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WA2026-04-14

Inquest into the Death of Wayne HARRIS

56y · Male·complications of advanced metastatic sigmoid adenocarcinoma in an adult man with…

A 56-year-old Aboriginal man died of advanced metastatic sigmoid adenocarcinoma while serving an 11-year sentence for child sex offences. He had been diagnosed with Stage 4 colorectal cancer in 2018 with an expected life…

oncologypalliative carecommunicationsystemchemotherapy
WA2026-03-26

Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

Brian Kealy, aged 42, died by suicide via hanging at Hakea Prison on 2 August 2024 while on remand. He had complex mental health needs including probable schizophrenia, anti-social personality disorder, and polysubstance…

psychiatrygeneral medicinecommunicationsystemolanzapine
WA2026-03-09

Inquest into the Death of Russell Graham PENNY

56y · Male·complications of viral hepatitis related advanced-chronic liver disease

Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was…

correctional healthgeneral medicinesystemcommunication
WA2026-01-08

Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…

cardiologyemergency medicinediagnosticsystem
WAcommunity2025-12-09

Inquest into the Suspected Death of Eric Donald BRANDRICK

47y · Male·unascertained

Eric Donald Brandrick, aged 47, disappeared from his home in North Fremantle, Western Australia, after 31 December 1989. He had suffered a severe stroke in September 1988 causing left-sided paralysis, visual impairment, …

emergency medicinegeneral medicine
WAhome2025-07-11

Inquest into the Death of Monique Jacinta GOMEZ

48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…

Monique Gomez, 48, died from a spontaneous intracerebral haemorrhage during hospitalization for stroke rehabilitation and treatment of schizoaffective disorder. An initial ischaemic stroke resulted from non-compliance wi…

general medicineneurologywarfarin
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, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…

correctional healthgeneral medicinebenzydamine
WAhospital2025-05-08

Inquest into the Death of Tony RUICH

55y · Male·decompensated liver failure in a man with metastatic hepatocellular carcinoma, w…

Tony Ruich, a 55-year-old sentenced prisoner, died from decompensated liver failure due to metastatic hepatocellular carcinoma with terminal palliative care. He had pre-existing cirrhosis diagnosed in 2012, likely from h…

hepatologypalliative careheroin
WA2025-03-27

Inquest into the Death of Travis Dion BAUMGARTEN

48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…

Travis Dion Baumgarten was a 48-year-old Aboriginal man serving a prison sentence at Acacia Prison in Western Australia who died on 5 December 2022 from complications of untreated HIV/AIDS. After HIV diagnosis in 1994, h…

infectious diseasesgeneral medicine
WA2025-03-10

Inquest into the Death of Ricky-Lee COUND

22y · Male·ligature compression of the neck (hanging)

Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…

psychologygeneral medicinediagnosticcommunicationaripiprazole
WAhome2025-02-12

Inquest into the Death of Kimberley Michael VULICH

64y · Male·complications in association with thermal injuries in a man with underlying chro…

Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …

general medicinegeriatric medicinecommunicationdelay
WA2024-11-15

Inquest into the death of Kingsley Dean Garlett

32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…

Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…

psychiatrypsychologysystemdelaymethadone
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
WA2024-07-10

Inquest into the Death of Kevin John KEATH

76y · Male·metastatic prostate cancer with terminal palliative care

Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…

oncologypalliative caresystemdelay
WAhospital2024-04-05

Inquest into the Suspected Death of Neil Lindsay KOBELT

27y · Male·unascertained

Neil Lindsay Kobelt, a 27-year-old man with diagnosed schizophrenia, disappeared from Kalgoorlie, Western Australia in February 1982, shortly after discharge from hospital for acute psychiatric crisis. He had relocated t…

psychiatrygeneral medicinecommunicationsystem
WAhospitalJuly 2023

Inquest into the Death of Lincoln Arthur CAMPBELL

52y · Male·end-stage throat cancer

Lincoln Campbell, a 52-year-old Aboriginal man with terminal throat cancer, disappeared from Kununurra Hospital on 24 December 2005 while receiving palliative care. He had a PEG feeding tube, required regular morphine an…

oncologypalliative caremorphine
WAhospital2023-11-29

Inquest into the Death of Samuel Edward ASHBY

46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…

Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…

psychiatrygeneral medicinediagnosticsystemclozapine
WAhospital2023-11-02

Inquest into the Death of Bradley James Raymond STINSON

66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…

Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…

palliative careoncologyproceduralsystemoxycodone

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