1,232 results
54y · Male·metastatic small cell lung cancer
Manuel Katsaros, aged 54, died from metastatic small cell lung cancer while in custody at Prince of Wales Hospital Annex receiving palliative care. The coroner found no systemic deficiencies or clinical errors. The patie…
44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…
Jeffrey Blundell, a 44-year-old man with severe intravenous drug use history, died from cardiogenic shock secondary to severe tricuspid valve regurgitation caused by infective endocarditis from non-sterile injection prac…
57y · Male·hepatocellular carcinoma and its complications
Anthony Sampieri, 57-year-old inmate with end-stage hepatocellular carcinoma secondary to hepatitis C and cirrhosis, died at Prince of Wales Hospital Correctional Annex after 10 days of palliative care. He had received a…
26y · Female·multiple blunt force injuries from fall from height; significant contributing co…
A 26-year-old woman with severe borderline personality disorder died by suicide following a fall from cliffs. She presented to hospital after a serious suicide attempt earlier the same day. Expert evidence indicates she …
31y · Male·hanging
B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…
30y · Male·Gunshot wound to the neck and head
Daniel Bolton, aged 30, died from a self-inflicted gunshot wound to the neck and head while attempting to avoid arrest by police. He had a history of drug addiction, mental health issues including depression, anxiety and…
76y · Female·Unknown
Heather Scott, a 76-year-old woman living in an isolated rural property in Upper Wilsons Creek, NSW, died on 28 February 2022 when her house was swept away during a catastrophic landslide triggered by intense rainfall. T…
38y · Female·unknown
Paula-Lee Denton disappeared in January 2014 and is presumed dead. She was a 38-year-old woman with a history of psychological trauma, PTSD, anxiety, and cannabis use. Following her mother's death in October 2013 and rec…
15y · Male·Hanging
A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…
55y · Male·ischaemic heart disease
Stefan Wakeman, aged 55, died of ischaemic heart disease while in custody at Metropolitan Remand and Reception Centre on 9 June 2019. Autopsy revealed significant coronary artery narrowing (40-50% to 70-80%) with emphyse…
0y · Female·Methylamphetamine toxicity
A newborn baby died 8 hours after birth from methylamphetamine toxicity acquired in utero. The mother unknowingly consumed methylamphetamine in the days before labour, likely by drinking from a contaminated bottle at a r…
17y · Male·hydrocarbon toxicity (petrol inhalation)
George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
28y · Male·neck compression from hanging
SH, a 28-year-old man, died by hanging in Cessnock Correctional Centre after seven weeks in custody. He was assessed at intake as having no self-harm risk and cleared for normal cell placement. During custody, he became …
5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity
LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…
27y · Male·Neck compression due to self-inflicted hanging
Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
Male·Hanging
This coronial finding concerns an unknown male known as 'Martin' found dead at Angledool, NSW in August 2015. The deceased died from hanging in a self-inflicted manner, with evidence of significant planning including res…
61y · Male·Could not be determined on the available evidence
Atilla Demirer, a 61-year-old Turkish-born Australian citizen, was found deceased in his Waterloo apartment between 20 July and 12 October 2021. Due to advanced decomposition, the pathologist could not determine cause of…
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
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