Visits by school groups are not encouraged when the Court is in session. Contact:localcourtmedia@courts.nsw.gov.auor(02) 9716 2804. Adequacy of emergency medical response and care, remote event, mass gathering event, primary health care clinic, Laura, Cook Shire Council, Torres and Cape Hospital and Health Service, Queensland Ambulance Service, nurses, fatigue leave, medical emergency, event management, risk assessment, female 17 years, myocardial scarring, past myocarditis, undiagnosed rheumatic fever, telecommunications blackspot, automated external defibrillator, event planning, risk assessment, approvals process, interagency approach, state wide mass event planning reform, Hollys Law. Coroners Court. NCA Newswire understands a fibreglass pool fell on the man and crushed him inside of a company warehouse in Beaudesert, around 85km south of Brisbane City. General enquiries North Queensland region Central Queensland region Sunshine Coast and South Queensland region Greater Brisbane region South East Queensland region 903 results found Domestic violence, manslaughter, abusive and violent relationship. This is an Aboriginal Designated Position, classified under 'special measures' of section 12 of the . Inquest, road accident, passenger vehicle overturned on country road, how the accident occurred, identity of the driver at the time of the incident. Coroners investigate certain deaths which are deemed to be unnatural, violent, or where the cause is unknown. Finalisation of adjourned 1998 inquest, circumstances of the cause of death, identification of the person or persons responsible, utility of the Coroners Act 1958 to a modern coronial investigation and the Coroners Act 2003 transitional provisions. Most matters that go to hearing will result in published findings. We need to keep this conversation going. Evidence is taken under oath. Domestic and Family Violence, Domestic Violence Protection Orders, Domestic and Family Violence Protection Act 2021, murder, Lionel Patea, Queensland Police Service, High Risk Teams, Queensland Health. She added that she would like to see a recommendation about community education and awareness programs that are specific to identifying the signs of coercive control. Contact details for your local court and the facilities available, Contact information for the Childrens Court, Contact details for Land Court and Land Appeal Court, Contact details for Murri Court case coordinators and community justice groups, Contact details for the Planning and Environment Court, Contacts for various court diversion, treatment and sentencing initiatives in Queensland, Lists of judges in the Supreme, District, and Planning and Environment Courts, and magistrates in Queensland, Who to contact for various media enquiries. These engineers break their silenceafterdecade of criticism over2011 Queensland flood handling, Police shoot man dead after being called to reported domestic violence incident in Sydney's south west, Anna called police to report an assault, but it backfired and she lost her home. recommendation for learning programs for officers needed to be prioritised. This means that any member of the public may attend the proceedings. He was not mentally ill, he was a master of manipulation, Magistrate Bentley told the court. Quad bike accident, mechanical defect, helmets. Fax 2568 1735. Lloyd Clarke addedother states need to "look at what Queensland started"and"follow suitas well". 1800 RESPECT . Flexible work options between the office and home (hybrid). Traffic controller, motor vehicle crash, codeine toxicity of driver, involuntary intoxication due to effects of renal dialysis, fitness to drive due to multiple medical conditions, legislative reform. School groups may be accommodated when the court is not in session or, alternatively, an officer of the Coronial Information and Support Program (CISP) may be able to come toa school to speak to students. Brisbane is the capital of and the most populated city in the Australian state of Queensland, and the third most populous city in Australia. The State of Queensland (Queensland Courts) 20112023, Response to Christensen, Corey James and Davy, Thomas Ian, Response to Nyholt, Nicole Sonia and Clark, Margaret Louisa, Response to Goodchild, Kate; Dorsett, Luke; Low, Cindy & Araghi, Roozbeh, Response to Hunt, Thomas and Kim, Youngeun, Response to Maynard, Marcia Anne Kathleen, Response to Holstein, Zachary James David, Response to House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith, Response to Hitchins, Steven John; Gudge, Shawn Bradley Joseph, Response to Glennon, Lardeen Bernadette; Glennon, Matthew David, Response to Recommendations from inquest into the deaths of Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan, Laval Donovan Zimmer and Troy Martin Foster, Response to Crowley, Byron James and Davis, Bernard Ashton, Response to Leonardi, Christine Nan and Leonardi, Samuel John, Response to Jensen, Ian Christoffer and Kepui, Timothy Ponde, Response to Maggs, Natasha Alison; Williams, Tiana Marie; Holland-Williams, Kody Peter Tugaga; Sullivan, Allan John; Hayes-McGuinness, Jordan Guy, Response to Wright, Verris Dawn; Carter, Jasmyn Louise, Response to Inquest into nine (9) deaths caused by Quad Bike accidents, Response to JE and JJ, two 16 year old boys, Response to Waugh, Harry McMaster Tickell, Response to Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret, Response to Hempel, Barry Ian; Lovell, Ian Ross, Response to Fuller, Matthew James; Barnes, Rueben Kelly; Sweeney, Mitchell Scott, Response to Owens, Kenneth Roland; Stiller, Daniel Arthur, Response to Arnold, Vicki; Leahy, Julie-Anne, Response to MacKenzie, Malcolm; Brown, Graham; Wilson, Robert, Response to Simpson-Willson, John Douglas, Response to Welburn, Dale Robert and McPherson, Kerri Leigh, Response to Mulrunji - aka Cameron Doomadgee, Response to Grace, Daniel Scott and Heffler, Raymond John, Response to Wright, Liam John and Powell, Charles Michael, Queensland Civil Administration Tribunal (QCAT), View the Summary of Findings and recommendations, Contacts - Industrial Relations Commission, Requesting a lengthy review or minor change hearing, Seeking a consent order from ADR Registrar, Practice Directions - Planning and Environment Court, Contacts - Planning and Environment Court, Judges of the Planning and Environment Court, Information and resources for going to court, Consolidated Practice Directions of the Land Court, Online Application for a Court Event (Magistrates Courts), Appealing from Magistrates to District Court, Information for Aboriginal and Torres Strait Islander participants, Coronial investigations - information for family and friends, About our Government Contracted Undertakers, About Childrens Court (Magistrates Court), About Childrens Court of Queensland (District Court), Practice directions - Mental Health Court, Judicial education - Domestic and family violence. Attorney General Direction to conduct an Inquest, 1983 cold case, female self-inflicted gunshot wound, suspected suicide, adequacy of original police investigation, cold case homicide review, original non-inquest findings of Coroner upheld. Coroners Court This section is for finding contact details. Coroners perform an important function in publicly examining deaths that are sudden, unexplained or otherwise not readily accountable.In many countries - including Australia, New Zealand, the Republic of Ireland, the United Kingdom and most Canadian provinces - coroners are empowered to make recommendations for improving public health and safety as part of their findings following death . The deputy state coroner made four recommendations requiring "immediate attention", includingtraining programs for all specialist police, state government funding for men's behaviour change programs and trials of a specialist domestic violencepolice station for 12 months. Deputy State Coroner Bentley's voice broke as she closed the inquest, offeringher condolences to Ms Clarkes parents Sue and Lloyd Clarke. WA woman died after being ramped outside hospital, coroner hears. Coronial registrars located in Brisbane assist the coroners by triaging and investigating less complex matters, such as deaths from natural causes. He sustained critical injuries from the incident that he was not able to recover from. Use the search feature to find something specific. Co-sleeping, risk factors, Department of Communities, Child Safety and Disability Services, child tracking register. A Coroner may subpoena a person to give evidence or produce a thing or documents at a time and date specified in the subpoena. Place of Death . For Aboriginal and Torres Strait Islander people. Queensland Government's Response to coronial recommendations, Information about coronial recommendations. Drowning,car overboard, cable cross river ferry,containment,safety management systems and regulator oversight. It does this by supporting families, providing expert advice to . Gas explosion on a drilling rig. Outside the Sydney Metropolitan Area, please contact the Assistant Coroner at your nearest Local Court. The State coroner's guidelines direct other coroners about the conduct of coronial investigations. "It's not just Queensland but we think that every state in Australia [should consider the recommendations], it's not just a Queensland problem," SueClarke said. The Queensland government has agreed to implement each one and has started an independent inquiry into broader cultural issues in the police service. Most (~95-98%) deaths reported to the ACT Coroner do not have a hearing held for the purposes of the inquest. Street address: Level 3, The Square Centre 478 Main Street Palmerston North radiological procedure performed, location of the injection/s, loss of consciousness, cause of death, adequacy of response and care provided. That failure probably came about because Baxter had not been violent and had no relevant criminal history.. Abdominal pain, hospital admission and diagnosis, surgical management, postoperative care. CISP staff can offer guidance and information during the coronial process. We acknowledge the traditional owners and custodians of the land on which we work and we pay respect to the Elders, past, present and future. Below you will find contact and location details for areas of Queensland Courts. The majority of statements provided by friends and associates of Hannah and Baxter provided insight into the controlling nature of Baxters personality and how it led to the deaths, Ms Bentley said. Spinal surgery, Jehovahs Witness, refractory back syndrome, haemorrhage. The Aboriginal Family Engagement Manager reports to the Court's Principal Registrar. Coroner Robin Kay. Coroner's Court Level 10, Central Law Courts 501 Hay Street PERTH WA 6000 Phone: (08) 9425 2900 or 1800 671 994 Please select one of the following options to submit feedback. Missing person, Army Officer, civilian police and military police investigations. Health care related death, discharge against medical advice, and presumption of capacity to make own health care decisions, hospital unaware of patients guardianship status at the time of discharge, stakeholders working towards improving information sharing, Health care related death, complication from elective percutaneous stenting of left of left descending artery, patient discharged too early following procedure, adequacy of documentation and communication, Health care related death, complication from elective percutaneous stenting of left descending artery, patient discharged too early following procedure, adequacy of documentation and communication, inquest, workplace death, identification of hazard and management of risk of moving vehicles, adequacy of investigations, adequacy of process adopted for decisions to prosecute, inquest, nursing home resident, immolation, burns, whether accidental or self-harm, risk assessments for smoking and/or self-harm, physical diseases as predictors of suicide in older adults, communication in concurrent investigations. Quad bike accident, roll over, helmets, children, supervision. Directions Hearing Forensic Medicine and Coroner's Court Complex, 1A Main Ave, Lidcombe Courtroom Four at 9:30am You can also read more about findings including what to do if you disagree with findings or would like an inquest reopened. The nine-day inquest concluded at the end of March, with lawyers putting forward a raft of suggestions about what more could be done to try and prevent anything similar from happening. Each Court is independent of the Queensland Department of Justice and Attorney-General and Queensland Government. Work place related death, camper trailer manufacturer, prototype boat rack, gas strut explosion, penetrating head injury, Issue with prototype design, risk assessment, training, supervision, staff qualifications and quality of gas strut. "As a community, we can get more skilful at providing and supporting opportunities for women and children to be safe.". Suicide, death in custody, hanging, life prisoner, hanging points. Support Aboriginal and Torres Strait Islander families as they navigate the coronial process. Lidcombe NSW 2141, Phone: 02 8584 7777 (The Age) "Again, education, the more educationpeople [have], will understand children areat risk as well. Visits by school groups are not encouraged when the Court is in session. Stabbing, double fatality, police investigation, police response, QAS response, decision to charge. Any person may attend and listen to the proceedings. Contact us. expose other matters of public importance. Sudden infant death syndrome, SIDS, co-sleeping, overlay, risk factors, parental drug use, child protection. For additional details concerning the Coroner's responsibilities, as well as answers to some commonly asked questions, please seeInformation About the Coroners Court and the Death of a Relative or Friend. The findings of an inquest into the deaths of Brisbane woman Hannah Clarke and her three young children have been handed down. Coroners' appointments, contact details and information about the merger of coroner areas. Street address: Level 1, Hastings District Court 106 Eastbourne Street West Hastings. SMS: 0418 226 576 (rates apply) Are bills set to rise? Located in Cairns, the northern coroner investigates deaths in the North Queensland region, which extends from Cairns south to Bowen, west to Mount Isa and north to the Papua New Guinea border. This concludes today's blog, but you can read more from our reporters in Brisbane about the inquest findings and responses. The regions are shown on the map (PDF, 2.2 MB) Read about the coroners in each region. Fire, suspicious circumstances, Mobile Home Park, smoke alarms. Rural hospital, failure to recogniseand respond to clinical deterioration, early warningand response systems, Queensland Adult Deterioration Detection System (Q-ADDS), effective clinical communication, escalation of clinical concerns. Australia's oldest running coal-fired power station is about to close. Ashleigh Hunter, 26, died on December 27, 2019, less than two hours after arriving by ambulance . TheACT Coroner's Courtislocated within theACT Magistrates Court building and sits wheneverit holds an inquest into the manner and cause of a death or an inquiry into the cause and origin of a fire. Death in care, intellectual and physical disability, choking on food, adequacy of resuscitation provided by carer and ambulance services, Public Advocate report. Re-opening, coronial investigations, jet ski collision, jet ski racing, pro stock race, collision, cavitation, additional contact, race bumping, unhooked, forensic recording analysis, engine control unit (ECU), MoTeC data, MoTec report and analysis, I2 analysis software, PWC (personal water craft). Brisbane's metropolitan area has a population of 2.5 million, and the South East Queensland region, centred on Brisbane, encompasses a population of more than 3.5 million. A NSW coroner has urged authorities to consider better public education after the teenager's death. On this Wikipedia the language links are at the top of the page across from the article title. Licence holder, medical fitness to drive, assessing fitness to drive, insulin dependent diabetes, diabetes mellitus, obligations of medical and general practitioners, Transport and Main Roads, motor vehicle accident, recommendations. The deputy state coroner has made four recommendations requiring immediate attention. Failure to obtain medical attention, failure to provide necessities of life, murder, unlawful killing, manslaughter, child abuse. Email: csu.hastings@justice.govt.nz. Inquest findings (since 2004) as well as non-inquest public interest matters (since 2012) are available below. This service may include material from Agence France-Presse (AFP), APTN, Reuters, AAP, CNN and the BBC World Service which is copyright and cannot be reproduced. What kind of message would you like to send? Health care related death, obstetric case, CTG tracing interpretation, obstructed labour, caesarean section, communication issues, amniotic fluid aspiration. Perth hospital staff missed the signs a seven-year-old girl was dying of sepsis because of the pressures caused by "inadequate" staffing, a coroner has found. Loss of life arising from capsize of two fishing vessels causes of loss recommendations as to safety improvements in fishing industry. To locate all Coroner's Court findings go to theDecisions database. The Coroners Court of Queensland is a court in the court hierarchy of Queensland, Australia. Death of newborn infant within 6 hours of birth , Group B Streptococcal disease (GBS) , infant dropped on her head minutes after birth , prescribed antibiotics not administered as directed,cause(s) of death , prevention of future deaths in similar circumstances. The state coroner oversees and coordinates the Queensland coronial system to ensure it is administered efficiently and appropriately. Domestic and Family Violence, DVConnect, Queensland Police Service, High Risk Teams. But MrClarke told reporters that while the inquest was over, their fight for change will remain ongoing. Free call: 1800 449 171Phone: +61 73096 2794 Email: fss.counsellors@health.qld.gov.au or fss_coronialnurses@health.qld.gov.au. Roaring Meg Falls, accidental slip and fall, alcohol and drug toxicity, Kuku Yalanji, Wujal Wujal, traditional owners, indigenous, aboriginal, culturally sensitive site, signage, mobile and satellite telephone coverage, telecommunication signal, police recovery operations from waterfall, rescue helicopter, Emergency Services Queensland, retrieval helicopter. Be part of a supportive, professional, and multi-disciplinary team. Death in custody, Indigenous prisoner, risk assessment, hanging, high dependency unit, supervision of prisoners, prison support and mental health services, information sharing between Queensland Corrective Services and Prison Mental Health Service employees. If youre unsure which coroner is handling an investigation, contact the Coroners Court. CORONERS: Inquest - Head Injuries, Bunk Beds, doctors working hours, emergency department care in regional hospital, emergency retrieval, open disclosure of adverse health events. They saythey wantthe recommendations to be brought in nationally. Claim this business Have a picture to share? Please don't include personal or financial information here. presented a series of recommendations for consideration, including, Max Verstappen takes Bahrain F1 pole, Aussie Oscar Piastri ousted in first Q1, Motocross rider dies after falling from bike at Victoria's Wonthaggi Motocross Track, 15 people rescued from Central Victorian mine after fire. This section is for finding contact details. * Reducing preventable deaths. A person who is granted leave to appear at a hearing is entitled to examine and cross-examine witnesses on matters relevant to the inquest or inquiry to which the hearing relates. Death in care, Brugada syndrome, Hypoxic brain injury, Automatic implantable cardioverter device, Treatment, Rehabilitation. Zachary Rolfe faces disciplinary action by the Northern Territory Police Force after its legal counsel launched an attack in Monday's coronial hearing, suggesting the constable tried to intimidate senior police officers and potentially "pervert the course of justice". Donald Trump releases song with Jan 6 defendants as he vows to forge on with 2024 presidential campaign, Protests break out in Iran as more schoolgirls hospitalised after suspected poisoning, With Russian forces closing, Svyat rolled the dice in the last days before Bakhmut fell, China should pursue 'peaceful reunification' to resolve 'Taiwan question', premier tells parliament, Barb has been boating around her outback station for months but she's not complaining, murdered by her estranged husband Rowan Baxter, Hannah Clarke's parents call for recommendations to be considered nationally, Coroner finds further actions by authorities 'unlikely' to have stopped Baxter from murdering Ms Clarke and their children, read more from our reporters in Brisbane about the inquest findings. The State Coroners Court in Lidcombe, Sydney is the state headquarters for the coronial jurisdiction in NSW. Townsville Hospital Acute Mental Health Unit, Health Service Officer vascular restraint, involuntary patient, obese, prone position, cardiac arrhythmia during a restraint. The ACT Coroners Court intends to reconsider and retrospectively publish certain in-chambers findings where recommendations were made, as part of its intention to publicise the work of the Court. the cause and origin of the fire or disaster, and. A Coroner holding an inquest must find, if possible: A Coroner holding an inquiry must find, if possible: Most matters dealt with by the ACT Coroners Court do not result in published findings. Aboriginal and Torres Strait Islander peoples are warned, findings contain the names of deceased persons. Death in custody, hanging; adequacy of psychiatric treatment; history of suicide attempts; hanging points. Apply online to reschedule a court date. Death in custody, police watchhouse, mixed drug toxicity, assessment and monitoring of prisoner health, police CPR skills and training, investigation of police related deaths. Death in custody, police shooting, prisoner arrested on interstate warrant, cardiac event, detained in hospital setting, application of handcuffs, risk assessment. Coroners Court Under the Coroners Act 2003, coroners are responsible for investigating reportable deaths that occur in Queensland. CD 125 of 2007 is an example of a file number. If the coroner refuses, the person may apply to the Chief Coroner for the review of the decision by the Coroner not to hold a hearing, and thereafter may apply to the Supreme Court. Other services you cancontact for support include: The State of Queensland (Queensland Health) 1996-2023, Use tab and cursor keys to move around the page (more information), Additional complications for those grieving, explaining the process when a death is reported to a coroner, providing information and support about autopsy examinations and outcomes, providing support for identifications and viewings, providing information and referrals to support groups and local services. Forensic Medicine and Coroner's Court Complex, 1A Main Ave, Lidcombe Courtroom One at 9:30am Before his Honour Magistrate Lee, Deputy State Coroner Friday 10 March 2023 Inquest into the Death of P.H. Latest court news and events including high profile trials and appeals, murder cases, celebrity court appearances, international courts and laws, death penalty, and jail time convictions. A person may request a coroner to hold a hearing. The court regularly reports on data and trends regarding preventable deaths in Victoria to help inform public health responses.About the roleThe Coroners Prevention Unit (CPU) provides support to Coroners to fulfil their prevention mandate to improve public health and safety. Phone: 06 350 0083. Otherwise, a Coroner may direct that written findings made outside of Court are published, for example, when recommendations are made or the matter is otherwise of public interest. WARNING - content in these findings may be distressing to readers. Often they now seemto focus on the partner, notchildren," Ms Clarkeadded. . Health care related death, paediatric cardiac surgery, Queensland Paediatric Cardiac Service, congenital aortic stenosis, fourth-time sternotomy & redo Konno, right ventricular outflow tract (RVOT) patch, CardioCel, wound management, sternal wound infection, mediastinitis, surgical debridement, VAC dressing, persistent post-debridement fevers and tachycardia, acute bleed from sternotomy wound 18 days post-operatively, after hours surgical assessment of acute bleed, Massive Transfusion Protocol, after hours theatre team call-in, emergency cardiac surgery, rupture of RVOT patch, catastrophic cardiac bleed. The former NSW State Coroner's Court and Morgue building was located at 44-46 Parramatta Road, Glebe for 48 years. Palmerston North. Elective bronchoscopy, bridging anticoagulation, patient history transcription error by admitting respiratory team, pulmonary haemorrhage, anthraco-silicotic lung disease. All courthouses Contact details for your local court and the facilities available Childrens Court Contact information for the Childrens Court Coroners Court Contacts for the Coroners Court Supreme Court (Court of Appeal) Contacts for the Court of Appeal A coronial autopsy or examination needs to be conducted when a death is considered 'reportable'.. A coronial autopsy or examination is ordered to determine how and why a person died, and in some cases to help establish the person's identity. Age. Aishwarya Aswath died on Easter Saturday 2021, hours after presenting to the Perth Children's Hospital emergency department with a fever and . Ingestion of Bacban, poison, nursing home, staff responses, hospital responses, standard of care. 1A Main Avenue Forensic Medicine and Coroners Court complex A death in custody is a death that occurs in one of the circumstances set out insection 3C of theCoroners Act 1997. Death in custody, avoiding being placed into custody, use of force, police shooting, domestic violence, mental health response, incident command, entry into yard, police training. At the time of being served with the subpoena you will be given an undertaking to appear which you must sign and return to the Coroner. First Nations prisoner, death in custody, natural causes, health care, human rights, sudden death in epilepsy, provision of anticonvulsant medication to prisoners, reception triage, monitoring of medication. Location: Dorset Coroner's Court, Civic Centre, Bourne Avenue, Bournemouth, BH2 6DY. For general enquiries, feedback, complaints and compliments: 13 QGOV (13 74 68 13 74 68) For COVID-19 related enquiries: Death in custody, natural causes, palliative care, exceptional circumstances parole. Domestic violence, intimate partner, manslaughter, criminal proceedings, exit from moving vehicle, police response, heightened post separation risks, non-lethal strangulation, domestic violence protection orders, cultural and linguistic diversity, English as second language (ESL), assessment of risk, supervision and rehabilitation of perpetrators, Queensland Domestic Family Violence Death Review and Advisory Board, Special Taskforce Domestic and Family Violence, Not Now Not Ever Report, sentencing principles. Search by keyword. Prescription opioids, drugs of dependence, opioid overdose, oxycodone, oxycontin; Schedule 8 medications, drugs of dependence; controlled drugs, doctor shopping, prescribing practices, real-time prescription monitoring, electronic recording and reporting of controlled drugs; Monitored Medicines Unit; oxycodone intoxication 20 month old male child death; drug toxicity fatalities - children. The Chief Coroner and the Lord Chancellor must give their consent to each proposed appointment. In such case the documents should be delivered to the Court Registry in theMagistrates Court Building Knowles Place, Canberra City. Queensland has seven specialist full-time coroners located in Cairns, Mackay, Brisbane and Southport. Skydiving multiple fatality, Australian Parachute Federation, Commonwealth Aviation Safety Authority, Skydive Australia, Skydive Cairns, solo sports jump, tandem, relative work, back to earth orientation, premature deployment of main chute, container incompatibility with pack volume, reserve chute; automatic activation device (AAD), consent for relative work, regulations, safety management system, drop zone, standardised checking of sports equipment, recommendation for sports jumpers to provide certification for new or altered sports rigs including compatibility of main chute to container, recommendation to introduce 6 month checks by DZSO or Chief Instructor for sports rigs at drop zones to ensure compatibility. Hearings will only be held for around 10 matters per year. Actions I am an accused in a criminal case Read here for more information if you have been reported, arrested or charged with committing a criminal offence. What to do if you are concerned about a coroner's decision. The Court provides us with a long and excruciatingly painful historical review of the Second Amendment since its inception in 1791, as well as the Fourteenth Amendment's due process clause enacted in 1868. The Coroners Court home page has links to guide citizens including legal and health practitioners on the coronial process and where to find support. If you are served with a subpoena to give evidence you will need to attend the hearing at the time and place specified in the subpoena. Could they have saved him? Death in custody, restraint, domestic violence. Findings are published on this website when an inquest was held or a coroner otherwise orders they be published in the public interest. "[That] he was a great father, and that his actions were somehow excused or explained by the fact that he was losing everything, was being victimised by the process, and that Hannah should not have kept his children from him.
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