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VICcommunity2023-10-26

Finding into death of KDR

51y · Male·Neck compression from hanging

A 51-year-old man with depression, a history of suicide attempts, and domestic violence in his relationship died by hanging on 29 January 2021. He had presented to mental health services on two occasions in January 2021 …

psychiatryemergency medicinemidazolam
WAcommunity2023-10-20

Inquest into the Death of Ashley Dean FILDES

34y · Male·gunshot injuries to the torso

Ashley Fildes, a 34-year-old man with schizophrenia, was fatally shot by police on 1 May 2020 after stabbing multiple people at a shopping centre while in acute psychosis. He had been non-compliant with depot antipsychot…

psychiatryemergency medicinepaliperidone depot
VIChome2023-10-17

Finding into death of J H

15y · Male·Electrocution

JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient p…

psychiatrypaediatricssystemcommunicationfluoxetine
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
SAhospital2023-10-12

Coroner's Finding: Philp, Afrika Rose Pearl

17y · Female·multiple injuries

Afrikah Rose Pearl Philp, aged 17, died from multiple injuries sustained in a high-speed vehicle collision on 6 October 2017 while being pursued by police. She had a complex medical history including psychogenic non-epil…

neurosurgerytrauma surgerysystemmethamphetamine
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…

general practicepain medicinemedicationcommunicationtramadol
NSW2023-10-11

Inquest into the death of Steven McHugh

60y · Male·Plastic bag asphyxia

Steven McHugh, a 60-year-old man, died from plastic bag asphyxia in Junee Correctional Centre on 31 March/1 April 2022. He had recently been extradited from Victoria to NSW to face additional charges and was held in prot…

correctional healthpsychiatry
VIChome2023-10-10

Finding into death of Abdurrahman Coskun

53y · Male·Neck compression in the circumstances of hanging

A 53-year-old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed …

psychiatrygeneral practicecommunicationsystemmirtazapine
VIChospital2023-10-05

Finding into death of Ruby-Lee Gold

28y · Female·Multiple injuries sustained in a fall from height

Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was r…

psychiatryemergency medicinesystemdelaydiazepam
ACT2023-10-04

In the matter of three deaths of AFP appointees in the Australian Capital TerritoryInquest into the Death of Richard RobertsInquest into the Death of Samantha BaglinInquest into the Death of Dominic Coleman

Unknown·Self-inflicted gunshot wound; suicide

Three Australian Federal Police (AFP) appointees died by suicide using AFP-issued firearms: Richard Roberts (57, PSO), Samantha Baglin (44), and Dominic Coleman (52, ASO). All three had untreated mental health conditions…

occupational and environmental healthpsychiatrysystemcommunication
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
VIChome2023-10-02

Finding into death of Student KCM

29y · Female·hanging

A 29-year-old international medical graduate student from Bangladesh died by hanging in July 2020. She was studying a Master of Public Health at Deakin University but had failed multiple units and was struggling academic…

public healthpsychiatrysystem
VIChome2023-10-02

Finding into death of Student FSB

35y · Male·Multiple injuries sustained in a fall from a height

A 35-year-old international student from Taiwan died by suicide via fall from an 18-storey apartment building. He had prior diagnoses of anxiety disorder, psychotic disorder, and adjustment disorder documented in Taiwan …

psychiatrysystemcommunicationsertraline
VIChome2023-10-02

Finding into death of Student XRG

22y · Male·Neck compression by ligature suspension (hanging)

A 22-year-old international student from India died by hanging at his home in Victoria. He was studying information technology at Monash University after experiencing academic difficulties, having failed multiple subject…

psychiatrypsychologysystem
VIChome2023-10-02

Finding into death of Student AHT

24y · Male·injuries sustained in a fall from a 15th floor apartment

A 24-year-old international student from China died by suicide, falling from the 15th floor of his apartment building. He was socially isolated in Melbourne, withdrew from activities he enjoyed in China, and experienced …

public healthpsychiatrysystem
TAShome2023-10-01

Coroner's Finding: Czerniejewski, Roswitha

66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet

A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumonitis. She had progressive immobility, lived on a couc…

general practicerheumatologysystem
VICcommunity2023-09-27

Finding into death of Ryan Govind Chisholm

20y · Male·Mixed drug toxicity (ethanol, cocaine, etizolam, diazepam, nordiazepam and oxyco…

Ryan Chisholm, a 20-year-old with a history of substance abuse and mental health concerns including anxiety and depression, died from mixed drug toxicity after consuming ethanol, cocaine, etizolam (a novel psychoactive s…

toxicologygeneral practicealcohol
NSWhome2023-09-25

Inquest into the death of Wayne Mullin

64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…

Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…

general practicerespiratory medicinemedicationcommunicationoxycodone
SAmental health2023-09-20

Coroner's Finding: Chessell, David Edward

43y · Male·compression of the neck due to hanging

A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide ex…

psychiatryemergency medicinesystemcommunicationmirtazapine
QLD2023-09-19

AJO - findings

34y · Male·Hanging

A 34-year-old remand prisoner died by hanging in his cell at Arthur Gorrie Correctional Centre. He had a history of child sexual offences and mental health issues including depression and past self-harm. Initial risk ass…

psychiatrycorrectional healthcannabis

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