Inquest proceedings list
Please note the dates for the inquest proceedings listed below are subject to change - the table below is updated at the end of each month.
General: Please call the CCQ Main Phone Line on (07) 3738 7050 if you have any queries in relation to the listed hearing dates or details.
Media enquiries: Accredited media can contact the DJAG Media Unit for assistance (requests must be made in writing via email) at media.relations@justice.qld.gov.au
Key: NPO Non-Publication Order; DTBF Date to be fixed.
All matters have been listed by alphabetical order (last name).
| Name of deceased | Hearing dates | Coroner | Inquest issues | NPO |
|---|---|---|---|---|
| ABC (a pseudonym) | Adjourned DTBF for findings | Coroner David O'Connell | 1. The information required by section 45(2) of the Coroners Act 2003, namely- (a) who the deceased person is? (b) how (i.e. by what means, and in what circumstances) the person died? (c) when the person died? (d) where the person died? (e) what was the medical cause of death? 2. In respect of the death of ABC- (a) were the prescribed timelines for the return of the unused self-administration VAD substances observed? (b) if such timelines were not observed, to what extent (if any) did they contribute to the death? (c) if such timelines had been observed, would this death likely have been prevented? 3. Are the currently mandated VAD procedures pertaining to the supply of VAD substances for self-administration and the recovery and disposal of unused self-administration VAD substances, adequate to minimize the risk of the unauthorised use of self-administration VAD substances or could they be made safer (e.g. by minimising the time they are not under the direct control of an authorised health professional whilst still maintaining appropriate recognition of the privacy, compassion, and autonomy interests of patients and their families)? | Yes |
| Abdi, Raghe Mohamed; Antill, Maurice Frederick; Antill, Zoe Dorothea | Adjourned DTBF for findings | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased persons, when, where and how they died and the cause of their deaths. 2. Examine the circumstances surrounding the deaths of Maurice and Zoe Antill at their residence on or around 16 December 2020. 3. Examine the circumstances leading up to the shooting of Raghe Abdi by police on 17 December 2020. 4. Whether the engagement and monitoring of Raghe ABDI by State and Commonwealth law enforcement officials prior to and following his release from custody in September 2020 was sufficient having regard to their statutory functions. 5. The sufficiency of the monitoring and response by the Queensland Police Service to alerts related to Raghe ABDI’s Electronic Monitoring Device (EMD), including the tamper alert on 16th December 2020. 6. Whether the applicable Queensland Police Service policies and procedures associated with EMD, the response to alerts and associated notifications are sufficient. 7. Consider whether the actions of the attending police officers, who were involved in the shooting of Raghe ABDI, were appropriate in the circumstances. 8. Consider the adequacy of the police investigation into the deaths. | Yes |
| Angus, Steven Richard | Inquest scheduled for 1 to 5 July 2024 at 10:00am in Court TBA at TOWNSVILLE | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where, and how he died and what caused his death; and 2. Consideration of the circumstances leading up to the death including: Mental health diagnosis, treatment and care a. Steven’s co-occurring substance use disorder and other mental health disorder/s, and the appropriate treatment for mental health consumers suffering the mental health condition/s with which Steven was diagnosed. b. Whether Steven had access to such treatment and absent Steven’s consent, could he be compelled to undergo such treatment? c. What is the role of the Veterans Liaison Officer (‘VLO’)13 where a Veteran presents to a HHS in the context of a mental health crises, and what, if any interaction did Steven have with the VLO prior to and on 20 April 2023? d. In all the circumstances, was the treatment afforded Steven, for the mental health condition/s diagnosed, appropriate? e. Whether there was any failure to provide appropriate care that caused or hastened the death? f. Whether any aspect of the care actually provided, caused or hastened the death? Suicidality g. Whether, in all the circumstances, there was an appropriate assessment of Steven’s suicide risk on 20 April 2023. h. Consideration of suicidality amongst ex-serving Australian Defence Force (‘ADF’) members such as Steven. i. Consideration of ‘subject precipitated homicide’, including the effect, if any, on first responders. 3. Whether the Police Officers involved acted in accordance with the Queensland Police Service (‘QPS’) policies and procedures then in force, and whether said actions were appropriate. 4. Whether any changes to procedures or policies could reduce the likelihood of death occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice. | No |
| Bahram, Mohamad Ikraam | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Consideration of the circumstances leading up to the shooting of the deceased by Police on 23 February 2020, including his mental health treatment: a. Mr Bahram’s pharmacological treatment; b. The challenges in diagnosing Mr Bahram and engagement with him by health professionals; c. The risk management screening tools used in respect of Mr Bahram and his deterioration in mental state; d. Whether a Police and Ambulance Intervention Plan (‘PAIP’) for Mr Bahram would have assisted his healthcare; e. Whether the information sharing provisions between the QPS and Qld Health with respect to persons experiencing a mental health incident were sufficient in the lead up to Mr Bahram’s death; f. The training provided to QPS officers in relation to persons experiencing mental health incidents and the use of the co-responder model in responding to such matters; 3. Whether the police officers involved acted in accordance with the Queensland Police Service (‘QPS’) policies and procedures then in force, and whether said actions were appropriate; 4. Whether the training provided to officers in responding to similar incidents is sufficient; 5. The adequacy of the investigation into the circumstances surrounding Mr Bahram’s death; and 6. Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice. | Yes |
| Bernard, Allison Neridine | Adjourned DTBF for hearing | Coroner Nerida Wilson | 1. Findings required by s 45(2) of the Coroners Act 2003, namely whether or not Allison Neridine Bernard is in fact deceased and, if so, how, when and where she died and what caused her death; 2. If deceased, the circumstances surrounding her death; and 3. If deceased, whether the actions of any other person contributed to her death. 4. The adequacy of the police investigation. | Yes |
| Campbell, Chloe Jane | Adjourned DTBF for findings | Coroner Carol Lee | 1. To determine the findings required by s 45(2) of the Coroners Act 2003, namely the identity of the deceased person, when, where and how she died and the cause of her death; 2. The appropriateness of the treatment and care Ms Campbell received during her admission to the Mental Health Unit at Logan Hospital between 18 and 30 April 2019; and 3. The adequacy of steps that have been taken to assess and address ligature risks at the Logan Hospital’s Mental Health Ward. | No |
| Campbell, Jamie Brian | Adjourned DTBF for findings | State Coroner Terry Ryan | 1.The findings required by s 45(2) of the Act; namely the identity of the deceased, when, where, and how, he died and what caused his death. 2.The circumstances surrounding the death including the reasonableness of: a.The actions of the QAS Officers in administering Droperidol to Mr Campbell. b.The monitoring by QAS Officers of Mr Campbells health status following the administration of Droperidol. 3.Whether the Ambulance Officers involved complied with the Queensland Ambulance Service (‘QAS’) policies and procedures then in force. 4.Whether the training provided to Ambulance Officers to respond to like incidents is appropriate. 5.Whether the Police Officers involved complied with the Queensland Police Service (‘QPS’) policies and procedures then in force. 6.Whether any preventative changes to procedures or policies could reduce the likelihood of death occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice. | Yes |
| Carrick, Audrey Yvette | Pre-inquest conference scheduled for 07 May 2024 at 10:30am in Court 5 at BRISBANE | Coroner Carol Lee | 1. Whether anticoagulation therapy should have been instituted to Ms Carrick at an earlier time. 2. Whether Ms Carrick's pre and post procedure heart failure was recognised and treated appropriately. 3. Whether a failure to implant a pacemaker contributed to Ms Carrick's death. 4. Whether there are any further recommendations which can be made which could prevent deaths from happening in similar circumstances in the future. | No |
| Conley, Darcey-Helen; Conley, Chloe-Ann | Inquest scheduled for 29 April to 03 May 2024 at 9:30am in Court 4 at BRISBANE | State Coroner Terry Ryan | 1. The findings required under Section 45 of the Coroners Act 2003, namely the identity of the deceased persons, when where and how they died, and the causes of their deaths. 2. The appropriateness of the response by Child Safety, Metro South Health and the Queensland Police Service to the child protection needs of Darcey-Helen Conley and Chloe-Ann Louise Conley. 3. The adequacy of the relevant policies and procedures of Child Safety, Metro South Health and the Queensland Police Service prior to the deaths. 4. The adequacy of the current policies and procedures of Child Safety, Metro South Health and the Queensland Police Service, having regard to any action that has been taken in response to the deaths. | Yes |
| Doherty, Janis Ellen | Inquest scheduled for 8 to 19 April 2024 at 10:00am in Court 4 at BRISBANE | Deputy State Coroner Stephanie Gallagher | 1.The findings required by s45(2) Coroners Act 2003; namely the identity of the Mrs Doherty (deceased), when, where and how she died and what caused her death. 2.Whether the treatment and management of the deceased provided by Dr Michael Walsh, Neurologist, was appropriate, including: 3.Whether the treatment and management of the deceased provided by Dr Parvin Delshad, General Practitioner, was appropriate; 4.Whether the treatment and management of the deceased provided at the Caboolture Hospital in the period 10 April 2020 to 20 April 2020 was appropriate, including: 5.Whether the treatment and management of the deceased provided at the Royal Brisbane and Women’s Hospital on and after 20 April 2020 was appropriate, including: 6.Whether any aspect of the treatment and management provided to the deceased from 1 November 2019 caused or hastened her death? 7.Whether any failure to provide treatment and management to the deceased from 1 November 2019 caused or hastened her death? | No |
| Edwards, Brad Arthur | Adjourned DTBF for findings | Deputy State Coroner Stephanie Gallagher | Scope of inquest on death required by s24(1) of the Coroners Act 1958; 1. the fact that a person has died; 2. the identity of the deceased person; 3. when, where, and how the death occurred; 4. the persons (if any) to be charged with murder, manslaughter, the offence of dangerous driving of a motor vehicle causing death as set forth in the Criminal Code, section 328A, or any offence set forth in the Criminal Code, section 311. | No |
| Essery, Christopher Glen | Inquest scheduled for 20 to 22 May 2024 at 10:00am in Court 5 at CAIRNS & 24, 27-31 May 2024 at 10:00am in BRISBANE in Court 4 | Deputy State Coroner Stephanie Gallagher | 1. To determine the findings required by s 45(2) of the Coroners Act 2003, namely the identity of the deceased person, when, where and how he died and the cause of his death;2. Whether the care afforded to Mr Essery at the Cairns Base Hospital was appropriate;3. Whether the care afforded to Mr Essery at the Princess Alexandra Hospital was appropriate; 4. Whether any aspect of the care afforded him caused or hastened his death; and 5. Whether any failure to provide him with care caused or hastened his death. | No |
| Francis, Glen | Inquest adjourned DTBF for hearing | State Coroner Terry Ryan | 1.The findings required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death. | No |
| Freear, Benjamin Anthony | Adjourned DTBF for hearing | State Coroner Terry Ryan | 1. The findings required by s45(2) of the Coroners Act 2003; a. The appropriateness of the police response to reported concerns about Benjamin Freear on 7 December 2019; b. The appropriateness of the actions of attending police officers on 8 December 2019; c. The adequacy of the police investigation into the death of Benjamin Freear; d. The diagnosis of Benjamin Freear with ADHD in April 2018; e. The mental health treatment provided to Benjamin Freear from April 2018 to the date of his death. | Yes |
| George, Milton Harrison | Inquest scheduled for 16 July 2024 at 10:00am in Court 4 at BRISBANE | State Coroner Terry Ryan | 1. Consideration of the circumstances leading up to Mr George’s death on 9 November 2022 including his mental health and substance misuse treatment and access to rehabilitation services. 2. Whether the involved Police officers complied with the Queensland Police Service policies and procedures in force: a. at the time Mr George was placed on an Emergency Examination Authority on 11 June 2022; and b. during his arrest and subsequent admission into the Watch house up until his death. 3. The appropriateness of Mr George being assessed as a Level 1 prisoner according to the Queensland Police Service policy at the time. 4. The appropriateness of the infrastructure of the Kowanyama watchhouse, 5. The appropriateness of medical care administered to Mr George by QPS and Kowanyama clinic staff after being found unresponsive. 6. The adequacy and appropriateness of training provided to the involved police officers and QPS policies in relation to operating the Kowanyama Watchhouse, particularly in relation to risk of suicide. 7. Whether there are any further recommendations which can be made which could prevent deaths from happening in similar circumstances in the future. | No |
| Gilbert, Luke Brian | Adjourned DTBF for findings | Deputy State Coroner Stephanie Gallagher | 1. The findings required by section 45(2) of the Coroners Act 2003 (Qld): namely the identity of the deceased, when, where and how he died and what caused his death. 2. The circumstances surrounding Mr Gilberts death and whether Qld Police Officers complied with the relevant policies and procedures. 3. Whether any recommendations might be made that could reduce the likelihood of deaths occurring in similar circumstances, or otherwise contribute to public health and safety, or the administration of justice. | Yes |
| Gilligan, Bridie | Inquest scheduled for 26 to 30 August 2024 at 10:00am in Court TBA at CAIRNS | Deputy State Coroner Stephanie Gallagher | 1. The findings required by section 45(2) of the Coroners Act 2003 | No |
| Haggett, Shirley Elizabeth | Adjourned DTBF for findings | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s45(2) of the Coroners Act 2003; 2. The adequacy and appropriateness of the pre-admission screening procedures and protocols at the Montserrat Day Hospital (Hospital) in the context of the following:* The Hospital’s licence limitations for the admission of patients to day surgery* The assessment of the suitability of high risk patients for admission to the Hospital for day surgery* The communication of pre-admission screening information to treating medical practitioners prior to the admission of patients to the Hospital for day surgery 3. The adequacy and appropriateness of the pre-operative surgical assessment of the suitability of the deceased to undergo day surgery at the Hospital including, but not limited to, the pre-operative estimate of the length of the surgery; 4. The adequacy and appropriateness of the pre-operative anaesthetic assessment of the suitability of the deceased to undergo day surgery at the Hospital; 5. The adequacy and appropriateness of the surgical management and treatment of the deceased intra-operatively; 6. The adequacy and appropriateness of the anaesthetic management and treatment of the deceased intra-operatively including, but not limited to, the choice of technique used to anaesthetise the deceased; 7. The adequacy and appropriateness of the surgical management and treatment of the deceased post-surgery; 8. The adequacy and appropriateness of the anaesthetic management and treatment of the deceased post-surgery; 9. The adequacy and appropriateness of the Hospital’s management and treatment of the deceased post-surgery; 10. The adequacy and appropriateness of the decision to transfer the deceased to the Redcliffe Hospital Emergency Department (ED) including, but not limited to, as to the timing of that decision; 11. The adequacy and appropriateness of the deceased’s management and treatment in the ED; 12. The adequacy and appropriateness of the deceased’s management and treatment in the Intensive Care Unit of the Redcliffe Hospital. | No |
| Harvey, Thompson James | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by s. 45 (2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Determine whether the authorities charged with providing for Mr. Harvey’s mental health and physical care at the Capricornia Correctional Centre prior to his death adequately discharged those responsibilities; 3. Whether the mental health assessments conducted of the deceased upon his induction and prior to his death at the Capricornia Correctional Centre were appropriate; 4. Whether the placement of the deceased and the frequency of the observations conducted whilst he was an inmate at the Capricornia Correctional Centre were sufficient; 5. Consider whether any changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice. | No |
| Ishak Ahmed, Faysal | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Based on the expert evidence, what was the likely cause of Mr Ishak Ahmed’s collapse on 22 December 2022 and could that have been identified and prevented prior to Mr Ishak Ahmed’s collapse; 3. The adequacy and appropriateness of the treatment and care provided to Mr Ishak Ahmed at the Manus Island Regional Processing Centre Immediately following his collapse on 22 December 2016, and whether any avoidable delay was outcome changing. | No |
| Jones, Anthony John | Adjourned DTBF for findings | State Coroner Terry Ryan | The findings required by s.43(4) – (a) so far as has been proved — (i) the cause and circumstances of the disappearance of such missing person; and (ii) whether such missing person is alive or dead; and (iii) if such missing person is alive or likely to be alive—the whereabouts of such missing person at the time of the inquiry; and (b) the persons (if any) committed for trial. The scope of the inquest is as follows: — (a) whether or not a person has died; (b) the identity of the deceased person; (c) when, where, and how the death occurred; (d) the persons (if any) to be charged with murder, manslaughter, the offence of dangerous driving of a motor vehicle causing death as set forth in the Criminal Code, section 328A, or any offence set forth in the Criminal Code, section 311. | Yes |
| Kerle, Wayne Thomas | Adjourned DTBF for hearing | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death. 2. The circumstances surrounding the death, including the appropriateness of: a. the decision of the arresting officer to arrest Wayne rather than issue him with a Notice to Appear (‘NTA’);b. the decision of the arresting officer to apply handcuffs to Wayne; c. the manual handling of Wayne by QPS Officers, including the placement of Wayne in the Police Van for transport to the Brisbane City Watchhouse; d. the monitoring by attending QPS Officers of Wayne’s health status, during search, arrest and transport to the Watchhouse; e. the attempted resuscitation of Wayne by QPS Officers; 3. Whether the Ambulance Officers involved provided appropriate care and/or assessment of Wayne; 4. Whether the training and equipment provided to Ambulance Officers to respond to like incidents is appropriate; 5. Whether the QPS Officers involved complied with the QPS policies and procedures then in force; 6. Whether the training and equipment provided to QPS Officers to respond to such incidents is appropriate; and 7. Whether any preventative recommendations might be made that could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice. | No |
| Kerr, Georgia | Pre inquest conference scheduled for 26 April 2024 at 10:00am in Court 10 at SOUTHPORT | Coroner Stephanie Williams | 1. The findings required by s.45(2) of the Coroners Act 2003 (Qld); namely the identity of the deceased, when, where and how she died and what caused her death; and 2. The circumstances which led to Ms Kerr's arrival at Gold Coast University Hospital on 25 January 2021. | No |
| McDowall, Maximillian Patrick | Inquest scheduled for 22 to 24 April at 10:00am in Court 4 at BRISBANE | Coroner Donald MacKenzie | 1. The findings required by s 45(2) of the Coroners Act 2003; namely the identity of the deceased, when where and how he died and what caused his death; 2. An examination of the circumstances surrounding Mr McDowall’s death on 27 May 2021, in particular: i. The ability of the bus driver to be able to sight Mr McDowall; and ii. What steps the bus driver took so as to keep a lookout for Mr McDowall. 3. The appropriateness of the traffic light sequence as it operated at the relevant intersection as at 27 May 2021; and 4. In light of the developments made to the relevant intersection since 27 May 2021, whether any further recommendations might be made to improve safety at the relevant intersection for both bus drivers and pedestrians. | No |
| McLeod Five | Adjourned DTBF for findings | Coroner Kerrie O'Callaghan | 1. The findings required by s. 45(2) of the Coroners Act 2003, namely the identity of the deceased persons, when, where and how they died and the cause of their deaths; 2. The appropriateness and adequacy of the police responses to the complaints of domestic and family violence and allegations of abuse made by Charmaine McLeod against her and her children; 3. The appropriateness and adequacy of the mental health responses by Queensland Health, associated entities and service providers responsible for Charmaine McLeod’s care, treatment and monitoring as well as their responses to her domestic and family violence complaints and child abuse complaints; 4. The appropriateness and adequacy of responses by relevant agencies to the protection, safety and welfare of the children, including Department of Children, Youth Justice and Multicultural Affairs, the Queensland Police Service and Queensland Health. | Yes |
| Major, Markiah | Pre inquest conference scheduled for 24 April at 10:00am in Court 1 at YARRABAH | Coroner Stephanie Williams | 1. Findings required by s45(2) of the Coroners Act 2003 (Qld); namely the identity of the suspected deceased, when, where and how he died and what caused his death. | No |
| Makin, Rickie James | Pre inquest conference scheduled for 20 May 2024 at 10:00am in Court 4 at BRISBANE | Coroner Donald MacKenzie | 1. Findings required by s45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. The adequacy of the Formal Safety Plan, Risk Assessment and consideration of weather conditions by The Wynnum Manly Sailing Club on 7 March, 2020; 3. The adequacy of the sailing skills, formal or standard training drills, recognised competencies, rescue drills (in particular man overboard skills) and management of safety equipment on the Lady Helena on 7 March, 2020; 4. Whether, given the prevailing weather conditions on Moreton Bay during the afternoon of 7 March 2020, the Wynnum Manly Sailing Club and/or the skipper of Lady Helena ought to abandoned participation in the yacht race that day?; 5. Whether any legislative or regulatory rules are warranted to mandate: (i) the wearing of PFDs and/or other safety equipment during the participation in competitive yacht racing; (ii) the wearing of other items or personal safety equipment which are appropriate. 6. Whether there are any further recommendations which can be made which could prevent deaths from happening in similar circumstances in the future. | No |
| Malayta, Robert George Kenneth | Pre-inquest conference scheduled for 14 May 2024 at 10:00am in Court 5 at BRISBANE | State Coroner Terry Ryan | 1. The findings required by s. 45(2) of the Coroners Act; namely the identity of the deceased, when, where and how he died and what caused his death. 2. The appropriateness of the actions of the Queensland Police Service on 24 & 25 February 2022. 3. The adequacy of the Queensland Police Service investigation into the circumstances surrounding the death. | No |
| Mason, Annette Jane | Adjourned DTBF for findings | State Coroner Terry Ryan | The findings required by s45 of the Coroners Act 2003: 1. who the deceased person is; 2. how the person died; 3. when the person died; 4. where the person died, 5. what caused the person to die. | Yes |
| Merlo, Mario Giovanni | Adjourned DTBF for hearing | State Coroner Terry Ryan | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Whether the police officers involved acted in accordance with the QPS policies and procedures; and 3. Whether the investigation by ESC was appropriate and sufficient. The court may also comment, pursuant to s46(1) of the Act, on anything connected to the death relating to public health or safety, the administration of justice or ways to prevent similar deaths from happening in similar circumstances in the future. | No |
| Nixon-McKellar, Steven Lee | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by s 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where, and how, he died and what caused his death. 2. The circumstances surrounding the death including: a. what, if any arrangements were made to transition Steven’s mental health treatment and care from the PMHS to a community mental health service when he was released on parole on 21 July 2021; b. what, if any conditions was Steven subject to under a Treatment Authority, when he was released on parole on 21 July 2021, and whether or not Steven was compliant with those conditions; c. what, if any engagement with illicit substance diversion programs Steven was offered when he was released on parole on 21 July 2021; and d. what, if any conditions was Steven subject to under his parole order (including random testing for illicit substances), and whether or not Steven was compliant with those conditions. 3. Whether the ambulance officers involved, on 7 October 2021, provided appropriate care and/or assessment of Steven. 4. Whether the police officers involved, on 7 October 2021, complied with the Queensland Police Service policies and procedures then in force. 5. Whether the training provided to police officers to respond to the incident was appropriate, including: a. the training provided to police officers in respect of the Lateral Vascular Neck Restraint; and b. what is the current training provided to police officers in respect of the Lateral Vascular Neck Restraint. 6. Whether any preventative recommendations might be made that could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice. | No |
| Olsen, Jeffrey | Pre-inquest conference scheduled for 10 September 2024 at 10:00am in Court 10 at SOUTHPORT | Coroner Stephanie Williams | The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; and 2. The care and treatment of Mr Olsen following his diagnosis of bowel cancer. | No |
| Phillips, Sharron | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by section 45(1) & (2) of the Coroners Act 2003, namely; whether or not Sharron Phillips is in fact deceased and, if so, how, when and where she died and what caused her death; 2. The circumstances surrounding Sharron Phillips’ disappearance; and 3. Consider whether the actions or omissions of any person caused the disappearance. | Yes |
| Pilkington, Peter Owen | Adjourned DTBF for hearing | State Coroner Terry Ryan | 1. The findings required by s45(2) of the Coroners Act 2003; and 2. Other issues yet to be determined. | No |
| Raisin, Mark James Richard | Inquest scheduled for 24 June to 28 June 2024 at 10:00am in Court TBA at TOWNSVILLE | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s45(2) of the Coroners Act 2003; and 2. Other issues yet to be determined. | Yes |
| Rivers, Jeremiah Harold | Adjourned DTBF for findings | Coroner Donald MacKenzie | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely whether or not Jeremiah Harold Rivers is in fact deceased and if so, how, when and where he died, and what caused his death; 2. If deceased, the circumstances surrounding his death; 3. If deceased, whether the actions of any other person contributed to his death, or disposal of his body; 4. The adequacy of the police investigation into his disappearance | No |
| Savage, Damon Paul William | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Whether the police use of lethal force against Mr Savage was in accordance with the Queensland Police Service ‘use of force’ policy in the Operational Procedures Manual at the time; 3. Whether there were any ‘less than lethal’ use of force options open to the officers which they did not take; 4. Whether the investigation by the Ethical Standards Command was appropriate and sufficient. | No |
| Schafer, Duke Allan Wayne | Inquest scheduled for 27 to 28 May 2024 at 10:00am in Court 5 at BRISBANE | State Coroner Terry Ryan | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Mr Bloomfiel's assessment and management whilst in QCS custody, including: i. The adequacy and appropriateness of the provision of psychological and psychiatric treatment in accordance with the court recommendations, including but not limited to whether recommended treatment of prisoner, including medication, can be enforced and, if so, in what circumstances; and ii. Whether the decision to reintegrate Mr Bloomfield into the mainstream prison population was appropriate. The court may also comment, pursuant to s46(1) of the Act, on anything connected to the death relating to public health or safety, the administration of justice or ways to prevent similar deaths from happening in similar circumstances in the future. | No |
| Shelton, Lester Gilmore | Inquest scheduled for 10 June 2024 at 10:00am in Court 4 at BRISBANE | Deputy State Coroner Stephanie Gallagher | * The findings required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death. * Whether Mr Shelton’s care at the Wolston Correctional Centre was appropriate and adequate. * Whether Mr Shelton’s care at the Brisbane Correctional Centre was appropriate and adequate. * Whether Mr Shelton’s care at the Princess Alexandra Hospital was appropriate and adequate. | No |
| Tafaifa, Selesa | Inquest scheduled for 7 to 17 May 2024 at 10:00am in Court 4 at BRISBANE | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s45(2) of the Coroners Act 2. The adequacy and appropriateness of diabetes and insulin management of persons in custody at Townsville Women’s Correctional Centre; 3. The adequacy and appropriateness of the actions of Queensland Corrective Services staff on 30 November 2021 4. The appropriateness of the use of safety hoods in Queensland Corrective Services custody 5. The adequacy and appropriateness of mental health care of Selesa Tafaifa whilst in custody at Townsville Women's Correctional Centre during the period of incarceration from 25 November 2020 to 30 November 2021 6. The adequacy and appropriateness of the health management by Townsville Hospital and Health Service / Queensland Corrective Services on and from 27 July 2020 | Yes |
| Thelander, Steven John | Pre-inquest conference scheduled for 24 April 2024 at 2:00pm in Court 5 at BRISBANE | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Whether Steven Thelander, and those in charge of his care, were appropriately informed of the services MultiCap would provide him; 3. Whether MultiCap appropriately discharged their responsibilities to Steven Thelander? 4. Whether there are ways to prevent a death occurring in similar circumstances in the future. | No |
| Tilberoo, Shiralee Deanne | Adjourned DTBF for findings | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how she died and the cause of her death; 2. Adequacy of checks conducted by watch house staff whilst Ms Tilberoo was in custody; 3. Adequacy of the provision of medical treatment in the watch house; 4. Appropriateness of current Queensland Police Service policies and procedures relating to the supervision of prisoners in watch houses; 5. Appropriateness of the communication and liaison with next of kin and family following a death in custody of Ms Tilberoo. | Yes |
| Uittenbosch, Shane Anthony | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Whether Shane Uittenbosch had access to, and received appropriate medical care whilst he was in custody; 3. The management of Shane Uittenbosch while housed in the Detention Unit; 4. The conditions in the Detention Unit at the time of Shane Uittenbosch’s death; 5. The decision to place Shane Uittenbosch on a Safety Order; 6. The practice in relation to the use of Safety Orders at Wolston Correctional Centre at the time of Shane Uittenbosch’s death; 7. The adequacy of the monitoring of prisoners housed in the Detention Unit, including the equipment used. | Yes |
| Valera, Gina | Adjourned DTBF for findings | State Coroner Terry Ryan | The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how she died and what caused her death; and: 1.Whether the mental health care and treatment given to Ms Valera at BWCC, including suicide/self-harm risk assessments, was appropriate and sufficient; 2.Whether the assessment that Ms Valera was suitable for residential placement was appropriate in the circumstances; and 3.Whether the provision of laced running shoes to prisoners in Correctional Centres is appropriate. The Court may also comment, pursuant to s46(1) of the Act, on anything connected to the death relating to public health or safety, the administration of justice or ways to prevent similar deaths from happening in similar circumstances in the future. | Yes |
| Vignes, Khrys Alan Mark-Kelly | Inquest scheduled for 10 July 2024 at 10:00am in Court 4 at BRISBANE | State Coroner Terry Ryan | 1 The findings required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how he died and the cause of his death. 2 Examine the circumstances and events, which led to the decision by Police to shoot Mr. Vignes on 29 March 2020, including but not limited to, the actions of Mr. Vignes that day, the police response, and the engagement and search management strategies employed to locate him by Police. 3 Whether the police officers involved acted in accordance with the Queensland Police Service policies and procedures then in force and whether said actions were appropriate. 4 Whether the training and equipment provided to officers in responding to a similar incident is sufficient. | Yes |
| Washington, Ashley Charles | Adjourned DTBF for findings | State Coroner Terry Ryan | 1. The findings required by s45(2) Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; 2. Whether the actions of Senior Constable Williams were appropriate in the circumstances; 3. Whether the actions of attending Queensland Police Service officers were appropriate in the circumstances; 4. Whether the actions of the attending Queensland Ambulance Service officers were appropriate in the circumstances. | No |
| Watcho, Constance May | Findings scheduled for 6 June 2024 at 10:00am in Court 4 at BRISBANE | Deputy State Coroner Stephanie Gallagher | 1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how she died and what caused her death; and 2. The identity of any other persons involved in the death of Constance May Watcho. | Yes |
| Whiskey Au Go-Go | Adjourned DTBF for findings | State Coroner Terry Ryan | a. The findings required by section 45(2) of the Act in respect of each of the deceased persons, in particular, the circumstances that led to the WAGG fire; b. Whether James Richard Finch and John Andrew Stuart were the only parties who caused or contributed to the deaths; c. The identity of any other parties who caused or contributed to the deaths; d. The adequacy of the investigations carried out into the causes of and parties responsible for the fire and the deaths, immediately thereafter, and over subsequent years; e. Whether there are any matters about which recommendations might be made pursuant to section 46 of the Act. | Yes |
| Wieambilla deaths; Dare, Alan Thomas Brendon; McCrow, Rachel Clare; Arnold, Matthew Joseph; Train, Gareth Daniel; Train, Nathaniel Charles and Train, Stacey Jane | Pre-inquest scheduled for 21 May 2024 at 10:00am in Court 4 at BRISBANE | State Coroner Terry Ryan | 1. The findings required by s45(2) of the Coroners Act; and 2. Other issues yet to be determined. | Yes |
| Williams, Russell James | Adjourned DTBF for findings | State Coroner Terry Ryan | a) Whether Mr Williams’ intake assessment was reasonable and appropriate in all the circumstances; b) Whether the making and cancellation of Mr Williams’ Temporary Safety Order and full Safety Order were reasonable and appropriate in the circumstances; c) Whether the supervision of Mr Williams, upon his return to Secure Unit, was reasonable and appropriate in the circumstances. | No |
| Wood, Jamie Shaun | Inquest scheduled for 22 July to 23 July 2024 at 10:00am in Court 4 at BRISBANE | Deputy State Coroner Gallagher | 1. The findings required by s45(2) of the Coroners Act; and 2. Other issues yet to be determined. | No |
| Wright, Daniel Thomas | Adjourned DTBF for findings | Deputy State Coroner Gallagher | 1. The clinical condition of and the care required by Daniel as at 6 February 2019; 2. Whether the transfer of Daniel from Townsville University Hospital to Mackay Hospital on 6 February 2019 was appropriate given his clinical condition and the care he required; 3. The clinical condition of and the care required by Daniel as at 28 February 2019; 4. Whether the discharge of Daniel from Mackay Hospital to the care of his parents on 28 February 2019 was appropriate, given his clinical condition and the care he required; 5. The clinical condition of and the care required by Daniel as at 19 March 2019; 6. Whether the discharge of Daniel from Mackay Hospital to the care of his parents on 19 March 2019 was appropriate, given his clinical condition and the care he required; 7. The appropriateness of the care afforded Daniel, and the support afforded his parents, by Mackay Hospital and Health Service during his admissions to and following discharge from the Mackay Hospital on 28 February 2019 and on 19 March 2019; 8. The appropriateness of the actions of the Department of Children, Youth Justice and Multicultural Affairs in relation to Daniel; 9. The level of effective information sharing between Mackay Hospital and Health Service and Department of Child Safety, Youth Justice and Multicultural affairs in respect of Daniel; and 10. Comment, if any, pursuant to s46(1) of the Act, on anything connected to the death relating to public health or safety, the administration of justice or ways to prevent similar deaths from happening in similar circumstances in the future. | No |
| Wylucki, Vlasta | Adjourned DTBF for findings | Deputy State Coroner Stephanie Gallagher | a. The findings required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how she died and the cause of death. b. The adequacy of checks conducted by the watch house staff whilst deceased was in custody. c. The adequacy of the provision of clinical treatment in the watch house. d. The appropriateness of current Queensland Police Service policies and procedures relating to the supervision of prisoners in watch houses. | Yes |