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[2021] WACOR 18 Page 2 Coroners Act 1996 (Section 26(1)) AMENDED RECORD OF INVESTIGATION INTO DEATH I, Philip John Urquhart, Coroner, having investigated the death of a female child referred to as Child AM with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 26 - 27 November Mixed Drug toxicity, Mental Health Plan, Schedule 8 substances, Drug Intoxication, Borderline Personality Disorder, Anxiety Disorder. chronic alcoholism and emphysema, Mixed prescription drug toxicity, accidental overdose, drugs & alcohol, central nervous system depressants, lung disease, physical health, pharmaceutical services branch, Poisons Act 1971, schedule 8 narcotic substances, Drowning, rock fishing, not wearing a personal floatation device, PFD, Boltons Beach, Triabunna, Coroner's comment, Coroner's recommendation, Long term missing person, 1985, cause of death unknown, circumstances unknown, Tasmania Police Missing Persons Unit, Queensland, Inquest, falls, domestic incident, older persons, Ambulance Tasmania, paramedic, transport not required, transport refused, subdural heamatoma, Royal Hobart Hospital, recommendations, Inquest, drugs & alcohol, misadventure, water related, drowning and intoxication with methamphetamine and other substances, Little Howrah Beach, Launceston General Hospital, sepsis, Medical Certificate of Death, Office of the Health Complaints Commissioner, poor medical treatment, entirely avoidable death, Inquest, falls, older persons, elderly persons, Royal Hobart Hospital, application pursuant to section 58 of the Coroners Act 1995, investigation re-opened, Coroner's comment, high falls risk, aspiration pneumonia, National Disability Insurance Scheme, NDIS, palliative care, epilepsy, brain injury. Water related, long term missing person, suspected death, undetermined cause of death, disappearance, intoxication, Fisherman's Wharf, Strahan. All rights reserved. Unreported judgments of the Supreme Court of Tasmania are available on AustLII (Australian Legal Information Institute). This includes rapid reversal requirements and perioperative management. Gemma was appointed acting Deputy CEO in 2019, Deputy CEO in 2020 and then Acting CEO on Greg Shanahan's retirement in November 2020. news / 26 August 2021. We then focus on specific rollover awareness factors during both our mentoring as well as our refresh programs. Coronial, single motor vehicle crash, multiple injuries, Toyota HiLux Utility, paddock, blunt trauma to the head, neck, thorax and arms, skull fractures, brusing of both lungs. The PWS Arthur River Visitor Centre is trialling selling sand flags to the public. Coroners Court Coronial Findings 2022-2023 Coronial Findings 2019-2021 Coronial Findings 2016-2018 Coronial Findings 2013-2015 Information for families Coronial Practice Handbook Tasmanian Suicide Register Contact the coroner's office Frequently Asked Questions A Health Practitioner's guide for writing a statement for the Coroner. The Networks goals include producing national data concerning domestic and family violence related homicides in accordance with the National Plan to Reduce Violence Against Women and their Children 2009-2021. Questions concerning its content can be sent by email to tasmania.police@police.tas.gov.au or by mail to GPO Box 308, Hobart, Tasmania, Australia 7001. Coronial, stairs, step, fall, head injuries, blunt force. The APCA Recreational Driving Guide, available to all Recreational Driver Pass holders, already contained advice to install sand flags under. Decision of Deputy State Coroner Forbes. the details needed to register the death with the Registry of Births, Deaths and Marriages. Transport & Traffic Related, Motor Vehicle Crash, Traumatic Injuries, Crash Investigation, East Tamar Highway, Inattention, Wire Rope Barrier. The coroner sits on the bench at the front of the courtroom, and lawyers sit facing them on another table. An Inquest sittings list for the Coroners Court is posted online at the end of every month (note: the list is subject to change). Decision of Deputy State Coroner Truscott, Coronial law, cause and manner of death, NSW trains removal of passenger, NSW Police Powers re intoxicated persons, CORONIAL LAW - Mandatory inquest - homicide by known persons since deceased - s.78, Coronial law, cause and manner of death, First Nations Patients, palliative care, death in corrections custody, Justice Health, care and treatment, CORONIAL LAW - s.27 (1) (a) Coroners Act 2009 - death as a result of homicide by a known person - mandatory inquest, CORONIAL LAW - death by hanging of a person in custody - was mental health care of an appropriate standard - should a mandatory notification have been made - access to rope and hanging points - adequacy of health information sharing -, CORONIAL LAW - death by hanging of a person in lawful custody - frequency of medication reviews - reduction of hanging points at Long Bay Correctional Centre, CORONIAL LAW - unidentified human remains, Eastern bank of the MacDonald River, near Wrights Creek Road St Albans NSW, CORONIAL LAW - death in custody, mandatory inquest, cause and manner of death, natural causes, CORONIAL LAW - cause and manner of death, laryngectomy, tracheal stenosis, respiratory rate, respiratory distress, alteration of calling criteria, Clinical Emergency Response System, vital sign observations, CORONIAL LAW - natural causes death of a person in lawful custody - was medical care and treatment appropriate. To find out more about inquests, go to the Northern Territory Government website. abc.net.au/news/kirra-lea-mcloughlin-coronial-inquest-findings/100194632 A coroner has found that a 27-year-old woman, whose death has been unsolved for almost seven years, lost her life at the hands of her de facto partner, describing him as a "habitual perpetrator" of domestic abuse. Inquest files are reports and associated . The coroner may comment and make recommendations about public health or safety, or the administration of justice, to help prevent similar deaths and incidents from happening again. DELIVERED AT: Darwin . I Found the Person I Was Looking For, What Now? FILE NO(s): D34/2020 . Aishwarya Aswath died on Easter Saturday 2021, hours after presenting to the Perth Children's Hospital emergency department with a fever and . The Magistrates Court (Coronial Division) publishes a small but important amount of records of investigations and findings. Transport and traffic related, St Helens, Coroner's finding, joint inquest, child and infant death, youth, transport and traffic related, Child Safety Services, Department of Communities, Tasmania, child protection systems, Sudden Unexpected Death in Infancy, co-sleeping, drowning, motor vehicle crash, exposure to risk, Drowning, River Derwent, Mental Illness and Health, Child and Infant Death, Sepsis, Royal Hobart Hospital, motor vehicle accident, transport and traffic related, epilepsy, suspended licence, medically unfit to drive, driving unlicenced, Risdon Road. Response from Tasmania Health Service Statewide and Mental Health Services received 8 March 2022. These types of deaths are called reportable deaths. Prior to discharge an appointment with the GP is to be made at a time asap after the patient returns to King Island. Findings and upcoming inquests - Coroners Court. 2 Exhibit 1, Tab 9. South Arm Highway, transport and traffic related, single vehicle, misadventure, pedestrian walking on road, struck from behind, multiple traumatic injuries, failure to stop and render assistance, alcohol and drugs, DPP, Department of Public Prosecution, driving with suspended licence, Simone Bridges, intentional self harm, mental illness and health, drowning, Howrah, Mental Health Act 2013, Protective Custody Order, involuntary admission, Royal Hobart Hospital, Tasmanian Health Service, alcohol and drugs, accidental death, intravenous injection of prescription medications, injection of crushed tablets intended for oral ingestion, methadone, quetiapine, diazepam, mirtazapine, cannabis, Tasmanian Opiod Pharmacotherapy Program, Transport & traffic related, motor vehicle accident, car crash, multi-organ failure, North West Regional Hospital, failure to properly diagnose. Unreported judgments of the Supreme Court of Tasmania are available on AustLII (Australian Legal Information Institute). We have also engaged the service of a Driver Trainer to provide additional coaching to all our drivers. Two of three deaths at Copper Mines of Tasmania 'avoidable', coroner finds Two of three deaths at Copper Mines of Tasmania 'avoidable', coroner finds By Loretta Lohberger Posted Thu 17 Jun 2021 at 7:29pm The three deaths at the Copper Mines of Tasmania's site occurred within six weeks of each other. Supreme Court Act 1935; District Court Act 1991; Environment, Resources & Development Court Act 1993; Magistrates Court Act 1991; Youth Court Act 1993 This may require viewing multiple records or images. 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.