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Recommendations concerning legislation with respect to construction and inspection of pool fencing.

Recommendation regarding warning labels. Missing persons, lost at sea, search and rescue.

Vessel Pilot Transfer. 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. 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. Recommendations concerning the recording of morphine administered; the supervision of provisionally registered foreign trained doctors and the publication of the provisional registration.

Recommendations concerning training for the diving industry, assessment of fitness to dive and other issues. Recommendations concerning the observation of patients administered sedatives. Recommendations concerning engine compartment door of buses.

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Recommendations concerning inspection of pools. 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.

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Recommendations concerning the suitability of prescribing certain medication to prisoners, supervision of prisoners. Recommendations concerning training for the diving industry. Recommendations concerning QPS critical incident management, adequacy of communication devices for police, access and sale of ammunition, protective apparel.

Recommendations concerning the recruitment and supervision of foreign trained doctors. Recommendations regarding training for nurses and medical staff, allocation of specialist medical services. Recommendations concerning training of Aboriginal Community police officers. Recommendations concerning risk management on rigs.

Recommendations regarding cessation of such pursuits. Last reviewed 20 July Last updated 31 July Hunt, Thomas and Kim, Youngeun PDF, KB 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.


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Banjo, Neil Richard PDF, KB Death in police operations, remote community, public nuisance offences, use of force, violent confrontation, open hand tactics. Blair, Colin Wayne PDF, KB 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.

Findings - Coroners Court

Pike, Kerri Anne; Dawson, Peter Michael and Turner, Tobias John PDF, KB 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.

Nebauer, Talieha; Fowell, William and Whiticker, Caitlin Wilkinson PDF, KB 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.


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Mr P - Non-inquest findings PDF, KB Health-care related death, severe hypoxic respiratory failure, pneumonia, pulmonary embolism, deep vein thrombosis, skin infection, morbid obesity, cholesterolosis, diverticular disease, cardiac arrest, computerised pulmonary angiogram, Ayr Hospital, The Townsville Hospital. Male child aged 20 months - Non-inquest findings PDF, KB 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.

Malone, Terrence Michael PDF, KB Death in custody, provision of disposable razors to prisoners, decision to suspend parole, mental health history, information sharing, suicide risk assessment. Davis, John PDF, KB Death in care, intellectual and physical disability, choking on food, adequacy of resuscitation provided by carer and ambulance services, Public Advocate report.

Morcombe, Daniel James PDF, 1MB Missing child, suspected death, police investigation, compelled evidence from persons of interest, resumption of inquest after murder conviction. Blackmore, Rinabel Tiglao - Non-inquest findings PDF, KB 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.

McManus, Vaughn Ross - Non-inquest findings PDF, KB 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.

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

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Hodgkinson, Bryan PDF, KB Finalisation of adjourned inquest, circumstances of the cause of death, identification of the person or persons responsible, utility of the Coroners Act to a modern coronial investigation and the Coroners Act transitional provisions. Winks, Russell PDF, KB Death in custody, police shooting, s46 comments from inquest, use of force model, police training, deployment of service rifles. Mann, Renae Jean PDF, KB 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.

Giorgio, Pasquale PDF, KB Death in custody, arrest for street offences, mental health concerns, homelessness, morbid obesity, positional asphyxia. Maynard, Marcia Anne Kathleen PDF, KB Suicide, insulin overdose, personal stressors, nurse witness to be called in an inquest, counter-therapeutic consequences for those involved.

Schuler, Bruce Gavin - Non-inquest findings PDF, KB Missing person, homicide, no body, successful prosecution, indictable offence, circumstantial evidence, Palmerville Station, Schuler; Struber, Wilson-Struber, fatal injuries sustained from gunshot wounds, no body, no parole legislation. Matthew Douglas McLachlan - Non-inquest findings PDF, KB 28 male, paraplegia, opioid pain medication dependency, being monitored, admitted to PA Hospital for urinary tract infection, self-administered additional pain medication, acquired externally to hospital without disclosure of concurrent hospital treatment , died in hospital due to inadvertent overdose, mixed drug toxicity.

Khazaei, Hamid PDF, 2MB Death in custody; asylum seeker detained under the Migration Act Cth , transfer to regional processing centre, clinical deterioration, sepsis, arrangements for medical transfers from regional processing centres, health care in regional processing countries. Thwaites, Andrew John PDF, KB 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.

Smit, Bernardus Johan PDF, KB 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. Farrell, Bethany Emily PDF, KB Death by drowning while engaged on introductory scuba dive in Whitsunday Islands, separation of novice diver from instructor and group, poor visibility, adequacy of instruction of deceased, and of lookout by servants of diving company, recommendations as to conduct of future introductory diving excursions, re-establishment of Dive and Snorkelling Death Review Panel.

House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith PDF, KB Prescription opioids, drugs of dependence, opioid overdose, oxycodone, fentanyl, Schedule 8 medications, controlled drugs, doctor shopping, prescribing practices, real-time prescription monitoring, electronic recording and reporting of controlled drugs. Robert Charles Royston - Non-inquest findings PDF, KB Drowning , 57 year old male, overnight fishing trip Cape Moreton, conditions changed, boat anchored from stern, swamped from waves breaking into stern whilst pulling anchor, stalled, capsized, life jackets not worn, first trip in boat, unfamiliar with water pump switch.

Beale, Tracy Ann PDF, KB Neck compression causing death, medical cause of death , possible asphyxia, possible vaso-vagal inhibition, domestic violence, law reform , consideration of amendment to s. Cheney, Danny George PDF, KB Construction, high voltage transmission towers and lines, spacer installation, electrocution, deviation from safe work method, sufficient knowledge. Schofield, Wayne Patrick; Redfern, Haydn Jonathan PDF, KB Aviation — double fatality in helicopter crash — consideration of cause of event — defective hydraulic belt, pilot and aircraft suitability for task, adverse weather event, considered.

Mr AC - Non-inquest findings PDF, KB 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. Glennon, Lardeen Bernadette; Glennon, Matthew David PDF, KB Fatal motor vehicle collision, speed a contributing factor, receipt of data downloaded from Airbag Control Module showing speed shortly prior to collision in excess of posted speed limit, weight to be placed upon such data, law reform by facilitation of proof of ACM data i.

Girven, Bianca — Non-inquest findings PDF, KB Asphyxia, boyfriend charged with murder and found of unsound mind, adequacy of mental health treatment provided to boyfriend prior to incident, mental. Recommendations from inquest into the deaths of Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan, Laval Donovan Zimmer and Troy Martin Foster PDF, KB Deaths in custody, police shootings, s 46 comments from inquest, use of force model, police training, mental illness, police officer welfare, investigation methodologies, body worn cameras, replica firearms, nuisance callers, information sharing.

Mr C - Non-inquest findings PDF, KB Elective bronchoscopy, bridging anticoagulation, patient history transcription error by admitting respiratory team, pulmonary haemorrhage, anthraco-silicotic lung disease. Mrs H - Non-inquest findings PDF, KB 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. Stephenson, Ethan PDF, KB 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.

Richards, Karen Louise PDF, KB Mixed drug toxicity; heroin overdose; doctor shopping; excessive delay in rendering first aid; excessive delay in phoning emergency services. Stimpson, Reginald - Non-inquest findings PDF, KB 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.

Hooper, Troy Ronald - Non-inquest findings PDF, KB 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. Tonkin, Nixon Martin PDF, KB Health care related death, obstetrics, CTG interpretation, obstructed labour, delayed diagnosis, caesarean section, impacted fetal head, head injuries due to method of delivery.

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

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DR - Non-inquest findings PDF, KB Death in care disability ; death in care involuntary mental health ; funded residential service provider; co-ordination of care issues. Turpin, Robert Noel PDF, KB Death in the course of a police operation, suicide, domestic violence, dissemination and interpretation of information to first response police. Biffin, Albert Eric PDF, KB Health care related death, low care nursing home, complications from incarcerated hernia, adequacy of medical assessment, nursing handover and nursing.

Jensen, Ian Christoffer and Kepui, Timothy Ponde PDF, KB Collisions between bicycles and motor vehicles, how the collisions occurred, whether Police investigative and prosecutorial responses were adequate in the circumstances. Trott, Leila Michelle PDF, KB Drowning, contribution of possible physical impairment due to coronary artery disease, work place health and maritime safety regulatory framework and investigations, remote area retrievals. ES, a 87 year old lady PDF, KB Death due to multiple drug toxicity, palliative care in the community, adequacy of palliative care support services provided to families, adequacy of supervision and guidance by medical clinicians, death due to multiple drug toxicity, appropriateness of care provided by family and others, whether medications administered to hasten death.

Bower, Malaki Ron - Non-inquest findings PDF, KB Health care related death, two year old boy, underlying diagnosis of croup, appropriateness of assessment and treatment at hospital including period o. Neitsch, Horst - non-inquest findings PDF, KB 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.

Walton, Christopher Jon PDF, KB inquest, awning collapse, method of construction, building inspections, building maintenance and modifications, awning scheme, significant corrosion and atmospheric factors. Hemsley, Joanne - non-inquest findings PDF, KB Health care related death, complication from elective percutaneous stenting of left descending artery, patient discharged too early following procedure, adequacy of documentation and communication.

Mr B, a 41 year old indigenous man - Non-inquest findings PDF, KB investigation, multiple presentations to rural hospital emergency department with ongoing headache, clinical assumption of acute alcohol withdrawal syndrome, failure to recognise and respond to clinical deterioration, use of early warning and response observation tools Q-ADDS , undiagnosed subdural haemorrhage.

C, a child aged 14 - Non-inquest findings PDF, KB death in care, child, person with a disability, foetal alcohol syndrome, intellectual impairment, swallowing difficulties, death due to choking.


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Calder, Michael James PDF, KB Inquest, health care related death, private hospital admission, headache, concurrent prescription of slow release and fast acting opiate medication, death due to opiate toxicity, communication and documentation between doctors and nurses. Plumb, Mark Anthony PDF, KB inquest, health care related death, regional private hospital, delay in recognising deteriorating patient, delay in transfer of patient. Antonio, Rachel PDF, KB inquest into suspected death, 16 year old child reported missing in , no body ever located, review of evidence gathered during investigation.

Mickelo, Garnett Allan PDF, KB Death in custody, health care related, coronary atherosclerosis, recent stent angiography, adequacy of medical treatment, adequacy of observations in prison.

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He moved with his family to Phoenix when he was 3. He left College Hill after two years and attended the University of Colorado. Having married the former Harriet Hoag in , Brown earned an M. He completed his internship in Fresno, Calif. Air Force as a flight surgeon and then returned to Iowa City, where he completed a dermatology residency. In , the family returned to Phoenix, where Brown established a successful practice.

He later married the former Pat McCracken in Brown subsequently went to Saudi Arabia, where he practiced dermatology with the Aramco Co.