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NSWhospital2023-12-15

Inquest into the death of Philip Nguyen

64y · Male·Metastatic Non-Small Cell Lung Cancer

Philip Nguyen, aged 64, died from metastatic non-small cell lung cancer whilst in lawful custody in Long Bay Hospital on 10 May 2020. He had been diagnosed with advanced lung cancer in February 2019 after presenting with…

oncologypalliative careoxycodone
NSWmental health2023-12-15

Inquest into the death of CC

33y · Male·Hanging

CC, a 33-year-old First Nations man with methamphetamine-induced bipolar disorder and psychosis, was admitted to the High Dependency Unit at Nepean Hospital on 7 June 2022 under involuntary mental health detention. Over …

psychiatryaddiction medicinecommunicationsystemmethamphetamine
NSWcommunity2023-12-14

Inquest into the disappearance and suspected death of XA

36y · Male·Unascertained

A 36-year-old male psychiatrist disappeared on 25 January 2023 and is presumed deceased. He had treatment-resistant depression, was in significant pain from a recent back injury, and was prescribed opioids (Lyrica, Endon…

psychiatrygeneral practicepregabalin
NSW2023-12-12

Inquest into the death of TH

57y · Male·Chronic Coronary Artery Atherosclerosis in the context of mirtazapine toxicity

A 57-year-old male prisoner died of chronic coronary artery atherosclerosis in the context of mirtazapine toxicity. He had been incarcerated for over 40 years following conviction for two murders committed at age 16. The…

mirtazapine
NSW2023-12-12

Inquest into the disappearance and suspected death of William Mainprize

27y · Male·unascertained

William Mainprize, a 27-year-old stockman, died when the livestock carrier Gulf Livestock 1 sank during Typhoon Maysak on 2 September 2020 off Japan. The vessel, which had experienced multiple safety breaches in the prec…

systemprocedural
NSWcommunity2023-11-30

Inquest into the death of Jacob Carr

53y · Male·Gunshot wound to the left thigh with transection of femoral artery and vein; exs…

Jacob Carr died from a gunshot wound to his left thigh sustained during a police operation at his home. He had assaulted his elderly mother, and police responded to a domestic violence call. During confrontation, Mr Carr…

emergency medicineparamedicinesystemdelayalcohol
NSWcommunity2023-11-30

Inquest into the Death of Andrew James Chee Quee - Decision

51y · Male·gunshot wound to the chest

Andrew Chee Quee, aged 51, died on 20 April 2020 from a gunshot wound to the chest fired by Probationary Constable Worboys in Rockdale, Sydney, during armed police confrontation. Chee Quee was armed with knives and hamme…

forensic medicinepsychiatry
NSW2023-11-24

Inquest into the death of Andrew Stark

48y · Male·Multiple Injuries

Andrew Stark, a 48-year-old Aboriginal man, died in a single-vehicle motor accident while being pursued by police for an unregistered vehicle in Gunnedah, NSW. During a 3:22-minute pursuit, speeds reached 174 km/h in a 5…

systemcommunication
NSWcommunity2023-11-17

Inquest into the death of SB

51y · Male·Stab wounds to the chest

A 51-year-old man with documented mental health issues including psychosis, paranoia, and delusions died from self-inflicted stab wounds during a police siege at his mother's home. He had breached a domestic violence ord…

psychiatryemergency medicinecommunicationsystemolanzapine
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he be…

psychiatrygeneral practicediagnosticsystemduloxetine
NSWcommunity2023-11-07

Inquest into the death of AAB

26y · Male·acute cocaine and alcohol toxicity

AAB, a 26-year-old man with a history of substance abuse and mental health issues, died from acute cocaine and alcohol toxicity while in police custody. He presented to a hotel with agitated, paranoid behaviour and was d…

emergency medicinetoxicologycocaine
NSWcommunity2023-11-07

Inquest into the death of DO

27y · Male·multiple blunt force injuries

A 27-year-old Colombian national died by suicide four days after arriving in Australia. He had disclosed suicidal ideation to his friend and family on 24 November, was recovered from a cliff edge that evening, but died t…

NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…

intensive careanaesthesiadiagnosticproceduralrocuronium
NSWhome2023-10-24

Inquest into the death of AW

2y · Female·effects of fire (smoke inhalation and thermal injury)

AW, a 2-year-old girl with 15a11.2 BP1-BP2 microdeletion syndrome and developmental delays, died on 14 April 2018 in a house fire at her rural NSW home. She died from smoke inhalation and thermal injury. The fire's exact…

paediatricssocial worksystemdelay
NSW2023-10-11

Inquest into the death of Steven McHugh

60y · Male·Plastic bag asphyxia

Steven McHugh, a 60-year-old man, died from plastic bag asphyxia in Junee Correctional Centre on 31 March/1 April 2022. He had recently been extradited from Victoria to NSW to face additional charges and was held in prot…

correctional healthpsychiatry
NSW2023-10-04

Inquest into the death of Melville Schrader

76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…

A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…

oncologygastroenterologydiagnosticsystempsyllium
NSWhospital2023-09-27

Inquest into the death of John O'Donnell

73y · Male·Complications of metastatic neuroendocrine lung carcinoma

John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at S…

oncologypalliative carecommunicationsystemlanreotide
NSWhome2023-09-25

Inquest into the death of Wayne Mullin

64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…

Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…

general practicerespiratory medicinemedicationcommunicationoxycodone
NSW2023-09-15

Inquest into the death of Sandra Lee Cawthorne

29y · Female·Multiple gunshot wounds to the head and chest, resulting in severe brain injury …

Sandra Cawthorne, aged 29, was fatally shot on 12 April 2004 in Arndell Park, Sydney. She sustained multiple gunshot wounds to the head and chest, and was five months pregnant. Despite a thorough 19-year police investiga…

NSW2023-09-14

Inquest into the disappearance and suspected death of Allan Beeby

74y · Male·Drowning

Alan Beeby, an experienced 74-year-old boatman, drowned after his newly purchased Halvorsen 42 motor yacht 'Eliza 1' capsized in moderate sea conditions (1m following seas, 15-18 knot winds from northeast). Expert naval …

occupational and environmental healthemergency medicinesystemdiagnostic
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