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WA2020-12-30

Inquest into the Death of Dennis Michael GREEN

Male·multiple injuries sustained in motorcycle crash

Dennis Green, a First Class Constable with WA Police, died on 7 December 2017 while undertaking a motorcycle training course on Julimar Road, Toodyay. His motorcycle crashed on a rural bend during a P1 (high-speed) devel…

diagnosticdelay
WA2020-12-22

Inquest into the Death of Jordan Robert ANDERSON

23y · Male·hypoxic brain injury and bronchopneumonia complicating ligature compression of t…

Jordan Robert Anderson, 23, died by suicide in Hakea Prison through ligature compression of the neck. Critical delays occurred when he was discovered unresponsive: 3 minutes 40 seconds elapsed before his cell door was un…

emergency medicinecardiologyproceduralcommunication
WAcommunity2020-12-17

Inquest into the Death of Jamie Douglas KNEALE

43y · Male·head injury

A 43-year-old man was struck by a police vehicle while riding his bicycle through a roundabout in Gosnells, sustaining fatal head injuries. The police driver failed to see the cyclist despite having clear visibility and …

WAprison2020-12-03

Inquest into the Death of Macker Joseph DINAH

57y · Male·atherosclerotic heart disease in a man with diabetes mellitus

Macker Joseph Dinah, a 57-year-old Aboriginal man, died suddenly in his prison cell from atherosclerotic heart disease complicated by diabetes mellitus. He had severe coronary artery disease affecting three vessels, prev…

cardiologygeneral medicinecannabis
WAhospital2020-12-02

Inquest into the Death of Simon John SHARPE

Male·non-specific interstitial pneumonia

Simon John Sharpe, a sentenced prisoner with incurable non-specific interstitial pneumonia, died on 30 June 2017 at Fiona Stanley Hospital from progression of his lung disease. Throughout his 17-month imprisonment, Sharp…

respiratory medicinetransplant medicine
WAhospital2020-12-01

Inquest into the Death of Tahlia Rose BEMBRIDGE

4y · Female·volvulus of the large intestine

Tahlia Rose Bembridge, a 4-year-old with Down syndrome and prior mid-gut volvulus, presented to Bunbury Hospital ED with vomiting and abdominal pain on 1 October 2015. Initial assessment excluded acute bowel obstruction.…

paediatricsemergency medicinecommunicationdelay
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…

psychiatrypsychologydiagnosticsystemmethamphetamine
WAcommunity2020-11-25

Inquest into the Death of Jamie Alan GRAHAM

50y · Male·acute renal failure due to dehydration in relation to environmental exposure

Jamie Graham, a 50-year-old Aboriginal man with type 2 diabetes, cognitive impairment, and alcohol dependence, died from acute renal failure due to dehydration after being stranded with two companions on a remote road wh…

systemcommunication
WA2020-11-20

Inquest into the Suspected Death of Gary Lance JOHNSON

57y · Male·severe right limb injury (right arm severed) from shark attack causing fatal blo…

Gary Johnson, an experienced recreational scuba diver and President of the Esperance Dive Club, died on 5 January 2020 following a fatal shark attack while diving at Devils Rock off the Western Australian coast. He was a…

WAhospital2020-11-20

Inquest into the Death of Trent Nathaniel ROBERTSON

44y · Male·head and neck injuries with terminal palliative care

Trent Robertson, 44, died from severe head and neck injuries sustained in a high-speed motorcycle crash on 27 May 2018 after evading a brief police traffic stop. Police observed him speeding at 92 km/h in a 60 km/h zone,…

trauma surgeryintensive care
WA2020-11-19

Inquest into the Death of Levi Shane Clement CONGDON

27y · Male·methylamphetamine toxicity

Levi Shane Clement Congdon, a 27-year-old male, died from methylamphetamine toxicity on 13 November 2017 at Royal Perth Hospital during a police search warrant execution. He ingested a fatal dose of methylamphetamine, re…

emergency medicinetoxicologycommunicationsystemmethamphetamine
WAcommunity2020-11-05

Inquest into the Suspected Death of Paul Clifford YORK

45y · Male·unascertained

Paul Clifford York, 45, disappeared from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdos…

psychiatrygeneral practicediagnosticsystemmirtazapine
WAcommunity2020-11-04

Inquest into the Death of Andrew John KEY

49y · Male·incised injury to the neck

Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health asse…

psychiatryemergency medicinecommunicationsystemquetiapine
WAprison2020-11-04

Inquest into the Death of Damien PURNELL

47y · Male·organ failure following cardiorespiratory impairment in a man with arteriosclero…

Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synthetic cannabinoids (Kronic). Despite immediate re…

emergency medicineintensive caresystemmethadone
WAcommunity2020-10-22

Inquest into the Death of Jordana KOSTOVSKI

27y · Female·Multiple injuries sustained in motor vehicle collision

A 27-year-old woman under the influence of alcohol and methylamphetamine deliberately drove her van head-on into oncoming traffic on Forrest Highway, resulting in her death. Police had attempted to intercept her for dang…

forensic medicinetoxicologyalcohol
WAhospital2020-10-19

Inquest into the Death of Renee Desiree RUYZING

21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg

A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…

orthopaedic surgeryemergency medicinediagnosticmedicationenoxaparin
WAcommunity2020-10-08

Inquest into the Death of Bradley Ronald Andrew DEMEZA

31y · Male·chest and abdominal injuries from motor vehicle crash

Bradley Demeza, aged 31, died from chest and abdominal injuries sustained in a single-vehicle crash on 9 May 2018. He was driving at excessive speed (estimated high speed) on an unsealed road while under the influence of…

alcohol
WAhospital2020-10-08

Inquest into the Death of Wayne Frederick LEESE

54y · Male·Complications including hepatic encephalopathy, pneumonia and multi-organ failur…

Wayne Frederick Leese, a 54-year-old prisoner, died from complications of hepatitis C and hepatocellular carcinoma including hepatic encephalopathy, pneumonia and multi-organ failure. He collapsed at Acacia Prison on 4 M…

hepatologyemergency medicinemethadone
WAcommunity2020-10-08

Inquest into the Death of Joshua David POLO

27y · Male·Chest and abdominal injuries from motor vehicle collision

Joshua Polo, age 27, died from blunt chest and abdominal injuries sustained in a motor vehicle collision on 23 March 2017 in Kalgoorlie. He was a passenger in a vehicle driven by Brandon Peterson, who was intoxicated by …

methamphetamine
WA2020-10-07

Inquest into the Death of JM (Name Subject to Suppression Order)

0y · Male·dehydration complicating diarrhoea (aetiology unknown)

A 10-week-old infant in out-of-home care in a remote Western Australian community developed acute diarrhoea and fever one day after routine immunisation. Despite appropriate initial care by foster parents and timely hosp…

paediatricsemergency medicinesystemparacetamol
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