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NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…

psychiatrycorrectional healthsystemcommunicationmethadone
NSWcommunity2025-09-18

Inquest into the death of Hillal Barbour

29y · Male·gunshot wound to the chest

Hillal Barbour, a 29-year-old man with schizophrenia, was fatally shot by police responding to a domestic violence call. He emerged from his home armed with two knives and advanced towards officers despite their instruct…

psychiatryemergency medicinecannabis
NSW2025-09-15

Inquest into the death of Robert Sievers

81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…

Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…

geriatric medicinepalliative careantiviral medication
NSWcommunity2025-09-11

Inquest into the disappearance and suspected death of Andrew Corton

47y · Male·presumed death, actual cause unknown

Andrew Patrick Reuben Corton, a 47-year-old man with schizophrenia and cannabis use, disappeared and is presumed deceased. He was last sighted years before being reported missing. He resided in boarding houses and subseq…

psychiatryemergency medicinecommunicationsystemcannabis
NSWhome2025-09-11

Inquest into the death of H GM

0y · Female·Unascertained

A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…

paediatricsemergency medicinediagnostic
NSWprison2025-09-10

Inquest into the death of RD

70y · Male·death by hanging, self-inflicted

A 70-year-old man died by hanging in prison while serving a sentence for child sexual offences. He had previously attempted suicide in 2017 when initially charged, and was subsequently treated with antidepressants and ps…

psychiatrygeneral practicecommunicationsystemsertraline
NSWcommunity2025-09-08

Inquest into the death of Rohan Lloyd

37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …

A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…

psychiatrygeneral practicediagnosticmedicationrisperidone
NSWprison2025-09-05

Inquest into the death of Dushyanthan Visvanathan

55y · Male·Complications of alcohol use disorder

Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…

addiction medicineemergency medicinecommunicationdocumentationdiazepam
NSWhome2025-09-04

Inquest into the death of Baby MA

0y · Female·Unascertained

An unnamed full-term baby was found deceased at Edmondson Park on 19 February 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's existence. Po…

obstetricsemergency medicinedelay
NSW2025-09-03

Inquest into the death of Daniel Leehy

47y · Male·ischaemic heart disease with seizure disorder and schizophrenia being other sign…

Daniel Leehy, a 47-year-old man in custody, died from ischaemic heart disease with significant coronary artery narrowing (60-80%) identified at autopsy. He had a 42-year history of epilepsy and schizophrenia with frequen…

forensic medicinepsychiatrysodium valproate
NSW2025-09-02

Inquest into the death of Robert Muir

64y · Male·Unascertained

Robert Alexander Muir, a 64-year-old man, was found deceased in Audley Cave in the Royal National Park in November 2022. He had been homeless, regularly attending the One Meal charity service from around 2014 until Decem…

forensic medicinepublic health
NSWhome2025-08-28

Inquest into the death of KBS

1y · Male·Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrh…

A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib fractures, extensive bruising, and patterned…

paediatricsforensic medicinecommunicationsystemcannabis
NSWhome2025-08-26

Inquest into the death of Valmai Jane Birch

34y · Female·Unascertained (possibilities: positional asphyxia, drowning, neck compression, d…

Valmai Jane Birch, a 34-year-old woman with a history of drug use, died between 9-21 March 2011 in circumstances that constituted homicide by her partner David Bagster. Her body was found face-down in a wheelie bin with …

forensic medicinemorphine
NSWcommunity2025-08-25

Inquest into the death of Ashley Paull

49y · Male·Multiple injuries sustained when struck by a truck

Ashley Paull, a 49-year-old Aboriginal man with schizophrenia, died after being struck by a truck while walking along the Pacific Highway following his release from police custody. He had been stopped for a positive road…

psychiatryemergency medicinecommunicationsystemmethamphetamine
NSWhospital2025-08-22

Inquest into the death of Frank Valentine

83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…

Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) and anaemia as contributory conditions. He was serv…

cardiologygastroenterologywarfarin
NSWcommunity2025-08-22

Inquest into the disappearance and suspected death of Habtom Ghilagaber

30y · Male·unknown - no postmortem examination performed

This inquest examined the 1995 disappearance of Habtom Ghilagaber, a 30-year-old Eritrean mathematics PhD student at UNSW who was reported missing on 25 September 1995, having last been seen alive on 5 September 1995. Th…

psychiatrypsychologysystemcommunicationantipsychotic medication
NSW2025-08-22

Inquest into the death of Michael Black

33y · Male·stab wound to the chest

Michael Black, a 33-year-old First Nations man, died from a stab wound to the chest while detained at Parklea Correctional Centre on 22 April 2020. He was stabbed by fellow inmate Emmett Sheard in a crowded holding cell …

correctional healthaddiction medicinediagnosticsystembuprenorphine
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…

emergency medicineendocrinologycommunicationdiagnosticmetformin
NSWhospital2025-08-14

Inquest into the death of Margaret Mariani

88y · Female·Complications of cholecystectomy surgery

Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to perito…

surgerygeneral surgerycommunicationdelayfentanyl
NSWmental health2025-08-13

Inquest into the death of Allyson Bailey

42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…

Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…

emergency medicineintensive carediagnosticcommunicationbaclofen
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