1,641 results
51y · Female·Multiple injuries sustained when struck by a car while lying on the Mornington P…
Lee Collings, 51, died by suicide after absconding from an Emergency Department. She presented with suicidal ideation and was triaged as Mental Health Category 4. Key failures included: the Crisis Assessment Team clinici…
38y · Male·Exsanguination due to penetration of arm veins
Declan Brennan, a 38-year-old sentenced prisoner at Acacia Prison due for release on 30 April 2008, died by suicide on 27 April 2008 from exsanguination due to penetrating wounds to his arm veins. Brennan had a long-stan…
38y · Female·Pulmonary Thromboembolism
Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…
Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)
Three immigration detainees died by suicide at Villawood Detention Centre in Sydney within three months in 2010. Josefa Rauluni (Fijian) jumped from a balcony on 20 September after being informed of imminent removal desp…
37y · Female·exsanguination from incised wounds to right wrist and elbow
Tracey Inglis, a 37-year-old woman with chronic pain from multiple orthopaedic injuries, hepatitis C, and a history of suicidal ideation, died by suicide while imprisoned. Critical clinical lessons include: the Initial R…
27y · Male·HEAD INJURY SUSTAINED IN A MOTOR VEHICLE COLLISION (PEDESTRIAN)
Mark Connolly, 27, with paranoid schizophrenia and command hallucinations, was admitted to the Low Dependency Unit of a psychiatric hospital despite expressing intent to jump from a moving car and requesting High Depende…
46y · Male·Ventricular arrhythmia in a man with epilepsy and documented episodes of bradyca…
Garry John Stephens, aged 46, died in Port Phillip Prison on 7 September 2007 from ventricular arrhythmia in a man with epilepsy and documented bradycardia episodes. The coroner accepted this as consistent with sudden un…
15y · Male·Gunshot wound to the chest
Tyler Cassidy, a 15-year-old boy, was fatally shot by Victoria Police on 11 December 2008 during a mental health crisis. He had stolen two large kitchen knives from Kmart and made threatening statements, explicitly deman…
27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…
Warwick Andrew Ashdown, a 27-year-old male with severe treatment-resistant paranoid schizophrenia, died at Graylands Hospital on 12 October 2007 from cardiac arrhythmia during physical restraint. After assaulting another…
23y · Male·Unknown - missing person, no conclusive evidence of death
Redae Berhane, a 23-year-old man with schizophrenia, severe stutter, and partial deafness, went missing on 6 August 2007 and has not been located despite extensive investigation. He had multiple psychiatric hospitalizati…
55y · Male·Cardiopulmonary arrest, respiratory failure and chronic obstructive airways dise…
Mr John Threadgold, a 55-year-old man with extensive psychiatric history (schizoaffective disorder, substance dependency), chronic obstructive airways disease, and alcohol abuse, died from cardiopulmonary arrest and resp…
Male·Ashton Michael Sunfly: ligature compression of the neck (hanging); Mitchell Nana…
This coronial inquiry examined five deaths in Balgo Aboriginal Community over a 24-month period: four suicides by hanging and one death from volatile substance abuse. The suicide rate in Balgo was more than 100 times the…
76y · Male·MULTIPLE INJURIES IN A TRAIN INCIDENT
A 76-year-old man with advanced dementia was admitted to a residential aged care facility on 26 June 2008. Within hours, he absconded through the front door and was struck by a train, sustaining fatal injuries. The RN ad…
Unknown·Multiple injuries from motor vehicle accident; Anthony Paul Thomson died from ru…
Motor vehicle accident involving 4 deaths on 8 May 2009 at Nambour Connection Road and Blackall Street intersection, Queensland: 5-year-old twins, a 60-year-old female driver, and 43-year-old male driver Anthony Paul Tho…
49y · Male·Acute blood loss from a single incised injury to left forearm
Jeremy Edward Chandler, a 49-year-old first-time prisoner, died by suicide in Melbourne Assessment Prison 36 hours after admission. He had been convicted of serious charges and remanded in custody pending sentencing. Des…
54y · Male·Hanging (self-inflicted), following the death of Lynette Ann Kent from stab woun…
Peter Griffin, aged 54, fatally stabbed his partner Lyn Kent and then hanged himself in November 2009 following relationship breakdown. The finding documents a 10-year relationship characterised by escalating family viol…
36y · Male·Gunshot wound to chest
Adam Quddus Salter, aged 36, experienced acute psychiatric decompensation on 18 November 2009 while living at his family home. After stabbing himself multiple times, paramedics and police were called. While paramedics tr…
34y · Male·Asphyxia consistent with plastic bag asphyxia
A 34-year-old male in pre-trial custody at Arthur Gorrie Correctional Centre died by asphyxiation using a plastic bag on 3 September 2008. He had a psychiatric history with prior suicide attempts and was on olanzapine. H…
26y · Female·compression of the neck consequent upon hanging
Amanda Kennedy, a 26-year-old woman with a history of trauma, substance abuse, depression, and multiple suicide attempts, died by hanging in the Northern Psychiatry Unit on 24 June 2010 while under involuntary psychiatri…
28y · Male·hanging
Aaron Nathan Stagg, 28-year-old man with likely Asperger's Syndrome and emerging paranoid psychosis, died by hanging on 5 March 2010 after a period of disengagement from mental health services. He was referred to Top End…
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