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NTcommunity1991-06-03

Inquest into the death of Ganamu Garrawurra

48y · Male·shotgun wound to the head

A 48-year-old Yolngu man with chronic mental illness (schizophrenia) died from a shotgun wound to the head on Elcho Island, NT in April 1990. After spearing two people with a fishing spear, police Task Force was called t…

psychiatryforensic medicinesystemcommunicationmelleril
ACThospital1989-12-22

Inquest Into The Circumstances Surrounding The Death Of Alex Nicholas Mersiades

3y · Male·cerebral oedema which caused coning at the base of the brain, caused by post-ope…

A 3-year-old boy died from cerebral oedema caused by post-operative hyponatraemia following scoliosis correction surgery. The operation was successful, but severe hyponatraemia developed in the early hours of 24 April 19…

surgeryanaesthesiadiagnosticdelay
NSW1980-12-19

Inquest into the deaths from the Appin Mine Disaster

Unknown·Explosion injuries and carbon monoxide poisoning from methane gas ignition in un…

On 24 July 1979, an explosion in Appin Colliery (NSW) killed 14 miners. The coroner determined the explosion resulted from ignition of methane gas in an unventilated B heading stub during a planned ventilation system cha…

communicationsystem
NSW1979-09-03

Inquiry into the fire and deaths at Luna Park

Unknown·Carbon monoxide poisoning and burns (or burns only in one case), accidentally su…

Seven children and teenagers died in the Luna Park Ghost Train fire on 9 June 1979 when the timber-framed building became engulfed in dense smoke and flames. The fire likely originated from a carelessly discarded cigaret…

systemdelay
WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…

psychiatryemergency medicinecommunicationsystemmethadone
WAprison

Inquest into the Death of Ian HEAD

74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …

Ian Head, a 74-year-old man with chronic obstructive pulmonary disease, hypertension, and chronic kidney disease, died from cardiac arrhythmia following COVID-19 infection while imprisoned at Acacia Prison. He had receiv…

general practiceemergency medicinecommunicationsystemparacetamol
WA

Inquest into the Death of Stanley John INMAN

19y · Male·complications of ligature compression of the neck

Stanley John Inman, 19-year-old Aboriginal male, died by suicide at St John of God Midland Hospital on 13 July 2020, two days after ligature compression of the neck at Acacia Prison. He was on low-level ARMS (at-risk man…

psychiatrypsychologycommunicationsystemmirtazapine
WAhome

Inquest into the Death of Baby AM

0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture

Baby AM died from severe hypoxic ischaemic encephalopathy secondary to uterine rupture during a planned home vaginal birth after caesarean (VBAC). The mother, Ms M, was 40 weeks and 5 days pregnant, attended by a private…

obstetricsmidwiferydiagnosticcommunication
WAcommunity

Inquest into the Death of Kim Martin FRANKER

36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…

A 36-year-old man with schizoaffective disorder, substance abuse issues, and undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescribed by his GP for tardive dyskinesia), amphetamine-type stimulants,…

psychiatrygeneral practicecommunicationsystembenzhexol
WAmental health

Inquest into the Death of David GRIEVE

45y · Male·Coronary Atherosclerosis

David Grieve, a 45-year-old man with chronic schizophrenia and multiple cardiac risk factors (hypertension, diabetes, obesity, smoking), died of coronary atherosclerosis while an involuntary psychiatric patient at Grayla…

psychiatrycardiologysystemcommunicationhaloperidol
WA

Inquest into the Death of Jarrod Arthur HAMPTON

22y · Male·drowning secondary to incapacitation from air embolism

A 22-year-old skilled and experienced pearl shell drift diver with over 600 logged dives died from drowning secondary to air embolism and cerebral arterial gas embolism while diving for Paspaley Pearling Company off Broo…

diving medicineoccupational and environmental healthsystemdelay
WAcommunity

Inquest into the Death of Radwan KANAWATI

41y · Male·atropine toxicity

A 41-year-old man with schizoaffective disorder, intellectual disability and sexual offending history died from atropine toxicity after ingesting 6-8ml of atropine liquid prescribed for hyper-salivation. He had been disc…

psychiatrycommunicationsystematropine
WAcommunity

Inquest into the Death of Gary John LYDDIETH

54y · Male·Unknown - death established on balance of probabilities but manner and cause und…

A 54-year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prio…

psychiatrygeneral medicinesystemcommunication
WAhome

Inquest into the death of Nicole Emily BICKNELL

18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration

An 18-year-old female, a naive drinker, consumed approximately 19-21 standard drinks over a few hours at her birthday party, including vodka cruisers, a full-strength Midori drinking game, and Polmos (95% alcohol). She r…

toxicologyemergency medicinedelaysystemalcohol
WAhome

Inquest into the Death of Satwant KAUR

57y · Female·Multiple penetrating (stab) injuries to the body and neck

Satwant Kaur, aged 57, was murdered by her stepson in her home on 5 December 2013 after he made multiple threats to kill her while in custody. Critical failures in intelligence sharing between the Department of Correctiv…

communicationsystemmethamphetamine
WAhome

Inquest into the Death of Anthony William KUSTER

44y · Male·Ligature compression of the neck and methylamphetamine effect

Anthony William Kuster, a 44-year-old man, died from ligature compression of the neck combined with methylamphetamine toxicity. He applied a tourniquet around his neck while heavily intoxicated with methylamphetamine aft…

toxicologyforensic medicinedelaymethamphetamine
WAhospital

Inquest into the Death of June Valerie LOBBAN

69y · Female·Intra-abdominal sepsis and shock with multi-organ failure following intestinal p…

A 69-year-old woman died from intra-abdominal sepsis and multi-organ failure following a perforated caecum that occurred after lumbar spine surgery. Post-operatively, she developed abdominal distension and pain initially…

neurosurgerygeneral surgerydiagnosticdelayfentanyl
WA

Inquest into the Death of Damien Mark MILLS

35y · Male·drowning (immersion)

Damien Mills, a 35-year-old mortgage broker, drowned in the Indian Ocean after falling off a charter boat returning from Rottnest Island on 31 October 2014. While intoxicated, he was likely knocked overboard during rough…

systemcommunication
WAhome

Inquest into the death of Christine TURVILLE (aka NICHOLLS)

56y · Female·Bronchial asthma and emphysema

A 56-year-old woman with long-standing schizophrenia, COPD, emphysema, and heavy smoking died during overnight leave from psychiatric hospitalisation. She was granted leave to check on her cat at her remote home on 24 Ma…

psychiatryrespiratory medicinedelaysystemolanzapine
WAhospital

Inquest into the death of Amanda Dana TAUAI

21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)

Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote …

general practiceemergency medicinediagnosticcommunicationmetoclopramide

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