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QLD2007-05-16

Davis, Jodie Maree

24y · Female·hypoxic brain damage due to cardiac arrest due to hanging

Jodie Maree Davis, aged 24, died by suicide in Townsville Correctional Centre in May 2002. She had a long history of self-harm dating from age 15, including multiple suicide attempts, and was assessed as high suicide ris…

psychiatrypsychologysystemcommunication
SA2007-04-26

Coroner's Finding: CHRISTOPHER Penelope Rae and TRENORDEN John

53y · Male·asphyxia from combined effects of neck compression from hanging and suffocation …

John Trenorden died by suicide in prison following his arrest for allegedly murdering his former business partner Penelope Christopher. Police correctly identified him as at-risk after he attempted to step in front of tr…

psychiatrygeneral practicecommunicationsystemallopurinol
QLD2007-03-30

Pittaway, Steven John and Coe, Paul Allen

Male·Coe: self-inflicted hanging; Pittaway: neck compression due to self-inflicted st…

Two men died by suicide in Bundaberg Watch House within 7 months. Paul Coe (38) hanged himself using his shirt from a door hinge on 11 June 2005, approximately 25 minutes after officers last physically checked him. Steve…

forensic medicinetoxicologysystemcommunicationmethamphetamine
QLD2007-03-01

McGeary, Corey Allan

20y · Male·Self-inflicted hanging

Corey McGeary, a 20-year-old remand prisoner with chronic risk factors for self-harm (history of suicide attempts, schizophrenia, personality disorder, severe childhood abuse, mild intellectual disability), died by hangi…

psychiatrypsychologycommunicationsystemolanzapine
SA2007-01-30

Coroner's Finding: CHALKLEN Stuart Murray

38y · Male·ischaemic heart disease due to severe coronary atherosclerosis

Stuart Murray Chalklen, aged 38, died in Adelaide Remand Centre from ischaemic heart disease due to severe coronary atherosclerosis. He complained of left shoulder pain (a recognised symptom of cardiac disease) to cellma…

cardiologyemergency medicinediagnosticsystem
QLDcommunity2007-01-19

Tyssen, Mario Emmy

45y · Male·Coronary artery disease due to severe atherosclerosis; acute myocardial infarcti…

Mario Emmy Tyssen, a 45-year-old man in custody on approved leave, died suddenly while gardening from coronary artery disease due to severe atherosclerosis. He had a documented history of cardiac symptoms (chest pain pre…

cardiologycorrectional healthmetformin
QLD2007-01-19

Fitzgerald, Darren Michael

34y · Male·heroin toxicity with possible contribution from coronary atherosclerosis

Darren Fitzgerald, a 34-year-old lifer serving for murder, died in Woodford Correctional Centre from heroin toxicity with possible contribution from coronary atherosclerosis. He had a documented history of drug abuse in …

forensic medicinecorrectional healthsystemdelayheroin
SA2006-11-16

Coroner's Finding: HARKIN Leonard Norman

51y · Male·ischaemic heart disease

A 51-year-old prisoner died from ischaemic heart disease after suffering a cardiac event while being transferred between prison units. He had complained of chest pain to correctional officers, was directed to walk to the…

cardiologyemergency medicineproceduraldelaymirtazapine
NTcommunity2006-10-23

Inquest into the death of Jodie Palipuaminni

27y · Female·Intracranial haemorrhage with associated blunt head, chest and abdominal trauma

A 27-year-old Aboriginal woman was killed by her violent partner while he was on parole with conditions explicitly prohibiting contact with her. Despite documented escalating domestic violence over 12 years (including bo…

correctional healthforensic medicinesystemcommunication
SA2006-10-18

Coroner's Finding: TURNER Barry Michael and GLENNIE Troy Michael

Neck compression due to hanging (self-inflicted)

Two men, Barry Michael Turner (35) and Troy Michael Glennie (28), died by hanging in Adelaide Remand Centre while on remand. Both had expressed suicidal ideation and were being monitored via 'yellow sheet' daily nursing …

psychiatrycorrectional healthsystemcommunicationquetiapine
NThospital2006-10-02

Inquest into the death of Freddie Peterson

30y · Male·diffuse alveolar damage, a complication of bacterial endocarditis

Freddie Peterson, a 30-year-old Aboriginal man from Papunya, died in custody from bacterial endocarditis complicated by diffuse alveolar damage. He was imprisoned for nine months and presented to the prison medical centr…

cardiologyinfectious diseasesranatidine
SA2006-09-25

Coroner's Finding: BROOKS Neil James and FOSTER Tracy Jayne

43y · Male·suffocation by plastic bag (Neil Brooks); neck compression due to strangulation …

Two deaths investigated in joint inquest: Tracy Jayne Foster died by strangulation in December 2002; Neil James Brooks, her partner charged with her murder, died by suffocation while on remand in May 2003. The coroner id…

psychiatrycorrectional healthcommunicationsystemzopiclone
NT2006-09-08

Inquest into the death of Hector Martin

36y · Male·Cerebrovascular accident (stroke) - massive intracranial haemorrhage

An Aboriginal man with chronic alcoholism and cirrhosis died from a massive stroke (cerebrovascular accident) while in prison custody. He presented with non-specific symptoms including vomiting on 9 March 2005 and was pl…

general practicecorrectional healthcommunicationsystemdiazepam
QLDhospital2006-08-10

Casey, Lenard John

39y · Male·Coronary thrombosis caused by coronary atherosclerosis

Lenard Casey, a 39-year-old Aboriginal man with severe coronary artery disease, died of acute coronary thrombosis while in custody. Arrested for assault on his partner, he developed chest pain at the police station and w…

cardiologyemergency medicinecommunicationmorphine
QLD2006-06-27

Williams, Stuart Ronald

45y · Male·Coronary artery thrombosis due to coronary artery atheroma

Stuart Ronald Williams, an Aboriginal male aged 45, died in custody at Capricornia Correctional Centre from coronary artery thrombosis secondary to coronary artery atherosclerosis. He had a significant cardiac history wi…

cardiologycorrectional health
QLD2006-06-08

Hewson, Jamie

36y · Male·gunshot wounds to the head and pelvis

Jamie Hewson, a 36-year-old farmer, was killed by police gunshot wounds following an 18-hour siege at his family farm. After allegedly threatening a neighbour with a rifle, a police response escalated from negotiators to…

emergency medicineforensic medicinecommunicationprocedural
SA2006-05-01

Coroner's Finding: HULSINGA Michael John

27y · Male·left temporal intracerebral haemorrhage due to arteriovenous malformation

Michael John Hulsinga, a 27-year-old male inmate with schizophrenia, died in custody from a spontaneous intracerebral haemorrhage due to arteriovenous malformation. He collapsed suddenly while eating dinner in his cell a…

forensic medicinepsychiatrysystemcommunicationsertraline
QLD2006-03-17

Smith, David Edward

21y · Male·Multiple stab wounds inflicted by Andrew Kranz who was assisted in the murder by…

David Edward Smith, 21, was murdered in prison by inmates with 31 stab wounds after being forcibly moved to a high-risk unit despite clear and repeated warnings of danger. Staff ignored his requests for protection and fa…

correctional healthcommunicationsystem
QLDhospital2006-03-13

Pettigrew, Wayne Matthew

54y · Male·chronic liver failure due to or as a consequence of hepatocellular carcinoma due…

Wayne Matthew Pettigrew, a 54-year-old man serving a life sentence, died of chronic liver failure secondary to hepatocellular carcinoma, hepatitis C, cirrhosis, and diabetes mellitus. He was admitted to Princess Alexandr…

palliative carehepatology
WA2006-03

Inquest into the Death of Leon John Donaldson

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…

psychiatrypsychologysystemcommunicationsodium valproate
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