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For all conditions of entry, read the COVID 19 (Coronavirus) Measures. Coronial findings To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. 600m that require vegetation removal. If a judgment is not listed in the List of Recent Decisions try clicking on the Refresh or Reload Button in your Browser to make sure you are viewing the latest version of the web page. 2023 Department of Police, Fire & Emergency Management, Family Violence Counselling Support Service, Research applications and requests (TILES), Special Response and Counter-Terrorism Command, Department of Police, Fire and Emergency Management, Personal Information Protection statement, Coroners findings into the death of Nicholas Whiteley. When the cause of death is unknown or seems unnatural, a judicial officer, known as a coroner, is involved to determine certain information. Magistrates Court : Coronial Findings 2019-2021 Transport & traffic related, older persons, physical health, car accident, environmental heat & cold exposure, dehydration, missing person, Tullah, Transport & traffic related, motor vehicle crash, car accident, speed, alcohol, illicit drugs, criminal prosecution, causing death by dangerous driving, Huonville. The reason for this is quite straightforward and that is that every employee has some role to play in reducing the likelihood of rollovers and incidents more broadly. PDF ORDER: Supp ress publication of the name of the deceased, the deceased 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. CITATION: Inquest into the death of HD (name suppressed) [2021] NTLC 029 . An inquest into her death was told there was intense demand on staff, who missed repeated opportunities to identify the seriousness of her condition. Older persons, physical health, Roy Fagan Centre, Emergency Guardianship Order, care, treatment and supervision, Alzheimer's disease, aspiration pneumonia. Coronial findings and recommendations - coroners.nsw.gov.au traumatic brain injury, homicide, Mitchell Clay Dowling, Jay David Blazely, one punch death, assault, death in care, order under the Guardianship and Administration Act 1995, Guardianship and Administration Board, intentional self harm, mental illness and health, Roy Fagan Centre, death in care, Mental Health Act 2013, mental health order, Millbrook Rise Centre, asphyxia, choking on food, supervision of meals, transport and traffic related, motor vehicle accident, two vehicle crash, Lebrina, death in care, Mental Health Act 2013, mixed prescription drug sedation, clozapine, olanzapine, Spencer Clinic, Burnie, North West Regional Hospital, Karingal Nursing Home, mental illness and health, coroner's recommendations. Intentional self-harm, mental illness & health, youth, St Helens District High School, asphyxia, police investigation. Intentional self-harm, mental illness & health, suicidal ideation, weapon, partial contact range gunshot wound of the head, psychiatrist, Department of Psychiatry, Guardianship and Administration Board, Firearms Act 1996. Geographic, leisure activity, caverneering, Tasmanian Caverneering Club, Mount Anne, North East Ridge, exploration, disappearance, undetermined cause of death. This is also called a public court hearing. Our intention now is to broaden this process by utilising our recently recruited Driver Trainer to provide programmed in cab refresh sessions and assessments (similar, in many respects, to what pilots undertake now). The Department will act on the Coroners recommendations. Mixed Drug toxicity, Mental Health Plan, Schedule 8 substances, Drug Intoxication, Borderline Personality Disorder, Anxiety Disorder. To find out more about inquests, go to the Northern Territory Government website. The APCA Recreational Driving Guide, available to all Recreational Driver Pass holders, already contained advice to install sand flags under. This includes a combination of in cab assistance, review/follow-up of telematic data and ongoing focus on travel times for higher risk activities. Surgical Complications, Royal Hobart Hospital, Calvary Hospital. For all conditions of entry, read the COVID 19 (Coronavirus) Measures. O'Donnell, Margaret Joy.pdf (PDF File, 135.6 KB), Donohue, Tracey Lee.pdf (PDF File, 103.1 KB), Tilley, Jennifer May.pdf (PDF File, 117.4 KB), Wells, Peter Williams.pdf (PDF File, 100.9 KB), Lowe, Paul 2021 TASCD 684.pdf (PDF File, 1.1 MB), Bennett, Anthony George.pdf (PDF File, 114.0 KB), Roberts Henry Arthur.pdf (PDF File, 112.3 KB), Breward, Bradley Wade.pdf (PDF File, 78.7 KB), Nicholson, Dale Waverley.pdf (PDF File, 104.2 KB), Larkins, Pamela Judith.pdf (PDF File, 96.7 KB), Lindburg, Jason Richard.pdf (PDF File, 105.5 KB), Wheldon, Jamie Damien.pdf (PDF File, 106.0 KB), Chilvers, Peter Michael.pdf (PDF File, 98.6 KB), Pearce, Jayden John.pdf (PDF File, 103.1 KB), Rosendale, Dwayne Edward (PDF File, 376.1 KB), Bester, Valentine Eric Neal (PDF File, 130.9 KB), Lane, Christopher Mark.pdf (PDF File, 97.2 KB), Hume, Rosemary Josephine.pdf (PDF File, 112.6 KB), Parsons, Anna Maree.pdf (PDF File, 402.4 KB), Reaks, Karen Tracey.pdf (PDF File, 98.7 KB), Suter, Nigel Douglas.pdf (PDF File, 98.0 KB), King, Nicholas Brian.pdf (PDF File, 99.7 KB), Sterling, Barbara Lynette.pdf (PDF File, 103.5 KB), Quirk, Stewart James (PDF File, 99.0 KB), Lockley, Shane Reginald.pdf (PDF File, 113.1 KB), Groves, Justin Thomas (PDF File, 117.3 KB), Cooper, Melanie Sarah 2021 TASCD 475.pdf (PDF File, 121.9 KB), Midson, Gilbert Arthur.pdf (PDF File, 111.4 KB), Williamson, Shane Elliott; Rowe, Rodney Leo; and Robertson, Adam David (PDF File, 141.8 KB), Fitz-gerald, Peter John (PDF File, 106.1 KB), Selby, Robert Norman (PDF File, 731.0 KB), Hildyard, Nicholas William (PDF File, 112.0 KB), Menzies, Mervyn Roy (PDF File, 109.0 KB), Sowden, James Robert (PDF File, 597.0 KB), Woolley, Byron Balfour (PDF File, 77.1 KB), Gleeson, Craig; Lucas, Alistair & Welsh, Michael (PDF File, 892.1 KB), Bryers, Wallace Edgar (PDF File, 398.7 KB), Carnes, Wendy Maree.pdf (PDF File, 110.5 KB), Beames, Michael James (PDF File, 117.6 KB), Marshall, David Basil (PDF File, 94.9 KB), Wade, Neville Ernest (PDF File, 100.0 KB), Ghanbarzadeh, Masoud (PDF File, 120.1 KB), Porthouse, David John (PDF File, 294.6 KB), Bester, Alec Laurence (PDF File, 294.3 KB), Stocks, Michelle Jayne (PDF File, 121.3 KB), Steffen, William Francis (PDF File, 82.6 KB), Bowerman, Valerie Joy (PDF File, 399.8 KB), Davis, Graeme Charles (PDF File, 122.6 KB), Rubenach, Timothy Luke (PDF File, 141.1 KB), Daly, Raymond Albert.pdf (PDF File, 268.2 KB), Clark, Philip Patrick (PDF File, 252.7 KB), Fischer, Rodney James (PDF File, 101.4 KB), Lattimer, Joseph Aaron (PDF File, 455.5 KB), Greene, Yvonne Beverley (PDF File, 86.2 KB), Clark-Robertson, Tyson Timothy (PDF File, 117.7 KB), Townsend, David Lester.pdf (PDF File, 132.8 KB), Buhler, Finn Ruben Leo (PDF File, 106.6 KB), Oakley, Joseph Richard. I Found the Person I Was Looking For, What Now? In some inquests recommendations launch are made to Ministers and Government and non-government agencies. We respectfully acknowledge the Tasmanian Aboriginal people as the traditional owners of the land upon which we work and pay our respect to Elders past and present. Aurora Australis shines over Perth. Older person, natural cause death, acute myocardial ischaemia, Launceston General Hospital, Emergency Department, triaged patients, assessment and treatment, monitoring of whereabouts, documentation of significant interactions, recommendations. In such an investigation the police officers are acting for, and under the control of, the Coroner. They usually seek to find out the identity of the deceased, the cause of death and the circumstances in which it may have occurred. Older persons, physical health, subdural haematoma, mechanical fall with head strike, Launceston General Hospital, George Town Hospital. Health and Community Services Complaints Commission, 2023 Northern Territory Government of Australia, URL: https://justice.nt.gov.au/attorney-general-and-justice/courts/inquests-findings We will use your rating to help improve the site. The following articles will help you research your family in Australia. 2 Exhibit 1, Tab 9. Inquest files are reports and associated files pertaining to investigations regarding the cause of certain deaths. FINDING OF: Judge Greg Cavanagh . The Northern Territory's coroners office investigates unexpected or suspected deaths on behalf of the community. Tree felling accident, chainsaw, Tasmanian Forest Industries Training Board, expired Forest Works Licence, non-compliant helmet, Coroner's recommendations, Homicide and assault, mental illness and health, weapon, Tasmanian Prison Service, Wilfred Lopes Centre, Risdon Prison, North Hobart, Daryl Royston Wayne Cook, Section 24 Criminal Justice Mental Impairment Act 1999, remissions of sentence, mental health services, coroner's comments, Transport & traffic related, work related, single vehicle crash, concrete truck, Tea Tree Road, speed, no seatbelt. The discharge summary or interim essential clinical details will be sent to the GP advising discharge date, appointment time with GP, discharge medications and legal status. the details needed to register the death with the Registry of Births, Deaths and Marriages. Domestic incident, homicide & assault, weapon, rifle, gunshot wound, murder, Klaus Neubert, estranged husband, Tasmania Police, family law, alcohol and drug related, mixed prescription drug toxicity (codeine, paracetamol, mirtazapine, promethazine, diazepam), accidental overdose, appropriate prescribing regime, stockpiling medication, Drugs & alcohol, intentional self-harm, mental illness & health, transport & traffic related, suicide, carbon monoxide inhalation, asphyxia, Launceston General Hostpial, Royal Hobart Hospital, Emergency Department, Inpatient Withdrawal Unit, Coroner's comments, Inquest, older person, person held in care, Guilford Young Grove, Roy Fagan Centre, emergency guardianship order, mental health, aspiration pneumonia, dementia, Quad bike roll-over, accident, head injury, drugs & alcohol, pillion passenger, dam, coroner's comment. A finding is the document handed down by a coroner . Check the List of Recent Decisions. Intentional self-harm, mental illness & health, Royal Hobart Hospital, Clarence and Eastern Districts Adult Community Mental Health Service, Statewide Mental Health Services, Department of Psychiatry Open Unit, suicidal ideation, suicidal crisis, K Block, anti-ligature amenities, intentional self harm, suicide, mental health and illness, mixed prescription drug toxicity, amisulpride, diazepam, mirtazapine, Tasmania Ambulance Service, delay in dispatch of ambulance. 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 Coroner's Office arranges for members of the Australian Federal Police to investigate the circumstances surrounding the death of a person and to provide a report to the Coroner. 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. The PWS Arthur River Visitor Centre is trialling selling sand flags to the public. All rights reserved. Home 2021 | Department of the Attorney-General and Justice Download Australian Domestic and Family Violence Death Review Network Data Report 2018 (pdf, 3 MB), If you have a complaint about the conduct of a magistrate, or delay in handing down a decision, please see the CourtsJudicial Complaints Policy (PDF, 56.3 KB), 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. For information on how to find Sentences for the last three months use the Sentences link. Safety assessments of driver performance not only occur at the end of probation but are undertaken on an ongoing basis. 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. Unreported judgments of the Supreme Court of Tasmania are available on AustLII (Australian Legal Information Institute). I Cant Find the Person Im Looking For, What Now? Older persons, physical health, Roy Fagan Centre, Guardianship and Administration Order, Public Guardian, care, treatment and supervision, dementia, aspiration pneumonia. We extend our sympathies to the family of Mr Whitely at this difficult time. During weekdays in business hours, transport can be arranged for the patient to be picked up at the airport and returned home if friends/relatives are unavailable. We extend our sympathies to the family of Mr Whitely at this difficult time. It is appropriate and timely to review the Model, which is an integral part of our policing strategy, said Acting Deputy Commissioner, Donna Adams. Gemma Lake has been appointed Chief Executive Officer of the Department of the Attorney-General and Justice. PDF In an emergency call triple zero (000) - Department of Health Please be aware some collections consist only of partial information indexed from the records and do not contain any images. A Health Practitioner's guide for writing a statement for the Coroner. Aishwarya Aswath's parents question slow pace of hospital change Coronial findings To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. Aishwarya Aswath . We often utilise telematic data for this process as well as timesheet reviews, camera evidence and even road user and customer anecdotal feedback. Coronial inquests and findings | Department of the Attorney-General and De Bruyns Transport continues to utilise the VicRoads Heavy Vehicle Rollover Prevention Program and, specifically, its dynamic load elements as the cornerstone of our induction training for all employees and not just those involved in harvest fish operations. The Coroner has prepared comprehensive and considered findings and they will be given careful . Perth hospital staff missed the signs a seven-year-old girl was dying of sepsis because of the pressures caused by "inadequate" staffing, a coroner has found. We recognise the Tasmanian Aboriginal people as the continuing custodians of the rich cultural heritage of lutruwita / Tasmania. 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. Identifying your sources helps others find the records you used. Australia, Tasmania, Coroner's Inquest Files - FamilySearch Search or sort for the relevant findings below. Response fromDe Bruyn's Transport 23 July 2022, Recommendation 1: Rollover Awareness and Training. 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. Transport & traffic related, motor vehicle crash, multiple blunt traumatic injuries, instantaneous death, Kimberley Road, Railton, crash scene investigation. Transport & traffic related, single motor vehicle collision, car crash, Glenfern, Derwent Valley Council, recommendations. Wednesday, 22 May 2013 - 5:16 pm. If a judgment is not listed in the List of Recent Decisions try clicking on . The collection includes records from 1868-1914. 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. 5 March 2023, 12:40 am. Water related, long term missing person, suspected death, undetermined cause of death, disappearance, intoxication, Fisherman's Wharf, Strahan. Aged care, falls, older persons, physical health, closed traumatic head injury, Bishop Davies Court, Extended Care Assistant, enrolled nurse, Franklin Unit, nightly checks, delayed care. Long Term Missing Person, D'Entrecasteaux Channel, Probable Drowning, Water Related, Coroner's, Coronial, Motor vehicle Crash, Blunt Traumas Injury to the head, lost control, seat belt, Adverse Medical Effects, Acute Gastrointestinal, Hobart Private Hospital, Royal Hobart Hospital, Child & Infant Death, Falls, Geographic, Leisure Activity, Conservation Area. submissions in making my findings. Drugs & alcohol, accidental overdose, prescription drugs, mixed drug toxicity, prescribing, Pharmaceutical Services Branch, Poisons Act 1971, Poisons Regulations 2018, schedule 8 substances, central nervous system depressants. Findings and upcoming inquests - Coroners Court | Queensland Courts The Australian Domestic and Family Violence Death Review Network was established in 2011 as an initiative of state and territory death review processes, and is endorsed by all state and territory Coroners and the Western Australian Ombudsman. Inquest, person in care, older person, Bishop Davies Nursing Home, Roy Fagan Centre, aspiration pneumonia, advanced dementia. The original records are located in the Tasmanian Archives and Heritage Office in Hobart, Tasmania. Inquest, work related, forklift rollover, farm, not wearing a seat belt, workplace, Work Health and Safety Act, guilty,Burnie, Law enforcement, mental illness & health, death in custody, secure mental health unit, Wilfred Lopes Centre, inquest, natural cause of death, Transport & traffic related, motor vehicle crash, truck, collision, incorrect side of the road, Black River, Transport & traffic related, motor vehicle crash, Iveco prime mover, Freighter trailer, truck, speed, work related, employment, workplace, request by senior next of kin not to hold inquest pursuant to s26A(2) of the Coroners Act 1995, undetermined cause of death, missing person, suspicious circumstances, Flinders Island, North East River, Salmon Rock, fishing, Joshua Kennedy, Stephanie Riggall. The extent of works is over a length of approximately 2.1km of Glenfern Road. coronial, organ failure, multiple snake bites, tiger snake, neuropathy, coagulopathy, farm. In some inquests recommendations launch are made to Ministers and Government and non-government agencies. The RHH carry out an investigation of the delays to administration of antibiotics on this occasion with a view to implementing steps to avoid their repetition. CORONER SARAH HELEN LINTON, DEPUTY STATE CORONER: HEARD : 14-15 APRIL 2021 DELIVERED : 27 JUNE 2021 FILE NO/S : CORC 202 of 2019 DECEASED : THORSAGER, JORDAN ALEXANDER Catchwords: Nil Legislation: Nil . Drugs & alcohol, mental illness & health, mixed prescription drug toxicity, Royal Hobart Hospital, Department of Emergency Medicine, Liverpool Street. All contents copyright Government of Western Australia. You are directed to the disclaimer and copyright notice and a Personal Information Protection statement governing the information provided. We have also engaged the service of a Driver Trainer to provide additional coaching to all our drivers. Works were completed and reported to the grant program on 30 June 2021. This may require viewing multiple records or images. JURISDICTION: Darwin . Two of three deaths at Copper Mines of Tasmania 'avoidable', coroner 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. 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). FILE NO(s): D34/2020 . We then focus on specific rollover awareness factors during both our mentoring as well as our refresh programs. Coronial, stairs, step, fall, head injuries, blunt force. 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. 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 Search the Supreme Court of Tasmania database. Motorcycle crash, motorbike, youth, de-identified, transport & traffic related, fence post, avid motocross & enduro competitor, well-maintained & appropriate safety equipment, abdominal trauma, reminder of supervision, Homicide & assault, missing person, murder, failing to report killing, accessory after the fact, hammer, Ian Rosewall, Renae Donald, Robert Broad, imprisonment. PDF Act : Coroner Sarah Helen Linton, Deputy State Coroner: Heard : Delivered 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 acknowledge the traditional owners and custodians of the land on which we work and we pay respect to the Elders, past, present and future. 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. New Chief Executive Officer Gemma Lake. In her long-awaited written findings, Deputy State Coroner Sarah Linton found there was a chance Aishwarya's life might have been saved with proper treatment. HEARING DATE(s): 27, 28 September 2021 . This collection includes inquest files from the coroners office in Tasmania. The page has been produced by Courts Tasmania, Search the Supreme Court of Tasmania database, personal information protection statement. A Health Practitioner's guide for writing a statement for 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.