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WAhome2018-08-03

Inquest into the Death of Jackie-Lee SMITH

56y · Female·Acute combined drug toxicity

A 56-year-old woman died from acute combined drug toxicity following a fall in her bathroom on 12 March 2015. She had recently transitioned from oxycodone to tramadol for chronic pain management due to concerns about opi…

general practicepain medicinetramadol
WAmental health2018-07-16

Inquest into the Death of Stanley KING

45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…

Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
WAcommunity2018-07-12

Inquest into the Death of Shane Christopher FLANDERS

29y · Male·unknown, probably immersion

Shane Flanders, a 29-year-old man with a complex psychiatric history including personality disorder, substance abuse, previous suicide attempt, and drug-induced psychosis, disappeared on 28 January 2016 after being relea…

psychiatryemergency medicinediagnosticcommunicationdextroamphetamine
WAhome2018-06-27

Inquest into the Death of Brook Damian CAIN

39y · Male·ligature compression of the neck (hanging)

A 39-year-old man with schizoaffective disorder and substance abuse died by suicide following arrest for criminal damage. While treated under a Community Treatment Order, he had poor medication compliance and ongoing dru…

psychiatryemergency medicinecommunicationsystemquetiapine
WAhospital2018-06-25

Inquest into the Death of LCTM

0y · Male·complications of head injury

A premature newborn died from severe head injuries inflicted deliberately by his teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had …

neonatologypaediatricscommunicationsystem
WAcommunity2018-06-22

Inquest into the Death of Isiah Duane KEARING

20y · Male·ligature compression of the neck (hanging)

Isiah Kearing, a 20-year-old Aboriginal man, died by hanging approximately 3 hours after being arrested by police for disorderly conduct at a community hall. He had expressed anger and humiliation about being arrested, f…

forensic medicineemergency medicinesystemalcohol
WAhospital2018-06-14

Inquest into the Death of Anne RZEPCZYNSKI

59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…

59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent in…

general surgeryintensive carediagnosticdelayantibiotics
WA2018-05-31

Inquest into the Death of Giuseppe DEL BORRELLO

78y · Male·unascertained

Giuseppe Del Borrello, a 78-year-old man, disappeared from Yanchep National Park on 1 January 1979 during a family picnic and was presumed dead. The coroner concluded he died around the time of his disappearance, but the…

general practicepsychiatrynitrazepam
WA2018-05-31

Inquest into the Death of John Lindsay FIELD

66y · Male·unascertained cause

John Lindsay Field, aged 66, disappeared on 13 May 1976 and was declared deceased by inquest in 2018. He left home in a depressed state on the anniversary of his wife's death. Extensive police investigation found no trac…

WAcommunity2018-05-31

Inquest into the Death of Charles TUDAWALI (aka Charlie Martin)

13y · Male·unascertained

Charles Tudawali, a 13-year-old Aboriginal boy with intellectual disability (mental age 7 years) and epilepsy requiring three-daily medication, went missing on 15 December 1976 while mustering horses in remote Kimberley …

WAcommunity2018-05-30

Inquest into the Death of Lachlan James MITCHELL

2y · Male·Hypoxic brain injury following immersion (drowning)

Lachlan Mitchell, a 2-year-old with global developmental delay and hypermobility, drowned in a swimming pool at a family day care home on 9 November 2015, suffering fatal hypoxic brain injury. While swimming pools were n…

emergency medicineintensive caresupervisionsystem
WAhome2018-05-30

Inquest into the Death of Patricia (Tricia) Alicia REVELL

2y · Female·unascertained; death in house fire due to smoke inhalation or thermal injury

Patricia (Tricia) Revell, aged 2 years 10 months, died in a house fire at a remote railway outpost in Zanthus, Western Australia on 20 July 1978. She was in bed with her infant sister when the fire started. Her mother re…

WA2018-05-02

Inquest into the Death of Gary FELTON, Chantelle Jane McDOUGALL, Leela McDOUGALL and Antonio Konstantin POPIC

Female·Unknown; coroner could not establish deaths beyond reasonable doubt

This coronial inquest investigated the disappearance of four people from a rural property in Nannup, Western Australia in July 2007: Chantelle McDougall (27), her daughter Leela, Tony Popic (40), and Simon (Gary Felton) …

systemdelaydiazepam
WA2018-05-02

Inquest into the Deaths of Chantelle Jane McDOUGALL, Leela McDOUGALL, Antonio Konstantin POPIC and Gary FELTON

Female·not established beyond reasonable doubt

This finding concerns four missing persons from Nannup, Western Australia (Chantelle McDougall, Leela McDougall, Tony Popic, and Simon/Gary Felton) who disappeared on or around 16 July 2007. While the coroner found reaso…

delaysystemdiazepam
WA2018-05-02

Inquest into the Death of Luke Anthony MURRAY

40y · Male·Drowning in the Indian Ocean

Luke Anthony Murray, a 40-year-old deck hand on the fishing vessel Napoleon, disappeared from the vessel in the early morning of 15 August 2016 while at sea approximately 50 nautical miles south west of Dirk Hartog Islan…

WA2018-04-30

Inquest into the Death of John Robert BORRADAILE

26y · Male·Neck injury from falling glass crate

A 26-year-old labourer died from severe neck trauma when a 1.4-tonne glass crate fell on him during container unloading at a small glass import business. The crate became destabilized while being dragged from a sea conta…

occupational and environmental healthemergency medicinesystemcommunication
WAcommunity2018-03-29

Inquest into the Death of Norman Leslie BALE

53y · Male·immersion (drowning)

Norman Leslie Bale, a 53-year-old experienced fisherman, died by drowning after taking an unseaworthy 12-foot aluminium dinghy with a defective outboard motor onto Nickol Bay near Karratha, Western Australia on 23 Septem…

systemdelay
WAcommunity2018-03-23

Inquest into the Death of Ali Mohammad SOLTANI

30y · Male·Drowning

A 30-year-old male drowned at Salmon Holes, Western Australia after being swept off rocks into the ocean while rock fishing. He was not wearing a life jacket. Although he initially surfaced and attempted to swim back to …

emergency medicineforensic medicinesystem
WAhospital2018-03-22

Inquest into the Death of Steven John COLLOFF

47y · Male·Organ failure following use of synthetic cannabinoids and consequent hyperthermi…

A 47-year-old man died from organ failure following synthetic cannabinoid use and consequent heat stroke. After smoking synthetic cannabinoids (AB-CHMINACA and 5F-AMB), he became confused and dehydrated in a hot environm…

toxicologyintensive careab-chminaca
WAhome2018-03-22

Inquest into the Death of Aileen Helen QUARTERMAINE

60y · Female·effects of fire in a woman with alcohol effect

A 60-year-old woman with chronic paranoid schizophrenia died in a domestic fire on 26 July 2014. The day before, her son sought help from police and mental health services after noticing signs of mental health deteriorat…

psychiatryemergency medicinecommunicationdiagnosticpaliperidone
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