Coroner's Finding: CL de-identified
33y · Female·hanging
A 33-year-old woman with major depressive disorder and a history of suicide attempts died by hanging five days after discharge from hospital following a carbon mo…
49 results for “sexual abuse and trauma”
33y · Female·hanging
A 33-year-old woman with major depressive disorder and a history of suicide attempts died by hanging five days after discharge from hospital following a carbon mo…
0y · Male·Traumatic head injury
A five-month-old boy died from traumatic head injury. Initial medical disagreement about whether injuries were from accidental fall or non-accid…
18y · Female·Mixed drug toxicity
TK, an 18-year-old woman with borderline personality disorder, chronic suicidality, and a history of childhood trauma, died from mixed drug toxicity following intentional overdose. She had multip…
34y · Male·Hanging
A 34-year-old remand prisoner died by hanging in his cell at Arthur Gorrie Correctional Centre. He had a history of child sexual…
32y · Male·unascertained; most likely exposure after walking in bushland
…son, a 32-year-old man with a complex psychiatric history including depression, anxiety, polysubstance use, and previous suicide attempts, disappeared on 11 December 2003, one week after discharge from an acute psychiat…
20y · Male·Ligature compression of the neck (hanging)
Allan Kevin Hudson, a 20-year-old male with a history of depression, suicidality, substance abuse and previous sexual trauma, died by hanging on 13 August 2006 at Sir Charles Gairdner Hospital's psychiatr…
17y · Female·Neck compression by hanging (suicide)
…on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as the child's legal guardian. Critical failures included: inadeq…
32y · Male·Hanging
Mr W, a 32-year-old man with lifelong anxiety, previous suicide attempts, and childhood trauma, died by hanging on 5 April 2019. He had been receiving care from a psychologist (Dr C.) a…
64y · Female·Blunt Force Trauma to the Head in the Setting of Prolonged Lie; Metastatic Breas…
Annie Ng, aged 64, died from blunt force head trauma sustained in her home on 27 February 2024, with death occurring 9 March 2024 at Royal Melbourne Hospital. …
15y · Female·toxicity to heroin
…tunity to conduct a LEAP database check that would have revealed her DHS status, multiple welfare warrants, and drug history. The DHS failed to obtain a safe custody warrant despite clear concerning indicators, includin…
33y · Female·Immersion (drowning) by suicide
Elizabeth Ann Studd, a 33-year-old woman with longstanding borderline personality disorder, died by drowning in the Swan River on 28 August 1999. She had a severel…
32y · Female·Injuries caused by asphyxiation and blunt force trauma to the head inflicted by …
…h resulted from asphyxiation (likely from manual neck compression/strangulation) combined with blunt force trauma to the head. The coronial inquest identified her ex-boyfriend Elliott Coulson as responsible. Key evidence…
15y · Female·hypoxic brain damage due to multiple drug toxicity
A 15-year-old girl in out-of-home residential care died from accidental overdose of heroin and methylamphetamine (speedballing) in her bedroom while a known drug user was present. She had complex trauma…
45y · Male·Hanging
PF, aged 45, died by hanging in custody at South Coast Correctional Centre following bail refusal and adverse legal advice. The coroner found his death was intentional self-harm. Although PF had a significant …
volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…
…ines three children (Master W aged 12, Miss B aged 17, Master JK aged 13) who died from volatile substance abuse in remote Aboriginal communities in the NT between 2018-2019. All three were known to government agencies …
45y · Male·gunshot wound to the chest with associated significant blood loss
…hot dead by NSW police executing a bench warrant at his home on 9 November 2021. He had suffered childhood sexual abuse, his brother died by suicide in custody, and he feared incarceration due to prior self-harm episodes…
23y · Female·Injuries sustained in a fall from a height
…gle, 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, anxiety, PTSD, and …
30y · Male·Hanging
Joshua Stachor, aged 30, died by hanging in Yatala Labour Prison on 19 November 2017. He was a remand prisoner on charges of domestic violence. The coroner found critical failures in his admission assessment o…
27y · Male·Global cerebral ischaemic injury in the setting of hanging
Jamie Kowalewsky, a 27-year-old with long-standing mental health issues including depression, substance abuse (ICE and cannabis), and previous suicide atte…
2y · Female·sequelae of blunt force head and spinal cord injuries
DB, aged 2 years 9 months, died from blunt force head and spinal cord injuries inflicted by her mother's boyfriend after DCJ closed its case in August 2015. The coro…
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