2,427 results
31y · Male·Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a m…
31-year-old Darren Culleton died from hypoxic brain injury after choking on the hood of his coveralls while in police custody. He had presented to St Vincent's Hospital with acute intoxication and self-harm behavior (att…
40y · Male·coronary artery atherosclerosis
Shane Narrier, a 40-year-old Aboriginal man, died from coronary artery atherosclerosis on 5 June 2020 at Acacia Prison. On 27 May 2020, he reported chest pains via the Custody Messaging System (CMS) to a prison nurse. Th…
29y · Male·Stab wound to the chest
Joshua Tovey, aged 29, was fatally stabbed by his brother Jesse on 18 January 2021 following a dispute over repaid money. Jesse was subject to a Community Corrections Order (CCO) for family violence offences at the time.…
26y · Female·multiple blunt force injuries from fall from height; significant contributing co…
A 26-year-old woman with severe borderline personality disorder died by suicide following a fall from cliffs. She presented to hospital after a serious suicide attempt earlier the same day. Expert evidence indicates she …
31y · Male·hanging
B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…
86y · Female·Bronchopneumonia complicating chest injuries sustained in a motor vehicle collis…
An 86-year-old woman died from bronchopneumonia complicating chest injuries sustained in a motor vehicle collision on 17 June 2019. A stolen vehicle being driven recklessly by an unlicensed driver under the influence of …
Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…
This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …
0y · Female·Sudden infant death syndrome (SIDS) category 2
Baby A, born on 6 August 2018 to a mother in remand custody at Dame Phyllis Frost Centre, died of SIDS category 2 on 18 August 2018 aged 12 days. She was born with neonatal abstinence syndrome due to maternal methadone u…
0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease
Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
15y · Male·Hanging
A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…
Female·unascertained
Two Indigenous women from the Pilbara disappeared in late 1998 without trace: Veronica Lockyer (33 years old) and her infant daughter Adell Partridge (7 months old). Veronica was last seen at a Centrelink office in South…
17y · Male·hydrocarbon toxicity (petrol inhalation)
George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
30y · Male·ligature compression of the neck (hanging)
Jomen Blanket, a 30-year-old Aboriginal and Torres Strait Islander man, died by suicide in prison on 12 June 2019 after eight months incarcerated for assault. He had a known suicide plan (hanging from his cell door using…
64y · Male·coronary atherosclerosis with early myocardial infarction
A 64-year-old man suffered acute myocardial infarction at home. His wife called triple-0 at 10:34 am reporting classic cardiac symptoms: sudden sweating, shortness of breath, and shoulder pain. The emergency dispatch sys…
28y · Male·neck compression from hanging
SH, a 28-year-old man, died by hanging in Cessnock Correctional Centre after seven weeks in custody. He was assessed at intake as having no self-harm risk and cleared for normal cell placement. During custody, he became …
27y · Male·Neck compression due to self-inflicted hanging
Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
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