2,612 results
27y · Male·undetermined
Peter Christofidis, a 27-year-old man with a significant history of mental illness including depression and early schizophrenia, disappeared on 14 March 1983 after driving from his home in Cheltenham to Hattah Kulkyne Na…
41y · Male·Cardiomegaly in a man with WHO Class III obesity
Michael Suckling, a 41-year-old Aboriginal man, died in prison from cardiomegaly secondary to morbid obesity (BMI 54.5). He gained approximately 117kg during his 3-year incarceration, with rapid initial weight gain from …
57y · Male·Hanging
A 57-year-old male inmate died by hanging at Long Bay Correctional Centre in January 2018. Although he had been psychiatrically assessed as experiencing major depression with psychotic features and was recommended by a p…
43y · Female·suffocation
Ms K, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car va…
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medic…
59y · Male·Hanging
Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…
19y · Male·In keeping with hanging
A 19-year-old male with depression and anxiety died by hanging at his home on 5 March 2021, hours after police and ambulance attended him in the early morning of 4 March following his brother's emergency call. Jet had co…
22y · Male·Immersion in water (drowning) in a man with combined drug effect
Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…
58y · Male·Hanging
Zoran Alic, a 58-year-old Serbian-born man detained at Marngoneet Correctional Centre on family violence charges, died by hanging on 29 April 2019. He was referred for psychiatric assessment on 28 March 2019 after report…
37y · Male·unascertained
Cyril Levitsky disappeared from Callan Park Hospital in 1970 while under treatment for schizophrenia. He was never found, though an unidentified male body discovered nearby in December 1970 may have been him. Despite ext…
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…
25y · Male·Gunshot injury to the head
SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver under the influence of amphetamines, cannab…
Multiple causes: Child 1 - blunt force trauma to chest and abdomen; Child 2 - he…
This cluster inquest examined four Victorian child deaths (2015-2017) involving parents' partners as perpetrators. Children 1-4 died from blunt force trauma, head injury, fire, and neck laceration respectively. Key syste…
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…
57y · Male·partially suspended hanging
A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …
51y · Male·gunshot wound to the chest
Andrew Chee Quee, 51, died from a gunshot wound sustained during a police confrontation at Bay Street, Rockdale, on 20 April 2020. He had a longstanding history of depression, substance abuse, and suicidal ideation. On t…
Female·Domestic violence homicides: Miss Yunupiŋu—stab wound to chest; Ngeygo Ragurrk—b…
This landmark coronial finding examines four domestic violence deaths of Aboriginal women in the Northern Territory—Miss Yunupiŋu (2018), Ngeygo Ragurrk (2019), Kumarn Rubuntja (2021), and Kumanjayi Haywood (2021)—all ki…
32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…
Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
59y · Male·compression of the neck secondary to hanging
A 59-year-old man with treatment-resistant depression, anxiety, and suicidal ideation died by hanging while on weekend leave from psychiatric care. He had been hospitalised four times in 2021 and was receiving electrocon…
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