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WAhome2025-07-11

Inquest into the Death of Monique Jacinta GOMEZ

48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…

Monique Gomez, 48, died from a spontaneous intracerebral haemorrhage during hospitalization for stroke rehabilitation and treatment of schizoaffective disorder. An initial ischaemic stroke resulted from non-compliance wi…

general medicineneurologywarfarin
WAcommunity2025-07-09

Inquest into the Death of Travis Barry Mark Kimberly HART

33y · Male·Heat stroke (environmental exposure) in a man with methylamphetamine effect

Travis Hart, 33, died from heat stroke with methylamphetamine effect after abandoning a vehicle during a police intercept in bushland near Kalgoorlie on 25 December 2022. He became separated from companions and was found…

emergency medicineforensic medicinedelaycommunicationmethamphetamine
WA2025-07-08

Inquest into the Death of Tim Alan LOOKER

29y · Male·ligature compression of the neck (hanging)

Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…

general practicepsychiatrysystemcommunicationdextroamphetamine
WA2025-07-03

Inquest into the Death of Nathan Barreto SEXTON

31y · Male·Gunshot injury to the head and neck (self-inflicted)

Nathan Barreto Sexton, 31 years old, died by suicide on 21 October 2023 near Merredin, Western Australia, from a self-inflicted gunshot wound to the head and neck. Prior to his death, he had committed serious armed offen…

methamphetamine
WAcommunity2025-07-02

Inquest into the Death of Donald Joseph Hemara WARD

50y · Male·Multiple injuries sustained in high-speed motorcycle crash

Donald Ward, aged 50, died from multiple injuries sustained in a high-speed motorcycle crash on 4 March 2023 in Karratha, WA. Ward left a nightclub intoxicated with alcohol (BAC 0.186%) and cannabis, obscured his number …

paramedicineemergency medicinepossibly diagnosticalcohol
WAhospital2025-06-30

Inquest into the death of Houston PEEL

29y · Male·ligature compression of the neck (hanging)

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…

emergency medicinepsychiatrycommunicationdelayolanzapine
WAhome2025-06-24

Inquest into the Death of Leighton Michael WOOD

44y · Male·bronchopneumonia in the setting of combined drug effect

Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…

psychiatrypathologyzuclopenthixol decanoate
WAcommunity2025-06-20

Inquest into the Death Suspected Death of Jeanne Christine D'ARCY

75y · Female·Presumed drowning; insufficient evidence to establish cause to requisite legal s…

This coronial finding addresses the disappearance of Jeanne D'Arcy, aged 75, from Cottesloe Beach, Western Australia on 13 April 2022. Following a distressing day that included legal consultation about her disputed housi…

diazepam
WA2025-06-12

Inquest into the Death of Graham John BUTLER

76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…

Graham John Butler, aged 76, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…

correctional healthgeneral medicinebenzydamine
WA2025-06-12

Inquest into the Death of Sam Phillip Chisholm LYNCH

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…

systemcommunicationdiazepam
WAcommunity2025-06-09

Inquest into the Death of Joyce Gladis CLARKE

29y · Female·gunshot wound to the abdomen

29-year-old Aboriginal woman (JC) of Ngarlawangga Yamatji Martu descent died from a gunshot wound inflicted by police on 17 September 2019. Four days prior, she was appropriately discharged from Sir Charles Gairdner Hosp…

psychiatryemergency medicinesystemmethamphetamine
WAcommunity2025-05-28

Inquest into the Suspected Death of Ian Steven TOLLI

54y · Male·unknown, possibly drowning, with possible contribution from marine predation or …

Ian Steven Tolli, aged 54, disappeared while kayaking at Point Peron on 15 December 2020 and is presumed drowned. He launched his kayak in choppy, windy conditions without wearing his lifejacket (which remained stowed in…

alcohol
WAcommunity2025-05-27

Inquest into the Suspected Death of George William LE VAUX

70y · Male·Unknown cause; presumed drowning but sudden medical event cannot be excluded

George William Le Vaux, a 70-year-old man with multiple chronic health conditions including severe headaches, back pain, fibromyalgia, and chronic fatigue syndrome, disappeared after being dropped at Swanbourne Beach on …

WAcommunity2025-05-13

Inquest into the Suspected Death of Lisa Joanne GOVAN

28y · Female·unascertained

Lisa Joanne Govan, aged 28, disappeared on 8 October 1999 in Kalgoorlie, Western Australia, last seen standing outside the Club Deroes outlaw motorcycle gang clubhouse at 7:30 am. The coroner established, beyond all reas…

cannabis
WA2025-05-09

Inquest into the Suspected Death of Hans Jurgen YUNGE

32y · Male·Unascertained; most likely heat exposure/death from exposure in harsh remote ter…

Hans Jurgen Yunge, a 32-year-old foreman, disappeared on 31 December 1969 in remote Pilbara, Western Australia after his utility vehicle suffered a flat tyre approximately 22 km from a work campsite near Millstream. He w…

delay
WAhospital2025-05-08

Inquest into the Death of Tony RUICH

55y · Male·decompensated liver failure in a man with metastatic hepatocellular carcinoma, w…

Tony Ruich, a 55-year-old sentenced prisoner, died from decompensated liver failure due to metastatic hepatocellular carcinoma with terminal palliative care. He had pre-existing cirrhosis diagnosed in 2012, likely from h…

hepatologypalliative careheroin
WA2025-05-05

Inquest into the Suspected Death of David Benjamin INGRAM

44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…

David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…

psychiatrygeneral practicecommunicationsystemolanzapine
WAcommunity2025-04-17

Inquest into the Suspected Death of Peter James GUIDERA

58y · Male·unascertained

Peter James Guidera, a 58-year-old man with a history of depression, suicidal ideation, and previous suicide attempts, disappeared on 8 May 1998 from Narrogin, Western Australia, shortly after receiving a distressing pho…

psychiatrygeneral practiceantidepressant medication
WAcommunity2025-04-17

Inquest into the Death of David Greenwood

42y · Male·Unascertained; most likely exposure after wandering in bushland

David Greenwood, a 42-year-old Aboriginal man with chronic alcohol dependence and a chronic chest infection, disappeared from Gindalbie Station near Kalgoorlie on 14 October 1984. He was experiencing delirium tremens (al…

WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…

paediatricspalliative care

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