Coronial Findings 2025

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.

Table: Coronial findings (decisions) 2024
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.

I can also advise that the Department of State Growth currently administers the Vulnerable
Road User Program, which provides an opportunity for Tasmanian local governments to apply
for grant funding to implement low-cost infrastructure treatments that improve road safety
outcomes for vulnerable road users (pedestrians, cyclists, etc.). Treatments typically delivered
under this program include footpaths, pedestrian refuges, cycling paths and pedestrian
crossings.

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
Last updated: 5 February 2025