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WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…

psychiatryintensive carecommunicationsystempaliperidone
WAprison2024-06-12

Inquest into the Death of Alf Deon EADES

46y · Male·head injury complicated by bronchopneumonia, with palliation

A 46-year-old remand prisoner died from traumatic brain injury sustained during a severe prison assault. Critical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress…

correctional healthneurosurgerycommunicationsystem
WA2024-06-12

Inquest into the Death of Petra Michelle MARQUIS

40y · Female·ligature compression of the neck (hanging)

Petra Michelle Marquis, a 40-year-old woman with a documented history of mental health issues including depression, anxiety, PTSD, and borderline personality disorder, died by suicide while in police custody after being …

psychiatryemergency medicineduloxetine
WAhome2024-05-28

Inquest into the Death of Cameron Anthony FYFE

27y · Male·gunshot injury to the head

A 27-year-old Western Australian police officer with a longstanding history of depression and anxiety took his own life using his police-issued firearm stored at home. He had struggled with mental health since 2017, atte…

occupational and environmental healthpsychiatrysystemcommunicationdesvenlafaxine
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

0y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
WAmental health2024-05-17

Inquest into the Death of Richard Anthony BOROS

50y · Male·upper airway obstruction (choking) from tissue paper

Richard Anthony Boros, a 50-year-old man with paranoid schizophrenia, died from upper airway obstruction (asphyxiation) after intentionally swallowing a dense ball of tissue paper while in the mental health assessment un…

psychiatryemergency medicinecommunicationsystemolanzapine
WA2024-05-08

Inquest into the Death of Michael John BIRD

22y · Male·Multiple injuries from fall from 21st floor balcony

Michael Bird, 22, died by suicide on 17 March 2022, jumping from the 21st floor of his new workplace on his first day as building manager. He had been experiencing auditory hallucinations and paranoid delusions about pol…

general practicepsychiatrycommunicationsystemzolpidem
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 January 2022 with self-harm and active suicidal ideation with a st…

emergency medicinepsychiatrysystemdelay
WAcommunity2024-04-26

Inquest into the Death of Warren John BULLOCK

49y · Male·Cardiac arrhythmia in a man with methylamphetamine effect and cardiomegaly

Warren John Bullock, aged 49, died from cardiac arrhythmia in the context of methylamphetamine effect and cardiomegaly on 1 July 2022 in Western Australia. He was being pursued by police following serious criminal allega…

methamphetamine
WAhospital2024-04-10

Inquest into the Death of Alan David RATCLIFF

65y · Male·complications of intracranial haemorrhage (hypertensive haemorrhage), with termi…

Alan David Ratcliff, a 65-year-old prisoner at Acacia Prison, died from complications of intracranial haemorrhage (hypertensive haemorrhage) on 20 June 2022. He collapsed on 12 June 2022 with stroke symptoms and was hosp…

neurologyemergency medicinedelay
WAhospital2024-04-08

Inquest into the Death of Child SK (Name Subject to Suppression Order)

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinici…

psychiatryemergency medicinesystemdelaysertraline
WAmental health2024-04-08

Inquest into the Death of Paul McLOUGHLIN

59y · Male·incised injuries to the neck

Paul McLoughlin, a 59-year-old man with long-standing bipolar affective disorder, schizoaffective disorder, and heavy cannabis use, died by suicide via incised neck wounds while on day leave from Graylands Hospital. He w…

psychiatryvenlafaxine
WAhospital2024-04-05

Inquest into the Suspected Death of Neil Lindsay KOBELT

27y · Male·unascertained

Neil Lindsay Kobelt, a 27-year-old man with diagnosed schizophrenia, disappeared from Kalgoorlie, Western Australia in February 1982, shortly after discharge from hospital for acute psychiatric crisis. He had relocated t…

psychiatrygeneral medicinecommunicationsystem
WAhome2024-04-04

Inquest into the Death of Child LT (Name Subject to Suppression Order)

11y · Male·unascertained

An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…

paediatricscardiologycommunicationsystemcocaine
WAhospital2024-04-04

Inquest into the Death of Karl Frederick Dominic HOLMES

66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …

Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellen…

oncologypalliative caresystemdelaymorphine
WAcommunity2024-03-26

Inquest into the Death of Damien Lyndon WOODS

18y · Male·Immersion (drowning) shortly after being washed into the sea whilst fishing off …

Damien Woods, 18, was swept into the Indian Ocean while rock fishing at Waychinicup National Park on 27 February 2021 when large waves knocked him and his cousin into treacherous waters. Although his cousin was rescued, …

WAmental health2024-03-07

Inquest into the Death of Petya Evgenieva PETROVA-CIZEK

41y · Female·ligature compression of the neck (hanging)

Petya, a 41-year-old Bulgarian-born woman, died by ligature compression of the neck while an involuntary psychiatric patient at Bentley Health Service Ward 6 on 16 December 2020. She had been admitted following acute psy…

psychiatrydiagnosticcommunicationescitalopram
WAprison2024-02-21

Inquest into the Death of Iain Campbell BUCHANAN

65y · Male·complications, including pneumonia, of traumatic brain injury

A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…

neurosurgeryemergency medicinedelaysystem
WA2024-02-06

Inquest into the Death of Phillip John ALLEN

47y · Male·ligature compression of the neck (hanging)

A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation, delusions about 'black magic', and auditory hallucinations, which wer…

psychiatrycorrectional healthcommunicationsystem
WAcommunity2024-01-22

Inquest into the Suspected Death of Tristan FRANK

14y · Male·unascertained

Tristan Frank, a 14-year-old Aboriginal boy from the Northern Territory, disappeared from Balgo Community, Western Australia on 3 December 2020. Extensive land searches involving police, community members, and specialist…

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