139 results
18y · Male·methadone toxicity
Thomas Ryan Keough, aged 18, died from methadone toxicity at Palm Lodge, a supported residential facility for people with mental illness, in August 2003. His body was not discovered for 48 hours after death. The coroner …
71y · Male·hypoxic brain injury due to hanging
A 71-year-old farmer with a 10-year history of major depressive disorder with melancholic features died by hanging on 22 July 2005, three days after admission to a private psychiatric hospital (Belmont) following a medic…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…
25y · Male·hypoxic-ischaemic brain injury due to plastic bag asphyxia
Graeme Eady, 25 years old with chronic depression first formally treated in July 2003, was admitted after a suicide attempt in September 2003. Following an altercation with another patient, he was transferred to H Floor …
31y · Male·Undetermined; most likely coronary atherosclerosis leading to arrhythmia, but as…
Sparka Huntington, a 31-year-old forensic mental health patient with a history of schizophrenia, violence, and drug use, died during physical restraint by hospital security officers and nursing staff on 14 December 2003.…
Female·multiple injuries due to a fall from height (suicide by jumping from multi-store…
A woman with major depressive disorder and psychotic features died by suicide at a shopping centre car park on 21 September 2004, six days after admission to Belmont Private Hospital under an involuntary treatment order.…
23y · Female·drowning and citalopram overdose
23-year-old woman with major depressive disorder presented to multiple healthcare providers on 17 March 2004 with suicidal ideation. She was referred to Flinders Medical Centre Emergency Department by her GP, where she w…
36y · Male·Multi-organ failure due to consequences of multiple injuries sustained following…
A 36-year-old man with chronic treatment-refractory paranoid schizophrenia was involuntarily detained in an acute psychiatric ward after a failed community trial. Despite being a documented high absconding risk, he was t…
51y · Male·ischaemic heart disease
A 51-year-old prisoner died from ischaemic heart disease after suffering a cardiac event while being transferred between prison units. He had complained of chest pain to correctional officers, was directed to walk to the…
67y · Male·Ligature Compression of the Neck (Hanging)
Robert David Abbott, aged 67, died by hanging in the secure ward of Joondalup Health Campus on 19 December 2003. He had a long history of depression exacerbated by chronic pain from a 2000 motor vehicle accident, and req…
20y · Male·diffuse cerebral oedema caused by hyponatraemia caused by excessive self-induced…
Jamie Johnson, 20, was intellectually disabled and lived in supported accommodation with carers. In June 2000, he was admitted with severe hyponatraemia and seizure from excessive water drinking (psychogenic polydipsia).…
Unknown·Multiple causes including neck compression due to hanging (Ward, Ryan, Cooper) a…
This inquest into four deaths on the Anangu Pitjantjatjara Lands involved multiple causes including hanging (three cases) and exposure with complications. Kunmanara Ward died by hanging while intoxicated with petrol; Kun…
36y · Male·hanging
Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Superviso…
29y · Male·Hanging
Craig Mark Allen, aged 29, died by hanging in cell 211 of Yatala Labour Prison on 16 October 2000, six days after admission for assault. Critical failures in prisoner management contributed to this preventable death. The…
21y · Male·multiple injuries from fall from water tower
A 21-year-old man with acute psychosis was admitted involuntarily to a psychiatric ward after being found climbing a power pole. After 8 days, despite being assessed at moderate suicide risk and displaying poor insight i…
15y · Male·compression of the neck by hanging
A 15-year-old Aboriginal male, Johnno Wurramarrba, from Groote Eylandt died by hanging in Don Dale Juvenile Detention Centre on 10 February 2000, while serving a 28-day sentence for property offences. Key preventable fac…
74y · Male·myocardial infarction
A 74-year-old male aged care resident died of myocardial infarction while detained under the Mental Health Act at Royal Adelaide Hospital. He had presented with hypokalaemia and sigmoid volvulus, refusing initial treatme…
21y · Male·Suffocation from hanging
Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…
52y · Male·Unascertained
GM, a 52-year-old man with bipolar affective disorder, died of unascertained causes after absconding from a mental health inpatient unit on 2 December 2015. He was admitted voluntarily for management of a suspected manic…
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