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VICmental health2020-09-18

Finding into death of Harley Robert Larking

23y · Male·Effects of fire

Harley Larking, a 23-year-old Aboriginal man with treatment-resistant schizoaffective disorder, died from effects of fire on 13 May 2016 while absconding from a psychiatric unit. He was on clozapine for only two weeks wh…

psychiatryAboriginal healthsystemdelayclozapine
VIChome2020-09-11

Finding into death of Mr A

44y · Male·compression of the neck consequent upon hanging

A 44-year-old man with a 42-year history of intimate partner violence died by hanging. He had recently separated from his wife and was enrolled in a 18-week men's behaviour change program, having completed 17 of 18 sessi…

general practicepsychiatrysystemdelayalcohol
NSWhospital2020-09-09

Inquest into the death of Grace HERINGTON

23y · Female·multiple blunt force injuries from fall from height

Grace Herington, 23, died from multiple blunt force injuries sustained in a fall from a highway off-ramp during an acute psychotic episode induced by cannabis use. She had attended Royal North Shore Hospital the previous…

emergency medicinepsychiatrycommunicationsystemcannabis
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagno…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol
VICcommunity2020-09-07

Finding into death of Ms WX

40y · Female·Injuries sustained when struck by a train (in circumstances where the deceased i…

A 40-year-old South Asian woman died by suicide when struck by a train, four weeks after arriving in Australia. She was deeply distressed by financial circumstances—construction delays on her new home and storage fees fo…

psychiatrygeneral practicesystemdelay
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …

emergency medicineintensive carediagnosticcommunicationparacetamol
NSWcommunity2020-09-04

Inquest into the death of Thomas HUNT

27y · Male·unascertained; likely death from entering water

Thomas Hunt, a 27-year-old man, died after entering the water near Bondi Beach on 23 March 2017, likely after experiencing an acute mental health crisis characterised by paranoid delusions and auditory hallucinations. Mu…

psychiatrygeneral practicediagnosticcommunication
NSW2020-09-04

Inquest into the death of Ivan MIKIC

34y · Male·Methadone toxicity, with coronary artery atherosclerosis as a significant contri…

Ivan Mikic, a 34-year-old prisoner at Wellington Correctional Centre, died from methadone toxicity on 3 November 2015. The methadone was not prescribed to him and was most likely obtained through diversion by another inm…

correctional healthaddiction medicinesystemmethadone
TAShospital2020-09-02

Coroner's Finding: Breen, Kylie Anne

40y · Female·hypoxic brain injury and acute lung injury; multiple drug toxicity with oxycodon…

A 40-year-old woman with advanced multiple sclerosis died from drug toxicity and hypoxic brain injury following intentional overdose and gas inhalation. She had completed an Advance Care Directive (ACD) 12 months prior r…

emergency medicineintensive carecommunicationsystemoxycodone
VICcommunity2020-08-31

Finding into death of Gregory David Tory

48y · Male·unascertained

Gregory David Tory, aged 48, disappeared from Mallacoota, Victoria in April 2018 and is presumed deceased. He had a history of methamphetamine use with associated paranoia and thought disorder, requiring psychiatric admi…

psychiatrygeneral practicecommunicationsystemmethamphetamine
VIC2020-08-31

Finding into death of Gavin Leslie Boyd

55y · Male·Electrocution

Gavin Boyd, a 55-year-old truck driver, died from electrocution when his trailer contacted overhead 22kV power lines while delivering fertiliser to a dairy farm. The farm owner directed him to unload in Paddock 1 but did…

communicationsystem
VICcommunity2020-08-31

Finding into death of Mr L

38y · Male·Consistent with Drowning

A 38-year-old male tourist from the UK drowned while swimming at an unpatrolled beach (Mounts Bay, Apollo Bay) in Victoria. Despite being described as a competent swimmer with recent ocean swimming experience, he encount…

systemcommunication
VIChome2020-08-31

Finding into death of Baby M

0y · Female·Sudden Infant Death Syndrome (SIDS Category II)

A 3-month-old female infant died from Sudden Infant Death Syndrome (SIDS Category II) after co-sleeping with her parents. The death occurred in the context of unsafe sleeping practices despite prior intervention by Child…

paediatricspaediatric surgerycommunicationsystemcannabis
VICcommunity2020-08-28

Finding into death of Heather Telfer

69y · Female·Toxicity to pentobarbitone in circumstances where she intended to end her own li…

Heather Telfer, a 69-year-old woman with longstanding asthma, chronic health anxiety, and significant social isolation, died from pentobarbitone toxicity. She had a prior suicide attempt 12 years earlier and expressed su…

general practicerespiratory medicinecommunicationsystempentobarbitone
TAShospital2020-08-27

Coroner's Finding: Murray, Geoffrey Raymond

74y · Male·acute myocardial ischaemia related to stenosis of the right coronary artery

Geoffrey Raymond Murray, aged 74, presented to Launceston General Hospital ED on 24 February 2019 with fever, vomiting and dizziness. After triage at 6:27pm, he waited unattended for over 4 hours without further medical …

emergency medicinecardiologycommunicationsystemparacetamol
QLDcommunity2020-08-27

Master Carr and Jaylen

17y · Male·multiple injuries due to motor vehicle collision

Two juvenile males, aged 17 and 16, died in a high-speed motor vehicle crash on the Gore Highway near Wyaga Creek on 21 April 2018. The vehicle, a stolen Holden Commodore, was traveling at approximately 170-175 km/h when…

forensic medicineproceduralsystemmethamphetamine
NSW2020-08-26

Inquest into the death of Tane Chatfield

22y · Male·hypoxic ischaemic encephalopathy as a result of hanging

Tane Chatfield, a 22-year-old Aboriginal man, died by hanging in his prison cell at Tamworth Correctional Centre on 20 September 2017. He had been admitted to hospital the preceding night with seizures, assessed as unlik…

emergency medicineneurologydiagnosticcommunicationparacetamol
NSWcommunity2020-08-25

Inquest into the disappearance and suspected death of Liam D'Arcy

36y · Male·Unknown; presumed unsurvivable injuries or drowning following intentional cliff …

Liam D'Arcy, a 36-year-old man with schizophrenia, disappeared on 23 June 2019 and is presumed to have died by intentional cliff jumping at The Gap, Watson's Bay. He had been stable on clozapine for 15 years but experien…

psychiatrycommunicationsystemclozapine
VIChome2020-08-24

Finding into death of Brittany Harvie

22y · Female·Complications of blunt force trauma to head, neck and chest

Brittany Harvie, aged 22, was killed by her de facto partner Mataio Aleluia in June 2015 following a 15-minute violent assault involving repeated punching to the head, neck and chest. She died from complications of blunt…

forensic medicinepsychiatrycommunicationsystemcannabis
WA2020-08-18

Inquest into the Death of Hayden Paul STACEY

22y · Male·gunshot injury to the chest

Hayden Paul Stacey, 22, died from a gunshot wound to the chest inflicted by police constable Lucinda Boon during a mental health crisis incident on 27 May 2018 at Peel Health Campus, Western Australia. Stacey had called …

emergency medicineparamedicinesystemcannabis

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