1,981 results
54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…
54-year-old man with schizophrenia died after acute mental health crisis during police response. Contributing factors included: arrhythmogenic cardiomyopathy (undetected cardiac condition); combined doxepin and venlafaxi…
49y · Male·Shotgun wound to the head
Andrew Lockwood, a 49-year-old man with depression and significant marital discord, died from a self-inflicted shotgun wound to the head on 2 April 2017. He had been diagnosed with major depression and alcohol dependency…
46y · Male·congestive cardiac failure due to cardiomyopathy and coronary artery atheroscler…
A 46-year-old man with significant cardiac and medical comorbidities died of congestive cardiac failure due to cardiomyopathy and coronary artery atherosclerosis while in police custody. He was correctly categorized as H…
31y · Male·Gunshot wounds to the neck and chest
Liam Scorsese, 31, died from gunshot wounds inflicted by police during a confrontation at his estranged partner's parents' home in Queensland. He had a history of violence, substance abuse (methamphetamine, cocaine), and…
29y · Female·Mixed Drug Toxicity
A 29-year-old woman died from mixed drug toxicity after being found unresponsive at a residential parenting program. She had complex medical conditions including coproporphyria, epilepsy, and opioid use disorder. Critica…
56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels
Julie-Anne Kettle, a 56-year-old woman with intellectual disabilities residing in a group home, died from bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric…
8y · Male·Suffocation
Brodie Moran, an 8-year-old boy, died by suffocation at the hands of his mother, Ms Finch, on 8 March 2018. Ms Finch had a history of depression and anxiety, experiencing significant deterioration in mental health follow…
61y · Female·Multiple drug (tapentadol, morphine, diazepam, citalopram) intoxication
Margaret Cahill, a 61-year-old nurse assistant, died from multiple drug intoxication after a GP administered 60mg intramuscular morphine without knowing she had consumed tapentadol 1-2 hours earlier. The coroner identifi…
51y · Male·blunt trauma of the chest sustained in a motor vehicle crash; hypovolemic shock …
A 51-year-old man with schizophrenia, bipolar disorder, chronic pain, and substance use disorder died from blunt chest trauma following a motor vehicle crash. He had a history of two previous crashes associated with high…
32y · Male·contact range gunshot wound to the forehead, self-inflicted
A 32-year-old male with long-standing depression and Asperger's syndrome died by firearm suicide. His medical care was appropriate and well-managed. However, critical systemic failures occurred in firearms licensing. He …
46y · Female·Accidental mixed prescription drug toxicity (tramadol, amitriptyline, codeine, d…
Michelle Jayne Stocks, aged 46, died from accidental mixed prescription drug toxicity in December 2018. She had complex medical conditions including emphysema, fibromyalgia, and chronic pain, managed by her GP Dr Q. retu…
91y · Female·Gunshot wound to the head
Gwen Adeline Smith, 91, was fatally shot by her husband Arthur Smith on 25 July 2018 at their home in Parwan, Victoria. Mr Smith then died by suicide. The couple had been experiencing significant stressors including fina…
3y · Female·gunshot wound to the head
A 3-year-old girl was killed by her mother, who was experiencing a severe psychotic episode with suicidal and homicidal ideation. The mother had a history of Brief Psychotic Disorder (diagnosed 2015), was on olanzapine 1…
39y · Female·Gunshot wound to the head
A 39-year-old woman with brief psychotic disorder experiencing suicidal and homicidal ideation killed her 4-year-old daughter and herself. She had been diagnosed with psychosis in 2015, treated with olanzapine, and disch…
38y · Male·Aspiration pneumonia
Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …
37y · Female·Multiple drug toxicity
Sharni Dee Connolly, a 37-year-old registered nurse turned naturopath, died from multiple drug toxicity following a hamstring injury requiring opioid analgesia. She was prescribed excessive quantities of pregabalin (105m…
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…
27y · Male·Gabriella: Multiple stab wounds; Tafari: Gunshot injuries to the head and abdome…
Two deaths in a domestic violence and police operation context. Gabriella Thompson, 27, was fatally stabbed by her partner Tafari Walton in domestic violence circumstances on 13 March 2019. Police received a concern for …
9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…
Bradyn Dillon, aged 9, was brutally beaten to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him …
30y · Male·neck compression
Mohamed Omar, a 30-year-old man with schizophrenia, died in Melbourne Assessment Prison on 25 June 2017 from neck compression while on remand. He had a history of command auditory hallucinations instructing self-harm, re…
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