1y · Male·Complications of acute lymphoblastic leukaemia
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
42y · Male·Ligature compression of the neck (hanging)
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
30y · Male·Unascertained; likely cardiac arrhythmia
Adam Troy Shepley, aged 30, died in police custody following restraint after climbing onto roofs while displaying drug-affected and paranoid behaviour. Post-mortem examination revealed an unascertained cause, likely a ca…
31y · Male·Status epilepsy secondary to cerebral cavernoma
Jesse Riley, a 31-year-old with undiagnosed cerebral cavernoma, experienced status epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggre…
62y · Female·Multiple (head, chest and limb) injuries
A 62-year-old woman driving on the Tasman Highway in Tasmania was affected by sun glare while approaching a blind left-hand curve. She shielded her eyes with her left hand, causing her vehicle to cross double white centr…
48y · Female·Complications of early onset dementia
Daina Louise Clark, aged 48, died from complications of early onset dementia at a specialist disability accommodation facility in June 2025. She had been diagnosed with early onset dementia in 2019 with an expected lifes…
73y · Male·Complications of pyelonephritis and hepatocellular carcinoma in a man with epile…
Ian Robert Cameron, a 73-year-old man with multiple disabilities including motor neuron disease, epilepsy, and intellectual disability, died at home in specialist disability accommodation from complications of pyelonephr…
14y · Male·Retroperitoneal haemorrhage secondary to abdominal injuries sustained in a motor…
A 14-year-old boy riding an illegally high-powered e-scooter (capable of 40-50 km/h) collided with a utility vehicle at a residential intersection. The e-scooter exceeded legal speed limits and age restrictions under Vic…
69y · Male·Pericarditis
A 69-year-old man with a history of atrial fibrillation, chronic kidney disease, congestive cardiac failure, and Fragile X Syndrome presented to the Emergency Department with dyspnea following an unwitnessed fall. He was…
29y · Male·Not determined; likely multiple injuries from fall from coastal cliff or drownin…
This inquest concerns the disappearance and suspected death of Gavin Cheng, a 29-year-old man last seen on 29 October 2023 in North Bondi, NSW. Gavin had a documented history of schizophrenia diagnosed in 2015, with peri…
69y · Male·advanced cholangiocarcinoma
Mr Lifa Faafete, aged 69, died from advanced cholangiocarcinoma while in remand custody at Metropolitan Special Programs Centre. He was appropriately transferred to Prince of Wales Hospital on 22 March 2025 for symptom m…
85y · Male·Aspiration pneumonia in the setting of ischaemic heart disease, type 2 diabetes …
An 85-year-old man died of aspiration pneumonia in a prison healthcare setting while receiving palliative care. He had experienced a stroke two years prior resulting in cognitive decline and required assistance with all …
38y · Male·Chest injuries and traumatic compression asphyxia of the chest
A 38-year-old plumber died from chest injuries and traumatic asphyxia after losing control of his Mercedes tipper truck on Bacchus Marsh Road. The vehicle veered left after driving over rough road surface, colliding with…
51y · Female·Unintentional prescription drug poisoning due to central nervous system depressi…
A 51-year-old woman with chronic pain, depression, and longstanding medication misuse died from unintentional prescription drug poisoning. She had been prescribed high-risk combinations of opioids and benzodiazepines ove…
51y · Male·Traumatic brain injuries resulting from blunt head trauma: multiple calvarial an…
Adrian Garcia, 51, died from traumatic brain injuries sustained during an assault in a public park in Sorell, Tasmania on 10 March 2021. He was heavily intoxicated when struck by a baseball bat multiple times by his fian…
14y · Female·Drowning in a person with epilepsy
PCH, a 14-year-old girl in out-of-home care with a history of epilepsy, drowned in a river while washing her hair during a family camping trip. She had experienced increased seizure frequency in October-November 2024, pr…
35y · Male·self-inflicted gunshot wound to the head
Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…
71y · Male·Multiple injuries sustained in a cycling accident caused by impact with a tree b…
Paul Storey, a 71-year-old active cyclist, died from multiple injuries sustained when his head struck a large tree branch hanging across a bicycle path on Black Mountain Peninsula, ACT. A public report of the hazardous t…
41y · Female·Multiple injuries from assault
A 41-year-old woman with physical disability and stable mental health was killed by her adult son through severe blunt force trauma including extensive rib fractures causing flail chest, pneumohaemothorax, liver lacerati…
48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…
Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…
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