50 results for “family violence exposure”
4y · Female·closed head injury with contributing extensive subcutaneous and intramuscular ha…
…ularly section 20(2) regarding mandatory drug assessments), failure to utilise available protective tools (family care meetings, investigation and assessment orders), inadequate investigation of 22 notifications, misinte…
40y · Male·hypothermia
…ghted systemic failures in the missing persons investigation, inadequate communication with the Aboriginal family, and delays in coronial processes. The case underscores the need for culturally sensitive protocols when i…
0y · Female·Sudden infant death whilst bed-sharing with risk factors including unsafe sleepi…
…y revealed no obvious cause, but documented face-down positioning, respiratory infection, passive smoking exposure, and unsafe sleep environment. Critical failures by Child Safety Services included: premature closure of …
Male·Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposure in cont…
… on the Anangu Pitjantjatjara Lands between May 2003 and March 2004. Three deaths were by hanging, one by exposure. All deaths involved petrol sniffing as a contributing factor or context, except Kunmanara Ryan. Key syst…
Troy Thomas Lee: acute neck compression due to hanging; Scott Leslie Matthews: m…
Two men died by suicide while on home detention bail awaiting trial. Troy Thomas Lee (38, hanging) and Scott Leslie Matthews (23, mixed drug toxicity from tramadol and alprazolam overdose) both died on their parents' pre…
9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…
Bradyn Dillon, aged 9, was brutally beaten to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him …
39y · Female·Gunshot wound to the head
A 39-year-old woman with brief psychotic disorder experiencing suicidal and homicidal ideation killed her 4-year-old daughter and herself. She had been diagnosed with psychosis in 2015, treated with olanzapine, and disch…
77y · Female·hypothermia from environmental cold exposure with contributing factors of advanc…
Mrs Janet Mackozdi, aged 77, died from hypothermia in an uninsulated shipping container at Mount Lloyd, Tasmania, on 23-24 July 2010. She had advanced Alzheimer's dementia and required 24-hour care. The coroner found her…
40y · Male·Gunshot wound to the head, self-inflicted
…uts, which generated sensational media coverage describing him as 'Mad Dog'. The coroner found this media exposure significantly distressed Tony and likely contributed to his refusal to surrender. During the siege, polic…
suicide by hanging or other means
Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…
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