Coronial
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NSW2025-08-22

Inquest into the death of Michael Black

33y · Male·stab wound to the chest

Michael Black, a 33-year-old First Nations man, died from a stab wound to the chest while detained at Parklea Correctional Centre on 22 April 2020. He was stabbed by fellow inmate Emmett Sheard in a crowded holding cell …

correctional healthaddiction medicinediagnosticsystembuprenorphine
VICmental health2025-07-24

Finding into death of Mr SWX

32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity

A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …

psychiatryemergency medicinemedicationcommunicationolanzapine
SAhome2025-03-31

Coroner's Finding: Constantine, Matthew Keith

33y · Male·hypoxic-ischaemic encephalopathy due to hanging with resuscitation

Matthew Keith Constantine, aged 33, died from hypoxic-ischaemic encephalopathy following a hanging attempt while under home detention. He was released from prison in December 2021 with parole conditions including electro…

intensive careemergency medicinemethamphetamine
VICmental health2025-01-23

Finding into death of Matthew James Howarth

26y · Male·Coronary artery atherosclerosis in the setting of schizoaffective disorder

Matthew Howarth, 26 years old with schizoaffective disorder, died of coronary artery atherosclerosis while an inpatient at a mental health secure care facility. He was involuntarily admitted on 16 November 2022 with psyc…

psychiatryemergency medicinezuclopenthixol
NSWhome2024-11-08

Inquest into the death of Chi Khanh Huynh

52y · Male·Significant blunt head trauma suffered from an assault inflicted by known person…

Chi Khanh Huynh, a 52-year-old man with long-standing drug dependencies and prior head trauma from a September 2018 scooter accident, died following a severe assault by Cheng Chia involving multiple punches and elbow str…

forensic medicinetoxicologymethamphetamine
NSW2023-07-21

Inquest into the death of Reuben Button

34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…

Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…

psychiatrygeneral practicediagnosticsystembuvidal
VIChome2023-01-30

Finding into death of Veronica Nelson

37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…

Veronica Nelson, a 37-year-old Aboriginal woman with opioid dependence, was arrested on minor theft charges, remanded in custody following a bail hearing, and held at Dame Phyllis Frost Centre (DPFC) women's prison. She …

general practiceaddiction medicinediagnosticsystembuprenorphine/naloxone
VIChome2022-12-05

Finding into death of Paul Kenneth Wright

45y · Male·stab injury to the chest

Paul Kenneth Wright, aged 45, died from a stab wound to the chest inflicted in self-defence by Beau Muscat on 16 September 2021. Paul had an extensive custodial history, acquired brain injury, and intellectual disability…

general practiceforensic medicinesystemcommunicationmethamphetamine
TAShome2022-08-12

Coroner's Finding: Meades Michelle Louise

51y · Female·blunt force head injuries, stab wounds of the right neck and gagging

Michelle Louise Meades, aged 51, died from blunt force head injuries, stab wounds to the neck, and gagging following a violent assault at a residential unit in Tasmania. Ms Meades had a history of methamphetamine and mar…

forensic medicineaddiction medicinemethamphetamine
VIC2022-08-05

Finding into death of Y GE

Male·Hanging

YGE, a man with major depressive disorder, suicidality, and illicit substance use, died by hanging at the Neighbourhood Justice Centre on 28 December 2019. He was subject to a family violence intervention order and had b…

psychiatrygeneral practiceheroin
TAScommunity2022-07-29

Coroner's Finding: Chamberlain, Pamela Jacqueline

55y · Female·asphyxia due to choking on food (steak)

A 55-year-old woman with multiple comorbidities including morbid obesity, schizophrenia, depression, and substance use disorder died from asphyxia caused by choking on food while at a friend's home in supported accommoda…

emergency medicinepsychiatrysystemcommunicationdiazepam
VICcommunity2022-06-24

Finding into death of H YO

44y · Male·Heroin toxicity

A 44-year-old man with a 24-year history of opioid addiction died from heroin toxicity two days after release from prison on a Community Corrections Order. He had been on opioid replacement therapy (Suboxone) but discont…

addiction medicinecorrectional healthsystemdelayheroin
VIChospital2021-09-27

Finding into death of Abigail Louise Cooke-Mitchell

42y · Female·Traumatic right subdural haematoma

A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment …

emergency medicineneurosurgerycommunicationdelaymorphine
VIChome2020-11-20

Finding into death of Baby S

1y · Male·head injury

Baby S, a 12-month-old boy, died from head injuries inflicted by his mother's de facto partner, Mr B, while the mother was away obtaining heroin. The child had multiple previous injuries documented by childcare staff and…

paediatricsgeneral practicediagnosticcommunicationheroin
VIChome2020-11-06

Finding into death of Robert Thomas Love

33y · Male·Undetermined

Robert Thomas Love, a 33-year-old man with a history of alcohol and drug abuse and mental health difficulties, was found dead in his home in February 2015. The cause of death remains undetermined. Key clinical concerns i…

addiction medicinegeneral practicebaclofen
SAhome2020-10-12

Coroner's Finding: BABAKHANI Sina

21y · Male·heroin toxicity

A 21-year-old man died from heroin toxicity while on home detention bail. He had been engaged in a methadone program and psychological treatment for heroin addiction, PTSD, depression and anxiety since June 2015. Despite…

addiction medicinepsychiatryheroin
SAhome2020-07-16

Coroner's Finding: KEIPERT Mathew James

44y · Male·Ischaemic heart disease due to coronary atherosclerosis

Mathew James Keipert, age 44, died of ischaemic heart disease due to coronary atherosclerosis while on home detention bail. He had significant cardiovascular risk factors including hypertension, heavy smoking (40 cigaret…

cardiologygeneral practicediagnosticdelaybuprenorphine
SAhospital2020-06-25

Coroner's Finding: KARTINYERI Laura Rose

44y · Female·multi-organ failure and polypharmaceutical overdose on a background of severe ch…

Laura Rose Kartinyeri, aged 44, died from multi-organ failure and polypharmaceutical overdose on a background of severe COPD. She had a long history of substance abuse, non-compliance with treatment, and hospital present…

respiratory medicineintensive carepregabalin
NSWhospital2020-06-12

Inquest into the death of Thomas John KEDWELL

66y · Male·respiratory infection on a background of metastatic carcinoma

Thomas Kedwell, aged 66, died in custody at Prince of Wales Hospital from respiratory infection secondary to metastatic carcinoma. He had undergone laryngectomy and tracheostomy for throat cancer in 2017, and presented w…

oncologypalliative carebuprenorphine/naloxone
SAhome2020-05-28

Coroner's Finding: WHITE Jeffrey Thomas

35y · Male·heroin toxicity

Jeffrey Thomas White, 35, died from heroin toxicity while on home detention bail. He had a 13-year history of polysubstance abuse including heroin, amphetamines, and methamphetamine. Three days before death, he contacted…

addiction medicinegeneral practicedelayheroin

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