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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. 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. Safety assessments of driver performance not only occur at the end of probation but are undertaken on an ongoing basis. Inquest findings (since 2004) as well as non-inquest public interest matters (since 2012) are available below. Councils Operations Manager, a qualified engineer, was charged with investigating improvements to the road. FINDING OF: Judge Greg Cavanagh . 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. 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. the details needed to register the death with the Registry of Births, Deaths and Marriages. In some inquests recommendations are made to Ministers and Government and non-government agencies. Tasmania Police has welcomed Coroner Robert Pearces findings into the death of Nicholas Whiteley at Westbury on 22 November 2010. To search for judgments, use the links below. Check the List of Recent Decisions. Response from Tasmania Health Service Statewide and Mental Health Services received 8 March 2022. 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. When the cause of death is unknown or seems unnatural, a judicial officer, known as a coroner, is involved to determine certain information. . 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. 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. 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. Water related, long term missing person, suspected death, undetermined cause of death, disappearance, intoxication, Fisherman's Wharf, Strahan. This may require viewing multiple records or images. O'Donnell, Margaret Joy.pdf (PDF File, 135.6 KB), Donohue, Tracey Lee.pdf (PDF File, 103.1 KB), Tilley, Jennifer May.pdf (PDF File, 117.4 KB), Wells, Peter Williams.pdf (PDF File, 100.9 KB), Lowe, Paul 2021 TASCD 684.pdf (PDF File, 1.1 MB), Bennett, Anthony George.pdf (PDF File, 114.0 KB), Roberts Henry Arthur.pdf (PDF File, 112.3 KB), Breward, Bradley Wade.pdf (PDF File, 78.7 KB), Nicholson, Dale Waverley.pdf (PDF File, 104.2 KB), Larkins, Pamela Judith.pdf (PDF File, 96.7 KB), Lindburg, Jason Richard.pdf (PDF File, 105.5 KB), Wheldon, Jamie Damien.pdf (PDF File, 106.0 KB), Chilvers, Peter Michael.pdf (PDF File, 98.6 KB), Pearce, Jayden John.pdf (PDF File, 103.1 KB), Rosendale, Dwayne Edward (PDF File, 376.1 KB), Bester, Valentine Eric Neal (PDF File, 130.9 KB), Lane, Christopher Mark.pdf (PDF File, 97.2 KB), Hume, Rosemary Josephine.pdf (PDF File, 112.6 KB), Parsons, Anna Maree.pdf (PDF File, 402.4 KB), Reaks, Karen Tracey.pdf (PDF File, 98.7 KB), Suter, Nigel Douglas.pdf (PDF File, 98.0 KB), King, Nicholas Brian.pdf (PDF File, 99.7 KB), Sterling, Barbara Lynette.pdf (PDF File, 103.5 KB), Quirk, Stewart James (PDF File, 99.0 KB), Lockley, Shane Reginald.pdf (PDF File, 113.1 KB), Groves, Justin Thomas (PDF File, 117.3 KB), Cooper, Melanie Sarah 2021 TASCD 475.pdf (PDF File, 121.9 KB), Midson, Gilbert Arthur.pdf (PDF File, 111.4 KB), Williamson, Shane Elliott; Rowe, Rodney Leo; and Robertson, Adam David (PDF File, 141.8 KB), Fitz-gerald, Peter John (PDF File, 106.1 KB), Selby, Robert Norman (PDF File, 731.0 KB), Hildyard, Nicholas William (PDF File, 112.0 KB), Menzies, Mervyn Roy (PDF File, 109.0 KB), Sowden, James Robert (PDF File, 597.0 KB), Woolley, Byron Balfour (PDF File, 77.1 KB), Gleeson, Craig; Lucas, Alistair & Welsh, Michael (PDF File, 892.1 KB), Bryers, Wallace Edgar (PDF File, 398.7 KB), Carnes, Wendy Maree.pdf (PDF File, 110.5 KB), Beames, Michael James (PDF File, 117.6 KB), Marshall, David Basil (PDF File, 94.9 KB), Wade, Neville Ernest (PDF File, 100.0 KB), Ghanbarzadeh, Masoud (PDF File, 120.1 KB), Porthouse, David John (PDF File, 294.6 KB), Bester, Alec Laurence (PDF File, 294.3 KB), Stocks, Michelle Jayne (PDF File, 121.3 KB), Steffen, William Francis (PDF File, 82.6 KB), Bowerman, Valerie Joy (PDF File, 399.8 KB), Davis, Graeme Charles (PDF File, 122.6 KB), Rubenach, Timothy Luke (PDF File, 141.1 KB), Daly, Raymond Albert.pdf (PDF File, 268.2 KB), Clark, Philip Patrick (PDF File, 252.7 KB), Fischer, Rodney James (PDF File, 101.4 KB), Lattimer, Joseph Aaron (PDF File, 455.5 KB), Greene, Yvonne Beverley (PDF File, 86.2 KB), Clark-Robertson, Tyson Timothy (PDF File, 117.7 KB), Townsend, David Lester.pdf (PDF File, 132.8 KB), Buhler, Finn Ruben Leo (PDF File, 106.6 KB), Oakley, Joseph Richard. 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. For all conditions of entry, read the COVID 19 (Coronavirus) Measures. Citations help you keep track of places you have searched and sources you have found. A Health Practitioner's guide for writing a statement for the Coroner. Transport & traffic related, motorcycle crash, single vehicle crash, high speed, multiple trauma. This page was last edited on 15 September 2022, at 08:56. This collection includes inquest files from the coroner's office in Tasmania. 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. (AMK) Web.pdf (PDF File, 307.3 KB), Kettle, Terrence Michael (AMK) Web.pdf (PDF File, 304.9 KB), Brewer, Ruby and Shanzel (PDF File, 164.5 KB), Golding, Laura Rebecca (PDF File, 127.5 KB), Woolley, Dale Robert (PDF File, 374.2 KB), Spencer, Melissa Mary - web.pdf (PDF File, 122.9 KB), Marshall, Eric Craig (PDF File, 843.8 KB), Besgrove, Trevor Scott (PDF File, 101.7 KB), Espie, James William (PDF File, 100.2 KB), Mansell, Robert Charles (PDF File, 488.0 KB), Nicolle, Paula Elizabeth (PDF File, 111.1 KB), Bond, Johnathon Lee.pdf (PDF File, 122.0 KB), Fish, Winston William - Web version.pdf (PDF File, 112.1 KB), Oliver, Colin Jamie.pdf (PDF File, 124.3 KB), Lockley, Rodney Dennis (PDF File, 107.8 KB), Pears, Phyllis (AMK) signed 11.09.20.pdf (PDF File, 437.3 KB), Murray, Geoffrey Raymond (PDF File, 107.1 KB), Harmon, Trinton John (PDF File, 586.4 KB), Wright, Maria Rebekah (PDF File, 148.8 KB), Wellington, Timothy John (PDF File, 298.7 KB), Maynard, Grant Godfrey (PDF File, 100.7 KB), Howe, Rowland Michael Chilton (PDF File, 118.7 KB), Howard, Noeline Dawn (PDF File, 124.1 KB), Williamson, Colin George (PDF File, 114.5 KB), Delios, Voula 2020 TASCD 458 (PDF File, 541.5 KB), Thompson, Michael Robert (PDF File, 134.3 KB), Lyons, Matthew Clayton - web.pdf (PDF File, 133.8 KB), Thompson, Paul Christopher (PDF File, 544.7 KB), Crowden, Jeffrey Donald (PDF File, 276.7 KB), Stone, Corrie Collean (PDF File, 85.4 KB), Shrimpton, Dallas Brooks (PDF File, 137.5 KB), Konstantinidis, Agis (PDF File, 124.6 KB), Crawford, Jacob Raymond (PDF File, 126.8 KB), Arnold, Derek William (PDF File, 116.8 KB), Dickinson, Mary Marguerite (PDF File, 485.6 KB), Tonner, Justin Michael (PDF File, 104.0 KB), McCarthy, Blake John (PDF File, 109.9 KB), Adams, Christopher Neil (PDF File, 98.7 KB), Griffin, James Geoffrey (PDF File, 101.4 KB), Hunter, Feryne Gaylene (PDF File, 137.7 KB), Dennis, Wayne Phillip (PDF File, 104.9 KB), Cashion, Brett Matthew (PDF File, 293.9 KB), Riley, Shane Patrick (PDF File, 375.3 KB), Tonks, Russell Rodney (PDF File, 100.7 KB), Ferguson, Roy Waldren Trevor (PDF File, 117.5 KB), Jones, Bradley James (PDF File, 124.8 KB), Hayward, Vanessa Claire (PDF File, 113.8 KB), Petterwood, Michael Lewis (PDF File, 115.5 KB), Pears, William Ernest (PDF File, 123.3 KB), Hargraves, Audrey Doreen (PDF File, 113.7 KB), Standaloft, Cora Gwendoline (PDF File, 100.4 KB), Button, Shirley Gwendoline (PDF File, 116.0 KB), Szemes, Kim Leonie Maree (PDF File, 104.5 KB), Shepperd, Stephen Charles (PDF File, 92.5 KB), Wilton, Melissa Joan (PDF File, 135.3 KB), Lawrence, Timothy Michael (PDF File, 137.5 KB), Kiley, Jordan Jackson (PDF File, 89.7 KB), Evans, Conor Maclaren (PDF File, 99.2 KB), Whitney, Margaret Ann (PDF File, 100.6 KB), Procter, Wilfred Pearson (PDF File, 118.3 KB), Combes, Margot Janeece (PDF File, 89.6 KB), Woodward, Ernest Henry (PDF File, 111.9 KB), Arundel-Clarke, Catherine Clara (PDF File, 99.6 KB), Woolley, Zedric Basil (PDF File, 118.2 KB), McInerney, Robert Edward (PDF File, 617.6 KB), Martin, Jack Hedley (PDF File, 374.5 KB), Mason, Alison Henderson (PDF File, 369.9 KB), Maxwell, Benjamin Murray (PDF File, 86.9 KB), Stewart, Keith Thomas (PDF File, 367.0 KB), McKenzie, Heather Patricia Dale (PDF File, 383.5 KB), Powell, Stephen Maxwell (PDF File, 309.1 KB), Roberts, Anna Jane and Stanley, Brett John (PDF File, 378.5 KB), Benneworth, Anthony John (PDF File, 414.5 KB), Long, Anthony Edward (PDF File, 412.9 KB), Frith, Aaron Douglas (PDF File, 363.8 KB), Sulman, Murray Matthew (PDF File, 373.0 KB), Peck, Edward Paisley (PDF File, 825.8 KB), O'Brien, Mark Andrew (PDF File, 369.6 KB), Clark, Darren Stuart (PDF File, 410.5 KB), Smith, Jordan Marcellus (PDF File, 380.9 KB), Bowerman, Graeme Anthony (PDF File, 415.1 KB), Picken, Jason Scott (PDF File, 362.0 KB), Jenkins, Mark Andrew (PDF File, 376.9 KB), Davies, Luke; Drobnjak, Aleksander; Ritter, Magnus; Roche, Anthony (PDF File, 839.6 KB), Stanley, Christopher Stephen (PDF File, 372.6 KB), McLean, Michael William (PDF File, 260.2 KB), Saltmarsh, Aidan Denis (PDF File, 384.2 KB), Jeffrey, Angela Joy (PDF File, 517.6 KB), Mead, Liam - Ruling on Evidence (PDF File, 147.9 KB), Horcicka, Josef Vratislav (PDF File, 488.4 KB), Eaton, Jodi Michelle (PDF File, 460.4 KB), Lukendlay, Charlotte (OM) Findings.pdf (PDF File, 751.2 KB), Nichols, James Raymond (PDF File, 397.8 KB), Russell, Allan Geoffrey (PDF File, 873.4 KB), Porteous, Shayne Edward (PDF File, 490.3 KB), Kranz, Lothar Wolfgang (PDF File, 501.6 KB), Davis, Catherine Joy (PDF File, 484.0 KB), Kenney, Margaret Patricia (PDF File, 510.8 KB), Ham, Roderick David Charles (PDF File, 487.1 KB), Best, Christopher Mark (PDF File, 497.5 KB), Close, Terrence Findings Web.pdf (PDF File, 943.2 KB), Finding Brendan Smith (Web) pdf.pdf (PDF File, 780.6 KB), Burns, Brendan Craig (PDF File, 324.4 KB), Glover, Gerald Samual (PDF File, 125.7 KB), Morris, Jason Simon (PDF File, 122.1 KB), Steshic, John Norman -web .pdf (PDF File, 495.7 KB), Paraskevas, Odissefs (PDF File, 396.0 KB), Nowitzki-Eisenburg, Heike (PDF File, 493.2 KB), Beltz, Sarah Rose -(Web).pdf (PDF File, 469.7 KB), Cowen, Craig -web.pdf (PDF File, 411.8 KB), Skrepetos, Stavroula (PDF File, 478.6 KB), Killer, Debbie Dubravka (PDF File, 411.5 KB), Brown, Tony David .pdf (PDF File, 595.0 KB), Stefaniw, Gerard Ernest (PDF File, 738.2 KB), Dunster, Kenneth Francis (PDF File, 743.5 KB), Roberts, Nigel Douglas (PDF File, 734.5 KB), Westbrook, Eden Jayde (PDF File, 314.2 KB), Richardson, Margaret Rita. I Found the Person I Was Looking For, What Now? 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. The following articles will help you research your family in Australia. Findings are published on this website when an inquest was held or a coroner otherwise orders they be published in the public interest. A Health Practitioner's guide for writing a statement for the Coroner. 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. CATCHWORDS: Domestic violence allegations made 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. The Northern Territory's coroners office investigates unexpected or suspected deaths on behalf of the community. Long Term Missing Person, Reportable Death, DNA, Inquest, work related, employment, accident, Derwent Valley, cherry orchard, trailer, SD Reid Holdings Pty Ltd, Reid Fruits, WorkSafe Tasmania, motor vehicle accident, two vehicle crash, Bass Highway, Carrick, drugs and alcohol, methamphetamine, incorrect side of roadway, Coroner's comment, Coronial, drowning, boat, Maria Island, Rock Lobster, FV Yimbala, Life Jackets, Coronial, injuries, head injuries, aspiration, head and facial, acute alcohol intoxication, Coronial, coroner, Crash injuries, Chest and pelvis, Tractor crash. 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. To access a finding not listed here, please makeapplication (DOC , 61.5 KB)to the Court. Geographic, leisure activity, caverneering, Tasmanian Caverneering Club, Mount Anne, North East Ridge, exploration, disappearance, undetermined cause of death. information and interpreting coronial determinations and findings regarding intent. 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. We extend our sympathies to the family of Mr Whitely at this difficult time. 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. 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. Response fromDe Bruyn's Transport 23 July 2022, Recommendation 1: Rollover Awareness and Training. 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 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.