tas coroners findings 2021

Safety assessments of driver performance not only occur at the end of probation but are undertaken on an ongoing basis. The page has been produced by Courts Tasmania, Search the Supreme Court of Tasmania database, personal information protection statement. 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. Drugs & alcohol, accidental overdose, prescription drugs, mixed drug toxicity, prescribing, Pharmaceutical Services Branch, Poisons Act 1971, Poisons Regulations 2018, schedule 8 substances, central nervous system depressants. 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. Response from Tasmania Parks and Wildlife Service11 August 2022. Please be aware some collections consist only of partial information indexed from the records and do not contain any images. Water related, long term missing person, suspected death, undetermined cause of death, disappearance, intoxication, Fisherman's Wharf, Strahan. Directions Hearing - Those seeking leave to appear. In some inquests recommendations launch are made to Ministers and Government and non-government agencies. 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. I Cant Find the Person Im Looking For, What Now? Coronial, held in care, guardianship order, inquest, person in care, Roy Fagan Centre, atherosclerotic, hypertensive cardiovascular disease. Unreported judgments of the Supreme Court of Tasmania are available on AustLII (Australian Legal Information Institute). Last updated: 16-Dec-2020 [ back to top ] This includes rapid reversal requirements and perioperative management. We will use your rating to help improve the site. Older persons, physical health, Roy Fagan Centre, Emergency Guardianship Order, care, treatment and supervision, Alzheimer's disease, aspiration pneumonia. The relevant Medical Officer will write the discharge appointment in the DMR as King Island Health Services can access these details. adverse medical effects, failure to diagnose, misdiagnosis, Hobart Private Hospital, carcinomatosis, failure to report death to Coroner, medical, hospital. Aishwarya Aswath's parents question slow pace of hospital change 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. This includes a combination of in cab assistance, review/follow-up of telematic data and ongoing focus on travel times for higher risk activities. The Department will act on the Coroners recommendations. The Coroner has prepared comprehensive and considered findings and they will be given careful . The PWS Arthur River Visitor Centre is trialling selling sand flags to the public. 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. Search the Supreme Court of Tasmania database. 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. 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. Courts Tasmania : Decisions The discharge summary or interim essential clinical details will be sent to the GP advising discharge date, appointment time with GP, discharge medications and legal status. We often utilise telematic data for this process as well as timesheet reviews, camera evidence and even road user and customer anecdotal feedback. CITATION: Inquest into the death of HD (name suppressed) [2021] NTLC 029 . 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. When the cause of death is unknown or seems unnatural, a judicial officer, known as a coroner, is involved to determine certain information. A grant from the Department of State Growth Safer Rural Road Program was secured on 23 March 2021 for: Vegetation reduction, site benching works, installation of guard rails and signage at Glenfern Road. Update provided by THS South 14 October 2022. 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. Download Australian Domestic and Family Violence Death Review Network Data Report 2018 (pdf, 3 MB), If you have a complaint about the conduct of a magistrate, or delay in handing down a decision, please see the CourtsJudicial Complaints Policy (PDF, 56.3 KB), 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. 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. Search by Case Name. (Web).pdf (PDF File, 406.9 KB), Death cannot be determined, Schedule 8 substances, Death is undetermined, Schedule 8 substances, Undetermined death, Mental Illness & Health, Health Treatment Order, GAB Order, Quad Bike, Sandy Cape Track, Coroner's Recommendation, Intentional self-harm, Statewide Mental Health Services, mental illness and health, Root Cause Analysis Report, Mental Health Act 2013, mental health facility rural or remote area, Coroner's recommendations, Drugs and alcohol, mental illness and health, physical health, epilepsy, Mental Health Act 2013, person held in care, methadone intoxication, Pharmaceutical Services Branch, methadone program, Alcohol and Drug Service, TOPP guidelines, Launceston General Hospital, Older Persons, Ischaemic heart disease, pulmonary disease, Royal Hobart Hospital, Drugs, Criminal Charges, Motor Vehicle Accident, Coroner's Comments, Seasonal Worker, Alcohol, Seat-Belt, Mental illness and health, physical health, person held in care, schizophrenia, morbid obesity, cardiac enlargement, Forensic Mental Health Service, Anglicare, Royal Hobart Hospital, coroner's recommendations, Coronial, findings, drowning, Frederick Henry Bay, Tasmania, Paddle, Kayak, Rochus Beach, Lime Bay, PFD, Wetsuit, Weather Forecast, Paddle Safe Guidelines, MAST Surf Life Saving Tasmania. Response fromDe Bruyn's Transport 23 July 2022, Recommendation 1: Rollover Awareness and Training. 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. 5 March 2023, 12:40 am. Prior to discharge an appointment with the GP is to be made at a time asap after the patient returns to King Island. Identifying your sources helps others find the records you used. Keep track of your research in a research log. The coroner can decide if the following lawyers can attend: a lawyer representing the coroner's . 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. Leisure activity, transport & traffic related, weather related, aircraft crash, private airfield, windsock, coroner's comment & recommendation, Transport and traffic related, weather related, motor vehicle accident, truck, speed, wet weather, improved roadway, advisory signage, Glengarry, aged care, older persons, fall from cliff, possible drowning, Derwent Waters, retirement village, Claremont, undetermined circumstances, Falls, leisure activity, older persons, Mersey Community Hospital, infection, avoidable, Root Cause Analysis, misdiagnosed, Adverse medical effects, Coroner's comment, operation, George Town Hospital, Launceston General Hospital, St. Vincent's Public Hospital, surgery, laparoscopic cholecystectomy, Adverse medical effects, older persons, reversal of Hartmann's procedure, post-operative complications, electrocardiogram, long QT syndrome, St Luke's Hospital, Launceston General Hospital, recommendation, Aged care, falls, older persons, Coroner's comment, bed alarms, Adverse medical effects, falls, leisure activity, older persons, Launceston General Hospital, LGH, undetermined cause of death, mental health and illness, Ambulance Tasmania, Mental Health Services, transport and traffic related, single motor vehicle crash, multiple chest injuries, failure to wear seatbelt, intoxicated, drink driving, drugs and alcohol, coroner's comments, Drowning, leisure activity, fishing, water related, weather related, winter, alcohol related, child and infant death, sudden unexpected death in infancy (SUDI), co-sleeping with parents, potential overlay whilst sleeping, sleeping in adult bed, smoking, unsafe sleeping environment, bronchopneumonia, Child Safety Services, Child Protection Services, Child and Youth Services, Drugs & Alcohol, Transport & Traffic Related, Motor Vehicle Accident, Speeding, Collision, Distraction, Orford, Learner Licence, water related, multiple injuries, personal water craft (PWC), jet ski, Chinaman's Bay, Dunalley, alcohol and drugs, operating a PWC whilst intoxicated, collision with stationary object, Traffic and transport related, youth, single vehicle motorcycle crash, blunt injuries of head, neck and chest, loss of control, sweeping turn, Strathaven Drive Rosetta, transport and traffic related, motor vehicle crash, Longford, Illawarra Road, methylamphetamine, cannabis, driving under influence of illicit substances, Drugs and alcohol, mental illness and health, mixed drug toxicity, respiratory arrest, methadone, diazepam, coroner's finding, coroner's comment, Transport & traffic related, car crash, older persons, Aged care, nursing home, fall, older persons, dementia, person held in care, Royal Hobart Hospital, Roy Fagan Centre, Public Guardian, guardianship order, medical review, Coroner's comments, Missing person, LTMP, unknown cause of death, bones, Launceston, Transport & traffic related, motorcycle crash, blunt force trauma, crash investigation, speed, unroadworthy, Electrocution, work related, Residual Current Devices, portable defibrillator, Coroner's finding, Coroner's recommendation, Coroner's comment, Natural cause death, location, West Tamar Highway, Lanena, older persons, physical health, The Public Trustee, Fall, work related, pulmonary thromboembolus, left medial malleolar fracture, anti-coagulation, risk of DVT and PE, coroner's finding, coroner's comment, Ladder fall, traumatic closed head injuries, working at height, training, home building site, recommendations, Workplace Health and Safety Act 2012, Missing person, water related, recreational fishing, suspected death, disappearance, Transport & traffic related, single vehicle crash, learner's licence, unlicenced, unroadworthy, wet conditions, speed, child survived, crash investigation, Coroner's comments, undetermined cause of death, missing person, Glen Huon, Coroner's finding, coroner's recommendations, gunshot wound, law enforcement, mental illness & health, weapon, police provoked shooting, Tasmania Police, Transport & traffic related, alcohol, drink driving, excessive speed, speeding, mobile phone usage, texting, single vehicle crash, unroadworthy, asphyxia, Turners Marsh, failure to wear seat belt, coroner's comments, adverse medical effects, hospital death, Mersey Community Hospital, sepsis, failure to remove intravenous cannula, Coroner's finding, water related, transport & traffic related, blunt force trauma with brain injury, leisure activity, misadventure, PWC, unlicensed and inexperienced PWC operators, Lake Trevallyn Dam, Tasmanian Jet Sport Boating Club, Coroner's finding, long-term missing person, older person, undetermined cause of death, body not located, North-West Tasmania, transport and traffic related, single motor vehicle crash, excessive speed, driving over speed limit, Lilydale, Homicide, murder, assault, stabbing, Devonport, Transport & traffic related, motor vehicle accident, pneumonia, older person, undiagnosed cervical spine fracture, guidelines, Royal Hobart Hospital, transport and traffic related, mobility scooter crash, single vehicle crash, no helmet, loss of control, Falls, older persons, closed head injury, left frontal/temporal subdural haematoma, anticoagulation, reverse anticoagulation protocol, Coroner's finding, Coroner's recommendation, alcohol and drugs, mixed alcohol and drug toxicity, unintentional, Amlodipine, drug interaction, Burnie, Silver Whisper cruise ship, Intentional self-harm, Mental illness & health, older persons, Mental Health Act 2013 (Tas), Mental Health Treatment Order, person held in care, community services, transport and traffic related, motor vehicle accident, two vehicle crash, multiple traumatic injuries, drugs and alcohol, alcohol intoxication, blood alcohol over legal limit, cannabis, Lauderdale, water related, drowning, scuba diving, rebreather, rebreather apparatus, displacement of mouthpiece, Visscher Island, Drowning, water related, Ansons Bay, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety, Drowning, water related, Coroner's comments, lifejackets (PFDs), lifejacket inflation process, boat maintenance, MAST, boating safety, transport and traffic related, motor vehicle collusion, two vehicle crash, failure to take care when overtaking, prime mover, sedan, Bass Highway, Deloraine, multiple injuries, Adverse medical effects, physical health, pulmonary embolism, deep vein thrombosis, prophylactic anticoagulant, Achilles tendon rupture, coroner's finding, coroner's comment, motor vehicle crash, transport and traffic related, Mornington, South Arm Highway, excessive speed, negligent driving, Traffic Act 1925, intentional self harm, mental illness and health, death in a public place, Tasman Bridge, Royal Hobart Hospital, Mental Health Act 2013 (Tas), decision not to involuntarily detain, Transport and traffic related, physical health, heart disease, positional asphyxia, workplace, coroner's finding, coroner's comments, transport and traffic related, motor vehicle accident, motorcycle accident, loss of control, traumatic injuries of head and chest, Kalang Avenue, Transport and traffic related, multiple blunt traumatic injuries, two-vehicle collision, West Tamar Highway, coroner's finding, transport and traffic related, single motor vehicle accident, motorsport, rally car, Scottsdale Classic Rally, Confederation of Australian Motor Sport Ltd, breach of National Rally Code, Transport and traffic related, motorcycle and motor vehicle crash, head-on collision, incorrect lane, multiple traumatic injuries, alcohol, coroner's finding, Transport and traffic related, motor vehicle crash, Domain Highway, multiple blunt injuries, drowning, capsize of boat, Marion Bay, Narrows channel, MAST, marine safety, water related, transport related, manslaughter, assault, subarachnoid haemorrhage, comments on passing sentence, Criminal Code, Transport and traffic related, single motorcycle crash, loss of control, chest and abdominal injuries, drugs and alcohol, unroadworthy, coroner's finding, Transport and traffic related, motorcycle crash, multiple traumatic injuries, drugs and alcohol, lost control, speed, unregistered and unlicensed, rear brake lock, coroner's finding, Drowning, Frederick Henry Bay, transport & traffic related, water related, PFD, boat licence, second hand boat inspection, Coroner's finding, Coroner's recommendation, Coroner's comments, Adverse medical effects, escherichia coli urosepsis, sepsis, kidney stone surgery, launceston, transport and traffic related, single motorcycle crash, Smithton, school zone, excessive speed, un-roadworthy vehicle, drug and alcohol, methamphetamine, Transport and traffic related, motorcycle and vehicle crash, blunt traumatic injuries, overtaking, following too closely, poor riding, coroner's finding, Transport and traffic related, motorcycle and vehicle crash, chest injuries, incorrect side of road, cornering technique, crosswinds, high risk of death, coroner's finding, transport and traffic related, single vehicle crash, motorcycle crash, multiple injuries, loss of control of vehicle, alcohol and drugs, blood alcohol level over legal limit, cannabis (THC), excessive speed, Transport and traffic related, motorcycle and motor vehicle crash, speed and alcohol, diffuse head injury, unroadworthy, coroner's finding, coroner's comment, missing person, suspected intentional self harm, undetermined cause of death, body not located, Bakers Beach, northern Tasmania, coroner's comments, ruling on evidence, whether evidence within scope of inquest, adolescent mental health, Tasmania, Liam Mead inquest, Coroners Act 1995 (Tas), adverse medical effects, hospital related death, Calvary St Luke's Hospital Launceston, reportable death, failure to report death, no post mortem performed, undetermined cause of death, homicide, assault, asphyxia, Bridgewater, Darren Dobson, strangulation/choking, coroner's recommendations, recommendation of enactment of indictable offence of choking, suffocation or strangulation, Two vehicle collision, transport and traffic related, multiple injuries, coroner's finding, Aspiration of gastric contents following vomiting, aged care, mental illness and health, older person, coroner's finding, inquest, child and infant death, global hypoxic brain injury, cessation of breathing, family violence context, non-accidental injury, rib fractures, transport and traffic related, intentional self harm, head injuries, mental health and illness, driver, intentionally driving into path of oncoming vehicle, Latrobe, Transport & traffic related, motorcycle and car collision, alcohol & drugs, Brooker Highway, Hanging, intentional self-harm, mental illness and health, drugs and alcohol, Coroner's finding, hypothermia, Overland Track, Lake St Clair, Parks and Wildlife Service, coroner's recommendations, bushwalker, winter inadequately equipped, transport and traffic related, single motor vehicle crash, Bass Highway, failure to wear seatbelt, alcohol, drink driving, driving over the limit, blood alcohol level of 0.157, speeding, failure to drive at speed limit, coroner's comments, Coroner's finding, transport & traffic related, motorcycle crash, multiple injuries, Drowning, water related, coroner's finding, fishing vessel, dinghy capsize, Coroner's finding, coroner's recommendation, head and chest injuries, Metro, pedestrian struck by bus, transport & traffic related, Mixed drug toxicity, serotonin syndrome, sertraline, tramadol, SSRIs, drugs & alcohol, coroner's finding, hospital death, abdominal aortic aneurysm (AAA), Royal Hobart Hospital, chimney vascular repair procedure, advanced coronary artery and peripheral vascular disease complicating repair, Urosepsis, pyelonephritis, lissencephaly, Royal Hobart Hospital, UTI, incorrect diagnosis, coroner's finding, coroner's recommendation, hospital related death, adverse medical affects, Smithton District Hospital, ischaemic small bowel, bowel obstruction, Crohn's disease, Coroner's finding, coroner's recommendations, adverse medical effects, PPI, gastrointestinal bleed, death review, Pulmonary thromboemboli, deep vein thrombosis, hip replacement, physical health, Coroner's finding, hospital death, Royal Hobart Hospital, Hobart Private Hospital, colonic cancer, hemicolectomy, sepsis, delayed diagnosis, workplace death, work related, transport related, farming property, motorcycle crash, use of motorcycles on private property, single vehicle crash, unroadworthy and unsafe vehicle, no working brakes, neurocardiogenic syncope whilst driving, Industrial accident, blunt force, blunt trauma, pedestrian, hit by utility vehicle, chest and abdomen. This is also called a public court hearing. There are also a series of sections totalling approx. Tree felling accident, chainsaw, Tasmanian Forest Industries Training Board, expired Forest Works Licence, non-compliant helmet, Coroner's recommendations, Homicide and assault, mental illness and health, weapon, Tasmanian Prison Service, Wilfred Lopes Centre, Risdon Prison, North Hobart, Daryl Royston Wayne Cook, Section 24 Criminal Justice Mental Impairment Act 1999, remissions of sentence, mental health services, coroner's comments, Transport & traffic related, work related, single vehicle crash, concrete truck, Tea Tree Road, speed, no seatbelt. Magistrates Court : Coroners Court Motorcycle Crash, Annual St Helens to Strahan Off Road Motorcycle ride, Alcohol, Intentional Self-Harm, Mental Illness, Transport and Traffic Related. Restrictions for Viewing Images in FamilySearch Historical Record Collections, https://www.familysearch.org/en/wiki/index.php?title=Australia,_Tasmania,_Coroner%27s_Inquest_Files_-_FamilySearch_Historical_Records&oldid=4946186, FamilySearch Historical Records Scheduled Collections, Tasmania (Australia) FamilySearch Historical Records, FamilySearch Historical Records Image Visibility Notice, This article describes a collection of records, Use the information to find the person in other records, Analyze the entry to see if it provides additional clues to find other records of the person or their family, The person may be recorded with an abbreviated or variant form of their name. The original records are located in the Tasmanian Archives and Heritage Office in Hobart, Tasmania. Inquests | NT.GOV.AU - Northern Territory Intentional self-harm, mental illness & health, youth, St Helens District High School, asphyxia, police investigation. Use the links in the left hand navigation bar to access the decicions of Tasmanian Courts and Tribunals. the details needed to register the death with the Registry of Births, Deaths and Marriages. In some inquests recommendations launch are made to Ministers and Government and non-government agencies. The THS Adult Anticoagulation statewide guideline includes when and how to reverse anticoagulation. Drugs & alcohol, mental illness & health, mixed prescription drug toxicity, Royal Hobart Hospital, Department of Emergency Medicine, Liverpool Street. Apply Clear filters Showing 11-20 of 82 results Inquest into the death of Albert Metledge launch 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. Mental illness & health, water related, drowning, Copper Alley Bay, Lymington, dinghy, police response, psychotic episode, rescue, aerial search. (ABC Northern Tasmania: Rick Eaves) 3 Section 53(2) Coroners Act 1996 (WA). 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. Works were completed and reported to the grant program on 30 June 2021. HEARING DATE(s): 27, 28 September 2021 . This is also called a public court hearing. This page was last edited on 15 September 2022, at 08:56. 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. information and interpreting coronial determinations and findings regarding intent. PDF Act : Coroner Sarah Helen Linton, Deputy State Coroner: Heard : Delivered CATCHWORDS: Domestic violence allegations made Sand flags are stored for easy access/attachment when field centre vehicles are accessing the tracks. It is acknowledged the Coroner has made no criticism of either Tasmania Police or Constable Blake in relation to the death of Mr Whiteley. A Health Practitioner's guide for writing a statement for the Coroner. 1 Section 279(1)(c) Criminal Code (WA). Coronial, peritoneal sepsis, multiple organ failure, bowel, perforation of the bowel. CORONIAL LAW - cause and manner of death - medical care and treatment of long-term mental health patients - prescribing of anti-psychotic and sedative . Mixed Drug toxicity, Mental Health Plan, Schedule 8 substances, Drug Intoxication, Borderline Personality Disorder, Anxiety Disorder. 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.

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