336 results
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical l…
68y · Male·Head injuries
Stephen O'Brien, aged 68, died from head injuries inflicted by his adult son Scott in a family violence incident. Stephen had been the primary carer for Scott, who had untreated mental illness (suspected schizophrenia), …
22y · Male·ligature compression of the neck (hanging)
Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…
23y · Male·Multiple injuries from being struck by train
Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…
59y · Male·hanging
A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …
55y · Female·Multiple injuries sustained in a train incident
Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…
58y · Male·Gunshot wound to the head
A 58-year-old Victoria Police Senior Sergeant died by firearm suicide at his workplace. He had a history of mild-to-moderate anxiety and depression managed with low-dose antidepressants and counselling since 2015, with n…
13y · Male·asphyxia as a result of hanging
MS, a 13-year-old Year 8 student, died by suicide by hanging on 16 February 2020. In the weeks before his death, MS engaged in self-harm by cutting his arms and expressed suicidal ideation to close friends through online…
45y · Female·Drowning whilst inebriated (ethanol)
FCP, aged 45, died by drowning while inebriated on 11 April 2020 at her home in Kilmore East, Victoria. She had a complex history of mental illness (psychosis, depression, anxiety, PTSD), substance abuse, and was in a re…
18y · Male·Heroin toxicity
Edward Grant Harris, an 18-year-old with autism spectrum disorder, ADHD, and borderline intellectual function, died from heroin toxicity in his supported accommodation. He had a complex history of behavioural challenges,…
48y · Female·Neck compression secondary to hanging
Ms HRZ, a 48-year-old Turkish-born woman, died by suicide on Christmas Day 2020 after experiencing years of family violence. She first endured abuse from her ex-husband, then sexual coercion, assault, stalking and threat…
50y · Male·ligature compression of the neck (hanging)
Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…
43y · Female·suffocation
Ms K, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car va…
51y · Male·gunshot wound to the chest
Andrew Chee Quee, 51, died from a gunshot wound sustained during a police confrontation at Bay Street, Rockdale, on 20 April 2020. He had a longstanding history of depression, substance abuse, and suicidal ideation. On t…
32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…
Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…
59y · Male·compression of the neck secondary to hanging
A 59-year-old man with treatment-resistant depression, anxiety, and suicidal ideation died by hanging while on weekend leave from psychiatric care. He had been hospitalised four times in 2021 and was receiving electrocon…
38y · Female·Hanging in the setting of multiple blunt force injuries
Samantha Joy Fraser, a 38-year-old psychologist, was murdered by her estranged husband Adrian Basham in July 2018 despite an active family violence intervention order. The coronial investigation identified systemic failu…
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…
18y · Female·Mixed drug toxicity
TK, an 18-year-old woman with borderline personality disorder, chronic suicidality, and a history of childhood trauma, died from mixed drug toxicity following intentional overdose. She had multiple psychiatric admissions…
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