48y · Male·Coronary atherosclerosis and minor trauma
… a 48-year-old Indigenous man with coronary artery disease, hypertension, diabetes, and bipolar affective disorder, died in Townsville Correctional Centre following a brief altercation with another prisoner. He had refus…
Ligature compression of the neck (hanging) in 12 cases; one open finding
This complex coronial inquest examined 13 Aboriginal children and young persons who died by suicide in the Kimberley R…
26y · Male·hanging, intentionally self-inflicted
A 26-year-old Aboriginal man died by suicide in custody following discharge from a Risk Intervention Team (RIT) management plan on 19 October 2021. He had self-harmed on 17 October, reporting voices telling him to cut hi…
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that n…
15y · Female·Hanging
Zakiya, a 15-year-old Barkindji Maraura woman, died by hanging at Mildura Base Hospital following a family argument about repaying a borrowed $300. She had disclosed experiences of childhood sexual abuse by her uncle, ph…
20y · Male·gunshot wound to the chest
A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during…
32y · Male·neck compression in the circumstances of hanging
…s despite explicit suicide risk indicators in his June 2017 complaint; (5) inadequate communication about complex claims processes for someone with PTSD-related cognitive difficulties. The coroner found DVA's failures c…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
… continuous rather than close observations, and that key psychiatric warnings (paranoid comments, thought-disordered writings) were not adequately communicated to treating psychiatrist Dr S., who should have reassessed a…
17y · Female·raised intracranial pressure due to hepatic encephalopathy related cerebral oede…
…ations of sexual abuse she had made, combined with her intellectual disability, epilepsy history, and past trauma. No criticism was directed at healthcare workers; the death could not have been predicted despite availabl…
47y · Female·Overdose of hydromorphone
A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…
56y · Male·head injuries inflicted by blunt force trauma
…rison five days earlier. Pattel had expressed clear intentions to kill someone prior to release and had a complex psychiatric history (likely schizophrenia mixed with Asperger's syndrome) that was poorly managed in pris…
37y · Male·Sergeant Huitson: gunshot wound to chest and abdomen; Ansell: multiple gunshot w…
This coronial inquiry examined a shooting incident on 3 August 1999 where Rodney Ansell, a man suffering from deteriorating mental health and chronic amphetamine abuse, opened fire on the Stuart Highway killing Sergeant …
16y · Male·complications of ligature compression of the neck (hanging)
Cleveland Keith Dodd, aged 16, died on 19 October 2023 from complications of ligature compression of the neck (hanging) while in custody at Unit 18, a youth detention facility within Casuarina Prison, Western Australia. …
17y · Female·Neck compression by hanging (suicide)
XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …
5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …
A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…
20y · Male·ligature compression of the neck (hanging)
…son, died by ligature compression of the neck (hanging) in a cleaning storeroom on 6 March 2013. He had a complex psychiatric history including drug-induced psychosis, depression, and anxiety, for which he was frequentl…
53y · Male·severe burns
Mr Bloomfield, a 53-year-old man with complex psychiatric and substance abuse history, was apprehended by police under section 10 Mental Health Act aft…
35y · Male·multi-drug toxicity
CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, dis…
62y · Female·Multiple injuries sustained from jumping from rocks at Torndirrup National Park …
Pamela Stone, a 62-year-old woman with a complex history of trauma, depression and relationship difficulties, presented to Albany Regional Hospital ED on …
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
…esity must be identified early and managed holistically; (4) Aboriginal prisoners require culturally safe, trauma-informed care with access to psychology services; (5) parole processes must enable timely APB consideratio…
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