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QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
NSWprison2021-06-11

Inquest into the death of F

49y · Male·hanging

A 49-year-old man with severe schizoaffective disorder died by hanging in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attem…

psychiatrycorrectional healthcommunicationsystemolanzapine
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicid…

psychiatryemergency medicinecommunicationsystemaripiprazole
VICmental health2021-05-28

Finding into death of Christopher John Peter Dewhurst

27y · Male·Multiple injuries sustained after being struck by a train

Christopher Dewhurst, 27, died by suicide after being struck by a train while on ground leave from a psychiatric unit. He was a compulsory patient subject to a Temporary Treatment Order, admitted with suicidal ideation a…

psychiatryemergency medicinecommunicationsystemdesvenlafaxine
NSW2021-05-26

Inquest into the death of Liam WOLF

19y · Male·unexpected arrhythmogenic event leading to a fall from height, blunt force head …

PTE Liam Wolf, a 19-year-old Australian Army recruit, died after collapsing on an obstacle course at Kapooka during the final training exercise. He experienced a sudden unexpected cardiac arrhythmia while climbing a ladd…

emergency medicinecardiologysystemdelay
VICcommunity2021-05-25

Finding into death of Kylie Jane Cay

44y · Female·haemoperitoneum due to ruptured splenic subcapsular haematoma in the setting of …

Kylie Cay, a 44-year-old woman, was brutally assaulted by her partner Justin Turner on 18 June 2016, sustaining rib fractures and other injuries. She was discharged from hospital on 20 June after imaging did not reveal a…

paramedicineemergency medicinediagnosticcommunication
QLD2021-05-24

SVE

43y · Male·Hanging

A 43-year-old man remanded in custody for serious sexual offences against children died by hanging in an older prison cell. While he expressed fears about safety and had passive suicidal ideation months before his death,…

psychiatrypsychologysystemdelay
QLD2021-05-24

Ahquee, Dylon James

19y · Male·Hanging

Dylon James Ahquee, aged 19, died by hanging in Townsville Correctional Centre on 26 December 2015. Despite documented self-harm and suicidal ideation as a juvenile, no Self-Harm Episode History flag was raised at adult …

correctional healthpsychologydiagnosticsystem
VICaged care2021-05-24

Finding into death of Julie-Anne Marie Kettle

56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels

Julie-Anne Kettle, a 56-year-old woman with intellectual disabilities residing in a group home, died from bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric…

general practicepsychiatrydiagnosticdelaylithium
NSWcommunity2021-05-21

Inquest into the death of Pono Wairua Aperahama

17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…

Pono Aperahama, a 17-year-old with severe traumatic brain injury and moderate intellectual disability, died from cardiac arrhythmia during restraint at a swimming pool. His escalating behaviour in 2017—triggered by schoo…

neurologypsychiatrysystemcommunication
VIChome2021-05-15

Finding into death of Ms ZT

27y · Female·Multiple sharp force injuries

Ms ZT, a 27-year-old Lebanese woman, was murdered by her husband Mr BR on 17 June 2016 through multiple sharp force injuries. The coroner's investigation revealed a prolonged pattern of severe domestic violence, physical…

communicationsystem
QLDcommunity2021-05-14

Cahill, Margaret Ann

61y · Female·Multiple drug (tapentadol, morphine, diazepam, citalopram) intoxication

Margaret Cahill, a 61-year-old nurse assistant, died from multiple drug intoxication after a GP administered 60mg intramuscular morphine without knowing she had consumed tapentadol 1-2 hours earlier. The coroner identifi…

general practiceemergency medicinediagnosticmedicationtapentadol
QLDhome2021-05-13

Baby J - Non-inquest findings

0y · Unknown·Category II Sudden Infant Death Syndrome (co-sleeping)

Baby J, a healthy 23-week-old infant, died from Category II Sudden Infant Death Syndrome (SIDS) associated with co-sleeping. He was found unresponsive while sleeping chest-to-chest with his father on makeshift bedding wi…

paediatricsemergency medicinesystemcommunicationmethamphetamine
NSW2021-05-12

Inquest into the death of Jack KOKAUA

30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …

Jack Kokaua, a 30-year-old with schizophrenia and coronary artery disease, died from malignant ventricular arrhythmia during a police encounter after absconding from hospital. Contributing factors included positional asp…

emergency medicinepsychiatryproceduralcommunicationzuclopenthixol
WAcommunity2021-05-10

Inquest into the Suspected Death of Jennie Anne KEHLET and the Death of Raymond Keith KEHLET

Female·Ray: homicide by a person or persons unknown involving blunt force trauma; Jenni…

A 47-year-old man (Ray) and 49-year-old woman (Jennie) died on or about 22 March 2015 during a prospecting trip in remote Western Australia near Sandstone. Ray's body was found in a disused mineshaft on 8 April 2015; Jen…

forensic medicineemergency medicinediagnosticdelay
NSWhospital2021-05-07

Inquest into the death of Channa

26y · Male·multiple injuries from fall from height

A 26-year-old man with schizophrenia was discharged from mental health inpatient care on a community treatment order without meeting his allocated case manager, confirmed accommodation, or drug and alcohol intervention. …

psychiatryemergency medicinecommunicationdelaypaliperidone
NSWhospitalPodcast2021-05-07

Inquest into the death of Brent Justin CROUGH

24y · Male·Complications of Brown Snake Bite

Brent Crough, a 24-year-old man, died from complications of brown snake bite in hospital. He was bitten on his right finger while separating the snake from his dog and was transported to Tamworth Base Hospital. Despite a…

emergency medicinetoxicologysystemdelaybrown snake antivenom
NSWcommunity2021-05-07

Inquest into the death of S

42y · Male·Gunshot wound to the head

A 42-year-old NSW Police Sergeant died from a self-inflicted gunshot wound while on highway patrol duty. One week prior, he had been notified of a criminal misconduct investigation by Professional Standards Command, but …

psychiatryoccupational and environmental healthsystemcommunication
QLD2021-05-04

Hambly, Scott

38y · Male·Aspiration pneumonia

Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …

cardiologypsychiatrycommunicationsystembisoprolol
VIChospital2021-04-30

Finding into death of Valerie Margaret Fraser

94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…

A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was n…

general medicinegastroenterologycommunicationdiagnostictamoxifen

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