Coronial findings (decisions) 2016

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 received by MCH Pharmacy on 25 February 2020.

This recommendation  was addressed by MCH pharmacy with the following practice implemented:

What occurred after that event was high dose of opioids when requested on a requisition are sent with medication charts to confirm the dosage is required, which also allows a pharmacist to review the dosage before providing.

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