332 results
56y · Male·unascertained; presumed suicide by unknown means
Gerald Vanderwerf, a 56-year-old man with a 40-year history of severe depression, suicidal ideation, and multiple suicide attempts, disappeared from the Grampian Ranges on 23 September 2016. The coroner found on the bala…
63y · Female·Insulin overdose (suicide)
Marcia Maynard, a 63-year-old registered nurse at Woodford Correctional Centre, died by insulin overdose on 3 October 2015 after self-administering the drug at a hotel. She was required to give evidence at an inquest int…
53y · Female·self-inflicted hanging
Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…
50y · Male·Single, contact-range shotgun discharge to the head
Carmelo Gusman, a 50-year-old man, died from a self-inflicted shotgun wound after killing his wife in a murder-suicide. His death followed a workplace back injury that caused him significant psychological distress, loss …
54y · Male·Extensive burns due to detonation of LPG gas cylinder
A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…
25y · Male·drowning
Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and St Vincent's Hospital …
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…
21y · Male·asphyxia from inhalation of helium
21-year-old Devlin Duffy died from asphyxia due to helium inhalation. He had connective tissue disease causing chronic pain and disability. In May 2016, his GP Dr N. diagnosed moderate depression and prescribed desvenlaf…
39y · Male·neck compression (due to hanging) and plastic bag asphyxia
John Steve Costi, aged 39, died by suicide in Adelaide Remand Centre on 27 November 2013. He fashioned a ligature from bedding strips and hanged himself using an unusual hanging point in his single cell between 4am and 6…
31y · Male·Hypoxic ischaemic brain injury secondary to hanging
Craig Akerblom, a 31-year-old man with depression, anxiety, substance abuse, and selective eating disorder, died by hanging resulting in hypoxic-ischaemic brain injury. He had been under care of multiple clinicians (GP, …
23y · Male·hanging
Jamie Austin, 23 years old, died by hanging on 2-3 November 2015 after being intercepted by police on 1 November for dangerous erratic driving. He disclosed suicidality to an off-duty detective who videoed the interactio…
31y · Male·carbon monoxide toxicity
Shaun Martin Keane, aged 31, died by carbon monoxide toxicity while on home detention bail following arrest for assault. He had a documented history of suicidal ideation, including a previous gassing attempt in 2010, and…
44y · Male·Multiple traumatic injuries sustained in a fall from height
Ashley Bryant, a 44-year-old former NSW police officer with 24 years service, died by suicide at Minyon Falls on 16 December 2013 while suffering from PTSD, depression and alcohol dependence. The coroner found these cond…
21y · Male·Combined effects of heroin toxicity and plastic bag asphyxia
A 21-year-old man with complex congenital heart disease (Fontan procedure) died from combined heroin toxicity and plastic bag asphyxia. He had a history of depression and suicidality since childhood. In August 2014, duri…
28y · Female·ligature compression of the neck
Mary Van Der Walt, a 28-year-old with depression, anxiety, and borderline personality disorder, died by hanging on 21 April 2014. Two police officers responding to her initial '000' call found her unresponsive and pulsel…
27y · Female·hanging, self-inflicted with intention of taking own life
A 27-year-old Aboriginal woman with borderline personality disorder died by suicide within hours of discharge from an emergency department. She presented after her GP attempted to schedule her under the Mental Health Act…
16y · Female·Mixed drug toxicity
Maria Liordos, a 16-year-old in state care with complex trauma, substance abuse, mental health issues and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant failures in supervision an…
Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…
This inquest examined three deaths in Tasmanian custody: Troy Monson (asphyxiation in prison van during transport in June 2015), Robin Michael (hanging in prison cell June 2015), and Scott Mitchell (cardiac arrhythmia fr…
47y · Female·Multiple injuries from being struck by a train
A 47-year-old woman with major depressive disorder and anxiety died by suicide while an involuntary psychiatric inpatient. She had attempted suicide in November 2014 and was admitted to Bentley Hospital for psychiatric t…
63y · Male·neck compression due to hanging
A 63-year-old man with treatment-resistant depression died by hanging. His wife had been maintaining a 'suicide watch' for six weeks prior to his death and telephoned his GP on the morning of his final appointment, expli…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.