Inquest proceedings list

2. Consideration of the circumstances leading up to the death including:

a. Steven’s mental health condition/s, and the appropriate treatment for him, including whether in all the circumstances there was an appropriate assessment of Steven’s suicide risk.

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’) 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 his condition/s 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?

g. Consideration of ‘subject precipitated homicide’, including the effect, if any, on first responders.

3. Whether the Queensland Police Service (‘QPS’) Officers involved acted in accordance with the 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.

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.

2. The appropriateness and adequacy of the medical care and treatment provided to Mr Bevan during his initial admission to Caboolture Private Hospital, including:

a) the identification of clinical issues at the time of discharge;

b) the provision of advice to Mr Bevan about clinical issues at the time of his discharge.

3. The appropriateness and adequacy of the medical care and treatment provided to Mr Bevan during his subsequent admission to Caboolture Private Hospital, including:

a) under whose specialist care should Mr Bevan have been admitted;

b) who was responsible for Mr Bevan’s ongoing clinical issues following his readmission;

c) coordination of the management of Mr Bevan’s ongoing clinical issues between medical specialists;

d) recognition of deterioration or lack of progress in Mr Bevan’s ongoing clinical issues and what response should have been made;

e) escalation of ongoing clinical issues by nursing staff;

f) consideration for further investigations and referrals and when they should have been instigated.

4. Whether any aspect of the medical care and treatment provided to Mr Bevan, by medical specialists or staff of the private hospital, caused or hastened his death.

5. Whether any recommendations can be made from the circumstances of Mr Bevan’s death.

1. The adequacy of the care and treatment of the deceased, including:

a. Whether the Roux-en Y gastric bypass surgery performed on the deceased was properly indicated, including as to whether there had been adequate investigation of her symptoms and whether, compared to alternative courses, the risks of the surgery compared to the possible benefits justified its performance;

b. whether the deceased was appropriately advised about the matters in (a) above prior to deciding to proceed with the surgery;

c. when and why the deceased developed pneumonia and the consequences of having done so; and

d. the circumstances surrounding and the appropriateness of the deceased’s discharge from hospital.

2. Cause of death – specifically, whether the cause of death included peritonitis and if so, when did it develop and why.

3. 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.

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. Whether Mr Carroll’s welfare was appropriately monitored during his period in custody at the Novotel Brisbane Airport Hotel, having regard to applicable policies and what was known by QPS and Queensland Health staff at the time.

2. The circumstances surrounding Ben’s disappearance; and

3. The adequacy of the police investigation into Ben’s disappearance.

3. Whether the medical treatment and management provided to the deceased during the period she was in custody at the Brisbane Women’s Correctional Centre was appropriate.

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.

2. Whether Mr Doughty’s treatment and management at the Maryborough Hospital (MBH) and the HBH during the admission of 17 September 2021 to 22 September 2021 was adequate and appropriate, including:

a) Whether or not the decision to cease Mr Doughty’s dual antiplatelet therapy (DAPT), namely by ceasing Clopidogrel 75mg daily, but to continue the Aspirin 100mg daily was appropriate?

b) Whether or not the initial investigations conducted on 17 September to investigate Mr Doughty’s suspected gastrointestinal bleed (GIB) were adequate and appropriate?

c) Whether or not it was likely Mr Doughty was suffering a lower GIB that had not been identified on the endoscopy performed on 17 September 2021, as was considered to be the case at the medical review on the morning of 18 September 2021?

d) The likelihood or otherwise that the suspected lower GIB was active and ongoing with hematochezia at the medical review on the morning of 18 September 2021;

e) The appropriateness and need for the further investigations recommended to investigate the suspected lower GIB, namely colonoscopy and CT angiogram, recommended on the morning of 18 September 2021;

f) Whether or not the decision/ recommendation of the medical team at HBH to cease all antiplatelet therapy (i.e. including the Aspirin) on 18 September 2021 was appropriate?

g) Whether or not the rationale for ceasing the DAPT and, in particular, the decision to cease the Aspirin after 18 September 2021 as set out in Exhibit B5 of the Brief or Evidence at paragraphs [30] to [34] was appropriate?

h) Whether or not it was appropriate to discharge Mr Doughty on 22 September 2021 without restarting the DAPT?

i) Whether or not it was appropriate to discharge Mr Doughty on 22 September 2021 without at least restarting the Aspirin?

j) Whether or not it was appropriate to discharge Mr Doughty on 22 September 2021 without further consultation with The Prince Charles Hospital (TPCH) Cardiology Team to set a plan for restarting the DAPT and/or Aspirin?

k) Whether or not it was appropriate to discharge Mr Doughty on 22 September 2021 leaving it to his General Practitioner to review Mr Doughty for the purpose of restarting the DAPT in one to two weeks, and to consider liaising with his primary cardiologist in that regard?

l) Whether or not it was appropriate to suggest to Mr Doughty’s General Practitioner that the time frame for restarting the DAPT was one to two weeks?

m) Whether or not it was recommended to Mr Doughty to recommence Aspirin prior to his discharge on 22 September 2021 and he refused? If so, whether or not the plan for restarting Mr Doughty’s DAPT as recommended in the Discharge Summary was adequate and appropriate?

3. Whether any failure to provide treatment and management to Mr Doughty at HBH caused or hastened his death?

4. Whether the response to Mr Doughty’s death on the part of HBH has been adequate and appropriate?

Date to be set for findings.

1. Consideration of the travel movements of Karen Edwards, Timothy Thomson and Gordon Twaddle from Alice Springs to Mount Isa, including the:

(a) Locations at which they stopped and the timings of those stops;

(b) Occasions on which they were observed in the company of a fourth rider; and

(c) Identity of the fourth rider.

2. Consideration of the movements and activities of Karen Edwards, Timothy Thomson and Gordon Twaddle in Mount Isa, including:

(a) Any sightings of them in Mount Isa;

(b) The circumstances of their camping at the Moondarra Caravan Park;

(c) The visits by a Toyota Landcruiser at their campsite at the Moondarra Caravan Park; and

(d) The identity of the driver of the Toyota Landcruiser.

3. The identity of any person/s involved in the deaths of Karen Edwards, Timothy Thomson and Gordon Twaddle.

2. With respect to the cause of Thea’s death, specifically, was it:

(a) Transposition of the great arteries;

(b) Maternal malperfusion;

(c) Vacuum induced delivery;

(d) Some other cause.

3. Should (a) or (b) above have been detected on imaging by the 20 or 36 week scans or by any other clinical indicator or investigation which ought appropriately been undertaken?

4. If the answer to the above question is “yes”, what would then have happened and would Thea’s death have been avoided as a result?

5. Did any inadequacy in the post-delivery care contribute to Thea’s death?

6. Are any changes to the practices, procedures or policies of the health service appropriate to reduce the likelihood of deaths occurring in similar circumstances or to otherwise contribute to public health and safety?

a. Whether the decision to triage Mr Francis as Category 3 on 25 October 2021, was appropriate;

b. Whether there was a failure to recognise and respond properly to Mr Francis’ deteriorating condition, including a review of his triage Category 3 from 25 October 2021; and;

c. Whether any aspect of the treatment and management provided to Mr Francis from 13 August 2021 to 16 November 2021 caused or hastened Mr Francis’ death.

3. Whether, in the absence of any incapacity to make decisions about his health care, Mr Francis was able to be compelled to receive medical treatment.

2. Determine the appropriateness of the Ear, Nose and Throat (‘ENT’) assessment of Mr Gallagher on 13 July 2023.

3. Determine the appropriateness of the clinical management of Mr Gallagher on 13 July 2023 and in the early morning of 14 July 2023, in the Surgical, Treatment and Rehabilitation Service (‘STARS’) which preceded Mr Gallagher’s death.

4. Determine the appropriateness of Mr Gallagher being cared for in the STARS given his presentation on 12 and 13 July 2023.

5. Determine whether there was any failure in care provided in the STARS, which caused Mr Gallagher’s death, including whether the resuscitative efforts were timely and adequate.

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.

1. The circumstances surrounding the death of Gladys, including whether there were indicators that she was at acute risk of self harm or taking her own life;

2. Whether the Department of Child Safety, Seniors and Disability Services (Dept of Child Safety) and Churches of Christ responded adequately to the risk that Gladys would self harm or take her own life, including whether they:

a) Recognised the risk

b) Communicated that risk to the foster carers and other responsible agencies

c) Arranged for relevant, appropriate and sufficient supports, and

d) Ensured appropriate visits were made to Gladys and her carer.

3. Whether the Dept of Child Safety and Churches of Christ communicated effectively with each other, and with Gladys’s foster carer, in relation to any risk to the health and wellbeing of Gladys.

4. Whether the Office of the Public Guardian (OPG) effectively monitored the systems responsible for Gladys, particularly given a) her complex trauma history; b) her known history of child sexual abuse, and c) the disclosure of sexual abuse in 2021.

5. Whether sufficient steps were taken by the Dept of Child Safety and Churches of Christ to provide appropriate support to Gladys and the foster carer she was placed with given: a) evidence of early exposure to trauma, including potential sexual abuse and b) after her disclosure of sexual abuse by a close family member in 2021.

6. Whether the Dept of Child Safety took into consideration the need to manage the cultural conflict presented by this case and what cultural expertise could and should be accessed in these circumstances?

7. Whether agencies responsible for the care of Gladys gave proper consideration to the risk to Gladys involved in returning to Mornington Island for holidays, given evidence of her exposure to trauma and her 2021 disclosure of sexual abuse.

8. Whether there was sufficient testing of Gladys for possible FASD or other neurodevelopmental trauma, given the history of her parents’ substance abuse? If not, what resources would be required to ensure adequate testing can take place?

9. Whether the Department of Education provided Gladys with adequate supports and communicated any known concern that she was at risk of self harm or taking her own life.

10. Whether Gidgee Healing responded appropriately to the risk that Gladys may self harm or suicide, and what additional resources might have assisted with the care of Gladys?

11. 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.

12. Whether there are sufficient resources in the area of Mt Isa to meet the needs of children and young people like Gladys who have experienced complex developmental trauma;

13. Whether there are service models in Mount Isa designed by Aboriginal and Torres Strait Islander communities to effectively engage Aboriginal and Torres Strait Islander children and their families, and if not, what more should be done to implement effective plans?

2. The circumstances surrounding the death, including;

a.  The management and mechanical servicing, maintenance, repair, and compliance of Dozer DZ804 prior to the incident;

b.  Identification and management of the risk of persons at the workplace, being the dozer push operations for the dragline bench preparation; and

c. The extent to which those risks were identified and managed prior to the incident; and

d.  The extent to which the risks are being managed now, or are proposed to be managed in the future.

3.  Whether the workplace, being the dozer push operations for the dragline bench preparation, at the time of the incident, had in place adequate policies, training, and procedures with respect to the work performed by dozer operators engaged in dragline bench preparation at the mine and the extent to which the risks are being managed now, or are proposed to be managed in the future.

4.  Whether the plant equipment used by dozer operators at the workplace, being the dozer push operations for the dragline bench preparation, at the time of the incident, was fitted with technology to manage and report on equipment performance as well as key safety features including increasing operator awareness and visibility, identifying and managing operator fatigue and distraction, and alerting operators to potential collisions and the extent to which the risks are being managed now, or are proposed to be managed in the future.

5.  The extent to which the workplace, being the mine site, at the time of the incident, had appropriate and adequate communications systems in place to assist staff members and first aid responders during emergency responses and the extent to which the communication systems on the mine site are being managed now, or are proposed to be managed in the future.

6.  Whether any preventative changes to equipment, procedures, or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to workplace health and safety.

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.

Inquest scheduled for 13 - 24 July 2026 at 10:00am in Court Room to be confirmed at BRISBANE

3. Whether the design and control of helicopter landing sites used for the purposes of SWH’s operations and the reopening of the park pad in March 2022 were undertaken with adequate understanding of the air operations to be conducted and with an appropriate risk assessment especially as to the risk of collision with traffic operating from one of the other helipads.

4. The adequacy of training (including “differences” or “familiarisation” training) undertaken by the SWH pilots involved in the accident before flying the EC 130 4B helicopter type on scenic flights.

5. The effectiveness of inflight broadcasts made by SWH pilots engaged in operations in the Southport CTAF area and the use of radio and other technologies to provide ‘alerted seeand-avoid’ in order to enhance situational awareness and maintain separation in an uncontrolled air traffic environment.

6. The extent to which SWH had appropriate and adequate ground to air communications systems in place to assist SWH pilots to see and avoid the presence of potentially conflicting air traffic.

7. The serviceability of the radio system on VH-XKQ and whether any defects in that system could have been discovered or detected before the date of the accident.

8. Whether the passengers on VH-XKQ and VH-XH9 were provided with adequate passenger safety briefing and otherwise correctly fitted onboard with the aircraft seatbelts and, if not, whether that impacted upon survivability and/or the extent of injuries sustained by surviving passengers.

9. The extent to which SWH’s scenic flight operations were regulated and the role of aviation authorities (CASA and Air Services Australia) in relation to those air operations at the date of the accident.

10. The extent to which CASA was involved in oversighting the SWH SMS and its "exposition" and the steps that CASA is able to take to be satisfied that the Drug and Alcohol Management Plan (DAMP) system required to be put in place by an air operator is being appropriately managed to detect inappropriate drug use by pilots engaged in air operations at uncontrolled heliports.

11. Whether any changes to the regulation of scenic flight operations at Seaworld or to the way in which such air operations are conducted would reduce the likelihood of deaths occurring in similar circumstances in the future or otherwise contribute to public safety.

2. In relation to the scaffolding in place at Mitchelton Football Club on 25 July 2021, to determine:

a. The safety risk assessments completed at the time of installation.

b. The ongoing monitoring undertaken or planned for safety risk management following installation.

c.  The applicable legislation, codes, standards, safety risk assessment protocols or guidelines and/or widely accepted industry practice for the installation of, and ongoing monitoring requirements for, the scaffolding.

d. Whether there was compliance with the applicable legislation, codes, standards, safety risk assessment protocols or guidelines and/or widely accepted industry practice for the installation of, and ongoing monitoring requirements for, the scaffolding.

3. Whether any changes to the legislation, codes, standards or safety risk assessment protocols or guidelines could reduce the likelihood of a death occurring in similar circumstances or otherwise contribute to public safety.

2. Consideration of the circumstances surrounding the birth of Hugo McGregor, including:

a. Whether the decision to commence Jenna McGregor on the Syntocinon infusion at 15:00pm on 11 March 2023 to induce labour, as appropriate in all the circumstances;

b. Whether or not the clinical indicia was such that the caesarean section should have been performed prior to 16:00pm on 11 March 2023, and, if so, what impact would that have had on Hugo McGregor chances of survival;

c. Whether the care and treatment administered to Jenna McGregor following the decision to proceed to caesarean section was appropriate in all the circumstances;

d. Whether there were any missed opportunities that may have changed the outcome for Hugo McGregor;

3.  Consideration, prospectively, as to whether any clinical indicators existed which indicated that Hugo McGregor would be born in the condition in which he was born;

4.  Whether any changes to practices, procedures or policies could reduce the likelihood of deaths occurring in similar circumstances.

2. Whether the intake and assessment process for Sharleigh’s anticipated respite admission to
Xavier Place was reasonable and appropriate;

3. Whether the decision to admit Sharleigh to Xavier Place on 10 December 2021 was reasonable and appropriate;

4. Whether the care provided to Sharleigh during her admission to Xavier Place was reasonable and appropriate;

5. Whether there are any matters about which preventative recommendations might be made pursuant to s. 46 of the Coroners Act 2003.

2. The basis upon which air operations at Caboolture Airfield involving the use of tow aircraft by the local gliding club were undertaken at the date of the accident and are currently, or proposed to be, undertaken, including the extent to which the Caboolture Gliding Club provided adequate information to and/or supervision of pilots engaged in air tow glider operations at the Airfield.

3. The extent to which risks presented by trees and buildings on and around the Airfield affecting visibility between runways and the use of intersecting runways were appropriately assessed and managed by the Caboolture Aero Club and other stakeholders prior to the accident and are proposed to be managed in the future.

4. The role and involvement of the Moreton Bay Regional Council (MBRC) in oversighting the lease of Caboolture Airfield to the Caboolture Aero Club in so far as air safety matters are concerned and the adequacy of responses by the MBRC and CASA to Aerodrome Safety Inspection reports and Obstacle Limitation Surveys commissioned by MBRC when provided to MBRC and CASA.

5. The role of the Civil Aviation Safety Authority (CASA) in respect of civil air operations at non-controlled aerodromes and the level of safety regulation that CASA has undertaken, or should undertake, concerning the safety of air operations at Caboolture Airfield.

6. The circumstances in which the student pilot of VH-EVR undertook pre-flight checks with the radio of the aircraft turned down and crossed runway 06/24 on the day of the accident; and the role of the pilot’s flight school and relevant flight instructors in providing adequate and appropriate instruction to, and supervision of, the student pilot in relation to Airfield and taxying procedures.

7. The radio call procedures to be used by pilots conducting operations from the Airfield in the Caboolture CTAF area and whether those procedures are sufficient to enable pilots to implement effective radio-alerted see-and-avoid principles to maintain separation from other aircraft in the CTAF airspace.

8. Whether having regard to the ATSB report of its investigation into the accident and the recommendations made in that report, any further changes to the regulation of air operations at Caboolture Airfield or introduction of other procedures or measures concerning the conduct of such operations would reduce the likelihood of deaths occurring in similar circumstances in the future or otherwise contribute to public safety.

4. The appropriateness and adequacy of any risk assessments conducted, and safety planning enacted by the Department of Families, Seniors, Disability Services and Child Safety involved in the Federal Circuit and Family Court of Australia (Division 2) proceedings regarding the children of the deceased.

a)  The mother contacted Atherton Hospital about 60 minutes after starting labour. Should she have been advised to come into the hospital at that point (given she was Group B Streptococcal (GBS) positive)?

b)  Were antibiotics administered to the mother in accordance with the relevant guidelines for GBS?

c)  If not, was the failure to administer antibiotics in accordance with the guidelines a factor in the death of the deceased?

2.  Did any aspect of the care afforded to the mother of the deceased at Atherton Hospital cause or hasten the death of the deceased?

3.  Did any aspect of the care afforded to the deceased at Atherton Hospital cause or hasten the death of the deceased?

4. Did any failure to provide care to the deceased or her mother at Atherton Hospital cause or hasten the death?

2. That nature and extent of all factors, including the prevailing conditions, and any human or mechanical factors, that caused or contributed to the Iveco Powerstar, Victorian registration YV2-1AY, colliding with the Honda Civic, Queensland registration 273-ZIA;

3. The nature and extent of any safety measures that may have prevented or reduced the risk of the collision occurring in the prevailing conditions; and

4. Whether there are any recommendations that might be made, that might prevent deaths from occurring in similar circumstances in the future.

a. The person’s mental health condition/s, and the appropriate treatment for them, including whether in all the circumstances there was an appropriate assessment of their suicide risk.

b. Whether the person had access to such treatment and absent their consent, could they be compelled to undergo such treatment?

c. In all the circumstances, was the treatment afforded the person, for their condition/s appropriate?

d. Whether there was any failure to provide appropriate care that caused or hastened the death?

e. Whether any aspect of the care actually provided, caused or hastened the death?

f. What notification, if any, did the ADF provide to the QPS in relation to the person’s medical restrictions concerning weapons, and what effect, if any, would this have had on their ability to retain the firearms for which they were licensed?

g. If notification was given to QPS, what action, if any, did QPS take?

h. Were any disclosures relating to potential Domestic and Family Violence (‘DFV’) in the home made to the ADF by other person’s?

i. If so, what supports or referrals, if any, were offered by the ADF?

j. If the person were to have become subject to a DFV order naming them as the Respondent, what, if any effect would this have had on their employment in the ADF and their ability to hold (civil) weapons licences?

3. Whether the QPS Officers involved acted in accordance with the 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.

5.  The adequacy of the relevant policies and procedures of Child Safety, the Department of Education, Children's Health Queensland, Darling Downs Hospital & Health Service, and Queensland Corrective Services prior to Elizabeth's death and currently, having regard to any action that has been taken in response to her death.

2. Determine the circumstances in which Mrs Thurlow was administered an overdose of morphine during the procedure to insert an intrathecal pump;

3. Determine whether the procedure was carried out appropriately in all of the circumstances, including but not limited to:

i. arrangements made with the hospital regarding the procedure;

ii. the qualifications and experience of the medical practitioners in respect of this particular procedure;

iii. The attendance of the Medtronics staff in theatre; and

iiii. The pre, intra and post-procedure care and treatment of Mrs Thurlow; and

4. Determine whether there are now adequate procedures in place to prevent similar deaths from occurring in Ramsay hospitals and health services.

2. The appropriateness of the decision not to issue a maximum-security order for Mr Clarke on 29 March 2019;

3. The adequacy of information sharing within Queensland Corrective Services on Mr Clarke’s transfer to Borallon Training and Correctional Centre;

4. The adequacy and appropriateness of the risk assessment that was conducted on Mr Clarke’s reception to BTCC;

5. Whether BTCC complied with the Custodial Operations Practice Directive: Prisoner Accommodation Management; Cell Allocation, in making the decision to accommodate Mr Clarke in shared cell accommodation at BTCC; and

5. The adequacy and appropriateness of information sharing between QCS and PMHS in relation to Mr Clarke

6. Mr Clarke’s assessment and management whilst in QCS custody, including:

i. The adequacy and appropriateness of the provision of psychological and psychiatric treatment of Mr Clarke; and

ii. Whether the decision to accommodate Mr Clarke in a shared cell at BTCC was appropriate; and

7. Whether there are any further recommendations which can be made which could prevent deaths from happening in similar circumstances in the future.

2.The adequacy of the drug and alcohol testing policies and protocols applied by Lee Crane Hire and BM Alliance Coal Operations Pty Limited.

3.The adequacy of communication to employees of Lee Crane Hire and BM Alliance Coal Operations Pty Limited regarding drug testing policies and procedures.

4.Whether Lee Crane Hire and BM Alliance Coal Operations Pty Limited offer support and/or rehabilitation referrals for employees who test positive for the presence of illicit drugs and/or alcohol.

5.The adequacy of training, policy, and/or procedures by Lee Crane Hire and BM Alliance Coal Operations Pty Limited to identify, assess, and manage psychosocial hazards and risks.

6.The adequacy of the Queensland Police Service investigation into the death of Drew Woodward.

7.Whether any preventative changes to procedures, or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to workplace health and safety.