Publishing a finding is decided on an individual basis, but the coroner may take into account a number of factors: In general, authorised findings for publication will include: Specific findings can be located by entering information in the search box below. Signage has been installed at the entrance to Sandy Cape Track (Temma) and the Arthur Beach Track (Gardiner Point, Arthur River): Quick release adaptors for sand flags were attached to all operational vehicles in the Field Centre likely to operate on the track. The Magistrates Court (Coronial Division) publishes a small but important amount of records of investigations and findings. Tasmania Police has welcomed Coroner Robert Pearces findings into the death of Nicholas Whiteley at Westbury on 22 November 2010. Updated response provided by THS - South 14 October 2022, RHH complies with the state record policy with regard to retention of records, In recognition of the deep history and culture of this Island, we would like to acknowledge and pay our respects to all Tasmanian Aboriginal people; the past and present custodians of the Land. Coronial, death in care, guardianship order, held in care, asphyxia, choking, food, Roy Fagan Centre, Inquest. Coronial, stairs, step, fall, head injuries, blunt force. With the reduced scale of the guard rail installation and favourable rates for the benching and vegetation reduction, the total cost requested from the grantor is $80,086.42, Updated response provided by THS South 14 October 2022. Inquest FindingsInquest Findings 2021. After an inquest, the coroner publishes their findings, which sets out theirdecisions and recommendations. Leisure activity, transport & traffic related, weather related, aircraft crash, private airfield, windsock, coroner's comment & recommendation, Transport and traffic related, weather related, motor vehicle accident, truck, speed, wet weather, improved roadway, advisory signage, Glengarry, aged care, older persons, fall from cliff, possible drowning, Derwent Waters, retirement village, Claremont, undetermined circumstances, Falls, leisure activity, older persons, Mersey Community Hospital, infection, avoidable, Root Cause Analysis, misdiagnosed, Adverse medical effects, Coroner's comment, operation, George Town Hospital, Launceston General Hospital, St. Vincent's Public Hospital, surgery, laparoscopic cholecystectomy, Adverse medical effects, older persons, reversal of Hartmann's procedure, post-operative complications, electrocardiogram, long QT syndrome, St Luke's Hospital, Launceston General Hospital, recommendation, Aged care, falls, older persons, Coroner's comment, bed alarms, Adverse medical effects, falls, leisure activity, older persons, Launceston General Hospital, LGH, undetermined cause of death, mental health and illness, Ambulance Tasmania, Mental Health Services, transport and traffic related, single motor vehicle crash, multiple chest injuries, failure to wear seatbelt, intoxicated, drink driving, drugs and alcohol, coroner's comments, Drowning, leisure activity, fishing, water related, weather related, winter, alcohol related, child and infant death, sudden unexpected death in infancy (SUDI), co-sleeping with parents, potential overlay whilst sleeping, sleeping in adult bed, smoking, unsafe sleeping environment, bronchopneumonia, Child Safety Services, Child Protection Services, Child and Youth Services, Drugs & Alcohol, Transport & Traffic Related, Motor Vehicle Accident, Speeding, Collision, Distraction, Orford, Learner Licence, water related, multiple injuries, personal water craft (PWC), jet ski, Chinaman's Bay, Dunalley, alcohol and drugs, operating a PWC whilst intoxicated, collision with stationary object, Traffic and transport related, youth, single vehicle motorcycle crash, blunt injuries of head, neck and chest, loss of control, sweeping turn, Strathaven Drive Rosetta, transport and traffic related, motor vehicle crash, Longford, Illawarra Road, methylamphetamine, cannabis, driving under influence of illicit substances, Drugs and alcohol, mental illness and health, mixed drug toxicity, respiratory arrest, methadone, diazepam, coroner's finding, coroner's comment, Transport & traffic related, car crash, older persons, Aged care, nursing home, fall, older persons, dementia, person held in care, Royal Hobart Hospital, Roy Fagan Centre, Public Guardian, guardianship order, medical review, Coroner's comments, Missing person, LTMP, unknown cause of death, bones, Launceston, Transport & traffic related, motorcycle crash, blunt force trauma, crash investigation, speed, unroadworthy, Electrocution, work related, Residual Current Devices, portable defibrillator, Coroner's finding, Coroner's recommendation, Coroner's comment, Natural cause death, location, West Tamar Highway, Lanena, older persons, physical health, The Public Trustee, Fall, work related, pulmonary thromboembolus, left medial malleolar fracture, anti-coagulation, risk of DVT and PE, coroner's finding, coroner's comment, Ladder fall, traumatic closed head injuries, working at height, training, home building site, recommendations, Workplace Health and Safety Act 2012, Missing person, water related, recreational fishing, suspected death, disappearance, Transport & traffic related, single vehicle crash, learner's licence, unlicenced, unroadworthy, wet conditions, speed, child survived, crash investigation, Coroner's comments, undetermined cause of death, missing person, Glen Huon, Coroner's finding, coroner's recommendations, gunshot wound, law enforcement, mental illness & health, weapon, police provoked shooting, Tasmania Police, 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, adverse medical effects, hospital death, Mersey Community Hospital, sepsis, failure to remove intravenous cannula, 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, Coroner's finding, long-term missing person, older person, undetermined cause of death, body not located, North-West Tasmania, transport and traffic related, single motor vehicle crash, excessive speed, driving over speed limit, Lilydale, Homicide, murder, assault, stabbing, Devonport, Transport & traffic related, motor vehicle accident, pneumonia, older person, undiagnosed cervical spine fracture, guidelines, Royal Hobart Hospital, transport and traffic related, mobility scooter crash, single vehicle crash, no helmet, loss of control, Falls, older persons, closed head injury, left frontal/temporal subdural haematoma, anticoagulation, reverse anticoagulation protocol, Coroner's finding, Coroner's recommendation, alcohol and drugs, mixed alcohol and drug toxicity, unintentional, Amlodipine, drug interaction, Burnie, Silver Whisper cruise ship, Intentional self-harm, Mental illness & health, older persons, Mental Health Act 2013 (Tas), Mental Health Treatment Order, person held in care, community services, 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, water related, drowning, scuba diving, rebreather, rebreather apparatus, displacement of mouthpiece, Visscher Island, Drowning, water related, Ansons Bay, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety, Drowning, water related, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety, transport and traffic related, motor vehicle collusion, two vehicle crash, failure to take care when overtaking, prime mover, sedan, Bass Highway, Deloraine, multiple injuries, Adverse medical effects, physical health, pulmonary embolism, deep vein thrombosis, prophylactic anticoagulant, Achilles tendon rupture, coroner's finding, coroner's comment, motor vehicle crash, transport and traffic related, Mornington, South Arm Highway, excessive speed, negligent driving, Traffic Act 1925, 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, Transport and traffic related, physical health, heart disease, positional asphyxia, workplace, coroner's finding, coroner's comments, transport and traffic related, motor vehicle accident, motorcycle accident, loss of control, traumatic injuries of head and chest, Kalang Avenue, Transport and traffic related, multiple blunt traumatic injuries, two-vehicle collision, West Tamar Highway, coroner's finding, 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, Transport and traffic related, motorcycle and motor vehicle crash, head-on collision, incorrect lane, multiple traumatic injuries, alcohol, coroner's finding, Transport and traffic related, motor vehicle crash, Domain Highway, multiple blunt injuries, drowning, capsize of boat, Marion Bay, Narrows channel, MAST, marine safety, water related, transport related, manslaughter, assault, subarachnoid haemorrhage, comments on passing sentence, Criminal Code, Transport and traffic related, single motorcycle crash, loss of control, chest and abdominal injuries, drugs and alcohol, unroadworthy, coroner's finding, Transport and traffic related, motorcycle crash, multiple traumatic injuries, drugs and alcohol, lost control, speed, unregistered and unlicensed, rear brake lock, coroner's finding, 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, Adverse medical effects, escherichia coli urosepsis, sepsis, kidney stone surgery, launceston, transport and traffic related, single motorcycle crash, Smithton, school zone, excessive speed, un-roadworthy vehicle, drug and alcohol, methamphetamine, Transport and traffic related, motorcycle and vehicle crash, blunt traumatic injuries, overtaking, following too closely, poor riding, coroner's finding, Transport and traffic related, motorcycle and vehicle crash, chest injuries, incorrect side of road, cornering technique, crosswinds, high risk of death, coroner's finding, 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, Transport and traffic related, motorcycle and motor vehicle crash, speed and alcohol, diffuse head injury, unroadworthy, coroner's finding, coroner's comment, missing person, suspected intentional self harm, undetermined cause of death, body not located, Bakers Beach, northern Tasmania, coroner's comments, ruling on evidence, whether evidence within scope of inquest, adolescent mental health, Tasmania, Liam Mead inquest, Coroners Act 1995 (Tas), 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, homicide, assault, asphyxia, Bridgewater, Darren Dobson, strangulation/choking, coroner's recommendations, recommendation of enactment of indictable offence of choking, suffocation or strangulation, Two vehicle collision, transport and traffic related, multiple injuries, coroner's finding, Aspiration of gastric contents following vomiting, aged care, mental illness and health, older person, coroner's finding, inquest, child and infant death, global hypoxic brain injury, cessation of breathing, family violence context, non-accidental injury, rib fractures, transport and traffic related, intentional self harm, head injuries, mental health and illness, driver, intentionally driving into path of oncoming vehicle, Latrobe, Transport & traffic related, motorcycle and car collision, alcohol & drugs, Brooker Highway, Hanging, intentional self-harm, mental illness and health, drugs and alcohol, Coroner's finding, hypothermia, Overland Track, Lake St Clair, Parks and Wildlife Service, coroner's recommendations, bushwalker, winter inadequately equipped, 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, Coroner's finding, transport & traffic related, motorcycle crash, multiple injuries, Drowning, water related, coroner's finding, fishing vessel, dinghy capsize, Coroner's finding, coroner's recommendation, head and chest injuries, Metro, pedestrian struck by bus, transport & traffic related, Mixed drug toxicity, serotonin syndrome, sertraline, tramadol, SSRIs, drugs & alcohol, coroner's finding, hospital death, abdominal aortic aneurysm (AAA), Royal Hobart Hospital, chimney vascular repair procedure, advanced coronary artery and peripheral vascular disease complicating repair, Urosepsis, pyelonephritis, lissencephaly, Royal Hobart Hospital, UTI, incorrect diagnosis, coroner's finding, coroner's recommendation, hospital related death, adverse medical affects, Smithton District Hospital, ischaemic small bowel, bowel obstruction, Crohn's disease, Coroner's finding, coroner's recommendations, adverse medical effects, PPI, gastrointestinal bleed, death review, Pulmonary thromboemboli, deep vein thrombosis, hip replacement, physical health, Coroner's finding, hospital death, Royal Hobart Hospital, Hobart Private Hospital, colonic cancer, hemicolectomy, sepsis, delayed diagnosis, 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, Industrial accident, blunt force, blunt trauma, pedestrian, hit by utility vehicle, chest and abdomen.
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