24 results
29y · Male·Not determined; likely multiple injuries from fall from coastal cliff or drownin…
This inquest concerns the disappearance and suspected death of Gavin Cheng, a 29-year-old man last seen on 29 October 2023 in North Bondi, NSW. Gavin had a documented history of schizophrenia diagnosed in 2015, with peri…
Deaths from injuries sustained in a mass stabbing attack
This inquest examined deaths resulting from a mass stabbing attack at Westfield Bondi Junction on 13 April 2024. The perpetrator, Joel Cauchi, had treatment-resistant schizophrenia and had ceased antipsychotic medication…
30y · Male·unknown - no postmortem examination performed
This inquest examined the 1995 disappearance of Habtom Ghilagaber, a 30-year-old Eritrean mathematics PhD student at UNSW who was reported missing on 25 September 1995, having last been seen alive on 5 September 1995. Th…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
92y · Female·Consequences of an assault
A 92-year-old woman with dementia died from consequences of an assault by another resident with unmanaged psychosis in an aged care facility. The assault occurred after the facility failed to adequately monitor, assess, …
27y · Male·Neck compression due to self-inflicted hanging
Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…
61y · Male·hanging, the result of actions undertaken by the deceased alone, voluntarily and…
Rickie Underwood Barron, aged 61, died by hanging in Tasmania's Ron Barwick Minimum Security Prison on 10-11 January 2022. He had been incarcerated since 2019 for sexual offences and received appropriate medical care for…
82y · Female·sepsis with septic shock due to ascending cholangitis
Nancy Campbell, an 82-year-old woman with delusional disorder subject to mental health treatment orders, died from sepsis with septic shock due to ascending cholangitis. She had gallstones identified on MRCP during psych…
29y · Male·Unascertainable - likely drowning or accidental injury during terrain navigation…
Mikael Felsch, aged 29, died on 16 December 2015 in Wollemi National Park after becoming stranded in bushland. He had a significant history of suicide attempts and mental health issues exacerbated by methylamphetamine us…
85y · Male·end stage dementia
Lawrence George Harvey, aged 85, died from end-stage dementia while lawfully detained under the Mental Health Act at Noarlunga Hospital. He had experienced progressive dementia since 2013 with increasing aggression, requ…
96y · Male·general inanition on a background of advanced dementia, chronic congestive cardi…
Colin Pryor Tucker, aged 96, died of general inanition on a background of advanced dementia, chronic congestive cardiac failure and pneumonia at Repatriation General Hospital. He was admitted with urinary retention, acut…
80y · Male·inanition complicating end stage dementia
An 80-year-old man with end-stage dementia died from inanition (severe malnutrition/dehydration) while subject to Mental Health Act inpatient treatment orders. He had been admitted after becoming aggressive at home due t…
85y · Female·ischaemic heart disease with renal failure
Fernanda Catalano, 85 years old, died of ischaemic heart disease with renal failure at Lyell McEwin Hospital. She had suffered an unwitnessed fall at her aged care facility on 20 April 2016, was transferred to hospital w…
52y · Male·asphyxia due to choking on food
Kenneth Dunster, a 52-year-old man with chronic schizophrenia and cognitive decline, died from asphyxia due to choking on food at Millbrook Rise Rehabilitation Centre. He had a documented, well-known choking risk due to …
59y · Female·blunt force head trauma
Sandra Deacon, aged 59, died from blunt force head trauma inflicted by multiple axe blows to the head by Garry Weigand on 30 September or 1 October 2014 at Budgewoi, NSW. This was a homicide case. Key clinical and system…
56y · Male·fatal cardiac arrhythmia due to complications from acute bronchopneumonia and ar…
Garry Weigand, a 56-year-old man with a history of brain injury and intellectual impairment, died in custody 17 days after arrest. He died from a fatal cardiac arrhythmia resulting from acute bronchopneumonia combined wi…
79y · Male·Head and neck injuries from blunt force trauma
Mr Risto Pedevski, a 79-year-old man, was fatally assaulted by his son George in November 2014 during a dispute over a gas hot water system. George had a long-standing diagnosis of schizophreniform disorder and paranoid …
82y · Male·end stage dementia
An 82-year-old man with end-stage vascular dementia died in an aged care facility under a guardianship detention order. He had resided at Helping Hand Mawson Lakes for two years with progressive cognitive decline, mobili…
55y · Male·Septicaemia due to hydronephrosis and infection
A 55-year-old man with complex medical and social problems died of septicaemia from renal infection. He had a history of cardiac disease requiring anticoagulation, alcohol dependence, depression, and chronic hoarding beh…
62y · Female·multiple self-inflicted stab wounds to the neck, thorax and abdomen
Rita Sally Greer, aged 62, died from multiple self-inflicted stab wounds while experiencing a severe psychotic episode. She had schizophrenia with documented poor medication compliance since 1990. On 10 September 2007, s…
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