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NSW2021-03-11

Inquest into the death of Nathan REYNOLDS

36y · Male·bronchial asthma

Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…

respiratory medicineemergency medicinediagnosticsystemsalbutamol
NSWhome2021-03-10

Inquest into the death of Z

2y · Male·traumatic head injury

A 2-year-7-month-old boy died from traumatic head injury inflicted by person(s) unknown after experiencing severe and escalating physical abuse over weeks. Despite 13 reports to FACS (now DCJ) between 2010-2012, includin…

paediatricsemergency medicinediagnosticcommunication
NSW2021-03-10

Inquest into the death of Michael FARRELL

This is a procedural judgment addressing the NSW Police Commissioner's Public Interest Immunity and protective order claims regarding disclosure of the Safe Driving Policy during the inquest into Michael Farrell's death.…

NSWcommunity2021-03-10

Inquest into the death of Tyrone ADAMS

Male

This judgment concerns procedural disclosure orders in the inquest into Tyrone Adams' death, not substantive coronial findings. Tyrone Adams died following a police pursuit of his vehicle. The coroner's decision addresse…

NSW2021-03-09

Inquest into the death of Robert MAXFIELD

45y · Male·multiple drug toxicity

Robert Maxfield, a 45-year-old inmate at Cooma Correctional Centre, died from multiple drug toxicity involving methadone and mirtazapine. He had a history of drug dependence and mental health conditions (schizophrenia, d…

forensic medicinepsychiatrymethadone
NSWPodcast2021-03-05

Inquest into the death of Nathan Macri

37y · Male·Combined effects of positional asphyxiation and multiple injuries

Nathan Macri, aged 37, died at Sydenham railway station after intoxication led to accidental collision with an incoming train at 11:06 pm. He became wedged between the train and platform, suffering positional asphyxiatio…

NSW2021-02-19

Inquest into the death of Dimitrios MAVRIS

48y · Male·hanging

Dimitrios Mavris, a 48-year-old man arrested for drug importation, died by hanging in the Surry Hills Cells Complex on 25 May 2018, approximately 40 hours after being taken into custody. He was initially assessed as pres…

correctional healthpsychiatrysystemcommunication
NSWcommunity2021-02-18

Inquest into the death of Dyllan KETTULE

19y · Male·gunshot wounds to the trunk

Dyllan Kettule, a 19-year-old, was fatally shot by unknown assailants outside his girlfriend's home in Canley Vale on 26 January 2014. Two gunshot wounds to the chest caused massive blood loss and death. This appears to …

cannabis
NSW2021-02-16

Inquest into the death of Ivan MILAT

74y · Male·metastatic gastro-oesophageal adenocarcinoma

Ivan Milat, aged 74, died of metastatic gastro-oesophageal adenocarcinoma whilst in lawful custody at Long Bay Correctional Centre. He presented with gastrointestinal symptoms from October 2018, was initially treated for…

gastroenterologyoncologycommunication
NSWhospital2021-02-08

Inquest into the death of Simone O'Donnell

24y · Female·Cardiac conducting system disease leading to asystole against a background of a …

A 24-year-old woman with complex congenital cardiac disease, cerebral palsy, and hydrocephalus was admitted to a secondary hospital with a respiratory tract infection and bradycardia with left bundle branch block. She de…

cardiologyemergency medicinesystemcommunicationoxycodone
NSWcommunity2021-01-29

Inquest into the death of Deborah Spencer

56y · Female·Blunt head injury, with hyoid bone fracture being a significant condition contri…

Deborah Spencer, a 56-year-old woman with a history of heavy alcohol use and previous falls, died from blunt head injury with hyoid bone fracture. She was found unconscious near Lemongrove Bridge in Penrith on 22 May 201…

emergency medicineintensive care
NSWcommunity2021-01-20

Inquest into the death of Jaland Small

17y · Male·Head injuries from severe blunt force trauma sustained when a motor vehicle coll…

Jaland Small, 17 years old, died from head injuries sustained when the car in which he was a passenger collided with a tree on Cedar Party Road near Taree. The vehicle was being driven by an intoxicated driver (alcohol l…

alcohol
NSWhome2020-12-24

Inquest into the death of Peter ALLEN

43y · Male·Undetermined — available evidence does not allow determination due to limitation…

Peter Allen died in a house fire on 26 November 2000 at Lismore, NSW. Due to significant deficiencies in the postmortem examination and fire investigation, the coroner could not determine the cause or manner of death. Th…

forensic medicinepathologydiagnosticproceduralalcohol
NSWPodcast2020-12-18

GORE Bernard - Findings

Male·The available evidence does not allow for any finding to be made as to the cause…

Bernard Gore, a man with Alzheimer's dementia, entered a fire stairwell at Westfield Bondi Junction shopping center in Sydney on 6 January 2017 and became trapped. He likely died within 24-48 hours from cardiac complicat…

systemcommunication
NSW2020-12-11

Inquest into the death of SB -findings - 11 December 2020

38y · Male·asphyxiation by ligature

A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotic…

psychiatrypsychologycommunicationsystemmirtazapine
NSWhome2020-12-11

Inquest into the death of X Y

45y · Male·Shotgun wound to the head

XY, a 45-year-old Aboriginal man, died from a self-inflicted gunshot wound during a police response to a domestic violence incident. He had been struggling with depression, grief, alcohol and methamphetamine use for year…

emergency medicinepsychiatrysystemdelaymethamphetamine
NSWcommunity2020-12-11

Inquest into the death of John FLAMISH

65y · Male·combined effects of smoke inhalation, burns and ischaemic heart disease

John Flamish, 65, died on 5 June 2017 from smoke inhalation, burns and ischaemic heart disease following a deliberately lit fire in the carpark of public housing at 22-24 Early Street, Parramatta. The fire was set in a p…

systemprocedural
NSWhospital2020-12-10

Inquest into the death of Richard Willett

86y · Male·Complication of metastatic colorectal adenocarcinoma

Richard Willett, 86-year-old prisoner, died from complications of metastatic colorectal adenocarcinoma while in NSW Corrective Services custody. He was diagnosed with advanced colon cancer with liver and lymph node metas…

oncologypalliative carechemotherapy
NSW2020-12-03

Inquest into the death of George CAMERON

81y · Male·plastic bag asphyxia

George Cameron, an 81-year-old man, died by asphyxiation using a plastic bag while in custody at Parklea Correctional Centre on 8 September 2017. He had been remanded in custody three days earlier after arrest. A Recepti…

psychiatryemergency medicinesystemdelay
NSWcommunity2020-12-02

Inquest into the suspected death of missing person Jasmine MORRIS

19y · Female·Unknown – not determined

Jasmine Morris was a 19-year-old Aboriginal woman last seen alive on 6 October 2009 in Grafton, NSW. She was reported missing on 20 October 2009 after a two-week absence. Despite extensive police investigation, her body …

systemdelaycannabis
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