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NSWcommunity2026-02-16

Inquest into the death of TL

42y · Female·unascertained

TL, a 42-year-old scientist living a nomadic lifestyle in Byron Bay, NSW, was last seen on 4 November 2019 at a service station. Her skeletal remains were discovered in July 2020 at a campsite in Cape Byron Recreational …

forensic medicine
NSWhome2026-02-13

Inquest into the death of Krista Kach - Decision

Female·Gunshot wound to the chest

On 14 September 2023, Krista Kach died from a gunshot wound to the chest following a police tactical response in Stockton, NSW. Police attended her residence after reports she was threatening others with an axe. During a…

NSW2026-02-09

Inquest into the disappearance and suspected death of Hazel Vidler

56y · Female·Unknown - not determined

This inquest concerns Hazel Clare Vidler, who disappeared in 1979 and is now presumed deceased. This is not a medical case requiring clinical lessons; rather, it is a coronial investigation into a missing person. The cor…

NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Recommendations

Deaths from injuries sustained in a mass stabbing attack

This inquest examined deaths resulting from a mass stabbing attack at Westfield Bondi Junction on 13 April 2024. The perpetrator, Joel Cauchi, had treatment-resistant schizophrenia and had ceased antipsychotic medication…

psychiatryemergency medicinesystemcommunicationantipsychotic medication
NSWmental health2026-02-05

Inquest into the deaths at Westfield Bondi Junction Executive Summary

41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…

On 13 April 2024, Joel Cauchi stabbed 16 people at Westfield Bondi Junction, NSW, fatally wounding six: Dawn Singleton, Jade Young, Yixuan Cheng, Ashlee Good, Faraz Tahir, and Pikria Darchia. Cauchi was shot and killed b…

psychiatrygeneral practicediagnosticcommunicationclozapine
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 3

Multiple penetrating knife wounds with hemorrhagic shock and traumatic cardiac a…

On 13 April 2024, Joel Cauchi, with inadequately managed treatment-resistant schizophrenia, stabbed six people to death and injured ten others at Westfield Bondi Junction shopping centre in Sydney. The coroner found Cauc…

emergency medicineparamedicinesystemcommunication
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 2

Female, male·Stab wounds inflicted by Joel Cauchi

Joel Cauchi, suffering a psychotic relapse of chronic schizophrenia, carried out a rapid active armed offender (AAO) attack at Westfield Bondi Junction shopping center on 13 April 2024. Within three minutes, he fatally s…

emergency medicinepublic healthcommunicationsystem
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

Joel Cauchi, a 40-year-old man with chronic treatment-resistant schizophrenia, carried out a stabbing attack at Westfield Bondi Junction shopping centre in Sydney on 13 April 2024, killing six people (Dawn Singleton, Jad…

psychiatrygeneral practicecommunicationsystemclozapine
NSW2026-01-30

Inquest into the death of Phuoc Van Nguyen

51y · Male·Hanging

A 51-year-old man with a complex mental health history and prior self-harm alert died by hanging in a correctional facility after a planned transfer. He requested protective custody following a physical altercation with …

psychiatrypsychologycommunicationsystemalprazolam
NSWhospital2026-01-22

Inquest into the death of JC

30y · Male·hanging

JC was a 30-year-old with a long history of benzodiazepine dependence and previous psychiatric episodes triggered by withdrawal. He presented to Calvary Mater Hospital after a deliberate overdose of 48 Etizolam tablets w…

emergency medicinepsychiatrydiagnosticcommunicationetizolam
NSWcommunity2026-01-20

Inquest into the disappearance and suspected death of AL

35y · Male·The available evidence does not allow for any finding to be made as to the cause…

A 35-year-old male with extensive mental health history died by intentional self-inflicted means on 13 September 2022 at Vaucluse, NSW. He had multiple psychiatric diagnoses including bipolar disorder, autism spectrum di…

psychiatrypsychology
NSWcommunity2026-01-16

Inquest into the death of Jerwin Royupa

21y · Male·Complications of multiple blunt force injuries sustained when voluntarily exitin…

Jerwin Royupa, a 21-year-old Filipino agricultural graduate, died on 15 March 2019 from injuries sustained when he exited a moving vehicle. He had arrived in Australia on a Subclass 407 training visa, sponsored by an agr…

occupational and environmental healthforensic medicinesystemprocedural
NSWhospital2026-01-13

Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…

Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …

general practiceemergency medicinediagnosticcommunicationceftriaxone
NSWhospital2025-12-22

Inquest into the death of Shane McMillan

40y · Male·Acute methylamphetamine toxicity

Shane McMillan, aged 40, died from acute methylamphetamine toxicity while in police custody. He was arrested for domestic violence offences on 1 December 2022 and presented to Orange Health Service twice that day with su…

emergency medicinetoxicologymethamphetamine
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …

emergency medicinecardiologycommunicationsystemamiodarone
NSWcommunity2025-12-17

Inquest into the death of DE

48y · Male·Multiple injuries

A 48-year-old man died in a motor vehicle collision during a police pursuit after assaulting his domestic partner and taking her vehicle without permission. He deliberately drove into the path of a semi-trailer with appa…

NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…

general practiceemergency medicinediagnosticdelay
NSW2025-12-16

Inquest into the disappearance and suspected death of Cenzig Sarac

24y · Male·The available evidence does not allow for any finding to be made as to the cause…

Cengiz Sarac, aged 24, disappeared on 5 August 2005 and is presumed dead. The Deputy State Coroner found on the balance of probabilities that he died on or shortly after 2 August 2005, based on extensive signs of life in…

NSWcommunity2025-12-09

Inquest into the deaths of Lynette Thompson and Alan Fletcher

58y · Female; male·Lynette: Thermal injuries (extensive burns) and complications thereof; Alan: Nec…

Two related deaths from domestic violence murder-suicide. Lynette Thompson (58, Aboriginal woman) died from severe burns inflicted by her partner Alan Fletcher (59) on 8 November 2020; Alan subsequently died by hanging. …

communicationsystempetrol
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam

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