754 results
78y · Male·Aspiration pneumonia on a background of advanced vascular dementia
Leonard John Warwick, 78, died on 14 February 2025 in Long Bay Hospital's Aged Care and Rehabilitation Unit while serving a life sentence without parole. He had advanced vascular dementia, hydrocephalus, type 2 diabetes,…
53y · Male·Hanging
PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoi…
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
86y · Male·ischaemic and hypertensive heart disease
An 86-year-old man died of ischaemic and hypertensive heart disease while serving a prison sentence. He had multiple comorbidities including atrial fibrillation, congestive cardiac failure, and cirrhosis. The coroner exa…
31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
56y · Male·complications of advanced metastatic sigmoid adenocarcinoma in an adult man with…
A 56-year-old Aboriginal man died of advanced metastatic sigmoid adenocarcinoma while serving an 11-year sentence for child sex offences. He had been diagnosed with Stage 4 colorectal cancer in 2018 with an expected life…
42y · Male·Ligature compression of the neck (hanging)
Brian Kealy, aged 42, died by suicide via hanging at Hakea Prison on 2 August 2024 while on remand. He had complex mental health needs including probable schizophrenia, anti-social personality disorder, and polysubstance…
69y · Male·advanced cholangiocarcinoma
Mr Lifa Faafete, aged 69, died from advanced cholangiocarcinoma while in remand custody at Metropolitan Special Programs Centre. He was appropriately transferred to Prince of Wales Hospital on 22 March 2025 for symptom m…
85y · Male·Aspiration pneumonia in the setting of ischaemic heart disease, type 2 diabetes …
An 85-year-old man died of aspiration pneumonia in a prison healthcare setting while receiving palliative care. He had experienced a stroke two years prior resulting in cognitive decline and required assistance with all …
66y · Male·metastatic adenocarcinoma (palliated) from an unidentified primary tumour
Bradley John Murdoch, a 66-year-old prisoner serving a life sentence for murder, died in the palliative care unit of Alice Springs Hospital from metastatic adenocarcinoma on 15 July 2025. He had presented to the correcti…
69y · Male·disseminated urothelial carcinoma of the bladder (palliated), bilateral lung ade…
A 69-year-old man died in prison custody from disseminated urothelial carcinoma of the bladder, bilateral lung adenocarcinoma, and severe emphysema. He had a significant smoking history and prior asbestos exposure. His l…
44y · Male·unascertained
Matthew Benjamin Holding, aged 44, died suddenly in prison on 2 January 2023. He had schizophrenia managed with antipsychotics and severe obesity (BMI 41.6). In December 2022, he showed signs of significant deterioration…
90y · Male·Ischaemic and valvular heart disease
Gerald Ridsdale, a 90-year-old man incarcerated at Port Phillip Prison, died from ischaemic and valvular heart disease following a period of palliative care. He had multiple chronic conditions including congestive cardia…
31y · Male·metastatic alveolar soft part sarcoma
31-year-old man serving a custodial sentence died of metastatic alveolar soft part sarcoma on 25 January 2022. Diagnosed April 2020, the ultra-rare cancer (1 in 10 million incidence) had already metastasised at discovery…
56y · Male·complications of viral hepatitis related advanced-chronic liver disease
Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was…
58y · Male·acute myocardial infarction caused by ischaemic heart disease
Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…
67y · Male·Congestive cardiac failure
Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and comple…
74y · Male·Incised wounds to limbs; other significant conditions being ischaemic heart dise…
Garry Reginald Dubois, a 74-year-old serving a life sentence for serious offences, died in custody from self-inflicted incised wounds to his limbs. He was on dual antiplatelet therapy for ischaemic heart disease, which c…
51y · Male·Hanging
A 51-year-old man with a complex mental health history and prior self-harm alert died by hanging in a correctional facility after a planned transfer. He requested protective custody following a physical altercation with …
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