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NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…

psychiatrycardiologycommunicationdiagnosticamisulpride
VIChome2024-05-20

Finding into death of Gwyn Pugh

63y · Male·Incised injuries to the neck and upper limbs

Gwyn Pugh, a 63-year-old man with longstanding bipolar affective disorder, died by suicide on 26 October 2022. He had been hospitalized for depression in April-May 2022 and received electroconvulsive therapy. Post-discha…

psychiatrygeneral practicecommunicationsystemmirtazapine
WAmental health2024-05-17

Inquest into the Death of Richard Anthony BOROS

50y · Male·upper airway obstruction (choking) from tissue paper

Richard Anthony Boros, a 50-year-old man with paranoid schizophrenia, died from upper airway obstruction (asphyxiation) after intentionally swallowing a dense ball of tissue paper while in the mental health assessment un…

psychiatryemergency medicinecommunicationsystemolanzapine
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel; coronary artery disease, diabetes mellitus and Crohn's disease …

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (with prior colectomy and ileostomy), and coronary artery disease, died from ischaemic bowel on day 17 of incarceration at Junee Correctional Centre du…

general practicegastroenterologydiagnosticcommunicationinsulin
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17…

general practicegastroenterologydiagnosticdelay
NSWmental health2024-05-16

Inquest into the death of Roger Frederick Schnelle

59y · Male·head injuries

Roger Schnelle, a 59-year-old accountant, died from head injuries sustained through intentional self-harm while involuntarily detained at Nolan House mental health facility in April 2021. He developed sudden onset severe…

psychiatrygeneral practicediagnosticcommunicationsertraline
VIChome2024-05-14

Finding into death of PJQ PJQ

18y · Female·Multidrug toxicity (GHB, amphetamines, benzodiazepines)

PJQ was an 18-year-old in state care who died from multidrug toxicity (GHB, amphetamines, benzodiazepines) after being discharged early from a residential rehabilitation program. She had complex trauma history, PTSD, and…

paediatricspsychiatrysystemdelayGHB
VIC2024-05-14

Finding into death of Brian Richard Pope

40y · Male·compression of the neck due to hanging

Brian Pope, a 40-year-old man with longstanding mental health issues including major depressive disorder, anxiety, learning disability (dyslexia), and substance abuse history, died by suicide in prison 20 days after rema…

psychiatrycorrectional healthcommunicationsystemmirtazapine
QLD2024-05-13

HARVEY, Thompson

33y · Male·Neck compression (hanging)

Thompson James Harvey, aged 33, died by hanging in his cell at Capricornia Correctional Centre on 13 November 2017, four days after remand for serious offences including attempted murder. He had a recent suicide attempt …

psychiatrypsychologycommunicationdiagnosticmorphine
WA2024-05-08

Inquest into the Death of Michael John BIRD

22y · Male·Multiple injuries from fall from 21st floor balcony

Michael Bird, 22, died by suicide on 17 March 2022, jumping from the 21st floor of his new workplace on his first day as building manager. He had been experiencing auditory hallucinations and paranoid delusions about pol…

general practicepsychiatrycommunicationsystemzolpidem
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 January 2022 with self-harm and active suicidal ideation with a st…

emergency medicinepsychiatrysystemdelay
TAShome2024-04-30

Coroner's Finding: Mason, Geoffrey

38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…

Geoffrey Russell Mason, aged 38, died from a gunshot wound to the neck fired by Constable Mitchell during a police response to a domestic incident on 17 February 2020 in Tasmania. Mason was intoxicated, had a long histor…

general practiceemergency medicinesystemalcohol
QLD2024-04-30

WILLIAMS, Russell James

51y · Male·Incised wound to the right arm

Russell Williams, aged 51, died by suicide in a Queensland prison on 15 May 2018 by cutting his right arm with a disposable razor blade. He was remanded on two historical murder charges and had spent 15 years in prison o…

psychiatrypsychologydiagnosticsystem
VIChome2024-04-29

Finding into death of Claudette Marie Daw

77y · Female·Effects of fire

Claudette Marie Daw, a 77-year-old with longstanding schizophrenia, died in a house fire at her home while her brother was hospitalised. The fire originated in her bedroom and was accidentally ignited, likely by a discar…

general practicepsychiatry
VIChome2024-04-29

Finding into death of Mr A

32y · Male·Neck compression in the setting of hanging

Mr A, a 32-year-old male with a history of family violence perpetration, mental illness (bipolar disorder, schizophrenia, PTSD), substance misuse, and prior suicide attempts, died by hanging on 21-22 November 2020. He wa…

psychiatrygeneral practicecommunicationsystemalcohol
VICmental health2024-04-26

Finding into death of Allison Leah Randall

37y · Female·Hanging

Allison Randall, a 37-year-old woman with a history of anxiety, depression, and childhood trauma, was admitted to the Northern Hospital psychiatric unit on 15 May 2020 following acute concerns about her partner's behavio…

psychiatrysystemdiazepam
VICcommunity2024-04-23

Finding into death of Carolyn Mary James

3y · Female·Effects of fire deliberately set by mother in motor vehicle

Carolyn James, a 3-year-old girl, died from the effects of fire when her mother deliberately set fire to a motor vehicle in which she, her sister, and mother were sitting. The investigation examined whether services had …

general practicepsychiatrydiagnosticsystem
VIChome2024-04-23

Finding into death of Caroline Anne Willis

69y · Female·Multiple stab wounds

Caroline Willis, aged 69, was fatally stabbed by her son Jamie in May 2018, two hours after he was served with a Family Violence Intervention Order (FVIO). The death was homicidal and occurred within a context of escalat…

psychiatrygeneral practicecommunicationsystemmethamphetamine
QLDhospital2024-04-22

Non-inquest findings into the death of Lenore

48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…

A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…

emergency medicineorthopaedic surgerydiagnosticsystemoxycodone
VICmental health2024-04-19

Finding into death of Allison Naomi Eagle

44y · Female·Unascertained, presumed sudden cardiac death

44-year-old woman with schizophrenia and bipolar affective disorder died unexpectedly in a psychiatric inpatient unit. She had obstructive sleep apnoea and was on multiple antipsychotic medications. On the night before h…

psychiatryrespiratory medicinezuclopenthixol deconoate

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