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NSW2022-12-09

Inquest into the death of Tyrone Adams

22y · Male·Multiple injuries to the chest, abdomen and limbs

Tyrone Adams, age 22, died in a motor vehicle collision on the M1 Motorway following a police pursuit. The initial pursuit was initiated based on questionable reasonable suspicion to stop a hire vehicle. The coroner foun…

proceduralcommunicationmethamphetamine
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…

paediatricsemergency medicinecommunicationsystemadrenaline
NSW2022-12-06

Inquest into the death of Jason RADFORD

48y · Male·Fatal cardiac arrhythmia which was the result of obstructive sleep apnoea

Jason Radford, a 48-year-old First Nations man, died of fatal cardiac arrhythmia secondary to obstructive sleep apnoea while in custody at Junee Correctional Centre. He had multiple comorbidities including obesity, type …

cardiologygeneral practicemethadone
NSWhospital2022-12-01

Inquest into death of RW

64y · Male·Pulmonary thromboembolus as a result of bilateral deep vein thrombosis which dev…

RW, a 64-year-old with chronic ischaemic heart disease, suffered traumatic brain injury from an intentional motorcycle collision and underwent emergency neurosurgery. He was subsequently treated with unfractionated hepar…

neurosurgeryintensive carecommunicationproceduralunfractionated heparin
NSW2022-11-24

Inquest into the death of Mervyn Douglas Morgan

59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma

Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…

gastroenterologyhepatologydiagnosticcommunicationsorafenib
NSW2022-11-24

Inquest into death of William EPERE

43y · Male·Hanging

William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite cle…

psychiatrycorrectional healthproceduralsystemescitalopram
NSW2022-11-22

Inquest into the death of Kai McEwan

25y · Male·Ruptured berry aneurysm and sequelae resulting in catastrophic subarachnoid and …

A 25-year-old Aboriginal man on remand in custody collapsed during a shower and was found to have suffered a catastrophic ruptured berry aneurysm causing massive subarachnoid and intracerebral haemorrhage with brain deat…

neurosurgeryintensive careaspirin
NSW2022-11-21

Inquest into death of Edward ENGLISH

87y · Male·Ischaemic heart disease with significant contributing conditions of liver cirrho…

Edward English, an 87-year-old man imprisoned for child sexual offence, died of ischaemic heart disease complicated by liver cirrhosis and pulmonary hypertension at Long Bay Correctional Centre Hospital. He had significa…

cardiologypalliative care
NSW2022-11-08

Inquest into the death of Andrew Gilbertson

42y · Male·methadone toxicity

Andrew Gilbertson, a 42-year-old man with bipolar disorder and substance use disorder, died from methadone toxicity while in custody at Long Bay Correctional Centre. He was not enrolled in opioid substitution therapy but…

forensic medicinepsychiatrysystemdelaymethadone
NSWcommunity2022-11-04

Inquest into the disappearance and suspected death of Morgan Rae

30y · Male·Unable to be ascertained

Morgan Rae, a 30-year-old man with chronic pain and recent life stressors, disappeared on 31 January 2020 from the Bundeena area. The coronal finding examines the NSW Police investigation into his disappearance. Critical…

systemcommunication
NSWhome2022-11-04

Inquest into the death of EW

75y · Female·Plastic bag asphyxia in the setting of blunt force head injury

EW, aged 75, died from asphyxiation in July 2019 after being struck by her husband MW, who then took his own life. EW had advancing dementia and severe mobility limitations, with MW as her sole carer. The coroner found t…

geriatric medicineoccupational therapysystemcommunication
NSW2022-10-28

Inquest into the death of Todd McKenzie

Male·Consequences of police tactical operation involving use of lethal force (specifi…

Todd McKenzie died following a police operation in Taree involving negotiation attempts, deployment of non-lethal options, and ultimately lethal force. This extensive coronial ruling concerns protective orders over polic…

emergency medicinecorrectional healthsystem
NSWhospital2022-10-28

Inquest into death of Dane LOCKWOOD

33y · Male·methylamphetamine toxicity; antecedent causes being the physiological effects of…

A 33-year-old man with methamphetamine addiction and possible schizophrenia attended the ED seeking help while acutely intoxicated, psychotic and sleep-deprived. After initially agreeing to medication, he attempted to le…

emergency medicinepsychiatrysystemdelaymethamphetamine
NSWhospital2022-10-26

Inquest into death of Lucas PEYRET

21y · Male·Hypoxic brain injury arising from severe anaphylactic shock due to administratio…

Lucas Peyret, a 21-year-old with no significant medical history, presented to hospital with acute appendicitis and underwent emergency laparoscopic appendicectomy. Surgery was routine and uneventful. Upon emergence from …

surgeryanaesthesiasugammadex
NSW2022-10-24

Inquest into the death of GL

69y · Male·neck compression due to hanging

GL, a 69-year-old Chinese national, died by hanging in Long Bay Correctional Centre's Medical Services Unit on 12 April 2022. He was incarcerated following the murder of his wife in September 2020 and had become a parapl…

psychiatrygeriatric medicine
NSWcommunity2022-10-21

Inquest into the death of Rachel Martin

28y · Female·Multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Rachel Martin, a 28-year-old SNAP support worker and pregnant woman, died attempting to prevent harm to a high-needs child (Riley) during respite care transport. While driving Riley home on the M1 Motorway, Riley exited …

social workpaediatricscommunicationsystem
NSWout-of-home care2022-10-21

Inquest into the death of Alex Raichman

11y · Male·Multiple injuries sustained when struck by train

Alex Raichman, 11, died when struck by a train after absconding from respite care at Civic Disability Services. Alex had autism, intellectual disability, and seizure disorder with documented absconding risk. Civic knew w…

paediatricspsychiatrysystemproceduralaripiprazole
NSWcommunity2022-10-21

Inquest into the death of Riley Christopher Shortland

8y · Male·multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Riley Shortland, an 8-year-old with severe autism spectrum disorder, global development delay, and ADHD, died when struck by a truck on the M1 Motorway after escaping from a vehicle during respite care. He removed his se…

occupational therapypsychologydiagnosticcommunication
NSWcommunity2022-10-21

Inquest into the disappearance and suspected death of Theo Jean Hayez

18y · Male·Unable to determine

Theo Hayez, an 18-year-old Belgian backpacker, disappeared from Byron Bay on 31 May 2019 after being ejected from a nightclub for approaching intoxication. Digital evidence traced his movements via Google location data t…

systemdelay
NSWhospital2022-10-14

Inquest into the death of Malouvailoa Tafau

20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…

Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…

cardiologyinfectious diseasesdiagnosticcommunicationflucloxacillin
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