2,612 results
54y · Male·Multiple injuries from collision with motor vehicle
Terence Gray, a 54-year-old man with chronic alcohol abuse and depression, was removed from a train at Grafton by a Passenger Services Supervisor (Mr Beadman) who lacked required authorization. The supervisor cited Mr Gr…
26y · Male·neck compression in the circumstances of hanging
A 26-year-old prisoner with a history of depression died by hanging in custody at Langi Kal Kal Prison. He had been prescribed desvenlafaxine for depression and was assessed regularly by medical staff throughout his inca…
72y · Male·Hanging
A 72-year-old male inmate at Long Bay Correctional Centre died by hanging in April 2017. He had a documented history of depression managed with antidepressant medications, and his medication (mirtazapine) was adjusted tw…
57y · Male·Clozapine toxicity on a background of right lower lobe of lung lesion (unspecifi…
Joshua Brown, a 57-year-old man with treatment-resistant schizophrenia managed in the community, died from clozapine toxicity. He had accumulated over 50 tablets of clozapine at home despite being prescribed 550mg daily …
43y · Male·head, chest and abdominal injuries sustained when intentionally stepping into th…
Adrian Steven Lacroix, a 43-year-old man with a long history of mental health problems, severe depression, and suicidal ideation since 2013, died by suicide on 6 March 2021. On the day of his death, following a police ca…
51y · Male·Hanging
A 51-year-old man with mild intellectual disability from childhood head injury died by hanging following family violence separation. He perpetrated physical, emotional and verbal abuse against his wife and children over …
49y · Female·combined prescription drug intoxication (zopiclone, amitriptyline, periciazine)
Karen Tracey Reaks, aged 49, died from combined prescription drug intoxication involving zopiclone, amitriptyline, and periciazine, with systemic lupus erythematosus as a contributing factor. She ingested medications in …
46y · Male·blunt force injuries from motor vehicle collision with a tree
A 46-year-old Aboriginal man died by suicide following a motor vehicle collision with a tree while being pursued by police responding to a welfare check. He had a complex history of depression, amphetamine addiction (ice…
70y · Female·Gunshot wounds to the head and chest
Marilyn June Burdon, aged 70, was fatally shot by her intimate partner Charles Bisucci on 21 August 2017 in Kew, Victoria. Bisucci subsequently took his own life. Critical systemic failures enabled this preventable intim…
varied: sudden unexpected death in infancy (unsafe sleeping environment); drowni…
Coroner's joint inquest into deaths of seven children (six infants and one child aged 16 years) between 2014 and 2018 in Tasmania. All families had history of Child Safety Services (CSS) involvement. Coroner found no dir…
49y · Female and male·Gunshot wound to head inflicted by spouse
Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…
38y · Male·Mixed drug toxicity
DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…
35y · Male·Not determined
Benjamin Batalha, aged 35, died in custody at Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. H…
27y · Male·Effects of fire
Brendon Crippen, 27, died from severe burns sustained in a deliberately set fire at his family's property. He had recently absconded from a Tasmanian psychiatric unit where he was subject to a compulsory treatment order …
47y · Male·Hanging
A 47-year-old man with chronic schizophrenia and alcohol dependence died by hanging at a rooming house. He had been non-compliant with antipsychotic medications for months, experiencing severe auditory hallucinations tha…
26y · Female·Neck injury due to stabbing
A 26-year-old woman was stabbed twice in the neck and fatally injured by her former de facto partner. Critical clinical and systemic failures preceded her death: her psychologist failed to notify police or health authori…
62y · Female·Unascertained
Marilyn, a 62-year-old woman with schizophrenia and intellectual disability, died at Caulfield Hospital on 27 October 2019 with an unascertained cause. She was admitted via the ED under mental health legislation with det…
35y · Male·unascertained - multifactorial: underlying ischaemic heart disease, drug intoxic…
David Perry, aged 35, died from unascertained causes during police arrest at Bellbrae on 11 January 2019. He presented to The Alfred with acute paranoia, hallucinations and agitation following synthetic cannabis use, and…
24y · Male·multiple stab wounds to the chest that he inflicted upon himself
A 24-year-old man with diagnosed schizophrenia experienced a relapse and engaged in a dangerous spree involving vehicle theft, assault, and police pursuit. Despite psychiatric treatment with antipsychotics, he stopped me…
39y · Male·Complications arising from widely disseminated primary pulmonary small cell carc…
A 39-year-old male inmate died from complications of widely disseminated small cell lung cancer with hepatitis C cirrhosis. He presented with acute psychosis and catatonia in December 2018, receiving appropriate psychiat…
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