142 results
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…
70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition
Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…
84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delir…
An 84-year-old man with Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency departmen…
42y · Female·Pneumonia, underlying severe cerebral palsy
Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…
63y · Male·pulmonary emphysema
Stanley McIntyre, a 63-year-old man with severe treatment-resistant schizophrenia, died from pulmonary emphasema on 23 June 2021 while subject to a Psychiatric Treatment Order. He had advanced COAD diagnosed only one mon…
79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…
John Reginald Wright, a 79-year-old remand prisoner, died from complications of peripheral vascular disease with diabetes, atrial fibrillation, cardiomyopathy and delirium. He was transferred to Princess Alexandra Hospit…
21y · Male·unascertained
Samaan Salah Tilmiz Elsamin, a 21-year-old with severe treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and extremely challenging violent behaviours, died at Joondalup Health Campus …
48y · Female·Combined effects of cardiac hypertrophy, chronic obstructive pulmonary disease a…
KD, a 48-year-old woman with chronic schizo-affective disorder, end-stage renal failure, COPD, cardiac hypertrophy and obesity, died from combined natural causes while under assessment order in psychiatric care. She pres…
57y · Male·Metastatic lung adenocarcinoma (stage IVA non-small cell lung cancer)
Trevor Charles Stone, a 57-year-old First Nations man imprisoned for sexual offences, died from metastatic lung adenocarcinoma with contributing comorbidities (diabetes, hypertension, dyslipidaemia, ischaemic heart disea…
24y · Male·neck compression secondary to hanging
Jamie Knowles, a 24-year-old with schizophrenia, died by suicide on 24 June 2024 while on an inpatient temporary treatment order at Kerferd Unit mental health service in Victoria. He was granted one hour of unescorted le…
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…
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 …
31y · Male·undetermined
Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas w…
36y · Male·ligature compression of the neck (hanging)
A 36-year-old man with schizoaffective disorder, traumatic brain injury, and substance use disorder died by ligature while an involuntary inpatient in a locked mental health ward. He was on hourly observations and had re…
63y · Male·Unascertained - natural causes. Cardiac arrest with secondary hypoxic-ischaemic …
A 63-year-old man with bipolar affective disorder, obstructive sleep apnoea, prostatic hyperplasia, and emphysema was admitted involuntarily to Northern Hospital on 24 March 2024 after exhibiting delirium and mania with …
34y · Male·Gunshot injuries to chest and left shoulder
Joseph Abela, a 34-year-old with chronic paranoid schizophrenia and polysubstance use, died from gunshot wounds inflicted by police during a mental health welfare check on 25 October 2021. Critical clinical failures prec…
84y · Male·Chronic small bowel obstruction
Lester Gilmore Shelton, aged 84, died of chronic small bowel obstruction on 4 October 2022 whilst in custody at Princess Alexandra Hospital (PAH), where he had been transferred from prison for end-of-life care. He had a …
36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…
Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…
66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…
Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…
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