| Name/event |
Findings delivered |
Coroner |
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 |
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 |
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 |
Morgan, Charles Ross Maxwell
Train overrun, suicide or accident.
|
15-03-2013 |
Lock |
Owens, Kenneth Roland and 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 |
| Name/event |
Findings delivered |
Coroner |
Gerhardt, Robert John
Death in custody, natural causes.
|
19-12-2012 |
Barnes |
Evans, William Alfred
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 and 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 |
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 |
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 |
Death of a Baby
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 and Isabella & Sanderson, Gregory
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 |
Baby M
Childbirth at home, unknown preganancy.
|
29-06-2012 |
Lock |
MacNicol, Jack Wallace
Fatal head injury while mustering cattle on motorcycle; not wearing helmet; adequacy of regulatory standards.
|
29-06-2012 |
Priestly |
Robinson, Ian; Charlesworth, Natarsha; Hatzidimitriadis; Park, Sang Won; Choi Seongeun
Adequacy of regulatory framework covering white water rafting.
|
29-06-2012 |
Priestley |
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 |
Watson, Eric Handley
Death in custody, natural causes.
|
31-05-2012 |
Barnes |
Perry, Anthony Mark
Death in custody - police watch house; accidental overdose; assessment of intoxicated prisoners.
|
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 |
| Name/event |
Findings delivered |
Coroner |
Thompson, Grace
Motor vehicle crash, alcohol breath testing at scene.
|
16-12-2011 |
Lock |
Inglis, Tracey Lee
Death in custody, suicide, management of pain relief.
|
09-12-2011 |
Barnes |
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 |
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 |
Smith, Darryl Robert
Death in a medical setting; adequacy of surgical equipment and management.
|
04-11-2011 |
Lock |
Schumacher, Ross Philip
Gun shot wound to the head; gun shot residue; contact wounds; adequacy of police investigation.
|
04-11-2011 |
Lock |
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 |
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 |
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 |
Currie, Sheldon Douglas
Death in custody, health care, infectious diseases.
|
03-11-2011 |
Barnes |
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 |
(C) a 15 month old child
Burns, trauma, Communications between government agencies.
|
27-06-2011 |
Lock |
Sleba, Leanne Margaret
Gunshot, accidental, criminal negligence, intentional, open finding.
|
27-06-2011 |
Previtera |
Crooks, Phyllis Anne
Police pursuit.
|
22-06-2011 |
Barnes |
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 |
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 |
| 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 |
Paterson, Gregory Clifford
Concrete pumping, hose whip, supervision of construction site, Workplace Health and Safety.
|
18-10-2010 |
Priestly |
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 |
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 |
Child at Mackay
Suicide, 15 year old Aboriginal girl, no history of mental illness.
|
05-03-2010 |
Kennedy |
Hockey, Barry John
Death in custody, natural causes and adequacy of medical care.
|
05-03-2010 |
Barnes |
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 |
| 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 |
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 |
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 |
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 |
Hanrick, Caitlyn
Police pursuits
|
17-07-2009 |
Barnes |
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 |
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 |
Hatch, Clay
Police shooting, mental health issues.
|
19-06-2009 |
Clements |
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 |
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 |
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 |
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 |
Glasgow, Benjamin
Inquest - Death of a Child following child birth, brow presentation, head injuries
|
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 |
| 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 |
Tynan, Kristina Ann
Police pursuits.
|
15-12-2008 |
McGinness |
Harris, Robert
McGinness
|
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 |
Deceased prisoner
Death in custody, natural causes.
|
05-11-2008 |
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 |
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 |
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 |
Doheny, Dominic Raphael
Mixed drug toxicity death of 36 year old man prescribed MS Contin. Recommendation regarding warning labels.
|
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 |
Shelley, Chloe Louise
Motor vehicle crash, speeding, condition of road.
|
17-07-2008 |
Lock |
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 |
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 |
Watson, Christina Mae
Inquest into the death of Christina Mae Watson who died whilst diving on the historic Shipwreck "Yongala".
|
24-04-2008 |
Glasgow |
Schibrowski, John Malcolm
Motor vehicle accident, Traffic accident investigation squad TAIS investigation, identity of driver
|
24-04-2008 |
Hennessy |
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 |
| 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 |
Walker, Nola Jean
Death in custody
|
23-11-2007 |
Barnes |
Gillies, Bradley James
Death at Southport on 1 May 2004, Motor vehicle incident, concrete truck roll over, telegraph pole.
|
23-11-2007 |
Kehoe |
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 |
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 |
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 |
Huntington, Sparka Isarva aka Huntington, James Philip
Restraint of mental health patients.
|
01-06-2007 |
Barnes |
Mental Health patient
Involuntary treatment orders, assessment of suicide risk, procedures for intermittent observation orders.
|
25-05-2007 |
Clements |
Skardoon, Dorothy Rae
Death following fall; recent eye procedure
|
25-05-2007 |
Lock |
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 |
Tyssen, Mario Emmy
Death in custody, health care of prisoners.
|
19-01-2007 |
Barnes |
Carroll, Leon Mark
Cause of Death-suicide, hanging points.
|
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 |
Marshall, Maxwell John
Control of prescription medication, the role of the Drug of Dependence Unity, autopsies by government medical officers.
|
19-01-2007 |
Barnes |
West, Ian Leslie
Bronchopneumonia following a severe head injury.
|
10-01-2007 |
Kennedy |
McDonald, Kerry-Ann
Multiple injuries as a consequence of motor vehicle trauma, Kawasaki loader.
|
10-01-2007 |
Kennedy |
| 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 |
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 |
Vidler-Cumming, Liam Richard
Shaken baby syndrome.
|
28-07-2006 |
Barnes |
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 |
Smith, David Edward
Death in custody, Prison murder, protective custody.
|
17-03-2006 |
Barnes |
Bourke, Raymond Francis
Death whilst attempting to avoid being taken into custody, suicide.
|
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 |
Muckan, David Jones
Psychiatric hospital death, benzodiasepines, obstructive sleep apnoea. Recommendations concerning the observation of patients administered sedatives.
|
03-02-2006 |
Barnes |
Crossman, Troy Samuel
Death in custody, recommendations concerning the management of 'at risk' prisoners, hanging points.
|
03-02-2006 |
Barnes |
| Name/event |
Findings delivered |
Coroner |
Hansen, Anthony Kenneth
Correctional Centre, transfer to hospital, death from natural causes.
|
22-12-2005 |
Barnes |
Partridge, Phillip Bruce
Death in custody, Police siege, suicide, mental health.
|
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 |
