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VIC2019-07-17

Finding into death of Fiona Warzywoda

33y · Female·Stab wounds to the chest (tension hemopneumothorax resulting from stab wounds)

A 33-year-old woman was fatally stabbed by her separated de facto partner following a 18-year relationship marked by escalating family violence. Multiple agencies had contact with the victim in the weeks before her death…

paediatricspsychiatrydiagnosticcommunication
WA2019-07-11

Inquest into the Death of Annabel NICOL

50y · Female·ligature compression of the neck (hanging)

Annabel Nicol, a 50-year-old woman, died by ligature compression of the neck (hanging) in Bandyup Women's Prison on 15 June 2015. She was a remand prisoner with chronic alcoholism, depression, and suicidal ideation who h…

psychiatrycorrectional healthsystemdelaymirtazapine
NSW2019-07-04

Inquest into the death of RP and DJ

Male·RP: fatal pressure to the neck; DJ: neck compression

Two remand inmates died in separate incidents at the Metropolitan Remand and Reception Centre after being placed with mentally ill cellmates exhibiting acute psychosis. RP died in 2010 from injuries inflicted by cellmate…

psychiatrydiagnosticcommunicationquetiapine
VIChospital2019-06-26

Finding into death of Trajce Laboski

27y · Male·Injuries sustained in descent from height

A 27-year-old man with schizophrenia was brought to Northern Hospital ED by police under Mental Health Act section 351 after threatening suicide and injecting testosterone. The Emergency Department doctor (Dr K.) assesse…

emergency medicinepsychiatrydiagnosticproceduraltestosterone
NSW2019-06-19

Inquest into the death of M A

44y · Male·Hanging

A 44-year-old man died by hanging in a prison cell two days after reception. Despite disclosing a history of depression and recent heavy methamphetamine use, he was not prescribed his usual escitalopram medication, was p…

psychiatrygeneral practicediagnosticcommunicationescitalopram
WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…

Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…

nephrologypalliative carecommunicationdelayinsulin
WAhospital2019-05-24

Inquest into the Death of Melanie Reanna TREGONNING

31y · Female·incised wounds to the neck and arms

A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…

emergency medicinepsychiatrycommunicationdiagnosticvenlafaxine
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
WAmental health2019-05-22

Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…

A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…

psychiatryemergency medicinecommunicationsystemchlorpromazine
WA2019-05-22

Inquest into the 5 Deaths in Casuarina Prison who are Mervyn Kenneth Douglas BELL and Bevan Stanley CAMERON and Brian Robert HONEYWOOD and JS (Name Subject to Suppression Order) and Aubrey Anthony Shannon WALLAM

Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…

Five male prisoners died by suicide at Casuarina Prison, Western Australia between 2014-2015. All deaths were by hanging or self-inflicted laceration. The coroner identified multiple systemic failures including: inadequa…

psychiatrypsychologysystemcommunication
WA2019-05-09

Inquest into the Death of Khamsani Victor JACKAMARRA (also known as Hajinoor)

36y · Male·Ligature compression of the neck (suicide by hanging)

A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…

psychiatryforensic medicinecommunicationsystemmethamphetamine
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…

psychiatryemergency medicinediagnosticcommunicationalcohol
QLD2019-05-08

Appleton, Garry Ronald

48y · Male·Hypovolaemic shock due to incised wounds to the arms; other significant conditio…

Garry Ronald Appleton, a 48-year-old Indigenous man with schizophrenia, emphysema, and coronary disease, died from hypovolaemic shock after cutting his forearms with a prison-issue razor blade while in custody at Brisban…

psychiatrypsychologycommunicationsystem
NT2019-05-07

Inquest into the death of Sean Daniel Collins

32y · Male·self-inflicted hanging

Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…

general practicepsychiatrydiagnosticcommunicationsertraline
WA2019-05-02

Inquest into the Death of Fazel CHEGENI NEJAD

34y · Male·ligature compression of the neck

Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…

psychiatrygeneral practicesystemcommunicationmirtazapine
VICcommunity2019-04-29

Finding into death of William Willms

63y · Male·Unknown

William Willms disappeared on 23 July 1973 at age 63 after boarding a bus to Lilydale railway station. He had recently self-discharged from psychiatric admission for endogenous depression and suicidal ideation. Despite e…

psychiatrygeneral practicesystemdelay
VICcommunity2019-04-16

Finding into death of Sophie Margery Nicholas

27y · Female·Injuries sustained in motor vehicle incident (pedestrian)

Sophie Nicholas, aged 27, died by suicide after being struck by a truck while walking along a road at 1:30am on 15 September 2016. She had longstanding borderline personality disorder (BPD) and alcohol dependency, with f…

psychiatryaddiction medicinecommunicationsystemalcohol
WAhospital2019-03-08

Inquest into the Death of Seanpol Martin Padraig O'NEILL

30y · Male·methadone toxicity

A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…

psychiatryemergency medicinecommunicationsystemmethadone
SAhospital2019-03-08

Coroner's Finding: PETERS Clinton Neal

40y · Male·metastatic malignant melanoma

A 40-year-old man with metastatic melanoma died at Queen Elizabeth Hospital on 2 September 2015. He had atypical nevi removed in 2009 and melanoma diagnosed in 2013, initially undergoing surgery with curative intent. How…

oncologyemergency medicinediagnosticdelay
NSWhospital2019-03-01

Inquest into the death of Stephen Kline

51y · Male·Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg bur…

Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. H…

plastic and reconstructive surgerypsychiatrydiagnosticsystemheparin
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