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WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…

psychiatryemergency medicinecommunicationsystemmethadone
VICcommunity

Tylercassidypart2 554208

Male·Multiple gunshot wounds from police shooting

Tyler Cassidy, 18, died after police shot him multiple times when he advanced on them with two knives in a public park. The coroner found that while Tyler's actions were deliberate, they were not voluntary—he was overwhe…

psychiatrycommunicationsystemalcohol
VIChome

Finding into death of Jarrad John Ford

24y · Male·Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs

A 24-year-old man with schizophrenia died from aspiration pneumonia following overdose of multiple drugs including diazepam, tramadol, morphine, and others. The day before death, he took excess diazepam to manage auditor…

psychiatryemergency medicinediagnosticsystemdiazepam
VICcommunity

Finding into death of Jacob Anton Van Berlo

19y · Male·Hanging (self-inflicted)

Jacob Van Berlo, a 19-year-old male, died by hanging following a suicide. He had a history of depression treated with sertraline and an uncontrolled gambling addiction. On the day of death, after receiving his weekly pay…

general practicepsychologycommunicationsystemsertraline
VICmental health

Finding into death of Rosemary Haldane

56y · Female·Combined drug toxicity

A 56-year-old woman with a long history of depression and recurrent suicide attempts died from combined drug toxicity while an inpatient at a private psychiatric hospital. She had been admitted following suicidal ideatio…

psychiatrygeneral practicealprazolam
VIChospital

Finding into death of Sydney Hugh Kennedy

66y · Male·Complications of chronic lithium therapy

Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…

psychiatrygeneral practicediagnosticcommunicationlithium
VIChome

Finding into death of Ross Malcolm Campbell

40y · Male·neck compression consequent upon hanging

Ross Campbell, a 40-year-old man with a history of family violence perpetration, alcohol abuse, and undiagnosed mental illness, died by hanging. He had attended a Men's Behavioural Change Program in 2011 following a fami…

general practicepsychiatrycommunicationsystemalcohol
VICmental health

Finding into death of GM

52y · Male·Unascertained

GM, a 52-year-old man with bipolar affective disorder, died of unascertained causes after absconding from a mental health inpatient unit on 2 December 2015. He was admitted voluntarily for management of a suspected manic…

psychiatryemergency medicinesystemcommunicationpholcodine
WAcommunity

Inquest into the Death of Sarah Jane RUTHERFORD

28y · Female·multiple injuries

Sarah Jane Rutherford, a 28-year-old with bipolar affective disorder and schizophrenia, died by suicide on 27 December 2009 after falling from a bridge onto the Mitchell Freeway while on leave from Graylands Hospital. Sh…

psychiatryemergency medicinerisperidone
WAhome

Inquest into the death of Christine TURVILLE (aka NICHOLLS)

56y · Female·Bronchial asthma and emphysema

A 56-year-old woman with long-standing schizophrenia, COPD, emphysema, and heavy smoking died during overnight leave from psychiatric hospitalisation. She was granted leave to check on her cat at her remote home on 24 Ma…

psychiatryrespiratory medicinedelaysystemolanzapine
WAmental health

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

24y · Male·complications of ligature compression of the neck (hanging)

Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involuntary patient. Despite initial improvement …

psychiatryneurologyescitalopram
WAcommunity

Inquest into the Death of Dean Anthony POLLARD

41y · Male·unknown

Dean Anthony Pollard was a 41-year-old man with a long history of schizophrenia and amphetamine-induced psychotic disorder who disappeared in May-June 2010 and is presumed dead. He had multiple psychiatric admissions bet…

psychiatryemergency medicinesystemcommunicationmethamphetamine
WAcommunity

Inquest into the Death of Gary John LYDDIETH

54y · Male·Unknown - death established on balance of probabilities but manner and cause und…

A 54-year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prio…

psychiatrygeneral medicinesystemcommunication
WAcommunity

Inquest into the Death of Radwan KANAWATI

41y · Male·atropine toxicity

A 41-year-old man with schizoaffective disorder, intellectual disability and sexual offending history died from atropine toxicity after ingesting 6-8ml of atropine liquid prescribed for hyper-salivation. He had been disc…

psychiatrycommunicationsystematropine
WAmental health

Inquest into the Death of David GRIEVE

45y · Male·Coronary Atherosclerosis

David Grieve, a 45-year-old man with chronic schizophrenia and multiple cardiac risk factors (hypertension, diabetes, obesity, smoking), died of coronary atherosclerosis while an involuntary psychiatric patient at Grayla…

psychiatrycardiologysystemcommunicationhaloperidol
WAcommunity

Inquest into the Death of Kim Martin FRANKER

36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…

A 36-year-old man with schizoaffective disorder, substance abuse issues, and undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescribed by his GP for tardive dyskinesia), amphetamine-type stimulants,…

psychiatrygeneral practicecommunicationsystembenzhexol
WAcommunity

Inquest into the Death of Paul DICKSON

34y · Male·multiple injuries

Paul Dickson, a 34-year-old man with severe paranoid schizophrenia managed on a Community Treatment Order, died by suicide on 11 November 2013 after stepping in front of a truck. He had been discharged from Graylands Hos…

psychiatryemergency medicineolanzapine
WAhospital

Inquest into the Death of Robin David MACARTNEY

62y · Male·bronchopneumonia in a man receiving terminal palliative care for metastatic carc…

Robin David Macartney, a 62-year-old prisoner serving a life sentence for murder, died from bronchopneumonia secondary to metastatic colon cancer. He was diagnosed with sigmoid colon cancer in December 2006 but refused s…

oncologygeneral surgery
WA

Inquest into the Death of Dragan JACOVIC

63y · Male·ischaemic heart disease

Dragan Jacovic, a 63-year-old life prisoner with extensive comorbidities including severe ischaemic heart disease, type 2 diabetes, chronic kidney disease, and chronic paranoid schizophrenia, was admitted to hospital on …

cardiologypsychiatryolanzapine
WA

Inquest into the Death of Stanley John INMAN

19y · Male·complications of ligature compression of the neck

Stanley John Inman, 19-year-old Aboriginal male, died by suicide at St John of God Midland Hospital on 13 July 2020, two days after ligature compression of the neck at Acacia Prison. He was on low-level ARMS (at-risk man…

psychiatrypsychologycommunicationsystemmirtazapine

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