128 results
15y · Male·Combined heroin and methamphetamine toxicity
T, a 15-year-old boy subject to a Care by Secretary Order, died from combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), …
19y · Male·gunshot wounds to chest and abdomen
Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man, died from gunshot wounds to his chest and abdomen at Yuendumu Police station on 9 November 2019. This coroner's report focuses on systemic failures in policing, youth…
50y · Male·ligature compression of the neck (hanging)
Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…
57y · Male·partially suspended hanging
A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …
27y · Male·Multiple gunshot wounds
Damon Savage, 27, died from multiple gunshot wounds during a police response to a domestic violence incident. He had called police while assaulting his partner, armed himself with two large knives, advanced towards offic…
37y · Male·Cardiomegaly giving rise to lethal cardiac arrhythmia in the setting of drug tox…
37-year-old Robert Phair died in Parklea Correctional Centre from cardiomegaly causing lethal cardiac arrhythmia in the setting of drug toxicity. He was placed in detoxification requiring four-hourly clinical observation…
37y · Male·multiple gunshot wounds
Brett Walker, 37, was shot by police on 9 July 2022 after a domestic violence incident 23 days post-release from prison. He had long-standing drug addiction and mental health issues including paranoid ideation, particula…
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…
31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…
A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…
32y · Male·methylamphetamine toxicity
Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…
Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…
Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…
16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…
LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…
6y · Unknown·methadone toxicity
A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…
29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…
Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…
33y · Male·Complications of methylamphetamine use
Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health di…
30y · Male·Drowning due to jumping from the Batman Bridge
A 30-year-old man with opioid use disorder, anxiety, and depression died by suicide from jumping the Batman Bridge. He had been prescribed escalating doses of clonazepam (1-8mg daily) over three years by general practiti…
32y · Female·Unknown
Tina Louise Greer, 32, disappeared on 18 January 2012 and is presumed deceased, killed by her partner Leslie Sharman who was involved in her coercive and controlling relationship, including domestic violence. The coroner…
33y · Male·Hanging
CC, a 33-year-old First Nations man with methamphetamine-induced bipolar disorder and psychosis, was admitted to the High Dependency Unit at Nepean Hospital on 7 June 2022 under involuntary mental health detention. Over …
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
31y · Male·Hanging
Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …
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