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NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
WAhospital2025-07-22

Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent behavior, died on 9 November 2022 at Joondalup Health Campu…

psychiatryintensive caresystemdelayclozapine
VICcommunity2025-07-17

Finding into death of John Michael Jurdeczka

62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…

John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…

speech pathologygeneral practicecommunicationsystemmorphine
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…

Maxwell Howard, 84, died from bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart disease while admitted to a mental health acute unit under a Temporary Treatment Order. He had multiple comorbid…

psychiatryemergency medicinecarbamazepine
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
NSWcommunity2025-07-10

Inquest into the death of Nathan Markl

31y · Male·Drowning

Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…

psychiatryaddiction medicinesystemdelaymethamphetamine
WA2025-07-08

Inquest into the Death of Tim Alan LOOKER

29y · Male·ligature compression of the neck (hanging)

Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…

general practicepsychiatrysystemcommunicationdextroamphetamine
VIChospital2025-07-08

Finding into death of KD

48y · Female·Combined effects of cardiac hypertrophy, chronic obstructive pulmonary disease a…

KD, a 48-year-old woman with chronic schizo-affective disorder, end-stage renal failure, COPD, cardiac hypertrophy and obesity, died from combined natural causes while under assessment order in psychiatric care. She pres…

psychiatryintensive careolanzapine
NSW2025-07-08

Inquest into the death of SF

19y · Male·Hanging

SF, a 19-year-old remand inmate with no prior custodial or mental health history, died by hanging in Goulburn Correctional Centre 18 hours after requesting protective placement due to safety fears. He had expressed depre…

correctional healthpsychiatrycommunicationsystem
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
VIC2025-07-07

Finding into death of Raymond John Blackney

83y · Male·end-stage Parkinson's disease (palliated)

Raymond John Blackney, an 83-year-old man with end-stage Parkinson's disease, died in custody at Port Phillip Prison from natural causes. He had complex medical needs including dementia, intellectual disability, and mult…

palliative caregeriatric medicinemorphine
TAScommunity2025-07-04

Coroner's Finding: de-identified PD

41y · Male·Chest and limb injuries resulting from deliberately jumping from the Tasman Brid…

A 41-year-old male with schizophrenia, depression, and PTSD died by suicide by jumping from the Tasman Bridge. He had a long history of methamphetamine use and psychotic episodes, with multiple involuntary mental health …

psychiatryemergency medicinemethamphetamine
TAScommunity2025-07-04

Coroner's Finding: de-identified KT

26y · Male·multiple injuries, primarily severe chest trauma, due to jumping from the Tasman…

A 26-year-old man with psychosis and acute schizophrenia died by suicide jumping from the Tasman Bridge. He had been diagnosed with ADHD, generalised anxiety disorder, and sleep-wake disorder in 2021, with subsequent psy…

psychiatryemergency medicinepaliperidone
TAS2025-07-04

Coroner's Finding: de-identified CF

24y · Male·blunt trauma and drowning due to intentional jumping from Tasman Bridge

A 24-year-old male international student and graduate employee experienced his first acute psychotic episode in December 2022, triggered by workplace stress and unsubstantiated beliefs about colleague manipulation. Initi…

psychiatryemergency medicinedelaycommunicationolanzapine
VIC2025-07-04

Finding into death of Brent Reker

35y · Male·Hanging

Brent Reker, a 35-year-old prisoner with extensive history of suicide attempts (including hanging, overdose, and self-harm), died by hanging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximate…

psychiatryemergency medicinecommunicationsystemmethadone
SAhospital2025-07-03

Coroner's Finding: Cheesman, Trevor Allan

70y · Male·complications arising from craniofacial resection and orbital exenteration for r…

A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, …

neurosurgeryENT surgerysystemolanzapine
SAhospital2025-07-03

Coroner's Finding: Provis, Adam James

50y · Male·in-hospital cardiac arrest on a background of seizures and atheroembolic cerebro…

A 50-year-old man with bipolar affective disorder, hypertension, anxiety, depression and history of alcohol abuse died from in-hospital cardiac arrest on a background of seizures and atheroembolic cerebrovascular disease…

psychiatryneurologythiamine
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …

psychiatryemergency medicinecommunicationsystemsertraline
VIChome2025-07-03

Finding into death of Stephanie Rebernik

69y · Female·Effects of fire

Stephanie Rebernik, aged 69, died in a house fire in 2023. She had an acquired brain injury from 1980 with cognitive decline, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviour…

occupational therapypsychiatrysystemdelayoxazepam
TAScommunity2025-07-02

Coroner's Finding: de-identified LM

41y · Male·multiple blunt force injuries sustained in a fall from height from the Tasman Br…

A 41-year-old man with a long history of alcohol and illicit drug abuse, poor mental health with suicidal ideation, and a history of Mental Health Act orders died by jumping from the Tasman Bridge in Hobart after threate…

psychiatryforensic medicinesystemalcohol
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