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Findings

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2008
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2005
2004

2008

Name/event

Findings delivered

Coroner
Batten, Derek , Tunstead , Peter and Tunstead, James 8/08/2008 Barnes
Inquest into the deaths of Derek Batten, Peter Tunstead and James Tunstead who went missing off the vessel Kaz II. Missing persons, lost at sea, search and rescue.
Shelley, Chloe Louise 17/07/2008 Lock
Death resulting from injuries sustained as a passenger in a motor vehicle accident on Bryan Jordan Drive, Gladstone. Vehicle lost control after travelling over undulations on road and hit light pole.
Watson, Christina Mae 20/06/2008 Glasgow

Inquest into the death of Christina Mae Watson who died whilst diving on the historic Shipwreck "Yongala".

Bock, Kristian 17/06/2008 Brassington
Death at Nerada near Innisfail on 29 October 2002, German National, Motor Vehicle Incident, Campervan and a Prime Mover towing a B Double Trailer.
Maggable, Kenneth 17/06/2008 Black
Death at Trinity Beach on 9 August 2005, Acute coronary occlusion, Extensive coronary atherosclerosis, Visited General Practitioner and Cairns Base Hospital.
O’Connell, Martin John 6/06/2008 Lock
Inquest, electrocution, safety switch (residual current device)
Irwin, Ross Frederick 6/06/2008 Barnes
Inquest into the suspected death of Ross Frederick Irwin. CORONERS: Inquest, suspected death, trawler fishing, adoption of the NSCV and other safety initiatives, MSQ investigation of marine incidents. Heard by State Coroner Michael Barnes and delivered on 06 June 2008.
Rouse, Christine Chloe 26/05/2008 Luxton
Death at Cloncurry Hospital on 12 March 2005, where a child drowned in a public pool.
Mosby, Phillemon Edward 23/05/2008 Barnes
Inquest into the suspected death of Phillemon Edward MOSBY.  Vessel Pilot Transfer. MSQ monitoring of pilot vessels, AMSA stipulating pilotage standards.
Gallaher, Sebastian Luke Paul 15/05/2008 Parker
Death at Gympie on 11 April 2006, where a child died of natural causes, subarachnoid haemorrhage, ruptured berry aneurysm.
Blinco, Ricky Glenn and Last, Michael Wayne 2/05/2008 Barnes
Inquest into the deaths of Michael Wayne LAST and Ricky Glenn BLINCO. Black Duck Valley, recreational off road motorcycling and four wheel driving, local authorities approval of four wheel driving parks, Workplace Health and Safety investigation of incidents in four wheel driving parks.
Brown, Robert Lee 1/05/2008 McLaughlin

Death at Collingwood on 25th of December 2006, motorcycle, multiple injuries, motor vehicle incident.

Bond, Jakai Ryan 10/04/2008 Barnes
Inquest, sudden death of an infant, co sleeping, asphyxia, head injuries.
Fitzgerald, Anthony Michael 28/03/2008 McLaughlin
Death at Esk on 4 April 2004, Aircraft crash, gyroplane.
Waite, Thomas Dion; Huynh, Mieng; Jacobs, James Henry; Gear, James Michael 17/03/2008 Barnes
Inquest, police shooting, mental health assessments, involuntary treatment criteria, post prison release mental health, prescription drug screening, dissemination of information to mental health information to police officers, critical incident command training.
Zwahlen, Bernhard 27/02/2008 Tonkin
Inquest, Hang glider (Airborne C2), static ground tow, failure to release tow line, absence of hook knife, modified tow equipment.
Jones, David Colin 11/02/2008 Killeen

Death at Glasshouse Mountains on 10 June 2007, motor vehicle incident.

Hauff-Green, Edward Thomas 31/01/2008 Lock

Inquest, mental health, emergency sedation.

Young, Janet 23/01/2008 Lock
Inquest, truck rollover, load restraint and centre of mass.
Schmidt, Shirley 17/01/2008 Barnes
Missing person, re-opening of inquest.
Wigg, Allan Thomas 16/01/2008 Brassington
Banana bagging machine machinery incident at Wangan on 3 December 2004

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2007

Name/event

Findings delivered

Coroner
Hall, Jordan James 20/12/2007 Halliday
Death at Redcliffe Hospital on 16 August 1997. Child Death, Head and abdominal injuries, Repeated blunt trauma.
Newman, Patricia Dell 20/12/2007 Springer

Death at Rockhampton Hospital on 29 March 2006, who died of congestive cardiac failure, essential hypertension.

Whittington, Frank Maurice 12/12/2007 Tonkin
Death occurred following surgery to replace the catheter delivering intrathecal morphine to provide analgesia via Medtronics SynchroMed EL Implantable pump 8627L-18.  The post-operative priming bolus dose was miscalculated, delivering a small overdose in a patient with a high level of tolerance to morphine.  Patient died of coronary atherosclerosis.
Burgen, Deborah Denise 7/12/2007 Barnes
Mt Isa Hospital, post operative internal bleeding, compliance with hospital policies, triaging of ED patients, tele medicine, referral to medical board.
Mills, Samuel John 29/11/2007 Barnes
Death in custody, correctional centre, suicide, hanging points, funding of prison mental health services.
Gillies, Bradley James 23/11/2007 Kehoe

Death at Southport on 1 May 2004, Motor vehicle incident, concrete truck roll over, telegraph pole.

Bodell, Margaret Florance Anne 23/11/2007 Clements
Chronic abstructive airways disorder, fitness for endoscopy, duodenal ulcer, end of life decision making, autopsy after exhumation, reportable deaths, duties under Coroners Act 2003, carbon dioxide retainers.
Scholz, Karl David 23/11/2007 Clements
Background of underlying dental disease, immediate need of teeth extraction, swelling of throat, transfer to hospital due to risk of airway obstruction, insertion of surgical drains, endotracheal tube, timing of extubation, decline on ward, query upper or lower respiratory problem, respiratory arrest.
Walker, Nola Jean 23/11/2007 Barnes
Death in custody, motor vehicle accident, QAS assessment of patients, QPS monitoring of prisoners.
Hanley, Timothy Michael 22/11/2007 Hennessy
Poisoning, Herbal Ecstasy, Internet Ordering at Rockhampton on 30/01/06
Huber, Arisa 6/11/2007 Clements
Sudden unexpected death of infant, in hospital, in bed with mother for breastfeeding, accidental suffocation, severe hypoxic episode.
Cvitic, Nardia Annett 29/10/2007 Clements
Medical procedure, complications.    
Murray, Kelvin Charles 16/10/2007 MacCallum
Possible Suicide, Overdose at Goodna on 03/09/04
Zupp, Jason John 12/10/2007 Toowoomba
Traffic Incident, Long Distance Truck Driver, Interstate, Driving Hours, Driving Fatigue at Taroom on 10/12/05
Fogarty, Kevin Edward 1/10/2007 Barnes
Melioidosis, community acquired pneumonia, work place exposure to tropical diseases, clinical support for rural and remote medical practitioners.
Effer, Anthony John 27/09/2007 Smith
Single Vehicle Traffic Incident, Pillion Passenger on a Motorcycle at Maryborough on 27/07/04
Crowston, Amanda Terese Francis 26/09/2007 Mack

Death at Pimlico on 7 November 2005, Aspiration of gastric content, drug abuse.

Waugh, Cappur William Embling 14/09/2007 Rinaudo
Motor vehicle accident, single vehicle roll-over, inadvertence, inattention, calculation of speed of vehicle.
Babington, Lynette 13/09/2007 Cornack
Death in residence at Oakey on 05/08/2006 due to a pulmonary embolism.
Henderson, Robert Joseph 3/09/2007 Clements
Mental Health, death in care, involuntary treatment order in the community, monitoring, drug abuse, risk of non compliance with medication.
Noffke, Veronica Margaret 29/08/2007 Webber
Death at Logan Hospital on 10/05/2005 due to coronary atherosclerosis with anti-coagulant therapy.
Case, Matthew Colin 24/08/2007 McLaughlin
Child, Drowning, Public Pool at Goodna on 24/09/05
Fitter, Maureen 24/08/2007 Lock
Hospital/health procedures death, Cardiac Tamponade, Peripherally inserted Central Catheter.
Lockhart River aircraft crash 17/08/2007 Barnes
Aircraft accident, pilot training, Civil Aviation Safety Authority oversight of aviation, crew resource management training, interaction between Civil Aviation Safety Authority & Australian Transport Safety Bureau.
Mental Health patient 17/08/2007 Clements
Mental Health, assessment of suicide risk, communication with family and hospital staff regarding risk, search of patient's property for dangerous items, hanging points.
Stiller-Smith, Felix Jake 10/08/2007 Clements
Infant death, undertermined cause, presence of amphetamines in breast milk, contact with the Department of Families.
Tang, Shannon Sheng Wen 10/08/2007 Clements
Medical procedure, gastric bypass, informed consent regarding mortality, complications.
Duckett, Alan Bernie-Johnson, Bruce William-Hughes, Allen John-Thompson, Katharine Anne 9/08/2007 Barnes
Aircraft crash, CASA staff training, automatic recording of engine parameters.
Howell, Thomas John 3/08/2007 Callaghan
Run over by a school bus at Gympie.
Bessell, Michael Ian Charlesworth 20/07/2007 Hennessy
Was the rider of a motorcycle involved in a two vehicle traffic incident at Burnett Highway near Mount Morgan on 20/07/07.
Aldred, Belinda Jayne 13/07/2007 Braes
Hanging at Mareeba.
Liddell, Matthew John 20/06/2007 Clements
Hanging death of young man receiving psychiatric care in hospital, procedure for observation of patients, procedure for assessment of suicide risk.
Eady, Graeme William Julian 20/06/2007 Clements
Plastic bag asphyxiation of young man receiving psychiatric care in hospital under involuntary treatment order, procedure for intermittent visual observations of patients.
Huntington, Sparka Isarva aka Huntington, James Philip 1/06/2007 Barnes
Restraint of mental health patients.
Skardoon, Dorothy Rae 25/05/2007 Lock
Death following fall; recent eye procedure
Mental Health patient 25/05/2007 Clements
Involuntary treatment orders, assessmentof suicide risk, procedures for intermittent observation orders.
Davis, Jodie Maree 16/05/2007 Tonkin
Death in custody, Townsville Correctional Centre.
Horsington, Margaret Isabel 4/05/2007 Rinaudo
Bowel obstruction, Fleet, diagnosis and treatment. inquest within the medical system at the Roma Hospital.
Lang, Michael Charles 1/05/2007 Brassington
Operating a backhoe when demolishing a pedestrian bridge at Broadbeach on 10 December 2003.
Thorpe, Geoffrey 18/04/2007 Guthridge
First aid training and equipment on an industrial site.
Smith, Arthur Lawrence 5/04/2007 Lock
Hospital/health procedures, death.
Pittaway, Steven John and Coe, Paul Allen 30/03/2007 Barnes
Watch house, inspection of prisoners, searching of prisoners, risk assessment of prisoners, elimination of hanging points.
Dee, Fiona Jane 23/03/2007 Clements
Elective Caesarean, spinal anaesthesia, cerebrospinal fluid leak, subdural haematoma, query epilipsy, query cardiac event, Tegretol, hyponatremia, epidural patch, postural headaches.
Davis, Shane William 21/03/2007 Hennessy
An industrial death at the Foxleigh Mine near Middlemount.
Gabiola, Peter 19/03/2007 Hillan
Death at Cluden on 23 July 2003, Workplace Incident, Purification Plant, Tractor.
Turnbull, John 13/03/2007 Clements
Work related accident, workplace health and safety, driveway construction, plant, vibrating rollers. 
Browne, Roger Bruce 6/03/2007 Hennesy
Industrial incident at Dawson Mine near Moura in Central Queensland.
Lather, David Andrew 1/03/2007 Previtera
Aspriation of gastric contents due to, or as a consequence of drug toxicity following the ingestion by Andrew of a large quantity of varied medication.
McGeary, Corey Allan 1/03/2007 Barnes
Death in custody, suicide, hanging points.
James, Joseph Edwin 23/02/2007 Barnes
Death in custody, natural causes.
Eddy, Michael John 12/02/2007 Barnes
Death in custody, positional asphyxia, amphetamine use, autopsy reports, registration of causes of death.
Marshall, Maxwell John 19/01/2007 Barnes
Control of prescription medication, the role of the Drug of Dependence Unity, autopsies by government medical officers.
Tyssen, Mario Emmy 19/01/2007 Barnes
Death in custody, health care of prisoners.
Carroll, Leon Mark 19/01/2007 Barnes
Cause of Death-suicide, hanging points.
Fitzgerald, Darren Michael 19/01/2007 Barnes
Death in custody, availability of opioid diversion and needle exchange programs in prisons, augmentation of intelligence responses at Woodford Correctional Centre, drugs in correctional facilities.
McDonald, Kerry-Ann 10/01/2007 Kennedy
Multiple injuries as a consequence of motor vehicle trauma, Kawasaki loader.
West, Ian Leslie 10/01/2007 Kennedy
Bronchopneumonia following a severe head injury.

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2006

Name/event

Findings delivered

Coroner
Conlan, Kathleen Anne 19/12/2006 Batts
Death at Gold Coast hospital on 28/11/2003 where no formal cause of death could be ascertained.
Day, Mark Walter 19/12/2006 Barnes
Death in custody, murder, supervision of dangerous prisoners.
Boyce, Amanda Helen 18/12/2006 Rinaudo
Death in spa, Reynolds equation, laminae flow, turbulent flow, hair entrapment, tangling and knotting.
Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane 15/12/2006 Previtera
Suicide by mental health patients.
Jones, Katherine Alison 14/12/2006 Killeen
Death at Nambour Plaza Shopping Centre, Nambour on 10 December 2005 whilst carrying out her employment duties at the Centre, a large galvanized steel gate fell on the deceased.
Czislowski, Kenneth Douglas 8/12/2006 Costello
Gyrocopters, failure of mechanical hub bar, aerial work other than recreational flight, cattle mustering.
Tierney, Beverley Ann 27/11/2006 Rinaudo
Drowning, wet drowning, dry drowning.
Petrelis, Andrew Nicholas 24/11/2006 Halliday
Opiate toxicity.
Jeffrey, Helen 13/11/2006 Taylor
Suicide by mental health patients.
Ali-Haapala, Anita 31/10/2006 Buckley
Risk management of patients in mental health facilities.
Blockley, Michael Gary; Watson, Stevie Lee; Teske, Neil Lackland; Donaldson, Michael Bruce; and Nugent, Christopher John 26/10/2006 McIntyre

Deaths at Linthorpe on 7 April 2006 and 11 April 2006 at Princess Alexandra Hospital, Motor vehicle incident, very high speed.

Mathers, John William 12/10/2006 Cornack
Motor vehicle accident, surgical error, failure to correctly operate blood infuser, training issues.
Mulrunji 27/09/2006 Clements
Death in custody.  Recommendation concerning arrest and policing, assessment and monitoring of health upon arrest, supervision and care in custody, investigation into deaths in police custody, diversionary centres and community patrols.
Rawson, Robert Donald 13/09/2006 Hennessy
Availability of quality medical equipment in regional hospitals.
Robinson, Terence James 8/09/2006 Barnes
Status epilepticus, monitoring of psychiatric patients, emergency sedation, transfer to primary hospitals.
Hamilton Island aircraft crash 7/09/2006 Barnes
Aircraft accident, fuel selector warning, chief pilot's duties, securing of evidence.
Grimley, Scott Robert 1/09/2006 Halliday
Electrocution at work.
Vernon, Colin John 24/08/2006 Callaghan
Death at North of Gympie on 7 May 2005, Motor vehicle incident.
Shaw, Lillian Margaret 11/08/2006 McLaughlin
Perforated ulcer and morphine toxicity.  Recommendations concerning the recording of morphine administered; the supervision of provisionally registered foreign trained doctors and the publication of the provisional registration.
Casey, Lenard John 10/08/2006 Barnes
Death in custody, natural causes.   
Bee, Calvin Wayne 9/08/2006 Barnes
Death in custody, riders concerning incarceration of alcoholic persons, sudden unexplained death in epilepsy.
Vidler-Cumming, Liam Richard 28/07/2006 Barnes
Shaken baby syndrome.
Zimitat, Vivian Bexley 28/07/2006 Hennessy
Regional neurology services availability; maintenance of appropriate records regarding regional and remote medical contact with specialty units in tertiary hospitals.
Hooymans, Kylie Danielle 7/07/2006 Taylor
Death at Tewantin on 13 March 2005, Hanging, Mental Health.
Palace Backpackers Hostel Fire 7/07/2006 Barnes
Arson in budget accommodation, fire safety reforms, Childers.
Ioane, Andrew Penetito 30/06/2006 Barnes
Death in custody, police pursuit, recommendations regarding police training.
Williams, Stuart Ronald 27/06/2006 Barnes
Death in custody, correctional centre, natural causes.
Hedges, John Walter 15/06/2006 Barnes
Accidental overdose, medical negligence, systemic failings in a clinical setting
Hewson, Jamie 8/06/2006 Barnes
Death in custody, police shooting.
Bell, Malcolm Robert 26/05/2006 Barnes
Police shooting, self-defence.
Marshall, Peter Whitoria 19/05/2006 Barnes
Safety procedures for deflation of truck tyres on mine site, supervision of autonomous skilled workers, rim design and tyre handling standards for mine trucks.
Baker, Rodney John 15/05/2006 Barnes
Trawler fishing, boat capsizing, hydrostatic released life rafts, PFDs, EPIRBs, search and rescue.
Karajic, Scott Meho 26/04/2006 Barnes
Gas drilling rig accident, supervision on drilling rigs, recommendations concerning the education of drilling rig supervisors and crew.
Adams, Michael James 13/04/2006 Halliday
Inquest, death in custody on 11/09/1997, hanging at Sir David Longland's Correctional Centre in Bribane.
Meech, Paul Andrew 7/04/2006 Barnes
Death in custody, watchhouse supervision, mental illness, involuntary assessment and involuntary treatment order, management of mental illness.
Rhodes, Daniel Cory 24/03/2006 Barnes
Police shooting, self defence.
Bismark, Lex Robert 23/03/2006 Barnes
Motor vehicl accident, recommendation concerning fitness to drive.
Bourke, Raymond Francis 17/03/2006 Barnes
Death whilst attempting to avoid being taken into custody, suicide.
Smith, David Edward 17/03/2006 Barnes
Death in custody, Prison murder, protective custody. 
Schumacher, Nicholas 16/03/2006 Smith
Death at Townsville on 12 September 2004, Child death, motor vehicle incident, navy cadet, troop carrier.
Matschoss, Wayne Barry 13/03/2006 Barnes
Death in custody, natural causes.
Pettigrew, Wayne Matthew 13/03/2006 Barnes
Death in custody, natural causes.
Creegan, Thomas 3/03/2006 Previtera
Diving accident at Hastings Reef, Great Barier Reef, Far North Queensland.  Recommendations concerning training for the diving industry, assessment of fitness to dive and other issues.
Hendy, Albert William 24/02/2006 Barnes
Death in custody, natural causes.
Sperling, Karl Peter 17/02/2006 Daley
Drowning of an army cadet on exercise.
Crossman, Troy Samuel 3/02/2006 Barnes
Death in custody, recommendations concerning the management of 'at risk' prisoners, hanging points.
Muckan, David Jones 3/02/2006 Barnes
Psychiatric hospital death, benzodiasepines, obstructive sleep apnoea.  Recommendations concerning the observation of patients administered sedatives.

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2005

Name/event

Findings delivered

Coroner
Dell, Maren Lyndsey 19/10/2005 Lock
Diving accident at Agincourt Reef, Great Barrier Reef, Far North Queensland.  Recommendations concerning training for the diving industry.
Partridge, Phillip Bruce 22/12/2005 Barnes
Death in custody, Police siege, suicide, mental health.
Hansen, Anthony Kenneth 22/12/2005 Barnes
Correctional Centre, transfer to hospital, death from natural causes.
Rowland, Jet Paul 16/12/2005 Clements
Motor vehicle accident, recommendations concerning fitness to drive, epilepsy and driving.
Croft, Penelope Ann 2/12/2005 Rinaudo
Motor vehicle accident. Recommendations concerning engine compartment door of buses.
Perry, Jye Conrad (a child) 29/11/2005 Hennessy
Mental health forensic patient, person of special notification.  Recommendations concerning flagging of files, integrated information system - medical and mental health, consequences of breach of limited community treatment conditions, confidentiality and proper disclosure to carers/family.
Robe, Pryde Michael 15/11/2005 Clements
Suicide, depression in juveniles. Recommendations concerning the management of mental health patients in the community.
Tognola, Phillip Allan Walter 1/11/2005 Spencer
Swimming pool drowning of a child. Recommendations concerning inspection of pools.
Liddington, Craig; Eva, Stewart; Carpenter, Andrew 28/10/2005 Hennessy
Emergency Medical Service (EMS) helicopter rescue, risks of night flying over water.  Recommendations concerning community helicopters providers - minimum standards for helicopters and pilots in EMS work, spatial disorientation in pilots, clinical co-ordination of EMS missions, provision of overnight medical care in remote communities (Hamilton Island) funding of community helicopter providers.
Fernandez, Adam Anthony 17/10/2005 Clements
Natural causes, capsicum spray.
Waldon, Mark Anthony aka Hurricane, Mark Anthony 14/10/2005 Clements
Natural causes, reaction to heroin withdrawal medication. Recommendations concerning the suitability of prescribing certain medication to prisoners, supervision of prisoners.
Irwin, Perry James; Coates, Damien Lawrence 10/10/2005 Barnes
Shooting of police officer, suicide of his assailant. Recommendations concerning QPS critical incident management, adequacy of communication devices for police, access and sale of ammunition, protective apparel.
Naidu, Alvin 21/09/2005 Clements
Recommendations concerning supervision of truants by the Department of Education.
Cook, Robert Edward 19/09/2005 Clements
Motor vehicle accident involving an elderly motor cyclist.
Sabadina, Kathryn Marnie 24/08/2005 Barnes
Anaphalactic shock. Recommendations concerning the recruitment and supervision of foreign trained doctors.
Pugh, Samuel 10/06/2005 Verra
Death south of Charters Towers on 17 August 2004, Highway Reward Mine, Rock fall.
Robinson, Jacinta Kate 4/05/2005 Clements
Death of a child undergoing surgery-cardiac tampenade. Recommendations regarding training for nurses and medical staff, allocation of specialist medical services.
Hope Vale man 7/04/2005 Barnes
Hope Vale man in an Aboriginal community police van. Recommendations concerning training of Aboriginal Community police officers.
Landue, Shone; Reid, Gary; Doolan, Stanley 9/02/2005 Clements
Recommendations concerning the inspection of boarding houses and fire safety. 

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2004

Name/event

Findings delivered

Coroner
Fiechtner, Rodney Joseph 20/12/2004 Barnes
Gas explosion on a drilling rig.  Recommendations concerning risk management on rigs.
Eason, David John 6/12/2004 Barnes
English tourist missing on Fraser Island for two years.  Recommendations concerning searches and wilderness signage.
Shoobridge, George Richard 28/10/2004 Previtera
Death at Cairns on 1 December 2002, Cardiorespiratory failure, drug overdose, methadone program.
Toohey, Alan Paul; Hill, Andrew Tasman 20/10/2004 Barnes
Police pursuit in Coen.  Recommendations regarding cessation of such pursuits.

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