Findings and upcoming inquests - Coroners Court

Inquest, work, health & safety incident, deceased fatally crushed by falling pipe from forklift unloading truck, non-suspicious death.

Inquest, road accident, pedestrian struck by unidentified vehicle, ‘how’ the accident occurred, identity of the driver at the time of the incident, admission as to driving.

Coroners, Drivers Licensing, Medical Certification, Fitness to Drive, Dementia, Elderly Driver, Notification to Licensing Authority.

Coroners, inquest, death in the course of police operations, conducted energy weapon, Taser, self-immolation, use of force, mental health response, incident command, police training.

Inquest, operation of limited category, ex-military “Warbirds” aircraft in Australia, airworthiness and maintenance, pilot training for aerobatic flight activity, regulatory framework, reporting systems.

Inquest, domestic violence, shooting of police officer, siege, automatic rifle, police shooting of armed offender, adequacy of police investigations, incident command, police intelligence.

Inquest, death in custody, elderly prisoner, natural causes, acute myeloid leukaemia, whether there was a delay in diagnosis and treatment.

Inquest, death in custody, natural causes, cirrhosis, splenomegaly, ruptured spleen, health care.

Rural property death; tractor roll-over; crush injuries; early model/vintage tractors; roll over protective structure (ROPS); sloping terrain; excessive weight with inadequate ballast.

Paediatric death, regional hospital; acute abdominal pain; Autism Spectrum Disorder (level 1); paediatric pain assessment; persisting and worsening vomiting; bilious vomitus; surgical admission to paediatric ward; failure to recognise and respond to clinical deterioration or parent concerns; lack of senior clinician oversight and input; premature closure and anchoring bias, inadequate nursing documentation (fluid balance chart, Children’s Early Warning Tool – CEWT); Ryan’s Rule; Root Cause Analysis (RCA); congenital band adhesion.

Inquest, road accident, passenger vehicle overturned on country road, how the accident occurred, identity of the driver at the time of the incident.

Inquest, death in custody, natural causes, health care, provision of Aspirin and anti-hypertensive medication to prisoner with history of cardiac illness.

Inquest, death in custody, natural causes, essential thrombocytosis, provision of medication.

Inquest, police shooting, death in custody, avoiding being placed into custody, use of force, mental health response, incident command, entry into residence, police training.

Inquest, death in custody, natural causes.

Death in custody, natural causes, health care, refusal of treatment  by prisoner.

Death in police operations, motorcycle crash, attempted interception, pursuit policy.

Roller door failure, design fault, multi residential premises.

Death in custody, natural causes, palliative care, exceptional circumstances parole.

First Nations prisoner, death in custody, natural causes, health care, human rights, sudden death in epilepsy, provision of anticonvulsant medication to prisoners, reception triage, monitoring of medication.

Domestic and family violence related death; high risk and recidivist perpetrators; female perpetrated intimate partner homicide; ‘violent resistance’; intimate partner homicide lethality risk factors; policing response to domestic and family violence incidents; Community Corrections; information sharing; trauma informed service delivery; problematic substance use; perpetrator accountability; men’s behavioural change programs; section 304B Criminal Code; Domestic and Family Violence Death Review & Advisory Board

Youth residential care; Sarina; voluntary placement 13 year old male child; in company with another; forcible entry into residential facility office, removed car keys belonging to staff member / carer; drove car to Bowen; single car collision; car ignited; cause of death effects of fire; passenger survived; key safe to be installed in facility office; consideration for additional staff or ‘awake’ staff on shift; consideration as to funding recommendations

Killing, retaliatory filicide, intimate partner homicide, lethality risk factors, domestic violence, coercive control, service systems, police response, police training, multi-disciplinary teams

Domestic and family violence; murder; suicide; intimate partner homicide; femicide; Queensland Police Service response; police policies and procedures; police reforms; multi-disciplinary police stations; embedded DV social workers

Death in custody, police shooting, edged weapon, avoiding being put into custody, mental health, parole supervision.

Coroners: inquest, death in custody, police shooting, chronic illness, mental health treatment, suicide.

Death in custody, suspected offending, avoiding being placed in custody, flooding, culvert design, grates, drowning, whether death preventable.

Death in custody, police shooting, prisoner arrested on interstate warrant, cardiac event, detained in hospital setting, application of handcuffs, risk assessment.

Non-intentional shooting in theatrical setting, criminal acts, role of armourer and adequacy of applicable work, health and safety standards.

Death in custody, avoiding being placed into custody, use of force, police shooting, domestic violence, mental health response, incident command, entry into yard, police training.

Missing person, fentanyl, prescribing, doctor shopping, police investigation.

Child in care, pool fence safety, foster carers, placement capacity.

Emergency examination authority, detention under Public Health Act 2005, death in custody, suspected self-harm, petrol sniffing, police restraint, lateral vascular neck restraint, ambulance response.

Road accident, passenger on route service, bus fatally injured when bus overturned, passenger seatbelts not fitted to bus, Coroner’s recommendation that seatbelts be fitted to route service buses within a reasonable time frame.

Death in care, Brugada syndrome, Hypoxic brain injury, Automatic implantable cardioverter device, Treatment, Rehabilitation.

Death in custody, First Nations man, hanging, suicide risk assessment, mental health services in prison.

Attorney General Direction to conduct an Inquest, 1983 cold case, female self-inflicted gunshot wound, suspected suicide, adequacy of original police investigation, cold case homicide review, original non-inquest findings of Coroner upheld.

Queensland Police Service, pursuit, pursuit policy, communications centre, dangerous driving, urgent duty driving, primary pursuit vehicle, radio communications.

Stabbing, double fatality, police investigation, police response, QAS response, decision to charge.

Suicide, death in custody, hanging, life prisoner, hanging points.

Baby, neonate, home birth, midwife, Neopuff, resuscitation, falsification of medical records.

Domestic and family violence, domestic abuse, mental health, protection orders, health care providers, service system contact.

Overseas national, working holiday visa, farm work, labour hire, pumpkin picking, death as a result of heat stroke, failure to implement adequate controls, Work Health and Safety Act 2011, Magistrates Court prosecution, Safe Work Australia, managing risks of working in heat, employer obligations to workers and foreign nationals, Harvest Trail Inquiry Report.

Intimate partner violence, private Domestic Violence application, service of Domestic Violence application and Order/s, dismissal of Domestic Violence application, parenting orders, stabbing, fatal injuries, set vehicle to fire, interfering with corpse, military service, Australian Defence Force, psychological care, Veteran’s Counselling Service, private psychologist, termination of therapeutic relationship, failure to disclose intention to harm.

Child Safety, foster care, missing children, murder, rape, incest, Thorburn.

Death in custody, natural causes.

Death in custody, suicide of young prisoner, transition from youth justice to adult prison, information sharing, hanging, whether death was suspicious, risk assessment.

Suicide, death in custody, remand prisoner, risk assessment, hanging points.

Co-sleeping, risk factors, Department of Communities, Child Safety and Disability Services, child tracking register.

Licence holder, medical fitness to drive, assessing fitness to drive, insulin dependent diabetes, diabetes mellitus, obligations of medical and general practitioners, Transport and Main Roads, motor vehicle accident, recommendations.

Pedestrian hit by car, difficult intersection, S46 comments from inquest, accident, weather conditions.

Death in custody, natural causes.

Death in custody, natural causes

SIDS, co-sleeping, risk factors, parental drug use, child protection, Qld Child Death Case Review, Department of Communities, Queensland Health, information exchange

Sudden infant death syndrome, SIDS, co-sleeping, overlay, risk factors, parental drug use, child protection.

Domestic and Family Violence, Domestic Violence Protection Orders, Domestic and Family Violence Protection Act 2021, murder, Lionel Patea, Queensland Police Service, High Risk Teams, Queensland Health.

Death in custody, police watchhouse, mixed drug toxicity, assessment and monitoring of prisoner health, police CPR skills and training, investigation of police related deaths.

Failure to obtain medical attention, failure to provide necessities of life, murder, unlawful killing, manslaughter, child abuse.

Domestic and Family Violence, DVConnect, Queensland Police Service, High Risk Teams.

Ingestion of Bacban, poison, nursing home, staff responses, hospital responses, standard of care

Death in custody, natural causes.

Death in custody, natural causes, terminally ill prisoner, capacity issues, substituted decision maker, palliative care, Human Rights Act 2019.

Missing person, methylamphetamine, searches, police investigation.

Townsville Hospital Acute Mental Health Unit, Health Service Officer vascular restraint, involuntary patient, obese, prone position, cardiac arrhythmia during a restraint

Ravenshoe café explosion; licence holder; medical fitness to drive; assessing fitness to drive; seizure; epilepsy; obligations of medical and general practitioners, continuity of care; Austroad guidelines; Transport and Main Roads; voluntary and good faith notifications to licencing authority; recommendation for working group to review fitness to drive protocols and provide education for medical profession.

Death in Iraq, Australian Embassy, close personal protection officer, security contract, Standard Operating Procedures, alcohol and drug consumption, weapons handling and storage.

Child death, child protection, Department of Child Safety, Youth and Women, SCAN, information sharing, adoption, permanency orders.

Death in custody, natural causes

Death in custody, natural causes.

Fatality in underground mining, asphyxiation via exposure to depleted-oxygen atmosphere, deceased misdirected to incorrect location by administrative failure to update sensor location data, recommendations concerning signage and access to “GOAF” areas containing irrespirable atmosphere.

Bilateral bronchopneumonia, lower lung crackles, community acquired pneumonia, red flags, blood streaked sputum, haemoptysis, general medical practitioner, failure to record vital signs, misdiagnosis, medical care and treatment, referral to the Office of Health Ombudsman.

Aircraft accident, tandem parachuting, parachuting operations, regulatory oversight of commercial parachuting operations.

Dreamworld, amusement device, Theme Park, safety management systems, ride maintenance, training, amusement device regulation, amusement device designer, amusement device modification, external safety audits.

Fire, suspicious circumstances, Mobile Home Park, smoke alarms.

radiological procedure performed, location of the injection/s, loss of consciousness, cause of death, adequacy of response and care provided.

Josephine Falls, Ngadjon-ji traditional owners, Wooroonooran National Park, drowning deaths, bottom pool, water related fatality, rainfall, adverse weather events, adequacy of signage, international visitors, weather conditions, Mount Bartle Frere catchment, water levels, automated warning systems, mobile phone blackspot, emergency response, SwiftWater rescue, Queensland Fire and Emergency Services, Queensland Police.

Death in custody, Indigenous prisoner, risk assessment, hanging, high dependency unit, supervision of prisoners, prison support and mental health services, information sharing between Queensland Corrective Services and Prison Mental Health Service employees.

Angiogram, stent, pseudo-aneurysm, infection, treatment and care.

Closure of Barrett Adolescent Centre, Commission of Inquiry, transition arrangements for adolescents to adult mental health services, alignment between adolescent mental health services and adult mental health services, dual diagnosis of intellectual disability and mental illness, NDIS, adequacy of care provided, recommendations by the COI, recommendations for the prevention of self-harm and suicide in adolescents and young people.

Skydiving multiple fatality, Australian Parachute Federation, Commonwealth Aviation Safety Authority, Skydive Australia, Skydive Cairns, solo sports jump, tandem, relative work, back to earth orientation, premature deployment of main chute, container incompatibility with pack volume, reserve chute; automatic activation device (AAD), consent for relative work, regulations, safety management system, drop zone, standardised checking of sports equipment, recommendation for sports jumpers to provide certification for new or altered sports rigs including compatibility of main chute to container, recommendation to introduce 6 month checks by DZSO or Chief Instructor for sports rigs at drop zones to ensure compatibility.

Loss of life arising from capsize of two fishing vessels – causes of loss – recommendations as to safety improvements in fishing industry

Prescription opioids, drugs of dependence, opioid overdose, oxycodone, oxycontin; Schedule 8 medications, drugs of dependence; controlled drugs, doctor shopping, prescribing practices, real-time prescription monitoring, electronic recording and reporting of controlled drugs; Monitored Medicines Unit; oxycodone intoxication 20 month old male child death; drug toxicity fatalities - children.

Re-opening, coronial investigations, jet ski collision, jet ski racing, pro stock race, collision, cavitation, additional contact, race bumping, unhooked, forensic recording analysis, engine control unit (ECU), MoTeC data, MoTec report and analysis, I2 analysis software, PWC (personal water craft).

Nursing home, care.

Adequacy of emergency medical response and care, remote event, mass gathering event, primary health care clinic, Laura, Cook Shire Council, Torres and Cape Hospital and Health Service, Queensland Ambulance Service, nurses, fatigue leave, medical emergency, event management, risk assessment, female 17 years, myocardial scarring, past myocarditis, undiagnosed rheumatic fever, telecommunications blackspot, automated external defibrillator, event planning, risk assessment, approvals process, interagency approach, state wide mass event planning reform, Holly’s Law.

Police restraint, amphetamine use, administration of sedative during restraint, restraint asphyxia.

Domestic and family violence death, Aboriginal intimate partner homicide,; remote indigenous community, perpetrator’s extensive domestic and family violence history, current domestic family violence order, perpetrator on parole, Queensland Domestic and Family Violence Death Review and Advisory Board, Queensland Government Framework for Action: Reshaping our approach to Aboriginal and Torres Strait Islander domestic and family violence (May 2019).

Death in custody,  provision of disposable razors to prisoners, decision to suspend parole,  mental health history,  information sharing, suicide risk assessment.

Death in care, intellectual and physical disability, choking on food, adequacy of resuscitation provided by carer and ambulance services, Public Advocate report.

Domestic violence, intimate partner, manslaughter, criminal proceedings, exit from moving vehicle, police response, heightened post separation risks, non-lethal strangulation, domestic violence protection orders, cultural and linguistic diversity, English as second language (ESL), assessment of risk, supervision and rehabilitation of perpetrators, Queensland Domestic Family Violence Death Review and Advisory Board, Special Taskforce Domestic and Family Violence, Not Now Not Ever Report, sentencing principles.

Roaring Meg Falls, accidental slip and fall, alcohol and drug toxicity, Kuku Yalanji, Wujal Wujal, traditional owners, indigenous, aboriginal, culturally sensitive site, signage, mobile and satellite telephone coverage, telecommunication signal, police recovery operations from waterfall, rescue helicopter, Emergency Services Queensland, retrieval helicopter.

Aviation fatality, light helicopter in experimental class,  failure inflight of rear stabilizer unit, excessive movement in bearing within tail rotor assembly , recommendations as to further investigation of two strikingly similar fatalities within Australia by aviation authorities

Aged care nursing home, adequacy of wound care management, death from sepsis due to skin ulcers, communication with family.

Finalisation of adjourned 1998 inquest, circumstances of the cause of death, identification of the person or persons responsible, utility of the Coroners Act 1958 to a modern coronial investigation and the Coroners Act 2003 transitional provisions.

Aged Care, palliative care, euthanasia, dementia, suffocation, CCTV, privacy, consent, public interest intervenor, cause of death undetermined.

Death in the course of a police operation, vehicle interception sites, motor cycle accident, police hand signals.

Health care related death, paediatric cardiac surgery, Queensland Paediatric Cardiac Service, congenital aortic stenosis, fourth-time sternotomy & redo Konno, right ventricular outflow tract (RVOT) patch, CardioCel, wound management, sternal wound infection, mediastinitis, surgical debridement, VAC dressing, persistent post-debridement fevers and tachycardia, acute bleed from sternotomy wound 18 days post-operatively, after hours surgical assessment of acute bleed, Massive Transfusion Protocol, after hours theatre team call-in, emergency cardiac surgery, rupture of RVOT patch, catastrophic cardiac bleed.

Suspected overdose of amitriptyline, adequacy and appropriateness of the care and treatment provided in hospital, medical clearance, assessment pods, sufficiency of changes to hospital policy and procedures.

Death of newborn infant within 6 hours of birth , Group B Streptococcal disease (GBS) , infant dropped on her head minutes after birth , prescribed antibiotics not administered as directed,  cause(s) of death , prevention of future deaths in similar circumstances.

Death in custody; asylum seeker detained under the Migration Act 1958 (Cth), transfer to regional processing centre, clinical deterioration, sepsis, arrangements for medical transfers from regional processing centres, health care in regional processing countries.

Summary of Findings and recommendations read out in court on 24 July 2017. View the Findings

Dive death investigation, recreational diving, carbon monoxide toxicity, drowning, contamination of breathing air from within electric air compressor, ignition of lubricating oil within over heated compressor, maintenance, filtration, ASA breathing air standards, testing for contamination. View the Summary of Findings and recommendations

Recreational aircraft, first flight on return to service, experienced pilot/engineer, partial engine failure on take-off, aerodynamic stall, collision with ground.

Chest pain presentation to emergency department; delay in diagnosis of STE elevation myocardial infarction (STEMI); delayed referral for emergency interventional cardiology; importance of timely review of all available pre-hospital ECG reports

Death in custody, hanging, communication between medical staff and Corrections staff, Root Cause Analysis, Chief Inspectors report.

Traffic controller, motor vehicle crash, codeine toxicity of driver, involuntary intoxication due to effects of renal dialysis, fitness to drive due to multiple medical conditions, legislative reform.

Recreational Aviation Australia, mid-air collision.

Health care related death, admission for inpatient bowel preparation for surveillance colonoscopy,  admission to outlying ward, failure to recognise & escalate intolerance to bowel preparation,  lack of documentation by ward call doctors,  clinical guideline for inpatient bowel preparation.

Health care related death, neurosurgery, delay in surgery.

Death in custody, natural causes.

Death in custody, natural causes.

Death in custody, restraint, domestic violence.

Death in  custody, mixed drug toxicity.

Aviation – double fatality in helicopter crash – consideration of cause of event – defective hydraulic belt, pilot and aircraft suitability for task, adverse weather event, considered.

Elective spinal surgery, Surgery Connect Program, private hospital, patient history taking, pre-operative assessments, obstructive sleep apnoea, ICU admission for post-operative monitoring, timely reporting of investigation findings for medical review.

Rural hospital, failure to recognise and respond to clinical deterioration, early warning and response systems, Queensland Adult Deterioration Detection System (Q-ADDS), effective clinical communication, escalation of clinical concerns.

Rugby League football, shoulder charge, carotid artery dissection, steps taken to mitigate risk of injury, rule  and penalty changes.

Missing person.

Missing person, Army Officer, civilian police and military police investigations.

Spinal surgery, Jehovah’s Witness, refractory back syndrome, haemorrhage.

Drowning,  car overboard, cable cross river ferry,  containment,  safety management systems and regulator oversight.

Elderly patient, SIADH (syndrome of inappropriate anti-diuretic hormone), impact of citaprolam and duloxetine on pre-existing hyponatraemia, management of severe hyponatraemia, hypertonic saline infusion, inter-hospital transfer processes, clinical communication, clinical documentation, recognition and response to clinical deterioration,  use of early warning & response observations tools (EWARS).

Suicide, smoking cessation, Varenicline, Champix, Chantix, neuropsychiatric symptoms, precautions, product label, Consumer Medicine Information leaflet, Product information document, routine forensic toxicology screening.

Elective bronchoscopy, bridging anticoagulation, patient history transcription error by admitting respiratory team, pulmonary haemorrhage, anthraco-silicotic lung disease.

Complication of NSAID use, timeliness of pathology collection, transport and testing at small rural hospital, senior medical officer failure to follow up and review blood results, failure to consider abnormal pathology result.

Russel Island; drink driving; speeding; mechanical defects; skateboarding on public roads; pedestrian safety; footpaths; street lighting; Council resourcing; police resourcing, speed enforcement, alcohol testing; and drug testing.

Health care related death, orthopaedic surgery, Aspirin prescribed post-operatively, pulmonary emboli and deep vein thrombosis, medication error - double up of anticoagulants (Clexane and Xarelto), adequacy of education, communication, handover and documentation.

Work place related death, camper trailer manufacturer, prototype boat rack, gas strut explosion, penetrating head injury, Issue with prototype design, risk assessment, training, supervision, staff qualifications and quality of gas strut.

Health care related death, obstetrics, CTG interpretation, obstructed labour, delayed diagnosis, caesarean section, impacted fetal head, head injuries due to method of delivery.

Health care related death, obstetric case, CTG tracing interpretation, obstructed labour, caesarean section, communication issues, amniotic fluid aspiration.

Colorectal surgery, post-operative fluid balance management, persisting low urine output and intermittent hypotension, hypoalbumaenia, multidisciplinary team, inter-team patient referrals.

Collisions between bicycles and motor vehicles, how the collisions occurred, whether Police investigative and prosecutorial responses were adequate in the circumstances.

Drowning, contribution of possible physical impairment due to coronary artery disease, work place health and maritime safety regulatory framework and investigations, remote area retrievals.

Domestic violence, manslaughter, abusive and violent relationship.

Health care related death, discharge against medical advice, and presumption of capacity to make own health care decisions, hospital unaware of patient’s guardianship status at the time of discharge, stakeholders working towards improving information sharing

Health care related death, complication from elective percutaneous stenting of left of left descending artery, patient discharged too early following procedure, adequacy of documentation and communication

Health care related death, complication from elective percutaneous stenting of left descending artery, patient discharged too early following procedure, adequacy of documentation and communication

inquest, workplace death, identification of hazard and management of risk of moving vehicles, adequacy of investigations, adequacy of process adopted for decisions to prosecute

inquest, nursing home resident, immolation, burns, whether accidental or self-harm, risk assessments for smoking and/or self-harm, physical diseases as predictors of suicide in older adults, communication in concurrent investigations

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

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

Abdominal pain, hospital admission and diagnosis, surgical management, postoperative care.

Coronary angiogram, stent procedure, discharge from Hospital, AHPRA investigation.

Inquest, missing person, police investigation.

Quad bike accident, helmets.

Quad bike accident, helmets, intoxication.

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

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

Quad bike accident, head injuries, helmets.

Quad bike accident.

Quad bike accident, mechanical defect, helmets.

Quad bike accident, roll over.

Inquest – Part heard as joint hearing – adequacy of regulatory framework covering white water rafting

Self-immolation.

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

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

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

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

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.

Inquest - Motor vehicle accident, identification of driver

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

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.

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

Inquest - Suicide, Mental Health Patient

Inquest - missing person

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

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

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

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