Highlights
INTRODUCTION
1. Section 45 of the Coroners Act 2003 provides that when an inquest is held the coroner’s written findings must be given to the family of the person who died, each of the persons or organisations granted leave to appear at the inquest and to officials with responsibility over any areas the subject of recommendations. These are my findings in relation to the death of Mason Jet Lee. They will be distributed in accordance with the requirements of the Act and posted on the web site of the Coroners Court of Queensland.
2. These findings and comments:
1. confirm the identity of the deceased person, the time, place and medical cause of his death;
2. consider whether the actions or omissions of any third party contributed to his death; and
3. 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.
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