2,762 results
47y · Male·Hanging
A 47-year-old man with newly diagnosed schizophrenia died by hanging. He had presented with paranoid delusions and was engaged with mental health services in February 2017. Critical deficiencies were identified in the me…
Male·multiple injuries sustained in motorcycle crash
Dennis Green, a First Class Constable with WA Police, died on 7 December 2017 while undertaking a motorcycle training course on Julimar Road, Toodyay. His motorcycle crashed on a rural bend during a P1 (high-speed) devel…
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…
86y · Male·combined effects of acute myeloid leukaemia, acute renal failure and staphylococ…
Patrick Lawrence Walsh, aged 86, died in custody at Royal Adelaide Hospital from combined acute myeloid leukaemia, acute renal failure, and staphylococcal pneumonia. He had a significant medical history including ischaem…
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…
20y · Female·Neck compression
Maddison Murphy-West, a 20-year-old woman, died from neck compression on 23 October 2013 in circumstances highly suggestive of homicide by her de facto partner, Troy Boothey, despite an initial presentation as suicide. T…
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…
45y · Male·Shotgun wound to the head
XY, a 45-year-old Aboriginal man, died from a self-inflicted gunshot wound during a police response to a domestic violence incident. He had been struggling with depression, grief, alcohol and methamphetamine use for year…
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…
81y · Male·plastic bag asphyxia
George Cameron, an 81-year-old man, died by asphyxiation using a plastic bag while in custody at Parklea Correctional Centre on 8 September 2017. He had been remanded in custody three days earlier after arrest. A Recepti…
19y · Female·Unknown – not determined
Jasmine Morris was a 19-year-old Aboriginal woman last seen alive on 6 October 2009 in Grafton, NSW. She was reported missing on 20 October 2009 after a two-week absence. Despite extensive police investigation, her body …
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.…
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…
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…
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