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WAcommunity2022-02-23

Inquest into the Suspected Death of Victoria Leigh McCLOY

22y · Female·Unknown cause; most likely drowning but insufficient evidence without body to de…

Victoria McCloy, aged 22, disappeared while rock fishing at Isthmus Beach, Torndirrup National Park, Albany on 23 November 2019. She and her partner Geoff Bignell went rock fishing; Geoff's body was later recovered showi…

WAhospital2022-02-14

Inquest into the Death of Jeffrey Lee STRETTLES

52y · Male·complications in association with advanced malignancy (hepatocellular carcinoma)…

Jeffrey Lee Strettles, a 52-year-old prisoner, died from complications of advanced hepatocellular carcinoma, end-stage cirrhosis, and generalised sepsis. He had contracted Hepatitis C in the late 1980s and was diagnosed …

gastroenterologyoncologysystemledipasvir
WA2022-02-10

Inquest into the Suspected Death of Naing Aung YAN

28y · Male·unascertained; manner of death: suicide

Naing Aung Yan, a 28-year-old Myanmar national working as an oiler on a Hong Kong-registered vessel anchored off Cape Preston, Western Australia, disappeared on 4 February 2019 and is presumed to have died by suicide. He…

WA2022-02-09

Inquest into the Suspected Death of Winston Abalona CHAVEZ

39y · Male·Unknown cause. Possible drowning, injuries from fall into water, or predation. D…

Winston Abalona Chavez, a 39-year-old Filipino oiler, disappeared from the cargo ship MV Baltic Frontier in Shark Bay, Western Australia on 8 May 2009. He had requested early release from his contract due to his mother's…

WA2022-02-09

Inquest into the Suspected Death of Pei Yao CHEN

41y · Male·Drowning in the Indian Ocean near B-7 Anchorage Point approximately 13 miles fro…

Pei Yao Chen, a 41-year-old Bosun, fell overboard from the cargo ship Cape Splendor while fishing from an accommodation ladder during a lunch break in October 2014. Despite wearing work clothes and no lifejacket (contrar…

system
WA2022-02-09

Inquest into the Suspected Death of Hok Cheun HOU

57y · Male·Unknown cause; likely drowning or injuries sustained when entering the water

Hok Cheun Hou, a 57-year-old Hong Kong national working as a general steward on the Coral Princess, disappeared in March 1989 approximately 200 nautical miles off Exmouth, Western Australia. He was last definitively seen…

WA2022-02-09

Inquest into the Suspected Death of Yaritosai TOMIOKA

47y · Male·unascertained; manner of death suicide by going overboard into the ocean

Yaritosai Tomioka, a 47-year-old Chief Engineer on a Japanese fishing vessel, disappeared from the Toku Ju Maru on 5 October 1972 in the Indian Ocean, 200 nautical miles west of Fremantle. A six-page suicide note was fou…

WA2022-02-09

Inquest into the Suspected Death of Fuh Jinn YANG

26y · Male·drowning in the Indian Ocean

This case involves the drowning death of Fuh Jinn Yang, a Taiwanese fisherman who died on 4 August 1984 while attempting a heroic rescue of a colleague who had fallen overboard from a fishing vessel off Broome, Western A…

WA2022-02-04

Inquest into the Death of Robert William ROMAN

55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…

A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented with headach…

nephrologyemergency medicinesystemcommunicationaspirin
WAhospital2022-01-25

Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…

psychiatrygeneral medicinecommunicationproceduralfluoxetine
WAhome2022-01-17

Inquest into the Death of Shaun Andrew WILLIS

54y · Male·Ligature compression of the neck (hanging)

Shaun Willis, aged 54, died by hanging at his home on 8 March 2019 following a turbulent separation and family violence history. He was arrested on 7 March for assaulted his ex-wife and served with a Family Violence Rest…

communicationsystemalcohol
WAhospital2022-01-17

Inquest into the Death of Peter Johnnie YOUNG

Male·Complications of alcohol and hepatitis C-related liver disease

Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…

hepatologygastroenterologysystemdelayquetiapine
WAhospital2022-01-06

Inquest into the Death of Louisa Betty RYAN

89y · Female·aspiration pneumonia with respiratory failure complicating major depression with…

Louisa Betty Ryan, 89 years old with major depression with catatonia, atrial fibrillation, pulmonary oedema, diabetes and Parkinsonism, died from aspiration pneumonia with respiratory failure following electroconvulsive …

psychiatryanaesthesia
WAhospital2022-01-05

Inquest into the Death of Terrence Alexander Penman WELLS

61y · Male·metastatic oesophageal neuroendocrine carcinoma

Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…

oncologypalliative caremedicationsystempantoprazole
WA2021-12-22

Inquest into the Death of Brett Ashley DUTURBURE

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

Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…

correctional healthpsychiatrysystemcommunication
WA2021-12-21

Inquest into the Death of Child JP (Name Subject to Suppression Order)

16y · Male·multiple injuries sustained in motor vehicle crash

A 16-year-old unlicensed driver died in a high-speed crash while being pursued by unmarked police over 14 km. The driver attempted a dangerous overtaking manoeuvre on a gravel verge while evading police. Two detectives i…

proceduralcommunicationcannabis
WA2021-12-21

Inquest into the Death of James Alexander TILBURY

77y · Male·early pneumonia in an elderly man receiving terminal palliative medical care for…

James Tilbury, a 77-year-old long-term prisoner, died from early pneumonia while receiving palliative care for an atypical brain meningioma. He had complex chronic conditions including COPD, prostate cancer, ischaemic he…

palliative careneurosurgerycommunicationsystemdexamethasone
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist m…

psychiatrypaediatricssystemdelay
WA2021-12-15

Inquest into the Death of Ohm SATHITPITTAYAYUDH

38y · Male·cardiac arrhythmia with acute circulatory failure in a man with acute drug effec…

Ohm Sathitpittayayudh, aged 38, died in custody at Karnet Prison Farm from cardiac arrhythmia with acute circulatory failure after ingesting 5F-ADB (Kronic), a synthetic cannabinoid. He had exemplary prison behaviour, go…

toxicologyforensic medicinesystem5f-adb
WAhome2021-12-03

Inquest into the Death of Elia WANI

29y · Male·acquired methaemoglobinaemia in association with sodium nitrite toxicity

Elia Wani, a 29-year-old man with bipolar affective disorder managed on a community treatment order, died from methaemoglobinaemia following sodium nitrite ingestion. He purchased 50g of sodium nitrite powder online on 1…

psychiatryemergency medicinesystemsodium nitrite
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