2,612 results
28y · Male·Hanging
Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner foun…
31y · Male·Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a m…
31-year-old Darren Culleton died from hypoxic brain injury after choking on the hood of his coveralls while in police custody. He had presented to St Vincent's Hospital with acute intoxication and self-harm behavior (att…
26y · Female·multiple blunt force injuries from fall from height; significant contributing co…
A 26-year-old woman with severe borderline personality disorder died by suicide following a fall from cliffs. She presented to hospital after a serious suicide attempt earlier the same day. Expert evidence indicates she …
55y · Female·Refractory seizures secondary to Lennox-Gastaut Syndrome (palliated)
Dorothy McIntosh, a 55-year-old woman with Lennox-Gastaut Syndrome and intellectual disability, died from refractory seizures in palliative care. She had experienced significant functional decline over 12 months, includi…
31y · Male·hanging
B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…
55y · Male·cardiac arrest in the setting of methylamphetamine toxicity, with possible serot…
Angelo Gioscio, aged 55, died from cardiac arrest in the setting of methylamphetamine toxicity with possible serotonin syndrome, complicated by pre-existing cardiac and respiratory disease, whilst in police presence. He …
30y · Male·Gunshot wound to the neck and head
Daniel Bolton, aged 30, died from a self-inflicted gunshot wound to the neck and head while attempting to avoid arrest by police. He had a history of drug addiction, mental health issues including depression, anxiety and…
Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…
This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …
86y · Male·carbon monoxide poisoning
An 86-year-old man with recent stroke, declining mental health, and expressed suicidal ideation died by carbon monoxide poisoning. He was assessed in hospital ED, deemed not to meet Mental Health Act criteria, and discha…
15y · Male·Hanging
A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…
55y · Male·ischaemic heart disease
Stefan Wakeman, aged 55, died of ischaemic heart disease while in custody at Metropolitan Remand and Reception Centre on 9 June 2019. Autopsy revealed significant coronary artery narrowing (40-50% to 70-80%) with emphyse…
17y · Male·hydrocarbon toxicity (petrol inhalation)
George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …
30y · Male·ligature compression of the neck (hanging)
Jomen Blanket, a 30-year-old Aboriginal and Torres Strait Islander man, died by suicide in prison on 12 June 2019 after eight months incarcerated for assault. He had a known suicide plan (hanging from his cell door using…
28y · Male·neck compression from hanging
SH, a 28-year-old man, died by hanging in Cessnock Correctional Centre after seven weeks in custody. He was assessed at intake as having no self-harm risk and cleared for normal cell placement. During custody, he became …
27y · Male·Neck compression due to self-inflicted hanging
Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
18y · Male·blunt trauma and drowning
An 18-year-old male with emerging depression died by suicide from the Tasman Bridge. He had presented to his GP in May 2021 with depressive symptoms, received antidepressant medication, and showed improvement by Septembe…
29y · Male·Pulmonary thromboembolism secondary to deep venous thrombosis
A 29-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis (DVT) following a suicide attempt by hanging. He was admitted to ICU and appropriately commenced on prophylactic enoxaparin 40mg dai…
27y · Male·Hanging
Marcus Caldwell, a 27-year-old with well-controlled schizophrenia on clozapine, died by suicide in February 2018. He worked at a pet boarding facility that experienced severe staffing shortages during peak season, result…
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