304 results
33y · Male·Complications of methylamphetamine use
Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health di…
30y · Male·Drowning due to jumping from the Batman Bridge
A 30-year-old man with opioid use disorder, anxiety, and depression died by suicide from jumping the Batman Bridge. He had been prescribed escalating doses of clonazepam (1-8mg daily) over three years by general practiti…
32y · Female·Unknown
Tina Louise Greer, 32, disappeared on 18 January 2012 and is presumed deceased, killed by her partner Leslie Sharman who was involved in her coercive and controlling relationship, including domestic violence. The coroner…
43y · Male·The combined effects of subacute myocardial injury and methadone toxicity
Timothy Ricketts, a 43-year-old man with complex psychiatric and substance use history, died from combined subacute myocardial injury and methadone toxicity. He had been admitted to hospital in November 2021 with elevate…
33y · Male·Hanging
CC, a 33-year-old First Nations man with methamphetamine-induced bipolar disorder and psychosis, was admitted to the High Dependency Unit at Nepean Hospital on 7 June 2022 under involuntary mental health detention. Over …
5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity
LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
31y · Male·Hanging
Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…
47y · Male·Multidrug toxicity (ethanol, quetiapine, baclofen, benzodiazepines)
Stuart Noble, 47, died from multidrug toxicity involving baclofen, quetiapine, benzodiazepines, and ethanol in an intentional overdose. He was prescribed baclofen off-label by his GP for alcohol use disorder despite it l…
46y · Male·Opioid toxicity (tapentadol and oxycodone)
Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…
36y · Male·hanging, with contributing factors of alcohol dependence and depression
Ross Johns, aged 36, died by hanging on 14-15 June 2021 after a long history of bipolar disorder, major depression, and alcohol dependence. He was discharged from Northside Mental Health Unit on 9 June 2021 following adm…
23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…
Brontë Haskins, aged 23, died by suicide via hanging on 18 February 2020, three days after her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination …
31y · Male·self-inflicted hanging
Bernard Hector, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Centre on 30 August 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearan…
64y · Female·Combined toxicity to alcohol and baclofen
Anna Lawrence, 64, died from combined toxicity of alcohol and baclofen on 30 April 2020. She had a 40+ year history of alcohol dependency, borderline personality disorder, depression, and multiple suicide attempts. Baclo…
33y · Male·Prolonged epileptic seizure resulting in gastric content aspiration and cardiac …
Roy Roberts, a 33-year-old Aboriginal man, died at Long Bay Correctional Complex from a prolonged epileptic seizure resulting in aspiration and cardiac arrest. He had experienced three prior seizure-like episodes in Apri…
41y · Male·Cardiomegaly and Coronary Artery Disease with significant contributing condition…
Jay Crich, a 41-year-old man in custody at Clarence Correctional Centre, died of cardiomegaly and coronary artery disease with emphysema and obesity as significant contributing conditions. He was discovered unresponsive …
37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…
Veronica Nelson, a 37-year-old Aboriginal woman with opioid dependence, was arrested on minor theft charges, remanded in custody following a bail hearing, and held at Dame Phyllis Frost Centre (DPFC) women's prison. She …
19y · Female·Hanging
Cody Watson, 19, died by hanging following childhood sexual abuse, family violence, and inadequate trauma-informed care. She disclosed abuse at 15, subsequently developing borderline personality disorder, anxiety, depres…
19y · Male·Stab wounds to the neck and chest
Taylor Oliver, a 19-year-old with schizophrenia and substance use disorder, died by self-inflicted stab wounds on 1 December 2019. He had been admitted to mental health inpatient care on 18 November 2019 following overdo…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.