Pubs and other licensed venues should be regularly checked for compliance with responsible service of alcohol laws, a coroner who investigated a drink-driving death says.
Jethro Wolf Douglas purchased 26 glasses of beer and consumed 25 over about seven hours at a hotel on Tasmania's west coast in May 2021.
The 24-year-old left the hotel at 12.14am before crashing his ute while driving at excessive speed more than five times over the legal blood-alcohol limit.
Coroner Robert Webster, whose findings were published on Friday, said CCTV footage from the hotel showed Mr Douglas was "significantly intoxicated".
Footage showed Mr Douglas's balance was affected at 7.53pm when he purchased his 14th beer.
He staggered at 11pm and at 11.45pm nearly fell into the bar before being served his 25th beer.
Mr Webster recommended regular, random spot checks of licensed premises to ensure alcohol is served responsibly.
He called for this to be undertaken as a joint initiative between Tasmania Police and the state's Commissioner for Licensing.
"Relying on any licensee and ... staff 'to do the right thing' in circumstances where the licensee has a direct financial interest in selling as much liquor as possible does not encourage the responsible service or consumption of liquor," Mr Webster said.
"Should this not occur then I expect there will continue to be deaths in similar circumstances to that of Mr Douglas ... because there appears to be nothing which deters a licensee to comply with his or her obligations under the act."
Mr Webster also called for improved communication between police and the commissioner with respect to potential liquor breaches.
It is an offence to sell or serve alcohol on licensed premises to a person who is intoxicated.
Under the law, a person is deemed intoxicated if their speech, balance, co-ordination or behaviour is noticeably affected.
Mr Webster said no investigation was conducted by the licensing division of Tasmania Police or the commissioner into whether alcohol had been served responsibly to Mr Douglas.
The commissioner wasn't informed about the crash and any possible link to liquor law breaches, with the coroner finding information-sharing arrangements didn't work as intended.
Tasmania Police supports the coroner's recommendations and is understood to be working with the commissioner to facilitate regular spot checks.
Police have said they will work to ensure a consistent state-wide approach to information sharing with the commissioner around potential breaches.
In comments in the coroner's report, the licensee said they did not have a culture of putting sales over patron safety and people were refused service if they were getting close to having "too much".
The licensee said staff take into account people's behaviour when serving alcohol but it was extremely difficult to monitor how many drinks a person had consumed, partly because the hotel has different bar areas.
The commissioner has been contacted for comment.
