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NSW2017-10-30

Inquiry into fire at 167 Parramatta Rd, Auburn

Deliberate pouring and igniting of an accelerant, petrol, by unknown persons

On 2 June 2015, a fire was deliberately lit at @Fitness Gym in Auburn, NSW. Investigation revealed that unknown persons poured petrol throughout the premises as an accelerant and ignited it at a steel pedestrian door aro…

NSWcommunity2017-10-25

Inquest into the death of KE

36y · Male·Shotgun wound to the head

KE was a 36-year-old with longstanding psychiatric history including borderline personality disorder, substance abuse, and multiple previous self-harm incidents. He was on bail with a residential condition preventing him…

psychiatryemergency medicinealcohol
NSWcommunity2017-10-17

Inquest into the death of Ashley Newton Bryant

44y · Male·Multiple traumatic injuries sustained in a fall from height

Ashley Bryant, a 44-year-old former NSW police officer with 24 years service, died by suicide at Minyon Falls on 16 December 2013 while suffering from PTSD, depression and alcohol dependence. The coroner found these cond…

psychiatryoccupational and environmental healthdiagnosticcommunicationtemazepam
NSWhome2017-10-13

Inquest into the death of D T

13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…

A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental health assessment, initiated antidepressant…

general practicepsychiatrydiagnosticcommunicationfluoxetine
NSWhome2017-09-29

Inquest into the death of Robin MacDonald, Colin Webb and Brian Wilson (Dungog Floods)

Unknown·Presumed freshwater drowning

Three residents of Dungog, NSW drowned on 21 April 2015 in an unprecedented flash flood: Robin MacDonald, Colin Webb, and Brian Wilson became trapped by rapidly rising floodwaters in their homes. The coroner found the fl…

system
NSWhome2017-09-15

Inquest into the death of Charles Welsford SMITHERS

32y · Male·Presumed cardiac arrhythmia with congenital coronary artery anomaly (absent righ…

Charles Smithers, a 32-year-old fit and active man, died suddenly in bed of presumed cardiac arrhythmia associated with a rare congenital coronary artery anomaly (absent right coronary artery). He had been well, with no …

cardiologyforensic medicinediagnostic
NSWhome2017-09-14

Inquest into the death of Lynne BARNETT

70y · Female·Unknown

Lynne Barnett, a 70-year-old woman, was found deceased at her home in Burwood, NSW in February 2017, having been dead for several weeks. Autopsy revealed moderate-to-advanced decomposition with only probable left ventric…

general practiceforensic medicinediagnostic
NSWhospital2017-09-08

Inquest into the death of James BARTON

21y · Male·external neck compression due to hanging; intentional self-harm

James Barton, aged 21, died by suicide on 27 March 2013, three days after discharge from psychiatric care. He was appropriately assessed and admitted as a mentally disordered person on 3 March following a deliberate over…

psychiatrytoxicologysystemcommunicationalprazolam
NSWhospital2017-09-07

Inquest into the death of Bruce Thomas

69y · Male·Metastatic non-small cell lung cancer on a background of dilated cardiomyopathy,…

Bruce Thomas, a 69-year-old man serving a custodial sentence, died of metastatic non-small cell lung cancer with concurrent dilated cardiomyopathy, COPD, and hypertension. Lung masses were discovered in May 2015 during a…

oncologycardiology
NSW2017-08-31

Inquest into the death of David WOTHERSPOON

31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging

David Wotherspoon, a 31-year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferr…

psychiatrycorrectional healthsystemcommunicationrisperidone
NSWhome2017-08-25

Inquest into the death of Matthew LEVESON

Male·Undetermined - no independent evidence of manner and cause established

Matthew Leveson disappeared from his Cronulla apartment on 23–24 September 2007. His remains were located in Royal National Park in May 2017 after Michael Atkins provided an induced statement to police in exchange for cr…

GHB
NSW2017-08-24

Inquest into the death of Joel MURPHY

18y · Male·Multiple injuries sustained in a motor vehicle collision

This is a fatal motor vehicle collision case involving an 18-year-old passenger killed when the driver lost control of a Toyota Hilux on a narrow, winding road (Tizzana Road, Ebenezer, NSW) at approximately 11:50 pm. The…

NSWcommunity2017-08-22

Inquest into the disappearance and death of Esmeraldo San Juan

41y · Male·Unknown; presumed drowning

Esmeraldo San Juan, a 41-year-old Filipino permanent resident, disappeared while rock fishing at Snapper Point on 19 March 2016 and is presumed to have drowned. He was last seen at 7pm intending to fish despite large wav…

NSWhospital2017-08-22

Inquest into the death of Tyson MATTHEWS

30y · Male·external neck compression due to hanging

Tyson Matthews, a 30-year-old man with long-standing mental illness (psychosis, depression, antisocial personality disorder) and substance abuse, died by hanging four days after presenting to a psychiatric emergency cent…

psychiatryemergency medicinepaliperidone
NSWcommunity2017-08-21

Inquest into the death of Samuel SEETO

29y · Male·Florid myocarditis

Samuel Seeto, a previously healthy 29-year-old, died from florid myocarditis after a general practitioner failed to detect his cardiac condition. He presented on 5 December 2015 with a 3-day history of fatigue, feeling c…

general practicecardiologydiagnosticcommunicationibuprofen
NSWhospital2017-08-21

Inquest into the death of Donald McKinnon

82y · Male·complications of metastatic pancreatic cancer with end stage liver failure

An 82-year-old man died of end-stage liver failure due to metastatic pancreatic cancer while serving a custodial sentence. He was comprehensively assessed on entry to prison and housed in an Aged Care Unit where his mult…

oncologygastroenterology
NSWcommunity2017-08-17

Inquest into the death of MC

45y · Male·gunshot wound to the chest

A man with a long history of depression, suicide attempts, and previous violent behaviour died when shot by police during an arrest for domestic violence. His partner had repeatedly warned police that he threatened to ma…

psychiatrygeneral practicecommunicationdiagnostic
NSWhome2017-08-15

Inquest into the death of Alyce POLLETT

20y · Female·unascertained

Alyce Pollett, a 20-year-old pregnant woman, was found dead in her bed on 14 July 2011 after being unwell for approximately one week with flu-like symptoms. Autopsy findings were concerning for possible asphyxia due to n…

obstetricsgeneral practicecommunicationsystem
NSWcommunity2017-08-08

Inquest into the disappearance and suspected death of Alan LY

25y · Male·Unable to be determined

Alan Ly, aged 25, disappeared on 22 September 2015 and is presumed dead. Evidence strongly suggests suicide: a handwritten note expressing long-standing suicidal ideation, recent paternal suicide, sleep disturbance, fina…

NSWhospital2017-08-07

Inquest into the death of AB

27y · Female·hanging, self-inflicted with intention of taking own life

A 27-year-old Aboriginal woman with borderline personality disorder died by suicide within hours of discharge from an emergency department. She presented after her GP attempted to schedule her under the Mental Health Act…

emergency medicinegeneral practicediagnosticcommunication
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