2,612 results
55y · Female·Multiple injuries sustained in a train incident
Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…
24y · Male·neck compression secondary to hanging
Jamie Knowles, a 24-year-old with schizophrenia, died by suicide on 24 June 2024 while on an inpatient temporary treatment order at Kerferd Unit mental health service in Victoria. He was granted one hour of unescorted le…
1y · Female·complications of acute bronchiolitis arising from Respiratory Syncytial Virus (R…
A 17-month-old First Nations child died from acute bronchiolitis due to respiratory syncytial virus (RSV) infection in inadequate accommodation following parental separation from domestic violence services. The coroner i…
15y · Female·hanging
Harmony, a 15-year-old girl, died by hanging at a motel on 14 January 2020 in circumstances of longstanding neglect, family violence and school disengagement. The coroner found multiple systemic failures: DCJ closed case…
73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…
Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…
43y · Male·Mixed drug toxicity (methadone, synthetic cannabinoids (5f-cumyl-pinaca and cumy…
Shayn Darmanin, a 43-year-old man with epilepsy, died from mixed drug toxicity involving methadone, synthetic cannabinoids, olanzapine, and duloxetine. He had a significant history of substance abuse, family violence off…
78y · Female·Bronchopneumonia
CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…
38y · Male·Compression of the neck (hanging)
Jason Muir, a 38-year-old Aboriginal man, died by suicide 24 days after release from custody. He had complex psychosocial needs including mental health issues, substance use history, and prior suicide attempts. While rei…
35y · Male·Hyponatraemia, with psychogenic polydipsia and schizophrenia/schizoaffective dis…
Daniel Turnbull, aged 35, died in custody from hyponatraemia secondary to psychogenic polydipsia whilst in a 24-hour surveillance cell at Bathurst Correctional Centre. He had a long history of schizophrenia managed with …
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
64y · Male·complications in association with thermal injuries in a man with underlying chro…
Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …
40y · Male·Aspiration pneumonia
Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…
24y · Male·Multiple gunshot wounds
Mohamad Ikraam Bahram, a 24-year-old man with schizophrenia managed under a community treatment authority, died after being shot by police on Mary Street Brisbane following an unprovoked assault on a tourist. He had pres…
30y · Female·Acute ethanol toxicity on a background of chronic alcoholism
Kathleen Arnold, aged 30, died from acute ethanol toxicity on a background of chronic alcoholism. She had a 20-year history of alcohol dependence, complex trauma from a childhood near-drowning incident, eating disorders,…
15y · Male·Combined heroin and methamphetamine toxicity
T, a 15-year-old boy subject to a Care by Secretary Order, died from combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), …
13y · Male·asphyxia as a result of hanging
MS, a 13-year-old Year 8 student, died by suicide by hanging on 16 February 2020. In the weeks before his death, MS engaged in self-harm by cutting his arms and expressed suicidal ideation to close friends through online…
33y · Male·gunshot wounds to chest and upper arm
A 33-year-old man with bipolar disorder on reducing doses of risperidone experienced a psychotic relapse and stabbed a stranger at a railway station. He then entered a police station with a knife, advancing on officers d…
45y · Female·Drowning whilst inebriated (ethanol)
FCP, aged 45, died by drowning while inebriated on 11 April 2020 at her home in Kilmore East, Victoria. She had a complex history of mental illness (psychosis, depression, anxiety, PTSD), substance abuse, and was in a re…
18y · Male·Heroin toxicity
Edward Grant Harris, an 18-year-old with autism spectrum disorder, ADHD, and borderline intellectual function, died from heroin toxicity in his supported accommodation. He had a complex history of behavioural challenges,…
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