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2014

Name/event Findings delivered Coroner
Wright, Karl Robert

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

18-11-2014 Lock
Beutel, Noelene Marie

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

17-11-2014 Hutton
Chettiar, Dharam Raj

Death in custody, natural causes.

04-11-2014 Ryan
Proberts, Mark William

Death in custody, natural causes.

03-11-2014 Ryan
Spencer, Lydia

Motor vehicle accident.

03-11-2014 Bentley
Villinger, Navina Friedericke

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 Bentley
Sweetnam, Garry; Mitchell, Andrew - Non-inquest findings

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

15-10-2014 McDougall
Hoare, Gregory Peter

Quad bike accident.

26-09-2014 Lock
Beauchamp, Reginald Hasted

Quad bike accident, head injuries, helmets.

26-09-2014 Lock
D and F, a child

Quad bike accident, roll over.

26-09-2014 Lock
Moore, Geoffrey Grahame

Quad bike accident, mechanical defect, helmets.

26-09-2014 Lock
P, aged 9 - Non-inquest findings

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

26-09-2014 Lock
McInnes, Zoe Louise

Quad bike accident, helmets.

26-09-2014 Lock
P, a child

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

26-09-2014 Lock
H, a child

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

26-09-2014 Lock
Haken, Guss Robert

Quad bike accident, helmets, intoxication.

26-09-2014 Lock
Hurst, Charles Kingston

Death in custody, hanging.

16-09-2014 Ryan
Two year old child - Non-inquest findings

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

09-09-2014 Clements
MacDonald, Wayne

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 O'Connell
A Patient - Non-inquest findings

Hospital-acquired legionella pneumonia.

03-09-2014 Lock
Abrahams, Amy Lee - Non-inquest findings

Motor vehicle accident, condition of road.

01-09-2014 McDougall
SG - Non-inquest findings

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

01-09-2014 Lock
Greenfield, Walter Robert

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

26-08-2014 Bentley
Punch, Jamie Robert Joseph

Death in custody, police pursuits.

12-08-2014 Ryan
Lam, Wai Kim

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

11-08-2014 Bentley
Crane, Sylvia - Non-inquest findings

Health care, waiting lists.

11-08-2014 Lock
A four month old baby - Non-inquest findings

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

07-08-2014 McDougall
Olive, Thomas (Tom) Andrew

Health care related death, rhabdomyolysis, LPIN1 gene.

05-08-2014 Lock
A Sailing Competitor - Non-inquest findings

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

04-08-2014 Lock
Copeland, Alison Ruth - Non-inquest findings

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

28-07-2014 Lock
Petersen, Nicole - Non-inquest findings

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 McDougall
Bowling, Dianne Judith

Mental health, case management, community and family input.

18-07-2014 Lock
Su, Che-Wei

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 Bentley
Faith, an 8 year old child

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 Bentley
O - Non-inquest findings

Anaesthetics, APHRA and HQCC investigation, unsatisfactory professional performance.

20-06-2014 Lock
Murray, Vaughan

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

17-06-2014 Hutton
Mahlo, Karen Lee

Suicide investigation.

13-06-2014 Clements
O'Shea, Kathleen Mary

Missing person, disappearance.

12-06-2014 Bentley
Milner, Laura Jayne; Yates, Samantha Ann

Motor vehicle accident, B double heavy vehicle combination.

10-06-2014 Baldwin
Bennett, Scott Anthony

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

05-06-2014 Lock
Humm, Deborah Lee

Suicide, domestic violence, fall.

29-05-2014 Bentley
Ellison, Ronald; Sylvester, Jacqueline

Death in police operations, attempted intercept.

20-05-2014 Ryan
C a motor racing participant - Non-inquest findings

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

01-05-2014 Lock
McGrath, Nathan David

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

17-04-2014 Ryan
Zessin, Ralph Frederick

Head injuries from a fall, whether pushed or fell.

02-04-2014 Lock
Platt, Christopher Robert Edmund - Non-inquest findings

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

31-03-2014 Lock
Baby T - Non-inquest findings

Death of a baby, baby slings.

25-03-2014 Lock
Birt, Dulcie Isabelle

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

21-03-2014 Lock
Nixon, Carey Scott

Motor vehicle/motor cycle crash, road rage.

21-03-2014 Lock
Molloy, Michael Patrick

Suicide, presumption against suicide, motor vehicle accident.

12-03-2014 Bentley
Forster, Adam Douglas

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

06-03-2014 Comans
Willis, Karen - Non-inquest findings

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

12-02-2014 McDougall
Caulton, Van Edward

Missing person,Centrelink.

11-02-2014 Bentley
Johnson, Nicholas Peter

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

07-02-2014 Hutton
King, Richard James - Non-inquest findings

Maritime collision, boat and surfer, Currumbin Bar.

05-02-2014 McDougall
George, Lynda Margaret - Non-inquest findings

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

31-01-2014 McDougall
Peuckert, Bay Roxas - Non-inquest findings

Farming incident, unsafe work practices, cherry picker.

24-01-2014 McDougall
Lingwood, Craig Steven

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

24-01-2014 Ryan

Back to top

2013

Name/event Findings delivered Coroner
Woods, Gavin Lyle

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

11-12-2013 Lock
Cook, Jenny Lee

Suicide, police investigation.

06-12-2013 Bentley
Sims, Desmond Arthur

Death in custody, natural causes.

06-12-2013 Ryan
Beresford, Samuel John

Gyroplane, investigatory and regulatory responsibility.

05-12-2013 Lock
Currie, Gordon

Death in custody, natural causes

02-12-2013 Clements
Sutcliffe, Peter Alan

Death in custody, siege, hanging.

19-11-2013 Ryan
Pollini, Brett Andrew

Suicide, bipolar affective disorder, child support agency.

11-11-2013 Lock
Wirraway Aircraft Crash

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

05-11-2013 Lock
Coulson, Elliott John

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

04-11-2013 Clements
Loveday, Marcia Joy

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 O'Connell
Draney, Kenneth

Death in custody, natural causes.

09-10-2013 Ryan
Hempel, Barry Ian; Lovell, Ian Ross

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

04-10-2013 Hutton
McPhee, Timothy

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

30-09-2013 O'Connell
Taylor, Scott Matthew

Death in police custody, Tasers.

24-09-2013 Ryan
Emerton, Andrew John Joseph

Death in custody, natural causes.

24-09-2013 Ryan
Bligh, William John - Non-inquest findings

Melioidosis, Palm Island, clinical management.

12-09-2013 Bentley
Morris, David Samuel

Death in custody, natural causes.

11-09-2013 Ryan
Quartermain, Robert George

Death in custody, natural causes.

11-09-2013 Ryan
Sparreboom, Sophie Claire - Non-inquest findings

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

05-09-2013 Lock
Auld, Michael Earle

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

26-08-2013 Priestly
Tuppurainen, Pekka

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 Priestly
Morris, Daniel Paul

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

15-08-2013 Bentley
Brennan, Phil John Richard

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 MacCallum
Fuller, Matthew James; Barnes, Rueben Kelly; Sweeney, Mitchell Scott

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

04-07-2013 Barnes
Black, Maryellen

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

02-07-2013 Priestly
Justin

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

02-07-2013 Priestly
Saccu, Jonathan Clarence

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 Priestly
Evans, Wendy Joy; Wilson, Lorraine Ruth

Re-opened Inquest, suspicious deaths.

28-06-2013 Barnes
Protheroe, Jason Paul

Death in custody, shooting.

14-06-2013 Barnes
Garrett-Pratt, Jake Michael

Child, ride-on lawn mower, rural property.

31-05-2013 Lock
Hussain, Meqdad

Death in custody, suicide, asylum seeker.

27-05-2013 Barnes
Thoresen, Cynthia

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

22-05-2013 Clements
Lalara, Hazel Marie

Death in custody, mental health care of prisoners.

16-05-2013 Barnes
Weazel, Maureen Ann

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

10-05-2013 Barrett
Thompson, Leanne Melissa

Hanging, forensic evidence, Child Protection.

03-05-2013 Lock
Brockel, Ronald James

Medical error, placement of feeding tube and review.

19-04-2013 Barnes
Hornby, Geoffrey John

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

19-04-2013 Barnes
McCarty, Lawrence

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

18-04-2013 Barnes
Borusiewicz, Luke Anthony

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 Priestly
Maitland, Michelle

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

12-04-2013 Priestly
Lambert, Stuart John

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

28-03-2013 MacCallum
Vearncombe, Muraka Jenny

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 Priestly
Ware, Benjamin Richard

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 Priestly
Morgan, Charles Ross Maxwell

Train overrun, suicide or accident.

15-03-2013 Lock
Owens, Kenneth Roland; Stiller, Daniel Arthur

Wide loads management, investigations of police related fatalities.

15-03-2013 Barnes
Arnold, Vicki; Leahy, Julie-Anne

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

01-03-2013 Barnes
SH and AW

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

25-01-2013 Lock
Ryan, Adam Trent

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

18-01-2013 Rinaudo

Back to top

2012

Name/event Findings delivered Coroner
Evans, William Alfred

Death in custody, natural causes.

19-12-2012 Barnes
Gerhardt, Robert John

Death in custody, natural causes.

19-12-2012 Barnes
Mitchell, Herbert John

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

14-12-2012 Barnes
Ley, Michael David

Death in custody, assessment and care of intoxicated prisoners.

12-12-2012 Barnes
Robinson, Nathan Kevin; Tschannen, Scott

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 Priestly
Cooper, Gerry Maxwell

Death in custody, natural causes.

07-12-2012 Barnes
Death of an infant

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

06-12-2012 Clements
McNaught, Judith

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 Hennessy
Bramble, Julie Anne

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 Hennessy
Death of a Baby - Non-inquest findings

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

03-12-2012 Clements
Hammett, Christopher

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 Hutton
Cardwell, Elizabeth Joan; Cardwell, Isabella Rose; Sanderson, Gregory Ryan

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

19-11-2012 Lock
Oakley, Meleta Eliza

Death in custody, police pursuit.

15-11-2012 Barnes
Galeano, Antonio Carmelo

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 Clements
Biddulph, Jayde Stephen Donovan

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

13-11-2012 Barnes
Lowe, George Robert

Police pursuit.

02-11-2012 Barnes
Short, James Leon

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

01-11-2012 McDougall
Cavanagh, Barry William

Police pursuit.

01-11-2012 Barnes
Chen, Sen Hung

Death in custody, natural causes.

26-10-2012 Barnes
Paudel, Preston

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

25-10-2012 Lock
Anderson, Stanley Charles

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

19-10-2012 Baldwin
Plumb, Joshua Jai

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 Clements
Boon, Jennifer Ann

Multi passenger vehicle, death of alighting passenger

10-10-2012 Tonkin
Davies, Mia

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

28-09-2012 Lock
Harold, Rex

Death in custody; natural causes

28-09-2012 Clements
Howse, Troy Jason

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 Hennessy
Diefenbach, Isabella Wren

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 Hennessy
Isles, MIchael

Missing person, suicide, work place management

14-09-2012 Barnes
Cundy, Cherie

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

13-09-2012 Hutton
Parry, Nerida Ann

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

06-09-2012 Rinaudo
Hay, Donald Mervyn

Death in custody, natural causes.

05-09-2012 Barnes
Atfield, Kelvyn John

Weapon/Firearm related.

04-09-2012 Hennessy
Cartledge, Adam

death in custody; hanging points

29-08-2012 Barnes
Ferguson, Angus William Keith

Police pursuits.

22-08-2012 Barnes
Krog, Shane Paul

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

13-08-2012 Taylor
Van Moolenbroek, Gregory David

Rural property numbering; ambulance response.

10-08-2012 Hutton
Barnett-Lonergan, Patrick Hugo

Missing person; fishing trawler.

08-08-2012 Hutton
Bucknall, David John

Death in custody; suicide; psychiatric care of prisoners.

07-08-2012 Barnes
Patient A

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

05-07-2012 Lock
Robinson, Ian; Charlesworth, Natarsha; Hatzidimitriadis; Park, Sang Won; Choi Seongeun

Adequacy of regulatory framework covering white water rafting.

29-06-2012 Priestley
MacNicol, Jack Wallace

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

29-06-2012 Priestly
Baby M

Childbirth at home, unknown preganancy.

29-06-2012 Lock
Dixon, Steven John

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

22-06-2012 Clements
Paton, Daniel William

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 Clements
Gold Coast Murder Suicide

Murder/suicide; domestic violence.

21-06-2012 Barnes
Inquest into the deaths caused by the South-East Queensland floods of January 2011

South-East Queensland floods.

05-06-2012 Barnes
Perry, Anthony Mark

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

31-05-2012 Barnes
Watson, Eric Handley

Death in custody, natural causes.

31-05-2012 Barnes
S

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 Hennessy
Lyne, Richard Henry

Death in custody; natural causes.

20-04-2012 Clements
Gates, Tony William

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

16-04-2012 Clements
Wall, Timothy John

Motorcycle collision with pedestrian, identification of rider.

05-04-2012 Lock
McKenzie, Brett Alexander Kevin; Ezzy, Abigail Denise; Nolan, Nicholas James; Thorley, Maxwell Ernest

Multiple fatality motor vehicle crash.

03-04-2012 Previtera
Fraser, Leonard John

Death in custody; natural causes.

20-03-2012 Barnes
Ford, Stuart Cecil

Death in custody; suicide.

06-03-2012 Barnes
Law, Roslyn Amelia

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 Lock
Vaggs, Lyji

Death in custody; restraint in hospital.

21-02-2012 Barnes
Mitchell, Robert Gary

Death in custody; suicide; hanging points.

20-01-2012 Barnes

Back to top

2011

Name/event Findings delivered Coroner
Thompson, Grace

Motor vehicle crash, alcohol breath testing at scene.

16-12-2011 Lock
Tait, Graham

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 Brassington
Inglis, Tracey Lee

Death in custody, suicide, management of pain relief.

09-12-2011 Barnes
Four Winns

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

25-11-2011 Clements
Choi, Seongeun; Park, Sang Won

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 Priestly
Schumacher, Ross Philip

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

04-11-2011 Lock
Smith, Darryl Robert

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

04-11-2011 Lock
Robinson, Ian

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 Priestly
Hatzidimitriadis, Georgina

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 Priestly
Currie, Sheldon Douglas

Death in custody, health care, infectious diseases.

03-11-2011 Barnes
Charlesworth, Natarsha

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 Priestly
Parsons, Anthony John

Death in custody; siege.

21-10-2011 Barnes
Hornby, Grace Ann; Hornby, Jessica Lee; Mansell, Denise Ann; Thomson, Anthony Paul

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

20-10-2011 Callaghan
Death of a prisoner

Death in custody, suicide.

14-10-2011 Barnes
Bonanno, Gregory Stephen

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 Hennessy
JTN and AJN

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 Hennessy
Saunders, Ryan Charles

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

07-10-2011 Barnes
Tiers, Matthew Maurice

Death in custody, natural causes.

29-09-2011 Barnes
Long, Kerry-Ann

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

20-09-2011 Clements
Anderson, John Clive

Death in custody; subacute infective endocarditis; specialist referral.

20-09-2011 Clements
Grillo, Carl Antony

Death in custody; vascular neck restraint; positional asphyxia.

07-09-2011 Barnes
Jones, Adrian Elliott

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

24-08-2011 Callaghan
Bird, Saxon Phillip

Surf life saving; risk management.

02-08-2011 Barnes
Gitanjali

Self-immolation.

15-07-2011 Lock
Elshazly, Hossam Mohamed

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 Priestly
Heidrich, Bela

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

29-06-2011 Hennessy
Sleba, Leanne Margaret

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

27-06-2011 Previtera
(C) a 15 month old child

Burns, trauma, Communications between government agencies.

27-06-2011 Lock
Chung, Sanglin; McGreevy, Moira Therese; McGreevy, Glen Raymond; Purdy, Rachel Gai; Whitmore, Cory James; Hamilton, Mark

Motor vehicle accident, Bruce Highway south of Gympie.

22-06-2011 Baldwin
Crooks, Phyllis Anne

Police pursuit.

22-06-2011 Barnes
Conlan, Kathleen Anne

Death in a medical setting.

14-06-2011 Barnes
Tranby, James Errol

Death in custody, necrotising fasciites.

09-06-2011 Barnes
Rawlins, Edward Arthur Anthony

Death in custody, natural causes.

01-06-2011 Barnes
Frost, Margery

Nursing Home, staffing levels, storage of lifting hoist.

31-05-2011 MacCallum
Bell, Christopher Steven

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

26-05-2011 Barnes
Barrie, Albert Edward

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

10-05-2011 Hennessy
Hoy, Samara Lee

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

05-04-2011 Hutton
Clarke, Daniel James

Death in custody; siege.

25-03-2011 Barnes
MacKenzie, Malcolm; Brown, Graham; Wilson, Robert

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 Hennessy
Collinson, Clay Marsden

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

16-02-2011 Barnes
Spicer, Phillip Glenn

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

09-02-2011 Barnes

Back to top

2010

Name/event Findings delivered Coroner
Bell, Jennifer Elizabeth

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

16-12-2010 Hodgins
King, Brenda Elizabeth

Head injuries.

13-12-2010 Lock
2 year old child

Child drowning, adequacy of supervision, swimming pool leglslation.

13-12-2010 Lock
Bennett, James Andrew

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

10-12-2010 Priestly
Francis, Marty Tanui

Death in custody, police pursuit.

17-11-2010 Barnes
Spence, Samantha Rose

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

29-10-2010 Clements
Little Gungallida Girl

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 Priestly
Paterson, Gregory Clifford

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

18-10-2010 Priestly
Barker, Jeremy Dylan

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

08-10-2010 Barnes
Dyer, Alan Kent

Police shooting, self defence, mental illness, tasers.

29-09-2010 Barnes
Petersen, David Robert

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

16-09-2010 Barnes
Simpson-Willson, John Douglas

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

07-09-2010 Lock
Graham, Travis Noel

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

03-09-2010 Ryan
Muir, Jason Andrew

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

31-08-2010 Clements
Clumpoint, Thomas Andrew

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

27-08-2010 Clements
Bellamy, Gordon John

Police pursuits.

25-08-2010 Barnes
Dossetto, Kate Emma

Sertraline toxicity.

19-08-2010 MacCallum
Watego, Stewart Clint

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

19-07-2010 Mack
Bornen, Andrew John

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

16-07-2010 Barnes
Mataia, Tofia Josen

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

09-07-2010 Barnes
Spencer, Annette Lee

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

28-06-2010 Lock
Livermore, Scott Phillip

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

25-06-2010 Taylor
Child at Rockhampton

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

24-06-2010 Hennessy
Robinson, Paul Gerard Joseph

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

24-06-2010 Hodgins
Challis, George Edgar

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

17-06-2010 Barnes
Whiting, Edith

Unexpected outcome of health procedure, Bundaberg hospital.

11-06-2010 Barnes
Muller, Bradley John

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

10-06-2010 Ryan
Edwards, Peeta Louise Josephine

Opiate toxicity, inadequate police investigation.

09-06-2010 Baldwin
O'Neill, Timothy Gerard

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

28-05-2010 Clements
Welburn, Dale Robert and McPherson, Kerri Leigh

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

21-05-2010 Batts
Cockshutt, Andrew James

Death in custody, hanging points.

20-05-2010 Barnes
Jeffrey, Lawrence Edward

Death in custody, natural causes.

19-05-2010 Barnes
Cramb, Fay - aka Valmae Beck

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

07-05-2010 Barnes
Mulrunji - aka Cameron Doomadgee

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

07-05-2010 Hine
Fraser Island 4WD Inquest - Ian Davy, Concetta Dell’Angelo and Takeshi Sakai

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 Barnes
Gillis, Wayne Anthony

Missing Person.

19-04-2010 Lock
Nguyen, Luong Bang

Death in custody, natural causes, drug addiction.

16-04-2010 Barnes
Millard, Allan Clive

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

15-04-2010 Barnes
Report on Police Pursuits

Police pursuits, preventative recommendations.

31-03-2010 Barnes
Howlett, Peter David

Adequacy of Queensland Ambulance Service policies and procedures.

25-03-2010 Risson
Birse, Joel Timothy

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

24-03-2010 Strofield
Barnes, Roy

Death in custody, natural causes, drug withdrawal symptoms.

17-03-2010 Barnes
Shekar, Sridhar

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

11-03-2010 Hutton
Johnstone, Brett Thomas

Police shooting.

10-03-2010 Barnes
Hockey, Barry John

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

05-03-2010 Barnes
Child at Mackay

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

05-03-2010 Kennedy
Frizzel, Casey Andrew

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 Muirhead
Preston, William Elliot

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

12-02-2010 Barnes
Pont, Elles John

Death in custody, natural causes.

27-01-2010 Barnes
Two children at Murgon

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

18-01-2010 Lebsanft

Back to top

2009

Name/event Findings delivered Coroner
Hirning, Amanda Lee

Inquest, pedestrian running down, motorcycle accident.

24-12-2009 Barnes
Goodna rail incident - Duncan, Hayden; Duncan, Glen and Fisher, Reginald

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

23-12-2009 Barnes
Davidson, Yvonne Alice

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 Hennessy
Shishko, Peter

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

16-12-2009 Barnes
Myers, Robert Hayes

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

16-12-2009 Barnes
Grace, Daniel Scott and Heffler, Raymond John

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 Hennessy
Miller, Michael James

Inquest, death in custody, suicide, water police operations

09-12-2009 Barnes
Congoo, Sharon Faye

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

08-12-2009 Priestly
Heywood, John Martin

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

03-12-2009 Barnes
Costelloe, Anthony Gayle

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

26-11-2009 Barnes
Johnston, Margaret Allan

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

20-11-2009 Lock
Baker, Philip

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

11-11-2009 Hennessy
O'Keefe, Albert William

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

06-11-2009 Priestly
Cullen, Matthew Raymond

Police pursuits, extended intercepts.

05-11-2009 Barnes
Ash, Peter Edward and Ash, Nicole Florence

Police pursuits, obligation to abandon attempted intercept

03-11-2009 Barnes
Juhas, Jeffrey; Donaldson, Virginia; Juhas, Jerome and McGill, Stephen

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

28-10-2009 Priestly
Hopkinson, Joshua Leslie

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 Risson
Anderson, Andrew Scott

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 Clements
McBride, Edward Alexander

Electrocution, Australian Defence Force and Church of Scientology.

15-10-2009 Lock
Kerkvliet, Kristen

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

08-10-2009 Baldwin
Hildebrandt, Talisha

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

07-10-2009 Smid
Irwin, Brett Andrew and Semyraha, Craig Anthony

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

06-10-2009 Barnes
Streader, Leon

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 Clements
Harvey, John Arthur

Truck hiring process, regulatory framework.

01-10-2009 Springer
Hadlow, Barry Gordon

Death in custody, adequacy of health care.

29-09-2009 Barnes
Zaza, Jean-Marie Jeremie Yannick

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 Fingleton
Leach, Irene Clare

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

15-09-2009 Black
Helicopter crash near Gunpowder

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

14-09-2009 Barnes
Blee, Jason George Elliott

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 Hennessy
Oram, Ronald Thomas

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

21-08-2009 Barnes
Duggan, David John

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

13-08-2009 Fingleton
McLennan, Lee-Anne Gai

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

17-07-2009 Hennessy
Hanrick, Caitlyn

Police pursuits

17-07-2009 Barnes
Coleman, Randall John

Death in custody, Strychnine poisoning

10-07-2009 Clements
Stanford, Tony John

Death in custody, hanging.

03-07-2009 Clements
Kingston, Vanessa Louise

Motor vehicle accident, whether condition of road contributed to accident

24-06-2009 Cornack
Nielsen, Shane Robert

Gunshot wound to head, adequacy of Police investigation.

19-06-2009 Lock
Emerson, Jarrod Barton

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 McLaughlin
Hatch, Clay

Police shooting, mental health issues.

19-06-2009 Clements
Woo, June

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

01-06-2009 Barnes
Downing, Cheyenne Ruby

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

01-06-2009 Black
Maczkowiack, Peter James and Mackowiack, Pauline Anne

Inquest epilepsy and commercial truck driver licensing.

14-05-2009 Hennessy
Brasher, Gryphyn David

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

14-05-2009 MacCallum
Tilse, Therese Josephine

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

13-05-2009 Mack
Hoy, Raleigh

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 MacCallum
Brown, Sarah Christine and Parr, Darren Mark

Inquest – Motor vehicle accident, identification of driver

01-05-2009 Hennessy
Joy, Michael Joseph

Death in care.

24-04-2009 Risson
Broe, Stephen James

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

24-04-2009 Barnes
Moore, Paul James

Police pursuits

22-04-2009 Barnes
Kay, Brendan Scott

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

21-04-2009 Tonkin
Madeo, Niceta Maria

Inquest - Police pursuits

26-03-2009 Barnes
Glasgow, Benjamin

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

20-03-2009 Lock
Woolgar, Shealah Ann

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

20-03-2009 Lock
Wright, Liam John and Powell, Charles Michael

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

20-03-2009 Lock
Blake, Melissa Maree

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

16-03-2009 Callaghan
Bauer, Maurice Henry

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 Callaghan
Cusack, Barry John Charles

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

27-02-2009 Luxton
Malu Sara vessel - Flora Enosa, Wilfred Baira, Ethena Enosa, Ted Harry, Valerie Saub

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

12-02-2009 Barnes
Lee-Chue, Allan Duncan

Inquest, death in custody, natural causes.

10-02-2009 Barnes
Zulpo, Kate Leanne

Inquest - Motor Vehicle Accident, condition of roadway

09-02-2009 Taylor
Clarke, Jon Edward Norman

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

09-02-2009 Taylor
Scholl, Philip Henry

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 Braes
Reid, Kylie Maree

Inquest - Hanging, suicide.

08-01-2009 Springer

Back to top

2008

Name/event Findings delivered Coroner
Trcka, Peter Joseph

Inquest - Trawler, EPIRBS, personal floatation devices.

24-12-2008 Brassington
Venturato, John Ernest

Inquest, wide load, oversize load, collision

22-12-2008 Brassington
Plint, Hannah Isabella Alyson

Child drowning

22-12-2008 Ryan
Steggall, Rhonda Joy

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

17-12-2008 Hennessy
Harris, Robert

McGinness

15-12-2008 McGinness
Tynan, Kristina Ann

Police pursuits.

15-12-2008 McGinness
Van Putten, Patricia

Inquest, suicide, mental health patient.

15-12-2008 McGinness
Shepherd, Craig Robert

Inquest: Coroners, police pursuits.

12-12-2008 Barnes
Sturgess, Jane Rose

Inquest - driver fatigue.

12-12-2008 Cornack
Fenner, Christine Maria

Inquest – missing person

11-12-2008 Batts
McVey, Oliver Steven

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 Clements
Wills, Ian Charles

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

26-11-2008 Rinaudo
Howe, Paul Gerrard

Truck accident, steep descent, driver inexperience.

26-11-2008 Killeen
Willowbank aircraft accident - Colin Hicklin, Barbara McLelland, Nigel O'Gorman, Susanne Williams, Anthony Winter

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

24-11-2008 Barnes
Boyd, Melanie Kate

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

05-11-2008 Smith
Deceased prisoner

Death in custody, natural causes.

05-11-2008 Barnes
Duncan, Joseph Douglas

Police pursuits

24-10-2008 Barnes
Maxfield, Annette

Exsanguinations following colorectal surgery, serious surgery in remote locations.

10-10-2008 Barnes
McKenzie, Jillian Peta

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

03-10-2008 Comans
Warren, Michael

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

25-09-2008 Clements
12 year old boy at Kowanyama

Department of Families, remote Indigenous community, child suicide.

19-09-2008 Barnes
Doheny, Dominic Raphael

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

12-09-2008 Lock
Neville, Elise Susannah

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 Lock
Bertram, Amanda Renee

Mixed drug toxicity

11-09-2008 Lock
Maslen, Samantha Anne

Police pursuits, tyre deflation devices.

27-08-2008 Barnes
Benson, Leim Matthew

Hanging death of 33 year old male.

25-08-2008 Lock
Greaves, Colin Arthur

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 Hennessy
Batten, Derek , Tunstead , Peter and Tunstead, James

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 Barnes
Bock, Kristian

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 Brassington
Shelley, Chloe Louise

Motor vehicle crash, speeding, condition of road.

17-07-2008 Lock
Maggable, Kenneth

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

17-06-2008 Black
O'Connell, Martin John

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

06-06-2008 Lock
Irwin, Ross Frederick

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

06-06-2008 Barnes
Rouse, Christine Chloe

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

26-05-2008 Luxton
Mosby, Phillemon Edward

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

23-05-2008 Barnes
Mountford-Smith, Trevor Bertram

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

19-05-2008 Taylor
Gallaher, Sebastian Luke Paul

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

15-05-2008 Parker
Blinco, Ricky Glenn; Last, Michael Wayne

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 Barnes
Brown, Robert Lee

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

01-05-2008 McLaughlin
Schibrowski, John Malcolm

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

24-04-2008 Hennessy
Watson, Christina Mae

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

24-04-2008 Glasgow
Bond, Jakai Ryan

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

10-04-2008 Barnes
Fitzgerald, Anthony Michael

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

28-03-2008 McLaughlin
Waite, Thomas Dion; Huynh, Mieng; Jacobs, James Henry; Gear, James Michael

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 Barnes
Zwahlen, Bernard

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

27-02-2008 Tonkin
Jones, David Colin

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

11-02-2008 Killeen
Hauff-Green, Edward Thomas

Mental health, emergency sedation.

31-01-2008 Lock
Young, Janet Louise

Truck rollover, load restraint and centre of mass.

23-01-2008 Lock
Schmidt, Shirley

Missing person, re-opening of inquest.

17-01-2008 Barnes
Wigg, Allan Thomas

Banana bagging machine machinery incident at Wangan on 3 December 2004

16-01-2008 Brassington

Back to top

2007

Name/event Findings delivered Coroner
Newman, Patricia Dell

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

20-12-2007 Springer
Hall, Jordan James

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

20-12-2007 Halliday
Whittington, Frank Maurice

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 Tonkin
Burgen, Deborah Denise

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

07-12-2007 Barnes
Mills, Samuel John

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

29-11-2007 Barnes
Tanner, Marjorie Joyce

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

28-11-2007 Taylor
Scholz, Karl David

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 Clements
Bodell, Margaret Florence Anne

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 Clements
Gillies, Bradley James

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

23-11-2007 Kehoe
Walker, Nola Jean

Death in custody

23-11-2007 Barnes
Hanley, Timothy Michael

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

22-11-2007 Hennessy
Huber, Arisa

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

06-11-2007 Clements
Cvitic, Nardia Annett

Medical procedure, complications.

29-10-2007 Clements
Murray, Kelvin Charles

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

16-10-2007 MacCallum
Zupp, Jason John

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

12-10-2007 Cornack
Fogarty, Kevin Edward

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

01-10-2007 Barnes
Crowston, Amanda Terese Francis

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

26-09-2007 Mack
Waugh, Cappur William Embling

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

14-09-2007 Rinaudo
Babington, Lynette

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

13-09-2007 Cornack
Henderson, Robert Joseph

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

03-09-2007 Clements
Noffke, Veronica Margaret

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

29-08-2007 Webber
Effer, Anthony John

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

27-08-2007 Smith
Case, Matthew Colin

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

24-08-2007 McLaughlin
Fitter, Maureen

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

24-08-2007 Lock
Lockhart River aircraft crash

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 Barnes
Mental Health patient

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 Clements
Stiller-Smith, Felix Jake

Infant death, undertermined cause, presence of amphetamines in breast milk, contact with the Department of Families.

10-08-2007 Clements
Tang, Shannon Sheng Wen

Medical procedure, gastric bypass, informed consent regarding mortality, complications.

10-08-2007 Clements
Duckett, Alan Bernie-Johnson, Bruce William-Hughes, Allen John-Thompson, Katharine Anne

Aircraft crash, CASA staff training, automatic recording of engine parameters.

09-08-2007 Barnes
Howell, Thomas John

Run over by a school bus at Gympie.

03-08-2007 Callaghan
Bessell, Michael Ian Charlesworth

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 Hennessy
Aldred, Belinda Jayne

Hanging at Mareeba

13-07-2007 Braes
Liddell, Matthew John

Hanging death of young man receiving psychiatric care in hospital, procedure for observation of patients, procedure for assessment of suicide risk.

20-06-2007 Clements
Eady, Graeme William Julian

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 Clements
Huntington, Sparka Isarva aka Huntington, James Philip

Restraint of mental health patients.

01-06-2007 Barnes
Skardoon, Dorothy Rae

Death following fall; recent eye procedure

25-05-2007 Lock
Mental Health patient

Involuntary treatment orders, assessment of suicide risk, procedures for intermittent observation orders.

25-05-2007 Clements
Davis, Jodie Maree

Death in custody, Townsville Correctional Centre.

16-05-2007 Tonkin
Horsington, Margaret Isabel

Bowel obstruction, Fleet, diagnosis and treatment. inquest within the medical system at the Roma Hospital.

04-05-2007 Rinaudo
Lang, Michael Charles

Operating a backhoe when demolishing a pedestrian bridge at Broadbeach on 10 December 2003.

01-05-2007 Brassington
Thorpe, Geoffrey

First aid training and equipment on an industrial site.

18-04-2007 Guthridge
Smith, Arthur Lawrence

Hospital/health procedures, death.

05-04-2007 Lock
Pittaway, Steven John and Coe, Paul Allen

Watch house, inspection of prisoners, searching of prisoners, risk assessment of prisoners, elimination of hanging points.

30-03-2007 Barnes
Dee, Fiona Jane

Elective Caesarean, spinal anaesthesia, cerebrospinal fluid leak, subdural haematoma, query epilipsy, query cardiac event, Tegretol, hyponatremia, epidural patch, postural headaches.

23-03-2007 Clements
Davis, Shane William

An industrial death at the Foxleigh Mine near Middlemount

21-03-2007 Hennessy
Gabiola, Peter

Death at Cluden on 23 July 2003, Workplace Incident, Purification Plant, Tractor.

19-03-2007 Hillan
Turnbull, John

Work related accident, workplace health and safety, driveway construction, plant, vibrating rollers.

13-03-2007 Clements
Browne, Roger Bruce

Industrial incident at Dawson Mine near Moura in Central Queensland.

06-03-2007 Hennessy
Lather, David Andrew

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 Previtera
McGeary, Corey Allan

Death in custody, suicide, hanging points.

01-03-2007 Barnes
James, Joseph Edwin

Death in custody, natural causes.

23-02-2007 Barnes
Russell, Andrew John and Harogh, Bianca Joan

Motor vehicle accident, high speed, seriously defective vehicle, street racing, poor judgment.

21-02-2007 McIntyre
Eddy, Michael John

Death in custody, positional asphyxia, amphetamine use, autopsy reports, registration of causes of death.

12-02-2007 Barnes
Carroll, Leon Mark

Cause of Death-suicide, hanging points.

19-01-2007 Barnes
Marshall, Maxwell John

Control of prescription medication, the role of the Drug of Dependence Unity, autopsies by government medical officers.

19-01-2007 Barnes
Tyssen, Mario Emmy

Death in custody, health care of prisoners.

19-01-2007 Barnes
Fitzgerald, Darren Michael

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 Barnes
McDonald, Kerry-Ann

Multiple injuries as a consequence of motor vehicle trauma, Kawasaki loader.

10-01-2007 Kennedy
West, Ian Leslie

Bronchopneumonia following a severe head injury.

10-01-2007 Kennedy

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2006

Name/event Findings delivered Coroner
Blockley, Michael Gary; Watson, Stevie Lee; Teske, Neil Lackland; Donaldson, Michael Bruce; and Nugent, Christopher John

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

06-04-2011 McIntyre
Day, Mark Walter

Death in custody, murder, supervision of dangerous prisoners.

19-12-2006 Barnes
Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

Suicide by mental health patients.

15-12-2006 Previtera
Czislowski, Kenneth Douglas

Gyrocopters, failure of mechanical hub bar, aerial work other than recreational flight, cattle mustering.

08-12-2006 Costello
Jones, Katherine Alison

Automatic sliding gates, workplace health and safety.

04-12-2006 Killeen
Tierney, Beverley Ann

Drowning, wet drowning, dry drowning.

27-11-2006 Rinaudo
Petrelis, Andrew Nicholas

Opiate toxicity.

24-11-2006 Halliday
Hogan, Kevin James and Hogan, Winifred Therese

Motor vehicle accident, signage, intersection safety, speed limits.

15-11-2006 Hennessy
Jeffrey, Helen

Suicide by mental health patients.

13-11-2006 Taylor
Ali-Haapala, Anita

Risk management of patients in mental health facilities.

31-10-2006 Buckley
Boyce, Amanda Helen

Death in spa, Reynolds equation, laminae flow, turbulent flow, hair entrapment, tangling and knotting.

18-10-2006 Rinaudo
Mathers, John William

Motor vehicle accident, surgical error, failure to correctly operate blood infuser, training issues.

12-10-2006 Cornack
Mulrunji

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 Clements
Beattie, Christian Paul

Aircraft accident, adequacy of Queensland Police Service policies and procedures regarding aircraft accident investigation.

14-09-2006 Cridland
Rawson, Robert Donald

Availability of quality medical equipment in regional hospitals.

13-09-2006 Hennessy
Robinson, Terence James

Status epilepticus, monitoring of psychiatric patients, emergency sedation, transfer to primary hospitals.

08-09-2006 Barnes
Hamilton Island aircraft crash

Aircraft accident, fuel selector warning, chief pilot's duties, securing of evidence.

07-09-2006 Barnes
Grimley, Scott Robert

Electrocution at work.

01-09-2006 Halliday
Vernon, Colin John

Death at North of Gympie on 7 May 2005, Motor vehicle incident.

24-08-2006 Callaghan
Shaw, Lillian Margaret

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 McLaughlin
Casey, Lenard John

Death in custody, natural causes.

10-08-2006 Barnes
Bee, Calvin Wayne

Death in custody, riders concerning incarceration of alcoholic persons, sudden unexplained death in epilepsy

09-08-2006 Barnes
Vidler-Cumming, Liam Richard

Shaken baby syndrome.

28-07-2006 Barnes
Zimitat, Vivian Bexley

Regional neurology services availability; maintenance of appropriate records regarding regional and remote medical contact with specialty units in tertiary hospitals.

28-07-2006 Hennessy
Palace Backpackers Hostel Fire

Arson in budget accommodation, fire safety reforms, Childers.

07-07-2006 Barnes
Hooymans, Kylie Danielle

Death at Tewantin on 13 March 2005, Hanging, Mental Health.

07-07-2006 Taylor
Ioane, Andrew Penetito

Death in custody, police pursuit, recommendations regarding police training.

30-06-2006 Barnes
Williams, Stuart Ronald

Death in custody, correctional centre, natural causes.

27-06-2006 Barnes
Hedges, John Walter

Accidental overdose, medical negligence, systemic failings in a clinical setting

15-06-2006 Barnes
Hewson, Jamie

Death in custody, police shooting.

08-06-2006 Barnes
Bell, Malcolm Robert

Police shooting, self-defence.

26-05-2006 Barnes
Marshall, Peter Whitoria

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 Barnes
Baker, Rodney John

Trawler fishing, boat capsizing, hydrostatic released life rafts, PFDs, EPIRBs, search and rescue.

15-05-2006 Barnes
Karajic, Scott Meho

Gas drilling rig accident, supervision on drilling rigs, recommendations concerning the education of drilling rig supervisors and crew.

26-04-2006 Barnes
Adams, Michael James

Inquest, death in custody on 11/09/1997, hanging at Sir David Longland's Correctional Centre in Bribane.

13-04-2006 Halliday
Meech, Paul Andrew

Death in custody, watchhouse supervision, mental illness, involuntary assessment and involuntary treatment order, management of mental illness.

07-04-2006 Barnes
Rhodes, Daniel Cory

Police shooting, self defence.

23-03-2006 Barnes
Bismark, Lex Robert

Motor vehicle accident, recommendation concerning fitness to drive.

23-03-2006 Barnes
Bourke, Raymond Francis

Death whilst attempting to avoid being taken into custody, suicide.

17-03-2006 Barnes
Smith, David Edward

Death in custody, Prison murder, protective custody.

17-03-2006 Barnes
Schumacher, Nicholas

Death at Townsville on 12 September 2004, Child death, motor vehicle incident, navy cadet, troop carrier.

16-03-2006 Smith
Matschoss, Wayne Barry

Death in custody, natural causes

13-03-2006 Barnes
Pettigrew, Wayne Matthew

Death in custody, natural causes.

13-03-2006 Barnes
Creegan, Thomas

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 Previtera
Hendy, Albert William

Death in custody, natural causes.

24-02-2006 Barnes
Sperling, Karl Peter

Drowning of an army cadet on exercise.

17-02-2006 Daley
Crossman, Troy Samuel

Death in custody, recommendations concerning the management of 'at risk' prisoners, hanging points.

03-02-2006 Barnes
Muckan, David Jones

Psychiatric hospital death, benzodiasepines, obstructive sleep apnoea. Recommendations concerning the observation of patients administered sedatives.

03-02-2006 Barnes

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2005

Name/event Findings delivered Coroner
Partridge, Phillip Bruce

Death in custody, Police siege, suicide, mental health.

22-12-2005 Barnes
Hansen, Anthony Kenneth

Correctional Centre, transfer to hospital, death from natural causes.

22-12-2005 Barnes
Croft, Penelope Ann

Motor vehicle accident. Recommendations concerning engine compartment door of buses.

02-12-2005 Rinaudo
Perry, Jye Conrad (a child)

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 Hennessy
Community Mental Health Patient

Inquest, hanging of young man receiving psychiatric care in the community after revocation of involuntary treatment order, assessment of suicide risk.

09-11-2005 Clements
Tognola, Phillip Allan Walter

Swimming pool drowning of a child. Recommendations concerning inspection of pools.

01-11-2005 Spencer
Liddington, Craig; Eva, Stewart; Carpenter, Andrew

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 Hennessy
Dell, Maren Lyndsey

Diving accident at Agincourt Reef, Great Barrier Reef, Far North Queensland. Recommendations concerning training for the diving industry.

19-10-2005 Lock
Fernandez, Adam Anthony

Natural causes, capsicum spray.

17-10-2005 clements
Waldon, Mark Anthony aka Hurricane, Mark Anthony

Natural causes, reaction to heroin withdrawal medication. Recommendations concerning the suitability of prescribing certain medication to prisoners, supervision of prisoners.

14-10-2005 Clements
Irwin, Perry James; Coates, Damien Lawrence

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 Barnes
Naidu, Alvin

Recommendations concerning supervision of truants by the Department of Education.

10-10-2005 Clements
Rowland, Jet Paul

Motor vehicle accident, recommendations concerning fitness to drive, epilepsy and driving.

15-09-2005 Clements
Cook, Robert Edward

Motor vehicle accident involving an elderly motor cyclist.

15-08-2005 Clements
Pugh, Samuel

Death south of Charters Towers on 17 August 2004, Highway Reward Mine, Rock fall.

10-06-2005 Verra
Robinson, Jacinta Kate

Death of a child undergoing surgery-cardiac tampenade. Recommendations regarding training for nurses and medical staff, allocation of specialist medical services.

04-05-2005 Clements
Hope Vale man

Hope Vale man in an Aboriginal community police van. Recommendations concerning training of Aboriginal Community police officers.

07-04-2005 Barnes
Landue, Shone; Reid, Gary; Doolan, Stanley

Recommendations concerning the inspection of boarding houses and fire safety.

09-02-2005 Clements
Sabadina, Kathryn Marnie

Anaphalactic shock. Recommendations concerning the recruitment and supervision of foreign trained doctors.

24-08-2004 Barnes

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2004

Name/event Findings delivered Coroner
Fiechtner, Rodney Joseph

Gas explosion on a drilling rig. Recommendations concerning risk management on rigs.

20-12-2004 Barnes
Eason, David John

English tourist missing on Fraser Island for two years. Recommendations concerning searches and wilderness signage.

06-12-2004 Barnes
Shoobridge, George Richard

Death at Cairns on 1 December 2002, Cardiorespiratory failure, drug overdose, methadone program.

28-10-2004 Previtera
Toohey, Alan Paul; Hill, Andrew Tasman

Police pursuit in Coen. Recommendations regarding cessation of such pursuits.

20-10-2004 Barnes
Lee, Julian Arasina

Restraint of mental health patients

30-09-2004 Previtera

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Last reviewed
21 June 2011
Last updated
29 August 2014

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