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NThospital2026-02-10

Inquest into the death of Martin Leach

67y · Male·Congestive cardiac failure

Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and comple…

emergency medicinecardiologysystemcommunicationmorphine
NThospital2025-01-10

Inquest into the death of Mati Tamwoy

66y · Male·infectious complications of plasmablastic myeloma

Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. Howe…

haematologyoncologysystemcommunicationchemotherapy agents
NThospital2024-12-06

Inquest into the death of Baby G

0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…

Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…

neonatologypaediatricsdiagnosticsystem
NT2024-06-12

Inquest into the death of Mr Dooley

37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia

Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …

cardiologygeneral practicediagnosticcommunicationatorvastatin
NTcommunity2024

Inquest into the death of Road Death 13 of 2024

77y · Male·Blunt force head and chest injuries from motor vehicle collision

A 77-year-old male with a history of seizures (2017, 2023) died from blunt force head and chest injuries sustained in a motor vehicle collision on 10 March 2024. The vehicle travelled at 157 km/h approaching a red traffi…

neurologycardiologysystemlamotrigine
NThospital2023-03-15

Inquest into the death of Janelle Pamkal

35y · Female·aortic dissection with associated acute aortitis

A 35-year-old Aboriginal woman with schizoaffective disorder presenting with acute psychosis and chest pain was appropriately referred for psychiatric assessment and retrieval. CareFlight transport was timely and the rec…

emergency medicinepsychiatryolanzapine
NThospital2021-01-07

Inquest into the death of Edgar Forrester

56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…

Edgar Forrester, a 56-year-old Aboriginal man, died of aspiration pneumonitis secondary to oesophageal squamous cell carcinoma with metastases while in custody. He presented with progressive dysphagia from September 2019…

general practicecardiologydiagnosticdelay
NThospital2020-07-17

Inquest into the death of Ishmael Nawirridj

51y · Male·Multiple organ failure due to Influenza A pneumonia, in the context of chronic k…

Ishmael Nalaiyir Nangarid, a 51-year-old Aboriginal man with complex medical history including myasthenia gravis, chronic kidney disease, COPD, and ischaemic heart disease, died from multiple organ failure due to Influen…

intensive carerespiratory medicinemedicationmeropenem
NT2019-09-27

Inquest into the death of Daryl Riley

42y · Male·ischaemic heart disease due to coronary artery atherosclerosis and left ventricu…

Daryl Jabangardi Riley, a 42-year-old Aboriginal prisoner, died of ischaemic heart disease due to coronary artery atherosclerosis and left ventricular hypertrophy while playing pool in the recreation room at Alice Spring…

cardiologygeneral practicediagnosticcommunication
NT2018-11-26

Inquest into the death of Jeremy aka Lawrence Tunkin

39y · Male·acute myocardial ischaemia, coronary artery thrombosis and coronary artery ather…

Jeremy Tunkin, an Aboriginal man with severe hearing loss, died of acute myocardial infarction while in prison custody. On 6 August 2017, he presented to the medical clinic with what prisoners identified as chest pain, b…

emergency medicinecardiologycommunicationdiagnosticadrenaline
NThospital2018-11-26

Inquest into the death of Jessica Poulson

0y · Female·Hypoplastic left heart syndrome

Jessica Agnes Poulson was a 17-day-old neonate born with hypoplastic left heart syndrome, a fatal congenital condition requiring emergency surgery unavailable in the Northern Territory. The parents elected palliative car…

paediatricscardiologymorphine
NThospital2018-01-11

Inquest into the death of Addison Anthony

35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…

A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…

emergency medicineintensive carecommunicationdiagnosticdicloxacillin
NT2017-01-13

Inquest into the death of Ronnie Beasley

40y · Male·ischaemic heart disease due to left ventricular hypertrophy and coronary artery …

A 40-year-old Aboriginal man with longstanding rheumatic heart disease, left ventricular hypertrophy, and coronary artery atherosclerosis died from acute myocardial infarction complicated by ventricular fibrillation whil…

cardiologyemergency medicineproceduralaspirin
NThome2016-10-17

Inquest into the death of Krista Lloyd

36y · Female·myocardial infarction as a consequence of severe focal coronary artery atheroscl…

Krista Lloyd, 36-year-old woman with undiagnosed coronary artery disease presenting with prior chest pain radiating to neck/jaw, suffered sudden out-of-hospital cardiac arrest on 1 May 2015 at home. Initial ECG showed po…

cardiologyemergency medicinediagnosticdelaymorphine
NT2016-09-02

Inquest into the death of Marrianne Munkara

45y · Female·Bronchiectasis

A 45-year-old Aboriginal woman with severe bronchiectasis, COPD, and cor pulmonale died at a sobering-up shelter after police protective custody. She had 15 hospital admissions in 2015 for acute exacerbations related to …

respiratory medicineemergency medicinesystemcommunication
NThospital2016-09-01

Inquest into the death of Kerry James Murphy

73y · Male·Acute subdural haematoma

Kerry James Murphy, 73, died from acute subdural haematoma following a fall in Royal Darwin Hospital's overcrowded Emergency Department. He was admitted with pneumonia, NSTEMI, and dizziness—significant fall risk factors…

emergency medicinecardiologysystemcommunicationblood thinners
NThospital2016-06-21

Inquest into the death of Kevin Steel

65y · Male·Congestive Cardiac Failure secondary to Ischaemic Heart Disease due to Non-Small…

Kevin John Steel, a 65-year-old Aboriginal man with advanced non-small cell lung cancer, ischaemic heart disease, atrial fibrillation, and multiple comorbidities, died in Alice Springs Hospital from congestive cardiac fa…

oncologypalliative care
NT2015-10-16

Inquest into the death of John Angeles

79y · Male·Ischaemic heart disease

John Angeles, aged 79, died of ischaemic heart disease while serving a life sentence for murder. He had severe triple-vessel coronary disease, chronic lung disease, and was on maximal medical therapy. The coroner found h…

cardiologypalliative caredelaymorphine
NT2015-08-14

Inquest into the death of Perry Langdon

59y · Male·idiopathic dilated cardiomyopathy (probably alcohol related)

A 59-year-old Aboriginal man died of idiopathic dilated cardiomyopathy in a Darwin police watch house following arrest for the minor offence of drinking in a designated public place. He had severe, documented cardiac dis…

emergency medicinecardiologysystemcommunication
NTprison2015-04-13

Inquest into the death of Raymond McDonald

49y · Male·cardiac hypertrophy (longstanding heart disease) complicated by chronic renal fa…

Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 m…

cardiologygeneral practicediagnosticdelay

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