findings pre-2012

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.

Response received by Calvary  - Lenah Valley Hospital 19 February 2026.

Calvary Hobart Actions

Calvary Hobart has implemented a range of quality and safety initiatives both proactively and in response to the coroner’s recommendations. Calvary has focused on strengthening assessment processes, communication at clinical handover, and documentation relating to patients requiring supervision. These initiatives include:

• An electronic alert functionality has been introduced within the clinical information system (i.PM) to identify patients who require a patient supervisor. This alert is visible within the Nursing Handover document, supporting improved situational awareness for staff and enhancing communication at transition points of care. This initiative is intended to improve consistency in staff recognising and responding to supervision requirements and is available at both Lenah Valley and St John’s Hospitals.
• A Patient Supervisor Checklist has been implemented to support a structured and standardised assessment process for Calvary Hobart staff. This tool assists clinicians to identify patients at increased risk and ensures a documented, comprehensive, and consistent approach to determining the need for supervision.
• Targeted education has been provided to relevant medical specialty groups to reinforce the requirement for clear documentation within the medical record following a patient fall with head strike. This includes documenting whether a head CT is required, together with the clinical rationale underpinning the decision.
• Additional education has been delivered to nursing staff regarding the importance of utilising the Comprehensive Care Plan to document identified risks, mitigation strategies, and the use of patient supervision. This aligns with Calvary’s commitment to person-centred care and effective multidisciplinary communication.

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.