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VICmental health2020-09-18

Finding into death of Harley Robert Larking

23y · Male·Effects of fire

Harley Larking, a 23-year-old Aboriginal man with treatment-resistant schizoaffective disorder, died from effects of fire on 13 May 2016 while absconding from a psychiatric unit. He was on clozapine for only two weeks wh…

psychiatryAboriginal healthsystemdelayclozapine
VIC2020-09-18

Finding into death of Michael James McBain

44y · Male·Subarachnoid haemorrhage due to ruptured anterior communicating artery aneurysm

A 44-year-old man died in prison from subarachnoid haemorrhage due to ruptured anterior communicating artery aneurysm. He had pre-existing hypertension, depression, anxiety, and chronic pain. While at the remand centre, …

forensic medicinepsychiatrymirtazapine
NSWhospital2020-09-17

Inquest into the death of Cemil GULER

80y · Male·metastatic hepatocellular carcinoma

Cemil Guler, an 80-year-old man, died from metastatic hepatocellular carcinoma at Braeside Hospital. He was a forensic patient under Mental Health Act detention after being found not guilty by reason of mental illness of…

oncologypalliative care
VIChome2020-09-11

Finding into death of Mr A

44y · Male·compression of the neck consequent upon hanging

A 44-year-old man with a 42-year history of intimate partner violence died by hanging. He had recently separated from his wife and was enrolled in a 18-week men's behaviour change program, having completed 17 of 18 sessi…

general practicepsychiatrysystemdelayalcohol
NSWhospital2020-09-09

Inquest into the death of Grace HERINGTON

23y · Female·multiple blunt force injuries from fall from height

Grace Herington, 23, died from multiple blunt force injuries sustained in a fall from a highway off-ramp during an acute psychotic episode induced by cannabis use. She had attended Royal North Shore Hospital the previous…

emergency medicinepsychiatrycommunicationsystemcannabis
VIChospital2020-09-07

Finding into death of Ms TP

37y · Female·Hypoxic ischaemic encephalopathy as a direct result of neck compression

Ms TP, a 37-year-old woman of Indian origin living in Victoria, died from hypoxic ischaemic encephalopathy resulting from ligature strangulation (neck compression). She was admitted to ICU in cardiac arrest and died nine…

intensive careemergency medicine
VICcommunity2020-09-07

Finding into death of Ms WX

40y · Female·Injuries sustained when struck by a train (in circumstances where the deceased i…

A 40-year-old South Asian woman died by suicide when struck by a train, four weeks after arriving in Australia. She was deeply distressed by financial circumstances—construction delays on her new home and storage fees fo…

psychiatrygeneral practicesystemdelay
VIChome2020-09-07

Finding into death of Ms MH

29y · Female·Hanging

A 29-year-old South Asian woman who emigrated to Australia in 2018 died by hanging. She had a history of suicidality in India but never received mental health treatment. She experienced multiple stressors including finan…

psychiatrypublic health
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
NSWcommunity2020-09-04

Inquest into the death of Thomas HUNT

27y · Male·unascertained; likely death from entering water

Thomas Hunt, a 27-year-old man, died after entering the water near Bondi Beach on 23 March 2017, likely after experiencing an acute mental health crisis characterised by paranoid delusions and auditory hallucinations. Mu…

psychiatrygeneral practicediagnosticcommunication
VICcommunity2020-08-31

Finding into death of Gregory David Tory

48y · Male·unascertained

Gregory David Tory, aged 48, disappeared from Mallacoota, Victoria in April 2018 and is presumed deceased. He had a history of methamphetamine use with associated paranoia and thought disorder, requiring psychiatric admi…

psychiatrygeneral practicecommunicationsystemmethamphetamine
VICcommunity2020-08-28

Finding into death of Heather Telfer

69y · Female·Toxicity to pentobarbitone in circumstances where she intended to end her own li…

Heather Telfer, a 69-year-old woman with longstanding asthma, chronic health anxiety, and significant social isolation, died from pentobarbitone toxicity. She had a prior suicide attempt 12 years earlier and expressed su…

general practicerespiratory medicinecommunicationsystempentobarbitone
NSW2020-08-26

Inquest into the death of Tane Chatfield

22y · Male·hypoxic ischaemic encephalopathy as a result of hanging

Tane Chatfield, a 22-year-old Aboriginal man, died by hanging in his prison cell at Tamworth Correctional Centre on 20 September 2017. He had been admitted to hospital the preceding night with seizures, assessed as unlik…

emergency medicineneurologydiagnosticcommunicationparacetamol
NSWcommunity2020-08-25

Inquest into the disappearance and suspected death of Liam D'Arcy

36y · Male·Unknown; presumed unsurvivable injuries or drowning following intentional cliff …

Liam D'Arcy, a 36-year-old man with schizophrenia, disappeared on 23 June 2019 and is presumed to have died by intentional cliff jumping at The Gap, Watson's Bay. He had been stable on clozapine for 15 years but experien…

psychiatrycommunicationsystemclozapine
VIChome2020-08-24

Finding into death of Brittany Harvie

22y · Female·Complications of blunt force trauma to head, neck and chest

Brittany Harvie, aged 22, was killed by her de facto partner Mataio Aleluia in June 2015 following a 15-minute violent assault involving repeated punching to the head, neck and chest. She died from complications of blunt…

forensic medicinepsychiatrycommunicationsystemcannabis
VIChome2020-08-24

Finding into death of Wayne Laurence Marshall

54y · Male·Methadone use in a man with asthma and sarcoidosis of the lungs

Wayne Marshall, a 54-year-old registered nurse, died from respiratory depression caused by methadone use in the context of underlying asthma and pulmonary sarcoidosis. He was found gasping for air at home and could not b…

emergency medicineintensive caremethadone
VIChome2020-08-17

Finding into death of Benjamin James Browne

29y · Male·Incised injury to the neck

Benjamin Browne, 29, died from a neck laceration sustained during acute behavioural disturbance in August 2018. He had diagnosed major depression with anxiety, prescribed mirtazapine but attended only two psychology sess…

general practicepsychologysystemcommunicationmirtazapine
TAScommunity2020-08-13

Coroner's Finding: Wright, Maria Rebekah

31y · Female·drowning, deliberately self-inflicted with intention of ending life

Maria Rebekah Wright, a 31-year-old woman with severe borderline personality disorder and chronic suicidality, died by drowning at Howrah Beach, Tasmania on 14 August 2017. She had been discharged from Royal Hobart Hospi…

psychiatrypsychologyparacetamol
TAShome2020-08-13

Coroner's Finding: Wellington, Timothy John

44y · Male·intravenous injection of foreign debris (crushed tablets) associated with chroni…

Timothy Wellington, a 44-year-old man with longstanding opioid and polysubstance use disorder, died from acute pulmonary hypertension caused by intravenous injection of foreign debris (crushed tablets). He had been presc…

general practiceaddiction medicinemedicationsystemmethadone
TAScommunity2020-08-07

Coroner's Finding: Delios, Voula 2020 TASCD 458

63y · Female·Multiple stab wounds to neck and chest

Voula Delios, a 63-year-old grocer in Hobart, was fatally stabbed by Daryl Cook on 23 July 2016, one day after his release from prison. Cook suffered from serious untreated mental illness, evidenced by extensive prison r…

psychiatrycorrectional healthdiagnosticsystemolanzapine

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