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NSW2025-07-08

Inquest into the death of SF

19y · Male·Hanging

SF, a 19-year-old remand inmate with no prior custodial or mental health history, died by hanging in Goulburn Correctional Centre 18 hours after requesting protective placement due to safety fears. He had expressed depre…

correctional healthpsychiatrycommunicationsystem
WA2025-07-08

Inquest into the Death of Tim Alan LOOKER

29y · Male·ligature compression of the neck (hanging)

Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…

general practicepsychiatrysystemcommunicationdextroamphetamine
VIC2025-07-07

Finding into death of Raymond John Blackney

83y · Male·end-stage Parkinson's disease (palliated)

Raymond John Blackney, an 83-year-old man with end-stage Parkinson's disease, died in custody at Port Phillip Prison from natural causes. He had complex medical needs including dementia, intellectual disability, and mult…

palliative caregeriatric medicinemorphine
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
VIC2025-07-04

Finding into death of Brent Reker

35y · Male·Hanging

Brent Reker, a 35-year-old prisoner with extensive history of suicide attempts (including hanging, overdose, and self-harm), died by hanging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximate…

psychiatryemergency medicinecommunicationsystemmethadone
TAS2025-07-04

Coroner's Finding: de-identified CF

24y · Male·blunt trauma and drowning due to intentional jumping from Tasman Bridge

A 24-year-old male international student and graduate employee experienced his first acute psychotic episode in December 2022, triggered by workplace stress and unsubstantiated beliefs about colleague manipulation. Initi…

psychiatryemergency medicinedelaycommunicationolanzapine
TAScommunity2025-07-04

Coroner's Finding: de-identified KT

26y · Male·multiple injuries, primarily severe chest trauma, due to jumping from the Tasman…

A 26-year-old man with psychosis and acute schizophrenia died by suicide jumping from the Tasman Bridge. He had been diagnosed with ADHD, generalised anxiety disorder, and sleep-wake disorder in 2021, with subsequent psy…

psychiatryemergency medicinepaliperidone
TAScommunity2025-07-04

Coroner's Finding: de-identified PD

41y · Male·Chest and limb injuries resulting from deliberately jumping from the Tasman Brid…

A 41-year-old male with schizophrenia, depression, and PTSD died by suicide by jumping from the Tasman Bridge. He had a long history of methamphetamine use and psychotic episodes, with multiple involuntary mental health …

psychiatryemergency medicinemethamphetamine
VIChome2025-07-03

Finding into death of Stephanie Rebernik

69y · Female·Effects of fire

Stephanie Rebernik, aged 69, died in a house fire in 2023. She had an acquired brain injury from 1980 with cognitive decline, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviour…

occupational therapypsychiatrysystemdelayoxazepam
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …

psychiatryemergency medicinecommunicationsystemsertraline
TAScommunity2025-07-02

Coroner's Finding: de-identified LM

41y · Male·multiple blunt force injuries sustained in a fall from height from the Tasman Br…

A 41-year-old man with a long history of alcohol and illicit drug abuse, poor mental health with suicidal ideation, and a history of Mental Health Act orders died by jumping from the Tasman Bridge in Hobart after threate…

psychiatryforensic medicinesystemalcohol
WAcommunity2025-07-02

Inquest into the Death of Donald Joseph Hemara WARD

50y · Male·Multiple injuries sustained in high-speed motorcycle crash

Donald Ward, aged 50, died from multiple injuries sustained in a high-speed motorcycle crash on 4 March 2023 in Karratha, WA. Ward left a nightclub intoxicated with alcohol (BAC 0.186%) and cannabis, obscured his number …

paramedicineemergency medicinepossibly diagnosticalcohol
TAScommunity2025-06-30

Coroner's Finding: de-identified EW

18y · Male·Death by suicide; cause cannot be definitively determined as body not recovered,…

An 18-year-old male with depression and anxiety died by suicide on 16 August 2022, jumping from the Tasman Bridge. He had been diagnosed with depression and anxiety in January 2022, saw a psychologist six times, and was …

general practicepsychiatryantidepressant medication
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

A 41-year-old man with schizophrenia died by suicide, jumping from the Tasman Bridge on Christmas Eve 2022. He had a 15-year history of mental illness with multiple suicide attempts, previously managed with antipsychotic…

psychiatrygeneral practicesystemdelaypaliperidone
TAScommunity2025-06-30

Coroner's Finding: de-identified IB

21y · Male·drowning

A 21-year-old male with schizophrenia and cannabis use died by suicide after jumping from the Tasman Bridge. He had been admitted to Royal Hobart Hospital on 7 May 2019 with suicidal ideation and auditory hallucinations …

psychiatryemergency medicinearipiprazole
TAScommunity2025-06-30

Coroner's Finding: de-identified HN

42y · Male·Drowning following chest injuries sustained from jumping from the Tasman Bridge

A 42-year-old man with long-standing, well-managed paranoid schizophrenia died by suicide from the Tasman Bridge. He had been compliant with clozapine therapy for over 20 years, maintained psychiatric stability, and had …

psychiatrygeneral practiceclozapine
WAhospital2025-06-30

Inquest into the death of Houston PEEL

29y · Male·ligature compression of the neck (hanging)

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…

emergency medicinepsychiatrycommunicationdelayolanzapine
QLD2025-06-26

Non-inquest findings into the death of Peter Raymond Thistleton

61y · Male·Multiple injuries due to motor vehicle collision (driver)

A 61-year-old truck driver died in a heavy vehicle rollover on the Burnett Highway. Evidence indicates he experienced fatigue-related microsleep while driving at 04:45 hours, causing the prime mover to drift onto the roa…

cannabis
VIChospital2025-06-25

Finding into death of RFV

87y · Male·Consequences of an assault with severe facial fractures

RFV, an 87-year-old man, died from severe facial fractures and traumatic brain injury sustained during an assault by his daughter-in-law. He presented to hospital in critical condition with cardiac arrest, multiple facia…

emergency medicineintensive caresystem
QLDhome2025-06-25

Non-inquest findings into the death of an eight month old twin whose family was known to Child Safety

0y · Male·Severe acute dehydration and acute malnutrition

An eight-month-old boy died from severe acute dehydration and malnutrition after receiving no or minimal fluid or food intake during a three-day drug binge by his mother and her partner. Child Safety was involved with th…

paediatricsemergency medicinediagnosticsystemmethamphetamine

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