2,612 results
35y · Male·Hanging
Brett McDonnell, a 36-year-old man, died by hanging in January 2018 while subject to a Community Corrections Order and facing pending criminal charges. He had a history of depression treated with Pristiq since 2015, but …
45y · Male·Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)
A 45-year-old male prisoner died in custody from combined drug toxicity after ingesting methadone, amitriptyline, gabapentin and paracetamol. He had a documented history of hoarding and misusing prescribed medications to…
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…
64y · Male·Heart failure secondary to alcohol related liver disease, coronary obstructive p…
Emanuel Mavridis, aged 64, died of heart failure secondary to alcohol-related liver disease, COPD, and ischaemic/alcoholic cardiomyopathy. He presented to Royal Adelaide Hospital hypotensive with metabolic acidosis and w…
72y · Male·ischaemic heart disease on a background of end-stage renal failure and frontotem…
Brenton Dutschke, aged 72, died of ischaemic heart disease on a background of end-stage renal failure and frontotemporal dementia while on a Level 3 Inpatient Treatment Order at Oakden Mental Health's Makk House. He had …
76y · Female·left lower lobe pneumonia complicating metapneumovirus infection
Maria Astachnowicz, aged 76, died from left lower lobe pneumonia complicating metapneumovirus infection at Lyell McEwin Hospital. She had extensive psychiatric history (schizoaffective disorder/bipolar) with chronic ment…
46y · Female·Hypoxic brain injury in the setting of plastic bag asphyxia
Michelle Williams, a 46-year-old woman with longstanding schizophrenia and depression, died from hypoxic brain injury due to plastic bag asphyxia while an involuntary inpatient in a psychiatric unit. On 27 August 2016, d…
82y · Male·atherosclerotic and hypertensive cardiovascular disease
Joseph Richard Oakley, aged 82, died from atherosclerotic and hypertensive cardiovascular disease at the Roy Fagan Centre, a psychiatric hospital for older persons. He had advanced Parkinson's disease, dementia, diabetes…
Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…
Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …
volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…
This inquest examines three children (Master W aged 12, Miss B aged 17, Master JK aged 13) who died from volatile substance abuse in remote Aboriginal communities in the NT between 2018-2019. All three were known to gove…
43y · Male·blunt neck trauma from compression of the neck
Stephen John Barton, aged 43, died from blunt neck trauma inflicted by roommate Lindon Sekrst in a psychiatric ward. Both were detained patients under Mental Health Act orders. Sekrst, a 23-year-old with paranoid ideatio…
30y · Male·unascertained
Daniel James Clement, a 30-year-old man with schizophrenia on a Psychiatric Treatment Order, disappeared from his mother's home in late May 2017 and was found deceased on the Murrumbidgee River in November 2017. His caus…
45y · Male·Shotgun wound to the head
XY, a 45-year-old Aboriginal man, died from a self-inflicted gunshot wound during a police response to a domestic violence incident. He had been struggling with depression, grief, alcohol and methamphetamine use for year…
38y · Male·asphyxiation by ligature
A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotic…
34y · Female·morphine toxicity (morphine probably ingested as heroin), accidental death
A 34-year-old woman subject to a Psychiatric Treatment Order died from morphine toxicity (accidental heroin overdose). While no deficiency in clinical care was identified, the coroner highlighted a critical gap in inform…
20y · Female·Plastic bag asphyxia with inhalation of helium
A 20-year-old woman with a history of depression, anxiety, and self-harm died by helium inhalation asphyxia. She had been treated by her GP with antidepressants and mental health referral to a psychologist but never disc…
81y · Male·plastic bag asphyxia
George Cameron, an 81-year-old man, died by asphyxiation using a plastic bag while in custody at Parklea Correctional Centre on 8 September 2017. He had been remanded in custody three days earlier after arrest. A Recepti…
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…
20y · Male·Hanging
Mitchell Boyd Branson, aged 20, died by hanging in Mildura in June 2019. He had a documented history of mental illness including PTSD stemming from exposure to traumatic internet imagery at age 10, a prior suicide attemp…
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…
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