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WAhome2026-08-04

Inquest into the Death of Paul Shen Vun WONG

40y · Male·Carbon monoxide toxicity

Paul Shen Vun Wong, a 40-year-old man with treatment-resistant schizophrenia and schizoaffective disorder, died from carbon monoxide toxicity at his Rockingham home in April 2023 while subject to a Community Treatment Or…

psychiatrygeneral medicinecommunicationsystemolanzapine
VIChospital2026-07-27

Finding into death of Alan Gordon Wolstenholme

72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…

A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…

cardiologyemergency medicinemedicationsystembuprenorphine
VIChome2026-07-02

Finding into death of AQV

32y · Male·Multiple injuries sustained in a fall from a height

AQV, 32, had escalating depression, alcohol use disorder, and suicidal ideation while perpetrating family violence against his partner. In June 2024, following an overdose with suicidal intent in NSW, he underwent a comp…

psychiatrygeneral practicealcohol
WA2026-06-08

Inquest into the Death of Mason SHAHZAD

40y · Male·ligature compression of the neck (hanging)

Mason Shahzad, a 40-year-old sentenced prisoner serving 30 years for serious family violence offences, died by ligature hanging in his cell at Acacia Prison on 11 November 2024. He had a history of depression, PTSD, and …

psychiatrycorrectional healthescitalopram
VIC2026-04-22

Finding into death of Natasha Stojkoski

38y · Female·Multiple injuries sustained when struck by a train

Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…

psychiatryoccupational and environmental healthsystemcommunicationescitalopram
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
WA2026-03-26

Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

Brian Kealy, aged 42, died by suicide via hanging at Hakea Prison on 2 August 2024 while on remand. He had complex mental health needs including probable schizophrenia, anti-social personality disorder, and polysubstance…

psychiatrygeneral medicinecommunicationsystemolanzapine
VIChome2026-02-17

Finding into death of Laurence Mark O'brien

22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…

Laurence O'Brien, a 22-year-old with acquired brain injury from a childhood motor vehicle accident, died from mixed drug toxicity involving eight substances including prescribed opioids, benzodiazepines, and unprescribed…

general practicepsychiatrymedicationsystemtapentadol
WAhome2026-01-23

Inquest into the Death of Sean Theo WINMAR (Mr STW)

46y · Male·Complications of ligature compression of the neck (hanging)

Sean Theo Winmar, a 46-year-old Aboriginal man, died by suicide on 11 August 2022 while on an interim supervision order after his release from prison. He had depression, substance use disorder, and chronic suicidal ideat…

general practiceaddiction medicinesystemdelaymethamphetamine
VIChome2026-01-08

Finding into death of L L

34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…

A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…

general practicerespiratory medicinesystemcommunicationgabapentin
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
NSWcommunity2025-11-03

Inquest into the death of JF

60y · Female·multiple injuries

JF, a 60-year-old woman with recurrent major depressive disorder and a history of suicide attempts, died by suicide at Redhead Headland on 12 February 2024. Despite three prior psychiatric hospitalizations and documented…

psychiatrygeneral practicesystemmirtazapine
VIC2025-10-27

Finding into death of Andrew Ewen Mallett

41y · Male·Undetermined, likely drowned

Andrew Mallett, a 41-year-old strong swimmer with fitness background, disappeared and is presumed drowned at Artillery Rock near Lorne on 28 November 2024. He entered the water to spearfish despite hazardous conditions i…

escitalopram
VIChome2025-06-05

Finding into death of Caine David Knight

26y · Male·Cardiomegaly in a man with Prader-Willi syndrome

Caine David Knight, aged 26, died from cardiomegaly with right ventricular hypertrophy in the context of Prader-Willi syndrome and severe obesity. He had a complex medical history including obesity hypoventilation syndro…

cardiologyrespiratory medicinequetiapine
VIChome2025-05-08

Finding into death of Mrs R

57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)

Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a p…

psychiatrygeneral practicecommunicationsystemescitalopram
TAShome2025-05-06

Coroner's Finding: de-identified YZ

59y · Male·Shotgun wound to the head

A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…

general practicepsychiatrycommunicationsystemescitalopram
WA2025-05-05

Inquest into the Suspected Death of David Benjamin INGRAM

44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…

David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChome2025-05-02

Finding into death of Rory James Van Geleuken

31y · Male·compression of the neck secondary to hanging

Rory Van Geleuken, a 31-year-old with longstanding major depressive disorder, generalised anxiety disorder, autism spectrum disorder, and ADHD, died by hanging. He had received mental health treatment since age 17, inclu…

psychiatrygeneral practiceescitalopram
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

Male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…

psychiatryemergency medicinediagnosticcommunicationescitalopram
VICcommunity2025-03-04

Finding into death of Andrea Dorothy Milner

55y · Female·Multiple injuries sustained in a train incident

Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…

psychiatrypsychologyescitalopram

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