334 results
41y · Male·ligature compression of the neck (hanging)
Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…
Male·unascertained
Nicholas Pavlidis disappeared in October 2015 after last being seen alive on 14 October 2015. His abandoned vehicle was reported to police on 24 October 2015 in Yanchep bushland, but initial police response treated it as…
37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …
A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…
31y · Male·asphyxia due to self-inflicted hanging
Benjamin Marshall, aged 31, died by self-inflicted hanging in October 2019, over two years after discharge from the Royal Australian Navy. He suffered from Bipolar Affective Disorder (BPAD), a genetic condition not causa…
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…
31y · Male·Mixed drug toxicity (heroin, bromazolam, metonitazine, protonitazene, methamphet…
Ryan Robinson, a 31-year-old man with longstanding opioid use disorder and complex mental health conditions, died from mixed drug toxicity involving heroin, novel psychoactive substances (nitazenes: metonitazene and prot…
21y · Female·Compression of the neck secondary to hanging
Lillian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a h…
17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…
Didbala, a 17-year-old Aboriginal girl with complex mental health conditions including psychosis, bipolar disorder and suspected FASD, died by hanging at a CASPA residential care house in Katherine on 3 October 2022. She…
50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…
William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…
45y · Male·Hanging
PF, aged 45, died by hanging in custody at South Coast Correctional Centre following bail refusal and adverse legal advice. The coroner found his death was intentional self-harm. Although PF had a significant history of …
18y · Male·Death by suicide; cause cannot be definitively determined as body not recovered,…
An 18-year-old male with depression and anxiety died by suicide on 16 August 2022, jumping from the Tasman Bridge. He had been diagnosed with depression and anxiety in January 2022, saw a psychologist six times, and was …
59y · Male·Shotgun wound to the head
A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…
31y · Male·compression of the neck secondary to hanging
Rory Van Geleuken, a 31-year-old with longstanding major depressive disorder, generalised anxiety disorder, autism spectrum disorder, and ADHD, died by hanging. He had received mental health treatment since age 17, inclu…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
47y · Male·Compression of the neck arising from hanging
47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinat…
18y · Male·Unascertained; likely hypothermia possibly in combination with drowning
Jodus Murphy, 18, disappeared from his mother's home on 12 May 2023 and was found deceased near the Goulburn River on 14 June 2023. He had experienced significant life disruption following his grandparents' relocation to…
32y · Female·mixed drug toxicity including phenobarbitone
A 32-year-old woman with borderline personality disorder and depression died by intentional self-administration of pentobarbitone (Lethabarb) accessed from her workplace. She had experienced extensive family violence in …
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical l…
68y · Male·Head injuries
Stephen O'Brien, aged 68, died from head injuries inflicted by his adult son Scott in a family violence incident. Stephen had been the primary carer for Scott, who had untreated mental illness (suspected schizophrenia), …
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