66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
40y · Male·neck compression consequent upon hanging
Ross Campbell, a 40-year-old man with a history of family violence perpetration, alcohol abuse, and undiagnosed mental illness, died by hanging. He had attended a Men's Behavioural Change Program in 2011 following a fami…
79y · Male·head injuries sustained in a fall from a bicycle
A 79-year-old man died from head injuries sustained in a bicycle fall on a rural road. While riding at approximately 40 km/h on a descent, he swerved to avoid mud and debris on the road surface, struck another cyclist's …
Male·drowning
Tony Guan died by drowning at Ascot Vale Leisure Centre in 2014. The coronal inquiry identified that three staff members were present but failed to notice the incident, highlighting systemic failures in pool supervision.…
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…
35y · Unknown·effects of fire
A 35-year-old died in a house fire on 26 November 2022 after inhaling smoke and toxic fire products. The fire originated in an upstairs bedroom, likely from an electrical device (vape or iPad) or smouldering cigarette. S…
51y · Male·Complications of chronic ethanol use
EH was a 51-year-old man with chronic alcohol dependence, liver cirrhosis, and recent hip fracture complications who died at home on 1 November 2022 whilst waiting for an ambulance. He had self-discharged from St Vincent…
19y · Male·Gunshot wound inflicted by NSW police officer during armed robbery
Ali Antoni El Hafiane, aged 19, was fatally shot by NSW Police during an armed robbery at the High Flyer Inn on 22 November 2010. The coroner found that while police acted courageously, the operation was poorly planned a…
13y · Female·Chest and Head Injuries sustained in motor vehicle crash
A 13-year-old Aboriginal girl was a passenger in a stolen vehicle that was pursued by Western Australian police. The vehicle driver, also aged 13 and inexperienced, lost control during the pursuit, causing the vehicle to…
83y · Female·Complications following fracture and surgical repair of the left hip in an elder…
Mrs Nola Inez Daniel, an 83-year-old with chronic lung disease, osteoporosis, and cardiac disease, was admitted to Regis Forrest Gardens for respite care on 24 December 2009. She sustained three falls on Christmas Day, w…
56y · Female·Bronchial asthma and emphysema
A 56-year-old woman with long-standing schizophrenia, COPD, emphysema, and heavy smoking died during overnight leave from psychiatric hospitalisation. She was granted leave to check on her cat at her remote home on 24 Ma…
35y · Male·drowning (immersion)
Damien Mills, a 35-year-old mortgage broker, drowned in the Indian Ocean after falling off a charter boat returning from Rottnest Island on 31 October 2014. While intoxicated, he was likely knocked overboard during rough…
69y · Female·Intra-abdominal sepsis and shock with multi-organ failure following intestinal p…
A 69-year-old woman died from intra-abdominal sepsis and multi-organ failure following a perforated caecum that occurred after lumbar spine surgery. Post-operatively, she developed abdominal distension and pain initially…
57y · Female·Multiple penetrating (stab) injuries to the body and neck
Satwant Kaur, aged 57, was murdered by her stepson in her home on 5 December 2013 after he made multiple threats to kill her while in custody. Critical failures in intelligence sharing between the Department of Correctiv…
Unknown·Multiple injuries sustained in motor vehicle collisions
This complex coronial finding examined six deaths arising from police pursuits in Western Australia between 2012-2014. The deceased included taxi driver Kuldeep Singh and passenger Dr D. (killed in a collision with a sto…
18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration
An 18-year-old female, a naive drinker, consumed approximately 19-21 standard drinks over a few hours at her birthday party, including vodka cruisers, a full-strength Midori drinking game, and Polmos (95% alcohol). She r…
22y · Female·Unable to determine - open finding
Petronella Albert, a 22-year-old Aboriginal woman from Broome, disappeared in late April or early May 1999 and is presumed deceased. The coronial inquest, conducted in 2017, established her death beyond reasonable doubt …
41y · Male·unknown
Dean Anthony Pollard was a 41-year-old man with a long history of schizophrenia and amphetamine-induced psychotic disorder who disappeared in May-June 2010 and is presumed dead. He had multiple psychiatric admissions bet…
54y · Male·Unknown - death established on balance of probabilities but manner and cause und…
A 54-year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prio…
41y · Male·atropine toxicity
A 41-year-old man with schizoaffective disorder, intellectual disability and sexual offending history died from atropine toxicity after ingesting 6-8ml of atropine liquid prescribed for hyper-salivation. He had been disc…
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