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NSW2020-12-03

Inquest into the death of George CAMERON

81y · Male·plastic bag asphyxia

George Cameron, an 81-year-old man, died by asphyxiation using a plastic bag while in custody at Parklea Correctional Centre on 8 September 2017. He had been remanded in custody three days earlier after arrest. A Recepti…

psychiatryemergency medicinesystemdelay
NSWcommunity2020-12-02

Inquest into the suspected death of missing person Jasmine MORRIS

19y · Female·Unknown – not determined

Jasmine Morris was a 19-year-old Aboriginal woman last seen alive on 6 October 2009 in Grafton, NSW. She was reported missing on 20 October 2009 after a two-week absence. Despite extensive police investigation, her body …

systemdelaycannabis
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…

psychiatrypsychologydiagnosticsystemmethamphetamine
VICcommunity2020-11-27

Finding into death of Nicholas Daniel Ficarra

26y · Male·unascertained; suspected suicide by firearm

Nicholas Daniel Ficarra, aged 26, disappeared on 14 January 2012 from his family farm in regional Victoria. He had a history of substance abuse (heroin, OxyContin, cannabis) from age 21 and severe mental illness from 200…

psychiatrygeneral practicesystemdelayheroin
TAShospital2020-11-26

Coroner's Finding: Kelly, Brian John

71y · Male·hydromorphone toxicity

71-year-old man with end-stage mesothelioma died from hydromorphone toxicity after receiving 20mg instead of the prescribed 2mg dose in the ED. The overdose was accidental but resulted from shocking inattention to basic …

palliative careemergency medicinemedicationsystemhydromorphone
SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…

psychiatrycardiologydiagnosticcommunicationolanzapine
WAcommunity2020-11-25

Inquest into the Death of Jamie Alan GRAHAM

50y · Male·acute renal failure due to dehydration in relation to environmental exposure

Jamie Graham, a 50-year-old Aboriginal man with type 2 diabetes, cognitive impairment, and alcohol dependence, died from acute renal failure due to dehydration after being stranded with two companions on a remote road wh…

systemcommunication
VICmental health2020-11-25

Finding into death of Thi Qui Tran

53y · Female·Heatstroke

Thi Qui Tran, a 53-year-old woman with schizophrenia on antipsychotic medications (zuclopenthixol and olanzapine), died of heatstroke on 9 February 2018 after collapsing on a street during extended unescorted leave from …

psychiatryintensive caresystemdelayzuclopenthixol
VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…

orthopaedic surgeryanaesthesiasystemenoxaparin
TAScommunity2020-11-23

Coroner's Finding: Golding, Laura Rebecca

51y · Female·drowning

Laura Golding, a 51-year-old transgender female with longstanding bipolar affective disorder and recent psychotic episodes, died by drowning on 13 October 2017 after taking an unmanned dinghy into Copper Alley Bay withou…

psychiatrygeneral practicesystemdelay
VIChome2020-11-20

Finding into death of Baby S

1y · Male·head injury

Baby S, a 12-month-old boy, died from head injuries inflicted by his mother's de facto partner, Mr B, while the mother was away obtaining heroin. The child had multiple previous injuries documented by childcare staff and…

paediatricsgeneral practicediagnosticcommunicationheroin
NSWhospital2020-11-20

Inquest into the death of Melissa Stokes

49y · Female·Fatal Cardiac Arrhythmia

Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-operative…

anaesthesiagynaecologycommunicationdelaytramadol
WA2020-11-19

Inquest into the Death of Levi Shane Clement CONGDON

27y · Male·methylamphetamine toxicity

Levi Shane Clement Congdon, a 27-year-old male, died from methylamphetamine toxicity on 13 November 2017 at Royal Perth Hospital during a police search warrant execution. He ingested a fatal dose of methylamphetamine, re…

emergency medicinetoxicologycommunicationsystemmethamphetamine
TAS2020-11-19

Coroner's Finding: Woolley, Dale Robert

51y · Male·Blunt trauma of the head, neck and chest sustained in a tractor crash (rollover)

Dale Woolley, an experienced 51-year-old farm machinery operator, died when a tractor he was driving rolled on a steep (18-19°), wet, slippery hill while distributing hay. The tractor slid downhill after losing traction,…

system
VICcommunity2020-11-19

Finding into death of Bhavita Patel

Blunt force trauma from impact with motor vehicle

Six people were fatally struck by a stolen vehicle deliberately driven through Bourke Street Mall in Melbourne CBD on 20 January 2017: Matthew Poh Chuan Si (33), Thalia Hakin (10), Yosuke Kanno (25), Jess Mudie (22), Zac…

systemcommunication
VICcommunity2020-11-19

Finding into death of Jess Mudie

Traumatic injuries sustained when struck by stolen motor vehicle (principally he…

Finding into six deaths resulting from the Bourke Street mass casualty incident on 20 January 2017 in Melbourne, Victoria. James Gargasoulas drove a stolen vehicle into crowds in Bourke Street Mall, killing Matthew Poh C…

systemcommunication
VICcommunity2020-11-19

Finding into death of Yosuke Kanno

Unknown·traumatic injuries (head injuries and multiple trauma) sustained when struck by …

Six people were killed on 20 January 2017 when James Gargasoulas drove a stolen vehicle into crowds on Bourke Street Mall in Melbourne's CBD, striking 33 pedestrians. The deceased were Matthew Poh Chuan Si (33), Thalia H…

systemmethamphetamine
QLD2020-11-16

Haynes, Barry

58y · Male·Metastatic non-small cell lung carcinoma

Barry Haynes, a 58-year-old Aboriginal man, died of metastatic non-small cell lung carcinoma while on remand in custody. He had stage 4 lung cancer with brain metastases diagnosed in November 2016, shortly before his arr…

oncologypalliative caresystemdelay
VIChome2020-11-16

Finding into death of Hilton Davis

50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity

A 50-year-old Torres Strait Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental healt…

general practiceforensic medicinecommunicationsystemoxycodone
NSWcommunity2020-11-16

Inquest into the death of D B

39y · Male·Self-inflicted death by hanging

A 39-year-old man with longstanding Bipolar I Disorder died by hanging on 28 December 2017, shortly after police attended a domestic disturbance at his mother's home. He had expressed suicidal ideation to his treating ps…

psychiatryemergency medicinecommunicationsystem

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