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NSWhospital2024-05-10

Inquest into the death of Finlay Browne

16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…

Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…

emergency medicinesurgerydiagnosticcommunication
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 January 2022 with self-harm and active suicidal ideation with a st…

emergency medicinepsychiatrysystemdelay
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…

sports medicineemergency medicinesystemdelaymidazolam
VICcommunity2024-05-02

Finding into death of Rodney Norman Galvin

21y · Male·Unascertained causes

Rodney Norman Galvin, age 21, disappeared from his home in Ballarat East, Victoria on 6 April 1987 and is presumed deceased. Despite extensive police investigation and multiple proof-of-life checks over decades, his body…

delaymethamphetamine
QLD2024-04-30

WILLIAMS, Russell James

51y · Male·Incised wound to the right arm

Russell Williams, aged 51, died by suicide in a Queensland prison on 15 May 2018 by cutting his right arm with a disposable razor blade. He was remanded on two historical murder charges and had spent 15 years in prison o…

psychiatrypsychologydiagnosticsystem
VIChome2024-04-29

Finding into death of Mr A

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…

psychiatrygeneral practicecommunicationsystemalcohol
VIChome2024-04-23

Finding into death of Caroline Anne Willis

69y · Female·Multiple stab wounds

Caroline Willis, aged 69, was fatally stabbed by her son Jamie in May 2018, two hours after he was served with a Family Violence Intervention Order (FVIO). The death was homicidal and occurred within a context of escalat…

psychiatrygeneral practicecommunicationsystemmethamphetamine
VIChome2024-04-23

Finding into death of Robert Norman Spencer

59y · Male·ischaemic heart disease in the setting of chronic ethanol use

Robert Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulan…

emergency medicineparamedicinesystemdelay
NSWcommunity2024-04-23

Inquests into the deaths of Mona Lisa and Jacinta Smith

Female·Mona: multiple internal injuries (including head and lung injuries) sustained in…

Mona Lisa Smith (16) and Jacinta 'Cindy' Rose Smith (15), Aboriginal girls from Bourke, NSW, died in a single-vehicle motor vehicle accident on 6 December 1987 when a Toyota utility driven by Alexander Grant rolled over …

forensic medicinediagnosticsystemalcohol
QLDhospital2024-04-22

Non-inquest findings into the death of Lenore

48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…

A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…

emergency medicineorthopaedic surgerydiagnosticsystemoxycodone
TASprison2024-04-18

Coroner's Finding: Gerard, Robert Harold

48y · Male·Hanging (partially suspended hanging using shoelaces as ligature)

Robert Harold Gerard, aged 48, died by hanging in Risdon Prison in May 2022 while on remand for serious charges. He had paranoid schizophrenia, a long history of substance abuse, and was experiencing depression and suici…

psychiatrycorrectional healthsystemdelayzuclopenthixol decanoate
VIC2024-04-18

Finding into death of Timothy Michael Funder

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…

psychiatrygeneral practicediagnosticdelayclozapine
NSWcommunity2024-04-18

Inquest into the death of Baby Q

0y · Female·unascertained

A nine-month-old First Nations child (Baby Q) was killed by her psychotic father in November 2018. The family, transient and homeless, were known to child protection and police in NSW and Queensland with complex mental h…

paediatricspsychiatrysystemcommunication
NSWcommunity2024-04-17

Inquest into the death of Michael Murray

44y · Male·Multiple blunt force injuries from fall from height

Michael Murray, aged 44, died following a fall from Landslide Lookout in the Blue Mountains. He had been diagnosed with borderline personality disorder (BPD) and chronic suicidality. His death highlighted critical gaps i…

psychiatrygeneral practicesystemdelaydiazepam
NSWhospital2024-04-12

Inquest into the death of Everett Carleton

0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …

Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …

obstetricsneonatologycommunicationprocedural
WAhospital2024-04-10

Inquest into the Death of Alan David RATCLIFF

65y · Male·complications of intracranial haemorrhage (hypertensive haemorrhage), with termi…

Alan David Ratcliff, a 65-year-old prisoner at Acacia Prison, died from complications of intracranial haemorrhage (hypertensive haemorrhage) on 20 June 2022. He collapsed on 12 June 2022 with stroke symptoms and was hosp…

neurologyemergency medicinedelay
WAhospital2024-04-08

Inquest into the Death of Child SK (Name Subject to Suppression Order)

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinici…

psychiatryemergency medicinesystemdelaysertraline
WAhospital2024-04-05

Inquest into the Suspected Death of Neil Lindsay KOBELT

27y · Male·unascertained

Neil Lindsay Kobelt, a 27-year-old man with diagnosed schizophrenia, disappeared from Kalgoorlie, Western Australia in February 1982, shortly after discharge from hospital for acute psychiatric crisis. He had relocated t…

psychiatrygeneral medicinecommunicationsystem
NThospital2024-04-05

Inquest into the death of Xysz Tacdliwaazy @Josh Ngalarina

22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)

A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block, they wer…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NSWhome2024-04-05

Inquest into the death of Todd McKenzie

40y · Male·gunshot wounds

Todd McKenzie, a 40-year-old man with treatment-resistant schizophrenia, died of gunshot wounds after a nine-hour police siege at his Taree home on 31 July 2019. Todd became acutely psychotic, waving a knife and expressi…

psychiatryforensic medicinediagnosticcommunication

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