23 results
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…
74y · Male·Incised wounds to limbs; other significant conditions being ischaemic heart dise…
Garry Reginald Dubois, a 74-year-old serving a life sentence for serious offences, died in custody from self-inflicted incised wounds to his limbs. He was on dual antiplatelet therapy for ischaemic heart disease, which c…
21y · Female·Compression of the neck secondary to hanging
Lillian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a h…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
17y · Female·Neck compression by hanging (suicide)
XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …
57y · Male·Ischaemic heart disease in a man with chronic schizophrenia
Jon Lewis, a 57-year-old man with chronic schizophrenia, ischaemic heart disease, diabetes, hypertension, and cardiomyopathy, died from acute myocardial infarction or fatal cardiac arrhythmia at a specialist disability a…
61y · Male·head injury sustained on impact by a car
Leslie Wallace Taylor, a 61-year-old man with intellectual disability who could not communicate verbally, died from head injury sustained when struck by a motor vehicle on Ballarat Road, Sunshine on 1 October 2022. Mr Ta…
85y · Female·Complications of a left ankle fracture (operated)
An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…
45y · Female·Neck compression secondary to hanging
Claire Louise Carroll, 45, died by hanging while experiencing severe untreated psychotic symptoms including auditory hallucinations, paranoid delusions, and persecutory ideation. She had complex mental health diagnoses (…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
43y · Female·Hypoxic ischaemic encephalopathy secondary to out of hospital cardiac arrest due…
43-year-old woman with severe, undiscovered coronary artery atherosclerosis died from out-of-hospital cardiac arrest while in police custody at Dame Phyllis Frost Centre. She had presented to ED 5 months earlier with leg…
70y · Male·Hemopericardium due to ruptured aortic dissection contributed to by hypertension
Mr James Brown, a 70-year-old prisoner with a long-standing history of hypertension and atrial fibrillation, died from hemopericardium due to ruptured aortic dissection. He collapsed with chest pain while at work in the …
70y · Male·Coronary atherosclerosis
Mirko Civic, a 70-year-old prisoner with a significant cardiac history including prior myocardial infarction, hypertension, and ischaemic heart disease, died of coronary atherosclerosis in September 2018. Critical clinic…
41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…
A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…
59y · Male·Intracerebral haemorrhage
A 59-year-old man imprisoned at Hopkins Correctional Centre collapsed on 16 July 2019 with a left thalamic intracerebral haemorrhage with intraventricular rupture. He was transferred to Royal Melbourne Hospital where an …
95y · Female·Complications post scooter versus car incident
A 95-year-old woman died from complications of injuries sustained in a collision between her motorised mobility scooter and a car while crossing Raymond Street in Sale. She suffered flail chest, hemopneumothorax, and spi…
59y · Male·Disseminated carcinoma on a background of emphysema
Robert Fullerton, a 59-year-old Aboriginal man from Palm Island, died from disseminated carcinoma while remanded in custody at Townsville Correctional Centre. He presented with abdominal pain on 5 December 2018, was diag…
47y · Male·mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam and diazepam)
Matthew Clayton Lyons, a 47-year-old man with longstanding schizophrenia, severe anxiety, and substance abuse history, died from mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam, diazepam). He had expre…
49y · Female·hypoxic ischaemic encephalopathy complicating cardiac arrest due to pulmonary th…
A 49-year-old woman with morbid obesity, obstructive sleep apnoea, and psychiatric history was admitted following deliberate medication overdose. She was intubated, managed in ICU, then transferred to the ward where she …
36y · Female·Nicotine toxicity
Rachel Mihail, a 36-year-old with a complex psychiatric history including PTSD, depression, anxiety, and agoraphobia, ingested liquid nicotine at home on 22 November 2017 after calling mental health triage expressing sui…
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