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WA2023-03-13

Inquest into the Death of Frank ALBERT

46y · Male·atherosclerotic heart disease

Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…

cardiologyemergency medicinesystemcommunicationquetiapine
WAmental health2023-02-13

Inquest into the Death of Philip SULLEY

58y · Male·coronary artery arteriosclerosis (natural causes)

Philip Sulley, 58, died of coronary artery arteriosclerosis on 27 April 2020 at Bentley Mental Health Unit. He presented to Royal Perth Hospital emergency department on 19 April 2020 with psychotic behaviour but was disc…

psychiatryemergency medicinecommunicationolanzapine
WAcommunity2023-02-03

Inquest into the Suspected Death of Roly NIXON

44y · Male·Unascertained; presumed exposure

Roly Nixon, a 44-year-old man with significant medical comorbidities including rheumatic heart disease, diabetes, organic psychosis and seizure disorder, disappeared from Fitzroy Crossing, Western Australia on 28 January…

emergency medicinecardiologywarfarin
WA2022-12-23

Inquest into the Death of Ms L (Name Subject to Suppression Order)

27y · Female·multiple injuries sustained from fall from 30-storey building

Ms L, a 27-year-old German national, died by suicide on 4 March 2021 after jumping from a 30-storey building in Perth. She had experienced depression since 2016, exacerbated by recent diagnoses of chlamydia and HPV16 in …

general practicegynaecologyfluoxetine
WAcommunity2022-12-12

Inquest into the Death of Lewis Henry Mark WESTON

22y · Male·ligature compression of the neck (hanging)

Lewis Weston, aged 22, died by suicide on 3 November 2020 while subject to a Community Treatment Order (CTO) for Schizoaffective Disorder. He presented with first-episode psychosis in 2017 and repeatedly refused antipsyc…

psychiatryemergency medicineolanzapine
WAhospital2022-10-07

Inquest into the Death of Justine PAINTER

51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…

Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…

gastroenterologypsychiatrycommunicationsystempaliperidone
WAcommunity2022-08-17

Inquest into the Death of Quoc Xuan TRAN

36y · Male·Immersion (drowning)

Quoc Xuan Tran, a 36-year-old man with schizoaffective disorder and autism spectrum disorder, died by drowning in the Swan River on 10 April 2019. He was subject to a Community Treatment Order and had experienced repeate…

psychiatryemergency medicinesystempaliperidone
WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…

psychiatrycorrectional healthsystemcommunicationtramadol
WA2022-07-15

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

21y · Male·complications of ligature compression of the neck (hanging)

Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
WAcommunity2022-06-09

Inquest into the Death of Desmond Edward JACK

33y · Male·Gunshot injury to the anterior trunk (chest and upper abdomen)

Desmond Jack, a 33-year-old with longstanding bipolar affective disorder and psychotic symptoms, died from a single gunshot wound to the anterior trunk after being shot by police officer Senior Constable Harrison on 28 M…

psychiatryemergency medicinesystemmirtazapine
WAhome2022-04-13

Inquest into the Death of Boris DRLESKI

45y · Male·bronchopneumonia and combined drug toxicity

Boris Drleski, a 45-year-old with treatment-resistant chronic paranoid schizophrenia, antisocial personality disorder, and polysubstance use disorder, died from bronchopneumonia and combined drug toxicity. He was managed…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
WAcommunity2022-04-01

Inquest into the Death of Cherdeena Shaye WYNNE

26y · Female·hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamph…

Ms Cherdeena Wynne, a 26-year-old Noongar Yamatji woman, died from hypoxic ischaemic encephalopathy and bronchopneumonia following cardiac arrest during police restraint on Albany Highway. She was intoxicated with methyl…

psychiatryemergency medicineproceduralcommunicationmethamphetamine
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
WAhospital2022-01-25

Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…

psychiatrygeneral medicinecommunicationproceduralfluoxetine
WAhospital2022-01-17

Inquest into the Death of Peter Johnnie YOUNG

Male·Complications of alcohol and hepatitis C-related liver disease

Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…

hepatologygastroenterologysystemdelayquetiapine
WAhospital2022-01-06

Inquest into the Death of Louisa Betty RYAN

89y · Female·aspiration pneumonia with respiratory failure complicating major depression with…

Louisa Betty Ryan, 89 years old with major depression with catatonia, atrial fibrillation, pulmonary oedema, diabetes and Parkinsonism, died from aspiration pneumonia with respiratory failure following electroconvulsive …

psychiatryanaesthesia
WA2021-12-22

Inquest into the Death of Brett Ashley DUTURBURE

29y · Male·ligature compression of the neck (hanging)

Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…

correctional healthpsychiatrysystemcommunication
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist m…

psychiatrypaediatricssystemdelay
WAhome2021-12-03

Inquest into the Death of Elia WANI

29y · Male·acquired methaemoglobinaemia in association with sodium nitrite toxicity

Elia Wani, a 29-year-old man with bipolar affective disorder managed on a community treatment order, died from methaemoglobinaemia following sodium nitrite ingestion. He purchased 50g of sodium nitrite powder online on 1…

psychiatryemergency medicinesystemsodium nitrite
WAhome2021-11-29

Inquest into the Death of Ly Minh TONG

38y · Male·Multiple gunshot wounds

A 38-year-old man with a history of methamphetamine use and mental health issues, subject to a violence restraining order, assaulted his father at home. The father reported to police that his son was armed with a knife, …

psychiatrytoxicologycommunicationsystemmethamphetamine
134515

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