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NSWhome2026-04-21

Inquest into the death of Michael

28y · Male·In keeping with Hanging

A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …

emergency medicineparamedicinesystemcommunicationvenlafaxine
VIChome2026-04-17

Finding into death of Simon Christopher Gaskill

50y · Male·unascertained

Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…

emergency medicinegeneral medicinecommunicationsystemalcohol
VIChome2026-04-17

Finding into death of Harrison William Ladd

25y · Male·Combined drug toxicity

Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…

general practicepsychiatrymedicationcommunicationclonazepam
VICcommunity2026-04-15

Finding into death of LX

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 …

addiction medicinepsychiatrymedicationsystemmethadone
VIChome2026-04-14

Finding into death of Justin James Filardo

45y · Male·Gunshot wounds to the head and left shoulder

Justin Filardo, aged 45, with a 28-year history of schizophrenia, was fatally shot by police after assaulting his sister Bianca in her bedroom. In the weeks prior, Justin had ceased his clozapine medication without clini…

psychiatrygeneral practicesystemdelayclozapine
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

DR was a 41-year-old man with bipolar disorder, severe alcohol dependence, and multiple psychosocial stressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …

psychiatryforensic medicinecommunicationsystemdiazepam
WAhospital2026-04-01

Inquest into the Death of David John HATCHER

60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…

David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospita…

respiratory medicineinfectious diseasesproceduralsystem
VIC2026-03-30

Finding into death of Hari Prasad Dhakal

57y · Male·Neck compression and hanging

A 57-year-old man with schizophrenia and schizoaffective disorder died by hanging in prison on 4 August 2024. He had been receiving antipsychotic treatment via injection (paliperidone) but ceased antipsychotic medication…

psychiatrygeneral practicesystemcommunicationpaliperidone
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
VICcommunity2026-03-27

Finding into death of Sacha Timothee Louis Lefebvre

52y · Male·Complications of chronic cardiac failure in the setting of ischaemic heart disea…

Sacha Timothee Louis Lefebvre, aged 52, died from complications of chronic cardiac failure with ischaemic heart disease and chronic anaemia whilst sleeping rough at Hawthorn Library. He had multiple chronic conditions in…

cardiologyemergency medicinesystemdelaymethamphetamine
WA2026-03-26

Inquest into the Death of Brian John KEALY

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…

psychiatrygeneral medicinecommunicationsystemolanzapine
NSWcommunity2026-03-25

Inquest into the disappearance and suspected death of Gavin Cheng

29y · Male·Not determined; likely multiple injuries from fall from coastal cliff or drownin…

This inquest concerns the disappearance and suspected death of Gavin Cheng, a 29-year-old man last seen on 29 October 2023 in North Bondi, NSW. Gavin had a documented history of schizophrenia diagnosed in 2015, with peri…

psychiatryemergency medicineantipsychotic medication
TAShome2026-03-23

Coroner's Finding: de-identified ZA

51y · Female·Unintentional prescription drug poisoning due to central nervous system depressi…

A 51-year-old woman with chronic pain, depression, and longstanding medication misuse died from unintentional prescription drug poisoning. She had been prescribed high-risk combinations of opioids and benzodiazepines ove…

general practicepain medicineoxycodone
NThome2026-03-20

Inquest into the death of Ralph Donald

35y · Male·self-inflicted gunshot wound to the head

Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…

psychiatryaddiction medicinesystemcommunication
NSWpolice custody2026-03-20

Inquest into the death of Phillip Walton

48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…

Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…

emergency medicineparamedicinediagnosticcommunicationclozapine
VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…

psychiatrypsychologycommunicationsystemalprazolam
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…

psychiatryemergency medicinesystemdelaytapentadol
VIChome2026-03-16

Finding into death of John O'Grady

63y · Male·Effects of fire

A 63-year-old man with bipolar disorder, Crohn's disease, ADHD and HIV died in a residential fire at his apartment. He was found with evidence of unsafe smoking in bed, including numerous cigarette butts throughout his u…

general practicepsychiatrysystemrisperidone
SA2026-03-13

Coroner's Finding: Holding, Matthew Benjamin

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…

psychiatrycorrectional healtholanzapine

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