221 results
30y · Male·unknown - no postmortem examination performed
This inquest examined the 1995 disappearance of Habtom Ghilagaber, a 30-year-old Eritrean mathematics PhD student at UNSW who was reported missing on 25 September 1995, having last been seen alive on 5 September 1995. Th…
62y · Male·Multiple sharp force injuries intentionally inflicted by client during home visi…
Stephen James Douglas, a 62-year-old community mental health nurse, was killed on 28 November 2019 by his client Peter Kemball during a home visit. Kemball had chronic schizophrenia and was experiencing psychosis with de…
65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…
A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
31y · Male·Drowning
Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
27y · Male·acute myeloid leukaemia
Hayden Dawes, aged 27, died from acute myeloid leukaemia (AML) while in custody at Mannus Correctional Centre on 30 December 2018. He had previously been treated for Hodgkins Lymphoma with BEACOPP chemotherapy (2014-2016…
33y · Male·hanging
Moses Kellie, aged 33, died by hanging at Villawood Immigration Detention Centre in January 2019 after four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attem…
29y · Male·hanging
Muhammad Hafizuddin Bin Zaini, a 29-year-old detainee in immigration detention at Villawood, died by hanging on 12 December 2020. He had a history of substance-induced psychotic disorder and was prescribed antipsychotic …
50y · Female·hanging
A 50-year-old woman with severe borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two …
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
33y · Male·gunshot wounds to chest and upper arm
A 33-year-old man with bipolar disorder on reducing doses of risperidone experienced a psychotic relapse and stabbed a stranger at a railway station. He then entered a police station with a knife, advancing on officers d…
89y · Male·Cervical spine trauma
Robert Driver, 89, died from cervical spine trauma sustained after being struck by another dementia-affected resident in an aged care facility. He was assessed overnight at the facility and transferred to hospital the fo…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
35y · Male·multi-drug toxicity
CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, dis…
43y · Female·suffocation
Ms K, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car va…
59y · Male·Hanging
Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…
62y · Male·not stated - body never found
KL, a 62-year-old journalist with a long history of depression, anxiety, and alcohol use disorder, was admitted to St Vincent's Hospital's psychiatric units (PECC and Caritas) in June 2020 following suicidal ideation. Af…
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