Coronial

218 results for asphyxia risk

VICcommunity2026-01-08

Finding into death of Dominic Joshua Clifford

23y · Male·Plastic bag asphyxia in setting of irrespirable atmosphere induced by nitrogen g…

Dominic Joshua Clifford, a 23-year-old with a complex history of mental illness including depression, anxiety, ADHD, and likely autism spectrum disorder, died by nitrogen gas inhalation in September 2024. He had multiple…

psychiatryfluoxetine
SA2018-01-17

Coroner's Finding: COSTI John Steve

39y · Male·neck compression (due to hanging) and plastic bag asphyxia

…d 6am, with his head covered by plastic bags. Costi had a 2009 history of self-harm but was assessed as low risk on induction in December 2012. He was remanded for 351 consecutive days awaiting trial for rape and robbery…

correctional healthpsychologysystemdelay
WAhome2024-04-04

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

11y · Male·unascertained

… of death was established; possible causes included sudden cardiac arrhythmia, seizure-related positional asphyxia, dehydration/malnutrition, or infection. The coroner found that Communities should have arranged medical …

paediatricscardiologycommunicationsystemcocaine
VIC2015-01-30

Finding into death of Matthew Aaron Condie

21y · Male·upper airway obstruction and plastic bag asphyxia

Matthew Aaron Condie, a 21-year-old prisoner serving a 12-year sentence at Port Phillip Prison, died by asphyxiation using a plastic bag on 27-28 September 2007. The coroner found his death was potentially preventable …

psychiatrypsychologycommunicationsystem
QLDhome2012-06-21

Gold Coast Murder Suicide

Unknown·Multiple causes: Antony Way died from stab wounds to neck and trunk; Tania Simps…

…their Robina apartment on 15 May 2011. He then abducted their 5-year-old daughter Kyla, drove to NSW, and asphyxiated her before killing himself. Rogers displayed escalating controlling, stalking, and obsessive behaviour…

psychologycommunicationsystem
SA2007-04-26

Coroner's Finding: CHRISTOPHER Penelope Rae and TRENORDEN John

53y · Male·asphyxia from combined effects of neck compression from hanging and suffocation …

…allegedly murdering his former business partner Penelope Christopher. Police correctly identified him as at-risk after he attempted to step in front of traffic and documented this on the PD331 screening form with 'At ris…

psychiatrygeneral practicecommunicationsystemallopurinol
SAmental health2010-05-07

Coroner's Finding: DOBRIJEVIC Sofija

73y · Female·neck compression by ligature

…ficer unfamiliar with psychiatry, and the psychiatric registrar. The clinical team assessed her as moderate risk of self-harm without access to this information. Despite her longstanding suicidal ideation history, risk a…

psychiatrygeriatric medicinecommunicationdiagnosticrisperidone
VICcommunity2013-01-21

Finding into death of Gaylee Antillia Kati

40y · Female·Crush injury to the chest

Gaylee Kati, a 40-year-old waste collection driver, was crushed against a power pole by the side loader arm of her truck on 28 June 2004. She had used cannabis after leaving the depot and before her death. She exited her…

occupational and environmental healthtoxicologyproceduralsystemcannabis
ACT2023-02-10

Inquest into the death of Joshua

18y · Male·asphyxia by hanging; intentional self-harm

…ished protocols; (2) ACTMHS closed the case within one month of hospitalisation for self-harm despite known risk factors (depression, isolation, family estrangement, academic stress); (3) No robust care plan was document…

psychiatryemergency medicinecommunicationsystemsertraline
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

…suicide hours later. The coroner identified critical gaps in discharge planning, capacity reassessment, and risk escalation, though could not definitively establish these caused his death. Key recommendations target stre…

psychiatryemergency medicinediagnosticcommunicationolanzapine
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

…nd lack of awareness that psychiatric patients and antipsychotic medications increase sudden cardiac arrest risk. There was also a five-hour initial response delay (Priority 4 tasking not escalated appropriately). Clinic…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VIC2022-09-02

Finding into death of Bazouni Bazouni

21y · Male·Hypoxic brain injury in the setting of drug toxicity

21-year-old Bazouni Bazouni died from hypoxic brain injury following methamphetamine toxicity ingested at Port Philip Prison. While the coroner concluded the death was not preventable given the excessive drug ingestion, …

emergency medicinecorrectional healthdiagnosticcommunicationmethamphetamine
VIC2025-09-24

Finding into death of Bryan Pham

24y · Male·multiple injuries and chest compression asphyxia (train strike)

…assessments when red flags present; (3) provide intensive discharge planning and community linkage for high-risk individuals with psychotic disorders and recent substance use; (4) recognise that generic advice to see GP/…

psychiatrycorrectional healthcommunicationsystemmethamphetamine
QLD2020-05-22

McGuire, Paul Thomas

Male·Asphyxia, caused by the inhalation of severely oxygen-depleted air

Paul McGuire, an experienced mine electrician, died from asphyxiation after opening a partially sealed hatch door to a GOAF (worked-out coal area) containing severely oxyg…

systemcommunication
VICcommunity2021-03-10

Finding into death of Jack David watson

26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases

Jack Watson, 26, died by intentional asphyxiation with inert gas on 2 August 2016. He had a long history of mental health issues including ADHD, depres…

psychiatryemergency medicinecommunicationsystemdextroamphetamine
ACTmental health2015-06-15

AN INQUEST INTO THE DEATH OF PETER ZOVAK

46y · Male·asphyxia by hanging

Peter Zovak, a 46-year-old with substance use history, presented to mental health services in November 2013 with first-episode psychosis. After initial hospital assessment and two CAT Team visits, his case was closed on …

psychiatryemergency medicinediagnosticcommunicationcannabis
ACTcommunity2020-09-25

Inquest into the death of ANTHONY ROMANAS CARISTO

54y · Male·Cardiac arrest in a person with cardiac hypertrophy and generalised atherosclero…

…nd no negligence by attending officers. Key clinical lesson: enhanced training on excited delirium syndrome risks, post-taser medical observation protocols, and taser restrictions for vulnerable populations (psychotic, i…

emergency medicineparamedicinedelaysystemmethamphetamine
TAShome2025-02-05

Coroner's Finding: de-identified MS

13y · Male·asphyxia as a result of hanging

…on Friday afternoon, despite concerning information, reflects significant workload pressures and incomplete risk assessment; (3) Informal student reports of peer concerns require robust follow-up processes. The coroner f…

psychologypsychiatrycommunicationsystem
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

…ces over 12 months, critical information was not shared between agencies. Court Link identified her as high-risk and attempted referral to a High Risk Team but the referral was never completed before her case closed. A d…

general practiceobstetricscommunicationsystemmethamphetamine
SAmental health2017-11-29

Coroner's Finding: MICHIE Tiffany Jayne.docx

22y · Female·plastic bag asphyxia, possibly contributed to by neck compression

A 22-year-old woman with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plast…

psychiatryemergency medicinediagnosticcommunicationmirtazapine

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