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WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…

psychiatrycorrectional healthsystemcommunicationtramadol
WA2022-07-20

Inquest into the Death of Seth Gregory Victor YEEDA

19y · Male·Rheumatic heart disease (severe aortic valve regurgitation)

Seth Yeeda, 19-year-old Aboriginal male with rheumatic heart disease from childhood, died in custody from severe aortic valve regurgitation. He had required aortic valve replacement surgery since 2014. In December 2017, …

cardiologycardiothoracic surgerysystemcommunication
WA2022-07-15

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

21y · Male·complications of ligature compression of the neck (hanging)

Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
WA2022-07-06

Inquest into the Death of Paul Stephen KEATING

60y · Male·atherosclerotic heart disease (cardiac arrhythmia secondary to severe long-stand…

Paul Stephen Keating, a 60-year-old man with severe atherosclerotic heart disease, died from cardiac arrhythmia while incarcerated in Casuarina Prison, Western Australia. He had significant coronary artery disease diagno…

cardiologycorrectional healthamiodarone
WAhospital2022-06-23

Inquest into the Death of Lee MILCHERDY

75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…

Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…

gastroenterologygeneral surgerycommunicationdiagnostic
WA2022-06-21

Inquest into the Death of Ashley Adrian LANE

56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…

Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
WA2022-06-17

Inquest into the 4 Deaths at Mount Augustus

heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…

Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…

emergency medicineforensic medicinesystemcommunication
WAcommunity2022-06-09

Inquest into the Death of Desmond Edward JACK

33y · Male·Gunshot injury to the anterior trunk (chest and upper abdomen)

Desmond Jack, a 33-year-old with longstanding bipolar affective disorder and psychotic symptoms, died from a single gunshot wound to the anterior trunk after being shot by police officer Senior Constable Harrison on 28 M…

psychiatryemergency medicinesystemmirtazapine
WAhospital2022-06-08

Inquest into the Death of Salvatore Giovanni OTRANTO

68y · Male·Complications following myocardial infarction and its treatment in a man with mu…

Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…

cardiologyintensive careproceduralenoxaparin
WA2022-05-20

Inquest into the Death of Kevin Ernest McCRACKEN

58y · Male·Hypertensive and valvular heart disease

Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and ao…

cardiologycorrectional healthsystemmedicationwarfarin
WAcommunity2022-04-13

Inquest into the Suspected Death of Faycal AL SAIDI

Male·Drowning

Faycal Al Saidi, a Belgian national unfamiliar with Australian coastal hazards, was swept into the ocean at Salmon Beach, Esperance, while walking on wet slippery rocks to take photographs. Despite warning signs, he did …

WAhome2022-04-13

Inquest into the Death of Boris DRLESKI

45y · Male·bronchopneumonia and combined drug toxicity

Boris Drleski, a 45-year-old with treatment-resistant chronic paranoid schizophrenia, antisocial personality disorder, and polysubstance use disorder, died from bronchopneumonia and combined drug toxicity. He was managed…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
WAcommunity2022-04-13

Inquest into the Death of Ms B (Name Subject to Suppression Order)

40y · Female·effects of fire including smoke inhalation, thermal injuries and incineration

Ms B, aged 40, died when a stolen Ferrari she was a passenger in collided with a steel barrier and caught fire following a police pursuit incident on 25 May 2019 in North Perth, WA. The driver (an offender) fled from pol…

forensic medicinecommunicationproceduralmethamphetamine
WAcommunity2022-04-01

Inquest into the Death of Cherdeena Shaye WYNNE

26y · Female·hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamph…

Ms Cherdeena Wynne, a 26-year-old Noongar Yamatji woman, died from hypoxic ischaemic encephalopathy and bronchopneumonia following cardiac arrest during police restraint on Albany Highway. She was intoxicated with methyl…

psychiatryemergency medicineproceduralcommunicationmethamphetamine
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…

emergency medicinegastroenterologydiagnosticcommunication
WA2022-03-28

Inquest into the Suspected Death of Michael Richard GRUBB

33y · Male·Drowning (unascertained - possible injury sustained upon reaching dinghy)

Michael Grubb, age 33, died by drowning in Cockburn Sound, Western Australia on 16 August 2019 after jumping from a yacht without a lifejacket to retrieve an adrift dinghy during severe weather conditions with gale-force…

systemdelay
WAcommunity2022-03-28

Inquest into the Suspected Death of Dinh Loi HO

30y · Male·Unascertained, but death most likely due to drowning

Dinh Loi Ho, a 30-year-old Vietnamese refugee without swimming ability, disappeared while abalone fishing at Sugarloaf Rock in Western Australia on 2 March 2020. He entered the ocean in inappropriate clothing without a l…

WAhospital2022-03-03

Inquest into Death of Van Tho NGUYEN

59y · Male·metastatic lung cancer, with palliation

Van Tho Nguyen, a 59-year-old remand prisoner with metastatic lung cancer, died of natural causes in a private hospital palliative care setting. He had been a lifelong smoker who developed advanced adenocarcinoma with bo…

oncologypalliative caresystemcommunicationchemotherapy agents
WAcommunity2022-02-25

Inquest into the Suspected Death of Crispin MITCHELL

54y · Male·Unknown; likely drowning in Cambridge Gulf waters, but exact cause could not be …

Crispin Mitchell, aged 54, disappeared on 20 February 1987 while travelling by small aluminium dinghy across Cambridge Gulf in rough weather with two companions. All three men were intoxicated; the dinghy lacked safety e…

delay
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
19101144

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