2,619 results
20y · Male·hanging
BK was a 20-year-old male with a history of depression diagnosed in 2015 who died by hanging in May 2018. He was a regular user of alcohol and cannabis with intermittent mental health treatment, having refused recommende…
30y · Male·exsanguination due to division of left brachial artery
Philip Michael Harris, aged 30, died in Yatala Labour Prison from exsanguination following self-inflicted lacerations to his left forearm that severed the brachial artery. He had a longstanding history of self-harm behav…
40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…
Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…
64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…
A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…
Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…
Five male prisoners died by suicide at Casuarina Prison, Western Australia between 2014-2015. All deaths were by hanging or self-inflicted laceration. The coroner identified multiple systemic failures including: inadequa…
42y · Female·Incised injury to the neck
A 42-year-old woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Cli…
54y · Female·malignant melanoma with brain metastases
A 54-year-old woman with metastatic melanoma died from brain metastases while detained under a Mental Health Act order at the Royal Adelaide Hospital. She had undergone surgery and radiotherapy for melanoma that had spre…
31y · Male·ischaemic heart disease
A 31-year-old male prisoner with significant pre-existing cardiac disease (previous myocardial infarction with stenting, cardiomegaly, left ventricular hypertrophy, coronary atherosclerosis) and poorly controlled diabete…
24y · Male·bronchopneumonia complicating oxycodone toxicity
Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping…
22y · Male·acute blood loss from incised injuries to left forearm
Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treat…
36y · Male·Ligature compression of the neck (suicide by hanging)
A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…
31y · Male·acute neck compression by ligature
Steven Malcolm Williams, aged 31, died in custody at Yatala Labour Prison on 1 January 2015 from acute neck compression by ligature. He had a 12-year history of schizophrenic disorder previously managed with antipsychoti…
45y · Female·methicillin resistant staphylococcus aureus (MRSA) endocarditis of the mitral va…
A 45-year-old woman with chronic renal failure requiring dialysis and bipolar disorder died of MRSA endocarditis of the mitral valve. She was detained under a Mental Health Act order due to manic episodes and non-complia…
91y · Male·ischaemic and hypertensive heart disease
Giovanni Catino, aged 91, died of ischaemic and hypertensive heart disease while detained under a Mental Health Act inpatient treatment order at Repatriation General Hospital. He had advanced Alzheimer's dementia with be…
54y · Male·incised wound to the neck
Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…
48y · Male·Hypovolaemic shock due to incised wounds to the arms; other significant conditio…
Garry Ronald Appleton, a 48-year-old Indigenous man with schizophrenia, emphysema, and coronary disease, died from hypovolaemic shock after cutting his forearms with a prison-issue razor blade while in custody at Brisban…
32y · Male·self-inflicted hanging
Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…
34y · Male·ligature compression of the neck
Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…
29y · Male·neck compression due to hanging
Nicholas Edward Bell, aged 29, died by hanging in Mobilong Prison on 29 April 2015. He had a documented history of mental illness, previous suicide attempts, substance abuse (methamphetamine, heroin, alcohol), and was as…
43y · Male·asphyxiation by ligature
A 43-year-old man in remand at Parklea Correctional Centre died by suicide via asphyxiation by ligature in July 2016. He was suffering from major depression and anxiety triggered by criminal charges. Expert psychiatric e…
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