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WAhome2025-01-23

Inquest into the Suspected Death of Benjamin Jacob VAN TRIGT

38y · Male·electrical injury

Benjamin Van Trigt, a 38-year-old man with schizoaffective disorder, died by electrocution at home on 17 November 2022 while on a Community Treatment Order (CTO). He had experienced multiple psychiatric relapses requirin…

psychiatryemergency medicinepaliperidone
VICmental health2025-01-23

Finding into death of Matthew James Howarth

26y · Male·Coronary artery atherosclerosis in the setting of schizoaffective disorder

Matthew Howarth, 26 years old with schizoaffective disorder, died of coronary artery atherosclerosis while an inpatient at a mental health secure care facility. He was involuntarily admitted on 16 November 2022 with psyc…

psychiatryemergency medicinezuclopenthixol
VIChome2025-01-20

Finding into death of Kim Marie Bartolo

47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…

Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…

psychiatryorthopaedic surgerycommunicationmedicationvenlafaxine
NSW2025-01-16

Inquest into the death of Tammy Michelle Shipley

47y · Female·hyponatraemia arising from primary polydipsia and complications of schizoaffecti…

Tammy Michelle Shipley, a 47-year-old Aboriginal woman with chronic schizoaffective disorder and bipolar disorder, died in custody on 20 December 2022 from hyponatraemia arising from primary polydipsia. She was arrested …

psychiatryemergency medicinediagnosticcommunicationbuprenorphine
VIChospital2025-01-10

Finding into death of William Thomas Gourley

39y · Male·Effects of fire (self-immolation)

William Gourley, a 39-year-old Aboriginal and Torres Strait Islander man with a long history of mental illness, depression, cannabis dependence, and psychosis, presented to the Latrobe Regional Hospital ED on 6 March 202…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VIChome2025-01-09

Finding into death of C M

25y · Female·Neck compression secondary to hanging

CM, a 25-year-old woman experiencing depression, anxiety, and substance misuse, died by suicide while in an intimate partner relationship characterised by documented family violence. She presented to hospital multiple ti…

emergency medicinepsychiatrydiagnosticsystemalprazolam
WA2025-01-08

Inquest into the Suspected Death of Tanghui HUANG

41y · Male·Unascertained - may have resulted from injuries sustained in fall from vessel or…

Tanghui Huang, a 41-year-old Chinese able seaman, disappeared from a bulk carrier vessel off Dampier, Western Australia on 21 April 2012. He was last seen painting the mooring winch at 11:30 am and was presumed to have f…

occupational and environmental healthpsychiatrysystemcommunicationtriazolam
WAprison2025-01-03

Inquest into the Death of Christopher John HILLSTEAD

59y · Male·ligature compression of the neck (hanging)

Christopher Hillstead, a 59-year-old prisoner serving a life sentence for wilful murder, died by suicide by hanging on 18 January 2021 at Acacia Prison, Western Australia. He had been pursuing tertiary education (master'…

psychiatrycorrectional healthcommunicationsystem
VIChome2025

Finding into death of CWQ

74y · Male·Unascertained

A 74-year-old man with a long-standing history of delusional disorder and social phobia died at his Melbourne home between August and December 2022; the cause of death was unascertained. He lived with his sister, who als…

psychiatrysystem
VIChospital2025

Finding into death of TBL

81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…

An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…

psychiatrygeneral practicesystemdelayrisperidone
NT2025

Inquest into the death of Kumanjayi Walker

19y · Male·gunshot wounds to chest and abdomen

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man, died from gunshot wounds to his chest and abdomen at Yuendumu Police station on 9 November 2019. This coroner's report focuses on systemic failures in policing, youth…

public healthpsychiatrycommunicationsystem
VIC2025

Finding into death of H S

50y · Male·acute alcohol toxicity

A 50-year-old man died from acute alcohol toxicity in a hotel room after consuming approximately 700mL of vodka over a 24-hour period. He had a 10-year history of escalating alcohol use, multiple presentations to hospita…

emergency medicineaddiction medicinesystemdelayalcohol
VIChome2025

Finding into death of Ms HRZ

48y · Female·Neck compression secondary to hanging

Ms HRZ, a 48-year-old Turkish-born woman, died by suicide on Christmas Day 2020 after experiencing years of family violence. She first endured abuse from her ex-husband, then sexual coercion, assault, stalking and threat…

general practicepsychologysystemcommunication
VIChospital2025

Finding into death of Ms NXA

54y · Female·neck compression secondary to hanging

Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt by overdose on 9 August 2021. She was experiencing severe tinnitus…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
WAAugust 2024

Inquest into the Death of Matthew Francis LEACH

50y · Male·ligature compression of the neck (hanging)

Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…

psychiatrypsychologysystemdelayvenlafaxine
SA2024-12-20

Coroner's Finding: Huddy, Kobee Michael David

20y · Male·gunshot wound to the chest

A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…

psychiatryemergency medicinecommunicationsystemcannabis
NSW2024-12-19

Inquest into the death of Ian Turner

35y · Male·multi-drug toxicity

CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, dis…

psychiatrygeneral practicediagnosticcommunicationamitriptyline
NSWcommunity2024-12-18

Inquest into the death of Olivia Gilffillan

23y · Female·unascertained

Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She …

psychiatryemergency medicinesystemclozapine
VICcommunity2024-12-16

Finding into death of C L

53y · Male·Cervical spine distraction and hanging

A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but discharged after 19 days with …

psychiatryemergency medicinesystemdelaymirtazapine
VIChome2024-12-16

Finding into death of Geoffrey Paul McConachy

82y · Male·Incised injury to right leg

Geoffrey McConachy, 82, died by suicide on 18 September 2023 following a stroke in late 2022 that caused speech impairment and severe depression. He explicitly expressed suicidal ideation and requested information about …

psychiatrygeneral practicecitalopram

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