Coronial findings - 2014 and earlier

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

Tip: please enter in a search box a name, year or a number of the coronial finding you are looking for.

Table: Coronial findings - 2014 and earlier
Title & TASCD number Keyword
Zimmerman, Manfred (PDF, 172.9 KB)
2016 TASCD 091
Transport & Traffic Related, Motor Vehicle Crash, driver, sole occupant, Royal Hobart Hospital, palliative, terminal lung cancer, emphysema
Youth Suicide (PDF, 819.6 KB)
2015 TASCD 298,299,300,301,302,303
Young, Dylan Broderick Ernest (PDF, 247.2 KB)
2017 TASCD 328
Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Wright, Mark Norman (PDF, 272.7 KB)
2017 TASCD 145
Transport & Traffic related, motor vehicle crash, Drugs & Alcohol
Woulleman-Jarvis, Anne Maree 2017 TASCD 188.pdf (PDF, 349.4 KB)
2017 TASCD 188
hospital, head injury, CT scan, fall, standing height, subacute subdural haematoma, closed head injury,
Woolley, Paul James (PDF, 497.0 KB)
2018 TASCD 40
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.
Woolley, Zedric Basil (PDF, 118.2 KB)
2019 TASCD 534
undetermined cause of death, missing person, Glen Huon
Woodward, Ernest Henry (PDF, 111.9 KB)
2019 TASCD 550
Missing person, water related, recreational fishing, suspected death, disappearance
Woods, Brian Oakley (PDF, 276.7 KB)
2017 TASCD 521
motorcycle crash, motorbike crash, transport and traffic related, speeding, Black Charlie's Opening, Tasman Highway, excessive spped, double white lines, blind corner.
Wilton, Meagan & Eyles, Benjamin (PDF, 187.4 KB)
2015 TASCD 436, 437
Homicide & Assault, Intentional Self-Harm, domestic violence, breakup, access to child, firearm seizure, unsafe storage of weapons, police intervention
Wilson, Jacob Leigh (PDF, 380.7 KB)
2019 TASCD 399
Transport and traffic related, single motorcycle crash, loss of control, chest and abdominal injuries, drugs and alcohol, unroadworthy, coroner's finding
Willox, Brian William (PDF, 162.0 KB)
2017 TASCD 408
fracture neck, fall standing height,
Williams, Leigh John (PDF, 160.9 KB)
2016 TASCD 065
Transport & Traffic Related, Motor Vehicle Crash, single vehicle, driver, sole occupant, alcohol, speed, mobile phone
Williams, Michael David (PDF, 399.0 KB)
2018 TASCD 475
homicide, murder, assault, head injury, Stainforth Court, Cornelian Bay
Williams, Brett (PDF, 573.5 KB)
2018 TASCD 143
murder, homicide, stabbing, Eggs and Bacon Bay,
Fisher, William (PDF, 402.8 KB)
2001 TASCD 48
body in fountain, burnt body, open finding, undetermined death.
Whitney, Margaret Ann (PDF, 100.6 KB)
2020 TASCD 64
Aged care, nursing home, fall, older persons, dementia, person held in care, Royal Hobart Hospital, Roy Fagan Centre, Public Guardian, guardianship order, medical review, Coroner's comments
White, Paul Marcus (PDF, 230.0 KB)
2016 TASCD 312
Drugs & Alcohol, Leisure Activity, football, methylamphetamine intoxication, heart disease, intravenous drug use
White, Janelle Lee (PDF, 105.4 KB)
2019 TASCD 556
Ladder fall, traumatic closed head injuries, working at height, training, home building site, recommendations, Workplace Health and Safety Act 2012
Westcott, Barbara (PDF, 611.4 KB)
2016 TASCD 286
Aged Care, Older Persons, inadequate care, Vaucluse Gardens, entrapment, first aid training, bed pole, KA524, records, Department of Health and Ageing, checks
Weir, Mary (PDF, 165.3 KB)
2015 TASCD 368
Adverse Medical Effects, Falls, Older Persons, Calvary Hospital, head injury, bathroom, walking frame, subdural haematoma, high risk falls prevention plan, chronic heart failure, cellulitis, swollen legs, unwitnessed fall, seizures, CT scan, aspirin, clopidogrel, Clexane, anticoagulant, presumed stroke, error, unsound medical practice, misdiagnosis
Weily, Richard Maurice (PDF, 322.5 KB)
2016 TASCD 323
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
Weedon, Jackson Nate John Daniel (PDF, 467.0 KB)
2018 TASCD 153
transport and traffic related, motorbike crash, motorcycle crash, single vehicle crash, speeding
Weber, Kevin Howard (PDF, 365.1 KB)
2018 TASCD 306
falls, leisure activity, fall striking head, subdural haematoma, hand rail, fall from steps.
Webb, Shanelle Jean (PDF, 497.5 KB)
2018 TASCD 493
SUDEP, Sudden unexpected death in epilepsy, night-time epileptic seizure, Oak Possability.
Wang, Yu Qian (PDF, 262.9 KB)
2017 TASCD 548
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.
Walsh, Chloe Michelle (PDF, 399.4 KB)
2018 TASCD 439
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)
Trent Walliker (PDF, 282.3 KB)
2017 TASCD 420 Trent Walliker
blunt force trauma, lower chest area, single vehicle accident, motorcycle accident
WAGG, Christopher William
2014 TASCD 199
Findings, Coronial, workplace, factory plant, paid work, zinc works, brain damage, mechanical asphyxia, neck compression, trapped, cherry picker, stairwell
Vince, Brock (PDF, 275.4 KB)
2018 TASCD 99
intentional self harm, St Helens Private Hospital, seroquel, quetiapine, drowning, bath, drugs & alcohol, re-examined findings
Van Galen, Esther Grace (PDF, 470.1 KB)
2018 TASCD 460
Child & Infant Death, baby death, overlay, bed sharing, SIDS, sudden infant death,
Unwin, David Paul (PDF, 409.3 KB)
2018 TASCD 466
Coroner's finding, coroner's recommendation, sepsis, kidney transplant, polycystic kidney disease, adverse medical effects, physical health
Towns, Martin John (PDF, 212.4 KB)
2018 TASCD 59
drugs and alcohol, fall, subdural haematoma
Tolputt, Trevor (PDF, 825.1 KB)
2019 TASCD 175
hypothermia, Overland Track, Lake St Clair, Parks and Wildlife Service, coroner's recommendations, bushwalker, winter inadequately equipped
Thorpe, Gloria Theresa (PDF, 205.9 KB)
2016 TASCD 099
Motor Vehicle Accident, Bass Highway, Rocky Cape, Multiple blunt traumatic injuries
Thompson, Ian Graham (PDF, 608.4 KB)
2018 TASCD 73
work related, workplace death, Tassal, fishing vessel, Efishent, Worksafe Tasmania, capstan, accident
Tetley, Andrew Jason (PDF, 166.2 KB)
2015 TASCD 371
Water Related, Drowning, Marine Fatality, missing person, disappearance, fisherman, fishing, Falmouth, PFD, lifejacket, dinghy, fall, boarding, dark
TETLEY, Barry Lindsay 2014 TASCD 246
sepsis, pneumonia, hospital death, Royal Hobart Hospital, Coronial finding, Tetley.
Teressa Beswick (PDF, 340.1 KB)
2016 TASCD 261
Adverse Medical Effects, Mersey Community Hospital, terminal cervical cancer, pneumonia, pain management, morphine overdose
Taylor, Michael John (PDF, 342.3 KB)
2018 TASCD 488
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
Tate, Magella Luisa Faye (PDF, 160.6 KB)
2017 TASCD 250
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.
Tabor, Pamela Lois and Belinda Ann (PDF, 163.0 KB)
2017 TASCD 403
motor vehicle, car crash, head injuries, chest injuries, multiple fatality
Swift, John McGregor
2015 TASCD 035
Transport & Traffic Related, Older Persons, Physical Health, Motor Vehicle Crash, driver, sole occupant, heart disease, cardiac event
Swan, Daniel Peter (PDF, 363.4 KB)
2019 TASCD 373
Transport and traffic related, multiple blunt traumatic injuries, two-vehicle collision, West Tamar Highway, coroner's finding
Summerfeldt; Ian Patrick.pdf (PDF, 243.7 KB)
2017 TASCD 002
hospital, renal failure, perforated gastric ulcer, sepsis, stomach pain,
Sulman, Murray Matthew (PDF, 373.0 KB)
2019 TASCD 396
motor vehicle crash, transport and traffic related, Mornington, South Arm Highway, excessive speed, negligent driving, Traffic Act 1925
Craig Sullivan Findings (PDF, 549.3 KB)
Suckling, James William (PDF, 523.8 KB)
2018 TASCD 509
North West Regional Hospital, hypovolemic shock, complication following surgery, incorrect diagnosis,
Stewart, Keith Thomas (PDF, 367.0 KB)
2019 TASCD 460
transport and traffic related, mobility scooter crash, single vehicle crash, no helmet, loss of control
Stewart, Justin Blade (PDF, 370.9 KB)
2018 TASCD 029
mixed drug toxicity, drugs and alcohol, schizophrenia, mental illness and health, Oxazepam, Quetiapine, Temazepam, Alprazolam, accidental overdose, antipsychotic drugs,
Stewart, Eileen Adeline (PDF, 284.7 KB)
2017 TASCD 553
long term missing person,
Steshic, John Norman -web .pdf (PDF, 495.7 KB)
2019 TASCD 103
coronial, hospital, heart disease, ischaemic heart disease, single vessel atherosclerosis
Sterling, William John (PDF, 227.3 KB)
2015 TASCD 182
Physical Health, Natural Cause Death, lung disease, intravenous drug use, hypertension, cardiovascular disease, hepatitis
Stephenson, Jason Scott (PDF, 292.0 KB)
2015 TASCD 225
Leisure Activity, Water Related, Physical Health, Drowning, Marine Fatality, scuba diving, diving equipment, age, fitness, obesity, breathlessness, Eddystone Point, cardiac
Stefaniw, Gerard Ernest (PDF, 738.2 KB)
2019 TASCD 8
death in care, order under the Guardianship and Administration Act 1995, Guardianship and Administration Board, intentional self harm, mental illness and health, Roy Fagan Centre
Steer, Michael Allan (PDF, 289.1 KB)
2018 TASCD 316
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,
Stanley, Christopher Stephen (PDF, 372.6 KB)
2019 TASCD 333
transport and traffic related, single motorcycle crash, Smithton, school zone, excessive speed, un-roadworthy vehicle, drug and alcohol, methamphetamine
Stacey, Leanne Maree (PDF, 162.5 KB)
2016 TASCD 044
Drugs & Alcohol, Physical Health, Misadventure, heart disease, mixed drug toxicity, morphine, benzodiazepine, dothiepin, intravenous drug use
Spanney, Kenneth David (PDF, 242.0 KB)
2017 TASCD 327
Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Smith, Kimberley Dale (PDF, 172.6 KB)
2015 TASCD 217
Water Related, Drowning, Marine Fatality, dinghy, missing person, hypothermia, Chasm Creek, Heybridge, Blythe River
Smith, James Maurice (PDF, 320.5 KB)
2017 TASCD 202
Hospital, haemopericardium, pericardial tamponade, aortic dissection, incorrect diagnosis, misdiagnosis, poor medical practice, inadequate diagnosis, inadequate hospital care, ischaemia, surgical delay, cardiac arrest,
Smith, Nicky Glenn (PDF, 437.8 KB)
2018 TASCD 396
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
Smith, Molly Jessie (PDF, 761.7 KB)
2017 TASCD 444
death in care, Roy Fagan Centre, mental illness and health, GP Assist, misdiagnosis, pneumonia, pyelonephritis.
Smith, Jordan Marcellus (PDF, 380.9 KB)
2019 TASCD 370
Transport and traffic related, motorcycle and motor vehicle crash, head-on collision, incorrect lane, multiple traumatic injuries, alcohol, coroner's finding
Smith, David Alan (PDF, 403.1 KB)
2019 TASCD 255
Two vehicle collision, transport and traffic related, multiple injuries, coroner's finding
Smith, Barry (PDF, 378.0 KB)
2019 TASCD 381
Transport and traffic related, physical health, heart disease, positional asphyxia, workplace, coroner's finding, coroner's comments
Smart, Joshua David (PDF, 197.7 KB)
2016 TASCD 038
exsaunguination/ hypovolaemic arrest, bleed from severed artery
Slater, Timothy Guy (PDF, 261.5 KB)
2015 TASCD 349
Undetermined, missing person, Fern Tree, Mental Illness & Health, Drugs & Alcohol, bushwalker
Slabkowski,_Mary.pdf (PDF, 82.7 KB)
2017 TASCD 64
Older person, fall, subarachnoid haemorrhage, closed head injury, in-home care, LGH, Anglicare Tasmania
Skrepetos, Stavroula (PDF, 478.6 KB)
2019 TASCD 34
older persons, abdominal aortic aneurysm (AAA), haemoperitoneum/retroperitoneal haematoma, Royal Hobart Hospital Emergency Department, falls
Simpson, Peter Lawrence (PDF, 359.8 KB)
2017 TASCD 514
drugs & alcohol, mixed prescription drug toxicity, methadone, diazepam, promethazine
Simpson, Bryan Thomas (PDF, 369.3 KB)
2018 TASCD 282
transport and traffic related, motor cycle crash, recommended speed, advisory speed sign.
Simmons, Lawrence John (PDF, 278.8 KB)
2018 TASCD 212
undetermined cause of death, disappearance, long term missing person,
Sheehan, Leon Dennis (PDF, 371.6 KB)
2018 TASCD 444
motor vehicle crash, transport and traffic related, positional asphyxia, drink driving, driving whilst alcohol in body, exceed 0.05, driving affected by alcohol.
Sheedy, Barbara (PDF, 166.9 KB)
2017 TASCD 182
Launceston General Hospital, fall, subdural haemorrhage, uncal herniation
Shayler-Appleton, Gemma Louise (PDF, 371.5 KB)
2018 TASCD 239
transport and traffic related, motor vehicle accident, pedestrian
Scott, Douglas Ian (PDF, 368.8 KB)
2018 TASCD 132
smoking, emphysema, oxygen concentrator, oxygen tubes, smoking using oxygen concentrator, oxygen deprivation, carbon dioxide toxicity, ignite oxygen, recommendation regarding medical oxygen concentrators.
Scheffer, Yolande (PDF, 87.7 KB)
2017 TASCD 62
Water related, drowning, Somerset beach, swimming, surf life saving, NWRH
Sansom, Ann Margaret (PDF, 224.0 KB)
2015 TASCD 224
Adverse Medical Effects, Physical Health, Royal Hobart Hospital, subarachnoid haemorrhage, perforation, aneurysm, endovascular coiling, complication, diabetes, cirrhosis
Saltmarsh, Aidan Denis (PDF, 384.2 KB)
2019 TASCD 332
transport and traffic related, single vehicle crash, motorcycle crash, multiple injuries, loss of control of vehicle, alcohol and drugs, blood alcohol level over legal limit, cannabis (THC), excessive speed
Mr S (PDF, 169.6 KB)
2015 TASCD 216
Mental Illness & Health, Work Related, Drug Overdose, tramadol, opiate pain relief, chronic pain, Mt Lyall Mine, colleagues, anti-depressant, workplace deaths
Mr S (PDF, 261.4 KB)
2015 TASCD 242
Intentional Self-Harm, Suicide, Transport & Traffic Related, Motor Vehicle Crash, driver, single occupant, tree, Powranna
Russell; Patricia Joy RC signed 26-3-18.pdf (PDF, 380.3 KB)
2018 TASCD 141
Health care, hospital, empyema, sepsis, complicating oesophageal perforation, diabetes, obesity, atherosclerotic coronary vascular disease
Russell, Allan Geoffrey (PDF, 873.4 KB)
2019 TASCD 152
Drowning, water related, coroner's finding, fishing vessel, dinghy capsize
Rushton, Ethan Charles & Kearnes, Christopher Peter (PDF, 131.0 KB)
2017 TASCD 440 and 441
Transport & Traffic related, motorcycle accident, speeding, drug & alcohol related
Mead, Liam - Ruling on Evidence (PDF, 147.9 KB)
ruling on evidence, whether evidence within scope of inquest, adolescent mental health, Tasmania, Liam Mead inquest, Coroners Act 1995 (Tas)
Ruling and Reasons on Objection to Admissibility of Evidence - Gleeson, Lucas and Welsh (PDF, 371.6 KB)
Copper Mines Tasmania, Barminco, mine deaths, ruling on admissibility of evidence, Mount Lyell mine, Queenstown mine, work place deaths, work related, location,
Ross, Ronald Charles (PDF, 273.6 KB)
2017 TASCD 535
Undetermined cause of death
Ronald Grundy, Aaron Jeffrey and Ian Smith.pdf (PDF, 490.8 KB)
2018 TASCD 375 376 377
Law Enforcement, death in custody, death in care, natural causes death, Wilfred Lopes Centre, Risdon Prison, Section 28(5) Coroners Act.
Rogers, Maureen Ann (PDF, 241.7 KB)
2015 TASCD 190
Older Persons, Physical Health, Launceston General Hospital, misdiagnosis, gastritis, aortic dissection, cardiac tamponade, CT scan
Rock, Scott
2015 TASCD 002
Homicide & Assault, Drugs & Alcohol, head injuries
Roberts-Burton, Blaze Christian (PDF, 180.5 KB)
2017 TASCD 130
alcohol, drugs, intoxication, run over by truck, body on highway, diazepam, temazepam, alprazolam, methylamphetamine,
Roberts, Theressa Mae (PDF, 398.2 KB)
2018 TASCD 412
Transport & traffic related, coroner's finding, pedestrian fatality
Roberts, Nigel Douglas (PDF, 734.5 KB)
2019 TASCD 9
death in care, Mental Health Act 2013, mixed prescription drug sedation, clozapine, olanzapine, Spencer Clinic, Burnie, North West Regional Hospital, Karingal Nursing Home, mental illness and health, coroner's recommendations
Roberts, Anna Jane and Stanley, Brett John (PDF, 378.5 KB)
2019 TASCD 439 and 440
transport and traffic related, motor vehicle accident, two vehicle crash, multiple traumatic injuries, drugs and alcohol, alcohol intoxication, blood alcohol over legal limit, cannabis, Lauderdale
Payton, Robert John (PDF, 179.5 KB)
2015 TASCD 76
Transport & Traffic Related, Motor Vehicle Crash, Bass Highway, Wiltshire, motor scooter, head-on, negligent driving, overtaking, proper lookout
Rivelli, Andrea (PDF, 214.1 KB)
2015 TASCD 372
Intentional Self-Harm, Mental Illness & Health, Suicide, tourist, traveller, meditation
Richardson, Kenneth Charles (PDF, 228.8 KB)
2016 TASCD 369
Physical Health, Older Persons, Adverse Medical Effects, Drug Overdose, Royal Hobart Hospital, digoxin toxicity, Digibind, heart disease, renal disease, congestive cardiac failure, mitral regurgitation, atrial fibrillation, blood testing, monitoring
Richardson, Margaret Rita.(Web).pdf (PDF, 406.9 KB)
coronial, artery dissection, ischaemic heart disease, renal scarring, emphysema
Rice, Luke Jesse (PDF, 420.9 KB)
2019 TASCD 491
Coroner's finding, water related, transport & traffic related, blunt force trauma with brain injury, leisure activity, misadventure, PWC, unlicensed and inexperienced PWC operators, Lake Trevallyn Dam, Tasmanian Jet Sport Boating Club
Renison_Decision_21-5-_08.pdf (PDF, 1.5 MB)
Reardon, Jean May (PDF, 299.1 KB)
2016 TASCD 253
Older persons, Physical Health, Royal Hobart Hospital, sepsis, pressure ulcer, bedridden
Reaney, Leigh Anthony (PDF, 432.9 KB)
2018 TASCD 071
blunt force, ground, fall, balcony, roof
Mr R (PDF, 356.3 KB)
2015 TASCD 422
Drugs & Alcohol, doxepin, mianserin, fluoxetine, combined drug intoxication, self-medication, depression, hypertensive heart disease
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, 3.9 MB)
2017 TASCD 329 330 331 332 333 334 and 335
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.
Powell, Stephen Maxwell (PDF, 309.1 KB)
2019 TASCD 417
Intentional self-harm, Mental illness & health, older persons, Mental Health Act 2013 (Tas), Mental Health Treatment Order, person held in care, community services
Powell, Arthur John (PDF, 164.3 KB)
2016 TASCD 370
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
Potts, Robert James (PDF, 110.6 KB)
2020 TASCD 44
Transport & traffic related, motorcycle crash, blunt force trauma, crash investigation, speed, unroadworthy
Porteous, Shayne Edward (PDF, 490.3 KB)
2019 TASCD 143
Mixed drug toxicity, serotonin syndrome, sertraline, tramadol, SSRIs, drugs & alcohol, coroner's finding
Plummer, Samuel Anthony (PDF, 348.4 KB)
2017 TASCD 469
sudden unexpected death in a person with epilepsy (SUDEP)
Plowright, Ben Wara 2017 TASCD 159 (PDF, 171.4 KB)
2017 TASCD 159
Drowning, water, river, threat to breathing,
Pitchford, Rhiannon Pearl Vanessa (PDF, 397.7 KB)
2018 TASCD 511
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
Pinner, Liam Christopher (PDF, 370.0 KB)
2018 TASCD 126
motor vehicle crash, motorcycle crash, loss control of motorcycle, motorbike crash,
Picken, Jason Scott (PDF, 362.0 KB)
2019 TASCD 369
manslaughter, assault, subarachnoid haemorrhage, comments on passing sentence, Criminal Code
Pel, Tracie Ann and Pel, Michael Geraddus (PDF, 371.1 KB)
2017 TASCD 393 & 394
motorcycle, passenger, neck injuries, chest injuries, abdominal injuries, round bale
Pedersen, Jonas Havskov (PDF, 235.0 KB)
2015 TASCD 239
Misadventure, Drugs & Alcohol, poppy tea, morphine intoxication, poppy fields, opium poppies
Peck, Edward Paisley (PDF, 825.8 KB)
2019 TASCD 386
intentional self harm, mental illness and health, death in a public place, Tasman Bridge, Royal Hobart Hospital, Mental Health Act 2013 (Tas), decision not to involuntarily detain
Peart, Alexander Alfred and Ruby Rose (PDF, 395.5 KB)
2018 TASCD 390 and 391
transport and traffic related, motor vehicle accident, child and infant death, Sorell causeway
Flockhart, Alexander Michael & Pauly, Damian Kenneth (PDF, 320.1 KB)
2017 TASCD 204 & 205
Coronial, violent, homicide, gunshot wounds, stab wound, firearms,
Patrick, Robert David (PDF, 368.9 KB)
2018 TASCD 398
West Coast District Hospital, medical related, abdominal aortic aneurysm
Paton, Benjamin Luke (PDF, 89.0 KB)
2019 TASCD 515
Transport & traffic related, alcohol, drink driving, excessive speed, speeding, mobile phone usage, texting, single vehicle crash, unroadworthy, asphyxia, Turners Marsh, failure to wear seat belt, coroner's comments
Patmore, Jason (PDF, 378.0 KB)
2018 TASCD 088
haemorrhagic stroke complicating anticoagulation, intravenous antibiotic therapy, deep vein thrombus, hospital, traumatic brain injury, bicycle crash,
Patmore, Jason - Decision as to Inquest.pdf (PDF, 417.9 KB)
decision not to inquest,
Pasinski, Alexander (PDF, 273.0 KB)
2016 TASCD 285
Mental Illness & Health, Death in Care, Launceston General Hospital, asphyxia, choking, Amitriptyline, Paliperidone, Chlorpromazine, Magill forceps, soft diet, schizophrenia
Paraskevas, Odissefs (PDF, 396.0 KB)
2019 TASCD 95
Pulmonary thromboembolism, deep vein thrombosis, D-dimer, Wells score, PERC, Coroner's recommendation
Palmer, Ian George (PDF, 404.1 KB)
2018 TASCD 492
transport and traffic related, motor vehicle crash, pedestrian struck, Launceston CBD, death by negligent driving
Paino, Sarah (PDF, 169.8 KB)
2017 TASCD 321
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,
Osborn, James Lee (PDF, 379.8 KB)
2018 TASCD 230
Mental Illness & Health, Intentional Self-Harm, drowning, jump off jetty with weight, false report of missing person.
Orton-Tracey, Jim (PDF, 399.8 KB)
2018 TASCD 311
pulmonary embolism, immobilised lower leg, 'moon boot', anticoagulation
Ordonez, Genaro Lotero (PDF, 178.1 KB)
2016 TASCD 041
Water Related, Leisure Activity, Drowning, Swimcart Beach, Binalong Bay, tourist, swim, rip, head injury, signs
Oosterloo, Jane (PDF, 371.8 KB)
2018 TASCD 364
hospital, medical, haemopericardium, surgical, Launceston General Hospital
O'Brien, Mark Andrew (PDF, 369.6 KB)
2019 TASCD 380
transport and traffic related, motor vehicle accident, motorcycle accident, loss of control, traumatic injuries of head and chest, Kalang Avenue
O'Day, Dennis James
2015 TASCD 109
Suicide, Intentional Self-Harm, Youth, Tasman Bridge, missing person, relationship breakdown
Nunn, Peter John (PDF, 360.1 KB)
2019 TASCD 479
transport and traffic related, single motor vehicle crash, excessive speed, driving over speed limit, Lilydale
Nowitzki-Eisenburg, Heike (PDF, 493.2 KB)
2019 TASCD 75
transport and traffic related, motor vehicle accident, two vehicle crash, Lilydale Road, adverse weather conditions, poor condition of road, excessive speed for conditions
Novaski, John James (PDF, 394.5 KB)
2019 TASCD 083
Coronial, atherosclerotic, hypertensive, cardiovascular disease, hospital, Launceston General Hospital, obesity, hypertension, complications of health care, missed or incorrect diagnosis
Norris Freda Kate (PDF, 167.0 KB)
2015 TASCD 223
Undetermined, Missing Person,
Noble, Murray (PDF, 168.7 KB)
2017 TASCD 89
house fire, combustion, asphyxia, smoke inhalation, inhalation of products of combustion,
NN (PDF, 397.9 KB)
2018 TASCD 274
Alcohol-induced central nervous system depression, alcohol-related heart disease, hypothermia, location, physical health
Nichols, James Raymond (PDF, 397.8 KB)
2019 TASCD 169
transport and traffic related, single motor vehicle crash, Bass Highway, failure to wear seatbelt, alcohol, drink driving, driving over the limit, blood alcohol level of 0.157, speeding, failure to drive at speed limit, coroner's comments
Newett, Margaret Wynne (PDF, 267.5 KB)
2016 TASCD 150
Ischaemic heart disease, calcific aortic valve sclerosis, hospital death, unsatisfactory treatment.
Nettlefold, Carmel (PDF, 164.3 KB)
2016 TASCD 084
Older Person, Homicide & Assault, head injury, stranger, manslaughter, New Town Road
Pearn Natalia (PDF, 254.9 KB)
2015 TASCD 264
Motor Vehicle Crash, Transport & Traffic Related, negligent driving, safety barrier, Midland Highway, Tim Ellis
Nancarrow, Maurice Cecil (PDF, 242.3 KB)
2017 TASCD 241
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,
Mwarabu, Alice (PDF, 414.7 KB)
2019 TASCD 376
Transport and traffic related, motor vehicle crash, Domain Highway, multiple blunt injuries
Mundy, Kaylene Louise (PDF, 182.9 KB)
2015 TASCD 306
Drugs & Alcohol, Misadventure, Alprazolam, Xanax, crushed tablets, intravenous drug use, heart failure, Tasmanian Alcohol & Drug Service
Muller Shar Marie (PDF, 168.0 KB)
2015 TASCD 304
Intentional Self-Harm, Suicide, missing person, Tasman Bridge, Mental Illness & Health
Mrs W (PDF, 163.2 KB)
2015 TASCD 318/15
Weather Related, Domestic Incident, falling tree, wind
Mrs F (PDF, 379.1 KB)
2018 TASCD 62
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, falls risk.
Mr S.pdf (PDF, 162.7 KB)
2016 TASCD 377
suicide, hanging, asphyxia, mental health, depression, mental health ward, Royal Hobart Hospital
Mr P (PDF, 91.3 KB)
2016 TASCD 254
Adverse Medical Effects, Physical Health, Royal Hobart Hospital, small bowel obstruction, adhesions, misdiagnosis, inadequate care
Mr JC 105 TASAD 2017.pdf (PDF, 172.4 KB)
2017 TASCD 105
Thermal burns, single motorbike accident,
Mr F (PDF, 154.0 KB)
2016 TASCD 149
scooter accident, skate park, laceration of heart,
Mr D (PDF, 209.7 KB)
2016 TASCD 372
Drugs & Alcohol, methylamphetamine
Mr. K - 2014 TASCD 393
Mr M (PDF, 404.6 KB)
2018 TASCD 025
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.
DI (PDF, 419.2 KB)
2019 TASCD 226
transport and traffic related, intentional self harm, head injuries, mental health and illness, driver, intentionally driving into path of oncoming vehicle, Latrobe
Mr T - 2013 TASCD 438
Findings, Coronial Division, Magistrates Court of Tasmania,motor cycle accident, cranial fractures,
Mr T
2015 TASCD 090
Domestic Incident, Domestic Accident, mechanic, car, motor vehicle, trolley jack, support stands, jack stands, car stands
Mr G
2015 TASCD 031
Mental Illness & Health, Death in Care, Royal Hobart Hospital, treatment order, schizophrenia, chest pain, cardiovascular disease, cardiac arrest
Mr D
2015 TASCD 069
suicide, exhaust fumes, Tasmania death
Moylan, Mark David (PDF, 222.0 KB)
2016 TASCD 195
Water Related, Leisure Activity, Marine Fatality, Drowning, Drugs & Alcohol, Mental Illness & Health, prescription, Tamar River, Gravelly Beach marina, dinghy, diazepam, missing person, PFD
Morris, Jason Simon (PDF, 122.1 KB)
2019 TASCD 110
natural cause death, death in custody, Coroners Act 1995, Risdon Prison, Royal Hobart Hospital, Whittle Ward, metastatic squamous cell carcinoma of the lung
Morris, Audrey Anne (PDF, 374.9 KB)
2018 TASCD 237
fire related, house fire, wood heater, smoke inhalation
Mordha, Debra Christine (PDF, 162.8 KB)
2017 TASCD 017
drug toxicity, overdose, prescription medication, tramadol, amitriptyline, venlafaxine, diazepam.
Monson, Troy Colin; Michael, Robin and Mitchell, Scott Clifford (PDF, 922.8 KB)
2017 TASCD 253, 254 and 255
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.
Mollross, Daniel (PDF, 392.1 KB)
2019 TASCD 335
Transport and traffic related, motorcycle and motor vehicle crash, speed and alcohol, diffuse head injury, unroadworthy, coroner's finding, coroner's comment
Mitchell, Kenneth Hudson (PDF, 243.4 KB)
2017 TASCD 326
Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Miss N (PDF, 235.7 KB)
2013 TASCD 347
hanging, suicide, anorexia
Miller, Melinda Shirley (PDF, 561.9 KB)
2018 TASCD 298
mental illness and health, Clozapine, Olanzapine, Community Treatment Order, Mental Health Act, natural cause death, coroner's recommendations
Kerry Michael (PDF, 374.1 KB)
2018 TASCD 168
homicide, murder, weapon, location, homicide and assault, Mount Roland, struck by rock.
McTye, Wilma (PDF, 399.3 KB)
2018 TASCD 417
older persons, falls, subdural haematoma, Lewy Body Dementia, aged care, Strathaven Aged Care Facility
McManus, Pamela (PDF, 208.1 KB)
2015 TASCD 427
Older Persons, Physical Health, Royal Hobart Hospital, John Street Medical Centre, Adverse Medical Effects, colon cancer, bowel, large volume aspiration, right hemicolectomy, misdiagnosis, anaemia, inadequate care
McLean, Michael William (PDF, 260.2 KB)
2019 TASCD 338
Transport and traffic related, motorcycle and vehicle crash, chest injuries, incorrect side of road, cornering technique, crosswinds, high risk of death, coroner's finding
McKenzie, Heather Patricia Dale (PDF, 383.5 KB)
2019 TASCD 430
alcohol and drugs, mixed alcohol and drug toxicity, unintentional, Amlodipine, drug interaction, Burnie, Silver Whisper cruise ship
McKenzie, Alan John (PDF, 538.9 KB)
2018 TASCD 499
Coronial, Coroner, heart failure secondary to ischaemic heart disease, arrhythmia, fall, cervical neck fractures, nursing home
McInerney, Robert Edward (PDF, 617.6 KB)
2019 TASCD 531
Coroner's finding, coroner's recommendations, gunshot wound, law enforcement, mental illness & health, weapon, police provoked shooting, Tasmania Police
McDougall, Kirsten Web (PDF, 168.4 KB)
2016 TASCD 211
Transport & Traffic Related, Motor Vehicle Crash, passenger, single vehicle, traumatic brain injury, aspiration pneumonia, Midland Highway, fatigue, fell asleep
McDermott, Janice Faye (PDF, 165.3 KB)
2016 TASCD 124
Transport & Traffic Related, train, level crossing, pedestrian, Box Hill Road, Claremont
McConnon, Desmond Keith (PDF, 159.6 KB)
2016 TASCD 406
Domestic Incident, Older Persons, fall, tree, trimming branches, safety equipment, harness, gardener
McCauley, Terence Bernard (PDF, 173.0 KB)
2015 TASCD 321
Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, negligent driving causing death, overtaking, following distance, lookout, head-on collision, Arthur Highway, Copping
McCallum, William
2015 TASCD 085
death, drowning, dover, hypothermia, kayak, immersion
McCall, Pamela (PDF, 318.8 KB)
2017 TASCD 173
prescription medication, overdose, prescribing, panadeine forte, mixed drug and alcohol toxicity, paracentamol, propranolol, mental health issue.
MC (PDF, 363.0 KB)
2018 TASCD 108
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.
MB (PDF, 458.8 KB)
2018 TASCD 241
drug overdose, tramadol, alprazolam, drugs & alcohol, mental illness & health, drug toxicity, sharing prescription drugs, supply prescription drug to another, drug interaction, sharing restricted medications.
Maxwell, Benjamin Murray (PDF, 86.9 KB)
2019 TASCD 497
Homicide, murder, assault, stabbing, Devonport
Mattathyahu, Judah (PDF, 415.7 KB)
2015 TASCD 286
Homicide & Assault, missing person, affair,
Mason, Alison Henderson (PDF, 369.9 KB)
2019 TASCD 485
Coroner's finding, long-term missing person, older person, undetermined cause of death, body not located, North-West Tasmania
Martin, Jack Hedley (PDF, 374.5 KB)
2019 TASCD 502
adverse medical effects, hospital death, Mersey Community Hospital, sepsis, failure to remove intravenous cannula
Marshall, Donald Joseph (PDF, 180.8 KB)
2016 TASCD 047
Water Related, Older Persons, Intentional Self-Harm, Geographic, Badger Island, Bass Strait, EPIRB, coordination, search
Marriott, Molli Margaret Anne (PDF, 374.2 KB)
2018 TASCD 42
Motor vehicle accident, traffic and transport related, child unrestrained, drugs and alcohol, learner driver
Whittle, Marion Olive 2017 TASCD 114 (PDF, 167.0 KB)
2017 TASCD 114
motor vehicle crash, cardiogenic shock, tricuspid regurgitation, Royal Hobart Hospital, corolla Sedan, traumatic papillary muscle laceration, blunt force, transport, vehicle occupant
Margaret Nicol Foran (PDF, 214.0 KB)
2016 TASCD 248
Older Persons, Homicide & Assault, Mental Illness & Health, strangulation, smothering, asphyxia, schizophrenia, psychotic, mother
Mansfield, Doreen (PDF, 842.3 KB)
2019 TASCD 69
Coronial, Findings, Inquest, death in care, Royal Hobart Hospital, fall from standing position/ height, complication of left femur fracture
Mansell John Ernest (PDF, 400.4 KB)
2016 TASCD 001
Leisure Activity, Motor Vehicle Crash, Targa, Porters Bridge Road, Deloraine, competitive sport, driver, racing, rally, CAMS, inexperience, Tarmac Rally Standing Regulations, breathalyse, HANS device, pace note, chicane, beginners briefing
MacQueen, Tyrone Frederick (PDF, 513.1 KB)
2018 TASCD 441
long term missing person, 1994, Ravenswood, northern Tasmania, mental illness and health, undetermined circumstances of death, undetermined cause of death
Mackozdi, Janet Lois (PDF, 795.0 KB)
2018 TASCD 274
older persons, elderly, elder abuse, hypothermia, dementia, coroner's recommendations, domestic incident, Mt Llyod
MacKinnon, Ian (PDF, 393.3 KB)
2018 TASCD 423
Work Related, tractor, agricultural machine, rock picker, crush by machine, crush by rock picker, farming, farm accident.
Macdonald, Shauna Maree (PDF, 161.6 KB)
2017 TASCD 063
drug toxicity, pentobarbital, drug use, drug overdose.
MA (PDF, 401.7 KB)
2019 TASCD 153
Coroner's finding, transport & traffic related, motorcycle crash, multiple injuries
Lunson, Nathan (PDF, 356.8 KB)
2016 TASCD 407
Drugs and alcohol, prescription drug toxicity, mental illness and health
Lukendlay, Charlotte (OM) Findings.pdf (PDF, 751.2 KB)
2019 TASCD 234
child and infant death, global hypoxic brain injury, cessation of breathing, family violence context, non-accidental injury, rib fractures
Lucas, Troy Dale (PDF, 193.2 KB)
2015 TASCD 120
Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Brooke Street, East Devonport, negligent driving causing death, sun, inattention, head-on collision
Lore, Margaret (PDF, 499.9 KB)
2019 TASCD 79
Head injury, cliff fall, hazardous area, Blackmans Bay blowhole, safety, public area, Coroner's recommendations
Long, Anthony Edward (PDF, 412.9 KB)
2019 TASCD 418
Drowning, water related, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety
Lockwood, Shane (PDF, 406.3 KB)
2018 TASCD 52
Mental health & illness, intentional self harm, Clozapine, Risperidone, Mental Health Order
Little, Neita Jean (PDF, 642.8 KB)
2018 TASCD 97
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.
Lewtas, Georgia Amy (PDF, 350.4 KB)
2019 TASCD 52
drowning, water related, Mersey Bluff, Devonport, youth, Surf Life Saving, coroner's recommendation, surf rescue, swimming, leisure activity
Lehmann, Matthias (PDF, 444.1 KB)
2017 TASCD 538
missing person, possible drowning, Spirit of Tasmania, possible suicide
Leemhuis, Leah Maree (PDF, 177.5 KB)
2015 TASCD 243
Motor Vehicle Crash, Transport & Traffic Related, Drugs & Alcohol, prescription medication, Diazepam, Sertralin, cannabis, fatigue, fell asleep, Bass Highway, Carrick, Astra sedan, seatbelt defect, airbag defect
Lee, Lester William (PDF, 407.0 KB)
2018 TASCD 286
long-term missing person, undetermined cause of death, Devonport
Leary, Leslie John (PDF, 183.1 KB)
2015 TASCD 083
Drowning, Water Related, Weather Related, rock lobster, dinghy, PFD, certificate of competency
Langford, Samuel Peter and Jones, Timothy Peter (PDF, 306.3 KB)
2017 TASCD 316 and 317
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.
Lane, Andrew Brian
2015 TASCD 034
Water Related, Weather Related, Leisure Activity, Geographic, Drowning, safety, fishing, dinghy, boat size, forecast, EPRIB, PFD, cold water immersion, Tooms Lake, Oatlands
KW (PDF, 371.9 KB)
2018 TASCD 297
Drugs & Alcohol, Leisure Activity, Misadventure, exposure to sun, mixed drug toxicity, excessive consumption of alcohol, preventing protective responses to dangerous environmental conditions
Kupsch, Jessica Ann (PDF, 256.3 KB)
2016 TASCD 217
Homicide & Assault, domestic violence, Penny Royal Hotel, family violence order, Launceston Police, drug treatment order, plea bargain
Kulla, Daniel and Macleod, Malcolm (PDF, 237.6 KB)
2016 TASCD 077, 078
Mental Illness & Health, Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Death in Care, abscond, citalopram, olanzapine, cannabis, unregistered, unroadworthy, unlicensed, speed, helmet
Kugel, Karen (PDF, 484.8 KB)
2019 TASCD 53
Homicide & assault, murder, stabbing, coroner's finding, restraint order
Kranz, Lothar Wolfgang (PDF, 501.6 KB)
2018 TASCD 174
hospital death, abdominal aortic aneurysm (AAA), Royal Hobart Hospital, chimney vascular repair procedure, advanced coronary artery and peripheral vascular disease complicating repair
Kokholm, Dan (PDF, 183.1 KB)
2015 TASCD 324
Leisure Activity, Geographic, Mount Ossa, Cradle Mountain, Lake St Clair, national park, bushwalking, mountaineering, climbing, missing person, disappearance, soldier, army, Vietnam, logbook, hut
KNIGHT,_Larry_Paul_-_2009_TASCD_25.pdf (PDF, 3.2 MB)
Knight, Milfred Keith (PDF, 449.5 KB)
2018 TASCD 192
aircraft crash, light aircraft, Devonport Airport, transport and traffic related, leisure activity
Kingston, Neil Robert (PDF, 142.9 KB)
2017 TASCD 439
Tree felling, chainsaw, domestic accident, no helmet, Coroner's recommendations
King, David John (PDF, 449.0 KB)
2018 TASCD 091
Royal Hobart Hospital, RHH, aspiration pneumonia, acquired brain injury, unwitnessed fall, group home, alcohol, alcohol via Percutaneous Endoscopic Gastrostomy, Drugs & Alcohol, Falls, Physical Health.
Killer, Debbie Dubravka (PDF, 411.5 KB)
2019 TASCD 42
undetermined cause of death, undetermined circumstances of death, Tasmania Police, incomplete investigation, Tasmania Police Manual, Forensic Services, forensic evidence, coroner's comments
Kenney, Margaret Patricia (PDF, 510.8 KB)
2019 TASCD 142
Coroner's finding, coroner's recommendations, adverse medical effects, PPI, gastrointestinal bleed, death review
Mr K (PDF, 173.1 KB)
2016 TASCD 006
Transport & Traffic Related, Motor Vehicle Crash, Motorcycle, Youth, learner, inexperience, pillion passenger
Jones, Tristan Adam (PDF, 522.4 KB)
2018 TASCD 425
subarachnoid haemorrhage, middle cerebral artery rupture, hospital policies, hospital transfers.
Jones, Gweneth Elsie (PDF, 373.1 KB)
2018 TASCD 399
Coronial, findings, blunt force, accidental fall, unwitnessed fall, lung bronchopneumonia, small dilstal pulmonary emboli,
Jones, Thomas Elvet
2015 TASCD 058
Transport & Traffic Related, Water Related, Fall, Location, Motor Vehicle Crash, Tasman Bridge collapse
Johnson, Damian (PDF, 187.6 KB)
2016 TASCD 417
Mercury Passage, Triabunna, Water Related, Leisure Related, Animal, great white shark, diver, scallops, Tasmania Police, Tas Maritime Radio
Jock, Chuak John (PDF, 275.1 KB)
2017 TASCD 546
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.
Jin, Kang (PDF, 242.3 KB)
2017 TASCD 150
Hypothermia, exposure, Overland Track, Cradle Mountain, Parks and Wildlife Service, tourist, unprepared bushwalker, search and rescue, coronial recommendations
Jenkins, Mark Andrew (PDF, 376.9 KB)
2019 TASCD 364
Transport and traffic related, motorcycle crash, multiple traumatic injuries, drugs and alcohol, lost control, speed, unregistered and unlicensed, rear brake lock, coroner's finding
Jeffrey, Angela Joy (PDF, 517.6 KB)
2019 TASCD 322
missing person, suspected intentional self harm, undetermined cause of death, body not located, Bakers Beach, northern Tasmania, coroner's comments
Jarman, Andrew John (PDF, 379.1 KB)
2018 TASCD 209
missing person, Drugs & Alcohol, Mental Illness & Health, human remains, Warrawee Reserve, asphyxia.
James, Damien Aron Web (PDF, 167.8 KB)
2016 TASCD 212
Motor Vehicle Crash, Transport & Traffic Related, single vehicle, driver, Powranna, Midland Highway, fatigue, fell asleep, driver licence testing
Jackson, Christopher George (PDF, 203.4 KB)
2016 TASCD 183
Youth, Water Related, Drugs & Alcohol, Drowning, boating, long term missing person, Derwent River, Kangaroo Bay
Jackson, Margaret Joan (PDF, 381.9 KB)
2018 TASCD 101
Transport & Traffic Related, motor vehicle crash, Interlaken Road, gravel road, drive without due care, inexperienced driver, speed limit.
Mr J (PDF, 181.0 KB)
2015 TASCD 323
Intentional Self-Harm, Older Persons, Physical Health, Mental Illness & Health, Suicide, independence, disability pension, heart disease, refusal of treatment, self-diagnosis, bowel cancer, nursing home, firearms licence, unregistered firearm
Mr J (PDF, 221.3 KB)
2015 TASCD 077
Adverse Medical Effects, prostatectomy, deep vein thrombosis, multiple pulmonary thromboemboli, prostate carcinoma, prostate cancer, TED stockings, sequential compression device, Calvary Hospital, blood clots, VTE, DVT, clexane, anticoagulation
J (PDF, 173.6 KB)
2015 TASCD 259
Child & Infant Death, drowning, solar dome pool cover, fencing
Hyland, Tobias Joseph (PDF, 241.0 KB)
2017 TASCD 325
Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Hughes, Joan May (PDF, 1.2 MB)
2019 TASCD 241
Aspiration of gastric contents following vomiting, aged care, mental illness and health, older person, coroner's finding, inquest
Howard, Lawrence Alan (PDF, 242.6 KB)
2017 TASCD 324
Domestic Incident, tree felling, chainsaw, poor tree felling techinique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Hovington, Byron Russell (PDF, 167.9 KB)
2015 TASCD 322
Drugs & Alcohol, Misadventure, Drug Overdose, Royal Hobart Hospital, methylamphetamine toxicity, hypoxic encephalopathy, cardiac arrest, intravenous drug use, jaw pain
Hoskinson, Neville Robert (PDF, 325.8 KB)
2017 TASCD 107
cardiac tamponade, proximal aortic dissection, hypertension, Launceston General Hospital, angiogram, radiology, transthoracic echocardiogram, delayed diagnosis, adverse medical effects
Hoskinson, Christopher & Hoskinson, Elaine (PDF, 186.1 KB)
2016 TASCD 142, 143
Transport & Traffic Related, Motor Vehicle Crash, Midlands Highway, Ross, mobile phone, log truck
Hosking, Jason Mathew Henry (PDF, 364.2 KB)
2017 TASCD 380
Royal Hobart Hospital, RHH, misdiagnosis, decision to discharge, discharge from hospital, Staphylococcus Aureus, sepsis, endocarditis,
Horsham, Gordon James (PDF, 371.7 KB)
2018 TASCD 327
Transport and Traffic Related, motor vehicle crash, motor vehicle accident, seatbelt, not wearing seatbelt, seatbelt fastened incorrectly,
Horcicka, Josef Vratislav (PDF, 488.4 KB)
2019 TASCD 298
adverse medical effects, hospital related death, Calvary St Luke's Hospital Launceston, reportable death, failure to report death, no post mortem performed, undetermined cause of death
Holmes, Michael John (PDF, 211.8 KB)
2015 TASCD 333
Undetermined, Drugs & Alcohol, Mental Illness & Health, missing person, suicide attempts, unemployment, isolation
Holmes, Julie Anne (PDF, 403.5 KB)
2019 TASCD 464
Transport & traffic related, motor vehicle accident, pneumonia, older person, undiagnosed cervical spine fracture, guidelines, Royal Hobart Hospital
Holmes, David Scott (PDF, 228.4 KB)
2017 TASCD 379
Transport & Traffic Related, Work Related, motor vehicle crash, truck crash, truck rollover, prime mover truck, cardiac arrhythmia, heart attack, physical health.
Hingston, Nicolle Clare (PDF, 230.2 KB)
2016 TASCD 374
cardiorespiratory arrest, pulmonary hypertension, cor pulmonale, congenital heart disease, ventricular septal defect, North West Regional Hospital, blood transfusion, premature discharge from hospital
Hill, Trent Terrence (PDF, 400.3 KB)
2018 TASCD 395
Finding, motor vehicle accident, alcohol, transport and traffic related
Hill, Phillip John (PDF, 323.5 KB)
2019 TASCD 135
hospital death, Royal Hobart Hospital, Hobart Private Hospital, colonic cancer, hemicolectomy, sepsis, delayed diagnosis
Higgins, Elizabeth Ann (PDF, 728.7 KB)
2017 TASCD 160
Drowning, water related, Little Howrah Beach
Hickman, Peter (PDF, 257.6 KB)
2016 TASCD 371
Transport & Traffic Related, Motor Vehicle Crash, Drugs & Alcohol, methylamphetamine, West Tamar Highway, Rosevears, single vehicle, oxycontin, amphetamine, alprazolam, methadone, Traffic Act, section 41A, bail
Hewitt, Robert Ian (PDF, 166.2 KB)
2016 TASCD 345
Transport & Traffic Related, Older Persons, Motor Vehicle Crash, Channel Highway, Oyster Cove, driver error
Henriksen, Wendy Margaret (PDF, 503.3 KB)
2016 TASCD 219
Coronial, hospital, sepsis, chemotherapy, Emergency Department,
Henri, Paul Lucien (PDF, 237.7 KB)
2015 TASCD 367
Older Persons, Aged Care, Physical Health, Royal Hobart Hospital, Huon Eldercare Nursing Home, pain, anxiety, drug management, morphine, MS Contin, starting dose, opiate naïve, cross tolerance, monitoring, observation, heart disease, aspiration pneumonia, Parkinson’s disease, sleep apnoea, cerebral infarction, hypoxic brain damage, Tramadol, quetiapine, CPAP, sedation, blood samples
Hedrick, Gary John (PDF, 264.3 KB)
2017 TASCD 388
Water related, drowning, alcohol, intoxication
HE (PDF, 118.2 KB)
2017 TASCD 181
echovirus type 9, myocarditis and pneumonitis, infant death, natural causes, St Mary's Community Hospital
Hayes, Teegan Rose Dana (PDF, 443.6 KB)
2018 TASCD 208
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.
Hay, Katrina Maree (PDF, 182.4 KB)
2015 TASCD 319
Misadventure, Drugs & Alcohol, intravenous drug use, crushed tablet, heart failure, pregnant, fetal death, pulmonary hypertension, cardiac arrest, microcrystalline cellulose, granulomas, granulomatous inflammatory reaction
Harrison, Jason Keith (PDF, 313.9 KB)
2016 TASCD 430
NWRH, WCDH, small bowel infarct, sepsis, mesenteric hernia, regional hospital
Harrison, John Joseph & Viney, Danny Leonard.pdf (PDF, 111.9 KB)
2017 TASCD 208; 2017 TASCD 209
Water related, drowning, recreational boating, Waterhouse Point, PFD, not wearing a life-jacket, Marine & Safety Tasmania, boat insufficiently equipped
Harris, Stephen Russell (PDF, 271.6 KB)
2017 TASCD 172
Death in care, cardiac arrhythmia, North West Regional Hospital, Spencer Clinic, Mental Health order, Paliperidone
Harper, Marlene Jean (PDF, 230.3 KB)
2016 TASCD 100
Older Persons, Physical Health, deep vein thrombosis, chronic lymphocytic leukaemia, atherosclerotic vascular disease, duplex ultrasound, anticoagulant, misdiagnosis
Hardy, Dion Ronald (PDF, 403.0 KB)
2019 TASCD 204
Transport & traffic related, motorcycle and car collision, alcohol & drugs, Brooker Highway
Hanlon, Louise Kamarnia May (PDF, 175.0 KB)
2016 TASCD 347
motor vehicle crash, car crash, motor accident, South Arm Road, provisional licence, P1.
Handasyde, Robert Neil (PDF, 232.2 KB)
2017 TASCD 187
medical care, older person, North West Regional Hospital, sepsis, septic shock, urinary tract infection, pyelonephritis
Hamlyn, Michael William (PDF, 369.1 KB)
2018 TASCD 104
Intentional self harm
Hamill, Tracey Fay (PDF, 407.5 KB)
2018 TASCD 359
transport and traffic related, motor vehicle accident, mental health and illness, depression, Penquite Road, Launceston
Ham, Roderick David Charles (PDF, 487.1 KB)
2019 TASCD 136
Pulmonary thromboemboli, deep vein thrombosis, hip replacement, physical health, Coroner's finding
Halson, Gary Peter (PDF, 367.5 KB)
2019 TASCD 334
Transport and traffic related, motorcycle and vehicle crash, blunt traumatic injuries, overtaking, following too closely, poor riding, coroner's finding
Hall, Alexander (PDF, 381.2 KB)
2018 TASCD 324
tractor accident, tractor crash, transport and traffic related, seatbelts, seatbelts in tractors
GW (PDF, 355.9 KB)
2018 TASCD 148
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.
Grey, Andrew Amos (PDF, 192.2 KB)
2016 TASCD 224
Drowning, Leisure Related, Water Related, Weather Related, Burns Bay, St Helens, lobster, Stormy Seas PFD, service
Greer, Rita (PDF, 422.0 KB)
2017 TASCD 059
self-inflicted stabbing, suicide, mental health, schizophrenia, section 58, re-open, re-investigation, Barbara Etter,
Green, Paul William (PDF, 457.7 KB)
2018 TASCD 336
carbon monoxide poisoning, exhaust gas, lawn mower exhaust, Mental Illness & Health, prevention of suicide, older persons, suicide prevention.
Greaves, Brett Jason (PDF, 375.3 KB)
2018 TASCD 299
transport and traffic related, motorcycle accident, coroner's recommendations
Graham, Dylan Rhys (PDF, 211.3 KB)
2017 TASCD 123
Elizabeth Street Pier, Salamanca, undetermined cause of death
Goss Brittany Kate (PDF, 187.0 KB)
2016 TASCD 011
Youth, Transport & Traffic Related, Motor Vehicle Crash, Weather Related, bus stop, pedestrian, rural, Collins Lane, West Tamar Highway, Sidmouth
Gorrie, Kurt Joshua (PDF, 568.9 KB)
2018 TASCD 309
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
Gordon, Mark Alexander (PDF, 235.7 KB)
2016 TASCD 282
Physical Health, Royal Hobart Hospital, misdiagnosis, inadequate care, cardiac arrest, heart disease, pericardial tamponade, aortic dissection, hypertension, diabetes, obesity, hepatic steatosis, thyroiditis, CT scan
Golus, Peter (PDF, 104.2 KB)
2019 TASCD 331
Adverse medical effects, escherichia coli urosepsis, sepsis, kidney stone surgery, launceston
Godley, David Geoffrey (PDF, 674.7 KB)
2018 TASCD 273
intentional self-harm, mental health and illness, psychosis, self-inflicted stabbing, weapon, drugs and alcohol, ice, cannabis, methamphetamine
Glover, Gerald Samual (PDF, 125.7 KB)
2019 TASCD 109
natural cause death, death in custody, Coroners Act 1995, Risdon Prison, dilated cardiomyopathy, emphysema, Correctional Primary Health
Thompson, Geoffrey Ross Sydney (PDF, 168.5 KB)
2015 TASCD 180
Drugs & Alcohol, prescription, promethazine, citalopram, ethanol, mixed drug toxicity
G Ms (PDF, 165.4 KB)
2015 TASCD 423
Intentional Self-Harm, Drugs & Alcohol, Mental Illness & Health, Suicide, bereavement, financial pressure, unemployment, outpatient support, addiction
FW (PDF, 398.6 KB)
2019 TASCD 105
Drowning, intentional self-harm, coroner's finding, coroner's recommendations
Fulham, Julianne (PDF, 493.8 KB)
2019 TASCD 183
hospital related death, adverse medical affects, Smithton District Hospital, ischaemic small bowel, bowel obstruction, Crohn's disease
Frith, Aaron Douglas (PDF, 363.8 KB)
2019 TASCD 398
Adverse medical effects, physical health, pulmonary embolism, deep vein thrombosis, prophylactic anticoagulant, Achilles tendon rupture, coroner's finding, coroner's comment
French, Steven John (PDF, 500.6 KB)
2017 TASCD 445
Adverse Medical Effects, Hospital death, stroke, Royal Hobart Hospital, North West Regional Hospital, misdiagnosis, shortcomings in care, inadequate care, failure to diagnose.
Freestone-Barks, Rosalind MacDonald Maxwell (PDF, 449.7 KB)
2017 TASCD 387
Motor bike accident, coronial, multiple injuries
Free, Maxwell John (PDF, 233.3 KB)
2017 TASCD 066
paracetamol, paracetamol overdose, drug overdose, paracetamol toxicity, organ failure, Royal Hobart Hospital.
Forward, Trudi Maree (PDF, 630.4 KB)
2018 TASCD 197
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,
Fletcher, Thomas Charles and Priest, Leonard Roger (PDF, 331.3 KB)
2018 TASCD 195 and 196
Leisure Activity, older persons, sports related, water related, weather related, boating, drowning, Park Beach Tasmania, capsize, life jackets.
Fletcher, Braidon Lewis (PDF, 284.8 KB)
2018 TASCD 300
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.
Fitzgerald, Oswyn Leigh (PDF, 272.7 KB)
2018 TASCD 89
transport and traffic related, single vehicle accident, Baskerville Raceway, cardiac arrhythmia
Fisher, Melissa (PDF, 160.2 KB)
2017 TASCD 129
fall, bush walking, Southwest National Park, fall from height, fall from Federation Peak,
Finding Brendan Smith (Web) pdf.pdf (PDF, 780.6 KB)
2019 TASCD 120
vehicle accident, tree, head injury, car crushed by falling tree, transport,
Fillisch, Eric (PDF, 424.2 KB)
2019 TASCD 413
water related, drowning, scuba diving, rebreather, rebreather apparatus, displacement of mouthpiece, Visscher Island
Field, Jayden Craig (PDF, 555.6 KB)
2015 TASCD 373
Misadventure, Drugs & Alcohol, Youth, taxi, fare evasion, head injury, CCTV, taxi camera, police investigation
Fenton, Timothy John (PDF, 409.2 KB)
2018 TASCD 462
adverse medical affects, inadequate treatment as a patient, Royal Hobart Hospital, ileus, aspiration pneumonia, sepsis, multiple organ failure, nasogastric tube
Fellows, Peter Leslie (PDF, 235.2 KB)
2017 TASCD 185
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,
Falvey, Theresa Mary (PDF, 378.0 KB)
2017 TASCD 373
Neck Injury, Single motor vehicle collison
Evans, Wendy Anne (PDF, 407.4 KB)
2019 TASCD 147
Coroner's finding, coroner's recommendation, head and chest injuries, Metro, pedestrian struck by bus, transport & traffic related
Evans, Jillian and John (PDF, 342.2 KB)
2018 TASCD 81 and 82
homicide, suicide, murder, murder suicide, violence, assault, domestic violence, delusions, bipolar, mental health,
Elias, Nebras (PDF, 496.5 KB)
2019 TASCD 1
transport and traffic related, motor vehicle accident, two vehicle crash, Lebrina
Edmonds, Ashley Samantha (PDF, 377.3 KB)
2018 TASCD 44
motor vehicle crash, transport and traffic related, Bradley Chaplin, school bus, inappropriate driving, driving offences.
Eaton, Jodi Michelle (PDF, 460.4 KB)
2019 TASCD 257
homicide, assault, asphyxia, Bridgewater, Darren Dobson, strangulation/choking, coroner's recommendations, recommendation of enactment of indictable offence of choking, suffocation or strangulation
Eaton, Jodi Michelle (PDF, 460.4 KB)
2019 TASCD 257
homicide, assault, asphyxia, Bridgewater, Darren Dobson, strangulation/choking, coroner's recommendations, recommendation of enactment of indictable offence of choking, suffocation or strangulation
Dunster, Kenneth Francis (PDF, 743.5 KB)
2019 TASCD 5
death in care, Mental Health Act 2013, mental health order, Millbrook Rise Centre, asphyxia, choking on food, supervision of meals
Dunk, Michael & Johnson, Elishka (PDF, 213.3 KB)
2018 TASCD 60; 2018 TASCD 61
homicide & assault, weapon, firearm, intentional self harm, mental illness & health
Dufty, David Richard (PDF, 552.6 KB)
2018 TASCD 434
death in custody, death in care, mental illness and health, Royal Hobart Hospital, metastatic carcinoma, schizophrenia
Duff, Jayde Kaylam (PDF, 479.9 KB)
2018 TASCD 457
transport and traffic related, motorcycle accident, drug and alcohol, methylamphetamine, cannabis, excessive speed, Meander Valley Road
DS (PDF, 302.2 KB)
2019 TASCD 17
Coroner's findings, drugs, alcohol
Drew, Malcolm (PDF, 165.3 KB)
2015 TASCD 369
Transport & Traffic Related, Motor Vehicle Crash, Driver, single vehicle, tree, tourist, Lyell Highway, head injuries, fatigue, fell asleep, tired, wet
Dransfield, Brian (PDF, 241.2 KB)
2017 TASCD 323
Domestic Incident, tree felling, chainsaw, poor tree felling technique, unsafe use of chainsaws, wood cutting, chainsaw training, recommendations regarding chainsaws
Dortkamp, John Andrew (PDF, 220.7 KB)
2015 TASCD 237
Death in Care, Millbrook Rise Centre, schizophrenia, emphysema, hypertrophy of the heart, treatment order, Physical Health, Mental Illness & Health
Dick, Braiden Taylor (PDF, 437.5 KB)
2018 TASCD 372
intentional self harm, suicide, youth, Child and Adolescent Mental Health Services, mental illness and health, Spencer Clinic
DF (PDF, 166.7 KB)
2017 TASCD 069
newborn death, infant death, premature baby, extreme prematurity, acute chorioamnionitis, 23 weeks gestation.
Dent, Freda Lillian Florence (PDF, 384.0 KB)
2018 TASCD 450
ischaemic heart disease, Freemasons, inadequate care, nursing home.
Delaney, Maxwell (PDF, 208.9 KB)
2016 TASCD 071
Aged Care, Eliza Purton Care Home, North West Regional Hospital, Falls, outdoor area, plastic chair, monitoring, fracture, pneumonia
Deaths from a Public Place (PDF, 509.2 KB)
2016 TASCD 385 386 387 388 389 390
Tasman Bridge, Intentional Self-Harm, Mental Illness & Health, Tasmanian Suicide Prevention Strategy, drowning, jump, fall, surveillance, telephones, signage, barrier .
Pearce, Jasmine Rose (PDF, 264.6 KB)
2015 TASCD 75
Child & Infant Death, Drugs & Alcohol, safe sleeping, bed sharing, suffocation, CPS, family violence, cumulative harm, Gateway Services, police
Dawson, Aidan Andrew (PDF, 395.5 KB)
2016 TASCD 091
Homicide & Assault, Drugs & Alcohol, domestic violence, stabbing, self-defence, Police Family Violence Order, Safe at Home
Davis, Ross James (PDF, 209.7 KB)
2015 TASCD 178
Drugs & Alcohol, Misadventure, intravenous drug use, injecting opiates, crushed pills, opiate analgesia, chronic pain, pulmonary disease, respiratory disease, morphine
Davis, Catherine Joy (PDF, 484.0 KB)
2019 TASCD 138
Urosepsis, pyelonephritis, lissencephaly, Royal Hobart Hospital, UTI, incorrect diagnosis, coroner's finding, coroner's recommendation
Davis, Alby Fox (PDF, 399.9 KB)
2018 TASCD 378
Coronial, Hypoxic Brain Injury, Bouncy Ball, Throat
Davies, Eva Fay (PDF, 365.9 KB)
2019 TASCD 428
Falls, older persons, closed head injury, left frontal/temporal subdural haematoma, anticoagulation, reverse anticoagulation protocol, Coroner's finding, Coroner's recommendation
Daniels, Scott Allen (PDF, 280.1 KB)
2018 TASCD 174
Drugs & Alcohol, Mental Illness & Health, Misadventure, positional asphyxia, clozapine, antipsychotic, cannabis, THC, marijuana.
Daley, Brian Owen (PDF, 374.1 KB)
2017 TASCD 532
carbon monoxide intoxication, inhalation of exhaust, petrol generator, boat, boating accident, Water Related, exhaust gas, carbon monoxide detector,
Ms D (PDF, 179.0 KB)
2015 TASCD 211
Drugs & Alcohol, mixed drug toxicity, amitriptyline, chlorpheniramine, diazepam, codeine, biventricular hypertrophy, antihistamines, opiates
Mr D (PDF, 372.3 KB)
2016 TASCD 009
Mental Illness & Health, stress, fall, anti-depressant, noncompliant, self-reporting, Launceston General Hospital, Crisis Team
Cuthbertson, Kevin Ross (PDF, 384.4 KB)
2018 TASCD 187
Transport & Traffic Related, crush by campervan, home mechanics, crushed working under vehicle, crushed working under campervan.
Crosswell, Wendy (PDF, 162.7 KB)
Adverse Medical Effects, Hospital, PEG tube, percutaneous endoscopic gastrostomy tube; RHH, Royal Hobart Hospital, pyelonephritis, nasogastric feeding tube, misdiagnosis, unacceptable standard of care, inadequate care, recommendations regarding PEG tubes, recommendation to hospitals.
Cross, Adrian John.pdf (PDF, 372.2 KB)
2018 TASCD 349
cyclist hit truck, transport and traffic related, bicycle rides into truck.
Cowen, Craig -web.pdf (PDF, 411.8 KB)
2019 TASCD 037
coronial, drowning, wharf, fall, alcohol, intoxication, water
Cooper, David Wade Archer (PDF, 166.1 KB)
2016 TASCD 432
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
Combes, Margot Janeece (PDF, 89.6 KB)
2020 TASCD 3
Fall, work related, pulmonary thromboembolus, left medial malleolar fracture, anti-coagulation, risk of DVT and PE, coroner's finding, coroner's comment
Cohen, Yvonne Dawn (PDF, 397.9 KB)
2018 TASCD 467
pneumonia, undiagnosed, North West Regional Hospital, standard of care, medical care
Cobham, David Alexander (PDF, 316.1 KB)
2016 TASCD 429
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.
Close, Terrence Findings Web.pdf (PDF, 943.2 KB)
2019 TASCD 119
Industrial accident, blunt force, blunt trauma, pedestrian, hit by utility vehicle, chest and abdomen
Clarke, Donald John (Word, 235.0 KB)
Physical Health, Adverse Medical Effects, Calvary St Luke's Hospital, Launceston General Hospital, cervical spine surgery, aspiration pneumonia, radiology, obesity, oxycodone, midazolam, tracheomalacia, endone
Clarke, Joshua (PDF, 179.0 KB)
2015 TASCD 106
Motor Vehicle Crash, Transport & Traffic Related, Drugs & Alcohol, York Plains Road, Lemont, seat belt, unroadworthy
Clark, Guy Redman (PDF, 513.8 KB)
2020 TASCD 22
Electrocution, work related, Residual Current Devices, portable defibrillator, Coroner's finding, Coroner's recommendation, Coroner's comment
Clark, Darren Stuart (PDF, 410.5 KB)
2019 TASCD 374
transport and traffic related, single motor vehicle accident, motorsport, rally car, Scottsdale Classic Rally, Confederation of Australian Motor Sport Ltd, breach of National Rally Code
CK (PDF, 176.9 KB)
2015 TASCD 420
Child & Infant Death, Transport & Traffic Related, Motor Vehicle Crash, bystander, four-wheel drive, Trial Harbour
CHUGG, Adrian David and BEAMISH, Bruce Anthony (PDF, 63.9 KB)
Bruce Anthony Beamish, Adrian Chugg
BEAMISH, Bruce Anthony and CHUGG, Adrian David (PDF, 63.9 KB)
Bruce Anthony Beamish, Adrian Chugg
Carr, Dennis Robert
2015 TASCD 001
Law Enforcement, Physical Health, Natural Cause Death, Death in Custody, Risdon Prison, Royal Hobart Hospital, Palliative Care Plan, cirrhosis of the liver, hepato-renal syndrome
Campbell, Kenneth Arthur (PDF, 371.8 KB)
2018 TASCD 225
ischaemic heart disease, atrial fibrillation, mitral valve regurgitation, congestive cardia failure, heart attack while driving, natural cause death, Transport & Traffic Related.
Mr C (PDF, 163.8 KB)
2015 TASCD 187
Domestic Incident, crushed, trolley jack, vehicle, ramp, chocking
Butterworth, Lucille (PDF, 503.2 KB)
2016 TASCD 096
Homicide & Assault, long term missing person, bus stop, Claremont, Box Hill Road, Geoffrey Hunt
Burns, Brendan Craig (PDF, 324.4 KB)
2019 TASCD 130
Coronial, Suicide, Asphyxia, Smoke inhalation, Caravan, Fire,
Burling, Gregory (PDF, 373.5 KB)
2017 TASCD 531
carbon monoxide intoxication, inhalation of exhaust, petrol generator, boat, boating accident, Water Related, exhaust gas, carbon monoxide detector,
Burkhardt, Wesley Ian (PDF, 372.1 KB)
2018 TASCD 231
transport & traffic related, motorcycle crash, motor vehicle crash, motorbike, methyl amphetamine, driving motorcycle under influence of drug, drug driving, motorcycle collides with truck.
Bunn, Lauren Elizabeth (PDF, 375.6 KB)
2018 TASCD 094
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.
Bugg, Margaret Evalina (PDF, 334.6 KB)
2017 TASCD 225
North West Regional Hospital, Yaraandoo Nursing Home, fall, stand up lifter, coroners recommendations
Bryan, Timothy David (PDF, 438.9 KB)
2018 TASCD 87
motor vehicle accident, transport and traffic related, drugs and alcohol, failure to wear a seat belt, drink driving
Bruinger, Stephen Guy (PDF, 364.8 KB)
2018 TASCD 350
medical related death, Royal Hobart Hospital, Emergency Department, overcrowding
Brown, Tony David .pdf (PDF, 595.0 KB)
2019 TASCD 022
traumatic brain injury, homicide, Mitchell Clay Dowling, Jay David Blazely, one punch death, assault,
Brown, Maddison Ann (PDF, 363.8 KB)
2018 TASCD 145
Transport & Traffic Related, motor vehicle crash, Murchison Highway, mobile phone while driving.
Broomhall, Tyler John (PDF, 240.7 KB)
2016 TASCD 313
Drugs & Alcohol, Leisure Activity, Physical Health, football, sport, methylamphetamine, intra-cerebral haemorrhage, delay in diagnosis, North West Regional Hospital
Broomhall, Callum Dane (PDF, 274.1 KB)
2018 TASCD 127
transport and traffic related, single vehicle crash, drink-driving, alcohol and drug related, failure to wear a seat-belt
Brook, Jason Mark (PDF, 184.9 KB)
2016 TASCD 194
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
Bronson, Connan Taiaroa (PDF, 170.2 KB)
2015 TASCD 179
Intentional Self-harm, Mental Illness & Health, Drugs & Alcohol, Suicide, cliff, itinerate
Britton, Eamon (PDF, 274.3 KB)
2018 TASCD 121
Long term missing person, missing person, human leg, DNA profiling, Forensic Science Service Tasmania, exhumation, bones, leg in Tamar River,
Bradshaw, Luke (PDF, 274.2 KB)
2016 TASCD 083
Water Related, Drugs & Alcohol, Drowning, Marine Fatality, Derwent River, Prince of Wales Bay, jetty
Bowerman, Graeme Anthony (PDF, 415.1 KB)
2019 TASCD 368
drowning, capsize of boat, Marion Bay, Narrows channel, MAST, marine safety, water related, transport related
Bowden, Frederick Rocky (PDF, 560.3 KB)
2018 TASCD 433
death in care, death in custody, mental illness and health, Roy Fagan Centre, schizophrenia, pneumonia, renal failure.
Bone, Christine Sylvia (PDF, 270.7 KB)
2016 TASCD 294
motor vehicle collision, coronial, abdominal injuries, chest injuries
Blazely, Corey Benjamin Maverick (PDF, 379.0 KB)
2018 TASCD 465
transport and traffic related, pedestrian struck by motor vehicle, Southern Outlet
Blackaby, Kobie (PDF, 210.2 KB)
2016 TASCD 210
Child & Infant Death, Water Related, Drowning, inflatable pool, fence, supervision
BK (PDF, 405.0 KB)
2019 TASCD 202
Hanging, intentional self-harm, mental illness and health, drugs and alcohol, Coroner's finding
Johnstone, BJay (PDF, 938.6 KB)
2017 TASCD 248
infant, ill-treat child, child death, infant death, child protection, Child & Infant Death, Homicide & Assault, family violence, assault child,
Bishop, Sarah Victoria (PDF, 164.4 KB)
2016 TASCD 346
Transport & Traffic Related, Motor Vehicle Crash, Channel Highway, Cygnet, dextromethorphan, robitussin, warnings, over the counter
Bird, Heather Mary (PDF, 243.3 KB)
2017 TASCD 126
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
Beuckelaers, Elfride Elisabeth (PDF, 174.9 KB)
2016 TASCD 090
Motor Vehicle Crash, Older Persons, driver, fail to give way, Bass Highway, Christmas Hills Road, Elizabeth Town
Best, Christopher Mark (PDF, 497.5 KB)
2019 TASCD 128
workplace death, work related, transport related, farming property, motorcycle crash, use of motorcycles on private property, single vehicle crash, unroadworthy and unsafe vehicle, no working brakes, neurocardiogenic syncope whilst driving
Bessell, Lynne - finding web.pdf (PDF, 475.3 KB)
2018 TASCD 107
coronial, metastatic carcinoma of colon, emphysema, acute bronchopneumonia,
Benneworth, Anthony John (PDF, 414.5 KB)
2019 TASCD 419
Drowning, water related, Ansons Bay, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety
Wicks, Benjamin (PDF, 639.6 KB)
2018 TASCD 491
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.
Beltz, Sarah Rose -(Web).pdf (PDF, 469.7 KB)
2019 TASCD 68
Coronial, Findings, Meningococcal, immunisation, disease, A, C,Y, W and B Strain, Neisseria meningitides, bacterial sepsis, hospital
Bedford, Sidney (PDF, 226.3 KB)
2016 TASCD 209
Falls, Older Persons, Launceston General Hospital, Physical Health, subdural haemorrhage, CT scan, misdiagnosis
Baxter, Joyce Kathleen (PDF, 291.9 KB)
2018 TASCD 236
Long term missing person, missing person, disappearance 1955, bones, Organ Pipes, Mt Wellington, human remains, DNA profiling, undetermined cause of death.
Barnes, Deearne Joan (PDF, 354.2 KB)
2016 TASCD 179
Physical Health, Mental Illness & Health, Drugs and Alcohol, Overdose, mixed drug toxicity, prescription medication, venlafaxine, methadone, amitriptyline, quetiapine, diazepam, chronic opioid therapy
Barker, Richard Carl (PDF, 255.0 KB)
2017 TASCD 302
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.
Balmer, Rosemary Joy (PDF, 166.2 KB)
2015 TASCD 181
Drugs & Alcohol, Misadventure, mixed prescription drug toxicity, oxycodone, amitriptyline, diazepam, diphenhydramine, paracetamol, chronic pain
Ball, Jeremy Dacre (PDF, 189.5 KB)
2016 TASCD 196
motor vehicle crash, suicide, semi-trailer, mental health, deliberate crash, prime mover, drive into prime mover, suicide by motor vehicle crash.
Ball, Betty Irene. (web) pdf.pdf (PDF, 494.0 KB)
2018 TASCD 56
spinocerebellar ataxia, hospital, St Luke's Calvary, Aged Care, inadequate care, constipation, Presbyterian Care, Older persons, physical health, bowel obstruction.
Baldock, Andrea Eileen (PDF, 256.4 KB)
2017 TASCD 313
sleeve gastrectomy, weight reduction surgery, gastroparesis, aspiration pneumonia, adverse medical effects, Launceston General Hospital, coroner's recommendations
Baby I (PDF, 379.5 KB)
2018 TASCD 468
Child & infant death, baby death, suffocation, overlaying whilst sleeping with adult, SUDI, coroner's finding, coroner's recommendation
Baby B (PDF, 345.2 KB)
2018 TASCD 131
SUDI, SIDS, child & infant death, sudden unexpected death in infancy, co-sleeping, coroner's recommendations
Mr B (PDF, 171.1 KB)
2015 TASCD 327
Work Related, crush, mechanic, trolley jack, jack stands
Mr B (PDF, 235.2 KB)
2015 TASCD 186
Water Related, Drowning, Marine Fatality, Older Persons, Derwent River, fishing, defective PFD, cardiac event, cold water immersion
Atkinson, James Robert (PDF, 272.4 KB)
2016 TASCD 090
Older Person, Falls, head injury, walking frame
Arundel-Clarke, Catherine Clara (PDF, 99.6 KB)
2019 TASCD 551
Transport & traffic related, single vehicle crash, learner's licence, unlicenced, unroadworthy, wet conditions, speed, child survived, crash investigation, Coroner's comments
Allie, Sue Denise (PDF, 382.0 KB)
2017 TASCD 415
Undetermined cause, Munchausen Syndrome, factitious disorder, superwarfarin (brodifacoum) toxicity
Allen, Vincent (PDF, 366.6 KB)
2017 TASCD 530
transport and traffic related, motor vehicle accident, drug and alcohol, dangerous driving
Alcohol - 2014 TASCDS 347, 348, 349, 350 (Word, 221.0 KB)
Aherne, Benjamin Mark & Clements, John William (PDF, 108.4 KB)
2015 TASCD 032, 033
Homicide & Assault, Intentional Self-Harm, Suicide, firearm, family violence, sexual dysfunction
AH (PDF, 465.3 KB)
2017 TASCD 405
Mental illness & health, intentional self harm, suicide, depression, Royal Hobart Hospital, Crisis Assessment and Treatment Team
ADT (PDF, 226.7 KB)
2016 TASCD 299
Child & Infant Death, Homicide & Assault, shaken baby, feeding, ill-treatment of a child
Adamson, Darryl (PDF, 166.9 KB)
2015 TASCD 289
Transport & Traffic Related, tractor, slasher, seizures, heart disease, orchard, cut-off switch, traumatic amputation
Mr A (PDF, 33.3 KB)
2015 TASCD 173
Misadventure, Drugs & Alcohol, Ritalin, methylphenidate, microcrystalline cellulose, intravenous injection, crushing pills, psychostimulant, foreign body granulomas of the lung, heart failure
274 TCD 2013 - MR. B
Coroner, findings, poppy, thebaine, signs
Davies, Luke; Drobnjak, Aleksander; Ritter, Magnus; Roche, Anthony (PDF, 839.6 KB)
2019 TASCD 348
Drowning, Frederick Henry Bay, transport & traffic related, water related, PFD, boat licence, second hand boat inspection, Coroner's finding, Coroner's recommendation, Coroner's comments
2014 TASCD 425 - RHODES, Luke Dale
Findings, Coronial Division, Magistrates Court of Tasmania, Drug Overdose
2014 TASCD 392 - Mr S
2014 TASCD 391 - INCHES, Christine Anne
2014 TASCD 346- APTED, Dale Robert
court,magistrate,magistrates,tasmania,australia,courts,coronial, morphine, intoxication
2014 TASCD 344 -DOUGAN, Kim Marlene Anne
motorcycle crash, severe trauma
2014 TASCD 327- FOX, Barbara Constance
Findings, Coronial Division, Magistrates Court of Tasmania,
2014 TASCD 325 - Ms I
2014 TASCD 318 - Mr H
Findings, Coronial Division, Magistrates Court of Tasmania,domestic accident, blunt force, ground surface, static object, fall, ladder, moveable step, unpowered equipment
2014 TASCD 317 - Mr G
Findings, Coronial Division, Magistrates Court of Tasmania,fall, blunt force, ground surface, ladder, moveable step, unpowered equipment
2014 TASCD 264 - RIGBY, Dayna Louise
2014 TASCD 262- TAYLOR, Craig Ewen
Findings, Coronial Division, Magistrates Court of Tasmania, , Drowning, body of water, threat to breathing, canoe, kayak, row boat, watercraft
2014 TASCD 260- CAMPBELL, Donald Laird
Findings, Coronial Division, Magistrates Court of Tasmania, drowning, water, weather, natural disasters, open sea, ocean, body of water
2014 TASCD 256- SCOTT, Ricky Charles
Findings, Coronial Division, Magistrates Court of Tasmania, , Drug overdose, poisioning, tramadol,codeine,morphine,amphetamine,diazepam,paracetamol, THC-COOH
2014 TASCD 252- ROBERTSON, Kylie
Findings, Coronial Division, Magistrates Court of Tasmania, Drug overdose, alcohol, alcoholic disease, poisoning by chemical
2014 TASCD 251- CLARK, Geoffrey Arthur
Findings, Coronial Division, Magistrates Court of Tasmania, Drowning, threat to breathing, open sea, ocean, fishing boat, trawler, watercraft
2014 TASCD 238 - JONES, Steven Paul
Findings, Coronial Division, Magistrates Court of Tasmania,overdose, drugs,
2014 TASCD 222 - HEENAN, Martin Francis
Findings, Coronial Division, Magistrates Court of Tasmania,overdose,, drug, alcohol, morphine, benzodiazepine, liver disease
2014 TASCD 221 - GRANT, Steven John
Findings, Coronial Division, Magistrates Court of Tasmania,overdose,alcohol, intoxication
2014 TASCD 210 - ROSEN, Elyssa Suzanne
Coroner, Tasmania, Findings, Diving, drowning, Tinderbox
2014 TASCD 202 - SKINNER, Timothy Mark
Findings, Coronial Division, Magistrates Court of Tasmania,drowning, threat to breathing, open sea, ocean, water, rocks, surf
2014 TASCD 201 - HART, Connor Robert Lincoln
Findings, Coronial Division, Magistrates Court of Tasmania,drowning, threat to breathing, open sea, ocean, water, rocks, surf
2014 TASCD 149- RICHARDS, Ruth Mary
Magistrates Court,Tasmania, Coronial Division, Blunt traumatic injuries, pedestrian hit by car, blunt force, transport injury,
2014 TASCD 124 -Drug Overdose
Drug, coroner, Tasmanis, mixed drug toxicity, methadone, amitriptyline, diazepam
2014 TASCD 066 - MCGAVIN, Richard Kenneth
Magistrates Court,Tasmania, Coronial Division, workplace fatalitity, roadworks, trucks,blunt force, pedestrian, heavy truck, crushing,
2014 TASCD 043- BABY R
Magistrates Court,Tasmania, Coronial Division, motor vechile fatality, blunt force, passenger, weather, rain,infant
2014 TASCD 04- CHAPPELL, Robert Adrian
Findings, Coronial Division, Magistrates Court of Tasmania,
2014 TASCD 025- MARRIOTT, Brendan Roy
Magistrates Court,Tasmania, Coronial Division, assault, gun shot, firearm, rifle, weapon,
2014 TASCD 021 - WHITE, Yvonne Lorraine
Findings, Coronial Division, Magistrates Court of Tasmania -Motor Vehicle Fatality, blunt injuries,vehicle occupant, passenger car,
2014 TASCD 000 - PERCY, Noel Alan
Findings, Coronial Division, Magistrates Court of Tasmania,death in custody, hanging, asphyxia
2014 TASCD 000 - BLASCHKE, Gordon Stefan
Findings, Coronial Division, Magistrates Court of Tasmania,overdose, drug,
2014 TASCD 345 - XEPAPAS, Stephen Sotorios
2013 TASCD 99- Mrs W
Findings, Coroner, drugs, toxicity, mixed prescription drugs, bipolar affective disorder
2013 TASCD 54 - Janice Peow Chye, FOO
Findings, Coronial Division, Magistrates Court of Tasmania.vehicle accident, tourist,head and neck injuries, blunt force, transport injury, vehicle occupant, minibus, passenger, transport
2013 TASCD 441- BURNS, Tanya Maree
Findings, Coronial Division, Magistrates Court of Tasmania,incineration, smoke inhalation, house fire, flame, smoke, fire, smoke, heating, thermal mechanism, elextric, gas radiator, heater
2013 TASCD 439- BOURKE, Simon Francis
Findings, Coronial Division, Magistrates Court of Tasmania, blunt traumatic injuries, aircraft, crash, ultra-light
2013 TASCD 437 - DALLEY, Paul Nicholas
Findings, Coronial Division, Magistrates Court of Tasmania, asphyxia, tractor, rolling
2013 TASCD 383 - GLOVER, Patricia Edna
Findings, Coronial Division, Magistrates Court of Tasmania.complications of health care, medical care, surgical, operation, gastroenterology device
2013 TASCD 374 -Unidentified female infant
2013 TASCD 349 - HAYERS, Aliesha Emily
Findings, Coronial Division, Magistrates Court of Tasmania.
Magistrates Court,Tasmania, Coronial Division, multiple organ failure, burns, hot bathwater, domestic accident
2013 TASCD 336 - SULLIVAN, Craig Anthony
Findings, Coronial Division, Magistrates Court of Tasmania, ruptre of a left frontal cerebral abscess, death in custody, dentention centre
2013 TASCD 272 - KNOWLES, Francis Joan
fall, nursing home, coroner,hospital
2013 TASCD 266 - BLAIN, Arthur Macfarlane
Findings, coroner, driver's licence, elderly, interstate licences, crash, transport, registrar of motor vehicles
2013 TASCD 256 - JOBLIIN, Robert John
Findings, Coronial Division, Magistrates Court of Tasmania, vehicle accident, blunt force, transport, passenger car, driver, rider, single motor vehicle accident, rail vehicle, train. railway,
2013 TASCD 255 - MRS D
Findings, Coronial Division, Magistrates Court of Tasmania, Suicde, Depression, motor vehicle exhause gas, poisioning, pressuired hose,pipe
2013 TASCD 253 - DAUNT, Linda
Findings, Coronial Division, Magistrates Court of Tasmania, vehicle accident, blunt force, transport, passenger car, driver, rider, single motor vehicle accident, head and chest injuries
2013 TASCD 236 - LINDSEY, Glen Michael
Findings, Coronial Division, Magistrates Court of Tasmania,fall, horse racing, harness, sulky, cart, industrial accident, brain injury, driver, rider, animal, horse
2013 TASCD 221 - Thomas, Andrew Michael
Findings, Coronial Division, Magistrates Court of Tasmania,Vehicle accident, blunt force, vechile occupant, tranport injury, driver, rider, operator
2013 TASCD 215 - PERRY, David
Coroner, Tasmania, recommendations, medical, medical examination, hookah, diving, warnging
2013 TASCD 213 - RAINBOW, Zac Cameron
Coroner, Tasmania, recommendations, Asphyxia, pram, strollers, pushers, threat to breathing, infatn, child,
2013 TASCD 212 - CLARKE, Benjamin David
Findings, Coronial Division, Magistrates Court of Tasmania, Drowning, fishing, sea, ocean, threat to breathing, paid work, rock lobster, crab potting. countryside
2013 TASCD 211- WHAYMAN, Timothy Glenn
Findings, Coronial Division, Magistrates Court of Tasmania, Drowning, fishing, sea, ocean, threat to breathing, paid work, rock lobster, crab potting. countryside
2013 TASCD 21 - WEBB, Zane David
Findings, Coroner, death in custody, epilepsy
2013 TASCD 189 - CHURCH, James Peter
Findings, Coronial Division, Magistrates Court of Tasmania, Head Injury, Fall from Height, blunt force, contact static obeject, building
2013 TASCD 186- WOOD, Beverley Joan
Findings, Coronial Division, Magistrates Court of Tasmania, neck and chest injuries, pinned under own car,blunt force, vehicle occupant, transport injury, passenger car
2013 TASCD 182 - DONNELLY, Trevor Darren Matthew
Findings, Coronial Division, Magistrates Court of Tasmania, Drowning, alcohol, threat to breathing, body of water, spa, hot tub, above-ground swimming pool
2013 TASCD 173 - BAKES, Walter Charles
Findings, Coronial Division, Magistrates Court of Tasmania,Asphyxia, smoke inhalation, house fire, flame, smoke, fire, smoke, heating, thermal mechanism, elextric, gas radiator, heater
2013 TASCD 171- WELLS, Kerry John
Findings, Coronial Division, Magistrates Court of Tasmania, Motor Vehicle Crash, Blunt Force, Transport Injury Event, Vehicle Occupant, Heavy Transport Vehicle, Thermal Mechanism, Heating, Fire or Flame
2013 TASCD 154 - Mr D
Findings, Coronial Division, Magistrates Court of Tasmania - Drowning, depression, threat to breathing, river, stream, creek, water
2013 TASCD 150- Mr W
Findings, Coroner, drugs, toxicity, mixed prescription drugs
2013 TASCD 144 - WHILEY, Stanley Valentine
Findings, Coronial Division, Magistrates Court of Tasmania ischaemic heart disease, complications of health care, adverse effects related to drugs, pharmaceutical substance, analgesic,antipyretic,antirheumatic and morphine
2013 TASCD 143 - SALTER, Phillip John
Findings, Coronial Division, Magistrates Court of Tasmania, Acute Myeloid Leukemia,
2013 TASCD 142 - MCKINLAY, James Stirling
Magistrates Court,Tasmania, Coronial Division, Fungsl Infection, Abdominal Surgery, Medical/Surgical Device, Hospitial, Surgical Pack, Complications of Health Care
2013 TASCD 141 -Mr K
Coroner, findings, Motor Vehicle Accident, Blunt Force, Tranport Injury Event, Vehicle Occupant, Motor Vehicle Crash,
2013 TASCD 122 - WHITELEY, Nicholas Martin
2013 TASCD 102 -ROBBINS, Leanne
Magistrate, Coroner, findings, recommendations, Motor Vehicle Crash, Fatal Blunt trauma injuries,
2013 TASCD 095 - OSBOURNE, Liam Robert
2013 TASCD 067 - WOOLLEY, Damien Leigh
Coroner, orchard, death, hydrolic mat roller, 'extenday'
2013 TASCD 065 - MACROW, Randolph Brian
Magistrates Court, Tasmania, Coronial, Suicide, Carbon Monoxide Poisoning
2013 TASCD 038 - YORK, Joanne Jean
2013 TASCD 036 - HIGLETT, Geoffrey William
Coroner, Magistrate, Hobart, Coronial, recommendations, tractor, farming, slasher, Bruny Island
2013 TASCD 023 - SHAW, Rebecca Jane
Coroner, findings, Motor Vehicle Accident, Blunt Force, Tranport Injury Event, Vehicle Occupant, Motor Vehicle Crash,
2013 TASCD 022 - KNOTT, Alicia Ellen
Coroner, findings, Motor Vehicle Accident, Blunt Force, Tranport Injury Event, Vehicle Occupant, Motor Vehicle Crash,
2013 TASCD 163 - Mr. H
2012 TASCD 90 - BOOTH, Lonnie
2012 TASCD 82 - BABY H
2012 TASCD 444 - Mr C
Findings, Coronial Division, Magistrates Court of Tasmania, drug intoxication, morphine,
2012 TASCD 377 - Ms C
Coroner, findings, suicide, hanging
2012 TASCD 376 - Master P
Findings, Coronial Division, Magistrates Court of Tasmania -infanct, co-sleeping, sleeping with parents, threat to breathing, bed sharing,
2012 TASCD 369 - TAYLOR, Zack Wayne
Coroner, Suffocation, Talcum Powder
2012 TASCD 354 - Mr M
Coroner, findings, suicide
2012 TASCD 349 - DINGLE, Simon Duncan
Coroner, recommendations, traumatic subarachnoid hemorrhage, blunt force inhuries, head and neck injuries,
2012 TASCD 340 - SCOTT, Beverley Dawn
Findings, Coronial Division, Magistrates Court of Tasmania, chest injuries, blunt force, falling, stumbling, falling same level, glass door, door, building, exposure to recent surgery, medical/surgical device, general hospital
2012 TASCD 339 - JAFFRAY, Reginald John
2012 TASCD 316 - Ms W
2012 TASCD 315 - BURMISTER, Garry Paul
2012 TASCD 314 - Ms F
2012 TASCD 312 - TREZONA, David Kenneth
2012 TASCD 303 - Ms L
2012 TASCD 290 - BOURKE, Melanie Patricia
2012 TASCD 289 - BROOKS, William Vernon
2012 TASCD 288 - HARRIS, David John
2012 TASCD 286 - MS R
2012 TASCD 285 - IND, Stephen David
2012 TASCD 272 - MS M
2012 TASCD 268 - DENT, Jonathan Paul
2012 TASCD 267 - MISS R
2012 TASCD 266 - BINGLEY, Andrew Bruce Erskine
2012 TASCD 264 - TAYLOR, Samuel George
2012 TASCD 246 - MR B
2012 TASCD 245 - HAY, Sandra Winifred
2012 TASCD 224 - BREEN Donald Martin
2012 TASCD 223 - ARCHER, Colin Gladstone
2012 TASCD 209 - CASELY, Gary Robert
2012 TASCD 205 - BINGLEY, Andrew Bruce
2012 TASCD 202 - BABY A
2012 TASCD 200 - BABY W
2012 TASCD 196 - GIULIANI, Paul
2012 TASCD 194 - STEWART, Robert Claude
2012 TASCD 192 - COOPER-WHITE, Leo Thomas
2012 TASCD 188 - MR B
2012 TASCD 152 - MRS M
2012 TASCD 151 - BELLETTE-COUTS, Ashley Philisity Maree
2012 TASCD 144 - POHLNER, Kenneth Kim
2012 TASCD 143 - NAUTA, Ellicia Stevie
2012 TASCD 142 - MUIRHEAD, Samantha
2012 TASCD 141 - KUOL, Kuol Piyom
2012 TASCD 138 - MUNNINGS, Helen Karel
2012 TASCD 136 - SALLESE, Nicola
2012 TASCD 134 - PEGG, William Edward
2012 TASCD 131 - SHOOBRIDGE, Diana Muriel
2012 TASCD 124 - FUNARI, Rachel
2012 TASCD 115 - Sherriff, John Charles
Coroner, Calvary Hospital, haemoperitoneum, laparoscopic hemicolectomy, caecal tumour, complication of surgery
2012 TASCD 112 - ANDERSON, Brendan Kenneth
2012 TASCD 094 - NEWTON, Blake Marcus
Overdose, Coroner, depression, combined drug intoxication, RHH
2012 TASCD 092 - LEVI, Rene
Magistrate, Coroner, Tasmania, Bicheno, drug, drugs, overdose, suicide, bystander, bystander effect, bipolar, abuse, dependence, benzodiazepine dependence, depression, alcohol, drug toxicity, toxicity, venlafaxine, diazepam, self harm,, Kitty Genovese (1935-1964), psychologist, social, psychoogical phenomenon, John Darley, Bibb Latane, research
2012 TASCD 087 - BATCHELOR, Ruth Marina
2012 TASCD 084 - SZABO, Eric Andrew
2012 TASCD 079 - RAYMENT, Dennis George
Coroner, warning, crushing, tree, tree fellers, hazardous, proper tree felling techiques
2012 TASCD 072 - DENMAN, Gloria Jean
Coroner, fire, housebound, television, carbon monoxide, operating smoke alarm, smoke alarm.
2012 TASCD 052 - GUNN, Donna Sharee
Motor Vehicle, Crash, Coroner, Tasmania, Driver, Fatigue, warning, driver fatigue, working fatigue
2012 TASCD 049 - FAZACKERLEY-WATSON, Corey Albert
Coroner, findings, court, drug overdose, alprazolam, drug treatment order, illicit drugs, Fazackerley-Watson, Robert Pearce
2012 TASCD 027 - SMITH, Christine Julie
Coroner, findings, mental health, Royal Hobart Hospital, RHH, hypoxic brain injury, drugs, emergency department, Psychiatry ward, benzodiazepine withdrawal.
2012 TASCD 026 - SNAPE, Ann
2012 TASCD 014 - LOVELL, Marcus Dean
2011 TASDCD 127 - PARSELL, Sadie Olive
Coroner, Tasmania, Barrington Lodge, fall, elderly, broken nock of femur, broken hip, AT, Ambulance Tasmania, delay, RHH, Royal Hobart Hospital
2011 TASCD 450 - BLACKABY, Karen Elizabeth
2011 TASCD 449 - WILLIAMS, Jeffrey Ray
Findings, Coroner, Workplace Standards, unsafe work practices, tractor, crushing, farm, maintenance of equipment
2011 TASCD 442 - BEER, Vaughan Matthew
Tasmania, Coroner, vehicle, crash, methadone, recommendations, driver impairment, cannabis, fatigue, drugs
2011 TASCD 422 - MR. M
Hospital, coroner, recommendation, patients, communication, surgery, communication issues, medical staff, medical procedure
2011 TASCD 421 - CLARKE, Christine Jan
Coroner, findings, electrocution, frying pan, hypertensive heart disease.
2011 TASCD 415 - MONEY, Douglas
Coroner, findings, undetermined, 'Loru'
2011 TASCD 410 - MENNITZ, Russell, Alfred
crash, motor vehicle, Queenstown
2011 TASCD 408 - DOYLE, Zachary George
Coroner, recommendations, fatality, crane, farming, Perseverance, Roaring Beach, Dover, workplace, safe operation, training, risk assessment,
2011 TASCD 403 - MR W.
Coroner, findings, Langford, ashphyxia, death in care, recommendations, emergency alert device
2011 TASCD 402 - MR S
Findings, Coroner, drugs, medication, temazepam, sertraline
2011 TASCD 398 - NEWELL, Christopher James
Overdose, Coroner, depression, combined drug intoxication, RHH
2011 TASCD 393 - BEAMES, Norman Valentine
Hospital, NWRH, North West Regional Hospital, CT scan, contrast agent injected, reaction, Isovue, iodine
2011 TASCD 391 - CONNOR, Kelvin John
2011 TASCD 387 - SLACK, Bobby Ray
Coroner, shark, Bruny Island, diviing, abalone
2011 TASCD 386 HULL, David Jocelyn
Finding, Coroner, drowning, boat, fisherman, Historial Missing Person, 'The Narrows", Marion Bay
2011 TASCD 370 - Mr K
Coroner, hanging, mental health, mental health services, NWRH
2011 TASCD 364 - Mr. L
2011 TASCD 354- Suicide for Publication
Coroner, Suicide, Firearm, Depression
2011 TASCD 347 - HOWELL, Rodney Peter
Diving, Coroner, gas embolism, regulator, dive, Hookah, dangerous activity, equipment faults
2011 TASCD 344 - GLEESON, Cherry
Coroner, findings, hyperthermia, environmental heat exposure, entrapment in boot, alcoholic, alcohol
2011 TASCD 343 - TIPPER, Pamela Mary
Coroner, alchol, choking, food, steak, choking on food, emphysema, bronchiolitis, hypertensive cardiovascular disease, Goodwood
2011 TASCD 340 - BOWKETT, Damien Steven
Coroner, Motor Bike Accident, Blunt Force, Transport Injury, Motorcyclist/Motorcycle Rider, Fracture of base of the Skull, Fracture of Ribs, Pelvic Bones, recommendation, speeding, speed, unfamiliar road, correctly inflated tyres, maintenance
2011 TASCD 319 - WAUGH, Claire Louise
Coroner, recommendations, suicide, DHHS, 1E, Northside, suspension points, hospital , LGH, Launceston General Hospital, Mental Health, Mental Health Act 1996, involuntary patient, death in care, recommendation, suicide risk, THC, amphetamines, cannabis, methylamphetamine, Health Act, Tasmania, Launceston,
2011 TASCD 306 - MURRAY, Xavier
Coroner, findings, recommendations, multiple births, infant, twins, preganacy, "Multiple pregnancy policy" hospital, paediatrician, birth asphyxia, hospital, Calvary Hospital, Royal Hobart Hospital.
2011 TASCD 300 - Lovell, Robbie
2011 TASCD 298 - KUKULJEVIC, Peter Cecil
Coroner, Tasmania, Recommendations, Murchison Highway, Tullah, Crash, speed, lost control, overtaking
2011 TASCD 29 - WOOLLEY, Raelene Judith
2011 TASCD 271 - LIMBRICK, Jeffrey David -
Coroner, finding, recommendation, RHH, NWRH, Royal Hobart Hospital, North West Regional Hospital, liver, liver dysfunction, complications
2011 TASCD 268 - GRICE, Billy John
2011 TASCD 268 - ALLEN, Judith Louise
Findings, coroner, recommendations, lap band surgery, Jehovah Witness, surgery, blood loss, surgery, RHH, autologous blood transfusions,
2011 TASCD 258 - RANSLEY, Shane Allan
Coroner, Findings, recommendations, Tasmania, crane, 'Franna", "29 tonne Franna crane", crane driver, speed, cannabis, THC, seat belt
2011 TASCD 257 - Motorcycle Accident
Motorcyle Crash, Blunt Force, Motorcyclist/Motorcycle Rider, Motorised Two or Three Wheeled Vehicle
2011 TASCD 256 - Baby RL
Coroner, Tasmania, baby, infant, Child Protection, premature, inquest, RHH
2011 TASCD 254 - MAHER, Kayla Maree
Coroner, recommendations, findings, motor vehicle crash, THC, passenger, male drivers, young male drivers, Novice Licensing system, Road Safety, Road Safety Strategy, driver, safety, curfews, vehicle power restrictions, DIER, alcohol interlock,
2011 TASCD 249 - REYNOLDS, Chrystal Tina
Findings, coroner, tasmania, recommendation, recommendations, methadone, amphetamines, cannabis, methadone programme, prescribing guidelines, TOPP, Tasmanian, Opioid Pharmacotherapy Program Policy.
2011 TASCD 212 - CUBIT, Ross Donald
Coroner, recommendation, Tasmania, drowning, alcohol, intoxication, race, life jacket, 'Storm Boy' yacht, "Pipe Opener", Derwent Sailing Squadron, rough, seas, weather, overboard, PFD, yachtsman
2011 TASCD 206 - WIGGINS, Charles Thomas
Coroner, recommendations, chainsaw, logging, clear felling, tree, bushman, tree-feller, Gunns, Work Place Standards, WST, safety helmetlogs, slippery, unsafe work practices, training, forest, harvesting, hazardous, Forestry Tasmania.
2011 TASCD 205 - BUENGER, Hans
2011 TASCD 204 -BUENGER, Gisela
2011 TASCD 2011 - LAWRENCE, Jay Harli
2011 TASCD 180 - Baby T
Findings, coroner, recommendation, safe sleeping, co-sleeping, sids, kids, DHHS, educating, parents
2011 TASCD 175 - HARRIS, Leonie
Coroner, coronial, magistrate, court, recommendations, missing, downed, boating,
2011 TASCD 174 - HARRIS, John Phillip
court,magistrate,magistrates,tasmania,australia,courts,coronial, Downed, Missing, Boating, Fisherman
2011 TASCD 172 -ARKINSTALL, Christine Alainie
2011 TASCD 171 - BEHREND, Adam Michael
2011 TASCD 170 - PEDDER, Danny Allan
2011 TASCD 169 - MOORE, Craig Robert
2011 TASCD 167 - STEELE, Roger
Coroner, Royal Hobart Hospital, RHH, ED, Emergency Department, protocols, triage, chest pain, ischaemic heart disease, Myocardial Perfusion Scan
2011 TASCD 166 - ZEWDU DESTA, Desalegn
Coroner, Tasmania, Cambridge, garbage truck, left hand drive, fatality, recommendations, seat belts, unsafe driveing, negligent driving
2011 TASCD 163 - HOWELLS, Theresa Rachael
Coroner, hanging, drugs, psychiatric problems, history of self harm
2011 TASCD 152 - CHAPMAN, Lennox Paul
2011 TASCD 132 - WAITE, Raymond Frederick
Findings, coroner, recommendations, recommendation, RHH, Royal Hobart Hospital, fall, X-ray, care, duty of care, DEM, Department of Emergency Medicine, doctor, geriatric, geriatric patients, elderly
2011 TASCD 131 - DAVIES, Joffre George
Coroner, Magistrate, Hobart, pedestrian, decreased mobility, poor eyesight, crash, unroadworthy.
2011 TASCD 130 -BARDENHAGEN, Guy Anthony
2011 TASCD 126 - LEE, Basil Alexander
2011 TASCD 125 - HOLLOWAY, Maxine Frances
Coroners, Findings, Coroner, drugs, drug, overdose, centrelink, pension, quetiapine, depression, paranoid delusions, schchizophrenia
2011 TASCD 121 - BAILEY, Elwyn Aubrey
2011 TASCD 115 - MS K
Coroner, magistrate, Court, swine flu, hospital, Mersey Community Hospital, Ambulance, Tasmania recommendation, Klippel-Feil, autism, flu, H1N1 90, management, patient, delay
2011 TASCD 114 - WILLCOX, Clint Anthony
Coroner, Findings, motor cycle, racing, endurance, riding, Preolenna, TERC, Tasmania Endurance Racing Club, crash
2011 TASCD 113 - PALECEK, Anna
Coroner, Tasmania, Hobart, Highway, Pedestrian, crossing, crash, injuries, car
2011 TASCD 070 -WILLIAMS, Sher-Ron Louise
Coroner, findings, recommendations, Tasmania, Australia, pedestrian, Brooker Highway
2011 TASCD 043 - VALENTINE, David Francis
Coroner, Coronial, Tasmania, Magistrates, Australia, Mental Health Patient, Bipolar,
2011 TASCD 042 - YOUNG, Jennifer Betty
Coroner, findings, recommendation, recommendations, overdose, drugs, quetiapine, benzodiazepam, pancreatitis, addiction, prescribed medication.
2011 TASCD 036- DAVIS, Timothy Graham
Coroner, Coronial, Magistrate, Court, Hobart, Tasmania, life jackets, boat, safety, warning, recomendation, drowning, alcohol, Dover Hotel, RSL, boat size, age of occupants, PFD's, weather conditions, personal floatation devices
2011 TASCD 030 - WILLIAMS, Claire Anne
Coroner, recommendations, Hobart, recommendation, hospital, nursing home, Freemasons, digitalis, toxicity, RHH, chronic renal failure, digoxin
2011 TASCD 026 - KELTY, Jackson
2011 TASCD 025 - DERMODY, Brendan William
2011 TASCD 024 - KILBY, Clement Bernard
2011 TASCD 023 - STURGESS, Ben Samuel
Recommendation, coroner, Tasmania, Magistrate, Court, vehicle, 4WD, snatch straps, tow bar, recovery operations, danger
2011 TASCD 01 MCLEOD, Alastair James Douglas
2011 TASCD 228 - LITTLEJOHN, Regan Anne
Coroner, findings, Tasmania, warning, tractor, farm, machinery, agricultural, children, infants, WST, work place standards, risk, danger, preventable, toddler
2011 TASCD 213 - LEE, Duncan Joseph
Coroner, Tasmania, mental health, mental illness, suicide, drowning, jump, bridge
2011 TASCD 073 - Suicide for Publication
Recommendation, coroner, Tasmania, Magistrate, Court, Suicide, Firearm, Smoking, Anti Smoking Drug, Champix, Weapon
2011 066 TASCD - JOHN, Glyn Edwin
Coroner, recommendations, ambulance, tasmania, AT, ladder, fall, domestic duties, home, safety
Coroner, Magistrate, NWRH, North West Regional Hospital, warning, diabetes, hypoglycaemia, medical treatment, Type II diabetes, obese
Fall, elderly, roof, coroner, warning, worplace health and safety, ladder, falls
2010 TASCD 423 - Baby J
2010 TASCD 421 - Baby R
Coroner, findings, recommendations, Tasmania, co-sleeping, infant, baby, Child Protection, DHHS, Department of Health & Human Services, baby, SIDS, CPS, alcohol, depression, family violence, suffocation, safe sleeping guidelines,
2010 TASCD 418 - STEIN, Joshua Phillip
Recommendation, coroner, Tasmania, Magistrate, Court, vehicle, 4WD, snatch straps, tow bar, recovery operations, danger
2010 TASCD 416 -BRYANT, Eileen Margaret
Hospital, coroner, recommendation, TAS, Tas Ambulance Service, fall, medication, care, treatment, Ouse, Amitriptyline, Tranadol
2010 TASCD 413 - CRACKNELL, Dorene May
Coroner, Magistrate, Court, Tasmania, recommend, recommendations, falls, elderly, hospital, Calvary Health, fall, medical notes, 'falls risk' assessment, health professionals.
Coroner, Tasmania, drug overdose, paracetamol, recommendation, warning, overdose, toxicity, venlafaxine, depression, mental illness
2010 TASCD 387 - NICHOLS, Timothy David
recommendations, coroner, magistrate, LGH, mental health, suicide, hanging, patient, psychiatric, review
2010 TASCD 371 - PARREMORE, Ricky James
Coroner, Findings, Recommendations, Warning, Hobart, Tasmania, crash, jetty, alcohol, THC, mixed drug intoxication, entrapment, alprazolam, diazepam, oxycodone, methadone, morphine, methylamphetamine, driving, intoxication
2010 TASCD 361 - GREEDY, Judd Robert
Coroner, coronial, magistrate, court, recommendations, mining, work place standards, WST, findings, Fingal, Cornwall Coal, legislation, mine, fatality, Inspector, Inspector of Mines,
2010 TASCD 342 - SHAW, Albert
Coroner, Magistrate, Recommendations, Recommendation, fall, elderly, nursing home, care, observation, nurse, nurses, patient, failure to monitor, Stathaven.
2010 TASCD 340 - YOUNG, Luke Andrew
2010 TASCD 339 - YOUNG, Julie Rosemarie
2010 TASCD 311 - HAYES, Adrian Brian
Coroner, coronial, magistrate, court, recommendations, mining, work place standards, WST, findings, Fingal, Cornwall Coal, legislation, mine, fatality, Inspector, Inspector of Mines,
2010 TASCD 278 - ROGERS, James Tasman
Magistrate, Coroner, findings, recommendations, alcohol, sport, government, report, football, cricket, AFL, acute ethanol toxicity, alcohol poisoning
2010 TASCD 277 - GREEN, Mark Leslie
Magistrate, Coroner, recommendation, alcohol, drinking, ecstasy, cannabis, fall, stairs, warning
2010 TASCD 247 - HEPBURN, Blair Anthony
Coroner, Magistrate, Hobart, Coronial, recommendation, trampoline, helment, child, asphyxia, entanglement, entangled, bicycle helmet, accident, clothesline
2010 TASCD 246 - PIPKIN, Glenn Patrick
2010 TASCD 213 - GUISE, Gabriel Robert Patrick
2010 TASCD 212 - GUISE, Mickael Francis
2010 TASCD 211 - APPLEBY, Justin Luke
2010 TASCD 209 - DEAN, Michael Laurence
Coroner, Coronial, Court, Magistrate, Drug, Drugs, PTSD, post traumatic stress syndrome, register, general practitioners, doctor, doctors, depression, mental illness, overdose, multiple practitioners, multiple drug toxicity, moclobemide, venlaxafine, zopidone, fluoxetine, oxazepam
2010 TASCD 183 - TSAPOGIAS, Dimitrios
2010 TASCD 182 - GARDINER, Royden Shane
2010 TASCD 181 - SMART, David Geoffrey
2010 TASCD 180 - SMART, Sharon Leigh
2010 TASCD 110 - DOODT, Russell Charles
Magistrate, Coroner, Tasmania, Bicheno, drug, drugs, overdose, suicide, bystander, bystander effect, bipolar, abuse, dependence, benzodiazepine dependence, depression, alcohol, drug toxicity, toxicity, venlafaxine, diazepam, self harm,, Kitty Genovese (1935-1964), psychologist, social, psychoogical phenomenon, John Darley, Bibb Latane, research
2010 TASCD 055 - NA CHAMPASSAK, Luc Ryan
Coroner, coronial, Hobart, Tasmania, Infant, death, hospital, HPH, Hobart Private Hospital, RHH, Royal Hobart Hospital, recommendations, "the private", neonatal, neonatal intensive care, sudden unexpected death, baby, new born, infant, pneumonitis, pneumonitis from inhaled squamous epithelial cells, bronco-pneumonia,continuous foetal monitoring, syntocinon augmented labours, pediatrician, perinatologist, protocols, observation of newly born infants, birth, examination of new born babies, midwife, midwives, guidelines, documentation, obstetrician, paediatricians, Root Cause Analysis, improved practices.
2010 TASCD 025 - TROTTER, Monty William
Coroner, coronial, magistrate, Launceston, Court, Train, work, recommendations, safety, recommendation, ANL, train, rail, workplace, health, compliance audits, Rail Safety Regulator, Wagon, repair, Union, Pacific national Tasmania, Safety Notices, recommendations
2010 TASCD 017 - Motor Vehicle Crash
Magistrate, Court, Investigation, motor vehicle crash, crash, coroner, suicide, findings, Midland Highway, Jericho, truck, mental health, depression
2010 TASCD 001 - COLSON, David James -
Magistrate, Coroner, Tasmania, Australia, Findings, Recommendations, work, workplace, diving, abalone, safe work practices, sea, Perkins Island, Smithton, commercial fishing industry, hyperthermia, boat, sinking, deckhand, quota, EPRIB, distress flares, failure to carry life jackets, life jackets, training, Coxwain, vessel load, Tasmaia police, training, marine incidents,bilge pump, fitted buoyancy, safety, legislation, searches
2010 TASCD 422 - TRIFFETT, Nicholas Edwin
Findings, Coroner, recommendations, Magistrate, truck, work, Irishtown, crash, bolt, bolts,
2010 TAS CD 248 - SMITH, Neville Robert
Magistrate, Court, Coroner, Tasmania, drowning, recommendation, Couta Rocks, Arthur River, drown, life jacket, cray pot, inflate life jacket, failure
2010 TAS CD 245 - CRACK, Jesse Roy
2009 TASCD 357 - Infant
2009 TASCD 250 - Motor Vehicle Crash
Coroner, Magistrate, Court, Coronial, driver, drinking, alcohol, high blood alcohol concentration, RSA, responsible service alcohol, 'P' plater, provisional licence, road, DIER, hospitality industry
2009 TASCD 25- KNIGHT, Larry Paul - Coronial Findings and Recommendations
Larry Paul KNIGHT, inquest, inquest findings, mining, hard rock, rockfall, Beaconsfield, mine collapse, ground support, workplace death, workplace standards
2009 TASCD 234 - Motor Vehicle Crash
Tasmania, Margate, Coroner, Coronial, Magistrate, recommendation, motor vehicle crash, recommendations, driver, truck, volvo, key, keys, ignition, Nissan, Datsun, disengage engine, safety, keys in ignition, dangerous, steering, education, mechanics
2009 TASCD 216 MARTINEZ, Josue Jonathan Francisco
motor vehicle crash - fatal - police officer - excessive speed
Magistrate, Tasmania, Australia, Coroner, Coronial, hospital, surgery, dangers, warning, lab band, weight reduction, hospital, RHH, Hobart Private Hospital, Doctor, operation
2009 TAS CD 239 - MYER FIRE
Court, Magistrate, Hobart, Tasmania, Coroner, Coronial, recommendations, falls, elderly, personal alarms, personal protection, alone, home, old, fracture, neck of femur, RHH, failure to report death, Royal Hobart Hospital.
2008 TASCE 116 - PEARCE, Evan Redmond
Magistrate, Coroner, Tasmania, crash, recommendations, alcohol, "p" platers, license, drivers, speed, alcohol, peer passengers, vehicles, restriction, parental supervision, inexperience, drivers, inexperienced drivers, offender, offender drivers, education,
Coroner, Coronial, Magistrate, Court, Hobart, Tasmania, life jackets, boat, safety, warning, recomendation, drowning, alcohol, Dover Hotel, RSL, boat size, age of occupants, PFD's, weather conditions, personal floatation devices
2008 TASCD 187 to 190 - SIDS
Magistrate, Court, Tasmania, Australia, Coroner, Coronial Coroners, recomendation, recommendations, SIDS, sudden infant death, death, infant, recommendations, alcohol, bed, bedding, sleeping, co-sleeping, smoke, cigarette, cigarrettes, tri-pillows, overlaying, bedding, bed sharing, prematurity, low birth weight, paediatric, paediatrician, asphyxia, safe sleeping practices, training package, hospital, education, SUDI, training, guidelines
2008 TASCD 140 - PEARCE, Sidney Thomas
2008 TASCD 139 - LISTER, Matthew David
2008 TASCD 138 - JONES, Jarrod Keith
2008 TASCD 106 - Intentional Firearm
Coroner, Magistrate, Hobart, Tasmania, suicide, gun, guns, hospital, doctor, medication, recommendation, Launceston, Launceston General Hospital, Ward 1E., recommendations, recommendation, hopsital, treatment, depression, general practitioner, psychiatrist, review process, DEM, department of emergency medicine, mental health, mental health patients, rifle, gun safe, safety, patient, written records, hospital records
Magistrate, Court, Tasmania, Coroner, coronial, Finding, Findings, drugs, prescription, prescribing, overdose, accidental, open, recommendations, recommendation, misunderstanding, propoxyphene, community, addiction, pharmacological, protocols, medical practitioners, prescribing, standance, dependence, oxycodone, morphine, Diazepam, floxetine, pain killers,
2007 TASCD 372 - Drownings Hippolyte Rocks
Magistrate, Court, Coronial, Australia, Tasmania, Drowning, hypothermia, fishing, competition, tuna, EPIRB, recommendation, bravery, weather conditions, bad weather
2007 TASCD 361 - PUGH, Stephen Montague
2007 TASCD 360 - WRATHALL, Andrea Lee
2007 TASCD 306 - Motorised Scooters
Court, Magistrate, Tasmania, Coroner, Coronial, warning, recommendation, safety, licensing, scooter, motorised scooter, disability, elderly,
2007 TASCD 300 - Motor Cycle
Coroner, Coronial, Magistrate, Tasmania, motor cycle, speed, alcohol, police, pursuit, warning, death, serious injury, psyhsical, protection, licensing, license, safety, public campaigns
Coroner, recommendation, warning, tasmania, australia, dam, child, children, drown, drowning, safety
2007 TASCD 261 - Binge drinking
2007 TASCD 204 - Cyclist
Coroner, Coronial, Burnie, warning, court, courts, magistrate, Tasmania, Australia, bicycle, parent, parental supervision, supervision, children, riding, danger, child, bike
2007 TASCD 163 - Wheelchair
Magistrate, Court, Coroner, Coronial, Tasmania, Australia, aged care, nursing home, wheelchair, maintenance, mobility, duty of care, nursing home, safety, fall, equipment, bald tyres, aspiration pneumonia, contusion,
2007 TASCD 061 - Methadone
Court, Tasmania, Australia, Coroner, Coronial, Recommendation, drug, drugs, methadone, IV lung, methadone programme, injecting, morphine, intravenous, MS Contin, Anamorph, DHHS, Alcohol and Drug Service, Tasmanian Methadone Policy 2000, dosage, benzodiazepines, morphine, patient, Xanax
2007 TASCD 004 - Home Maintenance Hazards
Tasmania, Court, Magistrate, Australia, Coroner, Coroners, Recommendation, Recommendations, fall, scaffolding, work, maintenance, plank, house, ladder, bracket, height, Australian, Standards, unsafe, equipment,
Magistrate, Court, Tasmania, Australia, Coroner, Coronial, Findings, Investigation, recommendation, drowning, alcohol, drown, wharf, hotel, licence, drunk, responsible serving of alcohol, accidental, intoxication, intoxicated, fall, water, river, Derwent River, marina, mooring lines, jetty, Tasports, drunk
court, coroner, magistrate, Tasmania, Australia, recommendations, motor, vehlicle, accident, fatality, deceased, car, weather, injuries, Bass Highway, Burnie, Round, Hill, road, Commodore, Armco railings, T-Bone, D.I.E.R, median strip barrier, protective barrier, slippery, speed, warning lights, resealing, Camry, Pajero, accident
2006 TASCD 149 - Infant
court, magistrate, magistrates, tasmania, australia, courts, coronial, infant, baby, bed-sharing, sudden, infant, death syndrome, co-sleeping, recommendation, warning, paediatric, committee, unsafe, sleeping, environment, sofa, beanbag, waterbed, sagging, mattress, overlaying, alcohol, drugs, doonas, smoker, cigarette
2006 TASCD 132 - Motor Vehicle Accident
2006 TASCD 104 - Intentional Overdose
Magistrate, Coroner, Coronial, coroners, magistrates, court, Hobart, Tasmania, hospital, recommendations, ambulance, police, Royal, Hobart, Hospital, RHH, overdose, drugs, osteoporosis, self-administered, drug, memorandum, understanding, guidelines, reportable, deaths, protocols, destruction, patient, medication, narcotic, narcotics, opiates, department of emergency medicine, DEM, BENZODIAZEPINE, OPIATE, TOXICITY,
court, magistrate, magistrates, tasmania, coroner, courts, alcohol, student, fall, university, head, injury, intoxicated, tripped, fractured, skull
Coroner, magistrate, court, magistrates, Tasmania, Australia, recommendations, deceased, alcohol, skateboard, hill, road, zigazgging, speed, speed wobbles, fell, struck, head, protective, helmet,
court,magistrate,magistrates,tasmania,australia,courts,coronial,Hospital,Latrobe,Student,insulin,diabetes,education,hypo,low blood,sugar level,paediatric,endocrinologist,thiamine,deficiency,hypoglycameia,syndrome,QT,Brugia
2005 TASCD 125 - CAFASSO, Victoria Anna Elizabeth
court,magistrate,magistrates,tasmania,australia,courts,coronial, multiple stab wounds, public assistance, rendered unconscious, brutally murdered, Beaumaris Beach, DNA, Tasmanian Police, Commissioner McCreadie, Deputy Commissioner Johnston, Italian/English citizen, British passport, University in Itay, Portsmouth University, Launceston, Larby's Cottage, Scamander, St Helens, Midlands Highway, Freshwater Creek, Crime Scene, attacked, stabbed, lacerated, bludgeoned, blunt object, pointed object, knife, Royal Hobart Hospital
2004 TASCD 371 - ATV September 2003
court,magistrate,magistrates,tasmania,australia,courts,coronial, ATV September 2003, Terrain, Vehicles, safety
2004 TASCD 182 - GRUNWALDT, Nancy
court,magistrate,magistrates,tasmania,australia,courts,coronial,margaret j,life raft, search,rescue,EPIRB,weather
2001 TASCD 80 - LONG, Fabian Guy
2001 TASCD 79 - SANTOS, Laurence Colin
court,magistrate,magistrates,tasmania,australia,courts,coronial,custody,prison,corrections,depressed,respiration; schizophrenia; clozapine,Jager, prescribed, side,effect,drug,accidental,psychiatrists,monotoring,
2001 TASCD 78 - NEWMAN, Jack
2001 TASCD 77 - HOLMES, Thomas Patrick
2001 TASCD 76 - DOUGLAS, Chris William
2001 - Deaths in Custody
1997 TASCD 450, 451, 452, 453, 454 SHOOBRIDGE, Rebecca Rose Oakley Sara Francise Oakley Anna Josephine Oakley Georgina Rose Oakley Peter Robert
172 TASCD 2013 - Walker, Frances Victoria
Findings, Coronial Division, Magistrates Court of Tasmania -Cardia Arrest, Acute on chronic renal failure, femur fracture of neck, fall, blunt force
171 TASCD 2012 - BLAKE, Hannah Maree
157 TASCD 2013 - Mr T
Findings, Coronial Division, Magistrates Court of Tasmania -firearm, injury to head, shotgun, firearm, weapon, shot by firearm
155 TASCD 2013 - JENKINS, Nita Joan
Findings, Coronial Division, Magistrates Court of Tasmania - Fatal arthymic cardiac event, ischaemic heart disease, pulmonary, fatty liver, heart failure, annemia, health care
144 TASCD 2013 - Mr W
Findings, Coronial Division, Magistrates Court of Tasmania -cerebral trauma, depression,rifle, weapon, firearm, shot by firearm
101 TASCD 2013 - Master B
Magistrates Court, Coronial Division, Bicyle, Blunt Traumatic Injuries, Motor Vehicle, transport injury, pedal cyclist
078 TASCD 2013 - BARNES, Janice Zoey
Findings, Coronial Division, Magistrates Court of Tasmania -Sepsis, bacterial infection of the blood, ischemic colitis
078 TASCD 2011 - GREGSON, Kellie Maree
Coroner, Tasmania, crash, accident, passenger, criminal charges, dangerous driving, collision, Tea Tree, negligent driving.
060 TASCD 2013 - BARTLE, Terry Charles
Coroner, findings, Product related, Gas, Fridge, Carbon Monoxide Toxicity, Caravan
059 TASCD 2013 - Williams, Matthew Keith
Coroner, findings, Product related, Gas, Fridge, Carbon Monoxide Toxicity, Caravan
058 TASCD 2013 - WILLIAM, Rodney Alan
Coroner, findings, Product related, Gas, Fridge, Carbon Monoxide Toxicity, Caravan
057 TASCD 2013 - BUDD, Arthur John
054 TASCD 2015 - SAUNDERS, Craig Steven
2013 TASCD 422 - GLANCY, Susan Helen
Coroner, Driver, travelling to work, crash
2013 TASCD 421 - FYLE, Shirley Lorraine
Coroner, truck, pedestrian, DeBruyns
2013 TASCD 153 - Mr K -
Findings, Coronial Division, Magistrates Court of Tasmania -gunshot, wound of head, weapon, firearm, rifle, piercing, shot by firearm
2013 TASCD 100 - MS M
Coroner, Tasmania, overdose, drugs, mixed drug intoxication
2012 TASCD 231 - NICHOLS, Ian David
2012 TASCD 028 - LYALL, Jakyung Seo
2012 TASCD 013 - MILLER, Normal Leslie -
Coroner, finding, recommendation, mental health, fire, criminal, prison
2011 TASCD 414 -TEMPLER, Bryan Eldred
Coroner, recommendations, smoking, elderly, fire, oxygen, fire training, smoking policy elderly
2011 TASCD 388 - MARSHALL, Donald John
Drowning, cray fishing, Cape Portland, fisherman, Fosters Island, 'Florence'
2011 TASCD 318 - MR M
overdose, hospital, RHH, Royal hobart Hospital, DEM, mixed drug toxicity, propranolol, venlaxafine, nortriptyline, cardiac conduction pathway, recommendation, patients, Mental Health Act, ED, National Clinical Handover Initiative,