Coronial

125 results for domestic violence perpetrator

VICaged care2019-05-30

Finding into death of S B

87y · Male·Complications of head injuries in setting of dementia

… and enter other residents' rooms; this behaviour was a known risk but managed only by redirection. The perpetrator had a history of aggression toward staff and prior violence, though no documented aggression toward res…

geriatric medicineforensic medicinesystemcommunicationclopidogrel
VIChome2022-10-24

Finding into death of Ying Ying Zhou

36y · Female·Stab wound to the neck

Ying Ying Zhou, aged 36, was fatally stabbed in the neck by her husband Wei Hu on 14 September 2019 in a domestic violence homicide-suicide. The death was preceded by escalating family violence including threats, sexual…

general practicepsychiatrycommunicationsystem
VIChome2022-12-20

Finding into death of Wei Hu

40y · Male·Stab wound to the chest

…from a stab wound to the chest inflicted by himself following a fatal incident involving intimate partner violence. The death occurred after Mr Hu stabbed his wife Ms Zhou and then himself in the presence of their eight-…

general practicepsychiatrycommunicationsystem
VIChome2021-09-21

Finding into death of Marilyn June Burdon

70y · Female·Gunshot wounds to the head and chest

… failure to escalate to firearms licensing authorities; (3) Bisucci's psychiatrist did not receive family violence training and was unaware of his violent history and ongoing illegal firearms access, limiting risk assess…

psychiatryforensic medicinediagnosticsystem
NTcommunity2004-12-10

Inquest into the death of Roselle Nelson

16y · Female·lacerations of the liver

…imes. However, witness reluctance due to fear of retaliation prevented definitive identification of the perpetrator. The coroner referred the matter to police and prosecution for further investigation.

VIChome2024-04-23

Finding into death of Evlyn Kay James

6y · Female·Effects of fire

…ion, and financial control by her husband, but professional services initially misidentified her as the perpetrator of family violence. Despite contacts with child protection, police, and mental health services, there w…

systemcommunication
VIChome2020-12-17

Finding into death of Maddison Murphy-West

20y · Female·Neck compression

…and blood pattern evidence all indicated the death was not self-inflicted. Police had attended two family violence incidents in the two months prior (7 August and 30 September 2013) but did not adequately investigate Ms …

forensic medicinesystemdelaymethamphetamine
VIChome2022-10-06

Finding into death of Ozlem Karakoc

34y · Female·Drowning

…ness (depression, bipolar disorder, schizoaffective disorder, PTSD), and had experienced prolonged family violence from Mr Davsanoglu including controlling, emotional, and financial abuse. In the months before her death,…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VIChome2012-05-08

Finding into death of Osbournes

36y · Male·Gunshot wound to the head

…te relationships, a prior suicide attempt in 2005, and was facing criminal charges for breaching a family violence intervention order and alleged sexual assault at the time of death. Critical gaps identified include: Cri…

communicationsystem
NSWhome2025-08-28

Inquest into the death of KBS

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

…en. Family and support services were involved but were unaware the mother's partner (who had a history of violence) was living in the home. Child protection agencies did not conduct a full safety assessment following his…

paediatricsforensic medicinecommunicationsystemcannabis
ACThome2021-04-29

Inquest into the death of Bradyn Stuart Dillon

9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…

Bradyn Dillon, aged 9, was brutally beaten to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him …

paediatricsgeneral practicediagnosticcommunicationmethamphetamine
VIChome2016-04-21

Finding into death of Kelly Ann Thompson

43y · Female·Stab wounds to the chest

… did not establish that these failures directly caused the death. The case reveals serious gaps in family violence risk assessment, inter-agency information sharing, and police adherence to established procedures and pol…

psychiatrygeneral practicediagnosticcommunicationfluoxetine
VICcommunity2024-04-23

Finding into death of Carolyn Mary James

3y · Female·Effects of fire deliberately set by mother in motor vehicle

…er services had adequate contact with the family prior to the incident. Evidence revealed multiple family violence risk factors including potential coercive control by the father, social isolation, and emotional abuse. W…

general practicepsychiatrydiagnosticsystem
VIChome2025-04-11

Finding into death of EDH

32y · Female·mixed drug toxicity including phenobarbitone

…istration of pentobarbitone (Lethabarb) accessed from her workplace. She had experienced extensive family violence in a coercive relationship, including sexual assault, physical violence, and ongoing harassment despite f…

psychiatrypsychologysystemcommunicationpentobarbitone
VIChome2018-07-31

Finding into death of Joy Maree Rowley

60y · Female·strangulation and suffocation by James Mulhall

…n February 2011. The coroner found multiple systemic failures in Victoria Police's response to the family violence situation. Key issues included: failure to execute warrants promptly, failure to record critical informat…

forensic medicineemergency medicinecommunicationsystemalcohol
WAhome- 12 September 2014

Inquest into the Death of Shionah Violet Teneille CARTER

26y · Female·Unlawful Homicide - positional asphyxia during violent assault and sexual attack

A 26-year-old Aboriginal woman died from positional asphyxia during a violent assault and sexual attack by her intimate partner. She sustained traumatic brain injuries causing concussion/unconsciousness, rendering her vu…

pathologyneurologysystemcommunicationmethamphetamine
VIChome2023-11-20

Finding into death of Caitlin Mary O'Brien

31y · Female·Compression of the neck

… via compression of the neck on 25 June 2019. The coroner identified multiple systemic failures in family violence recognition and risk management. Alfred Health clinicians had documented extensive family violence histor…

psychiatryemergency medicinediagnosticcommunicationcannabis
VIChome2015-10-30

Finding into death of Sargun Ragi

22y · Female·Effects of burns

Sargun Ragi, a 22-year-old woman recently arrived from India on a spousal visa, was killed by her husband Avjit Singh in October 2012 after obtaining an intervention order and leaving their relationship. The coroner foun…

systemcommunication
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

…) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). She had been assaulted 5 days prior, experiencing significant psychological trauma, anxiety…

emergency medicinecardiologycommunicationsystemamiodarone
VIChome2015-05-08

Finding into death of Divesh Sharma

5y · Male·unascertained

…ical lessons include: healthcare professionals seeing both spouses together may miss disclosure of family violence; family violence—including controlling behaviour—was not recognised; CALD communities may lack understand…

rehabilitation medicineneurologycommunicationsystemchloroform

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