15y · Male·compression of the neck by hanging
…tors; (4) inadequate mental health assessment on admission despite reported petrol sniffing and cannabis withdrawal; (5) possible depression and psychotic symptoms (hearing voices) not adequately documented or investigat…
0y · Female·subdural haemorrhage, intracranial haemorrhage and oedema caused by severe shaki…
… fractures. She was transferred to Royal Hobart Hospital ICU but died shortly after parents consented to withdrawal of life support. Her father admitted to violently shaking and squeezing her in frustration when she refu…
25y · Male·Gunshot injury to the head
SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver under the influence of amphetamines, cannab…
27y · Male·undetermined
Peter Christofidis, a 27-year-old man with a significant history of mental illness including depression and early schizophrenia, disappeared on 14 March 1983 after driving from his home in Cheltenham to Hattah Kulkyne Na…
25y · Male·The available evidence does not allow for any finding to be made as to the cause…
…ons include the importance of consistent mental health care, recognising warning signs (sleep disturbance, social withdrawal, farewell gestures), maintaining therapeutic continuity when patients discharge, and considerin…
52y · Male·Stab injuries to the chest
…proactive mental health screening and support, particularly those with chronic pain, financial stress, and social isolation.
41y · Male·unknown
…se) require sustained engagement; single assessments showing stability may miss chronic risk; the biopsychosocial trajectory toward withdrawal from services is common and dangerous; and structured follow-up with crisis p…
64y · Male·Multiple injuries sustained after jumping from a height
MB, a 64-year-old man with progressive major depression, died from multiple injuries sustained after jumping from a cliff at the Skillion near Terrigal. Over 18 months, his mental health deteriorated with depressive symp…
18y · Male·Death by suicide; cause cannot be definitively determined as body not recovered,…
An 18-year-old male with depression and anxiety died by suicide on 16 August 2022, jumping from the Tasman Bridge. He had been diagnosed with depression and anxiety in January 2022, saw a psychologist six times, and was …
17y · Female·Hanging
…s in adolescents is essential—Imanthi displayed depression, self-harm, sleep and appetite disturbance, and social withdrawal; (2) GPs assessing adolescent fatigue must screen for underlying psychiatric illness; (3) schoo…
Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…
Concurrent coronial inquests into six Aboriginal deaths in Ceduna, South Australia between 2004-2009. All deceased had severe alcohol addiction and comorbidities including pneumonia, cardiomyopathy, liver disease, and se…
20y · Female·Complications of neck compression in the setting of partial suspension
Madeline Howe, a 20-year-old Aboriginal woman, died by suicide on 8 May 2019 following partial suspension. She had experienced significant trauma including parental separation, family violence, and her brother's death by…
68y · Male·Hanging
Kent Thomas, aged 68, died by hanging in December 2018. He had experienced chronic tinnitus since 2013 which severely impacted his mental health and quality of life. Despite referral to mental health services and a reaso…
58y · Female·Complications of poorly controlled type 2 diabetes
Ms Kathleen Earl, aged 58, died from complications of poorly controlled type 2 diabetes in June 2022. She had an intellectual disability and received support from IHCS (Individual Support Worker) since 2005. Critical def…
24y · Male·Gunshot wounds to the chest
…vancing toward officers despite repeated verbal commands to drop the weapon. Officers attempted tactical withdrawal before firing five rounds. This case exemplifies victim-precipitated homicide, where the deceased's acti…
45y · Male·Gunshot injury to the chest (self-inflicted)
Scott Andrew Blanchard, a 45-year-old Detective Sergeant with the Western Australian Police Gang Crime Squad, died from a self-inflicted gunshot wound while on duty near Kalgoorlie. In June 2015, following a trip to Thai…
49y · Female·Multi-drug toxicity from intentional self-administration of intravenous fentanyl…
A 49-year-old paramedic with Ambulance Victoria died from multi-drug toxicity after deliberately self-administering intravenous fentanyl and midazolam accessed from her employer's medication safe. The coroner examined wh…
Male·Self-inflicted hanging
Leon Mark Carroll died by hanging in prison while on remand for sexual offences. Initial assessment identified significant suicide risk, but this was reversed by the High Risk Assessment Team after only 5-6 minutes consi…
23y · Male·Neck compression as a result of hanging
Jonathon Hogan, a 23-year-old Aboriginal man of Wiradjuri, Ngiyampaa and Murrawarri descent, died by hanging at Junee Correctional Centre on 3 February 2018 while serving remand. He had longstanding schizophrenia with pr…
22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…
Julieka Dhu, a 22-year-old Aboriginal woman, died on 4 August 2014 from staphylococcal septicaemia and pneumonia complicating osteomyelitis of a rib fracture sustained in April 2014. She was detained in police custody on…
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