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NSWcommunity2021-05-21

Inquest into the death of Pono Wairua Aperahama

17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…

Pono Aperahama, a 17-year-old with severe traumatic brain injury and moderate intellectual disability, died from cardiac arrhythmia during restraint at a swimming pool. His escalating behaviour in 2017—triggered by schoo…

neurologypsychiatrysystemcommunication
VIChome2021-05-20

Finding into death of Brodie Moran

8y · Male·Suffocation

Brodie Moran, an 8-year-old boy, died by suffocation at the hands of his mother, Ms Finch, on 8 March 2018. Ms Finch had a history of depression and anxiety, experiencing significant deterioration in mental health follow…

general practicepsychiatrysystemvenlafaxine
TAScommunity2021-05-12

Coroner's Finding: Ghanbarzadeh, Masoud

51y · Male·blunt trauma of the chest sustained in a motor vehicle crash; hypovolemic shock …

A 51-year-old man with schizophrenia, bipolar disorder, chronic pain, and substance use disorder died from blunt chest trauma following a motor vehicle crash. He had a history of two previous crashes associated with high…

general practicepsychiatrycommunicationdiazepam
TAShome2021-05-12

Coroner's Finding: NB

32y · Male·contact range gunshot wound to the forehead, self-inflicted

A 32-year-old male with long-standing depression and Asperger's syndrome died by firearm suicide. His medical care was appropriate and well-managed. However, critical systemic failures occurred in firearms licensing. He …

psychiatrygeneral practicesystem
NSW2021-05-12

Inquest into the death of Jack KOKAUA

30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …

Jack Kokaua, a 30-year-old with schizophrenia and coronary artery disease, died from malignant ventricular arrhythmia during a police encounter after absconding from hospital. Contributing factors included positional asp…

emergency medicinepsychiatryproceduralcommunicationzuclopenthixol
WAcommunity2021-05-11

Inquest into the Death of Janice Ann CROFT

64y · Female·phosphine toxicity from deliberate ingestion of aluminium phosphide fumigation p…

Janice Croft, 64, died from phosphine toxicity after deliberately ingesting fumigation pellets during a police intervention on her property facing eviction for mortgage default. Ms Croft had long-standing bipolar disorde…

emergency medicinetoxicologysystemlithium
WAhome2021-05-10

Inquest into the Death of Andre Walter BOND

42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…

Andre Walter Bond, a 42-year-old man with schizophrenia, schizoaffective disorder, Asperger's syndrome, and severe obesity, died from upper airway obstruction (choking) on food while dining at home. He had been recently …

psychiatryemergency medicinequetiapine
VIChospital2021-05-10

Finding into death of Karim Aarras

45y · Male·Blood loss due to multiple self-inflicted incised injuries

Karim Aarras, a 45-year-old man with longstanding mental health issues, chronic pain, and substance use disorder (methamphetamine), presented to police in a severely agitated state following self-harm with a broken bottl…

psychiatryemergency medicinemethamphetamine
VIC2021-05-07

Finding into death of Joanne Finch

42y · Female·Neck compression due to self-suspension

Joanne Finch, a 42-year-old woman remanded in custody on charges related to her son's death, died by hanging in her cell at Dame Phyllis Frost Centre on 24 July 2018. She had chronic suicidal ideation with periods of acu…

psychiatrypsychologyolanzapine
VIChome2021-05-07

Finding into death of Gwen Adeline Smith

91y · Female·Gunshot wound to the head

Gwen Adeline Smith, 91, was fatally shot by her husband Arthur Smith on 25 July 2018 at their home in Parwan, Victoria. Mr Smith then died by suicide. The couple had been experiencing significant stressors including fina…

general practicecardiothoracic surgerydoxepin
VICcommunity2021-05-07

Finding into death of Michael Gerald Anthony

26y · Male·Hypoxic ischaemic encephalopathy in the context of neck compression

A 26-year-old man with longstanding mental health issues and substance use died from hypoxic ischaemic encephalopathy caused by neck compression during a physical altercation with his brother at a family event. Mr Anthon…

forensic medicineintensive carealcohol
NSWhospital2021-05-07

Inquest into the death of Channa

26y · Male·multiple injuries from fall from height

A 26-year-old man with schizophrenia was discharged from mental health inpatient care on a community treatment order without meeting his allocated case manager, confirmed accommodation, or drug and alcohol intervention. …

psychiatryemergency medicinecommunicationdelaypaliperidone
NSWcommunity2021-05-07

Inquest into the death of S

42y · Male·Gunshot wound to the head

A 42-year-old NSW Police Sergeant died from a self-inflicted gunshot wound while on highway patrol duty. One week prior, he had been notified of a criminal misconduct investigation by Professional Standards Command, but …

psychiatryoccupational and environmental healthsystemcommunication
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

A 3-year-old girl was killed by her mother, who was experiencing a severe psychotic episode with suicidal and homicidal ideation. The mother had a history of Brief Psychotic Disorder (diagnosed 2015), was on olanzapine 1…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChome2021-05-05

Finding into death of Aisha Devi Beck

39y · Female·Gunshot wound to the head

A 39-year-old woman with brief psychotic disorder experiencing suicidal and homicidal ideation killed her 4-year-old daughter and herself. She had been diagnosed with psychosis in 2015, treated with olanzapine, and disch…

psychiatrygeneral practicecommunicationsystemolanzapine
QLD2021-05-04

Hambly, Scott

38y · Male·Aspiration pneumonia

Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …

cardiologypsychiatrycommunicationsystembisoprolol
VICcommunity2021-04-30

Finding into death of Kent Thomas

68y · Male·Hanging

Kent Thomas, aged 68, died by hanging in December 2018. He had experienced chronic tinnitus since 2013 which severely impacted his mental health and quality of life. Despite referral to mental health services and a reaso…

general practicepsychiatrydiagnosticdelayclonazepam
NSWhome2021-04-30

Inquest into the deaths of Gabriella THOMPSON and Tafari WALTON

27y · Male·Gabriella: Multiple stab wounds; Tafari: Gunshot injuries to the head and abdome…

Two deaths in a domestic violence and police operation context. Gabriella Thompson, 27, was fatally stabbed by her partner Tafari Walton in domestic violence circumstances on 13 March 2019. Police received a concern for …

psychiatrygeneral practicecommunicationsystemmethamphetamine
VIC2021-04-29

Finding into death of Spiros Boursinos

45y · Male·coronary artery disease and mechanical asphyxia in a man using cocaine

A 45-year-old man with a history of drug-induced psychosis, cocaine use, and underlying coronary artery disease died in police custody following physical restraint at a licensed bar. After consuming cocaine, he experienc…

emergency medicinepsychiatrycocaine
VIC2021-04-28

Finding into death of Mohamed Omar

30y · Male·neck compression

Mohamed Omar, a 30-year-old man with schizophrenia, died in Melbourne Assessment Prison on 25 June 2017 from neck compression while on remand. He had a history of command auditory hallucinations instructing self-harm, re…

psychiatrycorrectional healthflupenthixol depot injection

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