873 results
25y · Male·ligature compression of the neck (hanging)
A 25-year-old man with dexamphetamine-induced psychosis died by suicide while an involuntary psychiatric patient. He was transferred from a locked to an open ward on 19 April 2013 after appearing to improve clinically. H…
53y · Male·ligature compression of the neck (hanging)
John Stephen Passmore, a 53-year-old man with severe treatment-resistant paranoid schizophrenia, died by suicide while on community leave from psychiatric hospital. He had been an involuntary patient at Graylands Hospita…
44y · Male·Combined drug effect (oxycodone and benzodiazepines)
A 44-year-old man with a history of heroin addiction registered as a drug addict in 2010 died from combined drug effect involving oxycodone and benzodiazepines. Despite being a registered drug addict, he obtained prescri…
26y · Male·Multiple drug toxicity and bronchopneumonia
Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet ev…
22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…
Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan). He manipulated multiple GPs by misreprese…
51y · Female·Ischaemic heart disease
Pauline Margaret Dodd, 51, died of ischaemic heart disease at Sir Charles Gairdner Hospital on 4 March 2014. She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childh…
Male·Mr Maarif: immersion (drowning); Mr Khamis: unascertained (immersion or injury f…
Two men died during a snorkelling and spearfishing outing at Ethel Beach, Christmas Island on 7 April 2013. Zainul Maarif, a non-strong swimmer, drowned after the group underestimated dangerous sea conditions including s…
20y · Male·head injury
A 20-year-old male died from head injury when the car he was a passenger in crashed into a power pole during a police pursuit. The driver, intoxicated with a blood alcohol level of 0.247%, panicked when police activated …
64y · Female·multiple injuries sustained in head-on motor vehicle collision
A 64-year-old remote area nurse died in a head-on vehicle collision on a remote unsealed road whilst transporting a critically ill patient to hospital for emergency care. The coroner found that the primary cause was driv…
Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…
Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…
Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…
Five psychiatric patients from Alma Street Centre (Fremantle Hospital) died by suicide within 12 months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health ser…
Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…
Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…
Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…
Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…
Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…
Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…
Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…
Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…
39y · Male·Drowning
KHOR Foo Kun, a 39-year-old Malaysian national, was swept into the ocean on 12 June 2013 while fishing from a rock ledge north of the Quobba blow holes near Carnarvon, Western Australia. An unusually large wave washed hi…
48y · Female·Head injury
Frances May Cooper, a 48-year-old woman with chronic paranoid schizophrenia, died from head injuries after being struck by a train on 30 October 2011 while on unescorted leave from the mental health unit at Kalgoorlie Re…
Female·Multiple injuries
Yvonne Henderson was a middle-aged woman with chronic delusional disorder who died in a motor vehicle collision on 6 December 2010 while on approved leave from psychiatric hospitalisation. She was an involuntary patient …
68y · Male·Immersion (drowning), or alternatively injury sustained on rocks; cause of death…
Jan Zapotocky, a 68-year-old man, went fishing at Canal Rocks, Yallingup on 21 March 2014 and was washed into the ocean. His car was found in the car park five days later with fishing equipment inside. Expert opinion ind…
65y · Female·Early bronchopneumonia and hypoxic brain injury following aspiration of food (ch…
Anna Maria Cameron, a 65-year-old woman with treatment-resistant schizophrenia, died from aspiration choking while eating on a psychiatric ward. She had been recently transferred to a rehabilitation unit for reassessment…
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