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NSWcommunity2024-02-20

Inquest into the death of Jasmynd Gibbs

33y · Male·Complications of methylamphetamine use

Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health di…

correctional healthpsychiatrysystemcommunicationmethamphetamine
VIC2024-02-19

Finding into death of John Robert Gregg

52y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to coronary artery …

John Gregg, 52, died from hypoxic ischaemic encephalopathy and multi-organ failure following cardiac arrest during a recreational scuba dive. Autopsy revealed severe coronary artery atherosclerosis and borderline cardiom…

emergency medicineintensive carediagnosticcommunication
NSW2024-02-19

Inquest into the death of Siosiua Mateaki He Lotu Meyer

48y · Male·Complications of infective exacerbation of bronchiectasis with cor pulmonale

A 48-year-old man with a significant history of bronchiectasis died in police custody from infective exacerbation of bronchiectasis with cor pulmonale. The inquest examined whether police took appropriate steps to obtain…

respiratory medicineemergency medicinedelaysystem
TAS2024-02-15

Coroner's Finding: Joshua John Dingjan

24y · Male·Blunt trauma to the head, neck and chest sustained when a forklift toppled onto …

Joshua John Dingjan, aged 24, was fatally crushed when a Mitsubishi forklift overturned while he was attempting to unload a 1.9-tonne steel pack from a delivery truck parked perpendicular to the factory on a slope of app…

systemcommunication
WA2024-02-06

Inquest into the Death of Phillip John ALLEN

47y · Male·ligature compression of the neck (hanging)

A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation, delusions about 'black magic', and auditory hallucinations, which wer…

psychiatrycorrectional healthcommunicationsystem
VIChome2024-02-05

Finding into death of Ms KSI

22y · Female·Complications of cutaneous burns

A 22-year-old woman from Afghanistan died from complications of severe burns (75%+ body surface area) sustained during self-immolation on 5 February 2018. She was experiencing family violence from her husband and in-laws…

general practiceemergency medicinecommunicationsystem
NTcommunity2024-02-02

Inquest into the death of Shane Tapp

43y · Male·Not able to be determined

Shane Tapp, a 43-year-old man involved in illegal drug distribution in Katherine NT, was found dead in the Katherine River on 12 April 2021. His body showed advanced decomposition limiting post-mortem examination. He was…

forensic medicinetoxicologysystemdelaymethamphetamine
NSW2024-02-01

Inquest into the death of Timothy Garner

31y · Male·Hanging

Timothy Garner, a First Nations man with bipolar disorder and schizophrenia, died by hanging in custody at MRRC on 7 July 2018, five days after being cleared from Risk Intervention Team (RIT) management. The coroner foun…

psychiatrycorrectional healthdiagnosticcommunicationquetiapine
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

Robert John Ryan, a 35-year-old senior stockman, collapsed suddenly on 7 January 2015 at a farm gate near his workplace at Malahide in Tasmania, while driving his work utility during a normal workday. He presented with s…

toxicologyintensive carediagnosticdelayparoxetine
NSWhospital2024-01-30

Inquest into the death of Subash Subedi

26y · Male·Not able to be determined - skeletalised remains

Subash Subedi, a 26-year-old international student from Nepal, died in a stormwater drainage system beneath the M2 Motorway between February 2018 and April 2019. He presented to Westmead Hospital ED on 14 February 2018 w…

emergency medicinepsychiatrycommunicationsystemolanzapine
NSWhospital2024-01-29

Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…

cardiothoracic surgerygeneral surgerydiagnosticcommunicationmorphine
VIChome2024-01-25

Finding into death of Lachlan John Howe

13y · Male·Hanging

Lachlan John Howe, aged 13, died by hanging at his home on 18 May 2018 after being transported to Royal Children's Hospital. He had experienced significant family violence from his father, including emotional abuse, cont…

paediatricspsychiatrycommunicationsystem
SAcommunity2024-01-23

Coroner's Finding: Chua, Ardebby Oh

41y · Female·salt water drowning

Ms Ardebby Chua, a 41-year-old woman with no snorkelling experience, died from salt water drowning during a guided snorkelling tour near Blyth Island, South Australia. She aspirated water triggering laryngospasm and beca…

emergency medicinediving medicinesystemcommunication
NSWcommunity2024-01-23

Inquest into the disappearance and suspected death of Bruce Robinson

72y · Male·The available evidence does not allow for any finding to be made as to the cause…

Bruce Robinson, a 72-year-old man with a history of non-Hodgkin's lymphoma, schizophrenia, psychosis, and dementia, died on 27 October 2022 after jumping from a ferry into Sydney Harbour. He had been non-compliant with h…

psychiatryemergency medicinesystemolanzapine
TAScommunity2024-01-22

Coroner's Finding: de-identified TX

30y · Male·Drowning due to jumping from the Batman Bridge

A 30-year-old man with opioid use disorder, anxiety, and depression died by suicide from jumping the Batman Bridge. He had been prescribed escalating doses of clonazepam (1-8mg daily) over three years by general practiti…

general practicepsychiatrydiagnosticsystemclonazepam
TAShome2024-01-18

Coroner's Finding: KT - deidentified

47y · Female·insulin and mixed drug toxicity, the result of actions undertaken by the decease…

A 47-year-old woman with depression and a history of suicidal ideation died from insulin and mixed drug toxicity after deliberately injecting insulin from her daughter's insulin pens. She had been seen by her GP seven ti…

psychiatrypsychologycommunicationsysteminsulin
VIChospital2024-01-18

Finding into death of Lily Grace Arbuckle

0y · Female·Head injury

Lily Grace Arbuckle, a 9-week-old infant, died from head injury sustained when her mother placed her on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and …

obstetricspaediatricsdiagnosticcommunication
VIC2024-01-17

Finding into death of Baby ZCZ

0y · Female·Unascertained

Baby ZCZ, almost 15 weeks old, died of unascertained cause after being placed to sleep in a Fisher Price rocker at an unapproved home childcare service. Post-mortem examination including neuropathology, toxicology, bioch…

paediatricsforensic medicinesystem
VIChome2024-01-11

Finding into death of Madeline Jane Howe

20y · Female·Complications of neck compression in the setting of partial suspension

Madeline Howe, a 20-year-old Aboriginal woman, died by suicide on 8 May 2019 following partial suspension. She had experienced significant trauma including parental separation, family violence, and her brother's death by…

psychiatryemergency medicinecommunicationsystemfluoxetine
VIChospital2024-01-11

Finding into death of Michael Manuel Luno

66y · Male·Aspiration pneumonia in the setting of a small bowel obstruction

Michael Luno, a 66-year-old man with intellectual disability, autism, epilepsy, and swallowing difficulties, died from aspiration pneumonia complicating small bowel obstruction. He presented with vomiting and abdominal d…

emergency medicinegastroenterologycommunicationsystem

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