Inquest proceedings list

1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he passed and what caused his passing; and
2. whether the initial risk assessments in respect of self-harm conducted during ATJ’s final term of incarceration were adequate and appropriate; and
3. whether the supervision of ATJ was adequate and appropriate during his final term of incarceration at the Townsville Correctional Centre; and
4. whether the furnishings within cells at the Townsville Correctional Centre adequately mitigate the risk of exposure of hanging points.

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:

1. The adequacy of the mental health assessments of the deceased conducted by Redland Hospital on 27 September 2022, including whether the collateral information obtained was sufficient in the context of the deceased’s presentation;

2. The appropriateness of the management of the deceased in the Emergency Department of the Redland Hospital on 27 September 2022 following both self-harm attempts by the deceased within the Department;

3. The adequacy of the discharge plan put in place for the deceased by the Redland Hospital including whether it sufficiently addressed the deceased’s risk of harming himself or others and sufficiently involved the deceased’s family;

4. Whether during the deceased’s admission to the Redland Hospital on 27 September 2022 there were any missed opportunities to recognise and respond to an acute deterioration in the deceased’s mental health; and

5. 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

1.The findings required by s 45(2) of the Coroners Act 2003; namely the identity Mrs Brodie (deceased), when, where and how she died and what caused her death;

2.The adequacy and appropriateness of the treatment and care provided to the deceased by the Gold Coast University Hospital between January and August 2017 with respect to the management of the deceased’s heart failure;

3.The adequacy and appropriateness of the treatment and care provided to the deceased by Dr Feather, Dr Kapadia, Dr Thompson and Dr Deshpande during the period 19 August 2017 through to the deceased’s death with respect to the management of the deceased’s heart failure.

4.Considering the deceased’s medical co-morbidities, was there any clinically justifiable medical intervention that would have altered the outcome for the deceased during her hospitalisation from 19 August 2017 and her death.

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. 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 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 Acting Sergeant Lyons' actions in attempting to intercept the motorcycle.

3. The adequacy of the Queensland Police Service investigation into the circumstances surrounding the deaths.

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

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.

1. The findings required by s. 45(2) of the Coroners Act 2003

2. An examination of the factual context in which Mr Crocker proceeded with the job knowing he had to enter a restricted ceiling space with the power on;

3. A consideration of safety proposals including product design, safe installation practices for electrical equipment, in particular air-conditioner units, in restricted ceiling spaces;

4. Whether there was a missed opportunity to fit a residual current device (safety switch) to the air-conditioner unit involved in Mr Crocker’s death;

5. The regulatory framework regarding electrical safety when working in ceiling spaces at the time of the Jordan’s death and potential regulatory changes;

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

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:
a.Whether it was appropriate to prescribe sodium valproate 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 sodium valproate, 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 sodium valproate on 14 April 2020;
b.Whether L-carnitine should have been administered to the deceased?
c.Whether a liver biopsy should have been performed and, if so, when?
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 sodium valproate 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?

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?

1. The findings required by s,45(2) Coroners Act 2003; namely the identity of the deceased, when, where and how he died, and what caused his death;

2. Whether Dr Mazen Ashour’s treatment and management of Mr Doughty in the period 17 March 2021 to the date of his death on 5 October 2021was adequate and appropriate, including:

a. Whether or not Dr Ashour’s follow-up of Mr Doughty following his receipt of Angela Wotherspoon’s, Nurse Navigator, letter dated 19 August 2021 reporting a history of Mr Doughty experiencing melaena stools commencing one week following his previous discharge form the Hervey Bay Hospital (HBH) was adequate and appropriate?

b. Whether or not the investigations Dr Ashour arranged in response to the said reported history were adequate and appropriate?

c. Following on from those investigations, whether or not Dr Ashour’s follow-up, treatment and management of Mr Doughty was adequate and appropriate?

d. Whether or not Dr Ashour’s follow-up, treatment and management of Mr Doughty regarding the cessation of his antiplatelet therapy as referred to in the Discharge Summary from the HBH dated 22 September 2021 was adequate and appropriate?

3. 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? Notice of Inquest to Newspaper Version 7 – 10 February 2025

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?

4. Whether any aspect of the treatment and management provided to Mr Doughty caused or hastened his death?

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

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 medical treatment afforded to the deceased under the Queensland Opioid Treatment Program and the prescription of Methadone was appropriate and in accordance with the Queensland Medication-Assisted Treatment of Opioid Dependence – Clinical Guidelines 2018 (2018 Clinical Guidelines).
2. Whether the dispensation of Methadone to the deceased and her agent was appropriate and dispensed in accordance with the 2018 Clinical Guidelines.
3. Whether the Queensland Opioid Dependence Treatment Guidelines (2023 Clinical Guidelines) are adequate to minimise the risk of opioid overdose, in particular with respect to the prescribing of self-administered doses of Methadone, and the appointment of agents to collect those doses.
4. What Queensland Health measures are in place to communicate and address any potential concerns or non-compliance with the 2023 Clinical Guidelines amongst health services providers and between health services providers and pharmacists, and whether those measures are adequate.
5. Whether the actions of any person caused or contributed to the deceased’s death.
6. Whether any changes to the 2023 Clinical Guidelines could reduce the likelihood of death occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.

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.

1. The findings required by section 45(2) of the Coroners Act 2003 
2. Whether the care and level of supervision provided by Ms Lowry to the deceased on 29 April 2021 was appropriate.
3. Whether the systems and processes the Endeavour Foundation had in place for the care of the deceased regarding her diet and nutrition were appropriate.

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. 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?

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.

1. The formal findings required to be made pursuant to s 45(2) of the Coroners Act 2003 – incorporating the investigation as to how the mid-air collision (the accident) occurred, and the most likely cause of the accident.

2. The basis upon which passenger air operations involving scenic flights were conducted by Sea World Helicopters Pty Ltd (SWH) and whether safety management systems (SMS) affecting the conduct of those air operations, involving both ground crew and air crew, were in place and were adequate and appropriate.

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. Notice of Inquest to Newspaper Version 7 – 10 February 2025

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.

1. The findings required by s. 45(2) of the Coroners Act 2003 (Qld), namely the identity of the deceased person, when, where and how the person died, and what caused the person’s death; and

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

1. 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;
2. 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;
3. Whether the care and treatment administered to Jenna McGregor following the decision to proceed to caesarean section was appropriate in all the circumstances;
4. 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.

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.

1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how they died and what caused their deaths; and:

2. Whether, overall, the Queensland Police Service (QPS) response to the domestic violence (DV) complaints (and other call-outs) relating to Lizzie and Isei was in accordance with QPS policy and procedure in place at the time;

3. Whether there is any action which could have been taken by QPS Officers on 9 August 2022 which could have prevented the incident which led to Lizzie and Isei’s deaths; and

4.  Whether the QPS has made appropriate changes to training, policy and procedure to address any shortcomings identified in respect of DV responses relating to Lizzie and Isei.

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

2. 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

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

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.

The findings required by s. 45(2) of the Coroners Act 2003, namely the identity of each deceased person, when, where and how the person died, and what caused the person’s death; and

1.Consideration of the circumstances which led to the attendance of Constables Arnold, McCrow, Kirk and Brough at 251 Wains Road, Wieambilla on 12 December 2022, including:

a.The circumstances of Nathaniel Train’s unlawful entry into Queensland at Talwood in December 2021 and the adequacy of the subsequent police investigation.

b.The circumstances surrounding the issuing and broadcasting of a missing person’s report in relation to Nathaniel Train by the New South Wales Police Force in November and December 2022, including whether New South Wales Police Force officers acted in accordance with the relevant policies and procedures.

c.The information communicated by the New South Wales Police Force to the Queensland Police Service in the lead up to 12 December 2022, and the effect that that information had on the decision to send the four officers to the Wains Road property on 12 December 2022.

d.Consideration of the circumstances in Chinchilla and Tara police stations on 12 December 2022 which resulted in the decision for the four officers to attend the Wains Road property on the day and at the time they did.

2.Consideration of the circumstances surrounding the decision of Constables Arnold, McCrow, Kirk and Brough to enter the Wains Road property.

3.Consideration of the circumstances surrounding the fatal shooting of Constables Arnold and McCrow, including:

a.Who fired the shots that killed Constables Arnold and McCrow.
b.What guns and ammunition were used and whether they were obtained lawfully.
c.Whether Constables Arnold, McCrow, Kirk and Brough were adequately equipped and trained to respond to the incident.

4.Consideration of the circumstances surrounding the fatal shooting of Alan Dare, including:

a.Why Mr Dare attended at the Wains Road property and what information he had at the time of his attendance.
b.Who fired the shot(s) that killed Mr Dare.
c.What gun(s) and ammunition were used and whether they were obtained lawfully.

5.The adequacy and appropriateness of the Queensland Police Service response to the incident, other than the response by the Special Emergency Response Team, including:

a.Whether the Queensland Police Service communication system was adequate.
b.Whether appropriate advice was given to Constables Kirk and Brough whilst at 251 Wains Road, Wieambilla, up until such time as they were each able to exit the address.
c.Whether the Queensland Police Service Command and Control of the response to the incident, including communications about the incident to the Wieambilla community, including Mr Dare's family, was adequate and appropriate.
d.Whether the actions of the Queensland Police Service recovery and extraction team, including the decision to leave Alan Dare's body at the scene, were appropriate.

6.Consideration of the circumstances leading up to the shooting of Gareth Train, Stacey Train and Nathaniel Train by Queensland Police Service Special Emergency Response Team operatives, including whether the actions of the responding operatives were appropriate in the circumstances.

7.Consideration of the profiles and motivations of Gareth Train, Stacey Train and Nathaniel Train.

8.Whether anything was known to the authorities that would have indicated a risk that Gareth Train, Stacey Train and Nathaniel Train would act in the way they did on 12 December 2022, including the Queensland Police Service response to firearm related calls for service and investigations in the vicinity of the Wains Road property prior to 12 December 2022.

9.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.

1. The findings required by s45(2) of the Coroners Act; 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 death including:

a. Jamie’s co-occurring substance use disorder and other mental health disorder/s including any personality disorder/s.

b. Was there appropriate treatment for mental health consumers, within the public health or community systems, such as those suffering the mental health condition/s with which Jamie was diagnosed?

c. Was Jamie an appropriate candidate for such treatment?

d. Was such treatment offered to Jamie?

e. Absent Jamie’s consent, could Jamie be compelled, over the period of contact he had with mental health services to undergo such treatment?

f. In all the circumstances, was the treatment afforded Jamie, for the mental health condition/s diagnosed, appropriate?

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

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

3. 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.