73 results
volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…
This inquest examines 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 gove…
34y · Male·self-inflicted hanging
34-year-old Jordan Allen died by suicide on 1 February 2018 after absconding from Alice Springs Mental Health Unit during supervised cigarette leave. He was acutely psychotic with persecutory delusions related to methamp…
24y · Male·self-inflicted hanging
Linden Alan Kunoth, a 24-year-old Aboriginal man, died by suicide while on escorted leave from psychiatric care. He had been admitted with first-episode schizophrenia, presenting with florid psychosis and command halluci…
37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof
Daniel Bleaney, 37, experienced acute psychosis with command hallucinations while at sea and attempted suicide by jumping overboard. He was rescued and admitted involuntarily to Cowdy Ward, an open psychiatric ward, foll…
32y · Male·self-inflicted hanging
Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…
19y · Female·self-inflicted hanging
Sabrina Di Lembo, a 19-year-old law student, died by suicide after experiencing anxiety and panic attacks during exam preparation. Over nine weeks, she had 17 medical contacts but received inadequate assessment, no detai…
45y · Male·gunshot wound to the neck
Matthew Rosewarne, a 45-year-old man with chronic alcohol use disorder and recent relationship breakdown, was found dead in his shed with a gunshot wound to the neck. Although initially investigated as suicide, the coron…
53y · Female·self-inflicted hanging
Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…
26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis
Naomi Smith, aged 26, died from pulmonary embolism caused by dislodged deep vein thrombosis while in ICU at Royal Darwin Hospital. She had complex mental health needs (BPD, PTSD, depression) and morbid obesity. The criti…
37y · Male·water intoxication and olanzapine toxicity in association with schizophrenia
A 37-year-old Aboriginal male prisoner with a long history of treatment-resistant schizophrenia died at the Darwin Correctional Precinct. He was on high-dose olanzapine (15mg twice daily) and zuclopenthixol when he devel…
24y · Male·inhaled solvent toxicity (from petrol sniffing)
Edward James Laurie, a 24-year-old man with chronic petrol sniffing addiction since age 10 and underlying mental health issues including psychosis, died from inhaled solvent toxicity on 11 October 2015. Sixteen Applicati…
Female·Wendy Murphy: blunt head and chest trauma. Natalie McCormack: haemorrhage follow…
Two Aboriginal women, aged 36 and 31, died following prolonged domestic violence by their partners in Alice Springs. Both had extensive histories of police-documented assaults, domestic violence orders (DVOs), and uncoop…
23y · Male·self-inflicted hanging
Dean Jigili, a 23-year-old Aboriginal man, died by hanging after absconding from Cowdy Ward mental health unit on 13 January 2015. He had first-episode psychosis likely triggered by cannabis use, complicated by apparent …
17y · Female·self-inflicted hanging
Madeline (Maddy) Downman, 17-year-old Aboriginal girl in state care, died by hanging at a residential facility. She had complex psychiatric needs including depression, trauma, self-harm, and substance abuse, with four ye…
69y · Male·Blunt head trauma
Ronald Donaldson, a 69-year-old fencing contractor, was killed by Justin Osborne with a sledgehammer in Katherine on 3 December 2013. Osborne was experiencing untreated schizophrenia with acute psychotic symptoms and bel…
59y · Male·Cardiac arrest caused by Ischaemic Heart Disease
Angus Dixon, a 59-year-old Aboriginal man with ischaemic heart disease, diabetes, and a history of paranoid psychosis, died from acute myocardial infarction while an involuntary mental health patient at Alice Springs Hos…
29y · Female·multi-lobe community acquired pneumonia and respiratory failure
Clare Louise Harrison, a 29-year-old woman with long-standing anorexia nervosa diagnosed at age 17, died from community-acquired pneumonia and respiratory failure after a final 21-day admission to Alice Springs Hospital.…
49y · Male·cardiac hypertrophy (longstanding heart disease) complicated by chronic renal fa…
Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 m…
42y · Male·Sudden cardiac death in the context of schizophrenia
Anthony Graham Greig Faulkner, a 42-year-old man with longstanding schizophrenia (formerly diagnosed as bipolar disorder), died suddenly on 23 September 2013 while an involuntary psychiatric patient at Cowdy Ward, Royal …
62y · Male·Self-inflicted intentional hanging
Haidar Ali Ikhtiyar, a 62-year-old Afghan asylum seeker, died by hanging in an immigration detention centre on 15 June 2013. He had experienced anxiety, depression and PTSD during detention and was under psychological ca…
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