124 results
20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…
Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…
29y · Male·Hanging
ZH, a 29-year-old man serving a 9-year sentence for drug supply, died by hanging in his minimum-security cell at Parklea Correctional Centre on 11 August 2021. The coroner found his death was self-inflicted. Key clinical…
91y · Male·Cholangiocarcinoma
Stanley Stewart, a 91-year-old man with advanced cholangiocarcinoma, died from natural causes at Northern Hospital. He resided in a disability group home and received palliative care from his GP and the Melbourne City Mi…
44y · Male·Unascertained
Mark Skidmore, a 44-year-old man, died in Port Phillip Prison on 14 February 2017. Post-mortem examination revealed multiple prescribed drugs (methadone, mirtazapine, pregabalin) and unprescribed drugs (clonazepam, trama…
21y · Male·Hypoxic brain injury in the setting of drug toxicity
21-year-old Bazouni Bazouni died from hypoxic brain injury following methamphetamine toxicity ingested at Port Philip Prison. While the coroner concluded the death was not preventable given the excessive drug ingestion, …
83y · Male·General inanition and aspiration pneumonia on a background of end-stage Alzheime…
An 83-year-old man with end-stage Alzheimer's dementia died from general inanition and aspiration pneumonia while subject to a Mental Health Act order in hospital. He had experienced two episodes of aspiration pneumonia …
60y · Male·sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and m…
Henry Allen, a 60-year-old man with oral squamous cell carcinoma, lung cancer, and multiple comorbidities died from sepsis and aspiration pneumonia while in prison custody at Fiona Stanley Hospital. He received appropria…
21y · Male·complications of ligature compression of the neck (hanging)
Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…
57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…
Kevin Bugmy, a 57-year-old Aboriginal man, died of severe coronary artery disease while in custody at Cessnock Correctional Centre. The coroner found the care received for his chronic inhalant use disorder was grossly in…
56y · Female·sepsis secondary to disseminated pancreatic adenocarcinoma
Julie Michele Dunn, a 56-year-old female prisoner, died of sepsis secondary to disseminated pancreatic adenocarcinoma. She had presented months earlier with gastrointestinal symptoms (weight loss, nausea, vomiting, epiga…
32y · Male·Subarachnoid haemorrhage due to ruptured cerebral aneurysm
Jeffrey Ellington, a 32-year-old Aboriginal male inmate, died suddenly from subarachnoid haemorrhage due to ruptured cerebral aneurysm while performing work duties at Long Bay Correctional Complex on 21 August 2020. Expe…
52y · Female·Mixed drug toxicity (methadone, pregabalin, valproic acid, benzodiazepines)
A 52-year-old woman with chronic pain, epilepsy, and opioid dependence died from mixed drug toxicity after prescribed methadone, pregabalin, valproic acid, and benzodiazepines. She was admitted to Box Hill Hospital on 12…
72y · Male·Multiple stab and incised wounds to the chest and neck
Barry Gray, aged 72, was killed by his 22-year-old neighbor John Woodruff on 16-17 May 2013. Woodruff had been diagnosed with first episode psychosis in prison and released on a Community Corrections Order (CCO) on 30 Ap…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…
25y · Male·Multiple organ failure due to acute paracetamol poisoning
Danny Whitton, a 25-year-old Aboriginal prisoner at Junee Correctional Centre, died from acute paracetamol toxicity causing multi-organ failure. He presented to the prison medical clinic on 5 November 2015 with vomiting …
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 …
35y · Male·Not determined
Benjamin Batalha, aged 35, died in custody at Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. H…
22y · Male·Hanging
A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hospital to police custody follow…
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…
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