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Because of this there may be limitations on where and how images and indexes are available or who can see them. Transport & traffic related, mental Illness & health, motor vehicle, multiple severe crushing injuries, Davey Street, emergency services, Royal Hobart Hospital, crash investigation. 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. This page has been viewed 7,041 times (569 via redirect). Inquest findings (since 2004) as well as non-inquest public interest matters (since 2012) are available below. the details needed to register the death with the Registry of Births, Deaths and Marriages. The RHH carry out an investigation of the delays to administration of antibiotics on this occasion with a view to implementing steps to avoid their repetition. We respectfully acknowledge the Tasmanian Aboriginal people as the traditional owners of the land upon which we work and pay our respect to Elders past and present. Signage has been installed at the entrance to Sandy Cape Track (Temma) and the Arthur Beach Track (Gardiner Point, Arthur River): Quick release adaptors for sand flags were attached to all operational vehicles in the Field Centre likely to operate on the track. Patients should not be discharged from Spencer Clinic on Fridays to travel to King Island on the same day. 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. The following information may be found in these records: Before searching this collection, it is helpful to know: Compare each result from your search with what you know to determine if there is a match. 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. Unreported judgments of the Supreme Court of Tasmania are available on AustLII (Australian Legal Information Institute). 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. FILE NO(s): D34/2020 . Questions concerning its content can be sent by email to tasmania.police@police.tas.gov.au or by mail to GPO Box 308, Hobart, Tasmania, Australia 7001. The Magistrates Court (Coronial Division) publishes a small but important amount of records of investigations and findings. All contents copyright Government of Western Australia. submissions in making my findings. adverse medical effects, failure to diagnose, misdiagnosis, Hobart Private Hospital, carcinomatosis, failure to report death to Coroner, medical, hospital. The coroner decides whether to hold a public inquest into a death. 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. 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. 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. We have also engaged the service of a Driver Trainer to provide additional coaching to all our drivers. 1 Section 279(1)(c) Criminal Code (WA). Older persons, physical health, Mersey Community Hospital, gastroenteritis, ECG, myocardial infarction, haemopericardium, Root Cause Analysis, coroner's comment. Please be aware some collections consist only of partial information indexed from the records and do not contain any images. Aishwarya Aswath died on Easter Saturday 2021, hours after presenting to the Perth Children's Hospital emergency department with a fever and . To see the decisions published by the various Divisions of the Magistrates Court use the Magistrates Decisions link. We will use your rating to help improve the site. 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. Older persons, physical health, subdural haematoma, mechanical fall with head strike, Launceston General Hospital, George Town Hospital. To search for judgments, usethe links below. Inquest FindingsInquest Findings 2021. Water related, long term missing person, suspected death, undetermined cause of death, disappearance, intoxication, Fisherman's Wharf, Strahan. 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. 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. Supreme Court Act 1935; District Court Act 1991; Environment, Resources & Development Court Act 1993; Magistrates Court Act 1991; Youth Court Act 1993 3 Section 53(2) Coroners Act 1996 (WA). 2023 Department of Police, Fire & Emergency Management, Family Violence Counselling Support Service, Research applications and requests (TILES), Special Response and Counter-Terrorism Command, Department of Police, Fire and Emergency Management, Personal Information Protection statement, Coroners findings into the death of Nicholas Whiteley. The coroner's decision is also referred to as the coroner's findings or inquest findings. They usually seek to find out the identity of the deceased, the cause of death and the circumstances in which it may have occurred. Motorcycle crash, motorbike, youth, de-identified, transport & traffic related, fence post, avid motocross & enduro competitor, well-maintained & appropriate safety equipment, abdominal trauma, reminder of supervision, Homicide & assault, missing person, murder, failing to report killing, accessory after the fact, hammer, Ian Rosewall, Renae Donald, Robert Broad, imprisonment. 2 Exhibit 1, Tab 9. Decision of Deputy State Coroner Truscott, Coronial law, cause and manner of death, NSW trains removal of passenger, NSW Police Powers re intoxicated persons, CORONIAL LAW - Mandatory inquest - homicide by known persons since deceased - s.78, Coronial law, cause and manner of death, First Nations Patients, palliative care, death in corrections custody, Justice Health, care and treatment, CORONIAL LAW - s.27 (1) (a) Coroners Act 2009 - death as a result of homicide by a known person - mandatory inquest, CORONIAL LAW - death by hanging of a person in custody - was mental health care of an appropriate standard - should a mandatory notification have been made - access to rope and hanging points - adequacy of health information sharing -, CORONIAL LAW - death by hanging of a person in lawful custody - frequency of medication reviews - reduction of hanging points at Long Bay Correctional Centre, CORONIAL LAW - unidentified human remains, Eastern bank of the MacDonald River, near Wrights Creek Road St Albans NSW, CORONIAL LAW - death in custody, mandatory inquest, cause and manner of death, natural causes, CORONIAL LAW - cause and manner of death, laryngectomy, tracheal stenosis, respiratory rate, respiratory distress, alteration of calling criteria, Clinical Emergency Response System, vital sign observations, CORONIAL LAW - natural causes death of a person in lawful custody - was medical care and treatment appropriate. For all conditions of entry, read the COVID 19 (Coronavirus) Measures. CATCHWORDS: Domestic violence allegations made South Arm Highway, transport and traffic related, single vehicle, misadventure, pedestrian walking on road, struck from behind, multiple traumatic injuries, failure to stop and render assistance, alcohol and drugs, DPP, Department of Public Prosecution, driving with suspended licence, Simone Bridges, intentional self harm, mental illness and health, drowning, Howrah, Mental Health Act 2013, Protective Custody Order, involuntary admission, Royal Hobart Hospital, Tasmanian Health Service, alcohol and drugs, accidental death, intravenous injection of prescription medications, injection of crushed tablets intended for oral ingestion, methadone, quetiapine, diazepam, mirtazapine, cannabis, Tasmanian Opiod Pharmacotherapy Program, Transport & traffic related, motor vehicle accident, car crash, multi-organ failure, North West Regional Hospital, failure to properly diagnose. Coronial findings are listed in descending date order and can be adjusted by use of the filter on this page. traumatic brain injury, homicide, Mitchell Clay Dowling, Jay David Blazely, one punch death, assault, death in care, order under the Guardianship and Administration Act 1995, Guardianship and Administration Board, intentional self harm, mental illness and health, Roy Fagan Centre, death in care, Mental Health Act 2013, mental health order, Millbrook Rise Centre, asphyxia, choking on food, supervision of meals, transport and traffic related, motor vehicle accident, two vehicle crash, Lebrina, death in care, Mental Health Act 2013, mixed prescription drug sedation, clozapine, olanzapine, Spencer Clinic, Burnie, North West Regional Hospital, Karingal Nursing Home, mental illness and health, coroner's recommendations. Update provided by THS South 14 October 2022. Unreported judgments of the Supreme Court of Tasmania are available on AustLII (Australian Legal Information Institute). coronial, artery dissection, ischaemic heart disease, renal scarring, emphysema, the work of the courts being available to public scrutiny, possible harm from making an investigation publically available, homicides after the criminal process has been completed, any other death which has been reasonably widely reported in the news media for clarification of the factual findings, any death where health and safety recommendations can result in improvements and death prevention (for example, child protection systems issues, deaths in medical settings with recommendations for improvement), any other matter which the coroner believes is in the public interest. 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. Domestic incident, tree felling accident, hypothermia and rhabdomyolysis, traumatic crush injuries, chainsaws, lack of training, deficient falling techniques, recommendations. This page was last edited on 15 September 2022, at 08:56. A Health Practitioner's guide for writing a statement for the Coroner. A Health Practitioner's guide for writing a statement for the Coroner. These updates then influence our mentoring and internal checking efforts, especially when it comes to conducting safety observations and reviewing travel times and probation. After an inquest, the coroner publishes their findings, which sets out theirdecisions and recommendations. 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. 9:56pm Feb 24, 2023. This includes rapid reversal requirements and perioperative management. The original records are located in the Tasmanian Archives and Heritage Office in Hobart, Tasmania. Our intention now is to broaden this process by utilising our recently recruited Driver Trainer to provide programmed in cab refresh sessions and assessments (similar, in many respects, to what pilots undertake now). 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. 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. Sand flags are stored for easy access/attachment when field centre vehicles are accessing the tracks. Coronial findings To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. Search or sort for the relevant findings below. To search for judgments, use the links below. If a judgment is not listed in the List of Recent Decisions try clicking on the Refresh or Reload Button in your Browser to make sure you are viewing the latest version of the web page. There are also a series of sections totalling approx. 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. Older persons, physical health, Roy Fagan Centre, Guardianship and Administration Order, Public Guardian, care, treatment and supervision, dementia, aspiration pneumonia. Coronial, held in care, guardianship order, inquest, person in care, Roy Fagan Centre, atherosclerotic, hypertensive cardiovascular disease. Handbook for Medical Practioners and Students, Child C (Name Subject to Suppression Order), Child F (Name Subject to Suppression Order), Child B (Name Subject to Suppression Order), Baby E (Name Subject to Suppression Order), Child AM (Name Subject to Suppression Order), Child J (Name Subject to Suppression Order), Child JP (Name Subject to Suppression Order), Drage, Christopher Mervyn and Simpson, Trisjack Preston, Miss T (Name Subject to Suppression Order), Child JM (Name Subject to Suppression Order), Child RM (Name Subject to Suppression Order), Child SJC (Name Subject to Suppression Order), Headland, Zaraiyah-Lily and Andreas Hohaia, 5 Deaths in Casuarina Prison including Mervyn Kenneth Douglas BELL and Bevan Stanley CAMERON and Brian Robert HONEYWOOD and JS (Name Subject to Suppression Order) and Aubrey Anthony Shannon WALLAM, 13 Children and Young Persons in the Kimberley Region, Child KT (Name Subject to Suppression Order), Child L (Name Subject to Suppression Order), Pham, Uock and O'Neill, Justin and Pham, Jacob and Pham, Tuan, Carter, Mason Laurence and Turner, Murray Allan and Fairley, Chad Alan, Fairley, Chad Alan and Carter, Mason Laurence and Turner, Murray Allan, Felton,Gary, chantelle Jane McDougall, Leela McDougall and Antonio Konstantin Popic, McDougall, Chantell Jane and McDougall, Leela and Antonio Konstantin Popic and Gary Felton, Turner, Murray Allan and Carter, Mason Laurence and Fairley, Chad Alan, Beasley (also known as Graeme Leslie Syme), Miller, Keven Herbert Leban (aka Herb Miller), Cuzens, Jessica Rose & Cuzens, Jane Lesley Margaret & Glendinning, Heather, Glendinning, Heather & Cuzens, Jessica Rose & Cuzens, Jane Lesley Margaret, Hassan, Mohammad and Noor, Mohammad and Mr Sabibullah (Sabib Ullah), Noor, Mohammad and Hassan, Mohammad and Mr Sabibullah (Sabib Ullah), TP (a child) (Subject to a Suppression Order), TPL (a child Subject to a Suppression Order), McLean, Steven Walter & Wallam, Shane Henry, Till, Debra Alexandra and Raabe, Craig Allan, James, Robert (aka Philip Kevin Luckie and Robert John Coughlin), Vincent, Ian Bradley and Nelson, Kane Edwin. When the cause of death is unknown or seems unnatural, a judicial officer, known as a coroner, is involved to determine certain information. Response fromDe Bruyn's Transport 23 July 2022, Recommendation 1: Rollover Awareness and Training. We then focus on specific rollover awareness factors during both our mentoring as well as our refresh programs. In some inquests recommendations launch are made to Ministers and Government and non-government agencies. You are directed to the disclaimer and copyright notice and a Personal Information Protection statement governing the information provided. chronic alcoholism and emphysema, Mixed prescription drug toxicity, accidental overdose, drugs & alcohol, central nervous system depressants, lung disease, physical health, pharmaceutical services branch, Poisons Act 1971, schedule 8 narcotic substances, Drowning, rock fishing, not wearing a personal floatation device, PFD, Boltons Beach, Triabunna, Coroner's comment, Coroner's recommendation, Long term missing person, 1985, cause of death unknown, circumstances unknown, Tasmania Police Missing Persons Unit, Queensland, Inquest, falls, domestic incident, older persons, Ambulance Tasmania, paramedic, transport not required, transport refused, subdural heamatoma, Royal Hobart Hospital, recommendations, Inquest, drugs & alcohol, misadventure, water related, drowning and intoxication with methamphetamine and other substances, Little Howrah Beach, Launceston General Hospital, sepsis, Medical Certificate of Death, Office of the Health Complaints Commissioner, poor medical treatment, entirely avoidable death, Inquest, falls, older persons, elderly persons, Royal Hobart Hospital, application pursuant to section 58 of the Coroners Act 1995, investigation re-opened, Coroner's comment, high falls risk, aspiration pneumonia, National Disability Insurance Scheme, NDIS, palliative care, epilepsy, brain injury. [2021] WACOR 18 Page 2 Coroners Act 1996 (Section 26(1)) AMENDED RECORD OF INVESTIGATION INTO DEATH I, Philip John Urquhart, Coroner, having investigated the death of a female child referred to as Child AM with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 26 - 27 November Inquest files are reports and associated files pertaining to investigations regarding the cause of certain deaths. The coroner can decide if the following lawyers can attend: a lawyer representing the coroner's . This includes a combination of in cab assistance, review/follow-up of telematic data and ongoing focus on travel times for higher risk activities. Aboriginal and Torres Strait Islander peoples are warned, findings contain the names of deceased persons. 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). The relevant Medical Officer will write the discharge appointment in the DMR as King Island Health Services can access these details. The Northern Territory's coroners office investigates unexpected or suspected deaths on behalf of the community. I Found the Person I Was Looking For, What Now? Coronial, single motor vehicle crash, multiple injuries, Toyota HiLux Utility, paddock, blunt trauma to the head, neck, thorax and arms, skull fractures, brusing of both lungs. Prior to discharge an appointment with the GP is to be made at a time asap after the patient returns to King Island. Coronial, stairs, step, fall, head injuries, blunt force. information and interpreting coronial determinations and findings regarding intent. Coronial, peritoneal sepsis, multiple organ failure, bowel, perforation of the bowel. Search by Case Name. This is also called a public court hearing. 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 . coronial, organ failure, multiple snake bites, tiger snake, neuropathy, coagulopathy, farm. Apply Clear filters Showing 21-30 of 82 results Inquest into the death of Terence Gray launch Decision of Deputy State Coroner Truscott Geographic, leisure activity, caverneering, Tasmanian Caverneering Club, Mount Anne, North East Ridge, exploration, disappearance, undetermined cause of death. Inquest, bee sting, bee venom, anaphylactic reaction, anaphylaxis, Tasiliquid Gold, bee apiary, beehives, Coroner's recommendations, transport and traffic related, motor vehicle accident, two vehicle accident, Melton Mowbray, Highland Lakes Road, Midlands Highway, prescription medication, tramadol, diazepam, Leisure activity, misadventure, sports related, water related, personal water craft, PWC, Jet Ski, drowning, could not swim, no personal floatation device, PFD, alcohol, no licence, inexperienced, misadventure, fall from height, head injury, adolescent, youth, Penguin Primary School, Royal Hobart Hospital, North West Regional Hospital, Coroner's comment, undetermined cause of death, Penguin, natural causes, motorcycle crash, transport and traffic related, motor vehicle accident, Launceston, unlicenced rider, rider at fault, drugs and alcohol, exceeding speed limit, disobey road rules, exceed alcohol limit, riding unlawfully, Coroner's comment, incompetent rider, ride unsafely, multiple severe trauma, Older persons, acute myocardial ischaemia, coronary atherosclerosis, North West Regional Hospital, MET call, ECG results, Coroner's comment, Falls, older persons, Meadow Mews Plaza, acute subdural haematoma, Launceston General Hospital Emergency Department, no CT scan, Canadian CT scan rule, Drugs & alcohol, transport & traffic related, motor vehicle collision, Bass Highway, methamphetamine, MDMA, mobile phone, alcohol and drugs, illicit drugs, injection of methamphetamine, multiple organ failure, hypoxic encephalopathy due to cardiac arrest, misadventure, Death in Care,Guardianship Order, IVB metastatic adenocarcinoma of the rectum, schizophrenia, transport and traffic, motor vehicle crash, Brooker Highway, blunt traumatic injuries, alcohol and drug related, prescription medication, diazepam, oxazepam, tramadol, olanzapine, cannabis, THC, impaired driving, Royal Hobart Hospital, Whittle Ward, hospital, palliation, Guardianship Order, Guardianship and Administration Board, inquest, Death in care, Roy Fagan, Guardianship Order, aspiration pneumonia complicating advanced multifactorial dementia.