Coronial

332 results for social isolation

SAhome2002-09-06

Coroner's Finding: KEN Kunmanara (2)

27y · Male·hydrocarbon inhalation

This inquest involved three deaths from petrol inhalation (1999-2001) on the Anangu Pitjantjatjara Lands. All three deceased were chronic sniffers (10+ years) who died from respiratory depression/asphyxia with distinctiv…

forensic medicinetoxicologysystemdelaypetrol
VIC2024-05-14

Finding into death of Brian Richard Pope

40y · Male·compression of the neck due to hanging

Brian Pope, a 40-year-old man with longstanding mental health issues including major depressive disorder, anxiety, learning disability (dyslexia), and substance abuse history, died by suicide in prison 20 days after rema…

psychiatrycorrectional healthcommunicationsystemmirtazapine
QLDhome2019-04-04

Blackmore, Rinabel Tiglao - Non-inquest findings

44y · Female·Head injury sustained when exiting a moving vehicle

A 44-year-old Filipino woman died from head injuries after exiting a moving vehicle travelling at 100 km/h during an episode of domestic violence. Ms Blackmore had reported non-lethal strangulation and threats to police …

forensic medicineparamedicinecommunicationsystem
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…

general medicinepsychiatrydiagnosticprocedural
SAhome2002-09-06

Coroner's Finding: HUNT Kunmanara

25y · Female·inhalation of petrol (hydrocarbon inhalation)

…n a petrol-filled can in bed. The inquest examined not only the immediate cause of death but the systemic, social, and economic factors underlying petrol sniffing in this community. The finding identifies petrol sniffing…

toxicologyforensic medicinesystemdelaypetrol
SAcommunity2005-03-14

Coroner's Finding: Ryan Kunmanara

Unknown·Multiple; Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposu…

Four Aboriginal individuals died on Anangu Pitjantjatjara Lands between May 2003 and March 2004. Ward (19) and Ryan (25) died by hanging with evidence of petrol intoxication. Ken (35) died from exposure after wandering a…

psychiatryemergency medicinedelaysystempetrol
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…

psychiatryintensive carecommunicationsystempaliperidone
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…

Four Anangu (Aboriginal) young men died between May 2003 and March 2004 on the Anangu Pitjantjatjara Lands in South Australia. Three deaths were by hanging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked …

psychiatryemergency medicinesystemdelaypetrol
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

Joel Cauchi, a 40-year-old man with chronic treatment-resistant schizophrenia, carried out a stabbing attack at Westfield Bondi Junction shopping centre in Sydney on 13 April 2024, killing six people (Dawn Singleton, Jad…

psychiatrygeneral practicecommunicationsystemclozapine
WAmental health2015-12-31

Inquest into the Death of Anthony Ian EDWARDS

Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…

…ty grounds; (3) Clinical judgement cannot justify inadequate discharge planning—patients' vulnerability, isolation, loss of primary support, and recent self-harm attempts must trigger enhanced planning; (4) Suicide-rela…

psychiatryemergency medicinediagnosticcommunicationantidepressants
QLDhospital2012-06-22

Paton, Daniel William

45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia

A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…

anaesthesiapain medicinediagnosticmedicationmorphine

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