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VICmental health2023-09-15

Finding into death of Daylon John Roeton

28y · Male·Hanging

Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner foun…

psychiatryemergency medicinesystemproceduralolanzapam
WA2023-09-14

Inquest into the Death of Shane Reynold NARRIER

40y · Male·coronary artery atherosclerosis

Shane Narrier, a 40-year-old Aboriginal man, died from coronary artery atherosclerosis on 5 June 2020 at Acacia Prison. On 27 May 2020, he reported chest pains via the Custody Messaging System (CMS) to a prison nurse. Th…

cardiologyemergency medicinediagnosticcommunicationescitalopram
VIC2023-09-14

Finding into death of Darren Ricky Culleton

31y · Male·Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a m…

31-year-old Darren Culleton died from hypoxic brain injury after choking on the hood of his coveralls while in police custody. He had presented to St Vincent's Hospital with acute intoxication and self-harm behavior (att…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
NSW2023-09-14

Inquest into the disappearance and suspected death of Allan Beeby

74y · Male·Drowning

Alan Beeby, an experienced 74-year-old boatman, drowned after his newly purchased Halvorsen 42 motor yacht 'Eliza 1' capsized in moderate sea conditions (1m following seas, 15-18 knot winds from northeast). Expert naval …

occupational and environmental healthemergency medicinesystemdiagnostic
VICcommunity2023-09-13

Finding into death of Joshua Tovey

29y · Male·Stab wound to the chest

Joshua Tovey, aged 29, was fatally stabbed by his brother Jesse on 18 January 2021 following a dispute over repaid money. Jesse was subject to a Community Corrections Order (CCO) for family violence offences at the time.…

systemdelaymethamphetamine
NSWhospital2023-09-11

Inquest into the death of TE

26y · Female·multiple blunt force injuries from fall from height; significant contributing co…

A 26-year-old woman with severe borderline personality disorder died by suicide following a fall from cliffs. She presented to hospital after a serious suicide attempt earlier the same day. Expert evidence indicates she …

psychiatryemergency medicinediagnosticcommunicationpregabalin
NSWhome2023-09-08

Inquest into the death of BW

31y · Male·hanging

B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…

paediatricspsychiatrycommunicationsystemalcohol
VIC2023-09-07

Finding into death of Betty Torrance Sloan

86y · Female·Bronchopneumonia complicating chest injuries sustained in a motor vehicle collis…

An 86-year-old woman died from bronchopneumonia complicating chest injuries sustained in a motor vehicle collision on 17 June 2019. A stolen vehicle being driven recklessly by an unlicensed driver under the influence of …

intensive careemergency medicinecommunicationsystemmethamphetamine
NSWcommunity2023-09-05

Inquest into the death of Daniel Bolton

30y · Male·Gunshot wound to the neck and head

Daniel Bolton, aged 30, died from a self-inflicted gunshot wound to the neck and head while attempting to avoid arrest by police. He had a history of drug addiction, mental health issues including depression, anxiety and…

psychiatrygeneral practicesystemcommunicationcannabis
TAS2023-09-01

Coroner's Finding: Hunt, Paul George; Reynolds, Paul James; Darke, Simon Graham; Cooke, Robert Anthony

Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…

This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …

psychiatrypsychologysystemcommunicationpseudoephedrine
TAScommunity2023-08-31

Coroner's Finding: Douglas, Jethro Wolf

24y · Male·Multiple blunt traumatic injuries sustained in single motor vehicle crash

Jethro Wolf Douglas, aged 24, died from multiple blunt traumatic injuries sustained when he drove his vehicle at 101 km/h (twice the posted 50 km/h limit) around a curve he could not negotiate, resulting in a crash. His …

forensic medicinepublic healthsystemdelayalcohol
QLD2023-08-31

DODUNSKI, Gareth Leo

21y · Male·Gross cerebral trauma due to multiple comminuted depressed fractures of skull du…

Gareth Dodunski, a 21-year-old floorhand, was fatally struck by an ST-80 Iron Roughneck tool on 23 June 2013 while setting a dog collar on a drill string. The driller, Jacob Kilby, activated the ST-80 in a moment of inad…

occupational and environmental healthdiagnosticsystem
VIChome2023-08-31

Finding into death of Master H

1y · Male·Drowning

Master H, a 21-month-old boy, drowned in a dam on his family's rural property in Victoria. He was playing in the yard while his mother supervised from inside the house. Despite temporary fencing installed around the yard…

system
WAhospital2023-08-30

Inquest into the Death of Kevin George HOWLETT

83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)

An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …

vascular surgerygeneral medicinediagnosticcommunication
SAhospital2023-08-30

Coroner's Finding: Fergusson, Logan Scott

0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease

Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…

cardiologypaediatricsdelaydiagnosticheparin
QLD2023-08-30

Ganter, Wayne Joseph; Rawlings, Mark Robert; Roebig, Henry Phillip; Brischke, Wayne Anthony; and Weavell, Stuart Henry Russell…

Male·Multiple injuries due to or as a consequence of an aircraft accident (controlled…

On 11 March 2020, a Cessna 404 aircraft carrying five people crashed near Lockhart River, Queensland, killing all occupants. The pilot attempted two RNAV GNSS instrument approaches in poor weather with heavy rain and low…

aviation medicinediagnosticprocedural
VIC2023-08-30

Finding into death of Baby A

0y · Female·Sudden infant death syndrome (SIDS) category 2

Baby A, born on 6 August 2018 to a mother in remand custody at Dame Phyllis Frost Centre, died of SIDS category 2 on 18 August 2018 aged 12 days. She was born with neonatal abstinence syndrome due to maternal methadone u…

neonatologypaediatricssystemcommunicationmethadone
VICcommunity2023-08-28

Finding into death of Jorgen Bottern

86y · Male·carbon monoxide poisoning

An 86-year-old man with recent stroke, declining mental health, and expressed suicidal ideation died by carbon monoxide poisoning. He was assessed in hospital ED, deemed not to meet Mental Health Act criteria, and discha…

psychiatrygeneral practicesystem
NSWcommunity2023-08-25

Inquest into the death of SG

15y · Male·Hanging

A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…

psychiatrypaediatricscommunicationsystem
WA2023-08-23

Inquest into the Deaths of Adell Sherylee PARTRIDGE and Veronica Philomena LOCKYER

Female·unascertained

Two Indigenous women from the Pilbara disappeared in late 1998 without trace: Veronica Lockyer (33 years old) and her infant daughter Adell Partridge (7 months old). Veronica was last seen at a Centrelink office in South…

communicationsystem

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