4,457 results
57y · Male·Hanging
A 57-year-old male inmate died by hanging at Long Bay Correctional Centre in January 2018. Although he had been psychiatrically assessed as experiencing major depression with psychotic features and was recommended by a p…
43y · Female·suffocation
Ms K, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car va…
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medic…
59y · Male·Hanging
Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
0y · Male·Hypoxic ischaemic encephalopathy due to an out of hospital cardiac arrest second…
A 10-month-old boy drowned in a backyard fishpond after a 27-minute period of inadequate supervision. He was found unresponsive by his aunt and underwent prolonged resuscitation, suffering severe hypoxic brain injury. De…
19y · Male·In keeping with hanging
A 19-year-old male with depression and anxiety died by hanging at his home on 5 March 2021, hours after police and ambulance attended him in the early morning of 4 March following his brother's emergency call. Jet had co…
22y · Male·Immersion in water (drowning) in a man with combined drug effect
Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
58y · Male·Hanging
Zoran Alic, a 58-year-old Serbian-born man detained at Marngoneet Correctional Centre on family violence charges, died by hanging on 29 April 2019. He was referred for psychiatric assessment on 28 March 2019 after report…
5y · Female·Drowning
Alison Johns, aged 5 years, drowned in Lake Nagambie on 27 December 2022 while swimming with a borrowed inflatable ring in shallow water. A brief lapse in supervision occurred when her mother went swimming to a buoy; des…
1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…
A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…
37y · Male·unascertained
Cyril Levitsky disappeared from Callan Park Hospital in 1970 while under treatment for schizophrenia. He was never found, though an unidentified male body discovered nearby in December 1970 may have been him. Despite ext…
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…
31y · Female·unlawful homicide (manslaughter); specific cause could not be determined due to …
NW, aged 31, was killed by her partner on 9-10 October 2021 in Kununurra, Western Australia. She had a history of domestic violence victimization and had obtained a Family Violence Restraining Order. On the evening of he…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
25y · Male·Gunshot injury to the head
SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver under the influence of amphetamines, cannab…
Multiple causes: Child 1 - blunt force trauma to chest and abdomen; Child 2 - he…
This cluster inquest examined four Victorian child deaths (2015-2017) involving parents' partners as perpetrators. Children 1-4 died from blunt force trauma, head injury, fire, and neck laceration respectively. Key syste…
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…
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