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NSWcommunity2025-09-11

Inquest into the disappearance and suspected death of Andrew Corton

47y · Male·presumed death, actual cause unknown

Andrew Patrick Reuben Corton, a 47-year-old man with schizophrenia and cannabis use, disappeared and is presumed deceased. He was last sighted years before being reported missing. He resided in boarding houses and subseq…

psychiatryemergency medicinecommunicationsystemcannabis
NSWprison2025-09-10

Inquest into the death of RD

70y · Male·death by hanging, self-inflicted

A 70-year-old man died by hanging in prison while serving a sentence for child sexual offences. He had previously attempted suicide in 2017 when initially charged, and was subsequently treated with antidepressants and ps…

psychiatrygeneral practicecommunicationsystemsertraline
TAS2025-09-08

Coroner's Finding: Museum Cases

This finding concerns 177 specimens of human remains retained by the R.A. Rodda Museum following coronial autopsies between 1966 and 1991 without family consent or coronial authority. Forensic pathologists, particularly …

pathologyforensic medicineproceduralsystem
QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

Gina Valera, a 49-year-old woman with a history of depression and three prior suicide attempts, died by hanging in Brisbane Women's Correctional Centre nine days after admission on remand for attempted murder. She had be…

psychiatrycorrectional healthcommunicationsystemmirtazapine
NSWcommunity2025-09-08

Inquest into the death of Rohan Lloyd

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…

psychiatrygeneral practicediagnosticmedicationrisperidone
VICcommunity2025-09-05

Finding into death of R J

36y · Male·Heroin toxicity

A 36-year-old man with a history of homelessness and intravenous heroin use died from heroin toxicity after overdosing in a public toilet block. Emergency services were called promptly by a bystander who remained at the …

communicationsystemheroin
VICcommunity2025-09-05

Finding into death of Lisa Nicole Murphy

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…

emergency medicineintensive carecommunicationrisperidone
NSWprison2025-09-05

Inquest into the death of Dushyanthan Visvanathan

55y · Male·Complications of alcohol use disorder

Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…

addiction medicineemergency medicinecommunicationdocumentationdiazepam
VIChospital2025-09-03

Finding into death of Olivia Alexandra Evans

15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa

Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…

psychiatrypaediatricsdiagnosticsystemparacetamol
VIChome2025-09-02

Finding into death of Mr IKL

29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…

A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…

general practicepsychiatrydiagnosticmedicationgabapentin
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…

psychiatryemergency medicinediagnosticcommunicationolanzapine
TAShospital2025-08-29

Coroner's Finding: Scott, Nicholas Aaron

26y · Male·shotgun wound of the chest

Nicholas Aaron Scott, a 26-year-old prisoner with a history of self-harm, escaped from Royal Hobart Hospital on 2 January 2023 while under correctional officer supervision. He had been admitted for ingestion of foreign o…

correctional healthemergency medicineproceduralcommunicationmethamphetamine
VIChome2025-08-28

Finding into death of MJU & KJH

39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back

MJU (39) and her daughter KJH (6) were killed by MJU's husband CTH in a family violence homicide on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinati…

psychiatryemergency medicinediagnosticcommunicationmethamphetamine
NSWhome2025-08-28

Inquest into the death of KBS

1y · Male·Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrh…

A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib fractures, extensive bruising, and patterned…

paediatricsforensic medicinecommunicationsystemcannabis
VICcommunity2025-08-27

Finding into death of Conan James Smith

37y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

A 37-year-old man died in a deliberate head-on motor vehicle collision three days after his partner died from metastatic cancer. He was the sole carer for his 7-year-old son with autism and intellectual disability. The c…

psychiatrygeneral practicecommunicationdelaymirtazapine
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

A 7-year-old boy died in a head-on motor vehicle collision after his father deliberately drove their newly purchased car into an oncoming truck. The father had recently experienced severe stress following his partner's d…

paediatricspsychiatrycommunicationsystemmirtazapine
VICcommunity2025-08-25

Finding into death of Tracey Ellen Knowles

42y · Female·Unascertained; possibly mixed drug toxicity (heroin and methylamphetamine) or sm…

Tracey Ellen Knowles, aged 42, was found deceased in a vehicle on 19 July 2021 from an unascertained cause. She had a history of heroin use and experienced family violence. Police misidentified her as the 'predominant ag…

forensic medicinetoxicologysystemcommunicationheroin
NSWcommunity2025-08-25

Inquest into the death of Ashley Paull

49y · Male·Multiple injuries sustained when struck by a truck

Ashley Paull, a 49-year-old Aboriginal man with schizophrenia, died after being struck by a truck while walking along the Pacific Highway following his release from police custody. He had been stopped for a positive road…

psychiatryemergency medicinecommunicationsystemmethamphetamine
WAcommunity2025-08-22

Inquest into the Death of David Kalunda FLYNN

2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity

David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despi…

general practicegeneral surgerymedicationproceduralmorphine
NSW2025-08-22

Inquest into the death of Michael Black

33y · Male·stab wound to the chest

Michael Black, a 33-year-old First Nations man, died from a stab wound to the chest while detained at Parklea Correctional Centre on 22 April 2020. He was stabbed by fellow inmate Emmett Sheard in a crowded holding cell …

correctional healthaddiction medicinediagnosticsystembuprenorphine
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