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WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…

psychiatryemergency medicinedelaysystemrisperidone depot
WAhome2021-08-10

Inquest into the Death of Scott William MARTIN

40y · Male·Penetrating wounds to the chest

Scott William Martin, aged 40, was fatally stabbed in his apartment in Halls Head, Western Australia in January 2017 by Damian Maxfield, who was experiencing a methamphetamine-induced psychotic episode. Maxfield had been…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
WAhospital2021-07-30

Inquest into the Death of Chad RILEY

39y · Male·Cardiac arrhythmia following violent exertion necessitating physical restraint i…

39-year-old Chad Riley died from cardiac arrhythmia following violent exertion during physical restraint. He presented to hospital intoxicated with methylamphetamine, exhibiting drug-induced psychosis with agitation and …

emergency medicinepsychiatrysystemmethamphetamine
WAmental health2021-06-29

Inquest into the Death of Samuel Mark WALSH

38y · Male·carbon monoxide toxicity

Samuel Mark Walsh died by carbon monoxide toxicity (suicide) in October 2014 while subject to a custody order for a forensic mental health condition. He had paranoid schizophrenia and had been remarkably stable on clozap…

psychiatrypharmacydelaysystemclozapine
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
WAhome2021-03-25

Inquest into the Death of FJ (Name Subject to Suppression Order)

35y · Female·multiple injuries sustained in fall from sixth-floor balcony

FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…

psychiatrygeneral practicecommunicationsystemlithium
WAcommunity2021-03-25

Inquest into the Suspected Death of Jason Marcus LAWSON

32y · Male·unascertained; most likely exposure after walking in bushland

Jason Marcus Lawson, a 32-year-old man with a complex psychiatric history including depression, anxiety, polysubstance use, and previous suicide attempts, disappeared on 11 December 2003, one week after discharge from an…

psychiatrypsychologycommunicationdelaycitalopram
WAhospital2021-03-08

Inquest into the Death of Stephen Craig SOLLY

63y · Male·respiratory failure in a man with lung cancer, chronic obstructive pulmonary dis…

Stephen Craig Solly, aged 63, died from respiratory failure due to advanced lung cancer, COPD, and pulmonary fibrosis while an involuntary psychiatric patient at Graylands Hospital. He had paranoid schizophrenia, cogniti…

psychiatryrespiratory medicineduloxetine
WA2020-12-22

Inquest into the Death of Jordan Robert ANDERSON

23y · Male·hypoxic brain injury and bronchopneumonia complicating ligature compression of t…

Jordan Robert Anderson, 23, died by suicide in Hakea Prison through ligature compression of the neck. Critical delays occurred when he was discovered unresponsive: 3 minutes 40 seconds elapsed before his cell door was un…

emergency medicinecardiologyproceduralcommunication
WAhospital2020-12-02

Inquest into the Death of Simon John SHARPE

Male·non-specific interstitial pneumonia

Simon John Sharpe, a sentenced prisoner with incurable non-specific interstitial pneumonia, died on 30 June 2017 at Fiona Stanley Hospital from progression of his lung disease. Throughout his 17-month imprisonment, Sharp…

respiratory medicinetransplant medicine
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…

psychiatrypsychologydiagnosticsystemmethamphetamine
WAcommunity2020-11-05

Inquest into the Suspected Death of Paul Clifford YORK

45y · Male·unascertained

Paul Clifford York, 45, disappeared from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdos…

psychiatrygeneral practicediagnosticsystemmirtazapine
WAcommunity2020-11-04

Inquest into the Death of Andrew John KEY

49y · Male·incised injury to the neck

Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health asse…

psychiatryemergency medicinecommunicationsystemquetiapine
WAprison2020-11-04

Inquest into the Death of Damien PURNELL

47y · Male·organ failure following cardiorespiratory impairment in a man with arteriosclero…

Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synthetic cannabinoids (Kronic). Despite immediate re…

emergency medicineintensive caresystemmethadone
WAhospital2020-10-08

Inquest into the Death of Wayne Frederick LEESE

54y · Male·Complications including hepatic encephalopathy, pneumonia and multi-organ failur…

Wayne Frederick Leese, a 54-year-old prisoner, died from complications of hepatitis C and hepatocellular carcinoma including hepatic encephalopathy, pneumonia and multi-organ failure. He collapsed at Acacia Prison on 4 M…

hepatologyemergency medicinemethadone
WA2020-09-04

Inquest into the Suspected Death of Marek PETERA

41y · Male·suicide by unknown method, either through deliberate self-harm or by placing him…

Marek Petera, a 41-year-old Slovak-born Australian resident, disappeared from Drysdale River Station in Western Australia on 27 July 1999. He had left a suicide note for his daughter in June 1999, describing severe depre…

psychiatrygeneral practicediazepam
WAmental health2020-08-06

Inquest into the Death of Stephen Michael KELL

35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…

Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…

psychiatrygastroenterologysystemdelayclozapine
WAhome2020-07-16

Inquest into the Death of CHILD RM

17y · Female·ligature compression of the neck (hanging)

A 17-year-old girl in state care died by suicide on 16 April 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver…

paediatricspsychiatrysystemcommunicationalcohol
WAhospital2020-05-26

Inquest into the Death of Nualla Christine REILLY

74y · Female·Multiple injuries sustained when struck by train

A 74-year-old woman with borderline personality disorder, depression, anxiety and type 2 diabetes died by suicide after absconding from Fiona Stanley Hospital Emergency Department. She had been on extended psychiatric ad…

psychiatryemergency medicinecommunicationsystemamitriptyline
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