tas coroners findings 2021

The Networks goals include producing national data concerning domestic and family violence related homicides in accordance with the National Plan to Reduce Violence Against Women and their Children 2009-2021. Identifying your sources helps others find the records you used. Inquest FindingsInquest Findings 2021. There are six sections, each of approximately 50m long identified for sight benching on the eastern side of the road. Spencer Clinic will need to liaise with the King Island Heath Services to arrange. Perth hospital staff missed the signs a seven-year-old girl was dying of sepsis because of the pressures caused by "inadequate" staffing, a coroner has found. Inquest files are reports and associated files pertaining to investigations regarding the cause of certain deaths. TITLE OF COURT: Coroners Court . Transport & traffic related, motorcycle crash, single vehicle crash, high speed, multiple trauma. Inquest, transport & traffic related, work related, Ten Mile Creek Farm, tractor rollover, not wearing a seatbelt, blunt trauma of the head, neck & chest, WorkSafe Tasmania, Riverdale Dairies Pty Ltd, recommendation. DELIVERED ON: 9 November 2021 . Please consider that it may be upsetting to read details about a death in an inquest finding. Response fromDe Bruyn's Transport 23 July 2022, Recommendation 1: Rollover Awareness and Training. De Bruyns Transport continues to utilise the VicRoads Heavy Vehicle Rollover Prevention Program and, specifically, its dynamic load elements as the cornerstone of our induction training for all employees and not just those involved in harvest fish operations. vehicle accident, tree, head injury, car crushed by falling tree, transport. Response fromDerwent Valley Council 30 August 2022. The coroner may comment and make recommendations about public health or safety, or the administration of justice, to help prevent similar deaths and incidents from happening again. In some inquests recommendations are made to Ministers and Government and non-government agencies. Inquest, child & infant death, person held in care, Care and Protection Order, Children, Young Persons and their Families Act 1997, multi-systemic disabilities, hypoxic brain injury secondary to a cardiorespiratory arrest, Inquest, intentional self-harm, law enforcement, mental illness & health, person held in custody, Risdon Prison, HMP Risdon. The page has been produced by Courts Tasmania, Search the Supreme Court of Tasmania database, personal information protection statement. A Health Practitioner's guide for writing a statement for the Coroner. The relevant Medical Officer will write the discharge appointment in the DMR as King Island Health Services can access these details. Inquest, acute subdural haematoma, drugs & alcohol, assault, Coroner's comments, Long term missing person, deckhand, work related, water related, weather related, boating, dinghy, intentional self harm, suicide, hanging, mental illness and health, prescribing, drug seeking, pain medication, transport and traffic related, alcohol and drugs, single motorcycle crash, unlicenced, learner rider, speeding, riding at excessive speed, methamphetamine, unregistered, riding over blood alcohol limit, loss of control, Transport & traffic related, motor vehicle crash, Lebrina, speeding, death by negligent driving, charged and convicted. Coronial, death in care, guardianship order, held in care, asphyxia, choking, food, Roy Fagan Centre, Inquest. CATCHWORDS: Domestic violence allegations made For all conditions of entry, read the COVID 19 (Coronavirus) Measures. A Health Practitioner's guide for writing a statement for the Coroner. This division is a specialist court that conducts inquests and investigations into certain deaths ('reportable deaths') and incidents (including fires and explosions) regardless of whether a death occurred. In her long-awaited written findings, Deputy State Coroner Sarah Linton found there was a chance Aishwarya's life might have been saved with proper treatment. Accidental drug overdose, palliative care, end stage mesothelioma, hydromorphone toxicity, North West Regional Hospital, Emergency Department, Burnie, medical negligence, medical certificate of death, Coroner's comments. (PDF, 84.6 KB), Flow Chart of the Coronial Process (PDF, 316.1 KB), When to report a Death to the Coroner (PDF, 189.9 KB), Australian Domestic and Family Violence Death Review Network Data Report 2018 (pdf, 3 MB). The decision to make these findings available has been made by the Chief Magistrate, or their delegate, or the coroner presiding over the particular investigation, under Coroners Rules 2006. Transport and traffic related, St Helens, Coroner's finding, joint inquest, child and infant death, youth, transport and traffic related, Child Safety Services, Department of Communities, Tasmania, child protection systems, Sudden Unexpected Death in Infancy, co-sleeping, drowning, motor vehicle crash, exposure to risk, Drowning, River Derwent, Mental Illness and Health, Child and Infant Death, Sepsis, Royal Hobart Hospital, motor vehicle accident, transport and traffic related, epilepsy, suspended licence, medically unfit to drive, driving unlicenced, Risdon Road. They usually seek to find out the identity of the deceased, the cause of death and the circumstances in which it may have occurred. The Department will act on the Coroners recommendations. CORONIAL LAW - cause and manner of death - medical care and treatment of long-term mental health patients - prescribing of anti-psychotic and sedative . They usually seek to find out the identity of the deceased, the cause of death and the circumstances in which it may have occurred. FILE NO(s): D34/2020 . We acknowledge the traditional owners and custodians of the land on which we work and we pay respect to the Elders, past, present and future. Publishing a finding is decided on an individual basis, but the coroner may take into account a number of factors: In general, authorised findings for publication will include: Specific findings can be located by entering information in the search box below. Older persons, physical health, subdural haematoma, mechanical fall with head strike, Launceston General Hospital, George Town Hospital. Coronial, stairs, step, fall, head injuries, blunt force. DELIVERED AT: Darwin . coronial, mountain bike, collision, head injury, blunt force, Transport & traffic related, four wheeled all-terrain vehicle, ATV, quad bike, drink driving, alcohol, excessive speed, speeding, Bruny Island, coronial, Wheat Pack, House Fire, Incineration, Flame, Heating, Thermal Mechanism, Hypoxic brain and lung injury, drug toxicity and gas inhalation, suicide, euthanasia, multiple scleorosis, Advance Care Directive, Goals of Care Plan, Launceston General Hospital, Coroner's recommendation. Our Safe Operating Procedure for this specific task along with our Risk Register and our weather related guidance were all updated some time ago. This includes rapid reversal requirements and perioperative management. This was attempted but unfortunately was not achievable due to presence of shallow rock. Two of three deaths at Copper Mines of Tasmania 'avoidable', coroner finds Two of three deaths at Copper Mines of Tasmania 'avoidable', coroner finds By Loretta Lohberger Posted Thu 17 Jun 2021 at 7:29pm The three deaths at the Copper Mines of Tasmania's site occurred within six weeks of each other. With this work the Network seeks to contribute to the formation of evidence-based policy and decision making in relation to domestic and family violence, enhancing opportunities for prevention and intervention and contributing to the enhanced safety of women and their children across Australia. Updated response provided by THS - South 14 October 2022, RHH complies with the state record policy with regard to retention of records, In recognition of the deep history and culture of this Island, we would like to acknowledge and pay our respects to all Tasmanian Aboriginal people; the past and present custodians of the Land. CORONER SARAH HELEN LINTON, DEPUTY STATE CORONER: HEARD : 14-15 APRIL 2021 DELIVERED : 27 JUNE 2021 FILE NO/S : CORC 202 of 2019 DECEASED : THORSAGER, JORDAN ALEXANDER Catchwords: Nil Legislation: Nil . Transport & traffic related, older persons, physical health, car accident, environmental heat & cold exposure, dehydration, missing person, Tullah, Transport & traffic related, motor vehicle crash, car accident, speed, alcohol, illicit drugs, criminal prosecution, causing death by dangerous driving, Huonville. Older persons, physical health, Roy Fagan Centre, Emergency Guardianship and Administration Order, care, treatment and supervision, advanced dementia. Inquest, intentional self-harm, asphyxia, hypoxic encephalopathy, mental illness & health, Royal Hobart Hospital Emergency Department, recommendations, government, Psychiatric Emergency Nurses (PENs), mental health services reforms. adverse medical effects, failure to diagnose, misdiagnosis, Hobart Private Hospital, carcinomatosis, failure to report death to Coroner, medical, hospital. This may require viewing multiple records or images. The Coroner has prepared comprehensive and considered findings and they will be given careful . Coronial, held in care, guardianship order, inquest, person in care, Roy Fagan Centre, atherosclerotic, hypertensive cardiovascular disease. Inquest, work related, forklift rollover, farm, not wearing a seat belt, workplace, Work Health and Safety Act, guilty,Burnie, Law enforcement, mental illness & health, death in custody, secure mental health unit, Wilfred Lopes Centre, inquest, natural cause of death, Transport & traffic related, motor vehicle crash, truck, collision, incorrect side of the road, Black River, Transport & traffic related, motor vehicle crash, Iveco prime mover, Freighter trailer, truck, speed, work related, employment, workplace, request by senior next of kin not to hold inquest pursuant to s26A(2) of the Coroners Act 1995, undetermined cause of death, missing person, suspicious circumstances, Flinders Island, North East River, Salmon Rock, fishing, Joshua Kennedy, Stephanie Riggall. Adverse medical effects, older person, permanent tracheostomy, aspiration, airway obstruction, Hobart District Nursing Service, Ambulance Tasmania, Refusal of Treatment and Transport Policy, Coroner's recommendation. Coronial, peritoneal sepsis, multiple organ failure, bowel, perforation of the bowel. Coronial findings To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. Coronial, traumatic closed head injuries, motor vehicle crash, decision not to hold inquest, supervision order, Criminal Justice (Mental Impairment) Act 1995, Royal Hobart Hospital, aspiration pneumonia, coronial, coroner, suicide, stab wounds, neck and incised wounds to wrists, Older Persons, Falls, Aged Care, Medical Certificate Cause of Death, Coroner's Finding, Physical Health, long term missing person, undetermined cause of death, Knocklofty Reserve, child death, asthma, North West Regional Hospital, misdiagnosis, incorrect diagnosis, substandard medical treatment, Tasmanian Health Service, medico legal, Coroner's comments, Asthma Australia, Inquest, re-investigation, work related, transport & traffic related, truck driver, De Bruyns, prime mover, laden fish tanker, fish run, Esperance Coast Road, rollover, crash, training, frame rise, air suspension, recommendations, hypoxic brain injury, epilepsy, seizure, Royal Hobart Hospital, Nexus supported living, Coronial, treatment order, ischaemic heart disease. Search by Case Name. Intentional self-harm, mental illness & health, suicidal ideation, weapon, partial contact range gunshot wound of the head, psychiatrist, Department of Psychiatry, Guardianship and Administration Board, Firearms Act 1996. Water related, long term missing person, suspected death, undetermined cause of death, disappearance, intoxication, Fisherman's Wharf, Strahan. 9:56pm Feb 24, 2023. The PWS Arthur River Visitor Centre is trialling selling sand flags to the public. Tasmania Police has welcomed Coroner Robert Pearces findings into the death of Nicholas Whiteley at Westbury on 22 November 2010. Supreme Court Act 1935; District Court Act 1991; Environment, Resources & Development Court Act 1993; Magistrates Court Act 1991; Youth Court Act 1993 We extend our sympathies to the family of Mr Whitely at this difficult time. abc.net.au/news/kirra-lea-mcloughlin-coronial-inquest-findings/100194632 A coroner has found that a 27-year-old woman, whose death has been unsolved for almost seven years, lost her life at the hands of her de facto partner, describing him as a "habitual perpetrator" of domestic abuse. Transport & traffic related, mental Illness & health, motor vehicle, multiple severe crushing injuries, Davey Street, emergency services, Royal Hobart Hospital, crash investigation. Prior to discharge an appointment with the GP is to be made at a time asap after the patient returns to King Island. Coronial findings To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. Fionica James, Katurah Mamarika, Layla Leering, Robin Riley, Thomas Turpin, Fabian Andrews, Cassandra Martin, Pauline Iris Abbott, Kendrick Oliver and Joy McNamara, Michael Chisholm, Aaliyaha Webb and Julian Chisholm, Kevin Taylor, Lena Yali and Gregory McNamara, Peter Murphy (Suppression order lifted 19.4.17), Peter Murphy (Suppression order in place), Nauiyu Nambiyu Council Chambers, Daly River, Mohammed Ayubi, Muzafar Sefarali, Mohammed Zamen, Awar Nadar and Baquer Husani, Darwin Magistrates Court / Darwin Supreme Court, Robert Plasto-Lehner and David Gurralpa aka Moscow, Darwin Magistrates Court, Bulman (Opening) and Katherine Courts, Darwin Magistrates Court / Alice Springs Magistrates Court, Michael Anthony Hardy and Robert James Roe, Jaron Mamarika, Dwayne Bara, Jaross Amagula and Francene Huddleston, Barbara Malthouse, Nigel Inkamala, Daryl Inkamala, Dion Ngalken, Gordon Murray and Antonia Meneri, Nauiyu Nambiyu Govt. It is appropriate and timely to review the Model, which is an integral part of our policing strategy, said Acting Deputy Commissioner, Donna Adams. Drugs & alcohol, mental illness & health, mixed prescription drug toxicity, Royal Hobart Hospital, Department of Emergency Medicine, Liverpool Street. When the cause of death is unknown or seems unnatural, a judicial officer, known as a coroner, is involved to determine certain information. The Department is committed to the safety of officers and members of the community and its important to ensure the Model remains contemporary in its application, said Ms Adams. transport and traffic related, single vehicle motor accident, car crash, Port Sorell, failure to wear seat belt, drink driving, blood alcohol of 0.261 g/100ml, driving in excess of speed limit, 120km/h in a 80km/h zone, Mental illness & health, drugs & alcohol, accidental prescription medication overdose, morphine, doctor shopping, house fire, fire related, Latrobe, charging battery, combustible materials near charger, accidental, long term missing person, missing bushwalker, undetermined cause of death, South West National Park, Huon Track, ill-equipped, bushwalking, no personal locator beacon, PLB, Coroner's comments, Transport & traffic related, motor vehicle accident, pneumonia, Royal Hobart Hospital, reminder to medical practitioners, Motor vehicle crash, Nunamara, campervan, drink driving, inattention, incorrect side of the roadway, head-on collision, prime mover, transport and traffic related, motorcycle crash, multiple trauma, collision with stationary prime mover, Mayfield, unroadworthy, unregistered, unlicensed, failure to wear helmet, alcohol and drugs, cannabis, methylamphetamine, Transport and traffic related, motor vehicle crash, speed, alcohol, drugs, New Town, unroadworthy, reckless driving, manslaughter, death by dangerous driving, imprisonment, homicide, manslaughter, assault, consequences of stab injury, hypoxic brain injury, exsanguination, cardiac arrest, Deejay Feil, sentencing comments, Supreme Court of Tasmania, transport and traffic related, motor vehicle accident, Launceston, Wellington and Frederick Streets, manslaughter, ran red light, driving in excess of speed limit, driving whilst disqualified, decamped from scene, Dylan Lee, sentenced to imprisonment, natural cause death, atherosclerotic coronary vascular disease, Nyrstar Hobart Pty Ltd, Lutana, zinc works, factory, death at work place, Work Safe Tasmania, Undetermined Circumstances, Undetermined Cause of Death, Mount Wellington Park, East-West Fire Trail, Mental Health, DNA Analysis. Inquest Findings 2021 Coroner's inquest findings are available on the date of delivery of the finding or later by request in writing to the Office of the State Coroner. Councils Operations Manager, a qualified engineer, was charged with investigating improvements to the road. Domestic incident, homicide & assault, weapon, rifle, gunshot wound, murder, Klaus Neubert, estranged husband, Tasmania Police, family law, alcohol and drug related, mixed prescription drug toxicity (codeine, paracetamol, mirtazapine, promethazine, diazepam), accidental overdose, appropriate prescribing regime, stockpiling medication, Drugs & alcohol, intentional self-harm, mental illness & health, transport & traffic related, suicide, carbon monoxide inhalation, asphyxia, Launceston General Hostpial, Royal Hobart Hospital, Emergency Department, Inpatient Withdrawal Unit, Coroner's comments, Inquest, older person, person held in care, Guilford Young Grove, Roy Fagan Centre, emergency guardianship order, mental health, aspiration pneumonia, dementia, Quad bike roll-over, accident, head injury, drugs & alcohol, pillion passenger, dam, coroner's comment. Inquest, person in care, older person, Bishop Davies Nursing Home, Roy Fagan Centre, aspiration pneumonia, advanced dementia. Council Building, Daly River, Angel Blanco-Puerto, Phillip Lindsay, Barry Gaykamangu and Hannu Kononen, Erfinna Patricia Lay and John Weston Quirk, Raymond Curtain, Terrence Westwood, Gerald Thompson, Gregory Westerman, Graham Dearden and Ruth Vincent, Kumanjay Presley, Kunmanara Coulthard and Kunmanara Brumby, Jade Lange-Loades, Rory Lange-Loades and Nathaniel Rose, Glen Anthony Huitson and Rodney William Ansell, Matthew Neck, Amanda Bell and Matthew Batson, Gary Peter Tipungwuti, Patrick Raymond Kerinauia, Noeline Pauantulura, John Gerard Orsto, T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run). Geographic, leisure activity, caverneering, Tasmanian Caverneering Club, Mount Anne, North East Ridge, exploration, disappearance, undetermined cause of death. Aged care, falls, older persons, physical health, closed traumatic head injury, Bishop Davies Court, Extended Care Assistant, enrolled nurse, Franklin Unit, nightly checks, delayed care. Older person, natural cause death, acute myocardial ischaemia, Launceston General Hospital, Emergency Department, triaged patients, assessment and treatment, monitoring of whereabouts, documentation of significant interactions, recommendations. Search or sort for the relevant findings below. Health and Community Services Complaints Commission, 2023 Northern Territory Government of Australia, URL: https://justice.nt.gov.au/attorney-general-and-justice/courts/inquests-findings The Single Officer Response Model, which was formally adopted in 2008, aims to provide efficient service delivery while managing the risks that are inherent to policing. Response from Tasmania Health Service Statewide and Mental Health Services received 8 March 2022. Mixed Drug toxicity, Mental Health Plan, Schedule 8 substances, Drug Intoxication, Borderline Personality Disorder, Anxiety Disorder. To see the decisions published by the various Divisions of the Magistrates Court use the Magistrates Decisions link. Coroners Court Coronial Findings 2022-2023 Coronial Findings 2019-2021 Coronial Findings 2016-2018 Coronial Findings 2013-2015 Information for families Coronial Practice Handbook Tasmanian Suicide Register Contact the coroner's office Frequently Asked Questions A Health Practitioner's guide for writing a statement for the Coroner. When the cause of death is unknown or seems unnatural, a judicial officer, known as a coroner, is involved to determine certain information. Transport & traffic related, single motor vehicle collision, car crash, Glenfern, Derwent Valley Council, recommendations. Our three yearly refresh program already includes specific rollover awareness elements. The Magistrates Court (Coronial Division) publishes a small but important amount of records of investigations and findings. We will use your rating to help improve the site. In some inquests recommendations launch are made to Ministers and Government and non-government agencies. Please don't include personal or financial information here, Inquest into the death of Bronwynne RICHARDSON, Inquest into the death of Liselle HOUBERT, Inquest into the discovery of unidentified skeletal remains located at St Albans, Inquest into the death of Donald GREENAWAY, Inquest into the death of Timothy MOFFATT. The relevant Medical Officer in Spencer Clinic will contact the King Island GP as soon as practicable to advise of the patients discharge date from Spencer Clinic. Patients should not be discharged from Spencer Clinic on Fridays to travel to King Island on the same day. All contents copyright Government of Western Australia. The coroner's decision is also referred to as the coroner's findings or inquest findings. Derwent Valley Council has identified a number of sections at which sight distance could be improved via vegetation reduction and sight benching / reducing the slope of cut batters. The Coroner has prepared comprehensive and considered findings and they will be given careful consideration by the Corporate Management Group. Aboriginal and Torres Strait Islander peoples are warned, findings contain the names of deceased persons. Since the Coroners recommendation a Mental Health Short Stay Unit has been implemented to improve flow for mental health patients out of the ED.With the ED redevelopment, planning is underway to include a secure high acuity area for mental health patients as well as a calming, private area for lower acuity patients where they are able to wait for their assessment separate from non-mental health patients. Citations help you keep track of places you have searched and sources you have found. submissions in making my findings. It is acknowledged the Coroner has made no criticism of either Tasmania Police or Constable Blake in relation to the death of Mr Whiteley. To search for judgments, usethe links below. Apply Clear filters Showing 21-30 of 82 results Inquest into the death of Terence Gray launch Decision of Deputy State Coroner Truscott Aurora Australis shines over Perth. Further, the TSR is based on all cases investigated by the Tasmanian Coroners' Office under the Coroners Act 1995 (Tas), whereas the ABS organises state and territory-based mortality information according to the The coroner sits on the bench at the front of the courtroom, and lawyers sit facing them on another table. We then focus on specific rollover awareness factors during both our mentoring as well as our refresh programs. Long Term Missing Person, D'Entrecasteaux Channel, Probable Drowning, Water Related, Coroner's, Coronial, Motor vehicle Crash, Blunt Traumas Injury to the head, lost control, seat belt, Adverse Medical Effects, Acute Gastrointestinal, Hobart Private Hospital, Royal Hobart Hospital, Child & Infant Death, Falls, Geographic, Leisure Activity, Conservation Area. Sand flags are stored for easy access/attachment when field centre vehicles are accessing the tracks. Findings are also searchable by keyword. Coronial, Suicide, Asphyxia, Smoke inhalation, Caravan, Fire, natural cause death, death in custody, Coroners Act 1995, Risdon Prison, dilated cardiomyopathy, emphysema, Correctional Primary Health, natural cause death, death in custody, Coroners Act 1995, Risdon Prison, Royal Hobart Hospital, Whittle Ward, metastatic squamous cell carcinoma of the lung, coronial, hospital, heart disease, ischaemic heart disease, single vessel atherosclerosis, Drowning, intentional self-harm, coroner's finding, coroner's recommendations, Pulmonary thromboembolism, deep vein thrombosis, D-dimer, Wells score, PERC, Coroner's recommendation, Coronial, atherosclerotic, hypertensive, cardiovascular disease, hospital, Launceston General Hospital, obesity, hypertension, complications of health care, missed or incorrect diagnosis, Head injury, cliff fall, hazardous area, Blackmans Bay blowhole, safety, public area, Coroner's recommendations, transport and traffic related, motor vehicle accident, two vehicle crash, Lilydale Road, adverse weather conditions, poor condition of road, excessive speed for conditions, Coronial, Findings, Inquest, Death in care, Royal Hobart Hospital, Fall from standing Position/ Height, Complication of Left Femur Fracture, Coronial, Findings, Meningococcal, immunisation, disease, A, C,Y, W and B Strain, Neisseria meningitides, bacterial sepsis, hospital, drowning, water related, Mersey Bluff, Devonport, youth, Surf Life Saving, coroner's recommendation, surf rescue, swimming, leisure activity, Homicide & assault, murder, stabbing, coroner's finding, restraint order, coronial, drowning, wharf, fall, alcohol, intoxication, water, older persons, abdominal aortic aneurysm (AAA), haemoperitoneum/retroperitoneal haematoma, Royal Hobart Hospital Emergency Department, falls, undetermined cause of death, undetermined circumstances of death, Tasmania Police, incomplete investigation, Tasmania Police Manual, Forensic Services, forensic evidence, coroner's comments. Directions Hearing - Those seeking leave to appear. Older persons, physical health, Mersey Community Hospital, gastroenteritis, ECG, myocardial infarction, haemopericardium, Root Cause Analysis, coroner's comment. These updates then influence our mentoring and internal checking efforts, especially when it comes to conducting safety observations and reviewing travel times and probation. If you are unable to locate the findings you are looking for, please contact the Coroners Office. 3 Section 53(2) Coroners Act 1996 (WA). Use the links in the left hand navigation bar to access the decicions of Tasmanian Courts and Tribunals. The collection includes records from 1868-1914. Because of this there may be limitations on where and how images and indexes are available or who can see them. Intentional self-harm, mixed drug toxicity, overdose of prescription medication, criminal sexual misconduct, criminal charges, toxicological analysis, Launceston General Hospital. JURISDICTION: Darwin . The Coroner's Office arranges for members of the Australian Federal Police to investigate the circumstances surrounding the death of a person and to provide a report to the Coroner. We recognise the Tasmanian Aboriginal people as the continuing custodians of the rich cultural heritage of lutruwita / Tasmania. He developed a scope of works and issued a Request for Quotation to civil contractors in December 2020 with the following overview of works required: The unsealed section of Glenfern Road has a higher than average incidence of casualty crashes including a fatality in recent years. Mental illness & health, water related, drowning, Copper Alley Bay, Lymington, dinghy, police response, psychotic episode, rescue, aerial search. Inquest files are reports and associated . Transport & traffic related, motor vehicle crash, multiple blunt traumatic injuries, instantaneous death, Kimberley Road, Railton, crash scene investigation. This is also called a public court hearing. Unreported judgments of the Supreme Court of Tasmania are available on AustLII (Australian Legal Information Institute). Gemma Lake has been appointed Chief Executive Officer of the Department of the Attorney-General and Justice. An inquest into her death was told there was intense demand on staff, who missed repeated opportunities to identify the seriousness of her condition.