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WAhospital2025-03-06

Inquest into the Death of Jalen Hunter NORRIS

23y · Male·Multiple injuries from being struck by train

Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…

emergency medicinepsychiatrycommunicationdiagnosticcannabis
WAhome2025-01-23

Inquest into the Suspected Death of Benjamin Jacob VAN TRIGT

38y · Male·electrical injury

Benjamin Van Trigt, a 38-year-old man with schizoaffective disorder, died by electrocution at home on 17 November 2022 while on a Community Treatment Order (CTO). He had experienced multiple psychiatric relapses requirin…

psychiatryemergency medicinepaliperidone
WA2025-01-08

Inquest into the Suspected Death of Tanghui HUANG

41y · Male·Unascertained - may have resulted from injuries sustained in fall from vessel or…

Tanghui Huang, a 41-year-old Chinese able seaman, disappeared from a bulk carrier vessel off Dampier, Western Australia on 21 April 2012. He was last seen painting the mooring winch at 11:30 am and was presumed to have f…

occupational and environmental healthpsychiatrysystemcommunicationtriazolam
WAprison2025-01-03

Inquest into the Death of Christopher John HILLSTEAD

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'…

psychiatrycorrectional healthcommunicationsystem
WAAugust 2024

Inquest into the Death of Robert Allan EXELL

55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…

Robert Exell, a 55-year-old Aboriginal man, died from complications of liver cirrhosis and hepatocellular carcinoma while in custody. He had chronic hepatitis C and alcohol-related liver disease since at least 2012. Key …

hepatologygastroenterologydelaysystemmorphine
WA2024-12-23

Inquest into the Death of Frank MIKHAIL

68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…

Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…

respiratory medicineemergency medicinediagnosticcommunicationamitriptyline
WAcommunity2024-12-02

Inquest into the death of NW

31y · Female·unlawful homicide (manslaughter); specific cause could not be determined due to …

NW, aged 31, was killed by her partner on 9-10 October 2021 in Kununurra, Western Australia. She had a history of domestic violence victimization and had obtained a Family Violence Restraining Order. On the evening of he…

emergency medicineforensic medicinecommunicationsystem
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…

emergency medicineendocrinologymedicationsystemryzodeg insulin
WAhome2024-09-11

Inquest into the Death of Stephen Kenneth SHERWOOD

31y · Male·ligature compression of the neck (hanging)

Stephen Sherwood, a 31-year-old Aboriginal man with untreated mental health issues and history of methylamphetamine use, died by suicide on 13 April 2022. He had attempted suicide by wrist-cutting on 30 March 2022 and th…

psychiatryemergency medicinecommunicationmethamphetamine
WA2024-09-05

Inquest into the Death of Robert Fredrick PARNELL

29y · Male·butane and propane toxicity from inhalation of canola oil spray propellants

Robert Parnell, aged 29, died from butane and propane toxicity after inhaling propellants from a can of canola oil spray in a prison kitchen toilet. He had a long history of polysubstance use including solvent sniffing d…

forensic medicineemergency medicinesystemsupervisionbutane
WAmental health2024-08-28

Inquest into the Death of Peter Jonathon Rex BOLTON

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…

psychiatryemergency medicinehaloperidol
WAhome2024-07-31

Inquest into the Death of Joseph Charles ABELA

34y · Male·Gunshot injuries to chest and left shoulder

Joseph Abela, a 34-year-old with chronic paranoid schizophrenia and polysubstance use, died from gunshot wounds inflicted by police during a mental health welfare check on 25 October 2021. Critical clinical failures prec…

psychiatrycorrectional healthdiagnosticsystemhaloperidol
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
WA2024-07-10

Inquest into the Death of Jason Anthony THOMPSON

54y · Male·metastatic lung cancer with terminal palliative care

Jason Anthony Thompson, a 54-year-old long-term prisoner at Casuarina Prison, died from metastatic lung cancer. He collapsed on 17 February 2023 with suspected opioid overdose but was not transferred to hospital for appr…

emergency medicineoncologydelaynaloxone
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
WA2024-06-12

Inquest into the Death of Petra Michelle MARQUIS

40y · Female·ligature compression of the neck (hanging)

Petra Michelle Marquis, a 40-year-old woman with a documented history of mental health issues including depression, anxiety, PTSD, and borderline personality disorder, died by suicide while in police custody after being …

psychiatryemergency medicineduloxetine
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

0y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
WAmental health2024-05-17

Inquest into the Death of Richard Anthony BOROS

50y · Male·upper airway obstruction (choking) from tissue paper

Richard Anthony Boros, a 50-year-old man with paranoid schizophrenia, died from upper airway obstruction (asphyxiation) after intentionally swallowing a dense ball of tissue paper while in the mental health assessment un…

psychiatryemergency medicinecommunicationsystemolanzapine
WA2024-05-08

Inquest into the Death of Michael John BIRD

22y · Male·Multiple injuries from fall from 21st floor balcony

Michael Bird, 22, died by suicide on 17 March 2022, jumping from the 21st floor of his new workplace on his first day as building manager. He had been experiencing auditory hallucinations and paranoid delusions about pol…

general practicepsychiatrycommunicationsystemzolpidem
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 January 2022 with self-harm and active suicidal ideation with a st…

emergency medicinepsychiatrysystemdelay

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