139 results
27y · Male·compression of the neck due to hanging
Theo Papageorgiou, a 27-year-old man with a history of psychotic and manic symptoms since November 2014, was briefly detained under a mental health order in November 2015 but discharged after only six days despite contin…
68y · Male·Metastatic Pancreatic Adenocarcinoma
Ivan Leo Goolagong, a 68-year-old Wiradjuri man, died of metastatic pancreatic adenocarcinoma while in Long Bay Prison Hospital Medical Subacute Unit in July 2017, five months after undergoing a Whipple procedure. The co…
56y · Female·acute pentobarbitone toxicity
56-year-old woman died from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health issues, depression, substance use, and prior self-harm. She had recently obtain…
74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest. Hassan Khalif Shire Ali: gunshot wo…
On 9 November 2018, Hassan Khalif Shire Ali committed a premeditated ISIS-inspired terrorist attack in Bourke Street, Melbourne, using an improvised explosive device in his vehicle followed by a knife assault. He fatally…
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…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…
45y · Male·Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)
A 45-year-old male prisoner died in custody from combined drug toxicity after ingesting methadone, amitriptyline, gabapentin and paracetamol. He had a documented history of hoarding and misusing prescribed medications to…
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…
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 …
46y · Female·hypoxic brain injury due to hanging
A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation incl…
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…
44y · Male·Cardiac arrhythmia during physical restraint
Taare Rangi, a 44-year-old man with bipolar affective disorder, died from cardiac arrhythmia during physical restraint in a mental health unit. Critical failures occurred at multiple levels: (1) the decision to acutely s…
2y · Female·drowning
A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurred: the chil…
81y · Female·Complications of choking on a food bolus in a woman with dementia
Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…
54y · Male·Neck compression (hanging)
Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicidal ideation, and opioid dependence. On 1 July …
25y · Male·Injuries sustained when struck by a train (suicide)
Damon Brenden Amiet, a 25-year-old with schizoaffective disorder, borderline personality disorder, and antisocial personality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serio…
27y · Male·ligature strangulation
A 27-year-old male with treatment-resistant schizophrenia died from ligature strangulation by a co-patient at a secure forensic mental health facility. The deceased had multiple admissions for medication non-compliance a…
49y · Male·Hanging
A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepean Hospital under involuntary detention. He died by hanging on 27 May 2017 during an …
29y · Male·cardiac arrhythmia
David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…
30y · Male·ligature compression of the neck (hanging)
Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple…
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