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NSW2025-08-12

Inquest into the death of ZY

Female·Neck compression

Ms ZY died on 8 October 2023 in Riverwood, New South Wales. The cause of death was neck compression, and the manner of death was homicide by a person known to the deceased. Deputy State Coroner Carmel Forbes conducted an…

NSWcommunity2025-08-08

Inquest into the death of Stephen Douglas

62y · Male·Multiple sharp force injuries intentionally inflicted by client during home visi…

Stephen James Douglas, a 62-year-old community mental health nurse, was killed on 28 November 2019 by his client Peter Kemball during a home visit. Kemball had chronic schizophrenia and was experiencing psychosis with de…

psychiatrygeneral practicediagnosticsystempaliperidone
NSWhome2025-08-08

Inquest into the death of Jacob

0y · Male·Non-accidental infliction of significant force to the head/face and gum region, …

Jacob, a premature infant born at 29 weeks, was discharged from neonatal care at 11 weeks old and presented to hospital three days later with a subarachnoid haemorrhage and periorbital bruising. Despite being assessed as…

paediatricsforensic medicinediagnosticsystemmethamphetamine
NSWcustody2025-08-07

Inquest into the death of Lathan Brown

28y · Male·Cardiac arrhythmia

Lathan Brown, a 28-year-old Aboriginal man, died of cardiac arrhythmia while in custody at Wellington Correctional Centre on 6 January 2024. He suffered sudden cardiac arrest in his cell; emergency response was appropria…

cardiologyemergency medicinecommunicationsystem
NSW2025-07-31

Inquest into the death of Bruce John Hitchen

40y · Male·Unascertained

Bruce John Hitchen disappeared on or after 6 July 1987 when released from custody, with no confirmed sightings thereafter. The coroner found him deceased based on 38 years of absence, lack of any financial activity, no M…

systemdelay
NSWhome2025-07-30

Inquest into the death of Hilary Gordon-Squire

65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…

A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…

forensic medicinegeneral practicesystemdelaybenzodiazepines
NSW2025-07-24

Inquest into the death of PF

45y · Male·Hanging

PF, aged 45, died by hanging in custody at South Coast Correctional Centre following bail refusal and adverse legal advice. The coroner found his death was intentional self-harm. Although PF had a significant history of …

psychiatrypsychologydelay
NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
NSWhospital2025-07-22

Inquest into the death of Prabha Arunkumar

41y · Female·multiple stab wounds to the neck

This inquest examined the death of Prabha Arunkumar, a 41-year-old computer programmer who died from multiple stab wounds to the neck sustained during an attack in Parramatta Park on 7 March 2015. She was transported to …

trauma surgeryvascular surgery
NSWhospital2025-07-21

Inquest into the death of Colin Whaley

62y · Male·Complications of metastatic malignancy (likely lung primary)

Colin James Whaley, aged 62, died from complications of metastatic lung cancer while in custody at Junee Correctional Centre. He was a heavy smoker admitted to prison in June 2023. Significant weight loss (40kg) during i…

oncologypalliative care
NSWcommunity2025-07-15

Inquest into the disappearance and suspected death of Zac Barnes

18y · Male·unknown - available evidence does not allow for any finding to be made as to the…

This inquest concerns Zac Eran Barnes, an 18-year-old who disappeared on 13 November 2016 from Thornton, NSW, and is presumed deceased. The coroner found on the balance of probabilities that Zac died in suspicious circum…

systemMDMA
NSWhome2025-07-10

Inquest into the death of Min Young CHOI

42y · Male·Unascertained

A 42-year-old male of Korean nationality was found deceased in his apartment after an odour complaint. The body was severely decomposed, limiting forensic investigation. Post-mortem examination revealed no acute trauma, …

forensic medicineparacetamol
NSWcommunity2025-07-10

Inquest into the death of Nathan Markl

31y · Male·Drowning

Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…

psychiatryaddiction medicinesystemdelaymethamphetamine
NSW2025-07-08

Inquest into the death of SF

19y · Male·Hanging

SF, a 19-year-old remand inmate with no prior custodial or mental health history, died by hanging in Goulburn Correctional Centre 18 hours after requesting protective placement due to safety fears. He had expressed depre…

correctional healthpsychiatrycommunicationsystem
NSW2025-06-24

Inquest into the death of Scott Orrock

55y · Male·Multiple blunt force injuries

Scott Orrock, a 55-year-old experienced motorcyclist, died from multiple blunt force injuries following two successive motor vehicle collisions on the M4 Motorway westbound near the James Ruse Drive exit on 2 April 2020.…

system
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
NSWhome2025-06-18

Inquest into the death of Hillal Barbour Interlocutory Application Decision

Male·Gunshot wounds to the chest and lower abdomen

Hillal Barbour died from gunshot wounds sustained during a police response to a 000 call reporting welfare concerns. Officers responded to reports that Hillal was holding a shovel and following his mother. When police ar…

paramedicine
NSWhospital2025-06-17

Inquest into the Death of Philip William Walker

77y · Male·Aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopa…

Philip Walker, 77, died of aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopathy, COPD and atrial fibrillation while in prison custody. He had complex medical needs including dysphagia from …

respiratory medicineinfectious diseases
NSW2025-06-12

Inquest into the death of Roland Ashbolt

39y · Male·clozapine toxicity

Roland Ashbolt, a 39-year-old man remanded in custody with schizophrenia, died from clozapine toxicity. He had been prescribed clozapine (400mg daily) from January 2022 with good clinical response and therapeutic levels.…

psychiatryforensic medicineclozapine
NSW2025-06-03

Inquest into the death of Glenn Yates

52y · Male·Unascertained

Glenn Yates, a 52-year-old man, died in misadventure while travelling by boat in the ocean off Eden NSW. His death was unascertained, occurring during boat travel in November 2020. The coronial investigation found no sus…

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