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WAhome2026-08-04

Inquest into the Death of Paul Shen Vun WONG

40y · Male·Carbon monoxide toxicity

Paul Shen Vun Wong, a 40-year-old man with treatment-resistant schizophrenia and schizoaffective disorder, died from carbon monoxide toxicity at his Rockingham home in April 2023 while subject to a Community Treatment Or…

psychiatrygeneral medicinecommunicationsystemolanzapine
VICaged care2026-07-29

Finding into death of Lynette Patricia McHarry

69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…

Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…

geriatric medicinegeneral practicemedicationsystemclozapine
NSWcommunity2026-07-17

Inquest into the death of John Aramathuparambil John

62y · Male·complications of chronic alcohol misuse and olanzapine toxicity

John Aramathuparambil John, a 62-year-old with chronic alcohol dependence and depression, was arrested for trespass following a confused intrusion into a home on 6 June 2023. Police noted confusion and apparent intoxicat…

psychiatryaddiction medicinediagnosticcommunicationolanzapine
NSW2026-07-13

Inquest into the death of BS

34y · Male·Hanging

BS, a 34-year-old man with PTSD and depression from previous custodial assault, was remanded on drug importation charges at MRRC during COVID-19 restrictions. Critical clinical failures included: (1) 118-day delay in psy…

psychiatryforensic medicinediagnosticmedicationparacetamol
QLDhospital2026-07-07

Inquest into the death of Maxwell John Beever

83y · Male·Metastatic melanoma

Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…

emergency medicinegeneral medicinedelaydiagnosticoxycodone
WAhome2026-06-29

Inquest into the Death of David William LAVARS

Male·phosphine toxicity in a man with atherosclerotic heart disease

Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …

toxicologyparamedicineproceduralcommunicationaluminium phosphide
NSWmental health2026-06-23

Inquest into the death of SK

34y · Male·multiple gunshot wounds

SK, age 34, died on 10 January 2024 after being shot 12 times by NSW Police tactical officers at a medical practice in Nowra. He had chronic schizophrenia, opioid dependence, and was experiencing active psychosis. His GP…

general practicepsychiatrydiagnosticsystemmethadone
NThome2026-06-19

Inquest into the death of RL

17y · Male·Suicide by self-inflicted hanging

RL was a 17-year-old Alice Springs teenager who died by suicide while under Northern Territory mental health services' care. Critical clinical lessons emerged: failure to inform his mother about mental health deteriorati…

psychiatrypsychologycommunicationdiagnostic
SA2026-06-02

Coroner's Finding: Taylor, Nathan James

40y · Male·Unascertained

Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…

cardiologygeneral medicinediagnosticsystempaliperidone
NSWcommunity2026-05-19

Inquest into the death of Dion White-Cotterell

45y · Male·Multiple stab wounds

Dion White-Cotterell, 45, was stabbed to death (83 wounds) on 28 February 2019 by his neighbour Benjamin Moore in an unprovoked attack outside their townhouse in Parramatta. Moore, suffering acute schizophrenia relapse w…

psychiatrysystemcommunication
NSW2026-05-01

Inquest into the death of PE

53y · Male·Hanging

PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoi…

general practicepsychiatrysystemdelay
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication
SA2026-04-23

Coroner's Finding: Nash, Russell

Male·suicide

Russell Peter Nash, a serving South Australian Police officer and Bandmaster, died by suicide in 2021. Before his death, he complained of bullying and harassment by his Chief Inspector. His former supervisor subsequently…

occupational and environmental healthpsychiatrysystemcommunication
VIC2026-04-22

Finding into death of Natasha Stojkoski

38y · Female·Multiple injuries sustained when struck by a train

Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…

psychiatryoccupational and environmental healthsystemcommunicationescitalopram
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…

psychiatrypaediatricsdiagnosticsystem
VIChome2026-04-17

Finding into death of Simon Christopher Gaskill

50y · Male·unascertained

Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…

emergency medicinegeneral medicinecommunicationsystemalcohol
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone
VIChome2026-04-14

Finding into death of Justin James Filardo

45y · Male·Gunshot wounds to the head and left shoulder

Justin Filardo, aged 45, with a 28-year history of schizophrenia, was fatally shot by police after assaulting his sister Bianca in her bedroom. In the weeks prior, Justin had ceased his clozapine medication without clini…

psychiatrygeneral practicesystemdelayclozapine
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

DR was a 41-year-old man with bipolar disorder, severe alcohol dependence, and multiple psychosocial stressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …

psychiatryforensic medicinecommunicationsystemdiazepam
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