179 results
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…
Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…
50y · Male·ligature compression of the neck (hanging)
Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…
20y · Male·gunshot wound to the chest
A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…
59y · Male·compression of the neck secondary to hanging
A 59-year-old man with treatment-resistant depression, anxiety, and suicidal ideation died by hanging while on weekend leave from psychiatric care. He had been hospitalised four times in 2021 and was receiving electrocon…
62y · Male·not stated - body never found
KL, a 62-year-old journalist with a long history of depression, anxiety, and alcohol use disorder, was admitted to St Vincent's Hospital's psychiatric units (PECC and Caritas) in June 2020 following suicidal ideation. Af…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
50y · Male·Neck compression secondary to hanging
Jason, age 50, was found deceased by hanging at a footbridge in Kerang, Victoria on 18 October 2021, following an incident of family violence perpetrated by him against his partner 'P'. The coroner's investigation identi…
32y · Female·Neck compression in the setting of self-suspension
A 32-year-old woman with a documented history of intimate partner violence died by self-suspension. She had reported ongoing physical, sexual and psychological abuse to police on 12 May 2020 and was assessed under mental…
44y · Female·Neck compression in the circumstances of hanging
A 44-year-old woman died by hanging following rape in 2014 and protracted criminal proceedings. She experienced ongoing trauma and PTSD exacerbated by reopening her complaint and multiple court processes. She had multipl…
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 …
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 …
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…
16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…
LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…
32y · Male·Neck compression in the setting of hanging
Mr A, a 32-year-old male with a history of family violence perpetration, mental illness (bipolar disorder, schizophrenia, PTSD), substance misuse, and prior suicide attempts, died by hanging on 21-22 November 2020. He wa…
74y · Male·Small bowel obstruction due to extensive intra-abdominal adhesions
Timothy Funder, a 74-year-old man with schizophrenia, chronic obstructive pulmonary disease, and previous small bowel obstruction, died from small bowel obstruction due to extensive intra-abdominal adhesions. He presente…
42y · Female·Drowning due to combined drug (tramadol, venlafaxine, diazepam, quetiapine and c…
A 42-year-old woman with bipolar disorder, chronic pain, and emphysema died by drowning while scuba diving in shallow water after a 3-year hiatus from diving. She was taking multiple CNS-depressant medications (tramadol,…
59y · Male·incised injuries to the neck
Paul McLoughlin, a 59-year-old man with long-standing bipolar affective disorder, schizoaffective disorder, and heavy cannabis use, died by suicide via incised neck wounds while on day leave from Graylands Hospital. He w…
46y · Male·Multiple injuries sustained in a motorcycle incident
A 46-year-old man of Aboriginal descent died in a motorcycle accident on 21 March 2020 in Mildura, Victoria. He was riding an unregistered, unmaintained motorcycle that he had not been licensed to ride, and had consumed …
45y · Female·combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, queti…
QD, a 45-year-old woman with significant comorbidities including obesity, obstructive sleep apnoea, COPD, depression, and substance abuse history, died from mixed drug and alcohol intoxication. Toxicology revealed toxic/…
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