2,612 results
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…
43y · Male·asphyxia due to hanging - suicide
Brandon Sager, 43, died by suicide at the Brian Hennessy Rehabilitation Centre while subject to a psychiatric treatment order. He had a long history of schizophrenia and prior suicide attempts but had shown no signs of s…
51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…
Margaret Joy O'Donnell, aged 51, died between 9-15 June 2018. The cause of death could not be determined due to decomposition, but toxicology revealed mixed drug toxicity including fatal levels of methadone and hydromorp…
72y · Male·Multiple stab and incised wounds to the chest and neck
Barry Gray, aged 72, was killed by his 22-year-old neighbor John Woodruff on 16-17 May 2013. Woodruff had been diagnosed with first episode psychosis in prison and released on a Community Corrections Order (CCO) on 30 Ap…
49y · Male·hanging
A 49-year-old man with a history of PTSD, depression and anxiety died by suicide following police service of a warrant to vary a family violence intervention order. He learned for the first time on 2 December 2017 that h…
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…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring…
54y · Male·compression of the neck due to hanging
Anthony Lanzafame, a 54-year-old remand prisoner, died by hanging in his single cell at Adelaide Remand Centre on 24 May 2016. He had been on remand for 17 months facing murder charges and was undergoing trial when he di…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…
49y · Male·dilated cardiomyopathy due to chronic alcoholism
Jacob Cameron, aged 49, died of dilated cardiomyopathy due to chronic alcoholism while subject to a psychiatric treatment order for schizophrenia. He was found deceased at his home approximately 2-3 days after last being…
79y · Male·Complications of ischaemic heart disease
HV was a 79-year-old man who died in custody at Port Phillip Prison from complications of ischaemic heart disease. He had significant cardiac history including previous myocardial infarction, atrial fibrillation, pulmona…
27y · Male·Cause of death cannot be determined; most likely cardiac arrhythmia in the setti…
A 27-year-old man with schizophrenia subject to a Mental Health Act Treatment Order died of unknown cause, most likely cardiac arrhythmia. He had appropriate community mental health monitoring including regular appointme…
19y · Male·Hanging
Yohan Wepitiya-Gamage, a 19-year-old male remand prisoner with a history of psychosis and substance use, died by hanging in his cell at the Metropolitan Special Programs Centre in January 2016. Critical clinical lessons …
52y · Male·Stab injuries to the chest
Mark Edwards, a 52-year-old man, died by suicide via stab injuries to the chest on 11 December 2020. He had suffered a workplace injury in 2007 resulting in amputation of his right leg in 2017, chronic pain, multiple sur…
48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male
Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hypertrophy and old …
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…
42y · Male·hanging, an action taken by himself with the intention of ending his life
A 42-year-old man with acute psychosis was hospitalised for 26 days and discharged from a psychiatric facility to an isolated rural island where his partner and children had left. He had poor insight into his mental illn…
42y · Male·acute methadone intoxication
Paul William Lowe, a 42-year-old man with treatment-resistant epilepsy, schizophrenia, and long-standing opioid dependence, died from acute methadone intoxication on 12-13 August 2018. Evidence strongly indicates he inje…
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, …
9y · Female·suicide by hanging
A 9-year-old Aboriginal girl died by suicide while in out-of-home care. She had been removed from her Aboriginal parents at 10 months of age and placed with non-Aboriginal carers despite legislation requiring Aboriginal …
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