Findings - Coroners Court

%asset_contents% Blair, Colin Wayne (PDF, 974KB)

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.

06/09/2019 by State Coroner Terry Ryan Queensland Government response not required Mrs MDF - Non-inquest findings (PDF, 469KB) Abdominal pain, ischaemic colitis, delay in surgery, documenting communications. 05/09/2019 by McDougall Queensland Government response not required Mr DAC - Non-inquest findings (PDF, 443KB) Angiogram, stent, pseudo-aneurysm, infection, treatment and care. 03/09/2019 by Coroner James McDougall Queensland Government response not required Pike, Kerri Anne; Dawson, Peter Michael and Turner, Tobias John (PDF, 626KB)

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.

30/08/2019 by Wilson Queensland Government response not required Nebauer, Talieha; Fowell, William and Whiticker, Caitlin Wilkinson (PDF, 787KB)

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.

30/08/2019 by Lock Queensland Government response not required FV Cassandra & FV Dianne (PDF, 231KB) Loss of life arising from capsize of two fishing vessels – causes of loss – recommendations as to safety improvements in fishing industry 29/08/2019 by O'Connell