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2016

Name/event Findings delivered Government response
A - Non-inquest findings (PDF, 323.2 KB)

Motorcycle collision, loss of control, aquaplaned, tyres incorrectly fitted to vehicle.

12/02/2016 by Priestly
DM (PDF, 309.8 KB)

Domestic violence, response by agencies to violence, recommendations, ‘Not Now, Not Ever'.

09/02/2016 by Lock
Edwards, Sean Lawrence Guy (PDF, 642.6 KB)

Motor car racing, instructor training, race track safety features, gravel trap, tyre wall, mechanical failure causing crash, recommendations for conduct of private track.

05/02/2016 by Lock Government response not required
Adams, Jamie Christopher; Watkins, Gary Robert - Non-inquest findings (PDF, 584.5 KB)

Railway incident, Queensland Rail worker struck by train / track machine, Department of Transport and Main Roads investigation, workplace health and safety prosecution, failure of police to prosecute, contributing factors, former State Coroner’s direction not to hold an inquest.

19/01/2016 by Hutton
Reynolds, Michael John (PDF, 354.5 KB)

Death in custody, natural causes.

19/01/2016 by Ryan Government response not required
Mott, Melvin Thomas (PDF, 341.1 KB)

Death in custody, natural causes.

19/01/2016 by Ryan Government response not required
McCart, Thomas Gerard (PDF, 338.0 KB)

Death in custody, natural causes.

19/01/2016 by Ryan Government response not required
Kumeroa, Shaun Basil (PDF, 507.6 KB)

Death in custody, avoiding being placed in custody, police shooting, siege, involvement of negotiators and SERT police.

18/01/2016 by Ryan
Berrill, Robert Charles - Non-inquest findings (PDF, 600.2 KB)

Motorcycle collision, loss of control, experienced motorcyclist, risk taking behaviour

15/01/2016 by Priestly Government response not required
Barclay, Matthew Stephen (PDF, 1.1 MB)

Surf life-saving, risk management

15/01/2016 by Ryan

Back to top

2015

Name/event Findings delivered Government response
Barkley, Steven William - Non-inquest findings (PDF, 266.6 KB)

Intoxicated pedestrian, middle of road at night, dark and remote location, struck and killed by motor vehicle.

21/12/2015 by Priestly Government response not required
T, a child aged 15 months (PDF, 344.1 KB)

Child drowning, swimming pool, gate propped open, supervision.

18/12/2015 by Lock
Andrew - Non-inquest findings (PDF, 392.1 KB)

Non-inquest findings, motor vehicle collision, deceased asleep at the wheel, likely major contributor was cannabis and methamphetamine intoxication.

15/12/2015 by Priestly Government response not required
Frazer, Shane Craig - Non-inquest findings (PDF, 447.0 KB)

Motor vehicle collision, deceased driver overtaking on double lines, likely major contributor’s methamphetamine intoxication and fatigue.

15/12/2015 by Priestly Government response not required
Young, Anthony William; Young, David Kenneth Baring; Dekens, Louise Alexandra (PDF, 591.9 KB)

Death in custody, avoiding being placed in custody, police shooting, double domestic killing.

14/12/2015 by Ryan
Logan, Edward Wayne (PDF, 558.2 KB)

Death in custody, avoiding being placed in custody, police shooting.

14/12/2015 by Ryan
Meyer, Rebekka Tine Lousdal (PDF, 379.2 KB)

Cyclist death involving conventional truck and dog trailer, restricted forward visibility of conventional truck, ways to improve cyclist’s safety.

09/12/2015 by Clements Response to Meyer, Rebekka Tine Lousdal PDF, 314.8 KB
Maggs, Natasha Alison; Williams, Tiana Marie; Holland-Williams, Kody Peter Tugaga; Sullivan, Allan John; Hayes-McGuinness, Jordan Guy (PDF, 365.3 KB)

Collision, stationary vehicles, Pacific Motorway emergency phones, breakdown safety, roadside assistance, education campaign.

04/12/2015 by McDougall Response to Maggs, Natasha Alison; Williams, Tiana Marie; Holland-Williams, Kody Peter Tugaga; Sullivan, Allan John; Hayes-McGuinness, Jordan Guy PDF, 334.2 KB
Tewantin House Fire - Non-inquest findings (PDF, 1.1 MB)

House fire, multiple deaths, smoke alarms, ionisation type smoke alarms, photoelectric alarms

23/11/2015 by Ryan Government response not required
Child A - Non-inquest findings (PDF, 339.9 KB)

Child death, drowning, recreational dam.

11/11/2015 by Hutton Government response not required
Spence, John MIchael (PDF, 516.5 KB)

Death in custody, coronary atherosclerosis, seizures, high caffeine levels, adequacy of observations and response to Code Blue in prison.

04/11/2015 by Ryan Government response not required
Steer, Summer Alice (PDF, 1018.9 KB)

Button, coin, disc, lithium battery ingestion, aorta-oesophageal fistula,blood loss, hospital investigations.

03/11/2015 by Hutton
Wade, Kingsley Rex (PDF, 157.9 KB)

Sandblasting, diesel air compressor, breathing air being contaminated by carbon monoxide.

23/10/2015 by Comans
Jacobs, Dudley Gordon (PDF, 436.5 KB)

Capsize of conventional tug – failure to adhere to prescribed Marine Execution Plan – failure of emergency tow release.

23/10/2015 by O'Connell Government response not required
Robertson, Elsie May (PDF, 357.4 KB)

Violent death, domestic violence, Policelink call, police response.

23/10/2015 by Ryan Response to Robertson, Elsie May PDF, 307.2 KB
Rivett, Brent William (PDF, 742.5 KB)

Death in custody, siege situation, suicide, appropriateness of actions of attending police.

19/10/2015 by Ryan Government response not required
Thomas, Alexander David Joseph - Non-inquest findings (PDF, 172.7 KB)

Ingestion of various substances obtained over the internet, Beta-phenylethylamine toxicity.

14/10/2015 by Clements Government response not required
(P) a thirteen year old girl (PDF, 592.3 KB)

Death in care, death in police operations, child absconded in vehicle, restraint, residential care, intergenerational trauma, child protection, mental health services.

09/10/2015 by Ryan Response to (P) a thirteen year old girl PDF, 321.9 KB
Brady, Stanley John - Non-inquest findings (PDF, 169.1 KB)

Tree felling.

25/09/2015 by Clements Government response not required
Martin, James Thomas; Poate, Robert Hugh Frederick; Milosevic, Stjepan Rick (PDF, 576.2 KB)

Australian Defence Force, war in Afghanistan, insider attacks (Green on Blue), mentoring operations, risk assessments, risk mitigation, Australian Defence Force inquiries and investigations.

22/09/2015 by Lock Government response not required
Child Z - Non-inquest findings (PDF, 1006.2 KB)

Child death, drowning, cattle dip.

13/09/2015 by O'Connell Government response not required
Cole, Cameron Brandt (PDF, 746.2 KB)

Petroleum lease, drilling rig move, safety management systems, risk assessment, training, safety awareness, load restraint, vehicle design, emergency medical response at remote worksites.

11/09/2015 by Ryan Response to Cole, Cameron Brandt PDF, 393.1 KB
Wright, Verris Dawn; Carter, Jasmyn Louise (PDF, 881.1 KB)

Health care related death, recognising and responding to deteriorating patients, sepsis awareness, Queensland Adult Deterioration Detection System tools.

28/08/2015 by Lock
Gear, Christopher James; Sayer, Steven Frank - Non-inquest findings (PDF, 267.0 KB)

Swing stage scaffold failure, Workplace Health and Safety Queensland investigation and prosecution.

27/08/2015 by McDougall Government response not required
O'Connor, Scott Matthew (PDF, 557.8 KB)

Death in custody, hanging, maximum security unit, supervision of prisoners, prison mental health services.

14/08/2015 by Ryan
Brown, Maxwell Ronald (PDF, 326.9 KB)

Death in custody, natural causes.

14/08/2015 by Ryan Government response not required
Garrels, Jason Jon (PDF, 744.8 KB)

Building site, death by electrocution after coming in contact with temporary construction wiring, breaches of Wiring Rules involved in temporary electricity supply

11/08/2015 by O'Connell
Waterhouse, Jake Daniel (PDF, 221.3 KB)

Youth suicide, mental health and bipolar disorder, likely triggers for suicide.

03/08/2015 by Lock Government response not required
Inquest into nine (9) deaths caused by Quad Bike accidents (PDF, 1.3 MB)

Inquest, quad bike accident, rollover, operator protective systems, roll over protection systems, crush protection devices, crush protection vests, personal locator beacons, training, certification and licences, helmets, children, star rating system, police investigations.

03/08/2015 by Lock
Mills, Stephen John (PDF, 338.8 KB)

Fall in hospital, head injury, risk assessments and falls risk management, mental health medication management.

28/07/2015 by Lock Government response not required
KS - Non-inquest findings (PDF, 293.5 KB)

Management of chest pain presentation at rural hospital, misdiagnosis of NSTEMI, complications of anticoagulation therapy, NSTEMI and NSTEACS Clinical Pathways.

27/07/2015 by Kirkegaard Government response not required
Howman, Katie Lee (PDF, 727.6 KB)

Opioid dependency of heath care practitioner (nurse), Oxycodone, tramadol, fentanyl, Supervision by AHPRA, Doctor shopping, Accessibility to real time information of doctor attendances and prescriptions.

27/07/2015 by Clements
O'Rourke, Lachlan Maurice - Non-inquest findings (PDF, 224.3 KB)

Homicide, suicide, domestic violence.

08/07/2015 by Clements Government response not required
Burnett, Elissa Anne - Non-inquest findings (PDF, 169.2 KB)

Homicide, suicide, domestic violence.

08/07/2015 by Clements Government response not required
Payne, Emily Jade (PDF, 513.9 KB)

Single motor vehicle crash, seat belts, rural road, apprehension of bias application.

03/07/2015 by Lock Government response not required
Beckman, Seth David - Non-inquest findings (PDF, 151.0 KB)

Drowning in residential swimming pool, hyperventilation, shallow water blackout.

30/06/2015 by Clements Government response not required
Fenton, Peter Raymond (PDF, 940.0 KB)

Maritime accident, loading provisions onto ship from barge, crane, insulated container, chain and slings, job hazard analysis, work health and safety.

19/06/2015 by Ryan Government response not required
Sweeney, Michael Shawn (PDF, 510.1 KB)

Death in custody, avoiding being placed in custody, suburban hostage situation, use of firearms, appropriateness of actions of attending police.

19/06/2015 by Ryan Government response not required
Wilson, Brad Maxwell (PDF, 515.3 KB)

Natural causes, police arrest before death.

12/06/2015 by Ryan Government response not required
McIntosh, Robert Dennis (PDF, 462.1 KB)

Death in custody, natural causes,treatment of prisoners with cirrhosis of the liver and hepatitis C.

12/06/2015 by Ryan Response to McIntosh, Robert Dennis PDF, 314.4 KB
Ms C - Non-inquest findings (PDF, 175.0 KB)

Aged care facility, treatment of pressure sores, communication with Enduring Power of Attorney.

11/06/2015 by Lock Government response not required
McDonnell, Kevin Joseph John (PDF, 419.3 KB)

Mental health treatment, Involuntary Treatment Order, observations, leaving the ward.

10/06/2015 by Lock Response to McDonnell, Kevin Joseph John PDF, 309.2 KB
JE and JJ, two 16 year old boys (PDF, 536.9 KB)

Youth suicide, contagion, suicide cluster, community response, suicide prevention.

09/06/2015 by Ryan Response to JE and JJ, two 16 year old boys PDF, 309.8 KB
Reading, Neville Royston (PDF, 472.8 KB)

Death in police operations, restraint asphyxia, police first aid response.

09/06/2015 by Ryan Response to Reading, Neville Royston PDF, 214.2 KB
Vetters, Farrin John (PDF, 448.9 KB)

Death in custody, hanging points, management of ‘at risk’ prisoners.

28/05/2015 by Ryan Response to Vetters, Farrin John PDF, 307.8 KB
A, a six year old child (PDF, 393.5 KB)

Child in care, DOCS, drowning, pool, supervision, water safety, respite care, foster care.

27/05/2015 by Bentley Response to A, a six year old child PDF, 336.6 KB
SM - Non-inquest findings (PDF, 347.4 KB)

Health care related death, failure to recognise and respond to clinical deterioration, surgical patient, venous thromboembolism (VTE) risk management, oxygen prescribing, clinical handover, root cause analysis.

26/05/2015 by Kirkegaard Government response not required
Marr, Hunter Campbell (PDF, 535.3 KB)

Asthma, cough, ventolin inhaler, Mater Hospital, Asthma Action Plan.

08/05/2015 by McDougall Response to Marr, Hunter Campbell PDF, 409.9 KB
Fenton, Rebecca Louise (PDF, 328.9 KB)

Motor vehicle collision, CHR Intersection, Slip Lane, Micro-sleep, Boonal Coal Loader.

01/05/2015 by O'Connell Response to Fenton, Rebecca Louise PDF, 326.7 KB
McKenzie, Brett Alexander Kevin; Ezzy, Abigail Denise; Nolan, Nicholas James; Thorley, Maxwell Ernest (PDF, 264.1 KB)

Re-opening; fresh evidence, multiple fatality motor vehicle crash.

29/04/2015 by Previtera Government response not required
Lievesley, Tamiya Calais (PDF, 227.0 KB)

Death of a baby, drug use, morphine.

24/04/2015 by McDougall Government response not required
Bayliss, Mark Geoffrey (PDF, 212.8 KB)

Aluminium Privacy Screen, severe weather conditions, engineer, certification.

24/04/2015 by McDougall Government response not required
Peng, Sun (PDF, 174.3 KB)

Missing person, Weipa, Great Talent.

10/04/2015 by Bentley Government response not required
Boyles, William Roger - Non-inquest findings (PDF, 137.4 KB)

Motorcyclist, flooded road, swift water, drowned.

31/03/2015 by McDougall Government response not required
Bischoff, Noelene Gaye; Bischoff, Yvana Jean Yuri - Non-inquest findings (PDF, 239.4 KB)

Allergic type reaction, scombroid syndrome, histamine fish poisoning, asthma, food safety, Smartraveller website.

30/03/2015 by Ryan Government response not required
Mulhall, Terrance - Non-inquest findings (PDF, 274.0 KB)

Communication hospital, GP, Anaesthesia, Urology, Cardiology, Emergency Departments; electronic Medical Records(iEMR).

30/03/2015 by McDougall Government response not required
E, aged 14 - Non-inquest findings (PDF, 389.0 KB)

Child suicide, Child Safety Services, Child and Youth Mental Health Service.

24/03/2015 by McDougall Government response not required
R, aged one day - Non-inquest findings (PDF, 158.8 KB)

Suitability to home birth, meconium, AHPRA.

23/03/2015 by McDougall Government response not required
Press, Connon Kenneth (PDF, 307.0 KB)

Suicide, evidence, capacity to form intent, firearm, police investigation, scene preservation.

19/03/2015 by Ryan Government response not required
Cuttler, Melina Maree (PDF, 569.5 KB)

Mental health, psychotic presentation at Emergency Department, absconding from ED, fall from height, whether capacity for intent to suicide.

13/03/2015 by Lock Response to Cuttler, Melina Maree PDF, 307.9 KB
Kumar, Amit (PDF, 601.5 KB)

Citizen’s arrest, restraint asphyxia, positional asphyxia, centripetal obesity, coronary artery atherosclerosis.

11/03/2015 by Hutton Government response not required
Dow, Audrey Anne (PDF, 453.0 KB)

Careless, suspended or disqualified drivers, utilising mobile phone whilst driving, law reform recommendation for mid-range driving offences.

06/03/2015 by O'Connell Response to Dow, Audrey Anne PDF, 413.6 KB
Brogden, Jay Anthony (PDF, 476.4 KB)

Missing person, police investigation.

27/02/2015 by Bentley Response to Brogden, Jay Anthony PDF, 510.3 KB
Low, Paul Michael (PDF, 545.7 KB)

Police pursuits, attempted intercepts.

26/02/2015 by Ryan Response to Low, Paul Michael PDF, 310.9 KB
Newling, Robert William - Non-inquest findings (PDF, 138.7 KB)

Investigation, traffic accident, washing cars on roadside.

26/02/2015 by Clements Government response not required
Mapperson, Wayne George - Non-inquest findings (PDF, 239.2 KB)

Head injury, fall, employment, Office of Fair and Safe Work Queensland, available evidence, concerns.

20/02/2015 by McDougall Government response not required
Dennis, Jerry Arthur - Non-inquest findings (PDF, 281.0 KB)

Surf Life Saving Club training session, drowning, cardiomegaly.

11/02/2015 by McDougall Government response not required
Cameron, Michael James (PDF, 962.0 KB)

Workplace incident, crush injuries, mobile crane, free fall ability, lock out bar incorrectly installed, safety inspections.

09/02/2015 by Lock Government response not required
Carpenter, Harold James (PDF, 518.4 KB)

Death in custody, natural causes.

29/01/2015 by Lock Government response not required
Daw, Lilly Ella - Non-inquest findings (PDF, 223.5 KB)

Twin pregnancy, intrauterine foetal death, cystic encephalomalacia, Twin-Twin Transfusion Syndrome.

29/01/2015 by McDougall Government response not required
Waugh, Harry McMaster Tickell (PDF, 387.5 KB)

Death of a three year old due to reversing vehicle, rural situation, limitation of reverse camera view, use of child car restraints recommended in off road situations.

23/01/2015 by Clements Response to Waugh, Harry McMaster Tickell PDF, 212.7 KB
Candlin, Geoffrey George (PDF, 341.9 KB)

Traffic accident, heavy vehicle, Bruce Highway, Department of Transport and Main Roads, National Heavy Vehicle Accreditation Scheme, Maintenance Management Scheme, Transport inspectors.

23/01/2015 by Bentley Response to Candlin, Geoffrey George PDF, 403.3 KB

Back to top

2014

Name/event Findings delivered Government response
Uscinski, Barry Joseph (PDF, 476.0 KB)

Aircraft incident, replica Spitfire, RA-Aus, CASA, ATSB, Supermarine Aircraft Pty Ltd, weight / balance, dual battery.

29/12/2014 by Baldwin Response to Uscinski, Barry Joseph PDF, 322.9 KB
Canisi, Kyle Leslie (PDF, 548.7 KB)

Death in custody, prison assault, supervision of prisoners, association between prisoners.

17/12/2014 by Ryan Government response not required
Horace, Reynold David (PDF, 362.7 KB)

Death in custody, natural causes.

17/12/2014 by Ryan Government response not required
Courtney, Victor (PDF, 268.3 KB)

Death in custody, Natural Causes.

17/12/2014 by Ryan Government response not required
Dai, Xia - Non-inquest findings (PDF, 425.2 KB)

Investigation, scuba diving accident, inadequate advice and instruction regarding emergency ascent procedures, inadequate assessment of environmental conditions.

12/12/2014 by McDougall Government response not required
Hicks, Indianna Rose (PDF, 565.4 KB)

Coroners: inquest, SIDS, child day care, policy and procedures for safe sleeping.

12/12/2014 by Lock Response to Hicks, Indianna Rose PDF, 314.2 KB
Chen, Ruby Yan (PDF, 168.5 KB)

CORONERS: inquest, health care related death, massive air embolism, re-use of partially-used IV bag of Saline during aero-medical retrieval, air entering IV bag during re-spiking procedure.

12/12/2014 by O'Connell Response to Chen, Ruby Yan PDF, 323.8 KB
Knowles, Elizabeth Joy (PDF, 198.5 KB)

Coroners: inquest, suspicious house fire, alleged criminal activity leading up to house fire.

12/12/2014 by Clements Government response not required
Rowe, Laurence Edwin (PDF, 528.9 KB)

Industrial accident, forklift, system of work.

11/12/2014 by McDougall Response to Rowe, Laurence Edwin PDF, 213.9 KB
Baby A - Non-inquest findings (PDF, 788.6 KB)

Investigation, the inadequacy in assessing Baby A’s welfare throughout the mother’s labour.

09/12/2014 by McDougall Government response not required
LB - Non-inquest findings (PDF, 219.4 KB)

Death of a baby, inappropriate response of the Department of Communities, Child Safety and Disability to child protection concerns.

09/12/2014 by Bentley Government response not required
Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret (PDF, 554.4 KB)

Cairns and Hinterland Hospital and Health Service, Adult Deterioration Detection Tool, Pathology, Recognition and Management of Deteriorating Patient, Training, Culture, Staffing, Atherton Hospital, Mossman Hospital, doctor fatigue, ADDS, RMDP.

08/12/2014 by Bentley Response to Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret PDF, 331.7 KB
Kamp, Malcolm Donald (PDF, 232.5 KB)

Cyclists, road safety, semi-trailer, failure to allow sufficient clearance, inappropriate road design, inappropriate traffic restrictions, inappropriate risk management processes, safe use of highways and motorways by cyclists.

03/12/2014 by Hutton Response to Kamp, Malcolm Donald PDF, 216.4 KB
Slacks Creek House Fire (PDF, 555.6 KB)

House fire, multiple deaths, smoke alarms.

28/11/2014 by McDougall Response to Slacks Creek House Fire PDF, 440.6 KB
Smith, Rachel Danielle - Non-inquest findings (PDF, 236.1 KB)

Codeine, oxycodone, ‘doctor-shopper’, Prescription Shopping Program Alert Service.

26/11/2014 by McDougall Government response not required
Wallrock, William Charles - Non-inquest findings (PDF, 287.7 KB)

Pain relief following extraction of 3 wisdom teeth-Inappropriate supply by general practitioner of Physeptone (methadone)-Interaction with norfluoxetine and codeine.

26/11/2014 by Clements Government response not required
Richardson, Mathew (PDF, 626.5 KB)

Death in custody, suicide, engagement of the Special Emergency Response Team.

26/11/2014 by Ryan Government response not required
Peter, John Kelly (PDF, 437.4 KB)

Death in custody, natural causes.

25/11/2014 by Ryan Government response not required
Nash, Stephen Arthur (PDF, 731.9 KB)

Death in police operations; security providers, positional asphyxia.

24/11/2014 by Ryan Response to Nash, Stephen Arthur PDF, 215.3 KB
Wright, Karl Robert (PDF, 311.2 KB)

Coroners: inquest, multiple layers of clothing and gags, zip ties, sleeping bags, mechanical asphyxia, uncertainty if accident, suicide or homicide.

18/11/2014 by Lock Government response not required
Beutel, Noelene Marie (PDF, 331.3 KB)

Domestic violence, homicide, privacy, information sharing, police, General Practitioners.

17/11/2014 by Hutton Response to Beutel, Noelene Marie PDF, 371.5 KB
Chettiar, Dharam Raj (PDF, 346.1 KB)

Death in custody, natural causes.

04/11/2014 by Ryan Government response not required
Spencer, Lydia (PDF, 160.6 KB)

Motor vehicle accident.

03/11/2014 by Bentley Government response not required
Proberts, Mark William (PDF, 127.2 KB)

Death in custody, natural causes.

03/11/2014 by Ryan Government response not required
Villinger, Navina Friedericke (PDF, 782.6 KB)

Drowning, Workplace Health and Safety, Office of Fair and Safe Work Qld, adequacy of investigation, basis for decision not to prosecute, Granite Gorge Nature Park.

28/10/2014 by Bentley Response to Villinger, Navina Friedericke PDF, 411.1 KB
Sweetnam, Garry; Mitchell, Andrew - Non-inquest findings (PDF, 63.4 KB)

Investigation, plane crash, cause of crash, aircraft canopy.

15/10/2014 by McDougall Government response not required
Moore, Geoffrey Grahame (PDF, 64.7 KB)

Quad bike accident, mechanical defect, helmets.

26/09/2014 by Lock
McInnes, Zoe Louise (PDF, 64.3 KB)

Quad bike accident, helmets.

26/09/2014 by Lock
P, aged 9 - Non-inquest findings (PDF, 37.1 KB)

Investigation, children, rural property, mobility scooter, head injuries, helmets, supervision.

26/09/2014 by Lock Government response not required
D and F, a child (PDF, 59.2 KB)

Quad bike accident, roll over.

26/09/2014 by Lock
P, a child (PDF, 60.6 KB)

Quad bike accident, roll over, helmets, children, supervision.

26/09/2014 by Lock
Haken, Guss Robert (PDF, 53.5 KB)

Quad bike accident, helmets, intoxication.

26/09/2014 by Lock
H, a child (PDF, 68.7 KB)

Quad bike accident, roll over, children, supervision, helmets.

26/09/2014 by Lock
Beauchamp, Reginald Hasted (PDF, 64.1 KB)

Quad bike accident, head injuries, helmets.

26/09/2014 by Lock
Hoare, Gregory Peter (PDF, 68.3 KB)

Quad bike accident.

26/09/2014 by Lock
Hurst, Charles Kingston (PDF, 89.8 KB)

Death in custody, hanging.

16/09/2014 by Ryan Government response not required
Two year old child - Non-inquest findings (PDF, 31.0 KB)

Death of a child, drowning in swimming pool, lack of supervision, failure to close pool gate.

09/09/2014 by Clements Government response not required
MacDonald, Wayne (PDF, 124.3 KB)

Death caused by air blast from burst 22.5 inch truck tyre - " zipper failure" -proximity of truck driver to source of blast - comment upon alternative work procedures - necessity for care in maintaining minimum cold inflation.

09/09/2014 by O'Connell Response to MacDonald, Wayne PDF, 309.2 KB
A Patient - Non-inquest findings (PDF, 61.7 KB)

Hospital-acquired legionella pneumonia.

03/09/2014 by Lock Government response not required
Abrahams, Amy Lee - Non-inquest findings (PDF, 34.5 KB)

Motor vehicle accident, condition of road.

01/09/2014 by McDougall Government response not required
SG - Non-inquest findings (PDF, 58.7 KB)

Investigation, health care related, central venous line arterial puncture, vascular complication.

01/09/2014 by Lock Government response not required
Greenfield, Walter Robert (PDF, 112.4 KB)

Cairns Regional Council, road work, line marking, Traffic Guidance System, Manual of Uniform Traffic Devices.

26/08/2014 by Bentley Government response not required
Punch, Jamie Robert Joseph (PDF, 72.2 KB)

Death in custody, police pursuits.

12/08/2014 by Ryan Government response not required
Crane, Sylvia - Non-inquest findings (PDF, 69.7 KB)

Health care, waiting lists.

11/08/2014 by Lock Government response not required
Lam, Wai Kim (PDF, 101.5 KB)

Drowning, Great Barrier Reef, Office of Fair and Safe Work Queensland, non-compliance with investigation; breath hold diving.

11/08/2014 by Bentley Response to Lam, Wai Kim PDF, 213.8 KB
A four month old baby - Non-inquest findings (PDF, 42.5 KB)

Death of a baby, sudden infant death syndrome, Department of Communities, Child Safety and Disability Services.

07/08/2014 by McDougall Government response not required
Olive, Thomas (Tom) Andrew (PDF, 156.7 KB)

Health care related death, rhabdomyolysis, LPIN1 gene.

05/08/2014 by Lock Government response not required
A Sailing Competitor - Non-inquest findings (PDF, 47.0 KB)

Sailing competition danger of entrapment, trapeze harnesses, safety and rescue procedures.

04/08/2014 by Lock Government response not required
Copeland, Alison Ruth - Non-inquest findings (PDF, 42.4 KB)

Death in care, mental health and physical disabilities, access to suitable residential placements for people under 65.

28/07/2014 by Lock Government response not required
Petersen, Nicole - Non-inquest findings (PDF, 83.0 KB)

Consumption of poppy seeds and cough medicine, death from mixed drug toxicity, delay in seeking medical treatment, decision not to call an ambulance.

25/07/2014 by McDougall Government response not required
Bowling, Dianne Judith (PDF, 120.4 KB)

Mental health, case management, community and family input.

18/07/2014 by Lock Response to Bowling, Dianne Judith PDF, 316.9 KB
Su, Che-Wei (PDF, 142.3 KB)

Drowning, Mossman Gorge, Daintree National Park, Queensland Parks and Wildlife Service, Voyages Pty Ltd, Mossman Gorge Visitor Centre, Mossman River, Rex Creek

14/07/2014 by Bentley Response to Su, Che-Wei PDF, 402.9 KB
Faith, an 8 year old child (PDF, 195.2 KB)

Child death, child protection, Department of Communities, Child Safety and Disability Services, Department of Education, Training and Employment, child notifications, truancy, Centrelink, information sharing.

27/06/2014 by Bentley Response to Faith, an 8 year old child PDF, 548.4 KB
O - Non-inquest findings (PDF, 39.5 KB)

Anaesthetics, APHRA and HQCC investigation, unsatisfactory professional performance.

20/06/2014 by Lock Government response not required
Murray, Vaughan (PDF, 65.3 KB)

Death of a baby, suspicious circumstances, evidence of previous inflicted injury.

17/06/2014 by Hutton Government response not required
Mahlo, Karen Lee (PDF, 78.9 KB)

Suicide investigation.

13/06/2014 by Clements Government response not required
O'Shea, Kathleen Mary (PDF, 80.8 KB)

Missing person, disappearance.

12/06/2014 by Bentley Government response not required
Milner, Laura Jayne; Yates, Samantha Ann (PDF, 37.0 KB)

Motor vehicle accident, B double heavy vehicle combination.

10/06/2014 by Baldwin Government response not required
Bennett, Scott Anthony (PDF, 155.0 KB)

Motor vehicle crash, road train jack-knife, mechanical defects, road design.

05/06/2014 by Lock Response to Bennett, Scott Anthony PDF, 314.5 KB
Humm, Deborah Lee (PDF, 83.5 KB)

Suicide, domestic violence, fall.

29/05/2014 by Bentley Government response not required
Ellison, Ronald; Sylvester, Jacqueline (PDF, 84.7 KB)

Death in police operations, attempted intercept.

20/05/2014 by Ryan Government response not required
C a motor racing participant - Non-inquest findings (PDF, 37.2 KB)

Motor racing competition, recommendations for mandatory use of Forward Head Restraints.

01/05/2014 by Lock Government response not required
McGrath, Nathan David (PDF, 113.3 KB)

Death in custody, drug overdose, unclothed searches of prisoners.

17/04/2014 by Ryan Government response not required
Zessin, Ralph Frederick (PDF, 83.8 KB)

Head injuries from a fall, whether pushed or fell.

02/04/2014 by Lock Government response not required
Platt, Christopher Robert Edmund - Non-inquest findings (PDF, 93.8 KB)

Investigation, death not reported to coroner, health care related death, referral to Australian Health Practitioner Regulation Agency, disciplinary proceedings.

31/03/2014 by Lock Government response not required
Baby T - Non-inquest findings (PDF, 51.1 KB)

Death of a baby, baby slings.

25/03/2014 by Lock Government response not required
Birt, Dulcie Isabelle (PDF, 149.5 KB)

Missing person, body not found, conviction on plea of guilty for manslaughter, circumstances of death uncertain.

21/03/2014 by Lock Government response not required
Nixon, Carey Scott (PDF, 104.7 KB)

Motor vehicle/motor cycle crash, road rage.

21/03/2014 by Lock Government response not required
Molloy, Michael Patrick (PDF, 73.1 KB)

Suicide, presumption against suicide, motor vehicle accident.

12/03/2014 by Bentley Government response not required
Forster, Adam Douglas (PDF, 38.2 KB)

Work-place accident, small business, ball-mill.

06/03/2014 by Comans Response to Forster, Adam Douglas PDF, 331.6 KB
Willis, Karen - Non-inquest findings (PDF, 74.2 KB)

Asian herbal weight-loss medication, Slimming Factor, Sibutramine, cardiac issues.

12/02/2014 by McDougall Government response not required
Caulton, Van Edward (PDF, 67.0 KB)

Missing person,Centrelink.

11/02/2014 by Bentley Government response not required
Johnson, Nicholas Peter (PDF, 156.1 KB)

Fire, farmstay, budget accommodation, petrol generator, fire safety, rural numbering.

07/02/2014 by Hutton Response to Johnson, Nicholas Peter PDF, 357.5 KB
King, Richard James - Non-inquest findings (PDF, 104.5 KB)

Maritime collision, boat and surfer, Currumbin Bar.

05/02/2014 by McDougall Government response not required
George, Lynda Margaret - Non-inquest findings (PDF, 105.7 KB)

Death in hospital, surgery, deteriorating patient, post-operative care.

31/01/2014 by McDougall Government response not required
Lingwood, Craig Steven (PDF, 118.3 KB)

Death in custody, recognition of melanoma, management of urgent referrals to external providers, follow-up care.

24/01/2014 by Ryan Government response not required
Peuckert, Bay Roxas - Non-inquest findings (PDF, 67.1 KB)

Farming incident, unsafe work practices, cherry picker.

24/01/2014 by McDougall Government response not required

Back to top

2013

Name/event Findings delivered Government response
Woods, Gavin Lyle (PDF, 160.2 KB)

Education, workplace bullying/harassment, mental health illness, suicide.

11/12/2013 by Lock Response to Woods, Gavin Lyle PDF, 236.5 KB
Cook, Jenny Lee (PDF, 147.1 KB)

Suicide, police investigation.

06/12/2013 by Bentley Response to Cook, Jenny Lee PDF, 395.0 KB
Sims, Desmond Arthur (PDF, 83.3 KB)

Death in custody, natural causes.

06/12/2013 by Ryan Response to Sims, Desmond Arthur PDF, 311.0 KB
Beresford, Samuel John (PDF, 727.6 KB)

Gyroplane, investigatory and regulatory responsibility.

05/12/2013 by Lock Response to Beresford, Samuel John PDF, 310.7 KB
Currie, Gordon (PDF, 55.7 KB)

Death in custody, natural causes

02/12/2013 by Clements Government response not required
Sutcliffe, Peter Alan (PDF, 80.3 KB)

Death in custody, siege, hanging.

19/11/2013 by Ryan Government response not required
Pollini, Brett Andrew (PDF, 129.9 KB)

Suicide, bipolar affective disorder, child support agency.

11/11/2013 by Lock Government response not required
Wirraway Aircraft Crash (PDF, 1.1 MB)

Wirraway Aircraft crash 1950, aerodynamic stall, shark spotting, RAAF, re-opening of inquest.

05/11/2013 by Lock Government response not required
Coulson, Elliott John (PDF, 54.1 KB)

Death in custody, execution of extra-territorial search warrant, death so as to avoid being placed in police custody.

04/11/2013 by Clements Government response not required
Loveday, Marcia Joy (PDF, 183.8 KB)

Death in hospital, Ampicillin administered to patient allergic to penicillin, patient wearing medical alert bracelet, patient had existing hospital file noting allergies, cause of death, anaphylaxis or underlying conditions, hospital procedures reviewed, comment on design and use of medical alert devices.

28/10/2013 by O'Connell Response to Loveday, Marcia Joy PDF, 404.9 KB
Draney, Kenneth (PDF, 54.5 KB)

Death in custody, natural causes.

09/10/2013 by Ryan Government response not required
Hempel, Barry Ian; Lovell, Ian Ross (PDF, 98.8 KB)

Air crash, licensing, medical condition, mandatory reporting, epilepsy.

04/10/2013 by Hutton
McPhee, Timothy (PDF, 82.4 KB)

Workplace accident, house removal, building collapse when the jack was released, cause of collapse, whether reasonable precautions were taken.

30/09/2013 by O'Connell Response to McPhee, Timothy PDF, 328.9 KB
Taylor, Scott Matthew (PDF, 92.0 KB)

Death in police custody, Tasers.

24/09/2013 by Ryan Government response not required
Emerton, Andrew John Joseph (PDF, 97.4 KB)

Death in custody, natural causes.

24/09/2013 by Ryan Government response not required
Bligh, William John - Non-inquest findings (PDF, 68.9 KB)

Melioidosis, Palm Island, clinical management.

12/09/2013 by Bentley Government response not required
Quartermain, Robert George (PDF, 50.1 KB)

Death in custody, natural causes.

11/09/2013 by Ryan Government response not required
Morris, David Samuel (PDF, 46.8 KB)

Death in custody, natural causes.

11/09/2013 by Ryan Government response not required
Sparreboom, Sophie Claire - Non-inquest findings (PDF, 193.8 KB)

Child Birth, Gestational Diabetes, Induction, CTG Tracing Interpretation, Whether Caesarean section should have been escalated.

05/09/2013 by Lock Government response not required
Auld, Michael Earle (PDF, 587.2 KB)

Mining inquest, service crew member crushed between working platform on loader and tray of Landcruiser, safe working procedures, safety awareness.

26/08/2013 by Priestly Government response not required
Tuppurainen, Pekka (PDF, 745.9 KB)

Underground mine at Mt Isa, inadvertent entry of loader into stope, traumatic asphyxiation of operator, adequacy of control measures, adequacy of remedial action, implications of incident for effectiveness of safety management system.

20/08/2013 by Priestly Government response not required
Morris, Daniel Paul (PDF, 116.4 KB)

Electrocution, welding, Australian Standards, AS1674.2, Code of Practice, hazard-reducing devices, voltage reduction devices.

15/08/2013 by Bentley
Brennan, Phil John Richard (PDF, 106.1 KB)

Phil John Richard Brennan, Ipswich, disabled child, child safety notifications, duty of care to disabled children by government departments and non-government organisations, adequacy of medical care.

05/07/2013 by MacCallum Government response not required
Fuller, Matthew James; Barnes, Rueben Kelly; Sweeney, Mitchell Scott (PDF, 743.2 KB)

Insulation, metal staples, Home Insulation Program, workplace health and safety.

04/07/2013 by Barnes Response to Fuller, Matthew James; Barnes, Rueben Kelly; Sweeney, Mitchell Scott PDF, 318.2 KB
Black, Maryellen (PDF, 138.3 KB)

Involuntary patient, Mental Health Unit, Cairns Base Hospital, absconding and suicide, management of risk of absconding.

02/07/2013 by Priestly
Justin (PDF, 128.7 KB)

Inpatient suicide, choking on bar of soap, clinical management of long term, acute and complex patients, environmental risk management.

02/07/2013 by Priestly
Saccu, Jonathan Clarence (PDF, 133.3 KB)

Absconding from Mental Health Unit, suicide, management of risk of absconding, diagnosis and treatment, periodic observations, physical layout and proximity of reception to main entrance to Unit.

02/07/2013 by Priestly
Evans, Wendy Joy; Wilson, Lorraine Ruth (PDF, 229.5 KB)

Re-opened Inquest, suspicious deaths.

28/06/2013 by Barnes Government response not required
Protheroe, Jason Paul (PDF, 428.5 KB)

Death in custody, shooting.

14/06/2013 by Barnes Response to Protheroe, Jason Paul PDF, 337.5 KB
Garrett-Pratt, Jake Michael (PDF, 272.1 KB)

Child, ride-on lawn mower, rural property.

31/05/2013 by Lock Response to Garrett-Pratt, Jake Michael PDF, 250.7 KB
Hussain, Meqdad (PDF, 173.5 KB)

Death in custody, suicide, asylum seeker.

27/05/2013 by Barnes Government response not required
Thoresen, Cynthia (PDF, 1.1 MB)

Fall at home, failure to get medical attention, elderly neglect.

22/05/2013 by Clements Response to Thoresen, Cynthia PDF, 214.9 KB
Lalara, Hazel Marie (PDF, 120.6 KB)

Death in custody, mental health care of prisoners.

16/05/2013 by Barnes Government response not required
Weazel, Maureen Ann (PDF, 65.2 KB)

Whether there was an unreasonable denial of access to, and as a result treatment at, Cherbourg Hospital.

10/05/2013 by Barrett Government response not required
Thompson, Leanne Melissa (PDF, 196.2 KB)

Hanging, forensic evidence, Child Protection.

03/05/2013 by Lock Government response not required
Brockel, Ronald James (PDF, 208.5 KB)

Medical error, placement of feeding tube and review.

19/04/2013 by Barnes Government response not required
Hornby, Geoffrey John (PDF, 179.9 KB)

Death in custody, cardiac arrest, CPR, chest compressions.

19/04/2013 by Barnes
McCarty, Lawrence (PDF, 150.3 KB)

Death in custody, suicide, use of razor blades in prison, adequacy of medical care, adequacy of supervision of prisoners.

18/04/2013 by Barnes Response to McCarty, Lawrence PDF, 213.3 KB
Borusiewicz, Luke Anthony (PDF, 825.3 KB)

Child in foster care, fall from bed while unsupervised, severe head injury, no external signs of injury, child thought to be sleeping, later discovered unconscious.

16/04/2013 by Priestly
Maitland, Michelle (PDF, 265.5 KB)

Sporting club, gymnastics, fall, head injury, uncovered concrete floor, matting requirements, safety risk management, state and national association support.

12/04/2013 by Priestly Government response not required
Ware, Benjamin Richard (PDF, 138.0 KB)

Apparently intoxicated person admitted to Diversionary Centre during evening, failed to wake next morning, later found unconscious, died due to head injury, quality of care, adequacy of procedures to guide staff, quality of oversight by funding authority.

28/03/2013 by Priestly
Lambert, Stuart John (PDF, 168.2 KB)

Disabled adult, respite care, appropriateness of care and treatment, Disability Services, independent service providers.

28/03/2013 by MacCallum Government response not required
Vearncombe, Muraka Jenny (PDF, 443.2 KB)

Operation of slasher, ejection of debris, traumatic head injury, experienced operator, use of manufacturer’s safety information, adequacy of WHS investigation, missed opportunities for better industry awareness.

28/03/2013 by Priestly
Owens, Kenneth Roland; Stiller, Daniel Arthur (PDF, 267.8 KB)

Wide loads management, investigations of police related fatalities.

15/03/2013 by Barnes Response to Owens, Kenneth Roland; Stiller, Daniel Arthur PDF, 362.1 KB
Morgan, Charles Ross Maxwell (PDF, 131.5 KB)

Train overrun, suicide or accident.

15/03/2013 by Lock Government response not required
Arnold, Vicki; Leahy, Julie-Anne (PDF, 521.0 KB)

Re-opened inquests; principles applicable; circumstantial evidence; flawed investigations.

01/03/2013 by Barnes Response to Arnold, Vicki; Leahy, Julie-Anne PDF, 306.6 KB
SH and AW (PDF, 209.4 KB)

Suicide whilst inpatient, absconding, observation and leave policies, 'hotspot' for suicide, suitability of acute unit for some patients.

25/01/2013 by Lock Response to SH and AW PDF, 522.0 KB
Ryan, Adam Trent (PDF, 246.5 KB)

Adequacy of medical, nursing and mental health care at Charleville Hospital.

18/01/2013 by Rinaudo Response to Ryan, Adam Trent PDF, 409.6 KB

Back to top

2012

Name/event Findings delivered Government response
Evans, William Alfred (PDF, 130.8 KB)

Death in custody, natural causes.

19/12/2012 by Barnes
Gerhardt, Robert John (PDF, 140.7 KB)

Death in custody, natural causes.

19/12/2012 by Barnes
Mitchell, Herbert John (PDF, 101.2 KB)

Death in custody; assessment and care of intoxicated prisoners; diversion of intoxicated persons.

14/12/2012 by Barnes Response to Mitchell, Herbert John PDF, 396.5 KB
Ley, Michael David (PDF, 154.3 KB)

Death in custody, assessment and care of intoxicated prisoners.

12/12/2012 by Barnes
Robinson, Nathan Kevin; Tschannen, Scott (PDF, 88.4 KB)

Prawn trawler, hook-up and rollover, two crew trapped within, trawler sinks, cause of rollover, location of Master on trawler at moment of rollover.

10/12/2012 by Priestly
Cooper, Gerry Maxwell (PDF, 160.0 KB)

Death in custody, natural causes.

07/12/2012 by Barnes
Bramble, Julie Anne (PDF, 197.8 KB)

Death at home from septicaemia, housemates did not seek medical attention, whether there was a duty owed by housemates to deceased (referral).

06/12/2012 by Hennessy
Death of an infant (PDF, 83.5 KB)

Death of an infant, suspicious circumstances, evidence of inflicted injury.

06/12/2012 by Clements
McNaught, Judith (PDF, 231.0 KB)

Health-related death, death from septic shock following bile leak from laparoscopic cholecystectomy, whether medical care was adequate, whether nursing care adequate after patient transferred to low dependency unit one day post-surgery, referral of surgeons to AHPRA.

06/12/2012 by Hennessy
Death of a Baby - Non-inquest findings (PDF, 38.2 KB)

Death of a baby, vitamin k injections, subdural and subarachnoid haemorrhages, due to late onset vitamin K deficiency bleeding.

03/12/2012 by Clements
Hammett, Christopher (PDF, 163.1 KB)

Death in a medical setting; appropriateness of medical care; policies and procedures; post operative death by aspiration pneumonia; lack of care by post operative medical staff.

28/11/2012 by Hutton
Cardwell, Elizabeth Joan; Cardwell, Isabella Rose; Sanderson, Gregory Ryan (PDF, 140.1 KB)

Motor vehicle crash, triple fatality, speeding, second hand baby capsules.

19/11/2012 by Lock
Oakley, Meleta Eliza (PDF, 114.2 KB)

Death in custody, police pursuit.

15/11/2012 by Barnes
Galeano, Antonio Carmelo (PDF, 891.0 KB)

Death in custody; mental health assessment; protracted struggle with police; multiple & prolonged Taser activations; oleoresin spray; paramedic attendance; excited delirium; emergency management of highly agitated, likely drug affected individuals.

14/11/2012 by Clements Response to Galeano, Antonio Carmelo PDF, 352.6 KB
Biddulph, Jayde Stephen Donovan (PDF, 118.9 KB)

Death in custody, assessment of risk of prisoner to prisoner violence.

13/11/2012 by Barnes
Lowe, George Robert (PDF, 138.4 KB)

Police pursuit.

02/11/2012 by Barnes
Cavanagh, Barry William (PDF, 95.4 KB)

Police pursuit.

01/11/2012 by Barnes
Short, James Leon (PDF, 138.8 KB)

Truck, dog trailer, pedestrian over-run, reversing alarms.

01/11/2012 by McDougall
Chen, Sen Hung (PDF, 77.5 KB)

Death in custody, natural causes.

26/10/2012 by Barnes
Paudel, Preston (PDF, 307.1 KB)

Childbirth, CTG Tracing Interpretation, whether caesarean section should have been escalated

25/10/2012 by Lock Response to Paudel, Preston PDF, 216.0 KB
Anderson, Stanley Charles (PDF, 123.8 KB)

Death in a Nursing Home, design of the hoist and sling, level of care, whether procedures and protocols were appropriate.

19/10/2012 by Baldwin
Plumb, Joshua Jai (PDF, 123.8 KB)

Special needs child in hospital, type and frequency of nursing observations, hospital beds, bed bumpers, entrapment of head, cause of death including asphyxia, aspiration, pneumonia, epilepsy, neurological impairment

18/10/2012 by Clements
Boon, Jennifer Ann (PDF, 90.8 KB)

Multi passenger vehicle, death of alighting passenger

10/10/2012 by Tonkin Response to Boon, Jennifer Ann PDF, 309.8 KB
Harold, Rex (PDF, 96.7 KB)

Death in custody; natural causes

28/09/2012 by Clements
Davies, Mia (PDF, 249.9 KB)

Child Birth, CTG tracing interpretation, whether caesarean section should have been escalated

28/09/2012 by Lock Response to Davies, Mia PDF, 228.8 KB
Howse, Troy Jason (PDF, 97.3 KB)

Motor vehicle accident, identity of driver, refusal of doctors to allow a blood specimen to police during investigation of fatal accident, referral to Director of Public Prosecutions

20/09/2012 by Hennessy
Diefenbach, Isabella Wren (PDF, 351.9 KB)

inspection of decks and verandahs in rental properties for structural integrity, responsibilities and practices of real estate agents in inspections and receipt of expert reports and attending to repairs, accidental death of baby

19/09/2012 by Hennessy Response to Diefenbach, Isabella Wren PDF, 425.4 KB
Isles, MIchael (PDF, 574.9 KB)

Missing person, suicide, work place management

14/09/2012 by Barnes
Cundy, Cherie (PDF, 70.2 KB)

Adequacy and appropriateness of QPS response to 000 call, excited delirium

13/09/2012 by Hutton
Parry, Nerida Ann (PDF, 66.8 KB)

Laparoscopic cholecystectomy surgery, medical record keeping, contact with on-call doctors, hospital communication

06/09/2012 by Rinaudo
Hay, Donald Mervyn (PDF, 72.2 KB)

Death in custody, natural causes.

05/09/2012 by Barnes
Atfield, Kelvyn John (PDF, 82.4 KB)

Weapon/Firearm related.

04/09/2012 by Hennessy
Cartledge, Adam (PDF, 97.3 KB)

death in custody; hanging points

29/08/2012 by Barnes Response to Cartledge, Adam PDF, 233.6 KB
Ferguson, Angus William Keith (PDF, 105.3 KB)

Police pursuits.

22/08/2012 by Barnes
Krog, Shane Paul (PDF, 131.6 KB)

Death in a medical setting, appropriateness of medical care, policies and procedures.

13/08/2012 by Taylor
Van Moolenbroek, Gregory David (PDF, 53.5 KB)

Rural property numbering; ambulance response.

10/08/2012 by Hutton
Barnett-Lonergan, Patrick Hugo (PDF, 42.3 KB)

Missing person; fishing trawler.

08/08/2012 by Hutton
Bucknall, David John (PDF, 90.3 KB)

Death in custody; suicide; psychiatric care of prisoners.

07/08/2012 by Barnes
Patient A (PDF, 165.2 KB)

Suicide, mental health, treatment approach - in community or admit to hospital, communication with family, adequacy of root cause analysis.

05/07/2012 by Lock
Robinson, Ian; Charlesworth, Natarsha; Hatzidimitriadis; Park, Sang Won; Choi Seongeun (PDF, 78.6 KB)

Adequacy of regulatory framework covering white water rafting.

29/06/2012 by Priestley
MacNicol, Jack Wallace (PDF, 56.7 KB)

Fatal head injury while mustering cattle on motorcycle; not wearing helmet; adequacy of regulatory standards.

29/06/2012 by Priestly Response to MacNicol, Jack Wallace PDF, 308.9 KB
Baby M (PDF, 119.3 KB)

Childbirth at home, unknown preganancy.

29/06/2012 by Lock
Paton, Daniel William (PDF, 104.9 KB)

Post-operative pain management; use of patient controlled analgesia; concurrent administration of Temazepam and Phenergan; respiratory depression, obstructive sleep apnoea; sedation scoring.

22/06/2012 by Clements
Dixon, Steven John (PDF, 72.8 KB)

Death in custody; sudden unexpected death in epilepsy; appropriateness of medical care; policies and procedures.

22/06/2012 by Clements
Gold Coast Murder Suicide (PDF, 226.7 KB)

Murder/suicide; domestic violence.

21/06/2012 by Barnes
Inquest into the deaths caused by the South-East Queensland floods of January 2011 (PDF, 2.3 MB)

South-East Queensland floods.

05/06/2012 by Barnes
Perry, Anthony Mark (PDF, 89.5 KB)

Death in custody - police watch house; accidental overdose; assessment of intoxicated prisoners.

31/05/2012 by Barnes Response to Perry, Anthony Mark PDF, 212.8 KB
Watson, Eric Handley (PDF, 93.7 KB)

Death in custody, natural causes.

31/05/2012 by Barnes
S (PDF, 218.9 KB)

Death in care, child in care of Child Safety; absconding from care; appropriateness of placement of child; management of conflict with other child placed in the same facility; communication from service provider to Department; adequacy of Police search for missing child.

22/05/2012 by Hennessy
Lyne, Richard Henry (PDF, 38.3 KB)

Death in custody; natural causes.

20/04/2012 by Clements
Gates, Tony William (PDF, 72.6 KB)

Death in custody, adequacy of medical care at Wolston Correctional Centre.

16/04/2012 by Clements Response to Gates, Tony William PDF, 397.7 KB
Wall, Timothy John (PDF, 30.9 KB)

Motorcycle collision with pedestrian, identification of rider.

05/04/2012 by Lock Response to Wall, Timothy John PDF, 210.0 KB
McKenzie, Brett Alexander Kevin; Ezzy, Abigail Denise; Nolan, Nicholas James; Thorley, Maxwell Ernest (PDF, 224.0 KB)

Multiple fatality motor vehicle crash.

03/04/2012 by Previtera
Fraser, Leonard John (PDF, 82.1 KB)

Death in custody; natural causes.

20/03/2012 by Barnes
Ford, Stuart Cecil (PDF, 108.0 KB)

Death in custody; suicide.

06/03/2012 by Barnes
Law, Roslyn Amelia (PDF, 152.6 KB)

Motor vehicle crash; cattle straying on rural roads; fencing and rule in Searle v Wallbank; impairment due to cannabis intake; blood tests policy.

01/03/2012 by Lock
Vaggs, Lyji (PDF, 228.2 KB)

Death in custody; restraint in hospital.

21/02/2012 by Barnes
Mitchell, Robert Gary (PDF, 75.8 KB)

Death in custody; suicide; hanging points.

20/01/2012 by Barnes Response to Mitchell, Robert Gary PDF, 233.6 KB

Back to top

2011

Name/event Findings delivered Government response
Inglis, Tracey Lee (PDF, 98.3 KB)

Death in custody, suicide, management of pain relief.

09/12/2011 by Barnes
Tait, Graham (PDF, 321.8 KB)

Electrocution; contact with fallen powerlines; response to initial fault report; conductor clashing and short circuit fault protection measures; investigation by Electrical Safety Office and Workplace Health and Safety Queensland.

09/12/2011 by Brassington
Four Winns (PDF, 100.7 KB)

Recreational boating fatality; collision at sea; navigating in conditions of reduced visibility; "situational awareness"; recreational boat licensing.

25/11/2011 by Clements
Choi, Seongeun; Park, Sang Won (PDF, 500.7 KB)

Adventure tourism; white water rafting; Tully River; 8 person rafts; collision between rafts; diversion to hazardous route; capsize and entrapment with prolonged period of immersion; drowning; adequacy of safety risk management.

24/11/2011 by Priestly
Schumacher, Ross Philip (PDF, 242.3 KB)

Gun shot wound to the head; gun shot residue; contact wounds; adequacy of police investigation.

04/11/2011 by Lock
Smith, Darryl Robert (PDF, 269.7 KB)

Death in a medical setting; adequacy of surgical equipment and management.

04/11/2011 by Lock
Robinson, Ian (PDF, 632.3 KB)

Adventure tourism; white water rafting; Tully River; 8 person rafts; capsize; entrapment with prolonged period of immersion; drowning; adequacy of safety risk management.

03/11/2011 by Priestly
Hatzidimitriadis, Georgina (PDF, 1.1 MB)

Adventure tourism; white water sports rafting; two person inflatable rafts; Russell River; 2 guides and 11 rafters; capsize and entrapment; drowning; limited understanding of English; limited paddling proficiency.

03/11/2011 by Priestly
Charlesworth, Natarsha (PDF, 802.0 KB)

Adventure tourism; white water rafting; Tully River; 8 person rafts; capsize; entrapment; prolonged period of immersion; drowning; adequacy of safety risk management.

03/11/2011 by Priestly
Currie, Sheldon Douglas (PDF, 93.0 KB)

Death in custody, health care, infectious diseases.

03/11/2011 by Barnes
Parsons, Anthony John (PDF, 77.4 KB)

Death in custody; siege.

21/10/2011 by Barnes
Hornby, Grace Ann; Hornby, Jessica Lee; Mansell, Denise Ann; Thomson, Anthony Paul (PDF, 161.4 KB)

Motor vehicle accident, adequacy of safety precautions at intersection, mandatory reporting by health professionals concerning impaired drivers.

20/10/2011 by Callaghan
Death of a prisoner (PDF, 93.0 KB)

Death in custody, suicide.

14/10/2011 by Barnes
Bonanno, Gregory Stephen (PDF, 65.2 KB)

Motor vehicle accident on country road following resurfacing roadworks, whether signage at roadworks was sufficient, whether loose surface on road, whether training sufficient for traffic control operators.

11/10/2011 by Hennessy
JTN and AJN (PDF, 99.6 KB)

Young children perished in house fire, poor supervision, poor living conditions, access to lighters, previous intervention by Department of Child Safety, Queensland Health, whether authorities should have been involved with family at time of fire.

10/10/2011 by Hennessy
Saunders, Ryan Charles (PDF, 162.6 KB)

Death of a child, Rockhampton Base Hospital, appropriateness of medical care, policies and procedures.

07/10/2011 by Barnes Response to Saunders, Ryan Charles PDF, 320.3 KB
Tiers, Matthew Maurice (PDF, 90.9 KB)

Death in custody, natural causes.

29/09/2011 by Barnes
Long, Kerry-Ann (PDF, 95.7 KB)

Death in custody, natural causes; adequacy of medical and emergency treatment.

20/09/2011 by Clements
Anderson, John Clive (PDF, 74.7 KB)

Death in custody; subacute infective endocarditis; specialist referral.

20/09/2011 by Clements
Grillo, Carl Antony (PDF, 94.3 KB)

Death in custody; vascular neck restraint; positional asphyxia.

07/09/2011 by Barnes
Jones, Adrian Elliott (PDF, 205.3 KB)

Motor bike accident, debris on road after drilling, adequacy of police investigation.

24/08/2011 by Callaghan
Bird, Saxon Phillip (PDF, 225.4 KB)

Surf life saving; risk management.

02/08/2011 by Barnes
Gitanjali (PDF, 140.0 KB)

Self-immolation.

15/07/2011 by Lock Response to Gitanjali PDF, 311.1 KB
Heidrich, Bela (PDF, 158.2 KB)

Overlaying/smothering of newborn in hospital; breastfeeding lying down and supervision by nursing staff; breastfeeding policies.

29/06/2011 by Hennessy
Elshazly, Hossam Mohamed (PDF, 402.9 KB)

Collision; cyclist and truck at roundabout; design standard of roundabout at construction; current design standard; need for road authority to monitor risk and consider retrofitting roundabouts to current standard.

29/06/2011 by Priestly Response to Elshazly, Hossam Mohamed PDF, 431.8 KB
Sleba, Leanne Margaret (PDF, 130.6 KB)

Gunshot, accidental, criminal negligence, intentional, open finding.

27/06/2011 by Previtera
(C) a 15 month old child (PDF, 432.1 KB)

Burns, trauma, Communications between government agencies.

27/06/2011 by Lock Response to (C) a 15 month old child PDF, 316.6 KB
Crooks, Phyllis Anne (PDF, 101.4 KB)

Police pursuit.

22/06/2011 by Barnes
Chung, Sanglin; McGreevy, Moira Therese; McGreevy, Glen Raymond; Purdy, Rachel Gai; Whitmore, Cory James; Hamilton, Mark (PDF, 169.3 KB)

Motor vehicle accident, Bruce Highway south of Gympie.

22/06/2011 by Baldwin
Conlan, Kathleen Anne (PDF, 100.1 KB)

Death in a medical setting.

14/06/2011 by Barnes
Tranby, James Errol (PDF, 117.9 KB)

Death in custody, necrotising fasciites.

09/06/2011 by Barnes
Rawlins, Edward Arthur Anthony (PDF, 71.6 KB)

Death in custody, natural causes.

01/06/2011 by Barnes
Frost, Margery (PDF, 54.5 KB)

Nursing Home, staffing levels, storage of lifting hoist.

31/05/2011 by MacCallum
Bell, Christopher Steven (PDF, 112.8 KB)

Death in custody, hanging; adequacy of psychiatric treatment; history of suicide attempts; hanging points.

26/05/2011 by Barnes Response to Bell, Christopher Steven PDF, 233.6 KB
Barrie, Albert Edward (PDF, 55.3 KB)

Facilities for Crossing public road in vicinity of social venue; visibility around crossing area on public road at night; pedestrian safety.

10/05/2011 by Hennessy
Hoy, Samara Lee (PDF, 167.2 KB)

Death of baby, tight umbilical cord around neck, meconium aspiration, appropriateness of medical care, policies and procedures.

05/04/2011 by Hutton Response to Hoy, Samara Lee PDF, 215.4 KB
Clarke, Daniel James (PDF, 160.1 KB)

Death in custody; siege.

25/03/2011 by Barnes
MacKenzie, Malcolm; Brown, Graham; Wilson, Robert (PDF, 235.8 KB)

Fatal motor vehicle collisions occurring after drivers completed shift at mines in Bowen Basin; Fatigue in drivers; Commuting to mine sites; Policing of Fatigue Driving.

23/02/2011 by Hennessy Response to MacKenzie, Malcolm; Brown, Graham; Wilson, Robert PDF, 337.2 KB
Collinson, Clay Marsden (PDF, 77.6 KB)

Death in custody, police pursuit, compliance with QPS policy.

16/02/2011 by Barnes
Spicer, Phillip Glenn (PDF, 76.1 KB)

Death in custody, police pursuit, compliance with QPS policy.

09/02/2011 by Barnes

Back to top

2010

Name/event Findings delivered Government response
Bell, Jennifer Elizabeth (PDF, 136.6 KB)

Suicide, traffic incident, adequacy of clinical handover and psychiatric reviews.

16/12/2010 by Hodgins
King, Brenda Elizabeth (PDF, 105.5 KB)

Head injuries.

13/12/2010 by Lock
2 year old child (PDF, 103.7 KB)

Child drowning, adequacy of supervision, swimming pool leglslation.

13/12/2010 by Lock
Bennett, James Andrew (PDF, 587.7 KB)

Natural swimming hole within Council Reserve effectiveness of warning signs and safety rails need for exclusion zone.

10/12/2010 by Priestly
Francis, Marty Tanui (PDF, 89.1 KB)

Death in custody, police pursuit.

17/11/2010 by Barnes
Spence, Samantha Rose (PDF, 177.2 KB)

Death of a child, scoliosis correction, Chiari type 1, necessity of brain and spinal scanning.

29/10/2010 by Clements
Paterson, Gregory Clifford (PDF, 638.4 KB)

Concrete pumping, hose whip, supervision of construction site, Workplace Health and Safety.

18/10/2010 by Priestly
Little Gungallida Girl (PDF, 109.9 KB)

Death of a child, adequacy of nursing and medical reviews, quality of care and treatment at Doomadgee Hospital, cultural sensitivity issues relating to the death of Aboriginal and Torres Strait Islander persons.

18/10/2010 by Priestly
Barker, Jeremy Dylan (PDF, 96.3 KB)

Death in custody, hanging points, observation of “at risk” prisoners.

08/10/2010 by Barnes
Dyer, Alan Kent (PDF, 156.3 KB)

Police shooting, self defence, mental illness, tasers.

29/09/2010 by Barnes
Petersen, David Robert (PDF, 139.2 KB)

Adequacy of medical treatment, ruptured spleen, referral to Medical Board.

16/09/2010 by Barnes
Simpson-Willson, John Douglas (PDF, 334.7 KB)

Mental health and intellectual disability services provided to prisoners, release planning and discharge of dangerous prisoners.

07/09/2010 by Lock Response to Simpson-Willson, John Douglas PDF, 443.5 KB
Graham, Travis Noel (PDF, 71.8 KB)

Pharmacies filling prescriptions, Seroquel (Quetiapine) overdose, history of attempted suicide, cancellation of prescriptions.

03/09/2010 by Ryan
Muir, Jason Andrew (PDF, 90.4 KB)

Death in custody, hanging points, medication non-compliance.

31/08/2010 by Clements
Clumpoint, Thomas Andrew (PDF, 143.7 KB)

Death in custody, natural causes; adequacy of medical and emergency treatment; cell intercom system faults; contingency planning.

27/08/2010 by Clements
Bellamy, Gordon John (PDF, 107.5 KB)

Police pursuits.

25/08/2010 by Barnes
Dossetto, Kate Emma (PDF, 40.8 KB)

Sertraline toxicity.

19/08/2010 by MacCallum
Watego, Stewart Clint (PDF, 52.7 KB)

Death of a pedestrian, Motor Vehicle Accident, MacMillan Street, Ayr, 17th September 2006.

19/07/2010 by Mack
Bornen, Andrew John (PDF, 124.4 KB)

Death in police custody, restraint on a road, policing at night.

16/07/2010 by Barnes
Mataia, Tofia Josen (PDF, 165.6 KB)

Death in custody, restraint asphyxia, managing prisoners with mental illness, emergency responses.

09/07/2010 by Barnes
Spencer, Annette Lee (PDF, 401.0 KB)

Balcony collapse, method of construction, adequacy of building inspections, bearer span width and renovations.

28/06/2010 by Lock
Livermore, Scott Phillip (PDF, 44.0 KB)

Motor vehicle accident, reporting of any mental or physical incapacity to the Department of Transport and Main Roads.

25/06/2010 by Taylor
Child at Rockhampton (PDF, 114.5 KB)

Child death, drowning in public pool, adequacy of supervision, Workplace, health and safety investigation.

24/06/2010 by Hennessy
Robinson, Paul Gerard Joseph (PDF, 305.4 KB)

Truck roll-over, driver error, truck maintenance, faulty brakes & inadequate signage.

24/06/2010 by Hodgins
Challis, George Edgar (PDF, 110.3 KB)

Death in custody, response of prison officers to prisoner on prisoner assaults, preservation of evidence.

17/06/2010 by Barnes
Whiting, Edith (PDF, 132.9 KB)

Unexpected outcome of health procedure, Bundaberg hospital.

11/06/2010 by Barnes
Muller, Bradley John (PDF, 133.2 KB)

Doctor shopping, pharmacies filling prescriptions, Seroquel (Quetiapine) overdose, hospital accident and emergency response.

10/06/2010 by Ryan
Edwards, Peeta Louise Josephine (PDF, 43.3 KB)

Opiate toxicity, inadequate police investigation.

09/06/2010 by Baldwin
O'Neill, Timothy Gerard (PDF, 159.7 KB)

Boating accident, night navigation, use of navigational aids, recreational boat licensing, appropriate marking of navigational hazard, sea wall.

28/05/2010 by Clements
Welburn, Dale Robert and McPherson, Kerri Leigh (PDF, 49.7 KB)

Multi vehicle road accident, Bruce Highway near Childers, driver error, poor visibility, poor road design.

21/05/2010 by Batts Response to Welburn, Dale Robert and McPherson, Kerri Leigh PDF, 289.7 KB
Cockshutt, Andrew James (PDF, 105.8 KB)

Death in custody, hanging points.

20/05/2010 by Barnes
Jeffrey, Lawrence Edward (PDF, 78.4 KB)

Death in custody, natural causes.

19/05/2010 by Barnes
Cramb, Fay - aka Valmae Beck (PDF, 158.3 KB)

Death in custody, provision of health care to impaired patients, end of life decisions by prisoners.

07/05/2010 by Barnes
Mulrunji - aka Cameron Doomadgee (PDF, 693.0 KB)

Re-opened inquest, death in custody, police investigation, Crime and Misconduct Commission.

07/05/2010 by Hine
Fraser Island 4WD Inquest - Ian Davy, Concetta Dell’Angelo and Takeshi Sakai (PDF, 217.3 KB)

Inquest into the deaths of Ian Davy, Concetta Dell’Angelo, Takeshi Sakai and the regulation of 4WD hire motor vehicles on Fraser Island.

23/04/2010 by Barnes
Gillis, Wayne Anthony (PDF, 84.1 KB)

Missing Person.

19/04/2010 by Lock
Nguyen, Luong Bang (PDF, 86.6 KB)

Death in custody, natural causes, drug addiction.

16/04/2010 by Barnes
Millard, Allan Clive (PDF, 103.4 KB)

Death in custody, natural causes, adequacy of access to medical treatment.

15/04/2010 by Barnes
Report on Police Pursuits (PDF, 160.8 KB)

Police pursuits, preventative recommendations.

31/03/2010 by Barnes
Howlett, Peter David (PDF, 77.1 KB)

Adequacy of Queensland Ambulance Service policies and procedures.

25/03/2010 by Risson
Birse, Joel Timothy (PDF, 37.5 KB)

Death of a child, Blackall Show, motor cycle accident.

24/03/2010 by Strofield
Barnes, Roy (PDF, 119.6 KB)

Death in custody, natural causes, drug withdrawal symptoms.

17/03/2010 by Barnes
Shekar, Sridhar (PDF, 71.5 KB)

Jet-ski, personal watercraft, licensing, helmets, Hire and Drive Standard 2007.

11/03/2010 by Hutton
Johnstone, Brett Thomas (PDF, 107.6 KB)

Police shooting.

10/03/2010 by Barnes
Hockey, Barry John (PDF, 86.5 KB)

Death in custody, natural causes and adequacy of medical care.

05/03/2010 by Barnes
Child at Mackay (PDF, 91.8 KB)

Suicide, 15 year old Aboriginal girl, no history of mental illness.

05/03/2010 by Kennedy
Frizzel, Casey Andrew (PDF, 173.8 KB)

Death in workplace, heat stroke on new housing construction site in tropical conditions in North Queensland, lack of first aid training in workplace, response of Queensland Ambulance Services, failure to properly preserve scene of death.

19/02/2010 by Muirhead
Preston, William Elliot (PDF, 93.5 KB)

Death in custody, natural causes, emergency access to cells.

12/02/2010 by Barnes
Pont, Elles John (PDF, 74.7 KB)

Death in custody, natural causes.

27/01/2010 by Barnes
Two children at Murgon (PDF, 51.4 KB)

Child deaths, house fire, Department of Child Safety (now Department of Communities).

18/01/2010 by Lebsanft

Back to top

2009

Name/event Findings delivered Government response
Hirning, Amanda Lee (PDF, 81.1 KB)

Inquest, pedestrian running down, motorcycle accident.

24/12/2009 by Barnes
Goodna rail incident - Duncan, Hayden; Duncan, Glen and Fisher, Reginald (PDF, 135.2 KB)

Goodna rail incident - Duncan, Hayden; Duncan, Glen and Fisher, Reginald

23/12/2009 by Barnes
Shishko, Peter (PDF, 80.1 KB)

Death in custody, natural causes, sufficiency of medical supervision and response.

16/12/2009 by Barnes
Myers, Robert Hayes (PDF, 79.3 KB)

Death in custody, natural causes, adequacy of health care.

16/12/2009 by Barnes
Davidson, Yvonne Alice (PDF, 73.6 KB)

Whether protocol applying to percutaneous tracheostomy procedure was followed by Consultant at Rockhampton Hospital, whether unsuccessful procedure contributed to death, disciplinary action taken against doctor.

16/12/2009 by Hennessy
Grace, Daniel Scott and Heffler, Raymond John (PDF, 55.4 KB)

Single vehicle transport truck rollover accident on sweeping bend leading onto bridge over creek, identity of driver in issue, driver use of amphetamines and going into bend too fast and lost control of truck, reconstruction of mechanism of incident by expert analysis.

14/12/2009 by Hennessy Response to Grace, Daniel Scott and Heffler, Raymond John PDF, 333.4 KB
Miller, Michael James (PDF, 113.6 KB)

Inquest, death in custody, suicide, water police operations

09/12/2009 by Barnes
Congoo, Sharon Faye (PDF, 57.8 KB)

Quality of care, rural community, Mareeba hospital, bacterial septicaemia, medical record keeping.

08/12/2009 by Priestly
Heywood, John Martin (PDF, 72.7 KB)

Death in custody, natural causes, adequacy of health care.

03/12/2009 by Barnes
Costelloe, Anthony Gayle (PDF, 82.9 KB)

Death in prison custody, natural causes, quality of health care, Indigenous prisoner, cross cultural awareness.

26/11/2009 by Barnes
Johnston, Margaret Allan (PDF, 215.3 KB)

Insulin, hypoglycaemic brain injury, reliability of immunoassays, medication error or maladministration.

20/11/2009 by Lock
Baker, Philip (PDF, 58.6 KB)

Medical issues - 2 falls while in hospital whether falls contributed to subdural haematoma and cause of death.

11/11/2009 by Hennessy
O'Keefe, Albert William (PDF, 56.7 KB)

Inquest - motor vehicle accident, vehicles approaching from opposite directions, single lane bitumen road - rural setting, Duchess Road

06/11/2009 by Priestly
Cullen, Matthew Raymond (PDF, 86.1 KB)

Police pursuits, extended intercepts.

05/11/2009 by Barnes
Ash, Peter Edward and Ash, Nicole Florence (PDF, 91.0 KB)

Police pursuits, obligation to abandon attempted intercept

03/11/2009 by Barnes
Juhas, Jeffrey; Donaldson, Virginia; Juhas, Jerome and McGill, Stephen (PDF, 60.2 KB)

Motor vehicle accident, vehicles approaching from opposite directions, single lane bitumen road rural setting head on collision, multiple fatalities.

28/10/2009 by Priestly
Hopkinson, Joshua Leslie (PDF, 85.9 KB)

Supervision of apprentice, refurbishment of cylinder from a drill rig, hazards of uncontrolled release of stored energy in equipment used in coal mining activities, division of authority between Coal Mining Safety and Health Act 1999 and Workplace Health and Safety Act 1995.

19/10/2009 by Risson
Anderson, Andrew Scott (PDF, 163.8 KB)

Death in care of 14 year old, Child Safety (Communities), self inflicted gun shot, consideration of options for placement of child, limited availability of foster parent families, suitability of relative carer, excessive case load pressure, absence of supervision by carer and case worker, insufficient response when child missing, illicit drug and chroming use, attempted self harm, failure to transfer case.

16/10/2009 by Clements
McBride, Edward Alexander (PDF, 180.5 KB)

Electrocution, Australian Defence Force and Church of Scientology.

15/10/2009 by Lock
Kerkvliet, Kristen (PDF, 49.4 KB)

Death of a child, Kawasaki’s Disease, care in hospital.

08/10/2009 by Baldwin
Hildebrandt, Talisha (PDF, 44.4 KB)

Death of a baby, meconium aspiration, appropriateness of medical care, policies and procedures.

07/10/2009 by Smid
Irwin, Brett Andrew and Semyraha, Craig Anthony (PDF, 199.2 KB)

Shooting of a police officer, suicide of offender, threat assessment, coordination of special emergency services

06/10/2009 by Barnes
Streader, Leon (PDF, 124.3 KB)

Death in care, level 3 accredited accommodation, extreme heat conditions, medication and underlying health all possibly contributing to death, medical record keeping, treating doctor with financial interest in premises issuing cause of death certificate

01/10/2009 by Clements Response to Streader, Leon PDF, 302.9 KB
Harvey, John Arthur (PDF, 1.3 MB)

Truck hiring process, regulatory framework.

01/10/2009 by Springer
Hadlow, Barry Gordon (PDF, 72.5 KB)

Death in custody, adequacy of health care.

29/09/2009 by Barnes
Zaza, Jean-Marie Jeremie Yannick (PDF, 139.5 KB)

Infant drowning; pool safety and inspections; “Homestay” residential arrangements; residential tenancies and pool safety; review of swimming pool safety to Queensland Government

21/09/2009 by Fingleton
Leach, Irene Clare (PDF, 48.2 KB)

Waterlifts, standards, installation, safety audits, registration with workplace health and safety authorities

15/09/2009 by Black
Helicopter crash near Gunpowder (PDF, 172.3 KB)

Inquest, helicopter accident, Chief Pilots supervision of Line Pilots, CASA’s acceptance and audit of AOC holders operations manuals.

14/09/2009 by Barnes
Blee, Jason George Elliott (PDF, 435.1 KB)

Undergound Coal Mining – crushing of worker between shuttle car and rib (wall) of heading in bord and pillar panel; Notification to next-of-kin; No go zones; Shuttle car operation and design; Autopsies in industrial accidents

10/09/2009 by Hennessy Response to Blee, Jason George Elliott PDF, 321.7 KB
Oram, Ronald Thomas (PDF, 100.2 KB)

Death in custody, natural causes, initial medical assessment, response to prison health complaint, emergency access to cells

21/08/2009 by Barnes
Duggan, David John (PDF, 115.1 KB)

Death in Hospital; possible toxicity from medication; possible "access block"

13/08/2009 by Fingleton
McLennan, Lee-Anne Gai (PDF, 81.3 KB)

Identification of the involvement of a third vehicle in motor vehicle incident; Young driver; Texting while driving; Following too close.

17/07/2009 by Hennessy
Hanrick, Caitlyn (PDF, 1.1 MB)

Police pursuits

17/07/2009 by Barnes
Coleman, Randall John (PDF, 117.4 KB)

Death in custody, Strychnine poisoning

10/07/2009 by Clements
Stanford, Tony John (PDF, 110.1 KB)

Death in custody, hanging.

03/07/2009 by Clements
Kingston, Vanessa Louise (PDF, 47.2 KB)

Motor vehicle accident, whether condition of road contributed to accident

24/06/2009 by Cornack
Nielsen, Shane Robert (PDF, 138.2 KB)

Gunshot wound to head, adequacy of Police investigation.

19/06/2009 by Lock
Emerson, Jarrod Barton (PDF, 78.4 KB)

Motor vehicle accident, pedestrian struck while walking on roadway at night, off duty police officer driving private vehicle, compellability of witness at inquest discussed, discussion of police investigating police.

19/06/2009 by McLaughlin
Hatch, Clay (PDF, 141.9 KB)

Police shooting, mental health issues.

19/06/2009 by Clements
Downing, Cheyenne Ruby (PDF, 76.9 KB)

Swimming pool drowning of a child. Recommendations concerning legislation with respect to construction and inspection of pool fencing.

01/06/2009 by Black
Woo, June (PDF, 206.6 KB)

Palliative care for terminally ill patients, consent to with holding life sustaining measures, Guardianship and Administration Act 2000.

01/06/2009 by Barnes
Maczkowiack, Peter James and Mackowiack, Pauline Anne (PDF, 86.9 KB)

Inquest epilepsy and commercial truck driver licensing.

14/05/2009 by Hennessy
Brasher, Gryphyn David (PDF, 87.2 KB)

Inquest - Motor vehicle accident, failure of mechanical actuator, hand brake, steep driveway.

14/05/2009 by MacCallum
Tilse, Therese Josephine (PDF, 54.2 KB)

Death at Townsville Hospital, excessive paracetamol ingestion, fall from bed

13/05/2009 by Mack
Hoy, Raleigh (PDF, 98.3 KB)

Inquest – the management of Tarampa After Care Centre, the accreditation of level three facilities, the medical treatment of the deceased, and the link between Clozapine (Clozaril) and cardiomyopathy.

05/05/2009 by MacCallum Response to Hoy, Raleigh PDF, 327.3 KB
Brown, Sarah Christine and Parr, Darren Mark (PDF, 76.8 KB)

Inquest – Motor vehicle accident, identification of driver

01/05/2009 by Hennessy
Broe, Stephen James (PDF, 209.8 KB)

Inquest, deep technical recreation diving, decompression illness, investigation of diving deaths.

24/04/2009 by Barnes
Joy, Michael Joseph (PDF, 329.0 KB)

Death in care.

24/04/2009 by Risson
Moore, Paul James (PDF, 102.5 KB)

Police pursuits

22/04/2009 by Barnes
Kay, Brendan Scott (PDF, 88.3 KB)

Infant death, sub-glottic stenosis, extreme prematurity, chronic lung disease, SIDS, prolonged intubation, inter-hospital communication and discharge procedures, baby capsule.

21/04/2009 by Tonkin
Madeo, Niceta Maria (PDF, 163.1 KB)

Inquest - Police pursuits

26/03/2009 by Barnes
Glasgow, Benjamin (PDF, 118.9 KB)

Inquest - Death of a Child following child birth, brow presentation, head injuries

20/03/2009 by Lock
Wright, Liam John and Powell, Charles Michael (PDF, 180.8 KB)

Inquest - Suicide by train over-run, Mental Health Services at Logan Hospital, adequacy of care and of decision making

20/03/2009 by Lock Response to Wright, Liam John and Powell, Charles Michael PDF, 216.6 KB
Woolgar, Shealah Ann (PDF, 116.9 KB)

Inquest - unexpected outcome of medical procedure, Mitral valve heart surgery, perforation of heart during surgery, Blake's tubing

20/03/2009 by Lock
Blake, Melissa Maree (PDF, 785.7 KB)

Inquest – suicide, drowning, Mental Health Service, whether treatment appropriate

16/03/2009 by Callaghan
Bauer, Maurice Henry (PDF, 123.2 KB)

Inquest – Electrocution; contractor working live at time of death; wiring rules in electricity industry; training in wiring; need for safety alerts; investigation processes for inquests when death in the workplace.

05/03/2009 by Callaghan
Cusack, Barry John Charles (PDF, 74.3 KB)

Inquest mining accident, training issues, workplace health and safety management

27/02/2009 by Luxton
Malu Sara vessel - Flora Enosa, Wilfred Baira, Ethena Enosa, Ted Harry, Valerie Saub (PDF, 627.6 KB)

Inquest, DIAC procurement procedures, AMSA survey regime, MSQ boat builder accreditation regime, QPS and ATSB investigation methods.

12/02/2009 by Barnes
Lee-Chue, Allan Duncan (PDF, 91.4 KB)

Inquest, death in custody, natural causes.

10/02/2009 by Barnes
Clarke, Jon Edward Norman (PDF, 38.5 KB)

Inquest – chronic schizophrenia-paranoid type, heatstroke, effects of Clozapine

09/02/2009 by Taylor
Zulpo, Kate Leanne (PDF, 29.5 KB)

Inquest - Motor Vehicle Accident, condition of roadway

09/02/2009 by Taylor
Scholl, Philip Henry (PDF, 470.6 KB)

Inquest microlight aircraft accident, pilot training, Civil Aviation Safety Authority oversight of aviation, interaction between Civil Aviation Safety Authority and Australian Transport Safety Bureau.

27/01/2009 by Braes
Reid, Kylie Maree (PDF, 215.1 KB)

Inquest - Hanging, suicide.

08/01/2009 by Springer

Back to top

2008

Name/event Findings delivered Government response
Trcka, Peter Joseph (PDF, 228.7 KB)

Inquest - Trawler, EPIRBS, personal floatation devices.

24/12/2008 by Brassington
Plint, Hannah Isabella Alyson (PDF, 105.8 KB)

Child drowning

22/12/2008 by Ryan
Venturato, John Ernest (PDF, 529.0 KB)

Inquest, wide load, oversize load, collision

22/12/2008 by Brassington
Steggall, Rhonda Joy (PDF, 401.1 KB)

Sngle vehicle accident, condition of road surface, recent roadworks, lack of signage

17/12/2008 by Hennessy
Tynan, Kristina Ann (PDF, 94.0 KB)

Police pursuits.

15/12/2008 by McGinness
Van Putten, Patricia (PDF, 330.7 KB)

Inquest, suicide, mental health patient.

15/12/2008 by McGinness
Harris, Robert (PDF, 493.8 KB)

McGinness

15/12/2008 by McGinness
Sturgess, Jane Rose (PDF, 40.7 KB)

Inquest - driver fatigue.

12/12/2008 by Cornack
Shepherd, Craig Robert (PDF, 154.7 KB)

Inquest: Coroners, police pursuits.

12/12/2008 by Barnes
Fenner, Christine Maria (PDF, 59.3 KB)

Inquest – missing person

11/12/2008 by Batts
McVey, Oliver Steven (PDF, 237.5 KB)

Inquest premature second twin, patent ductus arteriosus, carbon dioxide build up when ventilated, appropriate ventilation modes and machine, problems with re-intubation

28/11/2008 by Clements
Howe, Paul Gerrard (PDF, 114.4 KB)

Truck accident, steep descent, driver inexperience.

26/11/2008 by Killeen
Wills, Ian Charles (PDF, 404.7 KB)

Motor vehicle truck rollover, state of brakes, state of road.

26/11/2008 by Rinaudo
Willowbank aircraft accident - Colin Hicklin, Barbara McLelland, Nigel O'Gorman, Susanne Williams, Anthony Winter (PDF, 165.3 KB)

Inquest, aircraft accident, parachuting operations, oversight of tandem parachuting by CASA and the APF

24/11/2008 by Barnes
Deceased prisoner (PDF, 58.4 KB)

Death in custody, natural causes.

05/11/2008 by Barnes
Boyd, Melanie Kate (PDF, 390.6 KB)

Death by drug toxicity, teenagers, youth party, consuming illicit and prescription drugs, excessive alcohol consumption, unsupervised, failure to call emergency services.

05/11/2008 by Smith
Duncan, Joseph Douglas (PDF, 108.7 KB)

Police pursuits

24/10/2008 by Barnes
Maxfield, Annette (PDF, 148.4 KB)

Exsanguinations following colorectal surgery, serious surgery in remote locations.

10/10/2008 by Barnes
McKenzie, Jillian Peta (PDF, 77.3 KB)

Presentation at Level One hospital with chest pains, compliance with hospital policies, staffing of Level One hospitals by junior doctors.

03/10/2008 by Comans
Warren, Michael (PDF, 111.7 KB)

Motor Neurone Disease, fire safety, smoking in a health facility with an impairment.

25/09/2008 by Clements
12 year old boy at Kowanyama (PDF, 131.8 KB)

Department of Families, remote Indigenous community, child suicide.

19/09/2008 by Barnes
Neville, Elise Susannah (PDF, 183.9 KB)

CORONERS: Inquest – Head Injuries, Bunk Beds, doctors working hours, emergency department care in regional hospital, emergency retrieval, open disclosure of adverse health events.

12/09/2008 by Lock
Doheny, Dominic Raphael (PDF, 119.8 KB)

Mixed drug toxicity death of 36 year old man prescribed MS Contin. Recommendation regarding warning labels.

12/09/2008 by Lock
Bertram, Amanda Renee (PDF, 56.7 KB)

Mixed drug toxicity

11/09/2008 by Lock
Maslen, Samantha Anne (PDF, 145.4 KB)

Police pursuits, tyre deflation devices.

27/08/2008 by Barnes
Benson, Leim Matthew (PDF, 387.9 KB)

Hanging death of 33 year old male.

25/08/2008 by Lock
Greaves, Colin Arthur (PDF, 216.1 KB)

Work related accident, fall from height, hydroblasting, Workplace Health and Safety, fatigue management systems, review of risk assessment procedures, Safe Hours of Work and Fatigue Management policies, competency based training.

18/08/2008 by Hennessy
Batten, Derek , Tunstead , Peter and Tunstead, James (PDF, 988.6 KB)

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.

08/08/2008 by Barnes
Bock, Kristian (PDF, 999.4 KB)

Death at Nerada near Innisfail on 29 October 2002, German National, Motor Vehicle Incident, Campervan and a Prime Mover towing a B Double Trailer.

17/07/2008 by Brassington
Shelley, Chloe Louise (PDF, 71.9 KB)

Motor vehicle crash, speeding, condition of road.

17/07/2008 by Lock
Maggable, Kenneth (PDF, 415.4 KB)

Death at Trinity Beach on 9 August 2005, Acute coronary occlusion, Extensive coronary atherosclerosis, Visited General Practitioner and Cairns Base Hospital.

17/06/2008 by Black
O'Connell, Martin John (PDF, 121.8 KB)

Electrocution, safety switch (residual current device - RCD).

06/06/2008 by Lock
Irwin, Ross Frederick (PDF, 210.8 KB)

Inquest into the suspected death - trawler fishing, adoption of the NSCV and other safety initiatives, MSQ investigation of marine incidents.

06/06/2008 by Barnes
Rouse, Christine Chloe (PDF, 238.4 KB)

Death at Cloncurry Hospital on 12 March 2005, where a child drowned in a public pool.

26/05/2008 by Luxton
Mosby, Phillemon Edward (PDF, 144.1 KB)

Inquest into the suspected death of Phillemon Edward MOSBY. Vessel Pilot Transfer. MSQ monitoring of pilot vessels, AMSA stipulating pilotage standards.

23/05/2008 by Barnes
Mountford-Smith, Trevor Bertram (PDF, 66.4 KB)

Missing person, last seen at motel, Caloundra assumed drowned.

19/05/2008 by Taylor
Gallaher, Sebastian Luke Paul (PDF, 2.2 MB)

Death at Gympie on 11 April 2006, where a child died of natural causes, subarachnoid haemorrhage, ruptured berry aneurysm

15/05/2008 by Parker
Blinco, Ricky Glenn; Last, Michael Wayne (PDF, 147.6 KB)

Black Duck Valley, recreational off road motorcycling and 4WDriving, local authorities approval of 4WD parks, Workplace Health and Safety investigation of incidents in 4WD parks.

02/05/2008 by Barnes
Brown, Robert Lee (PDF, 55.3 KB)

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

01/05/2008 by McLaughlin
Watson, Christina Mae (PDF, 62.5 KB)

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

24/04/2008 by Glasgow
Schibrowski, John Malcolm (PDF, 70.9 KB)

Motor vehicle accident, Traffic accident investigation squad TAIS investigation, identity of driver

24/04/2008 by Hennessy
Bond, Jakai Ryan (PDF, 102.2 KB)

Inquest, sudden death of an infant, co sleeping, asphyxia, head injuries.

10/04/2008 by Barnes
Fitzgerald, Anthony Michael (PDF, 61.6 KB)

Death at Esk on 4 April 2004, Aircraft crash, gyroplane.

28/03/2008 by McLaughlin
Waite, Thomas Dion; Huynh, Mieng; Jacobs, James Henry; Gear, James Michael (PDF, 811.3 KB)

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.

17/03/2008 by Barnes
Zwahlen, Bernard (PDF, 36.6 KB)

Hang glider (Airborne C2), static ground tow, failure to release tow line, absence of hook knife, modified tow equipment.

27/02/2008 by Tonkin
Jones, David Colin (PDF, 1.0 MB)

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

11/02/2008 by Killeen
Hauff-Green, Edward Thomas (PDF, 42.2 KB)

Mental health, emergency sedation.

31/01/2008 by Lock
Young, Janet Louise (PDF, 182.2 KB)

Truck rollover, load restraint and centre of mass.

23/01/2008 by Lock Response to Young, Janet Louise PDF, 320.6 KB
Schmidt, Shirley (PDF, 95.3 KB)

Missing person, re-opening of inquest.

17/01/2008 by Barnes
Wigg, Allan Thomas (PDF, 2.4 MB)

Banana bagging machine machinery incident at Wangan on 3 December 2004

16/01/2008 by Brassington

Back to top

2007

Name/event Findings delivered Government response
Newman, Patricia Dell (PDF, 40.5 KB)

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

20/12/2007 by Springer
Hall, Jordan James (PDF, 79.5 KB)

Death at Redcliffe Hospital on 16 August 1997. Child Death, Head and abdominal injuries, Repeated blunt trauma.

20/12/2007 by Halliday
Whittington, Frank Maurice (PDF, 68.2 KB)

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.

12/12/2007 by Tonkin
Burgen, Deborah Denise (PDF, 283.5 KB)

Mt Isa Hospital, post operative internal bleeding, compliance with hospital policies, triaging of ED patients, tele medicine, referral to medical board.

07/12/2007 by Barnes
Mills, Samuel John (PDF, 203.0 KB)

Death in custody, correctional centre, suicide, hanging points, funding of prison mental health services.

29/11/2007 by Barnes
Tanner, Marjorie Joyce (PDF, 63.4 KB)

Appropriateness of medical care at Maryborough and Hervey Bay Hospitals, policies and procedures, adequacy of inter-hospital transfer procedure.

28/11/2007 by Taylor
Bodell, Margaret Florence Anne (PDF, 164.5 KB)

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.

23/11/2007 by Clements
Walker, Nola Jean (PDF, 175.7 KB)

Death in custody

23/11/2007 by Barnes
Scholz, Karl David (PDF, 5.1 MB)

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.

23/11/2007 by Clements
Gillies, Bradley James (PDF, 4.8 MB)

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

23/11/2007 by Kehoe
Hanley, Timothy Michael (PDF, 25.2 KB)

Poisoning, Herbal Ecstasy, Internet Ordering at Rockhampton on 30/01/06

22/11/2007 by Hennessy
Huber, Arisa (PDF, 156.1 KB)

sudden unexpected death of infant, in hospital, in bed with mother for breastfeeding, accidental suffocation, severe hypoxic episode

06/11/2007 by Clements
Cvitic, Nardia Annett (PDF, 323.7 KB)

Medical procedure, complications.

29/10/2007 by Clements
Murray, Kelvin Charles (PDF, 1.6 MB)

Possible Suicide, Overdose at Goodna on 03/09/04

16/10/2007 by MacCallum
Zupp, Jason John (PDF, 44.5 KB)

Traffic Incident, Long Distance Truck Driver, Interstate, Driving Hours, Driving Fatigue at Taroom on 10/12/05

12/10/2007 by Cornack
Fogarty, Kevin Edward (PDF, 131.5 KB)

Melioidosis, community acquired pneumonia, work place exposure to tropical diseases, clinical support for rural and remote medical practitioners.

01/10/2007 by Barnes
Crowston, Amanda Terese Francis (PDF, 1.4 MB)

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

26/09/2007 by Mack
Waugh, Cappur William Embling (PDF, 106.7 KB)

Motor vehicle accident, single vehicle roll-over, inadvertence, inattention, calculation of speed of vehicle.

14/09/2007 by Rinaudo
Babington, Lynette (PDF, 48.2 KB)

Death in residence at Oakey on 05/08/2006 due to a pulmonary embolism.

13/09/2007 by Cornack
Henderson, Robert Joseph (PDF, 167.7 KB)

Mental Health, death in care, involuntary treatment order in the community, monitoring, drug abuse, risk of non compliance with medication.

03/09/2007 by Clements
Noffke, Veronica Margaret (PDF, 38.6 KB)

Death at Logan Hospital on 10/05/2005 due to coronary atherosclerosis with anti-coagulant therapy.

29/08/2007 by Webber
Effer, Anthony John (PDF, 1.1 MB)

Single Vehicle Traffic Incident, Pillion Passenger on a Motorcycle at Maryborough on 27/07/04

27/08/2007 by Smith
Fitter, Maureen (PDF, 121.8 KB)

Hospital/health procedures death, Cardiac Tamponade, Peripherally inserted Central Catheter.

24/08/2007 by Lock
Case, Matthew Colin (PDF, 6.2 MB)

Child, Drowning, Public Pool at Goodna on 24/09/05

24/08/2007 by McLaughlin
Mental Health patient (PDF, 163.9 KB)

Mental Health, assessment of suicide risk, communication with family and hospital staff regarding risk, search of patient's property for dangerous items, hanging points.

17/08/2007 by Clements
Lockhart River aircraft crash (PDF, 425.0 KB)

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.

17/08/2007 by Barnes
Tang, Shannon Sheng Wen (PDF, 226.6 KB)

Medical procedure, gastric bypass, informed consent regarding mortality, complications.

10/08/2007 by Clements
Stiller-Smith, Felix Jake (PDF, 82.0 KB)

Infant death, undertermined cause, presence of amphetamines in breast milk, contact with the Department of Families.

10/08/2007 by Clements
Duckett, Alan Bernie-Johnson, Bruce William-Hughes, Allen John-Thompson, Katharine Anne (PDF, 126.5 KB)

Aircraft crash, CASA staff training, automatic recording of engine parameters.

09/08/2007 by Barnes
Howell, Thomas John (PDF, 28.8 KB)

Run over by a school bus at Gympie.

03/08/2007 by Callaghan
Bessell, Michael Ian Charlesworth (PDF, 35.0 KB)

Was the rider of a motorcycle involved in a two vehicle traffic incident at Burnett Highway near Mount Morgan on 20/07/07

20/07/2007 by Hennessy
Aldred, Belinda Jayne (PDF, 65.1 KB)

Hanging at Mareeba

13/07/2007 by Braes
Eady, Graeme William Julian (PDF, 121.8 KB)

Plastic bag asphyxiation of young man receiving psychiatric care in hospital under involuntary treatment order, procedure for intermittent visual observations of patients.

20/06/2007 by Clements
Liddell, Matthew John (PDF, 140.4 KB)

Hanging death of young man receiving psychiatric care in hospital, procedure for observation of patients, procedure for assessment of suicide risk.

20/06/2007 by Clements
Huntington, Sparka Isarva aka Huntington, James Philip (PDF, 156.2 KB)

Restraint of mental health patients.

01/06/2007 by Barnes
Skardoon, Dorothy Rae (PDF, 117.9 KB)

Death following fall; recent eye procedure

25/05/2007 by Lock
Mental Health patient (PDF, 130.0 KB)

Involuntary treatment orders, assessment of suicide risk, procedures for intermittent observation orders.

25/05/2007 by Clements
Davis, Jodie Maree (PDF, 134.3 KB)

Death in custody, Townsville Correctional Centre.

16/05/2007 by Tonkin
Horsington, Margaret Isabel (PDF, 44.2 KB)

Bowel obstruction, Fleet, diagnosis and treatment. inquest within the medical system at the Roma Hospital.

04/05/2007 by Rinaudo
Lang, Michael Charles (PDF, 118.3 KB)

Operating a backhoe when demolishing a pedestrian bridge at Broadbeach on 10 December 2003.

01/05/2007 by Brassington
Thorpe, Geoffrey (PDF, 401.7 KB)

First aid training and equipment on an industrial site.

18/04/2007 by Guthridge
Smith, Arthur Lawrence (PDF, 84.8 KB)

Hospital/health procedures, death.

05/04/2007 by Lock
Pittaway, Steven John and Coe, Paul Allen (PDF, 110.4 KB)

Watch house, inspection of prisoners, searching of prisoners, risk assessment of prisoners, elimination of hanging points.

30/03/2007 by Barnes
Dee, Fiona Jane (PDF, 124.9 KB)

Elective Caesarean, spinal anaesthesia, cerebrospinal fluid leak, subdural haematoma, query epilipsy, query cardiac event, Tegretol, hyponatremia, epidural patch, postural headaches.

23/03/2007 by Clements
Davis, Shane William (PDF, 167.0 KB)

An industrial death at the Foxleigh Mine near Middlemount

21/03/2007 by Hennessy
Gabiola, Peter (PDF, 236.7 KB)

Death at Cluden on 23 July 2003, Workplace Incident, Purification Plant, Tractor.

19/03/2007 by Hillan
Turnbull, John (PDF, 73.5 KB)

Work related accident, workplace health and safety, driveway construction, plant, vibrating rollers.

13/03/2007 by Clements
Browne, Roger Bruce (PDF, 94.1 KB)

Industrial incident at Dawson Mine near Moura in Central Queensland.

06/03/2007 by Hennessy
Lather, David Andrew (PDF, 56.7 KB)

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.

02/03/2007 by Previtera
McGeary, Corey Allan (PDF, 80.5 KB)

Death in custody, suicide, hanging points.

01/03/2007 by Barnes
James, Joseph Edwin (PDF, 49.5 KB)

Death in custody, natural causes.

23/02/2007 by Barnes
Russell, Andrew John and Harogh, Bianca Joan (PDF, 149.4 KB)

Motor vehicle accident, high speed, seriously defective vehicle, street racing, poor judgment.

21/02/2007 by McIntyre
Eddy, Michael John (PDF, 135.4 KB)

Death in custody, positional asphyxia, amphetamine use, autopsy reports, registration of causes of death.

12/02/2007 by Barnes
Carroll, Leon Mark (PDF, 60.8 KB)

Cause of Death-suicide, hanging points.

19/01/2007 by Barnes
Fitzgerald, Darren Michael (PDF, 98.7 KB)

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.

19/01/2007 by Barnes
Marshall, Maxwell John (PDF, 139.4 KB)

Control of prescription medication, the role of the Drug of Dependence Unity, autopsies by government medical officers.

19/01/2007 by Barnes
Tyssen, Mario Emmy (PDF, 53.6 KB)

Death in custody, health care of prisoners.

19/01/2007 by Barnes
West, Ian Leslie (PDF, 92.4 KB)

Bronchopneumonia following a severe head injury.

10/01/2007 by Kennedy
McDonald, Kerry-Ann (PDF, 58.6 KB)

Multiple injuries as a consequence of motor vehicle trauma, Kawasaki loader.

10/01/2007 by Kennedy

Back to top

2006

Name/event Findings delivered Government response
Blockley, Michael Gary; Watson, Stevie Lee; Teske, Neil Lackland; Donaldson, Michael Bruce; and Nugent, Christopher John (PDF, 1.5 MB)

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

06/04/2011 by McIntyre
Day, Mark Walter (PDF, 65.0 KB)

Death in custody, murder, supervision of dangerous prisoners.

19/12/2006 by Barnes
Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane (PDF, 282.0 KB)

Suicide by mental health patients.

15/12/2006 by Previtera
Czislowski, Kenneth Douglas (PDF, 289.1 KB)

Gyrocopters, failure of mechanical hub bar, aerial work other than recreational flight, cattle mustering.

08/12/2006 by Costello
Jones, Katherine Alison (PDF, 41.9 KB)

Automatic sliding gates, workplace health and safety.

04/12/2006 by Killeen
Tierney, Beverley Ann (PDF, 48.3 KB)

Drowning, wet drowning, dry drowning.

27/11/2006 by Rinaudo
Petrelis, Andrew Nicholas (PDF, 139.6 KB)

Opiate toxicity.

24/11/2006 by Halliday
Hogan, Kevin James and Hogan, Winifred Therese (PDF, 42.5 KB)

Motor vehicle accident, signage, intersection safety, speed limits.

15/11/2006 by Hennessy
Jeffrey, Helen (PDF, 1.0 MB)

Suicide by mental health patients.

13/11/2006 by Taylor
Ali-Haapala, Anita (PDF, 154.0 KB)

Risk management of patients in mental health facilities.

31/10/2006 by Buckley
Boyce, Amanda Helen (PDF, 69.5 KB)

Death in spa, Reynolds equation, laminae flow, turbulent flow, hair entrapment, tangling and knotting.

18/10/2006 by Rinaudo
Mathers, John William (PDF, 480.2 KB)

Motor vehicle accident, surgical error, failure to correctly operate blood infuser, training issues.

12/10/2006 by Cornack
Mulrunji (PDF, 160.6 KB)

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.

27/09/2006 by Clements
Beattie, Christian Paul (PDF, 539.2 KB)

Aircraft accident, adequacy of Queensland Police Service policies and procedures regarding aircraft accident investigation.

14/09/2006 by Cridland
Rawson, Robert Donald (PDF, 594.9 KB)

Availability of quality medical equipment in regional hospitals.

13/09/2006 by Hennessy
Robinson, Terence James (PDF, 164.9 KB)

Status epilepticus, monitoring of psychiatric patients, emergency sedation, transfer to primary hospitals.

08/09/2006 by Barnes
Hamilton Island aircraft crash (PDF, 139.3 KB)

Aircraft accident, fuel selector warning, chief pilot's duties, securing of evidence.

07/09/2006 by Barnes
Grimley, Scott Robert (PDF, 52.2 KB)

Electrocution at work.

01/09/2006 by Halliday
Vernon, Colin John (PDF, 2.6 MB)

Death at North of Gympie on 7 May 2005, Motor vehicle incident.

24/08/2006 by Callaghan
Shaw, Lillian Margaret (PDF, 51.9 KB)

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.

11/08/2006 by McLaughlin
Casey, Lenard John (PDF, 78.5 KB)

Death in custody, natural causes.

10/08/2006 by Barnes
Bee, Calvin Wayne (PDF, 94.3 KB)

Death in custody, riders concerning incarceration of alcoholic persons, sudden unexplained death in epilepsy

09/08/2006 by Barnes
Zimitat, Vivian Bexley (PDF, 292.6 KB)

Regional neurology services availability; maintenance of appropriate records regarding regional and remote medical contact with specialty units in tertiary hospitals.

28/07/2006 by Hennessy
Vidler-Cumming, Liam Richard (PDF, 72.4 KB)

Shaken baby syndrome.

28/07/2006 by Barnes
Palace Backpackers Hostel Fire (PDF, 294.8 KB)

Arson in budget accommodation, fire safety reforms, Childers.

07/07/2006 by Barnes
Hooymans, Kylie Danielle (PDF, 1.3 MB)

Death at Tewantin on 13 March 2005, Hanging, Mental Health.

07/07/2006 by Taylor
Ioane, Andrew Penetito (PDF, 88.3 KB)

Death in custody, police pursuit, recommendations regarding police training.

30/06/2006 by Barnes
Williams, Stuart Ronald (PDF, 46.9 KB)

Death in custody, correctional centre, natural causes.

27/06/2006 by Barnes
Hedges, John Walter (PDF, 89.3 KB)

Accidental overdose, medical negligence, systemic failings in a clinical setting

15/06/2006 by Barnes
Hewson, Jamie (PDF, 96.7 KB)

Death in custody, police shooting.

08/06/2006 by Barnes
Bell, Malcolm Robert (PDF, 80.4 KB)

Police shooting, self-defence.

26/05/2006 by Barnes
Marshall, Peter Whitoria (PDF, 137.7 KB)

Safety procedures for deflation of truck tyres on mine site, supervision of autonomous skilled workers, rim design and tyre handling standards for mine trucks.

19/05/2006 by Barnes
Baker, Rodney John (PDF, 117.8 KB)

Trawler fishing, boat capsizing, hydrostatic released life rafts, PFDs, EPIRBs, search and rescue.

15/05/2006 by Barnes
Karajic, Scott Meho (PDF, 138.7 KB)

Gas drilling rig accident, supervision on drilling rigs, recommendations concerning the education of drilling rig supervisors and crew.

26/04/2006 by Barnes
Adams, Michael James (PDF, 147.5 KB)

Inquest, death in custody on 11/09/1997, hanging at Sir David Longland's Correctional Centre in Bribane.

13/04/2006 by Halliday
Meech, Paul Andrew (PDF, 180.8 KB)

Death in custody, watchhouse supervision, mental illness, involuntary assessment and involuntary treatment order, management of mental illness.

07/04/2006 by Barnes
Bismark, Lex Robert (PDF, 137.4 KB)

Motor vehicle accident, recommendation concerning fitness to drive.

23/03/2006 by Barnes
Rhodes, Daniel Cory (PDF, 144.2 KB)

Police shooting, self defence.

23/03/2006 by Barnes
Bourke, Raymond Francis (PDF, 48.2 KB)

Death whilst attempting to avoid being taken into custody, suicide.

17/03/2006 by Barnes
Smith, David Edward (PDF, 181.4 KB)

Death in custody, Prison murder, protective custody.

17/03/2006 by Barnes
Schumacher, Nicholas (PDF, 936.5 KB)

Death at Townsville on 12 September 2004, Child death, motor vehicle incident, navy cadet, troop carrier.

16/03/2006 by Smith
Pettigrew, Wayne Matthew (PDF, 89.8 KB)

Death in custody, natural causes.

13/03/2006 by Barnes
Matschoss, Wayne Barry (PDF, 91.6 KB)

Death in custody, natural causes

13/03/2006 by Barnes
Creegan, Thomas (PDF, 86.9 KB)

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.

03/03/2006 by Previtera
Hendy, Albert William (PDF, 82.0 KB)

Death in custody, natural causes.

24/02/2006 by Barnes
Sperling, Karl Peter (PDF, 56.1 KB)

Drowning of an army cadet on exercise.

17/02/2006 by Daley
Muckan, David Jones (PDF, 127.4 KB)

Psychiatric hospital death, benzodiasepines, obstructive sleep apnoea. Recommendations concerning the observation of patients administered sedatives.

03/02/2006 by Barnes
Crossman, Troy Samuel (PDF, 140.6 KB)

Death in custody, recommendations concerning the management of 'at risk' prisoners, hanging points.

03/02/2006 by Barnes

Back to top

2005

Name/event Findings delivered Government response
Hansen, Anthony Kenneth (PDF, 95.1 KB)

Correctional Centre, transfer to hospital, death from natural causes.

22/12/2005 by Barnes
Partridge, Phillip Bruce (PDF, 98.8 KB)

Death in custody, Police siege, suicide, mental health.

22/12/2005 by Barnes
Croft, Penelope Ann (PDF, 84.2 KB)

Motor vehicle accident. Recommendations concerning engine compartment door of buses.

02/12/2005 by Rinaudo
Perry, Jye Conrad (a child) (PDF, 87.4 KB)

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.

29/11/2005 by Hennessy
Community Mental Health Patient (PDF, 88.2 KB)

Inquest, hanging of young man receiving psychiatric care in the community after revocation of involuntary treatment order, assessment of suicide risk.

09/11/2005 by Clements
Tognola, Phillip Allan Walter (PDF, 96.1 KB)

Swimming pool drowning of a child. Recommendations concerning inspection of pools.

01/11/2005 by Spencer
Liddington, Craig; Eva, Stewart; Carpenter, Andrew (PDF, 151.2 KB)

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.

28/10/2005 by Hennessy
Dell, Maren Lyndsey (PDF, 49.2 KB)

Diving accident at Agincourt Reef, Great Barrier Reef, Far North Queensland. Recommendations concerning training for the diving industry.

19/10/2005 by Lock
Fernandez, Adam Anthony (PDF, 39.8 KB)

Natural causes, capsicum spray.

17/10/2005 by clements
Waldon, Mark Anthony aka Hurricane, Mark Anthony (PDF, 80.0 KB)

Natural causes, reaction to heroin withdrawal medication. Recommendations concerning the suitability of prescribing certain medication to prisoners, supervision of prisoners.

14/10/2005 by Clements
Naidu, Alvin (PDF, 81.1 KB)

Recommendations concerning supervision of truants by the Department of Education.

10/10/2005 by Clements
Irwin, Perry James; Coates, Damien Lawrence (PDF, 108.2 KB)

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.

10/10/2005 by Barnes
Rowland, Jet Paul (PDF, 219.7 KB)

Motor vehicle accident, recommendations concerning fitness to drive, epilepsy and driving.

15/09/2005 by Clements
Cook, Robert Edward (PDF, 52.7 KB)

Motor vehicle accident involving an elderly motor cyclist.

15/08/2005 by Clements
Pugh, Samuel (PDF, 48.7 KB)

Death south of Charters Towers on 17 August 2004, Highway Reward Mine, Rock fall.

10/06/2005 by Verra
Robinson, Jacinta Kate (PDF, 93.0 KB)

Death of a child undergoing surgery-cardiac tampenade. Recommendations regarding training for nurses and medical staff, allocation of specialist medical services.

04/05/2005 by Clements
Hope Vale man (PDF, 97.9 KB)

Hope Vale man in an Aboriginal community police van. Recommendations concerning training of Aboriginal Community police officers.

07/04/2005 by Barnes
Landue, Shone; Reid, Gary; Doolan, Stanley (PDF, 203.5 KB)

Recommendations concerning the inspection of boarding houses and fire safety.

09/02/2005 by Clements
Sabadina, Kathryn Marnie (PDF, 187.8 KB)

Anaphalactic shock. Recommendations concerning the recruitment and supervision of foreign trained doctors.

24/08/2004 by Barnes

Back to top

2004

Name/event Findings delivered Government response
Fiechtner, Rodney Joseph (PDF, 75.3 KB)

Gas explosion on a drilling rig. Recommendations concerning risk management on rigs.

20/12/2004 by Barnes
Eason, David John (PDF, 96.1 KB)

English tourist missing on Fraser Island for two years. Recommendations concerning searches and wilderness signage.

06/12/2004 by Barnes
Shoobridge, George Richard (PDF, 992.2 KB)

Death at Cairns on 1 December 2002, Cardiorespiratory failure, drug overdose, methadone program.

28/10/2004 by Previtera
Toohey, Alan Paul; Hill, Andrew Tasman (PDF, 119.8 KB)

Police pursuit in Coen. Recommendations regarding cessation of such pursuits.

20/10/2004 by Barnes
Lee, Julian Arasina (PDF, 653.1 KB)

Restraint of mental health patients

30/09/2004 by Previtera

Back to top

October 2015
  • Court holidays
Last reviewed
19 January 2016
Last updated
20 January 2016

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