During the reporting period, being the 12 months 1 July 2024 - 30 June 2025, 142 findings were handed down in relation to elderly falls, of which 77 were in relation to females and 65 in relation to males. These figures have increased from last financial year when 125 findings were handed down in the same period.
This table represents a list of coronial findings in respect of deaths of older persons occurring accidentally from falls or injuries in a nursing home, medical setting, hospital, or in their own home.
In each of these cases the coroner investigates the circumstances of the fall or injury sufficiently to enable a determination regarding whether there are any issues surrounding the care and treatment, connected to the death.
These investigations include a requirement that the aged care facility provide answers to questions regarding falls risks assessment and preventative measures implemented and an independent examination by Kevin Egan regarding any possible issues. On occasion the coroners may also seek a medical review of the treatment provided undertaken by the coronial medical consultant Dr Anthony J Bell.
Abbreviations.
RHH: Royal Hobart Hospital
NWRH: Northwest Regional Hospital
MCH: Mersey Community Hospital
LGH: Launceston General Hospital
RACF: Residential Aged Care Facility
| Local Case Number | Location | Investigation details | |
|---|---|---|---|
| H0287/2024 | Home and RHH |
Findings handed down on 1 July 2024. The coroner determined no care issues arose | |
| H0245/2024 | Home and RHH |
Findings handed down on 1 July 2024. The coroner determined no care issues arose | |
| H0171/2024 | Huon Reginald Care |
Findings handed down on 1 July 2024. The coroner determined no care issues arose | |
| H0634/2023 | Home and RHH |
Findings handed down on 2 July 2024. The coroner determined no care issues arose | |
L0374/2023 | Home and NWRH | Findings handed down on 3 July 2024. | |
| H0224/2024 | Home and RHH |
Findings handed down on 4 July 2024. The coroner determined no care issues arose | |
| H0292/2024 | Home , MCH and RHH |
Findings handed down on 11 July 2024. The coroner determined no care issues arose | |
| L0147/2022 | Home & LGH |
Findings handed down on 12 July 2024. The coroner determined no care issues arose | |
| H0259/2023 | Home & RHH |
Findings handed down on 12 July 2024. The coroner determined no care issues arose | |
| L0057/2022 | Home & NWRH |
Findings handed down on 1 August 2024. The coroner determined no care issues arose | |
| L0244/2022 | Home & LGH |
Findings handed down on 2 August 2024. The coroner determined to not to make any comments or recommendations given the RCA recommendations and their implementation. | |
| H0206/2024 | Home & NWRH |
Findings handed down on 19 August 2024. The coroner determined no care issues arose | |
| H0199/2024 | Home & RHH |
Findings handed down on 20 August 2024. The coroner determined no care issues arose | |
| L0252/2022 | Home & NWRH |
Findings handed down on 20 August 2024. The coroner determined no care issues arose | |
| H0350/2024 | Home & LGH |
Findings handed down on 30 August 2024. The coroner determined no care issues arose | |
| H0369/2024 | Home & HPH |
Findings handed down on 30 August 2024. The coroner determined no care issues arose | |
| H0348/2024 | Home & RHH |
Findings handed down on 3 September 2024. The coroner determined no care issues arose | |
| H0501/2023 | Respect Age Care & RHH |
Findings handed down on 10 September 2024. The coroner determined no care issues arose | |
| H0206/2022 | St Ann's Nursing Home |
Findings handed down on 10 September 2024. The coroner determined no care issues arose | |
| H0245/2023 | Barossa Park Lodge |
Findings handed down on 11 September 2024. The coroner determined no care issues arose. | |
| L0195/2022 | Home & NWRH |
Findings handed down on 12 September 2024. The coroner made a recommendation that the North West Regional Hospital re-visits the RCA recommendations and considers whether there is a current need to reinforce those recommendations and/or take any additional safety measures in order to prevent falls in the Emergency Department similar to the fall suffered by Mrs Chapman. Findings in relation to 2024 TASCD 502 | |
| H0186/2022 | Barossa Park Lodge & RHH |
Findings handed down on 13 September 2024. The coroner determined no care issues arose. | |
| H0703/2024 | Home & LGH |
Findings handed down on 16 September 2024. The coroner determined no care issues arose. | |
| H0273/2024 | Home & RHH |
Findings handed down on 17 September 2024. The coroner determined no care issues arose. | |
| H0061/2024 | Uniting AgeWell Queenborough |
Findings handed down on 17 September 2024. The coroner determined no care issues arose. | |
| H0183/2024 | Home |
Findings handed down on 18 September 2024. The coroner determined no care issues arose. | |
| H0200/2024 | Home & RHH |
Findings handed down on 19 September 2024. The coroner determined no care issues arose. | |
| H0201/2024 | Home |
Findings handed down on 19 September 2024. The coroner determined no care issues arose. | |
| H0404/2024 | Home & RHH |
Findings handed down on 20 September 2024. The coroner determined no care issues arose. | |
| H0399/2024 | Home |
Findings handed down on 20 September 2024. The coroner determined no care issues arose. | |
| H0613/2023 | One Care Barossa Park Lodge |
Findings handed down on 20 September 2024. The coroner determined no care issues arose. | |
| H0062/2022 | May Shaw Health Centre & RHH |
Findings handed down on 23 September 2024. The coroner determined no care issues arose. | |
| H0556/2023 | Southern Cross Care & RHH |
Findings handed down on 24 September 2024. The coroner determined no care issues arose. | |
| L0447/2023 | Home & LGH |
Findings handed down on 25 September 2024. The coroner determined no care issues arose. | |
| H0196/2022 | Gardens Nursing Home |
Findings handed down on 26 September 2024. The coroner determined no care issues arose. | |
| H0259/2024 | Home & Hobart Private |
Findings handed down on 26 September 2024. The coroner determined no care issues arose. | |
| H0349/2021 | Queen Victoria Care |
Findings handed down on 27 September 2024. The coroner determined given the very comprehensive response by the RACF and the improvements in the care provided there is no need to make any comments and or recommendations. Findings in relation to 2024 TASCD 567 | |
| H0172/2024 | Respect Derwent Views |
Findings handed down on 2 October 2024. The coroner determined no care issues arose. | |
| H0161/2024 | Southern Cross Care & RHH |
Findings handed down on 2 October 2024. The coroner determined no care issues arose. | |
| H0167/2024 | Home, RHH & St Johns |
Findings handed down on 3 October 2024. The coroner determined no care issues arose. | |
| H0241/2024 | Guilford Young Grove |
Findings handed down on 8 October 2024. The coroner determined no care issues arose. | |
| H0157/2023 | RHH |
Findings handed down on 11 October 2024. The coroner published his findings and can be read in full here Findings in relation to 2024 TASCD 601 | |
| H0195/2024 | Glenview Community Services |
Findings handed down on 11 October 2024. The coroner determined no care issues arose. | |
| H0371/2024 | Home & NWRH |
Findings handed down on 11 October 2024. The coroner determined no care issues arose. | |
| H0231/2024 | Uniting AgeWell Queenborough Rise |
Findings handed down on 14 October 2024. The coroner determined no care issues arose. | |
| H0173/2024 | Uniting Agewell Strathaven & RHH |
Findings handed down on 15 October 2024. The coroner determined no care issues arose. | |
| H0188/2024 | Regis Aged Care Eastern Shore & RHH |
Findings handed down on 15 October 2024. The coroner determined no care issues arose. | |
| H0274/2024 | Meercroft Care & NWRH |
Findings handed down on 16 October 2024. The coroner determined no care issues arose. | |
| L0038/2024 | Rubicon Grove |
Findings handed down on 16 October 2024. The coroner determined no care issues arose. | |
| H0413/2024 | Home |
Findings handed down on 16 October 2024. The coroner determined no care issues arose. | |
| H0560/2023 | Home & RHH |
Findings handed down on 17 October 2024. The coroner determined no care issues arose. | |
| H0056/2024 | Home & RHH |
Findings handed down on 18 October 2024. The coroner determined no care issues arose. | |
| H0049/2022 | RHH |
Findings handed down on 18 October 2024. The coroner made a recommendation that the use of the inpatient fall clinical pathway form be fully implemented by the THS and that it be completed by medical staff each time an inpatient suffers a fall. The corner published his findings and can be read in full here. Findings in relation to 2024 TASCD 616 | |
| H0158/2024 | Baptcare Karingal Community Nursing Home |
Findings handed down on 21 October 2024. The coroner determined no care issues arose. | |
| H0053/2024 | Toosey Aged and Community Care |
Findings were handed down on 22 October 2024. The coroner made a recommendation that Toosey Aged and Community Care reviews its practices and procedures relating to the frequency and documenting of falls risk assessments for residents and ensures that those practices and procedures comply with guidelines made by the Aged Care Safety and Quality Commission. The coroner made a recommendation that Toosey Aged and Community Care reviews its practices and procedures relating to documenting and implementing falls prevention measures arising from a falls risk assessment for a resident. The corner published her findings and can be read in full here. Findings in relation to 2024 TASCD 630 | |
| H0299/2024 | Ainslie Low Head Aged Care |
Findings handed down on 23 October 2024. The coroner determined no care issues arose. | |
| H0513/2024 | Home & RHH |
Findings handed down on 29 October 2024. The coroner determined no care issues arose. | |
| H0586/2024 | Home & Whittle Ward |
Findings handed down on 30 October 2024. The coroner determined no care issues arose. | |
| H0123/2021 | Public Area |
Findings handed down on 31 October 2024. The coroner made a recommendation that a fence, similar to that depicted in Figures 2 and 3, be erected around the three sides of the sunken sitting area. There should be a gate in the fence to provide access to the steps on each side of the area. The corner published his findings and can be read in full here. Findings in relation to 2024 TASCD 700 | |
| H0338/2022 | Queen Victoria |
Findings handed down on 31 October 2024. The coroner determined no care issues arose. | |
| L0274/2023 | Eliza Purton |
Findings handed down on 1 November 2024. The coroner determined no care issues arose. | |
| L0037/2024 | Meercroft Aged Care |
Findings handed down on 5 November 2024. The coroner determined no care issues arose. | |
| H0212/2024 | Huon Reginald Care |
Findings handed down on 6 November 2024. The coroner determined no care issues arose. | |
| H0222/2024 | Home |
Findings handed down on 14 November 2024. The coroner determined no care issues arose. | |
| H0279/2024 | Home & LGH |
Findings handed down on 15 November 2024. The coroner determined no care issues arose. | |
| H0301/2023 | Home & RHH |
Findings handed down on 15 November 2024. The coroner determined no care issues arose. | |
| H0575/2023 | Respect Aged Care Derwent Views |
Findings handed down on 18 November 2024. The Coroner made a recommendation that Respect Aged Care Derwent Views review its policies and processes surrounding the safety of resident, particularly those who are prone to wandering and falls including, but not limited to: * Adequacy and timeliness of risk assessments upon admission; * Access to and from the facility; * The adequacy of existing sensors to detect movement; and * The checking of residents overnight. | |
| H0747/2024 | Beaconsfield District Health Service & LGH |
Findings handed down on 18 November 2024. The coroner determined no care issues arose. | |
| H0630/2024 | Home & RHH |
Findings handed down on 19 November 2024. The coroner determined no care issues arose. | |
| H0643/2024 | Uniting AgeWell Strathaven |
Findings handed down on 25 November 2024. The coroner determined no care issues arose. | |
| L0230/2023 | May Shaw, LGH & Northeast Soldiers Memorial Hospital |
Findings handed down on 2 December 2024. The coroner determined no care issues arose. | |
| H0207/2022 | Mary Ogilvy Home |
Findings handed down on 3 December 2024. The coroner commented that Mary Ogilvy Home should, if it has not done so already, ensure that it has in place a system or regular checks of the operation of its bed and chair sensor alarms. | |
| H0247/2023 | Home & RHH |
Findings handed down on 4 December 2024. The coroner determined no care issues arose. | |
| H0820/2024 | Home & St Helens District Hospital |
Findings handed down on 5 December 2024. The coroner determined no care issues arose. | |
| H0746/2024 | Home & RHH |
Findings handed down on 6 December 2024. The coroner determined no care issues arose. | |
| L0408/2023 | Regis Tasmanian Legana |
Findings handed down on 6 December 2024. The coroner determined no care issues arose. | |
| H0799/2024 | Home, GP & MCH |
Findings handed down on 6 December 2024. The coroner determined no care issues arose. | |
| H0598/2023 | Home & RHH |
Findings handed down on 10 December 2024. The coroner determined no care issues arose. | |
| H0191/2022 | Home & RHH |
Findings handed down on 11 December 2024. The coroner determined no care issues arose. | |
| H0484/2024 | Home & NWRH |
Findings handed down on 11 December 2024. The coroner determined no care issues arose. | |
| H0801/2024 | Home & RHH |
Findings handed down on 13 December 2024. The coroner determined no care issues arose. | |
| H0628/2024 | Home |
Findings handed down on 16 December 2024. The coroner determined no care issues arose. | |
| H0024/2024 | Midlands Multi-Purpose Health Centre & RHH |
Findings handed down on 16 December 2024. The coroner determined no care issues arose. | |
| H0597/2024 | Derwent Villa |
Findings handed down on 16 December 2024. The coroner determined no care issues arose. | |
| H0327/2023 | Korongee Dementia Village & RHH |
Findings handed down on 17 December 2024. The coroner determined no care issues arose. | |
| L0012/2024 | Home & MCH |
Findings handed down on 17 December 2024. The coroner determined no care issues arose. | |
| H0349/2022 | Respect Aged Care & RHH |
Findings handed down on 18 December 2024. The coroner determined no care issues arose. | |
| L0100/2023 | Home & NWRH |
Findings handed down on 19 December 2024. The coroner determined no care issues arose. | |
| H0651/2024 | Home |
Findings handed down on 20 December 2024. The coroner determined no care issues arose. | |
| L0222/2023 | Home & NWRH |
Findings handed down on 6 January 2025. The coroner determined no care issues arose. | |
| H0351/2022 | Regis Tasmania Eastern Shore |
Findings handed down on 7 January 2025. The coroner determined no care issues arose. | |
| H0488/2022 | Southern Cross Care's Rosary Gardens & RHH |
Findings handed down on 7 January 2025. The coroner determined no care issues arose. | |
| H0645/2024 | Home & LGH |
Findings handed down on 9 January 2025. The coroner determined no care issues arose. | |
| H0309/2022 | Southern Cross Care's Rosary Gardens & RHH |
Findings handed down on 14 January 2025. The coroner determined no care issues arose. | |
| L0375/2022 | Sandhill Nursing Home & LGH |
Findings handed down on 24 January 2025. The coroner determined no care issues arose. | |
| H0094/2023 | Hawthorn Village & RHH |
Findings handed down on 14 February 2025. The coroner determined no care issues arose. | |
| H0857/2024 | Home & LGH |
Findings handed down on 17 February 2025. The coroner determined no care issues arose. | |
| H0186/2024 | Home & LGH |
Findings handed down on 19 February 2025. The coroner determined no care issues arose. | |
| H0567/2024 | Home & RHH |
Findings handed down on 19 February 2025. The coroner determined no care issues arose. | |
| H0223/2024 | Lillian Martin RACF & RHH |
Findings handed down on 20 February 2025. The coroner determined no care issues arose. | |
| H0606/2024 | Home |
Findings handed down on 4 March 2025. The coroner determined no care issues arose. | |
| H0571/2024 | Home & RHH |
Findings handed down on 5 March 2025. The coroner determined no care issues arose. | |
| H0045/2025 | Home & RHH |
Findings handed down on 12 March 2025. The coroner determined no care issues arose. | |
| L0382/2022 | Home, MCH & LGH |
Findings handed down on 17 March 2025. The coroner determined no care issues arose. | |
| H0616/2024 | Home |
Findings handed down on 17 March 2025. The coroner determined no care issues arose. | |
| H0724/2024 | Rivulet Nursing Home & RHH |
Findings handed down on 18 March 2025. The coroner determined no care issues arose. | |
| L0047/2023 | MCH |
Findings handed down on 24 March 2025. The coroner determined no care issues arose. | |
| H0813/2024 | OnceCare Limited Rubicon Lodge |
Findings handed down on 25 March 2025. The coroner determined no care issues arose. | |
| H0806/2024 | Home |
Findings handed down on 28 March 2025. The coroner determined no care issues arose. | |
| H0364/2023 | Huon Reginald Care |
Findings handed down on 31 March 2025. The coroner determined no care issues arose. | |
| H0771/2024 | Home & RHH |
Findings handed down on 29 March 2025. The coroner determined no care issues arose. | |
| H0321/2024 | Corumbene Nursing Home RACF & RHH |
Findings handed down on 9 April 2025. The coroner determined no care issues arose. | |
| H0592/2023 | Home & RHH |
Findings handed down on 28 April 2025. The coroner determined no care issues arose. | |
| H0714/2024 | Mount Esk Aged Care RACF |
Findings handed down on 29 April 2025. The coroner determined no care issues arose. | |
| H0095/2024 | Toosey Aged Care Facility |
Findings handed down on 1 May 2025. The coroner noted the previous recommendations of Coroner Olivia McTaggart in her findings into the death of Findings in relation to 2024 TASCD 630, and recommend the RACF consider and implement those recommendations. | |
| H0874/2024 | Home & NWRH |
Findings handed down on 5 May 2025. The coroner determined no care issues arose. | |
| H0046/2025 | Fairway Rise RACF |
Findings handed down on 5 May 2025. The coroner determined no care issues arose. | |
| L0195/2023 | Home & LGH |
Findings handed down on 6 May 2025. The coroner determined no care issues arose. | |
| H0007/2024 | Fairway Rise RACF |
Findings handed down on 7 May 2025. The coroner determined no care issues arose. | |
| H0315/2024 | Home & RHH |
Findings handed down on 12 May 2025. The coroner determined no care issues arose. | |
| H0015/2024 | Fairway Rise RACF |
Findings handed down on 13 May 2025. The coroner determined no care issues arose. | |
| H0612/2024 | LGH |
Findings handed down on 13 May 2025. The coroner determined no care issues arose. | |
| H0750/2024 | Meercroft Care & MCH |
Findings handed down on 15 May 2025. The coroner determined no care issues arose. | |
| H0993/2024 | Home & NWRH |
Findings handed down on 23 May 2025. The coroner determined no care issues arose. | |
| H0076/2025 | Home & NWRH |
Findings handed down on 23 May 2025. The coroner determined no care issues arose. | |
| De-identified GJ | Glenview RACF |
Findings handed down on 26 May 2025. The corner published her findings and can be read in full here. Findings in relation to de-identified GJ | |
| H0794/2024 | Queen Victoria Home & RHH |
Findings handed down on 27 May 2025. The coroner determined no care issues arose. | |
| H0362/2022 | Korongee Dementia Village RACF |
Findings handed down on 30 May 2025. The coroner determined no care issues arose. | |
| H0790/2024 | Home and Hobart Private Hospital |
Findings handed down on 30 May 2025. The coroner determined no care issues arose. | |
| H0070/2025 | Meercroft Care Inc RACF |
Findings handed down on 2 June 2025. The coroner determined no care issues arose. | |
| H0330/24 | Home |
Findings handed down on 2 June 2025. The coroner determined no care issues arose. | |
| H0092/2024 | Home & NWRH |
Findings handed down on 11 June 2025. The coroner determined no care issues arose. | |
| H0205/2025 | Home |
Findings handed down on 12 June 2025. The coroner determined no care issues arose. | |
| H0210/2025 | Home & Calvary Hospital |
Findings handed down on 13 June 2025. The coroner determined no care issues arose. | |
| H0065/2022 | Fairway Rise RACF |
Findings handed down on 16 June 2025. The coroner made the following recommendations. 1. All registered nursing staff be regularly assessed for competency including in the areas of; a. Wound classification; b. Wound management; and c. Recognising and responding to a deteriorating resident. Any area of skill development identified as lacking be addressed including by the provision of suitable education programs. 2. Residents are assessed for their care needs at the time of their entry into a RACF, at regular intervals during their residency at a RACF and at times of change in their condition noting the planning for a resident's care needs to be dynamic and responsive to changed in a resident's condition. The assessments are to utilise any industry accepted and standardised tools such as the Waterlook tool in the context of pressure wounds. 3. A workflow system be considered and if feasible implemented to provide clarity to staff as to the specific care needs of each of the residents in their care and which requires the attendance to those needs to be recorded and the creation of an alert if the care need is not attended to. 4. Care managers undertake a weekly review of all wound charts of RACF residents to ensure a. Wound management is appropriate and meeting the needs of the individual; b. No wound management tasks have been missed or overlooked; and c. Any education or training needs for nursing staff are identified and actioned. | |
| H0625/2024 | Fairway Rise RACF & RHH |
Findings handed down on 17 June 2025. The coroner determined no care issues arose. | |
| H0551/2023 | Southern Cross Care RACF |
Findings handed down on 18 June 2025. The coroner determined no care issues arose. | |
| H0166/2025 | Home & LGH |
Findings handed down on 20 June 2025. The coroner determined no care issues arose. | |
| H0347/2022 | Strathhaven RACF |
Findings handed down on 27 June 2025. The coroner determined no care issues arose. | |
| H0325/2022 | Home & RHH |
Findings handed down on 30 June 2025. The coroner determined no care issues arose. | |
| H0507/2022 | Home & RHH |
Findings handed down on 30 June 2025. The coroner determined no care issues arose. |
Falls Stats 25/26
During the reporting period, being the 12 months 1 July 2025 – 30 June 2026, 105 findings were handed down in relation to falls, of which 56 were in relation to females and 49 in relation to males. Finalisation figures have decreased from last financial year when 125 findings were handed down in the same period.
A list can be located on the Magistrates Court website. This table represents a list of coronial findings in respect of deaths of older persons occurring accidently from falls occurring or injuries in a nursing home, medical setting, hospital, or in their own home.
In each of these cases the coroner investigates the circumstances of the fall or injury sufficiently to enable a determination regarding whether there are any issues surrounding the care and treatment, connected to the death.
| Local Case Number | Location | Investigation details |
|---|---|---|
| L0374/2022 | Home | Findings handed down on 3 July 2025. The coroner determined no care issues arose. |
| H0545/2023 | Guildford Young Homes |
Findings handed down on 4 July 2025.
The coroner determined no care issues arose. |
| H0480/2022 | Strathglen United Aged Well | Findings handed down on 4 July 2025. The coroner determined no care issues arose. |
| H0899/2024 | Glenara Lakes RACF | Findings handed down on 4 July 2025. The coroner determined no care issues arose. |
| H0100/2025 | Meercroft RACF & NWRH | Findings handed down on 7 July 2025. The coroner determined no care issues arose. |
| H0870/2024 | Home & RHH | Findings handed down on 7 July 2025. The coroner determined no care issues arose. |
| H0400/2023 | Home | Findings handed down on 9 July 2025. The coroner determined no care issues arose. |
| H0982/2024 | Home & NWRH | Findings handed down on 10 July 2025. The coroner determined no care issues arose. |
| H0048/2023 | Barossa Park Lodge | Findings handed down on 23 July 2025. The coroner determined no care issues arose. |
| L0350/2023 | Melaleuca Home for the Aged Inc | Findings handed down on 25 July 2025. The coroner determined no care issues arose. |
| L0390/2023 | Home & LGH | Findings handed down on 30 July 2025. The coroner determined no care issues arose. |
| H0009/2024 | Regis Aged Care (RACF) | Findings handed down on 31 July 2025. The coroner determined no care issues arose. |
| H0211/2023 | Home & RHH | Findings handed down on 8 August 2025. The coroner determined no care issues arose. |
| L0399/2023 | Respect Aged Care Eliza Purton (RACF) | Findings handed down on 11 August 2025. The coroner determined no care issues arose. |
| H0251/2023 | Home & RHH | Findings handed down on 15 August 2025. The coroner determined no care issues arose. |
| L0214/2023 | Meercroft Care Inc (RACF) | Findings handed down on 15 August 2025. The coroner determined no care issues arose. |
| L0215/2023 | Mt St Vincent Nursing Home (RACF) | Findings handed down on 18 August 2025. The coroner determined no care issues arose. |
| L0275/2023 | Home & NWRH | Findings handed down on 18 August 2025. The coroner determined no care issues arose. |
| H0320/2023 | Queenborough Rise Uniting Age Well (RACF) | Findings handed down on 19 August 2025. The coroner determined no care issues arose. |
| H0539/2023 | Huon Reginald Care (RACF) | Findings handed down on 19 August 2025. The coroner determined no care issues arose. |
| H0596/2023 | Home | Findings handed down on 23 August 2025. The coroner determined no care issues arose. |
| H0108/2025 | One Care RACF | Findings handed down on 29 August 2025. The coroner determined no care issues arose. |
| H0778/2024 | Home & RHH | Findings handed down on 2 September 2025. The coroner determined no care issues arose. |
| H0089/2025 | Umina Park Aged Care Home (RACF) | Findings handed down on 4 September 2025. The coroner determined no care issues arose. |
| H0288/25 | Queen Victoria RACF | Findings handed down on 4 September 2025. The coroner determined no care issues arose. |
| H0102/2025 | Home & RHH | Findings handed down on 5 September 2025. The coroner determined no care issues arose. |
| H0248/2025 | Home | Findings handed down on 8 September 2025. The coroner determined no care issues arose. |
| H0299/2025 | Home | Findings handed down on 9 September 2025. The coroner determined no care issues arose. |
| H1001/2024 | Home & RHH | Findings handed down on 10 September 2025. The coroner determined no care issues arose. |
| H0974/2024 | Home & Deloraine District Hospital | Findings handed down on 11 September 2025. The coroner determined no care issues arose. |
| H0413/2025 | Home & RHH | Findings handed down on 17 September 2025. The coroner determined no care issues arose. |
| H0267/2025 | Home & RHH | Findings handed down on 22 September 2025. The coroner determined no care issues arose. |
| H0565/2024 | Emmerton Park Aged Care Services & NWRH | Findings handed down on 29 September 2025. The coroner determined no care issues arose. |
| H0980/2024 | Home & RHH | Findings handed down on 1 October 2025. The coroner determined no care issues arose. |
| H0213/2024 | Strathhaven RACF & RHH | Findings handed down on 2 October 2025. The coroner determined no care issues arose. |
| H0004/2024 | Huon Reginald Car, RHH & Roy Fagan Centre | Findings handed down on 13 October 2025. The coroner determined no care issues arose. |
| H0540/2023 | Home & RHH | Findings handed down on 14 October 2025. The coroner determined no care issues arose. |
| H0080/2025 | Meercroft Care Inc | Findings handed down on 14 October 2025. The coroner determined no care issues arose. |
| H0112/2024 | Home & RHH | Findings handed down on 17 October 2025. The coroner determined no care issues arose. |
| L0120/2023 | Mount Esk Aged Care | Findings handed down on 22 October 2025. The coroner determined no care issues arose. |
| H0212/2023 | Barossa Park Lodge | Findings handed down on 27 October 2025. The coroner determined no care issues arose. |
| L0002/2024 | Home & LGH | Findings handed down on 29 October 2025. The coroner determined no care issues arose. |
| H0331/2024 | Royal Hobart Hospital | Findings handed down on 4 November 2025. The coroner determined no care issues arose. |
| H0329/2024 | Community & RHH | Findings handed down on 5 November 2025. The coroner determined no care issues arose. |
| H0455/2024 | Home & NWRH | Findings handed down on 2 December 2025. The coroner determined no care issues arose. |
| H0267/2023 | Uniting Aged Well Strathhaven RACF | Findings handed down on 12 December 2025. The coroner determined no care issues arose. |
| H0716/2024 | Home & LGH | Findings handed down on 13 January 2026. The coroner determined no care issues arose. |
| H0808/2024 | Home & RHH | Findings handed down on 13 January 2026. The coroner made the following recommendation. That the Royal Hobart Hospital review its communication processes, and make any necessary improvement, to ensure that a patient's goals of care are adequately notified to all relevant treating staff. |
| H0744/2024 | Fairway Rise RACF | Findings handed down on 14 January 2026. The coroner determined no care issues arose. |
| H0885/2024 | Regis Nursing Home | Findings handed down on 14 January 2026. The coroner determined no care issues arose. |
| H0577/25 | Home & Whittle Ward | Findings handed down on 20 January 2026. The coroner determined no care issues arose. |
| H0171/2025 | Huon Reginald Care RACF | Findings handed down on 20 January 2026. The coroner determined no care issues arose. |
| H0164/2025 | Home, Calvary & RHH | Findings handed down on 21 January 2026. The coroner determined no care issues arose. |
| H0537/2024 | Fairway Rise RACF | Findings handed down on 22 January 2026. The coroner determined no care issues arose. |
| H0260/2023 | Home | Findings handed down on 22 January 2026. The coroner determined no care issues arose. |
| H0150/2023 | Home & RHH | Findings handed down on 23 January 2026. The coroner determined no care issues arose. |
| L0313/2023 | Home & LGH | Findings handed down on 23 January 2026. The coroner commented that the circumstances surrounding the hospitalisation indicate the importance of ensuring high quality and timely reporting of patient imaging. |
| H0174/2025 | Home & NWRH | Findings handed down on 23 January 2026. The coroner determined no care issues arose. |
| H0467/2025 | Home & NWRH | Findings handed down on 23 January 2026. The coroner determined no care issues arose. |
| H0497/2025 | Home & RHH | Findings handed down on 23 January 2026. The coroner determined no care issues arose. |
| H0705/2024 | Community & RHH | Findings handed down on 27 January 2026. The coroner determined no care issues arose. |
| H0609/2025 | Home & NWRH | Findings handed down on 28 January 2026. The coroner determined no care issues arose. |
| H0173/2025 | Melaleuca & NWRH | Findings handed down on 30 January 2026. The coroner determined no care issues arose. |
| H0192/2025 | Calvary Sandhill RACF | Findings handed down on 30 January 2026. The coroner determined no care issues arose. |
| H0334/2024 | Uniting AgeWell Aldersgate Village RACF | Findings handed down on 2 February 2026. The coroner determined no care issues arose. |
| H0838/2025 | Home & RHH | Findings handed down on 3 February 2026. The coroner determined no care issues arose. |
| H0815/2025 | Home & NWRH | Findings handed down on 3 February 2026. The coroner determined no care issues arose. |
| H0637/2025 | Home & RHH | Findings handed down on 3 February 2026. The coroner determined no care issues arose. |
| H0417/2024 | Home & LGH | Findings handed down on 4 February 2026. The coroner determined no care issues arose. |
| H0525/2025 | Home & RHH | Findings handed down on 4 February 2026. The coroner determined no care issues arose. |
| H0343/2024 | Home & RHH | Findings handed down on 4 February 2026. The coroner determined no care issues arose. |
| H0591/2025 | Home & RHH | Findings handed down on 10 February 2026. The coroner determined no care issues arose. |
| H0372/2025 | Home & Midlands Multi Purpose Centre | Findings handed down on 10 February 2026. The coroner determined no care issues arose. |
| H0450/2025 | Home & MCH | Findings handed down on 11 February 2026. The coroner determined no care issues arose. |
| H0684/2025 | Respect RACF & RHH | Findings handed down on 16 February 2026. The coroner determined no care issues arose. |
| H0847/2025 | Home & NWRH | Findings handed down on 17 February 2026. The coroner determined no care issues arose. |
| H0905/2025 | Home & RHH | Findings handed down on 18 February 2026. The coroner determined no care issues arose. |
| L0098/2023 | NWRH | Findings handed down on 19 February 2026. The coroner made comments around improvements in relation to quarterly audits to ensure falls were reviewed by FET. |
| H0144/2024 | MCH | Findings handed down on 24 February 2026. The coroner determined no care issues arose. |
| H0141/2024 | Home & RHH | Findings handed down on 24 February 2026. The coroner made the following recommendation, I recommend that the Royal Hobart Hospital, at appropriate intervals, reviews the operation and efficacy of its assessments and prevention strategies. |
| H0432/2024 | Southern Cross Care RACF & RHH & AT | Findings handed down on 2 March 2026. The coroner determined no care issues arose. |
| H0843/2024 | Home & RHH | Findings handed down on 3 March 2026. The coroner determined no care issues arose. |
| H0622/2025 | Derwent Views RACF | Findings handed down on 3 March 2026. The coroner determined no care issues arose. |
| H0852/2025 | RHH | Findings handed down on 6 March 2026. The coroner determined no care issues arose. |
| H0912/2024 | Glenview RACF & RHH | Findings handed down on 10 March 2026. The coroner determined no care issues arose. |
| H0451/2025 | One Care Bishop Davies Court RACF | Findings handed down on 13 March 2026. The coroner determined no care issues arose. |
| H0346/2024 | Mount Esk Aged Care RACF & LGH | Findings handed down on 13 March 2026. The coroner determined no care issues arose. |
| H0027/2026 | Home & RHH | Findings handed down on 23 March 2026. The coroner determined no care issues arose. |
| H0379/2024 | Home | Findings handed down on 13 April 2026. The coroner determined no care issues arose. |
| H0158/2026 | Home | Findings handed down on 11 May 2026. The coroner determined no care issues arose. |
| H0084/2026 | RHH | Findings handed down on 12 May 2026. The coroner determined no care issues arose. |
| H0278/2024 | Home & MCH | Findings handed down on 19 May 2026. The coroner determined no care issues arose. |
| H0258/2025 | Home & RHH | Findings handed down on 21 May 2026. The coroner determined no care issues arose. |
| H0849/2024 | One Care Bishop Davies Court RACF | Findings handed down on 22 May 2026. The coroner determined no care issues arose. |
| H0593/2023 | Lady Clarke Retirement Village | Findings handed down on 22 May 2026. The coroner determined no care issues arose. |
| L0357/2023 | Respect Fred French Home (RACF) | Findings handed down on 25 May 2026. The coroner determined no care issues arose. |
| H0111/2026 | Home | Findings handed down on 29 May 2026. The coroner determined no care issues arose. |
Falls Stats 23/24
During the reporting period, being the 12 months 1 July 2023 - 30 June 2024, 125 findings were handed down in relation to elderly falls, of which 66 were in relation to females and 59 in relation to males. These figures are very similar to the last financial year when 128 findings were handed down in the same period.
This table represents a list of coronial findings in respect of deaths of older persons occurring accidentally from falls or injuries in a nursing home, medical setting, hospital, or in their own home.
In each of these cases the coroner investigates the circumstances of the fall or injury sufficiently to enable a determination regarding whether there are any issues surrounding the care and treatment, connected to the death.
These investigations include a requirement that the aged care facility provide answers to questions regarding falls risks assessment and preventative measures implemented and an independent examination by Kevin Egan regarding any possible issues. On occasion the coroners may also seek a medical review of the treatment provided undertaken by the coronial medical consultant Dr Anthony J Bell.
| Local Case Number | Location | Investigation details |
|---|---|---|
| L0283/2018 | Home |
Inquest Findings handed down on 6 July 2023.
See above summary provided in Inquests. |
| H0018/2023 | Home |
Findings handed down on 14 July 2023.
The coroner determined no care issues arose. |
| H0025/2023 | Home |
Findings handed down on 14 July 2023.
The coroner determined no care issues arose. |
| L0118/2023 | Home |
Findings handed down on 14 July 2023.
The coroner determined no care issues arose. |
| L0008/2023 | Toosey Nursing Home |
Findings handed down on 17 July 2023.
The coroner determined no care issues arose. |
| L0158/2023 | Home |
Findings handed down on 26 July 2023.
The coroner determined no care issues arose. |
| L0101/2023 | Home |
Findings handed down on 1 August 2023.
The coroner determined no care issues arose. |
| L0306/2022 | Home | Findings handed down on 2 August 2023. The coroner made the following comment pursuant to Section 28 of the Coroners Act 1995: that it is important all members of the medical staff of all hospitals familiarise themselves with the requirements under the Coroners Act 1995. |
| L0149/2021 | Japara Nursing Home | Findings handed down on 7 August 2023. As a result of the investigation the following recommendation was made. In circumstances where a resident has been assessed as requiring a sensor mat, that he or she is to wear appropriate footwear and/or nonslip socks and that he or she is not to mobilise independently, the Japara Riverside Views ensure such recommendations are implemented at all times. |
| L0219/2021 | Home |
Findings handed down on 7 August 2023.
The coroner determined no care issues arose. |
| H0147/2021 | Guilford Young Grove |
Findings handed down on 8 August 2023.
The coroner commented to remind all RACF’s that where a resident is assessed as requiring a movement sensor alarm, they are to ensure that alarm is in place and switched on when a resident is either resting/and or sleeping alone in his or her room or unit. |
| H0226/2021 | Freemasons Lindisfarne |
Findings handed down on 14 August 2023.
The coroner determined no care issues arose. |
| H0259/2021 | Glenview Korongee |
Findings handed down on 14 August 2023.
The coroner determined no care issues arose. |
| H0362/2021 | Home |
Findings handed down on 14 August 2023.
The coroner determined no care issues arose. |
| H0144/2021 | Southern Cross Aged Care |
Findings handed down on 15 August 2023.
The coroner determined no care issues arose. |
| H0334/2021 | Home |
Findings handed down on 15 August 2023.
The coroner determined no care issues arose. |
| H0081/2023 | Home |
Findings handed down on 16 August 2023. The coroner determined no care issues arose. |
| H0184/2023 | Home |
Findings handed down on 17 August 2023.
The coroner determined no care issues arose. |
| H0011/2022 | Home |
Findings handed down on 18 August 2023.
The coroner agreed that the RCA conducted by THS concluded there was a ‘delay to definitive management, treatment and patient centered care which contributed to the death of an elderly trauma patient’. |
| H0083/2023 | Home |
Findings handed down on 21 August 2023. The coroner determined no care issues arose. |
| H0038/2023 | Rosary Gardens |
Findings handed down on 22 August 2023.
The coroner determined no care issues arose. |
| H0147/2023 | Queen Victoria |
Findings handed down on 23 August 2023. The coroner determined no care issues arose. |
| H0187/2023 | Home |
Findings handed down on 23 August 2023.
The coroner determined no care issues arose. |
| H0180/2023 | Home |
Findings handed down on 23 August 2023.
The coroner determined no care issues arose. |
| H0112/2021 | Freemasons Lindisfarne |
Findings handed down on 25 August 2023.
The coroner determined no care issues arose. |
| L0329/2021 | Home |
Findings handed down on 25 August 2023.
The coroner determined no care issues arose. |
| H0183/2023 | Southern Cross Care |
Findings handed down on 28 August 2023.
The coroner determined no care issues arose. |
| H0472/2022 | Wellington Views Aged Care |
Findings handed down on 28 August 2023.
The coroner determined no care issues arose. |
| L0169/2023 | Community |
Findings handed down on 28 August 2023.
The coroner determined no care issues arose. |
| L0132/2022 | Regis Aged Care |
Findings handed down on 31 August 2023.
The coroner determined no care issues arose. |
| L0115/2023 | Home |
Findings handed down on 1 September 2023.
The coroner determined no care issues arose. |
| H0141/2020 | Royal Hobart Hospital |
Findings handed down on 12 September 2023.
The coroner determined no care issues arose. |
| L0312/2021 | Home |
Findings handed down on 12 September 2023.
The coroner determined no care issues arose. |
| H0222/2023 | Home |
Findings handed down on 15 September 2023.
The coroner determined no care issues arose. |
| L0201/2023 | Tyler Village |
Findings handed down on 15 September 2023.
The coroner determined no care issues arose. |
| L0175/2023 | Umina Park Nursing Home |
Findings handed down on 18 September 2023.
The coroner determined no care issues arose. |
| H0240/2023 | Home |
Findings handed down on 19 September 2023.
The coroner determined no care issues arose. |
| L0314/2022 | Aminya May Shaw |
Findings handed down on 22 September 2023.
The coroner determined no care issues arose. |
| H0031/2023 | Home |
Findings handed down on 25 September 2023.
The coroner determined no care issues arose. |
| H0226/2023 | Home |
Findings handed down on 25 September 2023.
The coroner determined no care issues arose. |
| L0188/2023 | Home |
Findings handed down on 26 September 2023.
The coroner determined no care issues arose. |
| L0071/2023 | North West Regional Hospital |
Findings handed down on 26 September 2023.
The coroner determined no care issues arose. |
| H0100/2022 | Community |
Findings handed down on 4 October 2023.
The coroner commented that appropriate initiatives may go some way to increasing the availability of wheelchair-accessible taxis and thus preventing similar circumstances to those that led to Mr East embarking upon a risky journey in his own wheelchair. |
| H0042/2022 | Bishop Davies Court |
Findings handed down on 9 October 2023.
The coroner determined no care issues arose. |
| H0054/2022 | Strathglen |
Findings handed down on 9 October 2023.
The coroner determined no care issues arose. |
| H0347/2021 | Royal Hobart Hospital |
Findings handed down on 11 October 2023.
The coroner commented that it would be prudent in cases where a patient is admitted to the RHH soon after discharge from another hospital, that the treating staff at the RHH should contact the doctor at the other hospital under whose care the patient was admitted. |
| L0261/2023 | Home |
Findings handed down on 20 October 2023.
The coroner determined no care issues arose. |
| L0298/2023 | Home |
Findings handed down on 20 October 2023.
The coroner determined no care issues arose. |
| H0125/2023 | Home |
Findings handed down on 23 October 2023.
The coroner determined no care issues arose. |
| Valma Tweedie | Desmond Wood Facility |
Inquest Findings handed down on 23 October 2023. See above summary provided in Inquests. |
| H0056/2022 | Home |
Findings handed down on 30 October 2023. The coroner determined no care issues arose. |
| L0045/2022 | Home |
Findings handed down on 30 October 2023. The coroner determined no care issues arose. |
| H0039/2023 | St Anns Homes |
Findings handed down on 1 November 2023. The coroner determined no care issues arose. |
| H0337/2022 | Hobart Private Hospital |
Findings handed down on 1 November 2023. The coroner determined no care issues arose. |
| L0248/2023 | Respect Tyler Village |
Findings handed down on 3 November 2023. The coroner determined no care issues arose. |
| H0059/2022 | Home |
Findings handed down on 6 November 2023. The coroner determined no care issues arose. |
| H0061/2022 | Huon Regional Care |
Findings handed down on 13 November 2023. The coroner determined no care issues arose. |
| H0288/2023 | Home |
Findings handed down on 13 November 2023. The coroner determined no care issues arose. |
| H0418/2022 | Huon Regional Care |
Findings handed down on 13 November 2023. The coroner commented that imaging of the thorax should have been performed on Mrs Braim when she presented to hospital on the first occasion. |
| H0238/2023 | Home |
Findings handed down on 15 November 2023. The coroner determined no care issues arose. |
| H0294/2023 | Home |
Findings handed down on 16 November 2023.
The coroner determined no care issues arose. |
| L0329/2023 | Home and LGH |
Findings handed down on 16 November 2023.
The coroner determined no care issues arose. |
| H0063/2022 | Sandown Apartments and Aged Care Facility |
Findings handed down on 17 November 2023. The coroner determined no care issues arose. |
| H0070/2022 | Glenview Home for the Aged |
Findings handed down on 20 November 2023.
The coroner determined no care issues arose. |
| H0271/2023 | Home |
Findings handed down on 20 November 2023.
The coroner determined no care issues arose. |
| H0340/2022 | Royal Hobart Hospital |
Findings handed down on 21 November 2023.
The coroner determined no care issues arose. |
| H0032/2023 | Korongee |
Findings handed down on 22 November 2023.
The coroner determined no care issues arose. |
| L0308/2023 | Home |
Findings handed down on 22 November 2023.
The coroner determined no care issues arose. |
| L0267/2023 | Coroneagh Park and NWRH |
Findings handed down on 24 November 2023.
The coroner determined no care issues arose. |
| H0040/2023 | Bupa Aged Care |
Findings handed down on 28 November 2023.
The coroner determined no care issues arose. |
| H0208/2022 | Home |
Findings handed down on 29 November 2023. The coroner determined no care issues arose. |
| H0137/2023 | United Age Well |
Findings handed down on 11 December 2023. The coroner determined no care issues arose. |
| H0196/2023 | Home |
Findings handed down on 12 December 2023.
The coroner determined no care issues arose. |
| L0055/2022 | Home |
Findings handed down on 14 December 2023.
The coroner determined no care issues arose. |
| L0131/2023 | Home and LGH |
Findings handed down on 14 December 2023.
The coroner determined no care issues arose. |
| H0037/2023 | Home |
Findings handed down on 14 December 2023.
The coroner determined no care issues arose. |
| H0143/2023 | Glenview, Koronogee Village |
Findings handed down on 14 December 2023.
The coroner determined no care issues arose. |
| H0512/2023 | Home |
Findings handed down on 15 December 2023.
The coroner determined no care issues arose. |
| L0315/2023 | Home and NWRH |
Findings handed down on 15 December 2023.
The coroner determined no care issues arose. |
| H0315/2023 | Home |
Findings handed down on 15 December 2023.
The coroner determined no care issues arose. |
| L0234/2023 | Umina Park Nursing Home |
Findings handed down on 18 December 2023.
The coroner commented that the care Mr Reeve received at Umina Park Residential Aged Care Facility was not an acceptable standard and likely contributed to the fall that caused his death. |
| L0376/2023 | Home and NWRH |
Findings handed down on 19 January 2024.
The coroner determined no care issues arose. |
| L0386/2023 | Community |
Findings handed down on 22 January 2024.
The coroner determined no care issues arose. |
| L0380/2023 | Home and LGH |
Findings handed down on 22 January 2024.
The coroner determined no care issues arose. |
| H0334/2022 | Barrington Lodge |
Findings handed down on 23 January 2024.
The coroner determined no care issues arose. |
| H0608/2023 | Home |
Findings handed down on 29 January 2024.
The coroner determined no care issues arose. |
| L0238/2023 | One Care Port Sorell |
Findings handed down on 1 March 2024.
The coroner determined no care issues arose. |
| L0385/2023 | Tyler Village Respect Aged Care and LGH |
Findings handed down on 2 March 2024.
The coroner determined no care issues arose. |
| H0239/2023 | Barossa Park Lodge |
Findings handed down on 4 March 2024.
The coroner determined no care issues arose. |
| L0367/2023 | Home, MCH and NWRH |
Findings handed down on 5 March 2024.
The coroner determined no care issues arose. |
| H0458/2022 | Home |
Findings handed down on 6 March 2024.
The coroner determined no care issues arose. |
| H0579/2023 | Home |
Findings handed down on 6 March 2024.
The coroner determined no care issues arose. |
| L0068/2023 | Rubicon Grove Nursing Home |
Findings handed down on 8 March 2024.
The coroner determined no care issues arose. |
| H0279/2023 | Regis Nursing Home |
Findings handed down on 11 March 2024.
The coroner determined no care issues arose. |
| H0617/2023 | Home |
Findings handed down on 14 March 2024.
The coroner determined no care issues arose. |
| H0605/2023 | Home |
Findings handed down on 14 March 2024.
The coroner determined no care issues arose. |
| H0552/2023 | Home |
Findings handed down on 15 March 2024.
The coroner determined no care issues arose. |
| H0621/2023 | Home and RHH |
Findings handed down on 20 March 2024.
The coroner determined no care issues arose. |
| L0307/2023 | Home |
Findings handed down on 21 March 2024.
The coroner determined no care issues arose. |
| L0448/2023 | Home and LGH |
Findings handed down on 10 April 2024.
The coroner determined no care issues arose. |
| H0612/2023 | Home |
Findings handed down on 16 April 2024.
The coroner determined no care issues arose. |
| L0263/2023 | Umina Park |
Findings handed down on 16 April 2024.
The coroner determined no care issues arose. |
| L0435/2023 | Home |
Findings handed down on 17 April 2024.
The coroner determined no care issues arose. |
| H0182/2022 | Barossa Lodge |
Findings handed down on 18 April 2024.
The coroner determined no care issues arose. |
| H0192/2022 | Barossa Lodge |
Findings handed down on 23 April 2024.
The coroner determined no care issues arose. |
| H0623/2023 | Home |
Findings handed down on 29 April 2024.
The coroner determined no care issues arose. |
| L0311/2011 | Community |
Findings handed down on 2 May 2024.
The coroner recommended that a much larger sign in very bold and distinctive colour warning of the presence of the steps be erected in both directions. |
| H0565/2023 | Home and NWRH |
Findings handed down on 6 May 2024.
The coroner determined no care issues arose. |
| H0269/2023 | Home and RHH |
Findings handed down on 6 May 2024.
The coroner determined no care issues arose. |
| H0611/2023 | Home and RHH |
Findings handed down on 23 May 2024.
The coroner determined no care issues arose. |
| H0601/2023 | Home and RHH |
Findings handed down on 5 June 2024.
The coroner determined no care issues arose. |
| H0029/2024 | Community and RHH |
Findings handed down on 5 June 2024.
The coroner determined no care issues arose. |
| L0383/2023 | Meercroft Care |
Findings handed down on 6 June 2024.
The coroner determined no care issues arose. |
| H0308/2023 | Calvary Hospital and Mary Ogilvy Home |
Findings handed down on 7 June 2024.
The coroner determined no care issues arose. |
| H0076/2024 | Home |
Findings handed down on 7 June 2024.
The coroner determined no care issues arose. |
| H0625/2023 | Home |
Findings handed down on 11 June 2024.
The coroner determined no care issues arose. |
| H0070/2024 | Home |
Findings handed down on 13 June 2024.
The coroner determined no care issues arose. |
| L0450/2023 | Home and LGH |
Findings handed down on 18 June 2024.
The coroner determined no care issues arose. |
| H0576/2023 | Respect Mt St Vincent, MCH and RHH |
Findings handed down on 19 June 2024.
The coroner determined no care issues arose. |
| H0568/2023 | Regis Tasmania |
Findings handed down on 20 June 2024.
The coroner determined no care issues arose. |
| L0449/2023 | Rubicon Grove |
Findings handed down on 20 June 2024.
The coroner determined no care issues arose. |
| H0569/2023 | Home |
Findings handed down on 21 June 2024.
The coroner determined no care issues arose. |
| L0377/2023 | Respect Peace Haven |
Findings handed down on 21 June 2024.
The coroner determined no care issues arose. |
| H0001/2024 | Regis Eastern Shore |
Findings handed down on 25 June 2024.
The coroner determined no care issues arose. |
| H0069/2024 | Home and RHH |
Findings handed down on 28 June 2024.
The coroner determined no care issues arose |