72y · Male·ischaemic heart disease on a background of end-stage renal failure and frontotem…
…pertension, atrial fibrillation, and required haemodialysis. His dementia caused executive dysfunction, impulsivity, and aggressive behaviour that prevented mainstream nursing home placement and community care. He was t…
29y · Male·ligature compression of the neck (hanging)
Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…
30y · Male·neck compression
Mohamed Omar, a 30-year-old man with schizophrenia, died in Melbourne Assessment Prison on 25 June 2017 from neck compression while on remand. He had a history of command auditory hallucinations instructing self-harm, re…
26y · Male·Mixed drug toxicity (heroin, morphine, codeine combined with lorazepam, olanzapi…
Nicholas Lopes, a 26-year-old with treatment-resistant schizophrenia, intellectual disability, and substance use disorders, died from mixed drug toxicity (heroin combined with benzodiazepines and antipsychotics) two days…
31y · Male·Head and chest injury
Gyan Murray Jeffery, age 31, died from head and chest injuries sustained when struck by two motor vehicles on the South Western Highway at Argyle, Western Australia, on 30 September 2011. He had a longstanding history of…
20y · Female·injury caused by hanging
A 20-year-old woman with a long history of eating disorder, obsessive-compulsive behaviours, and adjustment difficulties died by suicide in October 2009. She had received treatment at the Bronte Centre in Melbourne and o…
65y · Female·Early bronchopneumonia and hypoxic brain injury following aspiration of food (ch…
…linical warning signs of dysphagia in her documented history, though her psychiatric condition involved impulsivity and long-term antipsychotic use may have caused mild tardive dyskinesia affecting swallowing coordinati…
23y · Female·Injuries sustained in a fall from a height
Jacqueline Pringle, 23, died from injuries sustained in a fall from the 60th floor of an apartment after consuming alcohol and MDMA at Crown Casino. She had a complex psychiatric history including major depression, anxie…
28y · Male·ligature compression of the neck (hanging)
Luke Isaac Forkin, a 28-year-old man with a long history of substance abuse and mental health issues, died by suicide while absent without leave from Graylands Hospital. He had been admitted involuntarily due to psychoti…
15y · Male·Ligature compression of the neck (hanging)
A 15-year-old Aboriginal boy in foster care died by suicide following apparent impulsive response to adolescent boundary conflicts. Despite stable, loving foster placement since age 4, Ethan remained neurologically vulne…
48y · Male·Gunshot wound to the chest during a police operation
Corey Selby, aged 48, died from a gunshot wound to the chest on 19 January 2023 outside Tenterfield Police Station after deliberately provoking police to shoot him. He had a complex mental health presentation comprising …
17y · Male·immersion (drowning)
Two Aboriginal teenagers, Trisjack Simpson (17) and Christopher Drage (16), drowned in the Swan River while attempting to swim across to evade police pursuit on 10 September 2018. Both had recently ingested cannabis. The…
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'…
Suicide by intentional fall or jump from Tasman Bridge
Coroner's inquiry into six suicide deaths at the Tasman Bridge, Hobart, Tasmania, between 2014-2015. All six deceased intentionally jumped from the 50-metre-high bridge despite its 1.59-metre safety fence. Deceased (aged…
17y · Male·Hypoxic ischaemic encephalopathy due to hanging
A 17-year-old male who transitioned from female died by hanging on 21 April 2020, seven days after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-…
28y · Male·Multiple head, facial and spinal injuries sustained in a single vehicle motorbik…
…tment agreements, and dose reduction plans; (5) the combination of high-risk medications and documented impulsivity, mental health issues, and substance misuse created significant driving impairment risk.
36y · Male·ligature compression of the neck (hanging)
A 36-year-old man with schizoaffective disorder, traumatic brain injury, and substance use disorder died by ligature while an involuntary inpatient in a locked mental health ward. He was on hourly observations and had re…
20y · Male·Self-inflicted hanging
Corey McGeary, a 20-year-old remand prisoner with chronic risk factors for self-harm (history of suicide attempts, schizophrenia, personality disorder, severe childhood abuse, mild intellectual disability), died by hangi…
23y · Male·injuries sustained when struck by train
Jarrod Christie, 23, a voluntary then involuntary psychiatric inpatient at Maroondah Hospital, absconded from the high-dependency unit on 22 December 2012 and died by suicide. Clinical lessons include: (1) GPs should ful…
15y · Male·Multiple injuries from motor vehicle collision
… P-plate restrictions. Key clinical/safety lessons include: early intervention for high-risk youth with impulsivity issues; strengthening peer passenger decision-making through education; implementation of night driving…
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