3,476 results
23y · Male·hypoxic brain injury and bronchopneumonia complicating ligature compression of t…
Jordan Robert Anderson, 23, died by suicide in Hakea Prison through ligature compression of the neck. Critical delays occurred when he was discovered unresponsive: 3 minutes 40 seconds elapsed before his cell door was un…
Male·The available evidence does not allow for any finding to be made as to the cause…
Bernard Gore, a man with Alzheimer's dementia, entered a fire stairwell at Westfield Bondi Junction shopping center in Sydney on 6 January 2017 and became trapped. He likely died within 24-48 hours from cardiac complicat…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…
89y · Male·multi-organ failure with pneumonia due to ingestion of a corrosive liquid (quate…
An 89-year-old man with severe dementia died from multi-organ failure following ingestion of concentrated Bacban (quaternary ammonium compound) left in his bathroom at an aged care facility. The cleaning staff member ina…
46y · Female·Hypoxic brain injury in the setting of plastic bag asphyxia
Michelle Williams, a 46-year-old woman with longstanding schizophrenia and depression, died from hypoxic brain injury due to plastic bag asphyxia while an involuntary inpatient in a psychiatric unit. On 27 August 2016, d…
48y · Male·Coronary atherosclerosis with acute cardiac event
Richard William Hobbs, aged 48, died from cardiac arrest in custody at Brisbane Correctional Centre on 21 November 2017. He had significant comorbidities including coronary artery disease (recent stent insertion), diabet…
Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…
Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …
volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…
This inquest examines three children (Master W aged 12, Miss B aged 17, Master JK aged 13) who died from volatile substance abuse in remote Aboriginal communities in the NT between 2018-2019. All three were known to gove…
30y · Male·unascertained
Daniel James Clement, a 30-year-old man with schizophrenia on a Psychiatric Treatment Order, disappeared from his mother's home in late May 2017 and was found deceased on the Murrumbidgee River in November 2017. His caus…
38y · Male·asphyxiation by ligature
A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotic…
34y · Female·morphine toxicity (morphine probably ingested as heroin), accidental death
A 34-year-old woman subject to a Psychiatric Treatment Order died from morphine toxicity (accidental heroin overdose). While no deficiency in clinical care was identified, the coroner highlighted a critical gap in inform…
20y · Female·Plastic bag asphyxia with inhalation of helium
A 20-year-old woman with a history of depression, anxiety, and self-harm died by helium inhalation asphyxia. She had been treated by her GP with antidepressants and mental health referral to a psychologist but never disc…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
38y · Male·combined effects of inhalation of products of combustion and incineration
Paul Scott Roberts, aged 38, died from incineration and inhalation of combustion products after setting himself alight during police attendance at his home on home detention bail. He had a history of chronic dysthymia, a…
20y · Male·Hanging
Mitchell Boyd Branson, aged 20, died by hanging in Mildura in June 2019. He had a documented history of mental illness including PTSD stemming from exposure to traumatic internet imagery at age 10, a prior suicide attemp…
4y · Female·volvulus of the large intestine
Tahlia Rose Bembridge, a 4-year-old with Down syndrome and prior mid-gut volvulus, presented to Bunbury Hospital ED with vomiting and abdominal pain on 1 October 2015. Initial assessment excluded acute bowel obstruction.…
42y · Male·ligature compression of the neck (hanging)
Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…
46y · Female·hypoxic brain injury due to hanging
A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation incl…
68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…
A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…
50y · Male·acute renal failure due to dehydration in relation to environmental exposure
Jamie Graham, a 50-year-old Aboriginal man with type 2 diabetes, cognitive impairment, and alcohol dependence, died from acute renal failure due to dehydration after being stranded with two companions on a remote road wh…
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