This Finding was the subject of an appeal to the Supreme Court of South Australia. See Onuma V The Coroner’s Court of South Australia [2011] sasc 218. This




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Deputy State Coroner



Inquest Number 11/2011 (1737/2008 & 1148/2009)

1 Exhibits C3 and C3a

2 Exhibit C4a

3 Exhibit C5a

4 Exhibit C5b

5 Exhibit C4a, page 2

6 Acute Respiratory Distress Syndrome

7 Exhibit C10a, page 17

8 Exhibit C10a, pages 18-19

9 Exhibit C18

10 Exhibit C18, page 8

11 Transcript, page 238

12 Transcript, page 239

13 Transcript, page 243

14 Transcript, page 243

15 Exhibit C18, page 6

16 Exhibit C18, page 6

17 Transcript, page 256

18 Transcript, page 243

19 Exhibit C16

20 Transcript, page 29

21 Exhibit C12e

22 Exhibit C12

23 Part of Exhibit C12

24 Transcript, page 94

25 Exhibit C12, CV, page 5 and Transcript, page 141

26 Exhibit C8, OCO1

27 Transcript, page 163

28 Transcript, page 268

29 Transcript, page 274

30 Transcript, page 274

31 Transcript, page 266

32 Transcript, pages 274-275

33 Transcript, page 224

34 Transcript, page 277

35 Exhibit C13

36 Exhibit C13b, pages 4-5

37 Exhibit C16a, page 18

38 Exhibit C16a, page 24

39 Transcript, page 174

40 Exhibit C12

41 Exhibit C16a, page 21

42 Exhibit C16a, page 16

43 Exhibit C12, OCO7

44 Exhibit C14, page 415

45 Exhibit C14, page 441

46 Transcript, page 199

47 Exhibit C13a

48 Exhibit C18

49 Exhibit C18, page 2

50 Transcript, page 252

51 Transcript, pages 253-254

52 Transcript, page 254

53 Transcript, page 254

54 Transcript, page 260

55 Transcript, page 261

56 Transcript, page 262

57 Transcript, page 262

58 Transcript, page 263

59 Transcript, page 195

60 Transcript, page 265

61 Transcript, page 266

62 Transcript, page 250

63 Exhibit C12e, page 4

64 Exhibit C12d, page 23

65 Exhibit C12e, page 11

66 Exhibit C12d, page 19

67 Exhibit C12d, page 15

68 Exhibit C12e, page 17

69 Exhibit C12e, page 27

70 Exhibit C7a

71 Exhibit C7b

72 Transcript, page 148

73 Exhibit C17a

74 Exhibit C17a, page 3

75 Transcript, page 237

76 Transcript, page 247

77 Transcript, page 211

78 Inquest into the death of Antonia D’Agostino - Inquest 13/2010 – finding delivered 30 December 2010

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