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NSW2021-10-12

Inquest into the death of Donald GREENAWAY

88y · Male·Metastatic prostate carcinoma

Donald Victor Greenaway, an 88-year-old man serving a 21-year prison sentence, died from metastatic prostate carcinoma in the Aged Care Ward at Long Bay Correctional Centre. He had been diagnosed with stage IV prostate c…

oncologyradiation oncologyandrogen deprivation therapy
NSWhospital2021-10-12

Inquest into the death of Bruce HODGES

78y · Male·cardiorespiratory failure due to complications of tracheal stenosis

Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…

emergency medicineENT surgerydiagnosticsystemnebulised saline
NSWhospital2021-10-05

Inquest into the death of Timothy MOFFATT

72y · Male·metastatic prostate carcinoma

Timothy Moffatt, a 72-year-old man in prison custody, died from metastatic prostate cancer. He had declined cancer treatment from 2014-2018 but agreed to chemotherapy after metastatic disease was identified. He also had …

oncologynephrologychemotherapy
NSWhospital2021-09-28

Inquest into the death of Gwenith ELKINGTON

60y · Female·acute cerebral bleed resulting from blunt trauma and late haemorrhagic progressi…

Gwenith Elkington, aged 60, died from acute cerebral bleed resulting from haemorrhagic progression of a traumatic brain injury sustained in a bathroom fall on 21 September 2015. The injury caused a contre coup contusion …

emergency medicineneurosurgerydelaycommunicationibuprofen
NSWcommunity2021-09-23

Inquest into the death of M F

46y · Male·blunt force injuries from motor vehicle collision with a tree

A 46-year-old Aboriginal man died by suicide following a motor vehicle collision with a tree while being pursued by police responding to a welfare check. He had a complex history of depression, amphetamine addiction (ice…

general practicepsychiatrysystemdelayamphetamine
NSWaged care2021-09-22

Inquest into the death of Vakabauta LEONE

47y · Female·complications of rapidly progressing motor neurone disease

A 47-year-old woman with motor neurone disease died from respiratory complications while in immigration detention, residing in aged care. She collapsed at 1:00am with respiratory distress. Nursing staff did not attempt C…

palliative careemergency medicinecommunicationdelay
NSWcommunity2021-08-23

Inquest into the death of Benjamin COLLIER

35y · Male·head and chest injuries as a result of a collision while riding a motorcycle

Benjamin Jake Collier, aged 35, died from head and chest injuries sustained in a high-speed motorcycle collision with a light pole on 8 January 2020 in Newcastle, NSW. The collision occurred shortly after a brief police …

forensic medicine
NSWcommunity2021-08-18

Inquest into the death of A F

24y · Male·multiple stab wounds to the chest that he inflicted upon himself

A 24-year-old man with diagnosed schizophrenia experienced a relapse and engaged in a dangerous spree involving vehicle theft, assault, and police pursuit. Despite psychiatric treatment with antipsychotics, he stopped me…

psychiatrygeneral practicesystemcommunicationlurasidone
NSWcommunity2021-07-30

Inquest into the death of A J

36y · Male·multiple injuries consistent with a fall from a height

A 36-year-old man with severe depression, social isolation, and recent life crises (job loss, marital breakdown, reduced child contact) posted suicidal messages on social media and stood on a cliff ledge. Police negotiat…

psychiatrycorrectional healthcommunicationdelaysertraline
NSW2021-07-15

Findings into the death of MH

22y · Male·Hanging

A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hospital to police custody follow…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

56-year-old woman died from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health issues, depression, substance use, and prior self-harm. She had recently obtain…

psychiatrypsychologysystemproceduralpentobarbitone
NSWhospital2021-06-24

Inquest into the death of William BERGER

74y · Male·Acute exacerbation of chronic airways disease, with carcinoma of prostate being …

William Berger, a 74-year-old man serving a life sentence for murder, died from acute exacerbation of chronic obstructive pulmonary disease (COPD) with metastatic prostate cancer as a significant contributing condition. …

respiratory medicineemergency medicinesalbutamol
NSWaged care2021-06-23

Inquest into the death of Victor Madeley

85y · Male·Diabetes mellitus and its complications

Victor Madeley, aged 85, died in custody at Long Bay Correctional Centre's aged care unit on 5 February 2020 from diabetes mellitus and its complications. He had extensive comorbidities including COPD, ischaemic heart di…

general medicinegeriatric medicine
NSWaged care2021-06-23

Inquest into the death of David Grahame Jones

88y · Male·General frailty and inanition; antecedent conditions: chronic cardiac and renal …

David Grahame Jones, aged 88, died in custody at Kevin Waller Aged Care Unit, Long Bay Correctional Centre from general frailty and inanition due to chronic cardiac and renal failure and diabetes. The coroner found he re…

geriatric medicinepalliative care
NSW2021-06-22

Inquest into the death of Mazam BASSAL

44y · Male·gunshot wound to the chest

Mazam Bassal, aged 44, was fatally shot during a workplace dispute at a signage manufacturing factory in NSW. The shooting occurred after escalating tensions over a commercial project. A known person discharged approxima…

NSWhome2021-06-18

Inquest into the death of Julian HORNE

47y · Male·acute alcohol intoxication

Julian Horne, 47, died from acute alcohol intoxication at home after 11 hospital admissions in 6 weeks during a severe binge relapse. He had lifelong struggles with alcohol, depression and anxiety, previously tried multi…

emergency medicineaddiction medicinesystemcommunicationalcohol
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicid…

psychiatryemergency medicinecommunicationsystemaripiprazole
NSW2021-06-11

Inquest into the death of Lester Collins (a pseudonym)

51y · Male·Gunshot wound to the head

A 51-year-old man with a history of domestic violence died by suicide during a police vehicle stop. After breaching an AVO against his former partner, he violently assaulted her with a knife and then obtained a firearm f…

communicationsystem
NSWprison2021-06-11

Inquest into the death of F

49y · Male·hanging

A 49-year-old man with severe schizoaffective disorder died by hanging in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attem…

psychiatrycorrectional healthcommunicationsystemolanzapine
NSWcommunity2021-06-08

Inquest into the death of Zhong Liu

54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…

54-year-old man with schizophrenia died after acute mental health crisis during police response. Contributing factors included: arrhythmogenic cardiomyopathy (undetected cardiac condition); combined doxepin and venlafaxi…

psychiatrygeneral practicemedicationcommunicationdoxepin
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