255 results
57y · Male·Neck compression and hanging
A 57-year-old man with schizophrenia and schizoaffective disorder died by hanging in prison on 4 August 2024. He had been receiving antipsychotic treatment via injection (paliperidone) but ceased antipsychotic medication…
63y · Male·Effects of fire
A 63-year-old man with bipolar disorder, Crohn's disease, ADHD and HIV died in a residential fire at his apartment. He was found with evidence of unsafe smoking in bed, including numerous cigarette butts throughout his u…
44y · Male·unascertained
Matthew Benjamin Holding, aged 44, died suddenly in prison on 2 January 2023. He had schizophrenia managed with antipsychotics and severe obesity (BMI 41.6). In December 2022, he showed signs of significant deterioration…
78y · Male·Acute pancreatitis
A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiting at Thomas Embling Hospital…
70y · Female·Multi-organ dysfunction complicating sepsis of unknown origin in setting of Alzh…
Suzanne Craig Morter, aged 70, with Down Syndrome and Alzheimer's dementia died from sepsis with multi-organ dysfunction of unknown origin. She collapsed at home on 9 May 2024 and was taken to hospital where investigatio…
48y · Female·Unascertained; presumed sudden cardiac arrhythmia
A 48-year-old woman with cerebral palsy, intellectual disability, and multiple comorbidities died unexpectedly in residential care. Post-mortem examination showed acute pulmonary oedema and intra-alveolar haemorrhage wit…
82y · Male·Ischaemic and hypertensive heart disease
An 82-year-old man with extensive medical comorbidities including ischaemic heart disease, triple vessel coronary artery disease (previously bypass grafted), diabetes, chronic kidney disease, and dementia died suddenly i…
64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis
Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…
54y · Male·Global hypoxic brain injury, cardiac arrest and blunt trauma to cervical spine
JI, a 54-year-old man with chronic schizophrenia, died from global hypoxic brain injury, cardiac arrest and cervical spine trauma following a fall onto a metal grate during an altercation with another resident at support…
37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …
A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…
52y · Female·unascertained - likely combination of underlying natural disease (myocardial inf…
Lisa Murphy, a 52-year-old woman with mental illness and substance use history, died following a physical altercation at a convenience store. She became involved in a verbal and physical confrontation with two women afte…
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…
9y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian)
Aluel Ajak, a 9-year-old girl with autism spectrum disorder, severe developmental delay, and moderate intellectual disability, died from injuries sustained when struck by a motor vehicle after absconding from her home. S…
61y · Female·Complications of Down's syndrome, epilepsy and advanced dementia
Jennifer Clayden, 61, with Down's syndrome, epilepsy and advanced dementia, died in Specialist Disability Accommodation on 9 May 2024 from complications of her underlying conditions. She had been transitioned to comfort-…
54y · Female·Unascertained - Definite SUDEP (Sudden Unexpected Nocturnal Death in Epilepsy)
A 54-year-old woman with epilepsy, intellectual disability, schizophrenia, and dementia died suddenly at her supported disability accommodation facility. She was observed asleep and snoring at 9:30pm; by 9:45pm she was u…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
47y · Male·Compression of the neck arising from hanging
47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinat…
24y · Male·Sudden unexpected death in epilepsy (SUDEP)
Aaron Forte, a 24-year-old man with epilepsy, Jacob's XXY Syndrome, intellectual disability, and schizophrenia, died of sudden unexpected death in epilepsy (SUDEP) while in specialist disability accommodation. He was fou…
33y · Male·hanging
Moses Kellie, aged 33, died by hanging at Villawood Immigration Detention Centre in January 2019 after four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attem…
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…
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