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NSWpolice custody2026-03-20

Inquest into the death of Phillip Walton

48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…

Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…

emergency medicineparamedicinediagnosticcommunicationclozapine
NSWhospital2026-01-22

Inquest into the death of JC

30y · Male·hanging

JC was a 30-year-old with a long history of benzodiazepine dependence and previous psychiatric episodes triggered by withdrawal. He presented to Calvary Mater Hospital after a deliberate overdose of 48 Etizolam tablets w…

emergency medicinepsychiatrydiagnosticcommunicationetizolam
TAShome2026-01-07

Coroner's Finding: de-identified UN

43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…

A 43-year-old man with long-standing opioid use disorder and polysubstance dependence died from hypoxic brain injury following cardiac arrest caused by drug poisoning. He had been prescribed large quantities of pregabali…

general practiceemergency medicinemedicationdiagnosticmethadone
NSW2025-10-22

Inquest into the Death of Frank Dwayne COLEMAN

43y · Male·methadone toxicity

Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …

addiction medicinepsychiatrydiagnosticsystemmethadone
QLDhome2025-10-15

Inquest into the death of Tristian Jaemes Frahm

11y · Male·Brown snake envenomation

An 11-year-old boy died from brown snake envenomation after falling from a ride-on mower at a rural property. He exhibited early collapse symptoms (dizziness, vomiting, slurred speech) consistent with snake venom-induced…

emergency medicinetoxicologydiagnosticdelay
VICcommunity2025-08-25

Finding into death of Tracey Ellen Knowles

42y · Female·Unascertained; possibly mixed drug toxicity (heroin and methylamphetamine) or sm…

Tracey Ellen Knowles, aged 42, was found deceased in a vehicle on 19 July 2021 from an unascertained cause. She had a history of heroin use and experienced family violence. Police misidentified her as the 'predominant ag…

forensic medicinetoxicologysystemcommunicationheroin
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
QLDhospital2025-06-02

Non-inquest findings into the death of Mr B.

42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…

A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …

radiologyintensive carediagnosticmedicationphenol 80%
QLDhospital2025-03-31

Inquest into the death of Jamie Brian Campbell

43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…

A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …

emergency medicinetoxicologydiagnosticmedicationmethamphetamine
ACThospital2025-02-26

Inquest Into The Death Of Jessica Hilary Bovill

43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…

A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…

emergency medicinetoxicologymedicationcommunicationamitriptyline
QLDcommunity2024-11-18

Inquest into the death of Ashley Charles Washington

31y · Male·Undetermined

Ashley Washington, a 31-year-old Kamilaroi man, died after police restraint and sedation during arrest in Toowoomba. He was apprehended following a report of property theft and stabbed a police dog and officer with sciss…

emergency medicineparamedicinediagnosticcommunicationmethamphetamine
TAShome2024-10-29

Coroner's Finding: Bird, Helen Frances

43y · Female·asphyxia due to hanging

Helen Bird, aged 43, was found hanging in her garage in July 2010. While initially ruled suicide, a reopened coronial investigation found the coroner believes she was killed by her husband Mark Bird. Evidence showed Hele…

general practicepsychiatrydiagnosticprocedural
NSW2024-06-20

Inquest into the death of Michael Baker

44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…

Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…

general practicepsychiatrydiagnosticcommunicationmethadone
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…

general practicepsychiatrymedicationdiagnosticcodeine
NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…

psychiatrycardiologycommunicationdiagnosticamisulpride
NSWcommunity2024-02-19

Inquest into the death of Omar Mohammad

33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity

Omar Mohammad, a 33-year-old man with recent mental health concerns and drug use, ingested a small plastic bag containing cocaine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversi…

emergency medicinetoxicologycommunicationdelaycocaine
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

Robert John Ryan, a 35-year-old senior stockman, collapsed suddenly on 7 January 2015 at a farm gate near his workplace at Malahide in Tasmania, while driving his work utility during a normal workday. He presented with s…

toxicologyintensive carediagnosticdelayparoxetine
VICcommunity2023-12-15

Finding into death of Elly Rose Warren

20y · Female·Aspiration of sand; cause of sand aspiration not determined

Elly Warren, a 20-year-old Australian volunteer worker, died in Mozambique on 9 November 2016 from aspiration of sand. The coroner found the cause of death was sand obstruction of her airways, though the precise circumst…

forensic medicinetoxicologydiagnosticsystem
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
NSWhome2023-04-26

Inquest into the death of AX

70y · Female·Cause of death could not be determined - available evidence does not allow a fin…

A 70-year-old woman died unexpectedly at home in August 2017. Initially certified as hypertensive heart disease without autopsy, the death was later investigated as a potential homicide following allegations by her forme…

forensic medicinecardiologysystemdelaycandesartan

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