139 results
29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…
Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…
64y · Female·hypoxic ischemic encephalopathy caused by neck compression and hanging
A 64-year-old woman with a history of childhood trauma, anxiety and depression was admitted to an acute mental health unit (Kurrajong Unit) under involuntary care following a suicide attempt. Within 24 hours, she accesse…
64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …
Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…
28y · Male·Hanging
Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner foun…
Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…
This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …
51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …
Ziad Hamawy, a 51-year-old man with chronic schizophrenia and polysubstance use disorder, died from opiate toxicity after cardiac arrest following his discharge from Concord Hospital's mental health unit on 18 March 2019…
31y · Female·Plastic bag asphyxia
31-year-old Veronika Kouros, a voluntary inpatient at Northern Psychiatry Unit with bipolar affective disorder, obsessive-compulsive disorder, and depression, died by plastic bag asphyxia on 19 March 2018. Despite hospit…
43y · Male·Hanging
Mathew James Luttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hospital following a suicide attempt on 11 November 20…
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…
55y · Male·Hanging
Christopher Traill, a 55-year-old lawyer with alcohol dependence and depression, died by hanging in a psychiatric inpatient unit on 25 February 2017, just hours after admission as a compulsory patient. He used his belt a…
21y · Female·Neck compression
Kira Shae James, a 21-year-old with psychosis, borderline personality disorder, and eating disorder, died by ligature at Thomas Embling Hospital while an involuntary inpatient under Mental Health Act orders. She had a le…
30y · Male·Gunshot wounds to the chest
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…
43y · Male·Hanging
William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite cle…
11y · Male·Multiple injuries sustained when struck by train
Alex Raichman, 11, died when struck by a train after absconding from respite care at Civic Disability Services. Alex had autism, intellectual disability, and seizure disorder with documented absconding risk. Civic knew w…
47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…
Ian Fackender, aged 47, died from gunshot wounds during a Community Treatment Order breach enforcement operation in his home. He had severe, treatment-resistant schizophrenia and was acutely psychotic during the incident…
26y · Female·hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamph…
Ms Cherdeena Wynne, a 26-year-old Noongar Yamatji woman, died from hypoxic ischaemic encephalopathy and bronchopneumonia following cardiac arrest during police restraint on Albany Highway. She was intoxicated with methyl…
36y · Male·hanging
A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…
53y · Female·Ligature strangulation
Michelle Hughes, a 53-year-old woman serving her first prison sentence for assault committed during drug-induced psychosis, died by ligature strangulation in her cell at Dame Phyllis Frost Centre Women's Prison on 26 Jan…
54y · Female·unascertained
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…
34y · Male·Neck compression by hanging
Frederick Row Row, a 34-year-old Aboriginal man, died by suicide in Capricornia Correctional Centre following a precipitous change in risk assessment from high to low in less than 48 hours. After assaulting another priso…
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