Coroner's Finding: FW
Date of death
2017-09
Finding date
2019-03-15
Cause of death
drowning
AI-generated summary
FW died by drowning in September 2017 at Bellerive, Tasmania, after entering the water from the Tasman Bridge. This case highlights systemic issues in public safety infrastructure and inter-agency coordination. While not a direct medical case, the coroner emphasizes the importance of rapid response systems for persons in crisis. The delayed implementation of live camera feeds to police dispatch represents a communication and system failure that could have assisted in timely location and potential rescue. Enhanced surveillance, live monitoring capabilities, and coordinated crisis response protocols are essential to prevent similar deaths. This case underscores the need for rapid escalation procedures and real-time communication between agencies when individuals are reported in potential crisis situations on high-risk locations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- delayed implementation of live camera feed to Police Radio Room
- technological difficulties in establishing live feed from new cameras
- system coordination delays between State Growth and Tasmania Police
- inadequate real-time surveillance and monitoring capabilities at time of death
Coroner's recommendations
- Establish transmission of live footage from Tasman Bridge cameras to Police Radio Room with priority by Cross-Agency Working Group, Tasmania Police, and State Growth
- State Growth ensure cameras installed on Tasman Bridge are subject to sufficient checks to ensure operational status and positioning to capture all pedestrian footways
- Tasmania Police continue to ensure all investigating officers are aware of high-quality, full-coverage camera footage and means to obtain this footage from State Growth for use in relevant investigations
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —