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WAhome2026-05-27

Inquest into the Death of Martin Carl QUITERIO

59y · Male·Multiple injuries

Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…

psychiatrygeneral practicesystemcommunicationhaloperidol
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

Jacob MacDonald, 51, died at the Forensic Hospital from combined effects of dilated cardiomyopathy with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patie…

psychiatrycardiologycommunicationsystemclozapine
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

Joel Cauchi, a 40-year-old man with chronic treatment-resistant schizophrenia, carried out a stabbing attack at Westfield Bondi Junction shopping centre in Sydney on 13 April 2024, killing six people (Dawn Singleton, Jad…

psychiatrygeneral practicecommunicationsystemclozapine
NSWmental health2026-02-05

Inquest into the deaths at Westfield Bondi Junction Executive Summary

41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…

On 13 April 2024, Joel Cauchi stabbed 16 people at Westfield Bondi Junction, NSW, fatally wounding six: Dawn Singleton, Jade Young, Yixuan Cheng, Ashlee Good, Faraz Tahir, and Pikria Darchia. Cauchi was shot and killed b…

psychiatrygeneral practicediagnosticcommunicationclozapine
VICaged care2026-01-19

Finding into death of Kevin Thomas Maloney

39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…

Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…

psychiatryaddiction medicinecommunicationsystemheroin
VICaged care2026-01-16

Finding into death of F M

40y · Female·Sudden unexpected death in epilepsy (SUDEP) in a woman with schizophrenia

FM, a 40-year-old woman with epilepsy and schizoaffective disorder, died from sudden unexpected death in epilepsy (SUDEP) at her disability group home. She had been prescribed periciazine (Neulactil) five days before dea…

neurologypsychiatrysystempericiazine
VICcommunity2026-01-08

Finding into death of Dominic Joshua Clifford

23y · Male·Plastic bag asphyxia in setting of irrespirable atmosphere induced by nitrogen g…

Dominic Joshua Clifford, a 23-year-old with a complex history of mental illness including depression, anxiety, ADHD, and likely autism spectrum disorder, died by nitrogen gas inhalation in September 2024. He had multiple…

psychiatryfluoxetine
VICcommunity2025-11-28

Finding into death of Niels Gunther Btb: Becker

39y · Male·Unascertained

Niels Gunther Becker, a 39-year-old man with schizophrenia on stable antipsychotic therapy, disappeared while hiking in the Victorian High Country on 26 October 2019. His last communication was a text message sent at 11:…

psychiatrygeneral practicearipiprazole
NSWcommunity2025-10-31

Inquest into the disappearance and suspected death of Sana Salman

34y · Female·not able to be determined - body not found

Sana Salman, a 34-year-old woman with bipolar disorder and schizoaffective disorder, went missing on 1 September 2022 after being discharged from Northern Beaches Hospital on 22 August 2022. She had been admitted for a p…

psychiatrysystemcommunicationclozapine
QLD2025-10-01

Inquest into the death of Duke Allan Wayne Schafer

36y · Male·Ligature strangulation

Duke Schafer, 36-year-old prisoner, was murdered by fellow inmate Carl Bloomfield in May 2020 at Woodford Correctional Centre. Bloomfield strangled Schafer in an unsupervised laundry area during a period when officers we…

psychiatrypsychologysystemcommunicationbuprenorphine
VIC2025-09-24

Finding into death of Bryan Pham

24y · Male·multiple injuries and chest compression asphyxia (train strike)

Bryan Pham, 24, died by suicide via train strike on 2 June 2020, two days after release from remand custody. He had schizophrenia, substance use disorder, and was recently incarcerated for assault and FVIO breach. While …

psychiatrycorrectional healthcommunicationsystemmethamphetamine
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…

emergency medicineendocrinologycommunicationdiagnosticmetformin
NSWcommunity2025-08-08

Inquest into the death of Stephen Douglas

62y · Male·Multiple sharp force injuries intentionally inflicted by client during home visi…

Stephen James Douglas, a 62-year-old community mental health nurse, was killed on 28 November 2019 by his client Peter Kemball during a home visit. Kemball had chronic schizophrenia and was experiencing psychosis with de…

psychiatrygeneral practicediagnosticsystempaliperidone
TAScommunity2025-06-30

Coroner's Finding: de-identified IB

21y · Male·drowning

A 21-year-old male with schizophrenia and cannabis use died by suicide after jumping from the Tasman Bridge. He had been admitted to Royal Hobart Hospital on 7 May 2019 with suicidal ideation and auditory hallucinations …

psychiatryemergency medicinearipiprazole
VIC2025-05-12

Finding into death of Timothy John Hacking

54y · Male·Cardiomyopathy (NOS)

Timothy Hacking, a 54-year-old man with intellectual disability, schizoaffective disorder, epilepsy and hypertension, died suddenly at his supported accommodation from cardiomyopathy. Autopsy revealed moderate coronary a…

cardiologyforensic medicinetelmisartan
SAcommunity2025-04-30

Coroner's Finding: Foster, Michelle Stephanie

36y · Female·head injury

A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…

psychiatryemergency medicinediagnosticcommunicationaripiprazole
WAprison2025-03-10

Inquest into the Death of Ricky-Lee COUND

22y · Male·ligature compression of the neck (hanging)

Ricky-Lee Cound, a 22-year-old Noongar man with Foetal Alcohol Spectrum Disorder (FASD), died by suicide in Hakea Prison on 25 March 2022 from ligature compression. Critical clinical lessons emerge: (1) his FASD diagnosi…

psychiatrypsychologydiagnosticcommunicationaripiprazole
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…

psychiatryemergency medicinediagnosticcommunicationketamine
QLDcommunity2025-02-11

Inquest into the death of Mohamad Ikraam Bahram

24y · Male·Multiple gunshot wounds

Mohamad Ikraam Bahram, a 24-year-old man with schizophrenia managed under a community treatment authority, died after being shot by police on Mary Street Brisbane following an unprovoked assault on a tourist. He had pres…

psychiatryforensic medicinesystemcommunicationaripiprazole
NSWcommunity2024-12-18

Inquest into the death of Olivia Gilffillan

23y · Female·unascertained

Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She …

psychiatryemergency medicinesystemclozapine

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