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NSW2017-08-01

Inquest into the death of BJ

Female·neck compression, as a result of hanging

BJ died on 27 August 2016 between 12:54pm and 1:40pm near Prune Street, Lavington, NSW from hanging. The death was ruled to be intentionally self-inflicted and occurred during a police operation, indicating a mental heal…

psychiatryemergency medicine
NSW2017-07-25

Inquest into the death of Paigh Bartholomew

21y · Female·mixed heroin and alprazolam toxicity

Paigh Bartholomew, 21-year-old Aboriginal woman, died from mixed heroin and alprazolam toxicity in a minimum-security correctional centre following systemic failures. She had been placed in a minimum-security facility de…

systemcommunicationheroin
NSW2017-07-13

Inquest into the suspected death of James Arthur Henney

41y · Male·unable to determine

James Arthur Henney disappeared on 13 March 1963 from his workplace, a nightclub in Sydney. His car was found abandoned near cliffs known to be used for suicide, with whiskey on the seat. Despite extensive investigations…

systemdelay
NSWhome2017-07-13

Inquest into the death of Warren MAGUIRE

40y · Male·multiple injuries sustained from fall from bathroom window

Warren Maguire, aged 40, died from multiple injuries sustained after exiting a bathroom window at his unit. The coroner found he was alive for 30-45 minutes after the fall. A concerned neighbour called police at 12:23 AM…

communicationsystemcitalopram
NSWcommunity2017-07-12

Inquest into the suspected death of missing person Benjamin Stephens

23y · Male·Unable to be determined from available evidence

Benjamin Stephens, aged 23, went missing on 18 March 2004 from rural NSW and was confirmed deceased in 2016 when his skull was discovered via DNA matching. In the months before his disappearance, Ben developed symptoms c…

psychiatrygeneral practicesystemdelayquetiapine
NSWmental health2017-07-11

Inquest into the death of CCW

68y · Female·Hypoxic Ischaemic Encephalopathy as a result of Hanging

A 68-year-old woman with longstanding psychotic illness presented to ED with acute relapse, homicidal ideation toward her husband, and vague suicidal threats. Psychiatry assessed suicide risk as low based on her denial o…

psychiatrygeriatric medicinecommunicationsystemquetiapine
NSW2017-07-11

Inquest into the death of LP

72y · Male·multiple injuries resulting from catastrophic head injury with massive disruptio…

A 72-year-old man with schizophrenia and a history of suicidal ideation died by jumping from level 7 of a shopping centre. He had stopped taking prescribed medications and had been planning this action, making calls to f…

psychiatrycorrectional health
NSWhospital2017-07-07

Inquest into the death of Benjamin Gilligan

22y · Male·Multiple injuries caused when the vehicle he was driving collided with a tree

22-year-old Benjamin Gilligan died in a motor vehicle crash while fleeing psychiatric care, having been recently diagnosed with methylamphetamine-induced psychosis. Key clinical issues identified: (1) communication break…

psychiatryemergency medicinecommunicationsystemmethamphetamine
NSWhospital2017-07-06

Inquest into the death of Kerry Forrest

56y · Female·Complications of cervical cancer

Kerry Forrest, aged 56, died in custody on 26 January 2016 from complications of advanced cervical cancer. She was serving a 25-year sentence after being diagnosed with terminal cervical cancer in 2012, prior to sentenci…

palliative careoncology
NSWhome2017-06-30

Inquiry into the fire at 58 Surveyor Street

Male·Ignition of liquid petroleum gas pooled in bedroom by cigarette lighter

Mr Bowdi Latham suffered catastrophic 75% total body surface area burns when LPG pooling in a bedroom ignited from a lighter on 4 December 2014. Investigation revealed an open copper gas pipe in the granny flat had been …

diagnosticprocedural
NSW2017-06-22

Inquest into the death of David BROWNE

28y · Male·Brain death due to large right acute subdural haematoma sustained as a result of…

David Browne died from brain death due to a subdural haematoma sustained during a professional boxing match on 11 September 2015. The coroner found the death was preventable. Critical failures occurred: the referee did n…

emergency medicineneurosurgerydiagnosticcommunication
NSW2017-06-19

Inquest into the death of Ian Baker

45y · Male·Multiple injuries sustained when struck the water after the boat lost control du…

Ian Baker, 45-year-old observer on a high-speed water ski racing boat, died from multiple injuries sustained when the vessel lost control at 187 km/hr during the Bridge to Bridge Water Ski Classic on the Hawkesbury River…

NSWhome2017-06-19

Inquest into the death of a person known as Paul LACHLAN

46y · Male·Hanging (suicide)

John Pritchard, born in the UK in 1968, died by suicide (hanging) in his Manly apartment in November 2014, having lived for 17 years under the assumed name Paul Lachlan. The inquest was primarily concerned with establish…

NSWcommunity2017-06-16

Inquest into the disappearance and suspected death of Thanagarajah SITHAMPARAPILLAI

62y · Male·undetermined

Thangarajah Sithamparapillai, a 62-year-old accountant, disappeared on 9 October 2015 after being last seen in bed appearing unwell. His car was found at Coogee beach car park. The coroner found he died on or about 9 Oct…

general practicepsychiatrydosulepin
NSWhospital2017-06-09

Inquest into the death of Colin HAY

69y · Male·Waldenstrom's Macroglobulinemia, a type of non-Hodgkin lymphoma

Colin Hay, a 69-year-old man serving a custodial sentence, died from Waldenstrom's Macroglobulinemia (a non-Hodgkin lymphoma) on 21 October 2016 in the Secure Unit Annex of Prince of Wales Hospital. He was diagnosed in J…

haematologyoncology
NSWcommunity2017-06-09

Inquest into the disappearance and suspected death of Katherine ACKLING-BRYEN

37y · Female·open finding - undetermined

Katherine Ackling-Bryen disappeared on 19 February 2016 and is presumed dead. She had a history of schizophreniform psychosis with a 2013 hospitalisation during which she expressed suicidal ideation. Post-discharge, she …

psychiatrygeneral practicesystemcommunicationanti-psychotic medication
NSWmental health2017-06-09

Inquest into the death of Ahlia RAFTERY

18y · Female·neck compression due to hanging

An 18-year-old female with depression and anxiety was admitted to a psychiatric intensive care unit (PICU) following acute suicidal ideation. Clinically significant issues included: inadequate communication of previous s…

psychiatrydiagnosticcommunicationfluoxetine
NSWhome2017-06-07

Inquest into the death of Craig LEISHMAN

46y · Male·Complications of chronic alcoholism and hypertension

Craig Leishman, 46, died from complications of chronic alcoholism and hypertension. He had a 10-year history of heavy alcohol use, liver failure (identified February 2016), and completed rehabilitation. Two weeks before …

intensive carepathologyalcohol
NSWhospital2017-06-06

Inquest into the death of Helen Ashburn

46y · Female·Prolonged effects and complications of a head injury, with upper airway obstruct…

Helen Ashburn, a 46-year-old woman with history of alcohol use, coagulopathy and seizures, died from prolonged effects of a severe head injury sustained on 25 October 2011. She presented to Kempsey Hospital with extensiv…

emergency medicineneurosurgerycommunicationdiagnostic
NSW2017-05-31

Inquest into the disappearance and suspected death of Caesar Llanto and death of Hector Collado

Male·Cesar Llanto: foul play (thrown overboard or killed); Hector Collado: multiple i…

Three deaths occurred on the bulk carrier MV Sage Sagittarius between August 30 and October 6, 2012. Cesar Llanto, the Chief Cook, disappeared in international waters; Hector Collado, the Chief Engineer, fell to his deat…

systemdelay
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