24y · Male·hanging
Alexander Varcoe, a 24-year-old Aboriginal man, died by hanging in Yatala Labour Prison while on remand awaiting trial for serious charges. He had a complex history including prior self-harm in 1995-96, alleged prison ra…
29y · Female·Exsanguination caused by a single stab wound to left lung
Jenny Lee Cook, age 29, died from a stab wound to the chest on 19 January 2009. Police concluded suicide within 20 hours but the investigation was fundamentally inadequate. Critical evidence was not obtained: Mr Cook's m…
45y · Male·exsanguination due to incised wound to neck
Lawrence McCarty, a 45-year-old man in custody on remand, died by suicide in prison on 30 April 2011 by slashing his neck with a dismantled razor blade. Clinical lessons include: (1) reception staff failed to adequately …
37y · Male·multiple gunshot wounds
Brett Walker, 37, was shot by police on 9 July 2022 after a domestic violence incident 23 days post-release from prison. He had long-standing drug addiction and mental health issues including paranoid ideation, particula…
27y · Male·hanging
Dalvir Singh, a 27-year-old Indian national, died by hanging in immigration detention on 13 February 2014. He had attempted suicide in police custody 16 days earlier but this critical information failed to reach detentio…
17y · Female·Hanging
Charli Powell, 17, died by hanging at Freebody Oval on 11 February 2019 during an abusive relationship with Rohan Rosewarne. The coroner found her death was intentionally self-inflicted but occurred in the context of sig…
31y · Female·mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam)
A 31-year-old woman with extensive history of deliberate self-harm and prescription drug abuse died from mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam). She presented to the emergency department with a r…
Male·Gunshot wound to the head
GH, an Iranian national on a permanent protection visa, died from a self-inflicted gunshot wound at a shooting range during an unlicensed 'try shooting' session. He had documented suicidal ideation for years and attempte…
34y · Female·Combined drug toxicity (propofol, sevoflurane and others)
A 34-year-old anaesthetist at Royal Melbourne Hospital died from combined drug toxicity involving propofol and sevoflurane—anaesthetic agents she accessed from unlocked theatre trolleys and administered to herself at hom…
26y · Female·Pentobarbitone toxicity
PA, a 26-year-old veterinary nurse, died by suicide on 12 September 2021 using pentobarbitone accessed from her workplace. She had a history of depression and anxiety managed by her GP with antidepressants, but had becom…
20y · Male·Ligature compression of the neck (hanging)
Leon John Donaldson, a 20-year-old sentenced prisoner with a documented history of self-harm, depression, and suicidal ideation, died by hanging in his cell at Casuarina Prison on 2 September 2004. He had been identified…
47y · Female·ligature compression of the neck (hanging)
A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…
22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)
A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block, they wer…
36y · Male·Ligature compression of the neck (suicide by hanging)
A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…
34y · Male·asphyxiation by hanging
A 34-year-old Aboriginal male died by suicide while on remand in prison. Despite a history of suicide attempts in 2004-2005, reception screening failed to identify suicide risk, partly because electronic alerts were not …
31y · Male·hanging
Mr Gavin Ellis, 31 years old, died by hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm h…
22y · Male·Hanging
A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hospital to police custody follow…
42y · Male·Incised injury to the neck resulting in exsanguination and air embolism
Naser Vukovic, a 42-year-old prisoner with severe psychotic symptoms and dual P1/S3 risk ratings, died by self-inflicted neck laceration in Melbourne Assessment Prison on 8 June 2016. Despite two prior self-harm incident…
45y · Male·gunshot wound to the chest with associated significant blood loss
Stanley Russell, a 45-year-old Aboriginal man with mild intellectual disability, was shot dead by NSW police executing a bench warrant at his home on 9 November 2021. He had suffered childhood sexual abuse, his brother d…
27y · Male·effects of fire
Sam Lynch, aged 27, died from effects of fire while in remand at Hakea Prison on 5 March 2024. Following a dispute over undelivered canteen items, Sam set his mattress ablaze with a lighter. The response was catastrophic…
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