128 results
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…
46y · Male·Opioid toxicity (tapentadol and oxycodone)
Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…
23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…
Brontë Haskins, aged 23, died by suicide via hanging on 18 February 2020, three days after her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination …
31y · Male·self-inflicted hanging
Bernard Hector, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Centre on 30 August 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearan…
33y · Male·Prolonged epileptic seizure resulting in gastric content aspiration and cardiac …
Roy Roberts, a 33-year-old Aboriginal man, died at Long Bay Correctional Complex from a prolonged epileptic seizure resulting in aspiration and cardiac arrest. He had experienced three prior seizure-like episodes in Apri…
37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…
Veronica Nelson, a 37-year-old Aboriginal woman with opioid dependence, was arrested on minor theft charges, remanded in custody following a bail hearing, and held at Dame Phyllis Frost Centre (DPFC) women's prison. She …
19y · Male·Stab wounds to the neck and chest
Taylor Oliver, a 19-year-old with schizophrenia and substance use disorder, died by self-inflicted stab wounds on 1 December 2019. He had been admitted to mental health inpatient care on 18 November 2019 following overdo…
38y · Male·Toxicity to gamma hydroxybutyrate
A 38-year-old man with a long history of drug use and criminal offending died from gamma hydroxybutyrate (GHB) toxicity after consuming approximately 60mL of GHB whilst at home. He had been released from prison on 11 May…
21y · Male·complications of ligature compression of the neck (hanging)
Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…
22y · Male·Hanging
A 22-year-old man with depression, alcohol addiction, and recent significant losses (parents, sister, friend) presented to Frankston ED on 14 January 2018 with active suicidal ideation and a specific plan to hang himself…
42y · Male·unascertained
Richard Vanderhelm, a 42-year-old man with a long history of substance dependence, disappeared on 21–24 May 2009 while undergoing community-based detoxification from methadone, cannabis and benzodiazepines at Somers Cara…
41y · Female·unable to determine
Carley Metcalfe, aged 41, was found deceased in the Brunswick River in November 2017, three weeks after disappearing. She had presented to Lismore Base Hospital on 1-2 November 2017 with acute psychosis related to schizo…
Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…
Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …
37y · Male·Acute external and internal blood loss from single stab wound to upper left ches…
MWJ, aged 37, was fatally stabbed by his intimate partner EW on 24 December 2016 during an escalating domestic argument. The coroner identified significant systemic failures in Community Corrections management of both of…
47y · Male·acute alcohol intoxication
Julian Horne, 47, died from acute alcohol intoxication at home after 11 hospital admissions in 6 weeks during a severe binge relapse. He had lifelong struggles with alcohol, depression and anxiety, previously tried multi…
26y · Male·multiple injuries from fall from height
A 26-year-old man with schizophrenia was discharged from mental health inpatient care on a community treatment order without meeting his allocated case manager, confirmed accommodation, or drug and alcohol intervention. …
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
Christopher Ritson, a 22-year-old with severe alcohol and polysubstance dependence (ICE, cannabis), depression, anxiety and social phobia, died by suicide via hanging on 17 March 2020, four days after discharge from hosp…
0y · Male·Sudden infant death syndrome category II (SIDS) - accidental asphyxiation due to…
An 8-week-old infant died from SIDS category II, likely due to accidental asphyxiation when the mother fell asleep and slumped forward over him. The infant was born to a mother with a 12-year history of heroin addiction …
volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…
This inquest examines three children (Master W aged 12, Miss B aged 17, Master JK aged 13) who died from volatile substance abuse in remote Aboriginal communities in the NT between 2018-2019. All three were known to gove…
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…
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