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WAhospital2025-06-30

Inquest into the death of Houston PEEL

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

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…

emergency medicinepsychiatrycommunicationdelayolanzapine
TAScommunity2025-06-30

Coroner's Finding: de-identified HN

42y · Male·Drowning following chest injuries sustained from jumping from the Tasman Bridge

A 42-year-old man with long-standing, well-managed paranoid schizophrenia died by suicide from the Tasman Bridge. He had been compliant with clozapine therapy for over 20 years, maintained psychiatric stability, and had …

psychiatrygeneral practiceclozapine
TAScommunity2025-06-30

Coroner's Finding: de-identified IB

21y · Male·drowning

A 21-year-old male with schizophrenia and cannabis use died by suicide after jumping from the Tasman Bridge. He had been admitted to Royal Hobart Hospital on 7 May 2019 with suicidal ideation and auditory hallucinations …

psychiatryemergency medicinearipiprazole
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

A 41-year-old man with schizophrenia died by suicide, jumping from the Tasman Bridge on Christmas Eve 2022. He had a 15-year history of mental illness with multiple suicide attempts, previously managed with antipsychotic…

psychiatrygeneral practicesystemdelaypaliperidone
TAScommunity2025-06-30

Coroner's Finding: de-identified EW

18y · Male·Death by suicide; cause cannot be definitively determined as body not recovered,…

An 18-year-old male with depression and anxiety died by suicide on 16 August 2022, jumping from the Tasman Bridge. He had been diagnosed with depression and anxiety in January 2022, saw a psychologist six times, and was …

general practicepsychiatryantidepressant medication
WAhome2025-06-24

Inquest into the Death of Leighton Michael WOOD

44y · Male·bronchopneumonia in the setting of combined drug effect

Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…

psychiatrypathologyzuclopenthixol decanoate
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

Two premature infants died from unsafe sleeping environments while in the care of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay i…

paediatricspsychiatrydiagnosticcommunicationmethadone
VIChome2025-06-24

Finding into death of Jessica Geddes

27y · Female·Complications of multiple blunt force injuries

Jessica Geddes, 27, was killed by her partner Robert Rickerby through multiple blunt force injuries on 6 November 2020. The autopsy revealed extensive acute, subacute and chronic injuries inconsistent with accidental tra…

general practicepsychiatrydiagnosticsystemmethamphetamine
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
TAScommunity2025-06-20

Coroner's Finding: Haig, Jeff

60y · Male·Undetermined - likely natural causes (centriacinar emphysema) or misadventure (f…

Jeff Malcolm Haig, a 60-year-old man with multiple sclerosis and documented paranoid and delusional beliefs about being monitored, was found deceased at Low Head, Tasmania on 26 August 2022, having last been seen alive o…

neurologygeneral practicesystemalcohol
NSW2025-06-12

Inquest into the death of Roland Ashbolt

39y · Male·clozapine toxicity

Roland Ashbolt, a 39-year-old man remanded in custody with schizophrenia, died from clozapine toxicity. He had been prescribed clozapine (400mg daily) from January 2022 with good clinical response and therapeutic levels.…

psychiatryforensic medicineclozapine
WAcommunity2025-06-09

Inquest into the Death of Joyce Gladis CLARKE

29y · Female·gunshot wound to the abdomen

29-year-old Aboriginal woman (JC) of Ngarlawangga Yamatji Martu descent died from a gunshot wound inflicted by police on 17 September 2019. Four days prior, she was appropriately discharged from Sir Charles Gairdner Hosp…

psychiatryemergency medicinesystemmethamphetamine
TAScommunity2025-06-04

Coroner's Finding: Mead, Dion Charles

45y · Male·thermal burns sustained in a motor vehicle fire

A 45-year-old man with a history of poor mental health died from thermal burns following a deliberate single-vehicle crash into a brick wall. He had experienced recent workplace stress and significant grief from his brot…

forensic medicinepsychiatry
NSWhome2025-05-30

Inquest into the Death of K.P.

3y · Male·unascertained

KP was a 3-month-old with intrauterine growth restriction born to a mother with documented mental health issues and cannabis use. Despite referral to SAFE START and child protection involvement, care coordination and fol…

paediatricspsychiatrysystemcommunicationcannabis
TASaged care2025-05-26

Coroner's Finding: de-identified GJ

94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …

A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…

geriatric medicineorthopaedic surgerysystemdelayoxazepam
VIChome2025-05-23

Finding into death of Shirley Annette Kidd

67y · Female·Head injuries

Shirley Kidd, aged 67, died from head injuries inflicted by her grandson Hayden during a cannabis-induced psychosis. Hayden had experienced severe childhood abuse by his stepfather and subsequently developed mental healt…

psychiatrygeneral practicesystemcannabis
VICaged care2025-05-21

Finding into death of Lorraine Joy Wight

77y · Female·Airways obstruction by tissue paper

A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues i…

geriatric medicinepsychiatrycommunicationsystemoxycodone
SAhome2025-05-20

Coroner's Finding: Johnstone, Aaron George

43y · Male·methylamphetamine and heroin toxicity

A 43-year-old man died from methylamphetamine and heroin toxicity while on home detention bail. He had a complex psychiatric history including depression, psychosis, PTSD, and polysubstance use disorder, with previous su…

psychiatryaddiction medicinemethamphetamine
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
VIChome2025-05-20

Finding into death of CDE

33y · Female·Sharp force neck and chest injuries

A 33-year-old woman was fatally assaulted by her intimate partner in July 2019 following a two-year relationship marked by documented family violence and his untreated mental health conditions. The perpetrator had a hist…

psychiatryemergency medicinesystemcommunicationsynthetic marijuana

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