- Coronial Findings 2024
- Coronial Findings 2023
- Coronial Findings 2022
- Coronial Findings 2021
- Coronial Findings 2020
- Coronial Findings 2019
- Coronial Findings 2018
- Coronial Findings 2017
- Coronial Findings 2016
- Coronial Findings 2015
- 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 |
---|---|---|---|---|
McIntosh, David John (PDF File, 226.4 KB) 2025 TASCD 299 |
Simon Cooper | 26-06-2025 | Inquest, Motor Vehicle Accident, Work Related, Transport and Traffic Related. | |
Infant W and Infant P (PDF File, 1001.4 KB) 2025 TASCD 300-301 |
Olivia McTaggart | 24-06-2025 | Infant Deaths, Inquest, Coroner's Recommendations, Suppression Order | These findings are also subject to a suppression order details are provided here. Magistrates Court : Suppression Order |
Findings in relation to Shane Navin, Leigh Mundy, Dennis Neagle and Anthony Seymour (PDF File, 549.1 KB) 2025 TASCD 284-287 |
Simon Cooper | 19-06-2025 | Targa, Motorsport Australia, Car Racing | |
de-identified YZ (PDF File, 108.5 KB) 2025 TASCD 199 |
Leigh Mackey | 06-05-2025 | Suicide, Firearm, Mental Health | |
Warn, Kenneth (PDF File, 91.9 KB) 2025 TASCD 192 |
Olivia McTaggart | 30-04-2025 | Motor Vehicle Crash, Passenger | |
de-identified OQ (PDF File, 94.4 KB) 2025 TASCD 187 |
Olivia McTaggart | 29-04-2025 | RHH, RCA, Subarachnoid Haemorrhage | |
Dow, Vicki Elizabeth (PDF File, 96.1 KB) 2025 TASCD 180 |
Jackie Hartnett | 23-04-2025 | RHH, Multiple Organ Failure | |
Decision in relation to Martin 'Marjorie' Harwood (PDF File, 161.0 KB) 2025 TASCD |
Olivia McTaggart | 11-04-2025 | Decision, Reportable Death, HMP, Transgender | |
Zito, Adelina (PDF File, 148.4 KB) 2025 TASCD 175 |
Leigh Mackey | 08-04-2025 | Acute Limb Ischaemia, RACF, Falls, Coroners Comments | |
Hay, Marc Edward (PDF File, 98.9 KB) 2025 TASCD 172 |
Simon Cooper | 01-04-2025 | Drowning, THC, MDMA | |
Seabourne, Bailey Matthew Grant (PDF File, 116.1 KB) 2025 TASCD 161 |
Leigh Mackey | 28-03-2025 | Motor Vehicle Accident, Speeding, Unrestrained. | |
de-identified BX (PDF File, 151.3 KB) 2025 TASCD 152 |
Leigh Mackey | 24-03-2025 | Bike, Repairworks, Coroners Recommendations | Response received by Department of State Growth 19 May 2025 Regarding your recommendations in relation to warning signs in circumstances where road works or road conditions pose a hazard to cyclists by the presence of debris on a road surface, and risk assessments for roadworks that impact the safety of cyclists as a vulnerable road user, in addition to other road users across the State’s road network. I can advise that officers within the Transport Group at the Department of State Growth have reviewed the department’s construction specifications for state road projects in conjunction with your recommendations. Section 160.07 of these specifications requires that a traffic management plan be developed for each construction project and states the standards and guidelines to be utilised when developing their plan. This specification requires, in part, adherence to the latest version of the Austroads Guide to Temporary Traffic Management (the Guide), which provide instructions for how vulnerable road users, including cyclists, are to be considered in temporary traffic management plans. The department has confirmed in their review that the safety measures in this Guide relating to vulnerable road users are in accordance with your recommendations. The Guide provides considerations and tools for how vulnerable road users, including cyclists, are to be considered when identifying risks and appropriate mitigations, including signage, for a temporary traffic management plan. In turn, while the department’s construction specifications already incorporate your recommendations, the department will send a notification reminding contractors that signage during on-going works needs to be specific to the site and consider vulnerable road users. |
Phillips, Helen Lynette (PDF File, 112.5 KB) 2025 TASCD 142 |
Leigh Mackey | 17-03-2025 | Fall, Ladder, MCH | |
Allford, Mary Kathleen; Foster, Trevor Allan; Watson, Peter John (PDF File, 445.7 KB) 2025 TASCD 88 89 90 |
Simon Cooper | 21-02-2025 | Inquest, Floods, Drowning, Coroner's Comments | |
Walker, Danielle Kate (PDF File, 116.1 KB) 2025 TASCD 78 |
Simon Cooper | 14-02-2025 | Inquest, motor vehicle accident | |
Explosion, Glenorchy (PDF File, 112.6 KB) 2025 TASCD 63 |
Simon Cooper | 05-02-2025 | Explosion, acetylene gas, storage | |
de-identified MS (PDF File, 321.2 KB) 2025 TASCD 61 |
Olivia McTaggart | 05-02-2025 | Inquest, Suicide, Coroners Comments | Please Note: Pursuant to section 57(1)(c) of the Coroners Act 1995 there is a Suppression Order. Contact the Registry for further information if required. |
de-identified IM (PDF File, 116.9 KB) 2025 TASCD 52 |
Leigh Mackey | 29-01-2025 | Sepsis, Calvary St Vincent's Hospital | |
Van Zelm, Robert Bernhard (PDF File, 134.8 KB) 2025 TASCD 53 |
Leigh Mackey | 29-01-2025 | Motorcycle, Paradise | |
Ward, Janet Robyn (PDF File, 85.5 KB) 2025 TASCD 51 |
Olivia McTaggart | 28-01-2025 | Death by Negligent Driving, Coroners Comment, Motor Vehicle Accident | |
Sheedy, Alan Noel (PDF File, 86.5 KB) 2025 TASCD 50 |
Leigh Mackey | 24-01-2025 | Fall, RACF | |
Connlley, Maurice Gordon (PDF File, 90.2 KB) 2025 TASCD 42 |
Olivia McTaggart | 21-01-2025 | Coroner's Recommendation, RCA, NWRH | |
Lowe, Wayne Anthony (PDF File, 94.0 KB) 2025 TASCD 40 |
Olivia McTaggart | 20-01-2025 | Fall, LGH, RCA | |
Rickard-Simms, Adrienne Rosemary (PDF File, 85.1 KB) 2025 TASCD 33 |
Leigh Mackey | 14-01-2025 | RACF, Fall, RHH |