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NSWcommunity2014-12-18

Inquest into the death of Kenneth MAWBY

59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…

A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease. Post-operatively, he experienced significant behavioural changes including agita…

neurologyneurosurgerycommunicationsystemmadopar
TAS2017-06-30

Coroner's Finding: Monson, Troy Colin; Michael, Robin and Mitchell, Scott Clifford

Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…

This inquest examined three deaths in Tasmanian custody: Troy Monson (asphyxiation in prison van during transport in June 2015), Robin Michael (hanging in prison cell June 2015), and Scott Mitchell (cardiac arrhythmia fr…

psychiatrypsychologydiagnosticsystemolanzapine
VICmental health2012-05-17

Finding into death of Peter Robin Tully

55y · Male·Hanging

Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week before admission. During hospitalisa…

psychiatryemergency medicinecommunicationsystemvenlafaxine
WAcommunity2019-02-07

Inquest into the 13 Deaths of Children and Young Persons in the Kimberley Region

Ligature compression of the neck (hanging) in 12 cases; one open finding

This complex coronial inquest examined 13 Aboriginal children and young persons who died by suicide in the Kimberley Region between 2012–2016. The coroner found 12 deaths were suicides and one open finding. Common contri…

psychiatrypaediatricsdiagnosticcommunicationalcohol
SAhome2017-07-25

Coroner's Finding: MCKENZIE Deborah Francis

22y · Female·compression of the neck consistent with hanging

22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…

general practiceemergency medicinediagnosticproceduralparacetamol
TAScommunity2016-05-25

Coroner's Finding: Barnes, Deearne Joan

53y · Female·mixed prescription drug toxicity

Deearne Joan Barnes, a 53-year-old woman with complex psychiatric history including depression, OCD, substance abuse disorder, and chronic non-cancer pain, died from mixed prescription drug toxicity …

psychiatrypain medicinediagnosticmedicationvenlafaxine
NSW2024-12-19

Inquest into the death of Ian Turner

35y · Male·multi-drug toxicity

CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, dis…

psychiatrygeneral practicediagnosticcommunicationamitriptyline
QLDhospital2012-02-21

Vaggs, Lyji

28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…

…) and later midazolam. Combined effects of prolonged restraint, medications with synergistic respiratory depression, obesity, and his violent resistance led to respiratory arrest. Key preventable failures: failure to adm…

psychiatryemergency medicinediagnosticmedicationolanzapine
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …

paediatricspsychiatrydiagnosticcommunicationalcohol
NSWcommunity2023-08-25

Inquest into the death of SG

15y · Male·Hanging

A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…

psychiatrypaediatricscommunicationsystem
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …

psychiatryemergency medicinecommunicationsystemdiazepam
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…

psychiatrypaediatricsdiagnosticsystem
NSW2021-05-12

Inquest into the death of Jack KOKAUA

30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …

Jack Kokaua, a 30-year-old with schizophrenia and coronary artery disease, died from malignant ventricular arrhythmia during a police encounter after absconding from hospital. Contributing factors included positional asp…

emergency medicinepsychiatryproceduralcommunicationzuclopenthixol

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