Dorothy Jean Atkins, 83, died in July 2017 at the home where she lived with her son and carer, David Baldock, in Tasmania's north.
Coroner Robert Webster recently published his findings into Ms Atkins death, following an inquest held in August 2022.
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Tasmanian coroner condemns 'troubling' lack of checks and balances
A Tasmanian grandmother who died in 2017 was neglected by her carer, and the government agency responsible for paying him had not checked whether the care being provided was adequate, a coroner has found.
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