49y · Male·hanging
A 49-year-old man with severe schizoaffective disorder died by hanging in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attem…
49y · Female and male·Gunshot wound to head inflicted by spouse
… Lock to specialist domestic violence support services despite her explicit disclosure of intimate partner abuse; a general practitioner treating both victim and perpetrator concurrently without formal risk assessment o…
suicide by hanging or other means
Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…
31y · Female·Compression of the neck
Caitlin O'Brien, a 31-year-old nurse, was murdered by her intimate partner Shea Sturt via compression of the neck on 25 June 2019. The coroner identified multiple systemic failures in family violence recognition and risk…
23y · Male·Michael Shane Chisholm: suicide by hanging. Aaliyaha Jane Webb: killing by suffo…
Michael Chisholm, aged 23, suffocated his two young children—Aaliyaha (8) and Julian (4)—at his home, then hanged himself. A critical failure in police procedure was identified: when the mother reported missing children …
42y · Male·incised wound to the neck
Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…
17y · Male·ligature compression of the neck (hanging)
Jesse Dellar, a 17-year-old with a history of ADHD, learning disability, depression, and childhood sexual abuse, was admitted to Albany Regional Hospital on 23 November 2010 after intentionally overdosing on his …
43y · Male·suffocation by plastic bag (Neil Brooks); neck compression due to strangulation …
Two deaths investigated in joint inquest: Tracy Jayne Foster died by strangulation in December 2002; Neil James Brooks, her partner charged with her murder, died by suffocation while on remand in May 2003. The coroner id…
18y · Female, female, male·Caitlin: suicide by hanging; Talieha: suicide by hanging; William: suicide by tr…
…p breakdown. Talieha had post-traumatic stress disorder and borderline personality disorder from childhood sexual abuse; she transitioned to an adult facility (PRCCU) with reduced supervision than anticipated, and experi…
39y · Male·Effects of fire (self-immolation)
William Gourley, a 39-year-old Aboriginal and Torres Strait Islander man with a long history of mental illness, depression, cannabis dependence, and psychosis, presented to the Latrobe Regional Hospital ED on 6 March 202…
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