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NSWcommunity2025-09-18

Inquest into the death of Hillal Barbour

29y · Male·gunshot wound to the chest

Hillal Barbour, a 29-year-old man with schizophrenia, was fatally shot by police responding to a domestic violence call. He emerged from his home armed with two knives and advanced towards officers despite their instruct…

psychiatryemergency medicinecannabis
VICmental health2025-09-17

Finding into death of Thi Thu Nguyen

61y · Female·Complications of pulmonary thromboembolism secondary to deep vein thrombosis

A 61-year-old Vietnamese woman died from pulmonary thromboembolism secondary to deep vein thrombosis while an involuntary psychiatric patient. She had been admitted following a suicide attempt and was placed on an Assess…

psychiatryemergency medicine
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…

psychiatrypsychologysystemcommunicationamitriptyline
VICaged care2025-09-15

Finding into death of Arto Aaro Bohm

74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…

A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while in aged care. Key cl…

geriatric medicinegeneral practicesystemcommunication
VIChome2025-09-11

Finding into death of ZSQ

26y · Female·Multiple stab wounds

ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…

emergency medicinepsychiatrycommunicationsystemcocaine
NSWhome2025-09-11

Inquest into the death of H GM

0y · Female·Unascertained

A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…

paediatricsemergency medicinediagnostic
NSWcommunity2025-09-11

Inquest into the disappearance and suspected death of Andrew Corton

47y · Male·presumed death, actual cause unknown

Andrew Patrick Reuben Corton, a 47-year-old man with schizophrenia and cannabis use, disappeared and is presumed deceased. He was last sighted years before being reported missing. He resided in boarding houses and subseq…

psychiatryemergency medicinecommunicationsystemcannabis
VIC2025-09-10

Finding into death of Tracie Lyndal Markwick

54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…

Tracie Lyndal Markwick, a 54-year-old woman with intellectual disability and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-moderate cho…

speech pathologyemergency medicineamisulpride
QLD2025-09-05

Findings into the death of Faysal Ishak AHMED

30y · Male·Acute pneumonia and multi-organ failure, due to or as a consequence of traumatic…

Faysal Ishak Ahmed, a 30-year-old Sudanese refugee, died from traumatic brain injury sustained in a fall down stairs at Manus Island Regional Processing Centre on 22 December 2016. He collapsed and fell while alone, like…

emergency medicineintensive caredelaymannitol
VICcommunity2025-09-05

Finding into death of Lisa Nicole Murphy

52y · Female·unascertained - likely combination of underlying natural disease (myocardial inf…

Lisa Murphy, a 52-year-old woman with mental illness and substance use history, died following a physical altercation at a convenience store. She became involved in a verbal and physical confrontation with two women afte…

emergency medicineintensive carecommunicationrisperidone
NSWprison2025-09-05

Inquest into the death of Dushyanthan Visvanathan

55y · Male·Complications of alcohol use disorder

Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…

addiction medicineemergency medicinecommunicationdocumentationdiazepam
NSWhome2025-09-04

Inquest into the death of Baby MA

0y · Female·Unascertained

An unnamed full-term baby was found deceased at Edmondson Park on 19 February 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's existence. Po…

obstetricsemergency medicinedelay
VIChospital2025-09-03

Finding into death of Olivia Alexandra Evans

15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa

Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…

psychiatrypaediatricsdiagnosticsystemparacetamol
NSW2025-09-03

Inquest into the death of Daniel Leehy

47y · Male·ischaemic heart disease with seizure disorder and schizophrenia being other sign…

Daniel Leehy, a 47-year-old man in custody, died from ischaemic heart disease with significant coronary artery narrowing (60-80%) identified at autopsy. He had a 42-year history of epilepsy and schizophrenia with frequen…

forensic medicinepsychiatrysodium valproate
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NT2025-08-29

Inquest into the death of Raylene Dick, David Hardy and Karen Bading

46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…

This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…

infectious diseasesintensive carediagnosticsystem
TAShospital2025-08-29

Coroner's Finding: Scott, Nicholas Aaron

26y · Male·shotgun wound of the chest

Nicholas Aaron Scott, a 26-year-old prisoner with a history of self-harm, escaped from Royal Hobart Hospital on 2 January 2023 while under correctional officer supervision. He had been admitted for ingestion of foreign o…

correctional healthemergency medicineproceduralcommunicationmethamphetamine
VIChome2025-08-28

Finding into death of MJU & KJH

39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back

MJU (39) and her daughter KJH (6) were killed by MJU's husband CTH in a family violence homicide on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinati…

psychiatryemergency medicinediagnosticcommunicationmethamphetamine
NSWhome2025-08-28

Inquest into the death of KBS

1y · Male·Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrh…

A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib fractures, extensive bruising, and patterned…

paediatricsforensic medicinecommunicationsystemcannabis
NSWcommunity2025-08-25

Inquest into the death of Ashley Paull

49y · Male·Multiple injuries sustained when struck by a truck

Ashley Paull, a 49-year-old Aboriginal man with schizophrenia, died after being struck by a truck while walking along the Pacific Highway following his release from police custody. He had been stopped for a positive road…

psychiatryemergency medicinecommunicationsystemmethamphetamine

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