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- Coronial Findings 2014
- Coronial Findings 2013
- findings pre-2012
The Magistrates Court (Coronial Division) publishes a small but important amount of records of investigations and findings.
The decision to make these findings available has been made by the Chief Magistrate, or their delegate, or the coroner presiding over the particular investigation, under Coroners Rules 2006.
Publishing a finding is decided on an individual basis, but the coroner may take into account a number of factors:
- the work of the courts being available to public scrutiny
- the death prevention role of the coroner
- family privacy
- sensitivity of the findings
- possible harm from making an investigation publically available
In general, authorised findings for publication will include:
- all public inquest findings
- motor vehicle crashes
- long-term missing persons cases
- homicides after the criminal process has been completed
- any other death which has been reasonably widely reported in the news media for clarification of the factual findings
- any death where health and safety recommendations can result in improvements and death prevention (for example, child protection systems issues, deaths in medical settings with recommendations for improvement)
- any other matter which the coroner believes is in the public interest
Specific findings can be located by entering information in the search box below. Please enter a keyword, name or year of the coronial finding you are looking for.
If you are unable to locate the findings you are looking for, please contact the Coroners’ Office.
Please consider that it may be upsetting to read details about a death in an inquest finding.
Title & TASCD number | Coroner | Date | Keyword | Responses to Coronial Recommendations |
---|---|---|---|---|
White, Janelle Lee (PDF File, 105.4 KB) 2019 TASCD 556 |
Andrew McKee | 18-12-2019 | Ladder fall, traumatic closed head injuries, working at height, training, home building site, recommendations, Workplace Health and Safety Act 2012 | |
Arundel-Clarke, Catherine Clara (PDF File, 99.6 KB) 2019 TASCD 551 |
Olivia McTaggart | 13-12-2019 | Transport & traffic related, single vehicle crash, learner's licence, unlicenced, unroadworthy, wet conditions, speed, child survived, crash investigation, Coroner's comments | |
Woodward, Ernest Henry (PDF File, 111.9 KB) 2019 TASCD 550 |
Simon Cooper | 13-12-2019 | Missing person, water related, recreational fishing, suspected death, disappearance | |
Woolley, Zedric Basil (PDF File, 118.2 KB) 2019 TASCD 534 |
Simon Cooper | 09-12-2019 | undetermined cause of death, missing person, Glen Huon | |
McInerney, Robert Edward (PDF File, 617.6 KB) 2019 TASCD 531 |
Olivia McTaggart | 06-12-2019 | Coroner's finding, coroner's recommendations, gunshot wound, law enforcement, mental illness & health, weapon, police provoked shooting, Tasmania Police | |
Paton, Benjamin Luke (PDF File, 89.0 KB) 2019 TASCD 515 |
Olivia McTaggart | 28-11-2019 | 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 | |
Martin, Jack Hedley (PDF File, 374.5 KB) 2019 TASCD 502 |
Simon Cooper | 21-11-2019 | adverse medical effects, hospital death, Mersey Community Hospital, sepsis, failure to remove intravenous cannula | |
Rice, Luke Jesse (PDF File, 420.9 KB) 2019 TASCD 491 |
Simon Cooper | 18-11-2019 | 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 | |
Mason, Alison Henderson (PDF File, 369.9 KB) 2019 TASCD 485 |
Simon Cooper | 15-11-2019 | Coroner's finding, long-term missing person, older person, undetermined cause of death, body not located, North-West Tasmania | |
Nunn, Peter John (PDF File, 360.1 KB) 2019 TASCD 479 |
Olivia McTaggart | 12-11-2019 | transport and traffic related, single motor vehicle crash, excessive speed, driving over speed limit, Lilydale | |
Maxwell, Benjamin Murray (PDF File, 86.9 KB) 2019 TASCD 497 |
Simon Cooper | 11-11-2019 | Homicide, murder, assault, stabbing, Devonport | |
Holmes, Julie Anne (PDF File, 403.5 KB) 2019 TASCD 464 |
Simon Cooper | 29-10-2019 | Transport & traffic related, motor vehicle accident, pneumonia, older person, undiagnosed cervical spine fracture, guidelines, Royal Hobart Hospital | |
Stewart, Keith Thomas (PDF File, 367.0 KB) 2019 TASCD 460 |
Simon Cooper | 28-10-2019 | transport and traffic related, mobility scooter crash, single vehicle crash, no helmet, loss of control | |
McKenzie, Heather Patricia Dale (PDF File, 383.5 KB) 2019 TASCD 430 |
Simon Cooper | 17-10-2019 | alcohol and drugs, mixed alcohol and drug toxicity, unintentional, Amlodipine, drug interaction, Burnie, Silver Whisper cruise ship | |
Davies, Eva Fay (PDF File, 365.9 KB) 2019 TASCD 428 |
Simon Cooper | 17-10-2019 | Falls, older persons, closed head injury, left frontal/temporal subdural haematoma, anticoagulation, reverse anticoagulation protocol, Coroner's finding, Coroner's recommendation | Updated response provided by THS South 14 October 2022 The THS Adult Anticoagulation statewide guideline includes when and how to reverse anticoagulation. This includes rapid reversal requirements and perioperative management. |
Powell, Stephen Maxwell (PDF File, 309.1 KB) 2019 TASCD 417 |
Simon Cooper | 16-10-2019 | Intentional self-harm, Mental illness & health, older persons, Mental Health Act 2013 (Tas), Mental Health Treatment Order, person held in care, community services | |
Roberts, Anna Jane and Stanley, Brett John (PDF File, 378.5 KB) 2019 TASCD 439 and 440 |
Olivia McTaggart | 15-10-2019 | 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 | |
Fillisch, Eric (PDF File, 424.2 KB) 2019 TASCD 413 |
Olivia McTaggart | 14-10-2019 | water related, drowning, scuba diving, rebreather, rebreather apparatus, displacement of mouthpiece, Visscher Island | |
Benneworth, Anthony John (PDF File, 414.5 KB) 2019 TASCD 419 |
Olivia McTaggart | 11-10-2019 | Drowning, water related, Ansons Bay, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety | |
Long, Anthony Edward (PDF File, 412.9 KB) 2019 TASCD 418 |
Olivia McTaggart | 11-10-2019 | Drowning, water related, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety | |
Frith, Aaron Douglas (PDF File, 363.8 KB) 2019 TASCD 398 |
Simon Cooper | 30-09-2019 | Adverse medical effects, physical health, pulmonary embolism, deep vein thrombosis, prophylactic anticoagulant, Achilles tendon rupture, coroner's finding, coroner's comment | |
Sulman, Murray Matthew (PDF File, 373.0 KB) 2019 TASCD 396 |
Olivia McTaggart | 27-09-2019 | motor vehicle crash, transport and traffic related, Mornington, South Arm Highway, excessive speed, negligent driving, Traffic Act 1925 | |
Peck, Edward Paisley (PDF File, 825.8 KB) 2019 TASCD 386 |
Olivia McTaggart | 26-09-2019 | 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 | |
Smith, Barry (PDF File, 378.0 KB) 2019 TASCD 381 |
Olivia McTaggart | 20-09-2019 | Transport and traffic related, physical health, heart disease, positional asphyxia, workplace, coroner's finding, coroner's comments | |
O'Brien, Mark Andrew (PDF File, 369.6 KB) 2019 TASCD 380 |
Olivia McTaggart | 17-09-2019 | transport and traffic related, motor vehicle accident, motorcycle accident, loss of control, traumatic injuries of head and chest, Kalang Avenue | |
Swan, Daniel Peter (PDF File, 363.4 KB) 2019 TASCD 373 |
Simon Cooper | 12-09-2019 | Transport and traffic related, multiple blunt traumatic injuries, two-vehicle collision, West Tamar Highway, coroner's finding | |
Smith, Jordan Marcellus (PDF File, 380.9 KB) 2019 TASCD 370 |
Andrew McKee | 11-09-2019 | Transport and traffic related, motorcycle and motor vehicle crash, head-on collision, incorrect lane, multiple traumatic injuries, alcohol, coroner's finding | |
Clark, Darren Stuart (PDF File, 410.5 KB) 2019 TASCD 374 |
Simon Cooper | 11-09-2019 | 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 | |
Bowerman, Graeme Anthony (PDF File, 415.1 KB) 2019 TASCD 368 |
Olivia McTaggart | 10-09-2019 | drowning, capsize of boat, Marion Bay, Narrows channel, MAST, marine safety, water related, transport related | |
Mwarabu, Alice (PDF File, 414.7 KB) 2019 TASCD 376 |
Simon Cooper | 10-09-2019 | Transport and traffic related, motor vehicle crash, Domain Highway, multiple blunt injuries | |
Picken, Jason Scott (PDF File, 362.0 KB) 2019 TASCD 369 |
Olivia McTaggart | 10-09-2019 | manslaughter, assault, subarachnoid haemorrhage, comments on passing sentence, Criminal Code | |
Wilson, Jacob Leigh (PDF File, 380.7 KB) 2019 TASCD 399 |
Olivia McTaggart | 09-09-2019 | Transport and traffic related, single motorcycle crash, loss of control, chest and abdominal injuries, drugs and alcohol, unroadworthy, coroner's finding | |
Jenkins, Mark Andrew (PDF File, 376.9 KB) 2019 TASCD 364 |
Andrew McKee | 09-09-2019 | Transport and traffic related, motorcycle crash, multiple traumatic injuries, drugs and alcohol, lost control, speed, unregistered and unlicensed, rear brake lock, coroner's finding | |
Davies, Luke; Drobnjak, Aleksander; Ritter, Magnus; Roche, Anthony (PDF File, 839.6 KB) 2019 TASCD 348 |
Simon Cooper | 30-08-2019 | 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 | |
Golus, Peter (PDF File, 104.2 KB) 2019 TASCD 331 |
Simon Cooper | 21-08-2019 | Adverse medical effects, escherichia coli urosepsis, sepsis, kidney stone surgery, launceston | |
Stanley, Christopher Stephen (PDF File, 372.6 KB) 2019 TASCD 333 |
Olivia McTaggart | 20-08-2019 | transport and traffic related, single motorcycle crash, Smithton, school zone, excessive speed, un-roadworthy vehicle, drug and alcohol, methamphetamine | |
Mollross, Daniel (PDF File, 392.1 KB) 2019 TASCD 335 |
Simon Cooper | 19-08-2019 | Transport and traffic related, motorcycle and motor vehicle crash, speed and alcohol, diffuse head injury, unroadworthy, coroner's finding, coroner's comment | |
Halson, Gary Peter (PDF File, 367.5 KB) 2019 TASCD 334 |
Olivia McTaggart | 19-08-2019 | Transport and traffic related, motorcycle and vehicle crash, blunt traumatic injuries, overtaking, following too closely, poor riding, coroner's finding | |
McLean, Michael William (PDF File, 260.2 KB) 2019 TASCD 338 |
Olivia McTaggart | 19-08-2019 | Transport and traffic related, motorcycle and vehicle crash, chest injuries, incorrect side of road, cornering technique, crosswinds, high risk of death, coroner's finding | |
Saltmarsh, Aidan Denis (PDF File, 384.2 KB) 2019 TASCD 332 |
Olivia McTaggart | 19-08-2019 | 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 | |
Jeffrey, Angela Joy (PDF File, 517.6 KB) 2019 TASCD 322 |
Simon Cooper | 13-08-2019 | missing person, suspected intentional self harm, undetermined cause of death, body not located, Bakers Beach, northern Tasmania, coroner's comments | |
Mead, Liam - Ruling on Evidence (PDF File, 147.9 KB) |
Ken Stanton | 02-08-2019 | ruling on evidence, whether evidence within scope of inquest, adolescent mental health, Tasmania, Liam Mead inquest, Coroners Act 1995 (Tas) | |
Horcicka, Josef Vratislav (PDF File, 488.4 KB) 2019 TASCD 298 |
Simon Cooper | 25-07-2019 | 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 | |
Eaton, Jodi Michelle (PDF File, 460.4 KB) 2019 TASCD 257 |
Olivia McTaggart | 03-07-2019 | homicide, assault, asphyxia, Bridgewater, Darren Dobson, strangulation/choking, coroner's recommendations, recommendation of enactment of indictable offence of choking, suffocation or strangulation | |
Smith, David Alan (PDF File, 403.1 KB) 2019 TASCD 255 |
Simon Cooper | 28-06-2019 | Two vehicle collision, transport and traffic related, multiple injuries, coroner's finding | |
Hughes, Joan May (PDF File, 1.2 MB) 2019 TASCD 241 |
Simon Cooper | 28-06-2019 | Aspiration of gastric contents following vomiting, aged care, mental illness and health, older person, coroner's finding, inquest | |
Lukendlay, Charlotte (OM) Findings.pdf (PDF File, 751.2 KB) 2019 TASCD 234 |
Coroner Olivia McTaggart | 26-06-2019 | child and infant death, global hypoxic brain injury, cessation of breathing, family violence context, non-accidental injury, rib fractures | |
DI (PDF File, 419.2 KB) 2019 TASCD 226 |
Olivia McTaggart | 16-06-2019 | transport and traffic related, intentional self harm, head injuries, mental health and illness, driver, intentionally driving into path of oncoming vehicle, Latrobe | |
Hardy, Dion Ronald (PDF File, 403.0 KB) 2019 TASCD 204 |
Simon Cooper | 03-06-2019 | Transport & traffic related, motorcycle and car collision, alcohol & drugs, Brooker Highway | |
BK (PDF File, 405.0 KB) 2019 TASCD 202 |
Simon Cooper | 23-05-2019 | Hanging, intentional self-harm, mental illness and health, drugs and alcohol, Coroner's finding | |
Tolputt, Trevor (PDF File, 825.1 KB) 2019 TASCD 175 |
Olivia McTaggart | 21-05-2019 | hypothermia, Overland Track, Lake St Clair, Parks and Wildlife Service, coroner's recommendations, bushwalker, winter inadequately equipped | |
Nichols, James Raymond (PDF File, 397.8 KB) 2019 TASCD 169 |
Simon Cooper | 17-05-2019 | 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 | |
MA (PDF File, 401.7 KB) 2019 TASCD 153 |
Simon Cooper | 13-05-2019 | Coroner's finding, transport & traffic related, motorcycle crash, multiple injuries | |
Russell, Allan Geoffrey (PDF File, 873.4 KB) 2019 TASCD 152 |
Simon Cooper | 10-05-2019 | Drowning, water related, coroner's finding, fishing vessel, dinghy capsize | |
Evans, Wendy Anne (PDF File, 407.4 KB) 2019 TASCD 147 |
Simon Cooper | 03-05-2019 | Coroner's finding, coroner's recommendation, head and chest injuries, Metro, pedestrian struck by bus, transport & traffic related | |
Kranz, Lothar Wolfgang (PDF File, 501.6 KB) 2018 TASCD 174 |
Rod Chandler | 24-04-2019 | hospital death, abdominal aortic aneurysm (AAA), Royal Hobart Hospital, chimney vascular repair procedure, advanced coronary artery and peripheral vascular disease complicating repair | |
Porteous, Shayne Edward (PDF File, 490.3 KB) 2019 TASCD 143 |
Olivia McTaggart | 24-04-2019 | Mixed drug toxicity, serotonin syndrome, sertraline, tramadol, SSRIs, drugs & alcohol, coroner's finding | |
Fulham, Julianne (PDF File, 493.8 KB) 2019 TASCD 183 |
Rod Chandler | 18-04-2019 | hospital related death, adverse medical affects, Smithton District Hospital, ischaemic small bowel, bowel obstruction, Crohn's disease | |
Kenney, Margaret Patricia (PDF File, 510.8 KB) 2019 TASCD 142 |
Rod Chandler | 18-04-2019 | Coroner's finding, coroner's recommendations, adverse medical effects, PPI, gastrointestinal bleed, death review | |
Davis, Catherine Joy (PDF File, 484.0 KB) 2019 TASCD 138 |
Rod Chandler | 18-04-2019 | Urosepsis, pyelonephritis, lissencephaly, Royal Hobart Hospital, UTI, incorrect diagnosis, coroner's finding, coroner's recommendation | Updated response provided by THS South 14 October 2022 In response to the following; The RHH carry out an investigation of the delays to administration of antibiotics on this occasion with a view to implementing steps to avoid their repetition. Report provided in June 2019 |
Hill, Phillip John (PDF File, 323.5 KB) 2019 TASCD 135 |
Rod Chandler | 16-04-2019 | hospital death, Royal Hobart Hospital, Hobart Private Hospital, colonic cancer, hemicolectomy, sepsis, delayed diagnosis | |
Ham, Roderick David Charles (PDF File, 487.1 KB) 2019 TASCD 136 |
Rod Chandler | 16-04-2019 | Pulmonary thromboemboli, deep vein thrombosis, hip replacement, physical health, Coroner's finding | |
Best, Christopher Mark (PDF File, 497.5 KB) 2019 TASCD 128 |
Olivia McTaggart | 29-03-2019 | 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 | |
Close, Terrence Findings Web.pdf (PDF File, 943.2 KB) 2019 TASCD 119 |
Simon Cooper | 27-03-2019 | Industrial accident, blunt force, blunt trauma, pedestrian, hit by utility vehicle, chest and abdomen | |
Finding Brendan Smith (Web) pdf.pdf (PDF File, 780.6 KB) 2019 TASCD 120 |
Olivia McTaggart | 27-03-2019 | vehicle accident, tree, head injury, car crushed by falling tree, transport, | |
Burns, Brendan Craig (PDF File, 324.4 KB) 2019 TASCD 130 |
Simon Cooper | 26-03-2019 | Coronial, Suicide, Asphyxia, Smoke inhalation, Caravan, Fire, | |
Glover, Gerald Samual (PDF File, 125.7 KB) 2019 TASCD 109 |
Olivia McTaggart | 22-03-2019 | natural cause death, death in custody, Coroners Act 1995, Risdon Prison, dilated cardiomyopathy, emphysema, Correctional Primary Health | |
Morris, Jason Simon (PDF File, 122.1 KB) 2019 TASCD 110 |
Olivia McTaggart | 22-03-2019 | natural cause death, death in custody, Coroners Act 1995, Risdon Prison, Royal Hobart Hospital, Whittle Ward, metastatic squamous cell carcinoma of the lung | |
Steshic, John Norman -web .pdf (PDF File, 495.7 KB) 2019 TASCD 103 |
Rod Chandler | 18-03-2019 | coronial, hospital, heart disease, ischaemic heart disease, single vessel atherosclerosis | |
FW (PDF File, 398.6 KB) 2019 TASCD 105 |
Olivia McTaggart | 15-03-2019 | Drowning, intentional self-harm, coroner's finding, coroner's recommendations | |
Paraskevas, Odissefs (PDF File, 396.0 KB) 2019 TASCD 95 |
Rod Chandler | 08-03-2019 | Pulmonary thromboembolism, deep vein thrombosis, D-dimer, Wells score, PERC, Coroner's recommendation | |
Novaski, John James (PDF File, 394.5 KB) 2019 TASCD 083 |
Rod Chandler | 01-03-2019 | Coronial, atherosclerotic, hypertensive, cardiovascular disease, hospital, Launceston General Hospital, obesity, hypertension, complications of health care, missed or incorrect diagnosis | |
Lore, Margaret (PDF File, 499.9 KB) 2019 TASCD 79 |
Olivia McTaggart | 26-02-2019 | Head injury, cliff fall, hazardous area, Blackmans Bay blowhole, safety, public area, Coroner's recommendations | |
Nowitzki-Eisenburg, Heike (PDF File, 493.2 KB) 2019 TASCD 75 |
Olivia McTaggart | 25-02-2019 | transport and traffic related, motor vehicle accident, two vehicle crash, Lilydale Road, adverse weather conditions, poor condition of road, excessive speed for conditions | |
Mansfield, Doreen (PDF File, 842.3 KB) 2019 TASCD 69 |
Simon Cooper | 22-02-2019 | Coronial, Findings, Inquest, Death in care, Royal Hobart Hospital, Fall from standing Position/ Height, Complication of Left Femur Fracture | Updated response provided by THS - South 14 October 2022 RHH complies with the state record policy with regard to retention of records |
Beltz, Sarah Rose -(Web).pdf (PDF File, 469.7 KB) 2019 TASCD 68 |
Simon cooper | 19-02-2019 | Coronial, Findings, Meningococcal, immunisation, disease, A, C,Y, W and B Strain, Neisseria meningitides, bacterial sepsis, hospital | |
Lewtas, Georgia Amy (PDF File, 350.4 KB) 2019 TASCD 52 |
Olivia McTaggart | 12-02-2019 | drowning, water related, Mersey Bluff, Devonport, youth, Surf Life Saving, coroner's recommendation, surf rescue, swimming, leisure activity | |
Kugel, Karen (PDF File, 484.8 KB) 2019 TASCD 53 |
Olivia McTaggart | 11-02-2019 | Homicide & assault, murder, stabbing, coroner's finding, restraint order | |
Cowen, Craig -web.pdf (PDF File, 411.8 KB) 2019 TASCD 037 |
Olivia McTaggart | 04-02-2019 | coronial, drowning, wharf, fall, alcohol, intoxication, water | |
Killer, Debbie Dubravka (PDF File, 411.5 KB) 2019 TASCD 42 |
Simon Cooper | 31-01-2019 | undetermined cause of death, undetermined circumstances of death, Tasmania Police, incomplete investigation, Tasmania Police Manual, Forensic Services, forensic evidence, coroner's comments | |
Skrepetos, Stavroula (PDF File, 478.6 KB) 2019 TASCD 34 |
Olivia McTaggart | 31-01-2019 | older persons, abdominal aortic aneurysm (AAA), haemoperitoneum/retroperitoneal haematoma, Royal Hobart Hospital Emergency Department, falls | |
Brown, Tony David .pdf (PDF File, 595.0 KB) 2019 TASCD 022 |
Simon Cooper | 21-01-2019 | traumatic brain injury, homicide, Mitchell Clay Dowling, Jay David Blazely, one punch death, assault, | |
DS (PDF File, 302.2 KB) 2019 TASCD 17 |
Olivia McTaggart | 21-01-2019 | Coroner's findings, drugs, alcohol | |
Stefaniw, Gerard Ernest (PDF File, 738.2 KB) 2019 TASCD 8 |
Simon Cooper | 18-01-2019 | 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 | |
Dunster, Kenneth Francis (PDF File, 743.5 KB) 2019 TASCD 5 |
Simon Cooper | 11-01-2019 | death in care, Mental Health Act 2013, mental health order, Millbrook Rise Centre, asphyxia, choking on food, supervision of meals | |
Elias, Nebras (PDF File, 496.5 KB) 2019 TASCD 1 |
Rod Chandler | 04-01-2019 | transport and traffic related, motor vehicle accident, two vehicle crash, Lebrina | |
Roberts, Nigel Douglas (PDF File, 734.5 KB) 2019 TASCD 9 |
Rod Chandler | 04-01-2019 | 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 | |
Richardson, Margaret Rita.(Web).pdf (PDF File, 406.9 KB) 2018 TASCD 470 |
Rod Chandler | 16-11-2018 | Older Person, Coronary Artery Dissection |