16 results
35y · Male·self-inflicted gunshot wound to the head
Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…
Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…
Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…
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…
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…
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…
32y · Male·self-inflicted hanging
Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…
45y · Male·gunshot wound to the neck
Matthew Rosewarne, a 45-year-old man with chronic alcohol use disorder and recent relationship breakdown, was found dead in his shed with a gunshot wound to the neck. Although initially investigated as suicide, the coron…
44y · Male·coronary artery disease superimposed upon chronic obstructive pulmonary disease …
John Benedict Munkara died at age 44 following cardiac arrest while in police custody after being found at Vestey's Beach. He had suffered severe, chronic alcohol abuse with multiple protective custody episodes. Critical…
24y · Male·inhaled solvent toxicity (from petrol sniffing)
Edward James Laurie, a 24-year-old man with chronic petrol sniffing addiction since age 10 and underlying mental health issues including psychosis, died from inhaled solvent toxicity on 11 October 2015. Sixteen Applicati…
43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity
A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exce…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)
Richard Mark Kiel, a 37-year-old with chronic opioid addiction, died from acute heart failure caused by lethally high levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed the…
Unknown·Erfinna Lay: Aspiration resulting from Acute Multiple Drug Toxicity; John Quirk:…
Two young people died from acute multiple drug toxicity in 2005. Erfinna Lay (22, female) died from aspiration after ingesting chloral hydrate prescribed to her partner. John Quirk (27, male) died from doloxene overdose …
Male·Suffocation as a result of acute petrol vapour inhalation
Three Aboriginal males died from acute petrol vapour inhalation while sniffing in remote Northern Territory communities. Napthan Presley (14 years, Willowra), Wallace Coulthard (21 years, Mutitjulu), and Trevor Brumby (3…
38y · Female·Multiple injuries sustained in a motor vehicle accident in which the deceased wa…
Rita Dandy, a 38-year-old Aboriginal woman with chronic alcohol use disorder, died from multiple injuries after being struck by a motor vehicle while lying on the Stuart Highway near Darwin. She had been released from pr…
14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)
A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…
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