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NSWprison2021-06-11

Inquest into the death of F

49y · Male·hanging

A 49-year-old man with severe schizoaffective disorder died by hanging in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attem…

psychiatrycorrectional healthcommunicationsystemolanzapine
NSW2021-06-11

Inquest into the death of Lester Collins (a pseudonym)

51y · Male·Gunshot wound to the head

A 51-year-old man with a history of domestic violence died by suicide during a police vehicle stop. After breaching an AVO against his former partner, he violently assaulted her with a knife and then obtained a firearm f…

communicationsystem
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicid…

psychiatryemergency medicinecommunicationsystemaripiprazole
QLDcommunity2021-06-10

McCoy, Damon Edward

20y · Male·Multiple injuries due to motor vehicle accident

A 20-year-old station hand died from multiple injuries sustained when the unregistered Toyota utility he was driving lost control at speed on a remote dirt road near Croydon, Queensland. The vehicle misjudged a sharp lef…

trauma surgerypathologyproceduralsystemalcohol
VIChospital2021-06-10

Finding into death of Carlene Margaret Salveson

80y · Female·pulmonary thromboembolism in the setting of deep leg vein thrombosis; squamous c…

An 80-year-old woman with treated squamous cell carcinoma of the pyriform fossa died from pulmonary thromboembolism secondary to bilateral deep vein thrombosis. She was admitted to hospital with poor oral intake, dehydra…

radiation oncologyoncologymedicationsystem
TAShospital2021-06-07

Coroner's Finding: RA

17y · Male·massive head injury sustained in a fall from height (approximately 3.5 metres th…

A 17-year-old male died from massive head injury sustained in a fall from approximately 3.5 metres through a shade sail at a primary school. He landed on concrete at 10:30 pm after the sail tore under his weight while ju…

emergency medicineneurosurgerysystem
VIChospital2021-06-03

Finding into death of John Reed

63y · Male·Head injury

Mr John Reed, aged 63, died from head injury sustained during an assault by his domestic partner Ms Gayle Dunlop on 18 July 2015 at their Seaford home. He was admitted to Alfred Hospital and died two days later. The rela…

emergency medicinetrauma surgerycommunicationsystem
SA2021-05-28

Coroner's Finding: GIBSON Ian Keith

46y · Male·congestive cardiac failure due to cardiomyopathy and coronary artery atheroscler…

A 46-year-old man with significant cardiac and medical comorbidities died of congestive cardiac failure due to cardiomyopathy and coronary artery atherosclerosis while in police custody. He was correctly categorized as H…

cardiologygeneral practiceproceduralcommunication
QLD2021-05-28

Scorsese, Liam Cooper

31y · Male·Gunshot wounds to the neck and chest

Liam Scorsese, 31, died from gunshot wounds inflicted by police during a confrontation at his estranged partner's parents' home in Queensland. He had a history of violence, substance abuse (methamphetamine, cocaine), and…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
VICmental health2021-05-28

Finding into death of Christopher John Peter Dewhurst

27y · Male·Multiple injuries sustained after being struck by a train

Christopher Dewhurst, 27, died by suicide after being struck by a train while on ground leave from a psychiatric unit. He was a compulsory patient subject to a Temporary Treatment Order, admitted with suicidal ideation a…

psychiatryemergency medicinecommunicationsystemdesvenlafaxine
NSW2021-05-26

Inquest into the death of Liam WOLF

19y · Male·unexpected arrhythmogenic event leading to a fall from height, blunt force head …

PTE Liam Wolf, a 19-year-old Australian Army recruit, died after collapsing on an obstacle course at Kapooka during the final training exercise. He experienced a sudden unexpected cardiac arrhythmia while climbing a ladd…

emergency medicinecardiologysystemdelay
VICcommunity2021-05-25

Finding into death of Kylie Jane Cay

44y · Female·haemoperitoneum due to ruptured splenic subcapsular haematoma in the setting of …

Kylie Cay, a 44-year-old woman, was brutally assaulted by her partner Justin Turner on 18 June 2016, sustaining rib fractures and other injuries. She was discharged from hospital on 20 June after imaging did not reveal a…

paramedicineemergency medicinediagnosticcommunication
QLD2021-05-24

SVE

43y · Male·Hanging

A 43-year-old man remanded in custody for serious sexual offences against children died by hanging in an older prison cell. While he expressed fears about safety and had passive suicidal ideation months before his death,…

psychiatrypsychologysystemdelay
QLD2021-05-24

Ahquee, Dylon James

19y · Male·Hanging

Dylon James Ahquee, aged 19, died by hanging in Townsville Correctional Centre on 26 December 2015. Despite documented self-harm and suicidal ideation as a juvenile, no Self-Harm Episode History flag was raised at adult …

correctional healthpsychologydiagnosticsystem
VIC2021-05-24

Finding into death of Melanie Diane Doherty

29y · Female·Mixed Drug Toxicity

A 29-year-old woman died from mixed drug toxicity after being found unresponsive at a residential parenting program. She had complex medical conditions including coproporphyria, epilepsy, and opioid use disorder. Critica…

addiction medicinepsychiatrymedicationcommunicationmethadone
VICaged care2021-05-24

Finding into death of Julie-Anne Marie Kettle

56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels

Julie-Anne Kettle, a 56-year-old woman with intellectual disabilities residing in a group home, died from bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric…

general practicepsychiatrydiagnosticdelaylithium
NSWcommunity2021-05-21

Inquest into the death of Pono Wairua Aperahama

17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…

Pono Aperahama, a 17-year-old with severe traumatic brain injury and moderate intellectual disability, died from cardiac arrhythmia during restraint at a swimming pool. His escalating behaviour in 2017—triggered by schoo…

neurologypsychiatrysystemcommunication
VIChome2021-05-20

Finding into death of Brodie Moran

8y · Male·Suffocation

Brodie Moran, an 8-year-old boy, died by suffocation at the hands of his mother, Ms Finch, on 8 March 2018. Ms Finch had a history of depression and anxiety, experiencing significant deterioration in mental health follow…

general practicepsychiatrysystemvenlafaxine
VIChome2021-05-15

Finding into death of Ms ZT

27y · Female·Multiple sharp force injuries

Ms ZT, a 27-year-old Lebanese woman, was murdered by her husband Mr BR on 17 June 2016 through multiple sharp force injuries. The coroner's investigation revealed a prolonged pattern of severe domestic violence, physical…

communicationsystem
QLDcommunity2021-05-14

Cahill, Margaret Ann

61y · Female·Multiple drug (tapentadol, morphine, diazepam, citalopram) intoxication

Margaret Cahill, a 61-year-old nurse assistant, died from multiple drug intoxication after a GP administered 60mg intramuscular morphine without knowing she had consumed tapentadol 1-2 hours earlier. The coroner identifi…

general practiceemergency medicinediagnosticmedicationtapentadol

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