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NSW2014-05-21

Inquest into the death of GB

38y · Male·asphyxiation due to hanging

A 38-year-old remand prisoner with a long history of drug dependency died by asphyxiation from hanging in his cell at a metropolitan remand centre in September 2011. He had been assessed multiple times by the Risk Interv…

psychiatryaddiction medicineproceduralmethamphetamine
VIChospital2014-05-20

Finding into death of Edward Tappe

58y · Male·Metastatic colorectal cancer

Edward Tappe, a 58-year-old male prisoner with metastatic colorectal cancer, died in St Augustine's Ward at St Vincent's Hospital in May 2013. He was diagnosed with colorectal cancer in July 2011, underwent hemicolectomy…

oncologypalliative carechemotherapy
VIChospital2014-05-01

Finding into death of Bassillios Byron Pantazis

68y · Male·Metastatic gastro-oesophageal adenocarcinoma

Bassillios Byron Pantazis, a 68-year-old man in custody at Port Phillip Prison, died from metastatic gastro-oesophageal adenocarcinoma. He had multiple comorbidities including ischaemic heart disease, diabetes, and chron…

oncologypalliative care
VIChome2014-04-30

Finding into death of Nathan Troy Chalkley

27y · Male·Toxicity to heroin

Nathan Chalkley, 27, died from heroin toxicity on 27 January 2007. He was released from Barwon Prison in October 2006 on parole after serving time for criminal offences. Despite engagement with corrections, a psychiatris…

psychiatryforensic medicinesystemheroin
SAhospital2014-04-17

Coroner's Finding: TABB Charles Andrew

50y · Male·multi-organ failure due to pancreatitis and generalised varicella zoster virus i…

Charles Andrew Tabb, a 50-year-old prisoner with non-Hodgkin's lymphoma (diagnosed 13 years prior, treated with bone marrow transplants), died of multi-organ failure from pancreatitis and disseminated varicella zoster vi…

haematologyinfectious diseases
VICprison2014-04-17

Finding into death of Darren John Parkes

29y · Male·stab wound to the chest

Darren Parkes, a 29-year-old remanded prisoner at Port Phillip Prison, was fatally stabbed by another inmate in March 2006. Prior to his death, Parkes had communicated realistic, reality-based fears for his safety to mul…

psychiatryemergency medicinecommunicationsystem
VICcommunity2014-04-07

Finding into death of Kirk Ardern

32y · Male·Multiple drug toxicity (including heroin)

Kirk Steven Ardern, a 32-year-old male with a long history of opioid dependence and substance abuse, died from multiple drug toxicity (including heroin) three days after release from prison. Two critical clinical failure…

general practiceaddiction medicinemedicationcommunicationheroin
VIC2014-03-21

Finding into death of Robert Theodore Stewart

59y · Male·Disseminated carcinoma (metastatic adenocarcinoma of unknown primary origin)

Robert Theodore Stewart was a 59-year-old man with metastatic carcinoma of unknown primary origin who died in custody at Port Phillip Prison on 19 December 2013. He had been incarcerated since 2008 and diagnosed with dis…

oncologypalliative care
VIC2014-03-18

Finding into death of Stephen Arthur Niit

45y · Male·Hanging

Stephen Arthur Nit, a 45-year-old paramedic with a history of alcoholism, was placed in police custody in intoxicated state after a family dispute. Despite expressing suicidal ideation to mental health staff and police, …

psychiatryemergency medicinecommunicationsystemalcohol
NSW2014-02-17

Inquest into the death of Patrick HUDD

75y · Male·Metastatic lung cancer

Patrick Hudd, a 75-year-old prisoner serving a 27-year sentence, died of metastatic lung cancer at Long Bay Correctional Centre. He was diagnosed with advanced lung cancer in 2012, received two courses of chemotherapy at…

oncologypalliative careoxycodone
NThospital2014-02-13

Inquest into the death of Peter Clarke

55y · Male·bronchopneumonia complicating metastatic carcinoma of the right lung, with emphy…

Peter Alexander Clarke, a 55-year-old Aboriginal man and serving prisoner, died of bronchopneumonia complicating metastatic lung carcinoma with emphysema, coronary atherosclerosis and chronic pancreatitis. He presented t…

emergency medicineintensive carediagnostic
QLDprison2014-01-24

Lingwood, Craig Steven

45y · Male·metastatic malignant melanoma

Craig Lingwood, a 45-year-old prisoner, died from metastatic melanoma in May 2011. He first complained of a suspicious mole (red, itchy, bleeding) in 2005-2006, but the prison doctor (Dr C.) assessed it as benign in Augu…

dermatologygeneral practicediagnosticsystem
VICprison2014-01-24

Finding into death of Adam Sasha Omerovic

40y · Male·Ligature compression of the neck in circumstances of being hanged

Adam Omerovic, a 40-year-old man with a long history of depression, substance abuse, and prior suicide attempts, died by hanging in a Melbourne Assessment Prison cell on 23 March 2010. He had been remanded on armed robbe…

psychiatrycorrectional healthdiagnosticsystemescitalopram
WAprison10July 2014

Inquest into the Death of Michael John KING

48y · Male·Ischaemic Heart Disease in association with Coronary Arteriosclerosis

A 48-year-old Aboriginal man died of ischaemic heart disease with coronary arteriosclerosis while in prison custody. He had significant pre-existing cardiac disease and was diagnosed with myocardial infarction in 1998, y…

cardiologypsychiatrycardiac medications
WAprison- 31 January 2014

Inquest into the Death of Amy TINKER

33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…

Amy Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with…

general practicehepatologycommunicationsystem
WA- 23 May 2014

Inquest into the Death of Ayumi KIMOTO

32y · Male·ligature compression of the neck (hanging)

A 32-year-old Japanese-American freelance photographer died by hanging in prison custody while remanded for importing prohibited material. He was comprehensively assessed on admission by experienced prison reception and …

correctional healthpsychiatry
WAprison- 20 March 2014

Inquest into the Death of Anthony Nigel AXTELL

38y · Male·Heart failure in a man with dilated cardiomyopathy and focal severe coronary art…

Anthony Axtell, a 38-year-old man with severe dilated cardiomyopathy from amphetamine use, died of heart failure while in prison custody. Initially treated successfully in 2002 with recovery to normal cardiac function by…

cardiologycardiothoracic surgerymedicationsystemamphetamine
WA- 12 September 2014

Inquest into the Death of Peter Philip HUMES

38y · Male·Ligature compression of the neck (hanging)

Peter Philip Humes, a 38-year-old Aboriginal man, died by suicide by hanging in Hakea Prison while on remand. He was assessed by prison officer Trevena and nurse Lee on admission using the MR011 'At-Risk' checklist and d…

general practicecorrectional healthsystemdelaymirtazapine
VIC2013-12-31

Finding into death of Wayne Joannou

26y · Male·Gunshot wound to head

Wayne Joannou, 26, died from a gunshot wound to the head on 18 February 2005 when the Special Operations Group attempted his arrest. He was a known violent offender with a 10-year criminal history and substance abuse iss…

addiction medicinepsychiatrysystemcommunicationheroin
VIChospital2013-12-19

Williamernestjolly 486312pdf

66y · Male·End stage chronic obstructive pulmonary disease

William Ernest Jolly, 66, died from end-stage COPD at Austin Hospital on 16 November 2012. He was serving a life sentence for murder, housed at Thomas Embling Hospital as a security patient with paranoid schizophrenia an…

respiratory medicinepsychiatry
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