Coronial
Filters
Filters:

110 results

WA2026-02-02

Inquest into the Death of Joshua Fredrik VAN MALSSEN

24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…

Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…

cardiologyrespiratory medicinecommunicationsystemloratadine
WAhospital2026-01-08

Inquest into the Death of Lewis Walter WARD

33y · Male·Complications of out of hospital cardiac arrest in a man with atherosclerotic ca…

A 33-year-old Indigenous man with Type 2 diabetes, hypertension and dyslipidemia collapsed while playing football in a prison in July 2023, sustaining an out-of-hospital cardiac arrest from which he did not recover. Auto…

cardiologyintensive caresystemcommunication
WAhospital2025-12-05

Inquest into the Death of Leslie Charles LINTON

64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis

Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…

cardiologypsychiatryrisperidone
WAhospital2025-11-27

Inquest into the Death of Stephen Joseph SCHIPP

58y · Male·complications of oesophageal cancer, with terminal palliative care

Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…

oncologypalliative caresystemdelaychemotherapy
WA2025-06-12

Inquest into the Death of Graham John BUTLER

76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…

Graham John Butler, aged 76, died from out-of-hospital cardiac arrest secondary to coronary artery atherosclerosis and diabetes whilst imprisoned at Acacia Prison. He had significant cardiac history including prior myoca…

cardiologyemergency medicinebenzydamine
WA2025-03-18

Inquest into the Death of Lex Gregory MAHER

45y · Male·atherosclerotic heart disease

Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…

cardiologycorrectional healthsystemcommunicationatorvastatin
WAhospital2025-02-21

Inquest into the Death of Fabian Alec COFFIN

51y · Male·complications of myocardial infarction in association with ischaemic heart disea…

A 51-year-old prisoner died from complications of myocardial infarction with ischaemic heart disease. He had multiple cardiovascular risk factors including type-2 diabetes, hypertension, high cholesterol, chronic kidney …

cardiologyemergency medicinediagnosticinsulin
WAhospital2024-11-13

Inquest into the death of Chloe Grace Tupper

31y · Female·organ failure due to anorexia nervosa

Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…

psychiatrypaediatricssystemcommunicationmirtazapine
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…

emergency medicineendocrinologymedicationsystemryzodeg insulin
WAhospital2024-08-09

Inquest into the Death of Lindsay WOODS

48y · Male·metastatic high-grade neuroendocrine carcinoma, treated palliatively

Lindsay Woods, a 48-year-old Aboriginal man with chronic paranoid schizophrenia, organic psychosis, and ischaemic heart disease, died from metastatic high-grade neuroendocrine carcinoma. He was subject to a custody order…

psychiatryoncologyclozapine
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
WAhome2024-04-04

Inquest into the Death of Child LT (Name Subject to Suppression Order)

11y · Male·unascertained

An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…

paediatricscardiologycommunicationsystemcocaine
WA2023-09-14

Inquest into the Death of Shane Reynold NARRIER

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…

cardiologyemergency medicinediagnosticcommunicationescitalopram
WA2023-07-18

Inquest into the Suspected Death of Terry Frank JENNINGS

73y · Male·Unknown - likely medical episode or drowning; insufficient evidence to determine…

Terry Frank Jennings, aged 73, disappeared while boating at Gnarabup Beach, Western Australia on 31 March 2022. He had recently been diagnosed with paroxysmal atrial fibrillation and commenced on Metoprolol and Eliquis a…

general practicecardiologymetoprolol
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
WAhospital2023-03-30

Inquest into the Death of Hugh WARD

89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …

Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities inclu…

neurologycardiologycommunicationsystemwarfarin
WA2023-03-13

Inquest into the Death of Frank ALBERT

46y · Male·atherosclerotic heart disease

Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…

cardiologyemergency medicinesystemcommunicationquetiapine
WAcommunity2023-02-03

Inquest into the Suspected Death of Roly NIXON

44y · Male·Unascertained; presumed exposure

Roly Nixon, a 44-year-old man with significant medical comorbidities including rheumatic heart disease, diabetes, organic psychosis and seizure disorder, disappeared from Fitzroy Crossing, Western Australia on 28 January…

emergency medicinecardiologywarfarin
WAprison2023-01-31

Inquest into the Death of Cally GRAHAM

31y · Female·hypoxic ischaemic encephalopathy, bronchopneumonia and myocardial ischaemia comp…

Cally Graham, age 31, died from hypoxic ischaemic encephalopathy, bronchopneumonia and myocardial ischaemia complicating cardiorespiratory arrest associated with probable Takotsubo cardiomyopathy and methylamphetamine ef…

emergency medicineintensive caresystemcommunicationmethamphetamine
WAhospital2023-01-11

Inquest into the Death of Colin Albert WINTER

71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…

Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key clinical lessons i…

respiratory medicinecardiologycommunicationsystem

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.