873 results
38y · Male·ligature compression of the neck (hanging)
Mark Quenton Fleury, a 38-year-old man with paranoid schizophrenia, died by suicide on 14 February 2016 while subject to a Community Treatment Order. In the final week of his life, he presented to emergency services and …
50y · Female·ligature compression of the neck (hanging)
Annabel Nicol, a 50-year-old woman, died by ligature compression of the neck (hanging) in Bandyup Women's Prison on 15 June 2015. She was a remand prisoner with chronic alcoholism, depression, and suicidal ideation who h…
45y · Male·severe chronic obstructive pulmonary disease
Troy Michael Conley, aged 45, died from severe chronic obstructive pulmonary disease (COPD) while imprisoned. He had developed progressive lung disease from occupational exposure to gyprock dust, intravenous drug use (ta…
35y · Male·atherosclerotic heart disease with methylamphetamine effect in a man under physi…
A 35-year-old male with severe pre-existing ischaemic heart disease and recent cardiac arrest (April 2016) presented with increasingly erratic and paranoid behaviour after methylamphetamine use and alcohol consumption. H…
44y · Female·pulmonary thromboembolism in a woman with likely myeloproliferative neoplasm
A 44-year-old previously healthy woman with BMI 30.5 and minimal comorbidities (snoring, back pain, knee pain) underwent elective sleeve gastrectomy for weight loss. Nine days post-op she presented with splenic rupture r…
66y · Male·acute myocardial infarction on a background of atherosclerotic cardiovascular di…
Malcolm Patrick O'Driscoll, a 66-year-old life-sentenced prisoner, died on 15 April 2017 at Acacia Prison from acute myocardial infarction on a background of severe atherosclerotic cardiovascular disease. He had been imp…
13y · Male·Epileptic seizure with aspiration
Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…
25y · Female·complications of opioid toxicity
Ellie Marlene Hare, 25, died from opioid toxicity after injecting methadone on two consecutive nights with Matthew Drake. She was opioid-naïve, having not used regularly for several years. On the morning of her death, Dr…
80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…
Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…
56y · Male·disseminated malignancy – known non-small cell carcinoma of lung
Colin George Graham, a 56-year-old Aboriginal man with severe COPD and lung cancer, died of disseminated non-small cell carcinoma while in prison custody receiving palliative care. The coroner found his medical care was …
31y · Female·incised wounds to the neck and arms
A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…
Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…
Five male prisoners died by suicide at Casuarina Prison, Western Australia between 2014-2015. All deaths were by hanging or self-inflicted laceration. The coroner identified multiple systemic failures including: inadequa…
64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…
A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…
40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…
Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…
57y · Male·Bronchopneumonia complicating metastatic and locally advanced primary adenocarci…
A 57-year-old male prisoner died from bronchopneumonia complicating metastatic lung adenocarcinoma. He was diagnosed with stage IV lung cancer in February 2016 while incarcerated and opted for palliative care, declining …
44y · Male·gunshot wound to abdomen
A 44-year-old male died from a gunshot wound to the abdomen sustained during a police response to a domestic violence incident. He became aggressive, wielded a knife, and lunged at police after Taser and pepper spray fai…
24y · Male·bronchopneumonia complicating oxycodone toxicity
Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping…
36y · Male·Ligature compression of the neck (suicide by hanging)
A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…
34y · Male·ligature compression of the neck
Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…
79y · Male·Valvular ischaemic heart disease in association with coronary arteriosclerosis
A 79-year-old prisoner with a long history of ischaemic heart disease and coronary arteriosclerosis suffered fatal cardiac arrest in his cell at Karnet Prison Farm. He had been appropriately managed with regular cardiova…
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