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NSW2015-02-25

Inquiry into the Fire 1 Bankshill St Carlingford Finding

Deliberate arson by persons unknown

A deliberate fire occurred on 15 December 2012 at 1 Bankshill Crescent, Carlingford NSW, destroying a Mercedes-Benz vehicle parked in the garage. CCTV footage confirmed two unknown persons deliberately lit the fire using…

NSWhome2015-02-25

Inquest into the death of Jean Vincent GOVINDEN

32y · Male·Gunshot wound to the head (contact range of fire)

Jean Vincent Didier Govinden, aged 32, died from a self-inflicted gunshot wound to the head on 14 March 2012 during a hostage situation at the Ghalloub family home in West Ryde, NSW. Govinden had held the family at gunpo…

NSWcommunity2015-02-20

Inquest into the disappearance and suspected death of Margery Joyce TAYLOR

50y · Female·unascertained

Margery Joyce Taylor, aged 50, disappeared on 7 September 1978 from Warren, NSW. She had a long history of bipolar disorder and depression with prior psychiatric hospitalisations. Two months before disappearance, she was…

psychiatrygeneral practicesystemdelay
NSWhospital2015-02-17

Inquest into the death of Neal Richardson

48y · Male·large cell carcinoma of lung with metastases

Neal Richardson, a 48-year-old man serving a 28-year prison sentence, died of large cell carcinoma of lung with metastases while receiving palliative care at Prince of Wales Hospital. He had presented to prison health se…

palliative careoncologydiagnosticmethadone
NSWhospital2015-02-13

Inquest into the death of Baby RD

0y · Male·Head injury from non-accidental trauma (forced shaking) occurring on 11 May 2009

Baby R, born at 28 weeks gestation, died of non-accidental head injury sustained on 11 May 2009 when forcefully shaken by a person or persons unknown while in parental care. The 5-month-old presented with cardiorespirato…

paediatricsintensive carediagnosticsystem
NSWaged care2015-02-03

Inquest into the death of Annalies Malm

45y · Female·terminal epileptic seizure

Annalies Malm, a 45-year-old woman with cerebral palsy, severe intellectual disability, and epilepsy, died from a terminal epileptic seizure with aspiration pneumonia. She received incorrect medication on 7 May 2012 by a…

neurologygeneral practicemedicationlamotrigine
NSWcommunity2015-01-30

Inquest into the death of Alec Samuel MEIKLE

17y · Male·Hanging (self-inflicted)

Alec Meikle was a 17-year-old apprentice in New South Wales who experienced bullying and harassment at his workplace at Downer EDI from January to May 2008. The incidents included creation of a 'Sphincter Dilation Chart'…

psychiatrygeneral practicesystemfluoxetine
NSWcommunity2015-01-23

Inquest into the death of XY

17y · Female·multiple blunt force injuries after being struck by a train

17-year-old X died by suicide on 18 December 2012 after being struck by a train. She received multiple psychiatric admissions and CAMHS outpatient care from July-December 2012 for suicidal ideation, overdose attempts, an…

psychiatryemergency medicinefluoxetine
NSW2015-01-16

Inquest into the death of James Ciappara

14y · Male·massive blood loss and pulmonary haemorrhage due to severe trauma following a mo…

James Ciappara, aged 14, died from massive blood loss and pulmonary haemorrhage following a motor vehicle collision. He was riding a motorised bicycle (Gasman) that he had acquired by swapping his BMX bike. Police observ…

NSWcommunity2015-01-07

Inquest into the disappearance of Stuart Michael Butler

20y · Male·Drowning

Stuart Michael Butler, a 20-year-old Irish tourist with minimal surfing experience and weak swimming ability, drowned at Tallow's Beach, Byron Bay on 19 July 2014 while attempting to surf in gale-force conditions (20-30 …

NSWhome2016-08-11

Inquest into the deaths of Mr TK and Mrs TK

Female·Mrs TK: gunshot wounds to the head and left forearm inflicted by Mr TK; Mr TK: s…

Mr TK and Mrs TK died on 28 March 2014 in their Carlton home in a murder-suicide tragedy. Following prolonged marital conflict precipitated by Mrs TK's extramarital affair with a work colleague and her expression of inte…

NSWhome2014-12-22

Inquest into the death of Margaret Elizabeth HILLS

60y · Female·undetermined

Margaret Elizabeth Hills, a 60-year-old woman with chronic pain and depression from a work-related spinal injury, disappeared on 2 February 2010 from her home in Katoomba, NSW. Her skeletal remains were discovered nearly…

general practicepsychiatrycommunicationdelay
NSWhospital2014-12-19

Inquest into the death of JX

32y · Male·multiple injuries sustained in a fall from height

A 32-year-old man with a history of psychotic episodes and depression died by suicide after jumping from a cliff while experiencing an acute psychotic relapse. The case reveals critical failings in mental health crisis r…

psychiatrypsychologycommunicationsystemvenlafaxine
NSWcommunity2014-12-18

Inquest into the death of Kenneth MAWBY

59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…

A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease. Post-operatively, he experienced significant behavioural changes including agita…

neurologyneurosurgerycommunicationsystemmadopar
NSWcommunity2014-12-16

Inquest into the death of Massimo SUKLAN

59y · Male·opiate toxicity

Massimo Suklan, a 59-year-old man with schizo-affective disorder, chronic pain, liver disease and hepatitis, died from opiate toxicity while living in primitive conditions at a mining camp near Lightning Ridge. He had re…

psychiatrygeneral practicesystemmorphine
NSW2014-12-09

Inquest into the death of Frederick Alfred McGREGOR

69y · Male·head injury sustained from assault

Frederick McGregor, aged 69, died from head injuries sustained in a violent assault by another detainee while in court cell custody. McGregor was placed in a cell with an 18-year-old who assaulted him after believing McG…

systemcommunication
NSWhospital2014-12-05

Inquest into the death of Edna Beryl WHALEN

89y · Female·Pulmonary embolism due to deep venous thrombosis

Edna Beryl Whalen, aged 89, died from pulmonary embolism secondary to deep vein thrombosis following delayed diagnosis of a femoral neck fracture. She fell on 8 January 2007 at an aged care facility and reported hip pain…

emergency medicineorthopaedic surgerydiagnosticdelay
NSW2014-11-27

Inquest into the death of DF (n/a,PDF File)

suicide

A death occurred during police operations in New South Wales, with suicide as the underlying cause. The Deputy State Coroner Dillon's inquest concluded on 27 November 2014. The coroner's investigation and findings determ…

NSW2014-11-27

Inquest into the death of Norma (n/a,PDF File)

Female

The coroner's findings in this inquest were removed due to potential prejudice to ongoing prosecution. The inquest concerned the death of Norma, with a decision issued by State Coroner Barnes on 27 November 2014 in NSW.

NSWhome2014-11-20

Inquests into the death MB and KB

Unknown·Sudden Infant Death Syndrome Category II (for both MB and KB)

Two infant deaths in the same family from unsafe sleeping environments: MB (9 months) died in 2006 on a lounge with parents, categorised as SIDS Category II; KB (24 days) died in 2013 co-sleeping on a lounge with her mot…

paediatricspathologysystemdelay
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