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NSWhospital2024-03-28

Inquest into the death of Monika Chetty

39y · Female·Complications from burns, such burns being from acid doused over 80% of Ms Chett…

Monika Chetty, aged 39, died from complications of severe acid burns covering 80% of her body sustained in early December 2013. She was found in bushland in West Hoxton on 4 January 2014 and died 27 days later at Concord…

plastic and reconstructive surgeryemergency medicinediagnosticsystem
NSWhome2024-03-26

Inquest into the death of MO

6y · Unknown·methadone toxicity

A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…

addiction medicinepaediatricsdiagnosticcommunicationmethadone
NSWhome2024-03-21

Inquest into the death of Brandon Rich

29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…

Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…

cardiologypsychiatrycommunicationsystemmethamphetamine
NSW2024-03-13

Inquest into the death of O A

44y · Male·multiple injuries from fall from cliff

A 44-year-old man with familial Mediterranean fever (FMF) and bipolar affective disorder with drug-induced psychosis died following a fall from a cliff at Vaucluse during a police rescue operation. He had been managing s…

rheumatologyallergy and immunologycommunicationsystemoxycodone
NSW2024-03-06

Inquest into the death of WM

59y · Male·Hanging

A 59-year-old man serving a life sentence died by hanging in his segregation cell at Lithgow Correctional Centre on 2-3 April 2020. He had a history of depression, anxiety, and a prior serious self-harm attempt in 2010 r…

psychiatryforensic medicinesystemmirtazapine
NSWmental health2024-03-06

Inquest into the death of RA

64y · Female·hypoxic ischemic encephalopathy caused by neck compression and hanging

A 64-year-old woman with a history of childhood trauma, anxiety and depression was admitted to an acute mental health unit (Kurrajong Unit) under involuntary care following a suicide attempt. Within 24 hours, she accesse…

psychiatryemergency medicinesystemproceduralmirtazapine
NSWcommunity2024-03

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 1

Unknown·Thermal injury and burns from bushfire exposure; smoke inhalation

The 2019/2020 NSW bushfire season was catastrophic, with 25 deaths investigated by the State Coroner through inquests and 41 fires through inquiries. Over 5.52 million hectares burned, destroying 2,476 homes and damaging…

systemdelay
NSWcommunity2024-03

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 2

systemic inquiry into 2019-2020 NSW bushfire season deaths - no single death exa…

Volume 2 of a comprehensive coronial inquiry into systemic issues arising from the 2019-2020 NSW bushfire season. The State Coroner examined 41 fires through Stage 1 hearings and conducted Stage 2 representative case stu…

systemcommunication
NSWcommunity2024-02-29

Inquest into the suspected death of Florabella Natalia Marion Remakel, aka Marion Barter

51y · Female·Unable to determine cause of death

Marion Barter (51) disappeared in 1997 after changing her identity to Florabella Natalia Marion Remakel. She sold her house, resigned from her teaching position, and travelled to England on 22 June 1997, returning on 2 A…

diagnosticsystem
NSWhospital2024-02-26

Inquest into the disappearance of Luke Huggard

31y · Male·Unable to be determined (uncertain whether drowning or other cause following app…

A 31-year-old man with schizoaffective disorder and substance use was admitted involuntarily to the Kiloh Centre after presenting in acute psychosis with suicidal ideation on 1 April 2017. His psychotic symptoms rapidly …

psychiatrydiagnosticcommunicationlisdexamfetamine
NSWcommunity2024-02-26

Inquest into the disappearance of Robert Hamish Duncan

78y · Male·Unknown - insufficient evidence to determine

Robert Hamish Duncan, a 78-year-old man with a long history of schizophrenia, disappeared on 12 April 2021 from Oxford Street, Sydney. He was last seen at a bus stop at 9:40pm. Despite extensive police investigation incl…

NSWhomePodcast2024-02-23

Inquest into the death of Natasha Lechner

39y · Female·Sudden cardiac arrhythmia following the administration of Kambo frog toxin

Natasha Lechner, a 39-year-old woman with chronic pain from degenerative disc disease, died from sudden cardiac arrhythmia triggered by Kambo frog toxin administration during a ceremony. She had completed Kambo practitio…

cardiologytoxicologydelaysystemkambo frog toxin
NSWcommunity2024-02-20

Inquest into the death of Jasmynd Gibbs

33y · Male·Complications of methylamphetamine use

Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health di…

correctional healthpsychiatrysystemcommunicationmethamphetamine
NSW2024-02-19

Inquest into the death of Siosiua Mateaki He Lotu Meyer

48y · Male·Complications of infective exacerbation of bronchiectasis with cor pulmonale

A 48-year-old man with a significant history of bronchiectasis died in police custody from infective exacerbation of bronchiectasis with cor pulmonale. The inquest examined whether police took appropriate steps to obtain…

respiratory medicineemergency medicinedelaysystem
NSWcommunity2024-02-19

Inquest into the death of Omar Mohammad

33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity

Omar Mohammad, a 33-year-old man with recent mental health concerns and drug use, ingested a small plastic bag containing cocaine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversi…

emergency medicinetoxicologycommunicationdelaycocaine
NSW2024-02-01

Inquest into the death of Timothy Garner

31y · Male·Hanging

Timothy Garner, a First Nations man with bipolar disorder and schizophrenia, died by hanging in custody at MRRC on 7 July 2018, five days after being cleared from Risk Intervention Team (RIT) management. The coroner foun…

psychiatrycorrectional healthdiagnosticcommunicationquetiapine
NSWhospital2024-01-30

Inquest into the death of Subash Subedi

26y · Male·Not able to be determined - skeletalised remains

Subash Subedi, a 26-year-old international student from Nepal, died in a stormwater drainage system beneath the M2 Motorway between February 2018 and April 2019. He presented to Westmead Hospital ED on 14 February 2018 w…

emergency medicinepsychiatrycommunicationsystemolanzapine
NSWhospital2024-01-29

Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…

cardiothoracic surgerygeneral surgerydiagnosticcommunicationmorphine
NSWcommunity2024-01-23

Inquest into the disappearance and suspected death of Bruce Robinson

72y · Male·The available evidence does not allow for any finding to be made as to the cause…

Bruce Robinson, a 72-year-old man with a history of non-Hodgkin's lymphoma, schizophrenia, psychosis, and dementia, died on 27 October 2022 after jumping from a ferry into Sydney Harbour. He had been non-compliant with h…

psychiatryemergency medicinesystemolanzapine
NSWhome2023-12-21

Inquest into the death of Timothy Ricketts

43y · Male·The combined effects of subacute myocardial injury and methadone toxicity

Timothy Ricketts, a 43-year-old man with complex psychiatric and substance use history, died from combined subacute myocardial injury and methadone toxicity. He had been admitted to hospital in November 2021 with elevate…

cardiologyaddiction medicinediagnosticdelaymethadone
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