implemented changes to improve their GLS. Experience interstate has shown that strengthening the GLS has a positive impact on road safety for new drivers:
In 2017, Tasmania’s GLS was reviewed against the national policy framework. The review identified a number of policy improvements that could be adopted in Tasmania to align the Tasmanian GLS with the Enhanced Model of the national policy framework. In November 2018, the Road Safety Advisory Council (RSAC) endorsed these recommended changes to improve Tasmania’s GLS. Strengthening Tasmania’s GLS is one of the major actions under the Towards Zero - Tasmanian Road Safety Strategy 2017-2026 that will contribute to the short-term goal of fewer than 200 serious injuries and deaths by 2026, and long-term goal of zero. Current Situation: The Government has committed under the First Year Agenda to upgrade the GLS to assist learner drivers and better protect the safety of Tasmania’s new drivers, while also improving the driver licensing pathway to obtain a provisional licence. On 26 March 2019, Cabinet endorsed a package of changes to Tasmania’s GLS that will align Tasmania’s GLS with the Enhanced Model under the national policy framework. Upgrading Tasmania’s GLS will help protect new drivers and make them and their passengers safer. Drivers will get more on-road supervised driving experience and have less distractions during a high-risk driving period of their lives. The changes were publicly announced by the previous Minister for Infrastructure on 5 May 2019. The public announcement was supported by detailed information on the Transport Tasmania website, around 250 emails to key stakeholders and briefings with the Australian Driver Trainers Association (ADTA) and Department of State Growth Driving Assessors. Digital Learning Platform A Request for Proposal (RFP) was released on 11 May 2019 seeking proposals from businesses to create a new digital platform and public education campaign to support the improvements to the licensing system. The RFP closed on 5 July 2019 and it is expected that a successful agency will be contracted and ready to commence work on the digital platform by the end of 2019. The digital learning platform will transform how people engage in learning the road rules and getting their licence. It will provide better support for culturally and linguistically diverse people as well as satisfying a range of literacy levels. Other improvements to support people to get their licence will include more online services and forms online and electronic logbooks. Removing as many literacy and access challenges as possible through contemporary service delivery will encourage more people to progress safely through the GLS and get their licence. Engagement with stakeholders will occur at key points throughout the Project to ensure content and resources developed to support the changes to the GLS are contemporary, engaging, effective and relevant for the target audience. The expected delivery date for the GLS changes is December 2020. Support programs for new drivers State Growth also provides programs that support people who face challenges in getting a licence, including access to a supervisory driver, literacy and problems obtaining identification documents such as birth certificates. A pilot case management approach for people failing multiple driving assessments is currently being developed, which is aimed at providing tailored individual support to help them progress through the GLS. In 2018-19 funding to Learner Driver Mentor Programs (LDMPs) was increased to $1 million per year. These programs provide disadvantaged people access to mentors and appropriate vehicles to obtain their learner logbook hours. The Government and Driver Mentoring Tasmania will be conducting a recruitment drive with a public media campaign aimed at increasing the number of volunteer driver mentors in the LDMP program which will enable even more learners to participate in the program. State Growth is currently running a media campaign to raise awareness of the need to encourage safe driving habits in young people. It will run during 2019/20 in the lead up to the implementation of the improved GLS. This campaign will help to acquaint the community with the reasoning behind changes to Tasmania’s GLS and reinforce the need for change. This is a precursor to the comprehensive public education campaign that will be developed by the successful business contracted to develop the GLS resources and supporting materials. The second phase of this campaign will commence around October 2019 Update provided by StateGrowth 20 September 2022 Graduated Licensing System
- Increased mandatory logbook hours for new learners and L1 licence holders from 50 to 80 hours, including 15 at night. L2 licence holders must complete 50 supervised hours. - A ban on mobile phone use, including hands free, for learner and P1 licence holders. Playing music or using GPS is allowed as long as it is set prior to driving and the driver does not interact with their phone while driving. - New maximum speeds of 90km/h for learners and 100km/h for P1 licence holders. P2 speed limits were unchanged. - Restricting P1 drivers under 25 years from carrying more than one passenger between the age of 16 and 21 (inclusive). Exemptions apply for employment, education and training, essential services (i.e. medical) and family circumstances. - Green P plates to be displayed by P2 drivers ensure so Tasmania Police can more easily identify P2 drivers who are required to drive with zero blood alcohol content. - A Safer Driver Reward granting a free three-year full licence to drivers who do not commit an offence during their provisional licence stages. For many young people a licence provides independence, facilitates social engagement and increases job opportunities. To assist young people, the Tasmanian Government also introduced offsets to allow learners to gain five hours credit for attending the Rotary Youth Driver Awareness Program and two hours credit for each one-hour lesson with a certified driving instructor (capped at 10 lessons).
An improved standalone driver knowledge test is available at Service Tasmania shops for those people who prefer to sit the test in person. The vast majority of Plates Plus users were aged 25 years and under, which is the key target demographic of the Saving Young Lives theme of the Towards Zero Action Plan 2020-2024 (Action Plan). A mandatory computer-based Hazard Perception Test (HPT) was introduced to the licensing system on 7 March 2022. Learners, and certain overseas conversion clients, must pass this before booking a practical driving assessment. As at 5 July 2022 it had been completed by 4 718 people. Learner Driver Mentor Programs The Tasmanian Government has increased funding to Learner Driver Mentor Programs (LDMP) to $1 million annually. These programs assist disadvantaged people to access mentors and appropriate vehicles to meet their required minimum learner logbook hours. The government is working with Driver Mentoring Tasmania and LDMPs to recruit more mentors across the second half of 2022 to enable even more learners to participate in the program. |
Ball, Jeremy Dacre (PDF File, 189.5 KB) 2016 TASCD 196 |
Simon Cooper | 30-06-2016 | motor vehicle crash, suicide, semi-trailer, mental health, deliberate crash, prime mover, drive into prime mover, suicide by motor vehicle crash. | |
McDougall, Kirsten Web (PDF File, 168.4 KB) 2016 TASCD 211 |
Olivia McTaggart | 29-06-2016 | Transport & Traffic Related, Motor Vehicle Crash, passenger, single vehicle, traumatic brain injury, aspiration pneumonia, Midland Highway, fatigue, fell asleep | Response provided by StateGrowth 14 August 2019 Response: Young drivers are at greatest risk of a crash in their first year of driving on their provisional licence. A proven measure to reduce the crash risk for young drivers is through an effective Graduated Licensing System (GLS). All Australian jurisdictions have some form of GLS in place. At the centre of a GLS is the recognition that new drivers need time and attention to develop safe driving skills. In 2014, the Australian Graduated Licensing Scheme Policy Framework (national policy framework, Attachment 1) was developed. It stipulates a three tiered best-practice GLS model informed by evidence that should be applied in Australian jurisdictions. In line with a commitment made by all state and territory transport Ministers under the National Road Safety Strategy 2011-2020, most jurisdictions have implemented changes to improve their GLS. Experience interstate has shown that strengthening the GLS has a positive impact on road safety for new drivers:
In 2017, Tasmania’s GLS was reviewed against the national policy framework. The review identified a number of policy improvements that could be adopted in Tasmania to align the Tasmanian GLS with the Enhanced Model of the national policy framework. In November 2018, the Road Safety Advisory Council (RSAC) endorsed these recommended changes to improve Tasmania’s GLS. Strengthening Tasmania’s GLS is one of the major actions under the Towards Zero - Tasmanian Road Safety Strategy 2017-2026 that will contribute to the short-term goal of fewer than 200 serious injuries and deaths by 2026, and long-term goal of zero. Current Situation: The Government has committed under the First Year Agenda to upgrade the GLS to assist learner drivers and better protect the safety of Tasmania’s new drivers, while also improving the driver licensing pathway to obtain a provisional licence. On 26 March 2019, Cabinet endorsed a package of changes to Tasmania’s GLS that will align Tasmania’s GLS with the Enhanced Model under the national policy framework. Upgrading Tasmania’s GLS will help protect new drivers and make them and their passengers safer. Drivers will get more on-road supervised driving experience and have less distractions during a high-risk driving period of their lives. The changes were publicly announced by the previous Minister for Infrastructure on 5 May 2019. The public announcement was supported by detailed information on the Transport Tasmania website, around 250 emails to key stakeholders and briefings with the Australian Driver Trainers Association (ADTA) and Department of State Growth Driving Assessors. Digital Learning Platform A Request for Proposal (RFP) was released on 11 May 2019 seeking proposals from businesses to create a new digital platform and public education campaign to support the improvements to the licensing system. The RFP closed on 5 July 2019 and it is expected that a successful agency will be contracted and ready to commence work on the digital platform by the end of 2019. The digital learning platform will transform how people engage in learning the road rules and getting their licence. It will provide better support for culturally and linguistically diverse people as well as satisfying a range of literacy levels. Other improvements to support people to get their licence will include more online services and forms online and electronic logbooks. Removing as many literacy and access challenges as possible through contemporary service delivery will encourage more people to progress safely through the GLS and get their licence. Engagement with stakeholders will occur at key points throughout the Project to ensure content and resources developed to support the changes to the GLS are contemporary, engaging, effective and relevant for the target audience. The expected delivery date for the GLS changes is December 2020. Support programs for new drivers State Growth also provides programs that support people who face challenges in getting a licence, including access to a supervisory driver, literacy and problems obtaining identification documents such as birth certificates. A pilot case management approach for people failing multiple driving assessments is currently being developed, which is aimed at providing tailored individual support to help them progress through the GLS. In 2018-19 funding to Learner Driver Mentor Programs (LDMPs) was increased to $1 million per year. These programs provide disadvantaged people access to mentors and appropriate vehicles to obtain their learner logbook hours. The Government and Driver Mentoring Tasmania will be conducting a recruitment drive with a public media campaign aimed at increasing the number of volunteer driver mentors in the LDMP program which will enable even more learners to participate in the program. State Growth is currently running a media campaign to raise awareness of the need to encourage safe driving habits in young people. It will run during 2019/20 in the lead up to the implementation of the improved GLS. This campaign will help to acquaint the community with the reasoning behind changes to Tasmania’s GLS and reinforce the need for change. This is a precursor to the comprehensive public education campaign that will be developed by the successful business contracted to develop the GLS resources and supporting materials. The second phase of this campaign will commence around October 2019 Update provided by StateGrowth 20 September 2022 Graduated Licensing System
- Increased mandatory logbook hours for new learners and L1 licence holders from 50 to 80 hours, including 15 at night. L2 licence holders must complete 50 supervised hours. - A ban on mobile phone use, including hands free, for learner and P1 licence holders. Playing music or using GPS is allowed as long as it is set prior to driving and the driver does not interact with their phone while driving. - New maximum speeds of 90km/h for learners and 100km/h for P1 licence holders. P2 speed limits were unchanged. - Restricting P1 drivers under 25 years from carrying more than one passenger between the age of 16 and 21 (inclusive). Exemptions apply for employment, education and training, essential services (i.e. medical) and family circumstances. - Green P plates to be displayed by P2 drivers ensure so Tasmania Police can more easily identify P2 drivers who are required to drive with zero blood alcohol content. - A Safer Driver Reward granting a free three-year full licence to drivers who do not commit an offence during their provisional licence stages. For many young people a licence provides independence, facilitates social engagement and increases job opportunities. To assist young people, the Tasmanian Government also introduced offsets to allow learners to gain five hours credit for attending the Rotary Youth Driver Awareness Program and two hours credit for each one-hour lesson with a certified driving instructor (capped at 10 lessons).
An improved standalone driver knowledge test is available at Service Tasmania shops for those people who prefer to sit the test in person. The vast majority of Plates Plus users were aged 25 years and under, which is the key target demographic of the Saving Young Lives theme of the Towards Zero Action Plan 2020-2024 (Action Plan). A mandatory computer-based Hazard Perception Test (HPT) was introduced to the licensing system on 7 March 2022. Learners, and certain overseas conversion clients, must pass this before booking a practical driving assessment. As at 5 July 2022 it had been completed by 4 718 people. Learner Driver Mentor Programs The Tasmanian Government has increased funding to Learner Driver Mentor Programs (LDMP) to $1 million annually. These programs assist disadvantaged people to access mentors and appropriate vehicles to meet their required minimum learner logbook hours. The government is working with Driver Mentoring Tasmania and LDMPs to recruit more mentors across the second half of 2022 to enable even more learners to participate in the program. |
Mr P (PDF File, 91.3 KB) 2016 TASCD 254 |
Simon Cooper | 27-06-2016 | Adverse Medical Effects, Physical Health, Royal Hobart Hospital, small bowel obstruction, adhesions, misdiagnosis, inadequate care | |
Brook, Jason Mark (PDF File, 184.9 KB) 2016 TASCD 194 |
Olivia McTaggart | 27-06-2016 | Physical Health, Transport & Traffic Related, Motor Vehicle Crash, Mersey Community Hospital, North West Regional Hospital, motorcycle, surgery, deep vein thrombosis, pulmonary embolism, anticoagulation, immobilisation, inadequate care | |
Grey, Andrew Amos (PDF File, 192.2 KB) 2016 TASCD 224 |
Simon Cooper | 27-06-2016 | Drowning, Leisure Related, Water Related, Weather Related, Burns Bay, St Helens, lobster, Stormy Seas PFD, service | Response Received from Marine and Safety Tasmania (MAST) 16 July 2019
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Moylan, Mark David (PDF File, 222.0 KB) 2016 TASCD 195 |
Simon Cooper | 24-06-2016 | Water Related, Leisure Activity, Marine Fatality, Drowning, Drugs & Alcohol, Mental Illness & Health, prescription, Tamar River, Gravelly Beach marina, dinghy, diazepam, missing person, PFD | |
Gordon, Mark Alexander (PDF File, 235.7 KB) 2016 TASCD 282 |
Rod Chandler | 20-06-2016 | Physical Health, Royal Hobart Hospital, misdiagnosis, inadequate care, cardiac arrest, heart disease, pericardial tamponade, aortic dissection, hypertension, diabetes, obesity, hepatic steatosis, thyroiditis, CT scan | |
Jackson, Christopher George (PDF File, 203.4 KB) 2016 TASCD 183 |
Simon Cooper | 31-05-2016 | Youth, Water Related, Drugs & Alcohol, Drowning, boating, long term missing person, Derwent River, Kangaroo Bay | |
Barnes, Deearne Joan (PDF File, 354.2 KB) 2016 TASCD 179 |
Stephen Carey | 25-05-2016 | Physical Health, Mental Illness & Health, Drugs and Alcohol, Overdose, mixed drug toxicity, prescription medication, venlafaxine, methadone, amitriptyline, quetiapine, diazepam, chronic opioid therapy | |
Mr F (PDF File, 154.0 KB) 2016 TASCD 149 |
Simon Cooper | 13-05-2016 | scooter accident, skate park, laceration of heart, | |
Butterworth, Lucille (PDF File, 503.2 KB) 2016 TASCD 096 |
Simon Cooper | 02-05-2016 | Homicide & Assault, long term missing person, bus stop, Claremont, Box Hill Road, Geoffrey Hunt | |
McDermott, Janice Faye (PDF File, 165.3 KB) 2016 TASCD 124 |
Olivia McTaggart | 26-04-2016 | Transport & Traffic Related, train, level crossing, pedestrian, Box Hill Road, Claremont | |
Hoskinson, Christopher & Hoskinson, Elaine (PDF File, 186.1 KB) 2016 TASCD 142, 143 |
Stephen Carey | 25-04-2016 | Transport & Traffic Related, Motor Vehicle Crash, Midlands Highway, Ross, mobile phone, log truck | Response received from State Growth on 31 July 2019 The Road Safety Advisory Council (RSAC) (through the Road Safety Branch, State Growth) continues to educate the community about the dangers of distraction, particularly the use of mobile phones whilst driving. Some activities undertaken by RSAC and Tasmania Police include: Public education
Enforcement
Development of the new five year Action Plan RSAC is currently developing the next five year road safety action plan, to be released in December this year. Under this plan, we will tackle distraction and mobile phone use through:
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Stacey, Leanne Maree (PDF File, 162.5 KB) 2016 TASCD 044 |
Stephen Carey | 25-04-2016 | Drugs & Alcohol, Physical Health, Misadventure, heart disease, mixed drug toxicity, morphine, benzodiazepine, dothiepin, intravenous drug use | |
Newett, Margaret Wynne (PDF File, 267.5 KB) 2016 TASCD 150 |
Rod Chandler | 21-04-2016 | Ischaemic heart disease, calcific aortic valve sclerosis, hospital death, unsatisfactory treatment. | |
Harper, Marlene Jean (PDF File, 230.3 KB) 2016 TASCD 100 |
Rod Chandler | 20-04-2016 | Older Persons, Physical Health, deep vein thrombosis, chronic lymphocytic leukaemia, atherosclerotic vascular disease, duplex ultrasound, anticoagulant, misdiagnosis | |
Dawson, Aidan Andrew (PDF File, 395.5 KB) 2016 TASCD 091 |
Olivia McTaggart | 06-04-2016 | Homicide & Assault, Drugs & Alcohol, domestic violence, stabbing, self-defence, Police Family Violence Order, Safe at Home | |
Zimmerman, Manfred (PDF File, 172.9 KB) 2016 TASCD 091 |
Olivia McTaggart | 25-03-2016 | Transport & Traffic Related, Motor Vehicle Crash, driver, sole occupant, Royal Hobart Hospital, palliative, terminal lung cancer, emphysema | |
Beuckelaers, Elfride Elisabeth (PDF File, 174.9 KB) 2016 TASCD 090 |
Olivia McTaggart | 25-03-2016 | Motor Vehicle Crash, Older Persons, driver, fail to give way, Bass Highway, Christmas Hills Road, Elizabeth Town | |
Thorpe, Gloria Theresa (PDF File, 205.9 KB) 2016 TASCD 099 |
Olivia McTaggart | 25-03-2016 | Motor Vehicle Accident, Bass Highway, Rocky Cape, Multiple blunt traumatic injuries | |
Nettlefold, Carmel (PDF File, 164.3 KB) 2016 TASCD 084 |
Simon Cooper | 24-03-2016 | Older Person, Homicide & Assault, head injury, stranger, manslaughter, New Town Road | |
Bradshaw, Luke (PDF File, 274.2 KB) 2016 TASCD 083 |
Olivia McTaggart | 21-03-2016 | Water Related, Drugs & Alcohol, Drowning, Marine Fatality, Derwent River, Prince of Wales Bay, jetty | |
Kulla, Daniel and Macleod, Malcolm (PDF File, 237.6 KB) 2016 TASCD 077, 078 |
Simon Cooper | 18-03-2016 | Mental Illness & Health, Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Death in Care, abscond, citalopram, olanzapine, cannabis, unregistered, unroadworthy, unlicensed, speed, helmet | |
Williams, Leigh John (PDF File, 160.9 KB) 2016 TASCD 065 |
Olivia McTaggart | 03-03-2016 | Transport & Traffic Related, Motor Vehicle Crash, single vehicle, driver, sole occupant, alcohol, speed, mobile phone | |
Macdonald, Shauna Maree (PDF File, 161.6 KB) 2017 TASCD 063 |
Duncan Fairley | 20-02-2016 | drug toxicity, pentobarbital, drug use, drug overdose. | |
Goss, Brittany Kate (PDF File, 187.0 KB) 2016 TASCD 011 |
Stephen Carey | 29-01-2016 | Youth, Transport & Traffic Related, Motor Vehicle Crash, Weather Related, bus stop, pedestrian, rural, Collins Lane, West Tamar Highway, Sidmouth | |
Mr D (PDF File, 372.3 KB) 2016 TASCD 009 |
Stephen Carey | 29-01-2016 | Mental Illness & Health, stress, fall, anti-depressant, noncompliant, self-reporting, Launceston General Hospital, Crisis Team | |
Ordonez, Genaro Lotero (PDF File, 178.1 KB) 2016 TASCD 041 |
Stephen Carey | 29-01-2016 | Water Related, Leisure Activity, Drowning, Swimcart Beach, Binalong Bay, tourist, swim, rip, head injury, signs | |
Smart, Joshua David (PDF File, 197.7 KB) 2016 TASCD 038 |
01-01-2016 | exsaunguination/ hypovolaemic arrest, bleed from severed artery | ||
Delaney, Maxwell (PDF File, 208.9 KB) 2016 TASCD 071 |
Stephen Carey | 28-01-2016 | Aged Care, Eliza Purton Care Home, North West Regional Hospital, Falls, outdoor area, plastic chair, monitoring, fracture, pneumonia | Response received from Respect Aged Care 26 July 2019 In addition to the removal of lightweight plastic chairs which were removed at the time of Recommendation |
Atkinson, James Robert (PDF File, 272.4 KB) 2016 TASCD 090 |
Stephen Carey | 28-01-2016 | Older Person, Falls, head injury, walking frame | |
Marshall, Donald Joseph (PDF File, 180.8 KB) 2016 TASCD 047 |
Simon Cooper | 21-01-2016 | Water Related, Older Persons, Intentional Self-Harm, Geographic, Badger Island, Bass Strait, EPIRB, coordination, search | |
Mansell, John Ernest (PDF File, 400.4 KB) 2016 TASCD 001 |
Simon Cooper | 20-01-2016 | Leisure Activity, Motor Vehicle Crash, Targa, Porters Bridge Road, Deloraine, Driver Racing, Rally, CAMS, Tarmac Rally Standing Regulations, Breathalyse, HANS device | Response received from Motorsport Australia 25 July 2019
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Mr K (PDF File, 173.1 KB) 2016 TASCD 006 |
Simon Cooper | 04-01-2016 | Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Youth, learner, inexperience, pillion passenger | |
Summerfeldt; Ian Patrick.pdf (PDF File, 243.7 KB) 2017 TASCD 002 |
Rod Chandler | 03-01-2016 | hospital, renal failure, perforated gastric ulcer, sepsis, stomach pain, | |
Richardson, Margaret Rita.(Web).pdf (PDF File, 406.9 KB) |
01-01-2016 | coronial, artery dissection, ischaemic heart disease, renal scarring, emphysema |