2,612 results
50y · Female·Hanging
Karla Lee Jordan, a 50-year-old accountant at Ballarat Health Services, died by hanging on 29 August 2019. The coroner found workplace stress from a toxic workplace culture was the primary suicide stressor. Following a r…
32y · Female·mixed drug toxicity including phenobarbitone
A 32-year-old woman with borderline personality disorder and depression died by intentional self-administration of pentobarbitone (Lethabarb) accessed from her workplace. She had experienced extensive family violence in …
64y · Male·Complications of congestive cardiac failure on a background of cardiac hypertrop…
QBT, a 64-year-old man with complex medical and psychiatric history including schizophrenia, COPD, and hypertension, was admitted to Bendigo Hospital on an Assessment Order after police concerns about mental health deter…
41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm
Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
43y · Male·compression of the neck in keeping with hanging
A 43-year-old man on home detention died by hanging in September 2021. He had a history of epilepsy, depression, anxiety, illicit drug use, and previous suicide attempts. In the weeks before death, he presented to hospit…
33y · Male·hypoxic-ischaemic encephalopathy due to hanging with resuscitation
Matthew Keith Constantine, aged 33, died from hypoxic-ischaemic encephalopathy following a hanging attempt while under home detention. He was released from prison in December 2021 with parole conditions including electro…
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical l…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…
Travis Dion Baumgarten was a 48-year-old Aboriginal man serving a prison sentence at Acacia Prison in Western Australia who died on 5 December 2022 from complications of untreated HIV/AIDS. After HIV diagnosis in 1994, h…
41y · Male·complications of acute ethanol toxicity
Mr RJ, a 41-year-old man with a history of progressive alcohol misuse and mental health conditions (anxiety and depression), died from complications of acute ethanol toxicity following cardiac arrest due to aspiration an…
90y · Female·Surgical repair of fractured neck of femur sustained in a fall complicated by CO…
Maria Grazia Nardiello, aged 90, died following surgical repair of a fractured neck of femur sustained in a fall at an aged care facility, complicated by COVID-19 infection. She was pushed by another resident with dement…
59y · Male·Unascertained
Jonathan Townsend, a 59-year-old Navy veteran with PTSD, alcohol use disorder, and multiple psychiatric comorbidities, died at home on 5 November 2021. The cause of death was unascertained despite autopsy and toxicology.…
68y · Male·Head injuries
Stephen O'Brien, aged 68, died from head injuries inflicted by his adult son Scott in a family violence incident. Stephen had been the primary carer for Scott, who had untreated mental illness (suspected schizophrenia), …
23y · Male·Multiple injuries from being struck by train
Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…
59y · Male·hanging
A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …
33y · Male·hanging
Moses Kellie, aged 33, died by hanging at Villawood Immigration Detention Centre in January 2019 after four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attem…
50y · Female·hanging
A 50-year-old woman with severe borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two …
29y · Male·hanging
Muhammad Hafizuddin Bin Zaini, a 29-year-old detainee in immigration detention at Villawood, died by hanging on 12 December 2020. He had a history of substance-induced psychotic disorder and was prescribed antipsychotic …
59y · Female·multiple injuries from fall from height
Fiona Turnbull, a 59-year-old woman with chronic schizophrenia on clozapine, died from multiple injuries after falling from her third-floor balcony on 12 October 2017 during a psychotic relapse. The death occurred shortl…
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