2,612 results
41y · Female·Cardiomegaly
Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle a…
70y · Female·Asphyxia due to airway obstruction
Anna Lee, a 70-year-old retired psychiatric nurse, died from asphyxia due to airway obstruction while an inpatient in a mental health unit. She was admitted with first-episode mania with psychotic features, triggered by …
89y · Male·unascertained - natural causes
Harold Edward Burgess, aged 89, died in Port Phillip Prison's medical unit from unascertained natural causes following a fall on 6 November 2022 that resulted in cervical spine fractures. He was deemed unsuitable for sur…
54y · Male·Cardiomyopathy (NOS)
Timothy Hacking, a 54-year-old man with intellectual disability, schizoaffective disorder, epilepsy and hypertension, died suddenly at his supported accommodation from cardiomyopathy. Autopsy revealed moderate coronary a…
54y · Female·Pulmonary thromboembolism complicating left calf deep venous thrombosis in the s…
54-year-old woman with frontotemporal dementia and Parkinson's disease died from pulmonary thromboembolism complicating deep venous thrombosis. She fell during the night at a disability accommodation facility and was fou…
33y · Male·sharp force injuries of the neck
Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 following a NSW Police operation.…
57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)
Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a p…
59y · Male·Shotgun wound to the head
A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…
18y · Male·compression of the neck in keeping with hanging
An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…
44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…
David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…
49y · Male·undetermined
A 49-year-old man with paranoid schizophrenia on clozapine became non-compliant with mental health appointments in July 2021. After threatening clinic staff while acutely psychotic, mental health services and police atte…
31y · Male·compression of the neck secondary to hanging
Rory Van Geleuken, a 31-year-old with longstanding major depressive disorder, generalised anxiety disorder, autism spectrum disorder, and ADHD, died by hanging. He had received mental health treatment since age 17, inclu…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
44y · Male·Complications following seizure on a background of acquired epilepsy; acquired b…
Anthony Dzaja, aged 44, died from complications of seizures secondary to acquired brain injury sustained in a 1997 motor vehicle accident. He had progressively deteriorated over several years with worsening epilepsy, cog…
58y · Male·unascertained
Peter James Guidera, a 58-year-old man with a history of depression, suicidal ideation, and previous suicide attempts, disappeared on 8 May 1998 from Narrogin, Western Australia, shortly after receiving a distressing pho…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
47y · Male·Compression of the neck arising from hanging
47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinat…
18y · Male·Unascertained; likely hypothermia possibly in combination with drowning
Jodus Murphy, 18, disappeared from his mother's home on 12 May 2023 and was found deceased near the Goulburn River on 14 June 2023. He had experienced significant life disruption following his grandparents' relocation to…
35y · Male·Neck compression due to hanging
Joshua Gonzalez, 35, died by suicide on 5 September 2020 after being discharged from Footscray Hospital. He had been apprehended by police under section 351 of the Mental Health Act after threatening self-harm and asking…
38y · Female·end stage renal failure (Stage 5 chronic kidney disease)
Ms Harwood, a 38-year-old transgender woman with end-stage renal disease, died of natural causes following refusal of dialysis. Her mother claimed the death was suicide prompted by fear of returning to prison following a…
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