Coronial
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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 hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…

psychiatrygeneral practicediagnosticcommunicationolanzapine
WA2026-02-02

Inquest into the Death of Joshua Fredrik VAN MALSSEN

24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…

Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…

cardiologyrespiratory medicinecommunicationsystemloratadine
VIChospital2025-08-18

Finding into death of B T

53y · Male·Complications of hypoxic brain injury secondary to mixed drug toxicity (methylam…

BT, a 53-year-old man with substance use disorder and mental health conditions, died from complications of hypoxic brain injury secondary to mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene). He inje…

emergency medicineintensive caremethamphetamine
TAShome2024-04-30

Coroner's Finding: Mason, Geoffrey

38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…

Geoffrey Russell Mason, aged 38, died from a gunshot wound to the neck fired by Constable Mitchell during a police response to a domestic incident on 17 February 2020 in Tasmania. Mason was intoxicated, had a long histor…

general practiceemergency medicinesystemalcohol
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure - cause undetermined

Robert John Ryan, aged 35, a farm worker at Malahide, suffered a sudden severe medical collapse on 7 January 2015, presenting with vomiting, sweating, confusion, hypothermia and incontinence. Diagnosed as chemical poison…

general practiceemergency medicineparoxetine
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

Robert John Ryan, a 35-year-old senior stockman, collapsed suddenly on 7 January 2015 at a farm gate near his workplace at Malahide in Tasmania, while driving his work utility during a normal workday. He presented with s…

toxicologyintensive carediagnosticdelayparoxetine
VICcommunity2023-10-09

Finding into death of Benjamin Paul Ray

Head and chest injuries from ballistic trauma (shotgun wounds)

Two men, Benjamin Ray (49) and Kevin Doherty (50), were fatally shot by Travis Cashmore (45) on a rural road in Victoria on 22 July 2022. Cashmore had growing animosity toward Doherty following a December 2021 incident w…

paroxetine
TAS2023-09-01

Coroner's Finding: Hunt, Paul George; Reynolds, Paul James; Darke, Simon Graham; Cooke, Robert Anthony

Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…

This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …

psychiatrypsychologysystemcommunicationpseudoephedrine
VIChospital2023-04-18

Finding into death of James Bernard Williamson

54y · Male·hypoglycaemic encephalopathy complicating multiple injuries in a man with chroni…

James Williamson, a 54-year-old man with diabetes, chronic lung disease, and ischaemic heart disease, died from hypoglycaemic encephalopathy following multiple traumatic injuries. He was found unresponsive in his apartme…

intensive careneurologymethamphetamine
QLDcommunity2023-04-05

Grimes, William George

31y · Male·Burns

31-year-old George Grimes with longstanding schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with …

psychiatryemergency medicinediagnosticcommunicationquetiapine
SAmental health2023-03-03

Coroner's Finding: Paxford, Mathew George

27y · Male·hanging

A 27-year-old man with deteriorating mental health and acute psychotic symptoms died by hanging from a bathroom door in an acute mental health unit. He had expressed suicidal ideation, told his parents he needed to die t…

psychiatryemergency medicinecommunicationsystemdiazepam
WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…

psychiatrycorrectional healthsystemcommunicationtramadol
VIC2022-07-18

Finding into death of Dominic Salvatore Mele

53y · Male·Mechanical asphyxia in the setting of a ride-on lawnmower incident (driver)

Dominic Salvatore Mele, a 53-year-old gardening contractor, died from mechanical asphyxia after a ride-on lawnmower rolled sideways while he was mowing across a steep 60-degree embankment. The Ferris F-50XT mower was not…

paroxetine
VIChome2022-05-25

Finding into death of Margaret Anne Brown

68y · Female·Cardiomyopathy with atrial fibrillation, pulmonary hypertension, and alcohol int…

Margaret Brown, a 68-year-old woman with significant cardiac disease (cardiomyopathy, atrial fibrillation, pulmonary hypertension) and chronic alcohol abuse, died at home from cardiomyopathy with alcohol intoxication as …

cardiologyemergency medicineamiodarone
WAhome2021-05-10

Inquest into the Death of Andre Walter BOND

42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…

Andre Walter Bond, a 42-year-old man with schizophrenia, schizoaffective disorder, Asperger's syndrome, and severe obesity, died from upper airway obstruction (choking) on food while dining at home. He had been recently …

psychiatryemergency medicinequetiapine
NSW2020-10-23

Inquest into the death of Ye Chiu

67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…

Ye Chiu, a 67-year-old Chinese-speaking prisoner on remand, died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hypona…

psychiatryemergency medicinesystemcommunicationparoxetine
VIChome2020-04-17

Finding into death of Karen Frazer

56y · Female·Cardiomegaly

Karen Frazer, a 56-year-old woman with intellectual disability, schizophrenia, anxiety, hypertension, and COPD, died from cardiomegaly (enlarged heart with biventricular hypertrophy). She was found unresponsive on the to…

forensic medicinegeneral practicecarbamazepine
WAcommunity2020-02-03

Inquest into the Death of Jose DA SILVA

34y · Male·unascertained; most likely immersion after swimming at City Beach

Jose da Silva, a 34-year-old man with a history of schizophrenia and problematic alcohol use, disappeared on 30 April 2017 from Perth, Western Australia. The coroner found he died on or about that date, most likely from …

psychiatrygeneral practiceolanzapine
SAhome2019-10-29

Coroner's Finding: LATTUCA Christophe Thomas Bruno

34y · Male·neck compression due to hanging

A 34-year-old male on home detention bail died by hanging. He had a history of mental health issues, depression, and prior suicide threats, but did not disclose these to correctional services staff. In the 24 hours befor…

general practicepsychiatryalcohol
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…

A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide attempts within 48 hours preceding as…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate

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