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WA2025-05-05

Inquest into the Suspected Death of David Benjamin INGRAM

44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…

David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…

psychiatrygeneral practicecommunicationsystemolanzapine
WAcommunity2025-04-17

Inquest into the Suspected Death of Peter James GUIDERA

58y · Male·unascertained

Peter James Guidera, a 58-year-old man with a history of depression, suicidal ideation, and previous suicide attempts, disappeared on 8 May 1998 from Narrogin, Western Australia, shortly after receiving a distressing pho…

psychiatrygeneral practiceantidepressant medication
WAprison2025-04-10

Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…

emergency medicineneurosurgerydiagnosticcommunicationparacetamol
WA2025-03-27

Inquest into the Death of Travis Dion BAUMGARTEN

48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…

Travis Dion Baumgarten was a 48-year-old Aboriginal man serving a prison sentence at Acacia Prison in Western Australia who died on 5 December 2022 from complications of untreated HIV/AIDS. After HIV diagnosis in 1994, h…

infectious diseasesgeneral medicine
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
WAhome2025-02-12

Inquest into the Death of Kimberley Michael VULICH

64y · Male·complications in association with thermal injuries in a man with underlying chro…

Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …

general medicinegeriatric medicinecommunicationdelay
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 Matthew Francis LEACH

50y · Male·ligature compression of the neck (hanging)

Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…

psychiatrypsychologysystemdelayvenlafaxine
WAcommunity2024-12-06

Inquest into the death of Jaxon Charles Kinnane

22y · Male·Immersion in water (drowning) in a man with combined drug effect

Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…

psychiatrycorrectional healthcommunicationsystempaliperidone
WA2024-11-15

Inquest into the death of Kingsley Dean Garlett

32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…

Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…

psychiatrypsychologysystemdelaymethadone
WAhospital2024-11-13

Inquest into the death of Chloe Grace Tupper

31y · Female·organ failure due to anorexia nervosa

Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…

psychiatrypaediatricssystemcommunicationmirtazapine
WAcommunity2024-10-22

Inquest into the Death of Karl Jonathan TURNER

49y · Male·combined drug toxicity

Karl Turner, a 49-year-old man with schizoaffective disorder and chronic polysubstance use, died from combined drug toxicity (heroin, morphine, pregabalin, methylamphetamine, and cannabis). He was managed on a Community …

psychiatryintensive caresystemdelaymorphine
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
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
WAcommunity2024-08-13

Inquest into the Death of Amy Rebecca DEANE-JOHNS

48y · Female·Combined drug toxicity (predominantly methadone)

Amy Rebecca Deane-Johns, aged 48, died from combined drug toxicity predominantly involving methadone that she had taken without knowledge or authorization. She had a long history of mental illness with 18 inpatient admis…

psychiatrymethadone
WAhospital2024-08-09

Inquest into the Death of Lindsay WOODS

48y · Male·metastatic high-grade neuroendocrine carcinoma, treated palliatively

Lindsay Woods, a 48-year-old Aboriginal man with chronic paranoid schizophrenia, organic psychosis, and ischaemic heart disease, died from metastatic high-grade neuroendocrine carcinoma. He was subject to a custody order…

psychiatryoncologyclozapine
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

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