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WA2025-07-08

Inquest into the Death of Tim Alan LOOKER

29y · Male·ligature compression of the neck (hanging)

Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…

general practicepsychiatrysystemcommunicationdextroamphetamine
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
TAS2025-07-04

Coroner's Finding: de-identified CF

24y · Male·blunt trauma and drowning due to intentional jumping from Tasman Bridge

A 24-year-old male international student and graduate employee experienced his first acute psychotic episode in December 2022, triggered by workplace stress and unsubstantiated beliefs about colleague manipulation. Initi…

psychiatryemergency medicinedelaycommunicationolanzapine
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

A 41-year-old man with schizophrenia died by suicide, jumping from the Tasman Bridge on Christmas Eve 2022. He had a 15-year history of mental illness with multiple suicide attempts, previously managed with antipsychotic…

psychiatrygeneral practicesystemdelaypaliperidone
VIChome2025-06-24

Finding into death of Jessica Geddes

27y · Female·Complications of multiple blunt force injuries

Jessica Geddes, 27, was killed by her partner Robert Rickerby through multiple blunt force injuries on 6 November 2020. The autopsy revealed extensive acute, subacute and chronic injuries inconsistent with accidental tra…

general practicepsychiatrydiagnosticsystemmethamphetamine
TAScommunity2025-06-20

Coroner's Finding: Haig, Jeff

60y · Male·Undetermined - likely natural causes (centriacinar emphysema) or misadventure (f…

Jeff Malcolm Haig, a 60-year-old man with multiple sclerosis and documented paranoid and delusional beliefs about being monitored, was found deceased at Low Head, Tasmania on 26 August 2022, having last been seen alive o…

neurologygeneral practicesystemalcohol
TASaged care2025-06-16

Coroner's Finding: McDonald, Maureen June

87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…

Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …

geriatric medicinegeneral practicesystemcommunicationantibiotics
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
VIChome2025-05-23

Finding into death of Shirley Annette Kidd

67y · Female·Head injuries

Shirley Kidd, aged 67, died from head injuries inflicted by her grandson Hayden during a cannabis-induced psychosis. Hayden had experienced severe childhood abuse by his stepfather and subsequently developed mental healt…

psychiatrygeneral practicesystemcannabis
VICaged care2025-05-21

Finding into death of Lorraine Joy Wight

77y · Female·Airways obstruction by tissue paper

A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues i…

geriatric medicinepsychiatrycommunicationsystemoxycodone
SA2025-05-20

Coroner's Finding: Pham, Duy Ngoc

35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…

emergency medicinegeneral practicedelaycommunicationmethamphetamine
VIChome2025-05-08

Finding into death of Mrs R

57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)

Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a p…

psychiatrygeneral practicecommunicationsystemescitalopram
TAShome2025-05-06

Coroner's Finding: de-identified YZ

59y · Male·Shotgun wound to the head

A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…

general practicepsychiatrycommunicationsystemescitalopram
SAhome2025-05-06

Coroner's Finding: Weetra, Michael Lionel Richard

18y · Male·compression of the neck in keeping with hanging

An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…

psychiatrygeneral practicecommunicationsystemdiazepam
WA2025-05-05

Inquest into the Suspected Death of David Benjamin INGRAM

44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…

David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…

psychiatrygeneral practicecommunicationsystemolanzapine
NSW2025-05-02

Inquest into the death of Emmett Brown

25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…

Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…

correctional healthaddiction medicinediagnosticsystemmethadone
TAShospital2025-04-29

Coroner's Finding: de-identified OQ

41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…

A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…

emergency medicineneurosurgerydiagnosticcommunicationchlorpromazine
WAhospital2025-04-17

Inquest into the Death of Colin Stanley Francis NICHOLSON

69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…

Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…

haematologygeneral practicediagnosticcommunicationparacetamol
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…

psychiatryemergency medicinediagnosticcommunicationescitalopram
QLDaged care2025-04-17

Non-inquest findings into the death of Mr H.

89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…

An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …

geriatric medicinegeneral practicediagnosticcommunicationmacrogol
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