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NSWhome2022-02-24

Inquest into the death of Therese WILLIAMS

60y · Female·ischaemic heart disease

A 60-year-old woman was found deceased at her home, having enjoyed an evening with friends the previous evening. Autopsy revealed focal narrowing (40%) of one major coronary artery with mild left ventricular scarring and…

general practiceforensic medicinediagnosticeutroxsig
NSW2022-02-18

Inquest into the death of Ricardo Damien Arquero

40y · Male·Bronchial Asthma

Ricardo Arquero, a 40-year-old man serving a prison sentence, died from acute bronchial asthma at Glen Innes Correctional Centre on 19 August 2019. He had a documented history of asthma since childhood and was provided w…

general practiceemergency medicinesalbutamol
NSWcommunity2022-02-18

Inquest into the death of SP

36y · Male·hanging

A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…

emergency medicineparamedicinecommunicationsystem
NSWmental health2022-02-14

Inquest into the death of Janice GAUL

Female·Multiple injuries sustained when deceased placed herself in front of a moving tr…

On 2 July 1988, an unidentified woman died at Cabramatta railway station after deliberately placing herself in front of a moving train, sustaining multiple fatal injuries. She was identified through fingerprint analysis …

psychiatryforensic medicinesystem
NSW2022-02-14

Inquest into the death of Khaled DIB

42y · Male·Cardiomegaly and myocardial bridging of the left anterior descending coronary ar…

Khaled Dib, a 42-year-old prisoner at Dawn De Loas Correctional Centre, collapsed suddenly while in his cell on 5 September 2019 and could not be revived. Post-mortem examination revealed cardiomegaly and myocardial brid…

forensic medicineemergency medicinecocaine
NSW2022-02-09

Inquest into the death of IM

37y · Male·Sharp force injuries of the neck and left arm

A 37-year-old male remanded in custody at Cessnock Correction Centre died by suicide on 3 September 2019 from self-inflicted sharp force injuries to the neck and left arm. He had been in custody for 44 days following cha…

forensic medicinepsychiatrycommunication
NSWhome2022-02-07

Inquest into the death of Chatchaya ITTIVITHCHAI

1y · Female·blunt force injury of the head sustained when she fell from a third-floor window…

A 15-month-old girl died from blunt force head injury after falling from a third-floor apartment window lacking a safety lock. The building was governed by company title rather than strata title, meaning no child window …

system
NSW2022-02-07

Inquest into the death of Chin Hung HO

64y · Male·Closed Head Injury

Chin Hung Ho, a 64-year-old man in custody at Macquarie Correctional Centre, collapsed during morning muster on 22 March 2021 and struck his head on concrete flooring. CCTV footage captured the collapse, which appeared c…

forensic medicineneurosurgery
NSWhospital2022-02-07

Inquest into the death of Jose Manuel XAVIER

64y · Male·Consequences of metastatic oesophageal carcinoma with Stanford B dissection thor…

Jose Manuel Xavier, a 64-year-old prisoner, died from metastatic oesophageal carcinoma with a contributing Stanford B thoracic aortic dissection. He was diagnosed with oesophageal cancer in July 2019 after presenting wit…

palliative caregastroenterologymorphine
NSWhospital2022-02-01

Inquest into the death of Ivan CHRISTOV

70y · Male·complications of chronic obstructive pulmonary disease and ischaemic heart disea…

A 70-year-old man with end-stage COPD, ischaemic heart disease, and obstructive sleep apnoea collapsed in his prison cell and was transferred to hospital in respiratory distress. Despite having documented 'not for resusc…

emergency medicinerespiratory medicinecommunicationdelay
NSWmental health2022-02-01

Inquest into the death of Camilla MARGOLIS

34y · Female·multiple blunt force injuries

Camilla Margolis, 34, died by suicide at Echo Point Lookout in the Blue Mountains hours after discharge from mental health inpatient care. She had complex borderline personality disorder with chronic suicidality across 2…

psychiatryemergency medicinecommunicationsystemmirtazapine
NSW2022-01-25

Inquest into the death of Nick NEWMAN

33y · Male·Multiple gunshot wounds

Nick Newman, 33, died from multiple gunshot wounds during execution of an arrest warrant for serious child sexual assault offences. Police conducted inadequate risk assessment despite accessible intelligence indicating h…

diagnosticcommunication
NSWhospital2021-12-23

Inquest into the death of Shelley YOUNG

65y · Female·choking on a tangerine

Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine whi…

psychiatrygeriatric medicinecommunicationsystemclozapine
NSWcommunity2021-12-23

Inquest into the deaths of Judith CHRUPALO and Christopher CLEE

73y · Female·Unknown due to decomposition

Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …

geriatric medicinepsychiatrydiagnosticcommunication
NSW2021-12-22

Inquest into the death of Jack LOH

Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions

Jack Loh, a 6-month-old boy, died from unrecognised pulmonary hypertension while in unsafe sleeping conditions at a family day care centre. Jack was placed prone (face down) in an undersized bassinet with loose bedding m…

cardiologypathologysystemdelay
NSWcommunity2021-12-21

Inquest into the deaths of Lars FALKHOLT, Vivian FALKHOLT, Jessica FALKHOLT and Annabelle FALKHOLT, and Craig WHITALL

Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…

Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …

general practiceemergency medicinemedicationcommunicationmethadone
NSWhome2021-12-20

Inquest into the death of Harland SUTTON

5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained

A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…

paediatricsemergency medicinesystemmedicationfurosemide
NSWcommunity2021-12-17

Inquiry into the fire at Reedy Swamp Tarraganda Bega/Tathra

Death from fire exposure during bushfire - the finding does not concern individu…

On 18 March 2018, a major bushfire commenced in an electrical easement near Reedy Swamp and rapidly spread to the coastal town of Tathra on the NSW South Coast, destroying approximately 1,400 hectares of bushland and dam…

systemcommunication
NSWhospital2021-12-15

Inquest into the death of Bailey Mackander

20y · Male·Multiple injuries from fall from height

Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…

psychiatrypsychologydiagnosticcommunicationmethamphetamine
NSW2021-12-15

MACKANDER Bailey 2019-351386 - REDACTED Findings gicen by Mag Truscott DSC on 15-12-2021 can be published

20y · Male·Multiple injuries from fall from height

Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring…

psychiatrypsychologydiagnosticsystemmethamphetamine
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