Coronial findings and recommendations - coroners.nsw.gov.au Coronial findings To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. Spencer Clinic will need to liaise with the King Island Heath Services to arrange. Citations help you keep track of places you have searched and sources you have found. Coroner finds 'habitual' abuser and de facto partner caused Kirra-Lea The relevant Medical Officer will write the discharge appointment in the DMR as King Island Health Services can access these details. [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 Patients should not be discharged from Spencer Clinic on Fridays to travel to King Island on the same day. We will use your rating to help improve the site. This is also called a public court hearing. Council Building, Daly River, Angel Blanco-Puerto, Phillip Lindsay, Barry Gaykamangu and Hannu Kononen, Erfinna Patricia Lay and John Weston Quirk, Raymond Curtain, Terrence Westwood, Gerald Thompson, Gregory Westerman, Graham Dearden and Ruth Vincent, Kumanjay Presley, Kunmanara Coulthard and Kunmanara Brumby, Jade Lange-Loades, Rory Lange-Loades and Nathaniel Rose, Glen Anthony Huitson and Rodney William Ansell, Matthew Neck, Amanda Bell and Matthew Batson, Gary Peter Tipungwuti, Patrick Raymond Kerinauia, Noeline Pauantulura, John Gerard Orsto, T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run). Mixed Drug toxicity, Mental Health Plan, Schedule 8 substances, Drug Intoxication, Borderline Personality Disorder, Anxiety Disorder. In such an investigation the police officers are acting for, and under the control of, the Coroner. 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. A recent meeting with the Director of Nursin at the King Island Health service and Senior Nursing staff of the North West Regional Hospital clarified the process surrounding the discharge of patients from Spencer Clinic Inpatient Ward to King Island. It is appropriate and timely to review the Model, which is an integral part of our policing strategy, said Acting Deputy Commissioner, Donna Adams. Coronial, Suicide, Asphyxia, Smoke inhalation, Caravan, Fire, natural cause death, death in custody, Coroners Act 1995, Risdon Prison, dilated cardiomyopathy, emphysema, Correctional Primary Health, natural cause death, death in custody, Coroners Act 1995, Risdon Prison, Royal Hobart Hospital, Whittle Ward, metastatic squamous cell carcinoma of the lung, coronial, hospital, heart disease, ischaemic heart disease, single vessel atherosclerosis, Drowning, intentional self-harm, coroner's finding, coroner's recommendations, Pulmonary thromboembolism, deep vein thrombosis, D-dimer, Wells score, PERC, Coroner's recommendation, Coronial, atherosclerotic, hypertensive, cardiovascular disease, hospital, Launceston General Hospital, obesity, hypertension, complications of health care, missed or incorrect diagnosis, Head injury, cliff fall, hazardous area, Blackmans Bay blowhole, safety, public area, Coroner's recommendations, transport and traffic related, motor vehicle accident, two vehicle crash, Lilydale Road, adverse weather conditions, poor condition of road, excessive speed for conditions, Coronial, Findings, Inquest, Death in care, Royal Hobart Hospital, Fall from standing Position/ Height, Complication of Left Femur Fracture, Coronial, Findings, Meningococcal, immunisation, disease, A, C,Y, W and B Strain, Neisseria meningitides, bacterial sepsis, hospital, drowning, water related, Mersey Bluff, Devonport, youth, Surf Life Saving, coroner's recommendation, surf rescue, swimming, leisure activity, Homicide & assault, murder, stabbing, coroner's finding, restraint order, coronial, drowning, wharf, fall, alcohol, intoxication, water, older persons, abdominal aortic aneurysm (AAA), haemoperitoneum/retroperitoneal haematoma, Royal Hobart Hospital Emergency Department, falls, undetermined cause of death, undetermined circumstances of death, Tasmania Police, incomplete investigation, Tasmania Police Manual, Forensic Services, forensic evidence, coroner's comments. Wednesday, 22 May 2013 - 5:16 pm. 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. 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. Councils Operations Manager, a qualified engineer, was charged with investigating improvements to the road. This may require viewing multiple records or images. Inquest, acute subdural haematoma, drugs & alcohol, assault, Coroner's comments, Long term missing person, deckhand, work related, water related, weather related, boating, dinghy, intentional self harm, suicide, hanging, mental illness and health, prescribing, drug seeking, pain medication, transport and traffic related, alcohol and drugs, single motorcycle crash, unlicenced, learner rider, speeding, riding at excessive speed, methamphetamine, unregistered, riding over blood alcohol limit, loss of control, Transport & traffic related, motor vehicle crash, Lebrina, speeding, death by negligent driving, charged and convicted. For information on how to find Sentences for the last three months use the Sentences link. Intentional self-harm, mixed drug toxicity, overdose of prescription medication, criminal sexual misconduct, criminal charges, toxicological analysis, Launceston General Hospital. Further, the TSR is based on all cases investigated by the Tasmanian Coroners' Office under the Coroners Act 1995 (Tas), whereas the ABS organises state and territory-based mortality information according to the This includes a combination of in cab assistance, review/follow-up of telematic data and ongoing focus on travel times for higher risk activities. However, rights to view these data are limited by contract and subject to change. Inquest, transport & traffic related, work related, Ten Mile Creek Farm, tractor rollover, not wearing a seatbelt, blunt trauma of the head, neck & chest, WorkSafe Tasmania, Riverdale Dairies Pty Ltd, recommendation. Response from Tasmania Parks and Wildlife Service11 August 2022. coronial, organ failure, multiple snake bites, tiger snake, neuropathy, coagulopathy, farm. They usually seek to find out the identity of the deceased, the cause of death and the circumstances in which it may have occurred. Acute methadone toxicity, prescription drug overdose, Pharmaceutical Services Branch, breach of Poisons Act 1971, Coroner's comment, Inquest, person held in care, Roy Fagan Centre, comments, recommendations, pneumonia, Guardianship Order, Public Guardian, Guardianship and Administration Board, fall, Homicide and assault, weapon, drugs and alcohol, hypovolemic shock, multiple stab wounds, popliteal artery, manslaughter, Robert Michael Allen, coroner's comments, Drugs & alcohol, mental illness & health, methadone, methadone program, take-away doses, Tasmanian Opioid Pharmacotherapy Program, drug toxicity, Child & infant death, baby, co-sleeping, bed sharing, suffocation, avoidable, Transport & traffic related, motorbike, motorcycle, dirt bike, unroadworthy, crash, accident, speed, illicit drugs, erratic, unlicensed, unregistered, Single motorcycle crash, transport & traffic related, head injury, existing injuries, Harley Davidson, drugs, THC, cannabis. Geographic, leisure activity, caverneering, Tasmanian Caverneering Club, Mount Anne, North East Ridge, exploration, disappearance, undetermined cause of death. 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. 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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