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.

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.

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

Response from Marine and Safety Tasmania (MAST)  16 July 2019

• Boatwise articles, MAST TV with expert Dr David Smart into CO monitors, facebook, education nights,

Response from Marine and Safety Tasmania (MAST)  16 July 2019

• Boatwise articles, MAST TV with expert Dr David Smart into CO monitors, facebook, education nights,

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.

Updated response provided by THS South 14 October 2022

Feedback is provided through existing case review within Medical Imaging

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:
Triggers for immediate contact with ICU Senior Registrar/Consultant and Home unit consultant
*             Admission to ICU is required
*             ICU/MED Reg at MET call unsure of diagnosis and appropriate treatment to provide
*             Difference of opinion between members of the MET regarding  
assessment/treatment
*             2 MET calls on the same patient with a 24-hour period
Other issues for Med Reg and ICU Reg to consider -
Can the patient remain on this ward/unit?
*             Can this ward manage high O2 or certain medications/infusions?
*             Does this patient require ECG monitoring & or telemetry?
*             Is the nursing & JMO capability supported?
Role guidelines & patient presentation/ vital signs/Investigation results criteria for immediate ICU consult/referral for Junior staff
Further the Standard 8 -  Recognising & Responding to Deterioration – Clinical Case Review Subcommittee was established – membership included Consultants form various specialties to review cases that flag patients who trigger a more in-depth case review.  Triggers include
*Unplanned admission to ICU,
*Change of Goals of Care at a MET call
*Death at a MET call
*>1 MET call in same admission
*Other Serious concern or adverse event
Standard 8 Chair is currently an Intensivist Consultant with a significant proportion of the Committee members being medical consultants  
The RHH also implemented a standalone Obstetric Emergency Response (OER) and the Code Newborn to compliment the Code Blue /MET for adult & Paediatric calls.

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.

Updated response provided by THS South 14 October 2022

Nil recommendations for THS
Discussed at Statewide  Quality and Safety Committee
All JMOs are reminded of the dangers of prolonged digoxin use
Discussion with Primary Health Tasmania  education and training regarding GP training

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:

• The Victorian GLS evaluation found 42.5% fewer drivers aged 18–23 years have been involved in fatal or serious injury crashes in the decade since the GLS was introduced in 2007-2008
• A three year evaluation of Queensland’s GLS showed a 38.32% reduction in fatalities for P1 provisional drivers and an overall reduction of 31% for all novice driver categories
• A 2011 review of NSW’s GLS found fatal crash involvement rates for young drivers (under 26) declined by 51% from 1999-2000 to 2009-10, with the reduction in crash rates coinciding with the introduction of the revised GLS (minimum 120 hours logged experience over 12 months on L plates) in 2000.
• In comparison, the number of young (17-25) drivers and passengers of young drivers killed or seriously injured has fallen 13% from 61 in 2008 to 53 in 2018.

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

• Road trauma is the second leading cause of death for young people in Tasmania. Young drivers are at the greatest risk of a crash in their first year of driving solo.
• On 1 December 2020 the Tasmanian Government implemented regulatory changes to Tasmania’s Graduated Licensing System (GLS) to improve the safety of young drivers, their passengers and other road users.
• The changes strengthen Tasmania’s GLS and brings us further in line with the ‘Enhanced’ model under the Australian Graduated Licensing Scheme Policy Framework.
• The regulatory changes were:

- 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).

Plates Plus

• On 8 July 2021 the Tasmanian Government launched the Plates Plus platform – an online learning and assessment tool to obtain a learner driver licence.  This tool has a significant focus on awareness and training with regard to the ‘Fatal Five’  - the five biggest contributors to serious and fatal accidents on our roads.
• - Speed
• - Seatbelts
• - Alcohol and drugs
• - Distraction
• - Fatigue

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).

Hazard Perception Test

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.

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:

• The Victorian GLS evaluation found 42.5% fewer drivers aged 18–23 years have been involved in fatal or serious injury crashes in the decade since the GLS was introduced in 2007-2008
• A three year evaluation of Queensland’s GLS showed a 38.32% reduction in fatalities for P1 provisional drivers and an overall reduction of 31% for all novice driver categories
• A 2011 review of NSW’s GLS found fatal crash involvement rates for young drivers (under 26) declined by 51% from 1999-2000 to 2009-10, with the reduction in crash rates coinciding with the introduction of the revised GLS (minimum 120 hours logged experience over 12 months on L plates) in 2000.
• In comparison, the number of young (17-25) drivers and passengers of young drivers killed or seriously injured has fallen 13% from 61 in 2008 to 53 in 2018.

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

• Road trauma is the second leading cause of death for young people in Tasmania. Young drivers are at the greatest risk of a crash in their first year of driving solo.
• On 1 December 2020 the Tasmanian Government implemented regulatory changes to Tasmania’s Graduated Licensing System (GLS) to improve the safety of young drivers, their passengers and other road users.
• The changes strengthen Tasmania’s GLS and brings us further in line with the ‘Enhanced’ model under the Australian Graduated Licensing Scheme Policy Framework.
• The regulatory changes were:

- 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).

Plates Plus

• On 8 July 2021 the Tasmanian Government launched the Plates Plus platform – an online learning and assessment tool to obtain a learner driver licence.  This tool has a significant focus on awareness and training with regard to the ‘Fatal Five’  - the five biggest contributors to serious and fatal accidents on our roads.
• - Speed
• - Seatbelts
• - Alcohol and drugs
• - Distraction
• - Fatigue

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).

Hazard Perception Test

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.

Response Received from Marine and Safety Tasmania (MAST)  16 July 2019

• AS 4758 was written into legislation in 2010, numerous Boatwise articles, Education Nights, MAST TV, school education programs, Facebook, website, PR campaigns, TV interviews, Boatsafe Partner program
• Servicing inflatables has also been a major part of MAST work over the 15 years. Including Boatsafe Education nights, numerous Boatwise articles, PR campaigns, Facebook, School programs, Inland anglers talks, MAST TV, Newspaper articles,  numerous TV interviews, newspaper articles, Boatsafe Partners

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

• RSAC has a long running campaign ‘Don’t be a goose.  Leave your phone alone.’ https://www.rsac.tas.gov.au/campaign/leave-phone-alone/
• In the recent Road Torque series on Southern Cross television, a three minute episode focused on the effects of using a mobile phone whilst driving
• RSAC provides a grant to the RACT to conduct the ‘Ready for the road’ program for students from years 10-12 focusing on safe driving behaviours and high risk behaviours including mobile phone use
• RSAC provides a grant to the Rotary Youth Driver Awareness Program delivered to 4,000 students per year in Tasmania.  The program focuses on safe driving behaviours and high risk behaviours including mobile phone use.

Enforcement

• Tasmania Police recently introduced unmarked motorcycle enforcement in the CBDs of the South, North and North-West of the State.  These officers focus on high risk behaviours including mobile phone use.

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:

• Undertaking a review of road safety related penalties, including mobile phone use
• Review of the graduated licensing system to include banning of mobile phone use, including hands-free, for learner and provisional drivers
• Increased enforcement of distraction through trialling of new technologies that detect mobile phone use.

• Response received from StateGrowth  
  (PDF, 99.5 KB)

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
the incident the following is a summary of action taken from the recommendations:
Recommendation
Steps to ensure that the use of chairs in outdoor areas is confined to areas where the base
upon which the chairs are placed is level and stable.
Action
* A requirement of the refurbishment program undertaken at Eliza Purton (and other
Respect facilities) has included the need for suitably surfaced, flat courtyard/
outdoor areas.
* Chairs are not provided in areas that are not suitably flat.
* Outdoor furniture is risk assessed for purpose prior to being put in place.

Recommendation
A formal procedure be in place to provide ongoing monitor
of aged care facilities.
Action
* Each consumer is considered in the context of their particular assessments and
choices to enable individual care planning, inclusive of their outdoor needs.
* Allied Health Professionals are involved in the assessment of all consumers in
relation to their mobility, seating and
activities safely.
* More recently a ‘dignity of risk’ approach has been introduced supporting
to make their own choices and accept personal risk. A formal process of risk
assessment and risk mitigation is undertaken and documented.
* An extension of the call bell system is available in certain areas of the facility grounds
i.e. in the form of pendent or wrist watch alarms. Consumers who wish to use this
system are encouraged to stay within the confines of the monitored areas.
Recommendation
An assessment on whether the most appropriate action was taken upon the initial
movement of Mr Delaney given the circumstances indicated the possibility that he had
suffered a neck injury.
Action
* Review of the incident indicated that further education and guidance for staff would
be beneficial. This included:
o Initial review and debriefing with the
differently.
o Introduction of the Emergency Decision Guidelines as a reference guide for
staff.
o Review of the Mobility and Falls Prevention Policy.
o Review of the Incident Management Policy to include not moving individu
after falls until they have been assessed by a Registered Nurse who will
identify the risk of injury
injury are not to be moved (unless at risk of further danger). An ambulance is
to be called immediately.

Response received from  Motorsport Australia 25 July 2019

• We confirm that the CAMS TRSR are applied for all Targa events. We have in fact added a Targa Appendix to the TRSR, which provides specific details as to the requirements for a Targa Rally.
• As advised by CAMS in our letter to the Tasmanian Police (dated 18/07/2016), each competitor is required to undergo a compulsory alcohol breath test at the commencement of each Leg (day) of the events. Furthermore, random alcohol and drug testing is also conducted throughout the event pursuant to the CAMS Alcohol and Drug Policies. ;
• CAMS has created a process involving Targa Australia, the Course Checker and CAMS’ Technical and Safety Managers to review all aspects of past events, and use that knowledge as a tool to assist with planning future events.
• CAMS has appointed a Motor Sport Safety Advisor, whose is responsible for assessing safety and assisting the course checker at these events.
• This now occurs at each event with each event holding specific briefings for First Timers and all Competitors, with First Timers required to attend all briefings.
• Frontal Head Restraints (of which HANS is a type of FHR) are mandatory for all Full Competition competitors at Targa Events.
• CAMS has reviewed the uses of pace notes and it presently sits with the Australian Rally Commission (a delegated body of CAMS) for further consideration. The Event Organisers produce route instructions, which are supplied to all competitors, and these route instructions are checked (by the Course Checker) to ensure uniformity of symbols, meanings and for accuracy. However, individual competitors may make their own pace notes, or choose to use a third party’s. Pace notes by their very nature are a set of specific notes designed to provide additional detail (beyond the supplied route instruction) as deemed useful by the individual competitor.
• Yes, there is no longer a contractual prohibition on the use of chicanes in any agreement between CAMS and Targa Australia. Targa Australia events utilise modern virtual chicane technology, in conjunction with Rallysafe to address maximum and average speed requirements, as per our regulations