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    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: Please contact DJAG Media Relations for assistance (requests must be made in writing via email).

    Key: NPO Non-Publication Order; DTBF Date to be fixed.

    All matters have been grouped by current inquest status and then alphabetical order (last name). Please expand each category to view all current inquest proceedings.

    Inquest scheduled for 27 November 2023 at 2pm and 28 November to 1 December 2023 at 10:00 in Court 3 at CAIRNS

    Name of deceased / Matter nameDetailed inquest statusCoronerIssues to be consideredNPO
    Bernard, Allison NeridineInquest scheduled for 19 February to 23 February 2024 at 10:00am in Court 4 at BRISBANECoroner Nerida Wilson1. 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, Jamie BrianInquest scheduled for 19 December 2023 at 10:00am in Court 4 at BRISBANEState Coroner Terry Ryan1. 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 Campbell's 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 the training provided to Police Officers to respond to like incidents is appropriate.
    7. 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.    		No
    Conley, Darcey-Helen;  Conley,  Chloe-AnnPre-inquest Conference scheduled for 18 December 2023 at 10:00am in Court 4 at BRISBANEState 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 to reports and notifications it received in the days following the birth of Darcey-Helen Conley on 14 May 2017;

    3. The appropriateness of the response by Child Safety to reports and notifications received in the period 29 May 2017 to 6 December 2017;

    4. The appropriateness of the decision by Child Safety to return Darcey-Helen Conley to the care of her mother on 6 December 2017 on an Intervention with Parental Agreement (IPA);

    5. The appropriateness of the response by Child Safety to reports and notifications it received in the period between the return of Darcey-Helen Conley to her mother on an IPA on 6 December 2017 and the closure of the IPA on 5 July 2018 with a referral to Intensive Family Support;

    6. The appropriateness of the decision of the Logan Hospital at the time of the birth of Chloe-Ann Louise Conley on 10 October 2018 not to make a notification or report to Child Safety;

    7. The appropriateness of the response by Child Safety to notifications on 11 February 2019 that Intensive Family Support had closed their case due to the mother of the children disengaging from their services;

    8. Whether Queensland Police Service should have made a referral to Child Safety after the Crime Stoppers Unit received a report of the mother’s use of and dealing in Methylamphetamine;

    9. The appropriateness of the response by Child Safety to reports and notification received between 3 November 2019 to 12 November 2019;

    10. The appropriateness of the decision by Child Safety on 12 November 2019 that the concerns it had been informed of did not meet the threshold for the recording of the notification.

    		No
    Doherty, Janis EllenPre-Inquest Conference scheduled for 28 November 2023 at 10:00am in Court 5 at BRISBANEDeputy State Coroner Stephanie Gallagher1. The findings required by s45(2) Coroners Act 2003; namely the identity of the 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:
    a. Whether it was appropriate to prescribe sodium valproate (Epilim) for the symptomatic management of migraines suffered by the deceased in the  context of her known cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL);
    b. The appropriateness of his education and monitoring of the deceased for the signs and symptoms of the side effects of Epilim, including liver dysfunction;
    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:
    a. The appropriateness of the timing of the decision to cease Epilim on 14 April 2020;
    b. Whether L-carnitine should have been administered to the deceased;
    c. Whether a liver biopsy should have been performed;
    d. Whether the deceased should have been seen by a Hepatologist at a time earlier than she was;
    e. Whether the deceased should have been transferred to the Royal Brisbane and Women’s Hospital at a time earlier than she was;
    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:
    a. Whether it was appropriate to recommence the deceased on Epilim in the period 27 April 2020 to 3 May 2020;
    b. The appropriateness of the timing of the liver biopsy performed on 30 April 2020;
    c. Whether L-carnitine should have been administered to the deceased;
    d. The appropriateness of the decision that the deceased was not a suitable candidate for liver transplant;
    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 ArthurInquest scheduled for 30 November 2023 at 10:00am in Court 5 at BRISBANEDeputy State Coroner Stephanie GallagherScope 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 GlenPre inquest conference scheduled for 29 February 2024 at 10:00am in Court 4 at BRISBANEDeputy State Coroner Stephanie Gallagher1. 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
    Haggett, Shirley ElizabethInquest scheduled for 04 December 2023 to 15 December  2023 at 10:00am in Court 4 at BRISBANEDeputy State Coroner Stephanie Gallagher1. 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
    McDowall, Maximilian PatrickPre-Inquest Conference scheduled for 24 November 2023 at 10:00am in Court  4 at BRISBANECoroner 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
    Rivers, Jeremiah HaroldInquest scheduled for 27 November 2023 to 01 December 2023 at 10:00 in Court 4 at BRISBANECoroner Donald MacKenzie1. 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; and
    4. The adequacy of the police investigation into his disappearance.    		No
    Tafaifa, SelesaInquest scheduled for 09 October 2023 to 13 Oct 2023 at 10:00am in Court 5 at TOWNSVILLE and 16 October to 20 October 2023 at 10:00am in Court 4 at BRISBANEDeputy State Coroner Stephanie Gallagher

    1. The findings required by s45(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 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
    Valera, GinaInquest scheduled for 5 and 6 March 2024 at 10:00am in Court 4 at BRISBANEState Coroner Terry Ryan1. In addition to the findings required to be made in accordance with s.45(2) of the Act, the following issues will be investigated at the inquest:
    a. Whether the mental health care and treatment given to Ms Valera at TCPH, including suicide/self-harm risk assessments, was appropriate and sufficient;
    b. Whether the mental health care and treatment given to Ms Valera at BWCC, including suicide/self-harm risk assessments, was appropriate and sufficient;
    c. Whether the assessment that Ms Valera was suitable for residential placement was appropriate in the circumstances; and
    d. Whether the provision of laced running shoes to prisoners in Correctional Centres is appropriate.
    2. His Honour 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
    Vignes, Khrys Alan Mark-KellyInquest scheduled for 27 November 2023 at 2pm and 28 November to 01 December 2023 at 9:00am in Court 5, level 3 at CAIRNSState Coroner Terry Ryan1.  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.    		No

    Wieambilla deaths

    Arnold, Matthew Joseph; Dare, Alan Thomas Brendon; McCrow, Rachel Clare; Train, Gareth Daniel; Train, Nathaniel Charles; Train, Stacey Jane

    		Pre-Inquest Conference scheduled for 23 November 2023 at 10:00am in Court  4 at BRISBANEState Coroner Terry Ryan1. The findings required by s45(2) of the Coroners Act; and
    2. Other issues yet to be determined.    		No

    Name of deceased / Matter nameDetailed inquest statusCoronerIssues to be consideredNPO
    Abdi, Raghe Mohamed; Antill, Maurice Frederick; Antill, Zoe Dorothea Adjourned DTBF for hearingDeputy State Coroner Stephanie Gallagher1. 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
    Brown, Samuel TimothyAdjourned DTBF for hearingDeputy State Coroner Stephanie Gallagher1. The findings required by s.45 (2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how they died and the cause of their death.
    2. The circumstances surrounding the death, including the mechanism by which the injuries were inflicted, and the involvement of another party.
    3. The response of the Queensland Police Service to the death, including the basis for decisions about prosecution actions.
    4. Whether any recommendations can be made to prevent deaths from occurring in similar circumstances.    		No
    Campbell, Chloe JaneAdjourned DTBF for hearingCoroner Carol Lee1. 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
    Freear, Benjamin AnthonyAdjourned DTBF for hearingState Coroner Terry Ryan1. 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 HarrisonAdjourned DTBF for hearingState Coroner Terry Ryan1. The findings required by s45(2) of the Coroners Act 2003; and
    2. Other issues yet to be determined    		No
    Ishak Ahmed, FaysalAdjourned DTBF for hearingState Coroner Terry Ryan1. 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 adequacy and appropriateness of the medical care and treatment provided to Mr. Ishak Ahmed whilst he was detained at the Manus Island Regional Processing Centre;
    3. The adequacy and appropriateness of the treatment and care provided to Mr. Ishak Ahmed at the Manus Island Regional Processing Centre immediately following a fall on 22 December 2016, until the time of his medical evacuation;
    4. The adequacy and appropriateness of the policies and procedures in place at, and with respect to, the Manus Island Regional Processing Centre in December 2016 relating to medical evacuations;
    5. Whether there was an avoidable delay in Mr. Ishak Ahmed being medically evacuated from the Manus Island Regional Processing Centre to Australia;
    6. The adequacy and appropriateness of any steps taken by the International Health and Medical Services or Department of Immigration and Border Protection, to prevent a similar death from occurring.    		No
    Kerle, Wayne ThomasAdjourned DTBF for hearingDeputy State Coroner Stephanie Gallagher1. 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
    Thelander, Steven JohnAdjourned DTBF for hearingDeputy State Coroner Stephanie Gallagher1. 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

    Name of deceased / Matter nameDetailed inquest statusCoronerIssues to be consideredNPO
    Bahram, Mohamad IkraamAdjourned DTBF for findingsState Coroner Terry Ryan1. 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
    Gilbert, Luke BrianAdjourned DTBF for findingsDeputy State Coroner Stephanie Gallagher1. 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
    Greer, Tina LouiseAdjourned DTBF for findingsCoroner Kerrie O'Callaghan1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the suspected deceased, when, where and how she died and what caused her death;
    2. The adequacy of the Queensland Police Service (QPS) response to allegations of domestic and family violence (DFV) perpetrated against Tina Louise Greer by Les Sharman.
    3. The adequacy of the QPS investigation into the disappearance of Tina Greer.
    4. What improvements have been made by QPS into investigating allegations of DFV and the disappearance of women who are suspected or known victims of DFV including by reference to the policies and procedures in place at the time of Ms Greer’s disappearance.
    5. The adequacy of the response by Salvation Army Gold Coast Recovery Services, Fairhaven to disclosures of DFV by Ms Greer.
    6. What improvements have been made by Salvation Army Gold Coast Recovery Services, Fairhaven to help support victims of DFV who are engaged with Salvation Army recovery services.
    7. The adequacy of services and support provided to victims of DFV by the Department of Child Safety when assessing whether a child is at risk of harm.
    8. 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.    		No
    Harvey, Thompson JamesAdjourned DTBF for findingsState Coroner Terry Ryan1. 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
    Inquest into the death of a 13-year-oldAdjourned DTBF for findingsCoroner Carol Lee1. The findings required by section 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused this death;
    2. The circumstances surrounding the death and, in particular, the chain of decision-making in the lead up to it by relevant individuals from the Department of Children, Youth Justice and Multicultural Affairs (“the Department”) and the service provider responsible for the custody and care of the 13-year-old child;
    3. The adequacy of policies and procedures of the Department governing issues around notice, consent and supervision with respect to children in the custody and care of the Department undertaking potentially risky recreational activities;
    4. The placement history of the 13-year-old child and the level of supervision, both generally and in the days leading to the death, exercised by the Department in relation to his daily care and activities;
    5. What actions have been taken since this death to prevent deaths from happening in similar circumstances in the future;
    6. Whether there are any matters about which preventative recommendations might be made pursuant to section 46 of the Coroners Act 2003.    		Yes
    Jones, Anthony JohnAdjourned DTBF for findingsState Coroner Terry RyanThe 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
    Klumper, Joshua WilliamAdjourned DTBF for findingsDeputy State Coroner Stephanie Gallagher1. Whether the decision to close Joshua to the Child and Youth Mental Health Service in February 2017, was appropriate in the circumstances and made in accordance with relevant policies and procedures;
    2. Whether the treatment and care provided to Joshua on 2 September 2017 was appropriate in the circumstances;
    3. Whether Ms Wharton gave consent to Joshua being placed on the morphine and midazolam infusion on 14 September 2017.    		No
    McLeod FiveAdjourned DTBF for findingsCoroner Kerrie O'Callaghan1. 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
    Mason, Annette JaneAdjourned DTBF for findingsState Coroner Terry RyanThe 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
    Nixon-McKellar, Steven LeeAdjourned DTBF for findingsState Coroner Terry Ryan1. 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 and 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. 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 police officers involved, on 7 October 2021, complied with the Queensland Police Service policies and procedures then in force;
    4. 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;
    5. 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
    Phillips, SharronAdjourned DTBF for findingsState Coroner Terry Ryan1. 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
    Savage, Damon Paul WilliamAdjourned DTBF for findingsState Coroner Terry Ryan1. 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
    Tilberoo, Shiralee DeanneAdjourned DTBF for findingsDeputy State Coroner  Stephanie Gallagher1. 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
    Te Paa, Aaliyah KiriKowhai;  Coolwell, Rayvenna Tyrone Elizabeth; Barefoot; Robertson, Cayenne MurielAdjourned DTBF for findingsState Coroner Terry Ryan1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how each of them died and what caused each of their deaths;
    2. The adequacy and appropriateness of the actions of the Queensland Police Service on 7 June 2020;
    3. The adequacy of the Queensland Police Service Investigation into the circumstances surrounding the deaths.    		No
    Uittenbosch, Shane AnthonyAdjourned DTBF for findingsState Coroner Terry Ryan1. 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
    Washington, Ashley CharlesAdjourned DTBF for findingsState Coroner Terry Ryan1. 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
    Whiskey Au Go-GoAdjourned DTBF for findingsState Coroner Terry Ryana. 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
    Williams, Russell JamesAdjourned DTBF for findingsState Coroner Terry Ryana) 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
    Wylucki, VlastaAdjourned DTBF for findingsDeputy State Coroner Stephanie Gallaghera. 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

    Name of deceased / Matter nameDetailed inquest statusCoronerIssues to be consideredNPO
    Kohl, JenniferFindings scheduled for 1 December 2023 at 10:00am in Court 10 at SOUTHPORTCoroner Carol Lee1. 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;
    2. What caused the mower to roll and land on Ms Kohl;
    3. Whether Mr Jacobi and Ms Singleton had implemented appropriate workplace health and safety measures in relation to the use of the mower on the property;
    4. Whether the Queensland Ambulance Service appropriately dispatched the paramedics and Queensland Fire and Emergency Services to the accident scene;
    5. Whether there was a delay in the dispatch of emergency services, and if so, could this have been avoided, and would it have made any difference to the outcome;
    6. What measures are in place to safeguard international backpackers, such as Ms Kohl and Mr Tunik, undertaking farm work, and are these measures adequate.    		No