Coronial Inquests published by the Australian, Queensland Coroner.

McGuire, Paul Thomas

Inquest into the death of McGuire, Paul Thomas

Fatality in underground mining, asphyxiation via exposure to depleted-oxygen atmosphere, deceased misdirected to incorrect location by administrative failure to update sensor location data, recommendations concerning signage and access to “GOAF” areas containing irrespirable atmosphere.

O\’Connell on 22/05/2020



Inquest into the death of FD – Non-inquest findings

Percutaneous Endoscopic Gastrostomy (PEG), post-PEG insertion care & complications, rural hospital presentation, delayed recognition & response to sepsis, Adult Sepsis Pathway, RESIST Sepsis Program, Queensland Sepsis Collaborative, delayed acceptance for interhospital transfer, management of urgent interhospital transfer from rural hospital to regional tertiary hospital.

byKirkegaard on 08/05/2020


T and P

Inquest into the death of T and P – Non-inquest findings

Accidental child drowning; domestic swimming pool, non-compliance with pool safety standards, pool safety obligations for landlords and tenants of residential rental properties, protective parenting, relationship between supervisory neglect and risk of accidental death for children.

Kirkegaard on 06/05/2020


Hinder Nyobi Jade; Hinder River James & Hinder Charlie

Queensland Government response not required Domestic and family violence, homicide-suicide, filicide, retaliatory paternal filicide, coercive control, caravan explosion, explosives, mechanism of explosion, police response to domestic violence, storage and security of explosives, mines, domestic and family violence reforms to security requirements for explosives licenses.https://www.courts.qld.gov.au/__data/assets/pdf_file/0008/643796/nif-hinderdeaths-20200330.pdf