1,232 results
50y · Female·hanging
A 50-year-old woman with severe borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two …
33y · Male·hanging
Moses Kellie, aged 33, died by hanging at Villawood Immigration Detention Centre in January 2019 after four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attem…
1y · Female·complications of acute bronchiolitis arising from Respiratory Syncytial Virus (R…
A 17-month-old First Nations child died from acute bronchiolitis due to respiratory syncytial virus (RSV) infection in inadequate accommodation following parental separation from domestic violence services. The coroner i…
15y · Female·hanging
Harmony, a 15-year-old girl, died by hanging at a motel on 14 January 2020 in circumstances of longstanding neglect, family violence and school disengagement. The coroner found multiple systemic failures: DCJ closed case…
48y · Male·Multiple traumatic injuries
Alan James Green (Wally), aged 48, died on 14 December 2021 from multiple traumatic injuries sustained in a motorcycle crash while being pursued by NSW Police for failing to stop at a traffic stop. The police decision to…
20y · Male·Drowning precipitated by a seizure
Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
2y · Male·Penetrating injuries to the head and neck caused by multiple dog bites
Jyedon Pollard, a 2-year-old Wiradjuri boy, died from penetrating injuries to his head and neck after being attacked by two dogs (a Rottweiler and Red Heeler cross) at a motel where his family was staying in emergency ac…
82y · Male·Ischaemic heart disease due to coronary atherosclerosis with significant contrib…
An 82-year-old man with advanced ischaemic heart disease and emphysema died from myocardial infarction while in custody in the Acute Care Management Unit of a correctional facility. Correctional officers failed to read h…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
35y · Male·Hyponatraemia, with psychogenic polydipsia and schizophrenia/schizoaffective dis…
Daniel Turnbull, aged 35, died in custody from hyponatraemia secondary to psychogenic polydipsia whilst in a 24-hour surveillance cell at Bathurst Correctional Centre. He had a long history of schizophrenia managed with …
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
Male·unknown
Unidentified skeletal remains were found in a garbage bag in bushland at Royal National Park, Sutherland, on 22 September 2018. The remains showed significant fire damage and deliberate concealment, indicating highly sus…
33y · Male·gunshot wounds to chest and upper arm
A 33-year-old man with bipolar disorder on reducing doses of risperidone experienced a psychotic relapse and stabbed a stranger at a railway station. He then entered a police station with a knife, advancing on officers d…
67y · Male·Liver abscess and complications thereof on the background of pancreatic adenocar…
Stephen Paul Bourke, aged 67, died in custody at Prince of Wales Hospital from a liver abscess complicated by pancreatic adenocarcinoma. He had multiple comorbidities including coronary artery disease, diabetes, and prio…
71y · Male·The available evidence and the absence of any postmortem examination does not al…
This coronial finding concerns a missing person inquest where KHL, a 71-year-old man, disappeared while rock fishing at Eagle Rock in Royal National Park, NSW in August 2023. The coroner found KHL deceased based on exten…
89y · Male·Cervical spine trauma
Robert Driver, 89, died from cervical spine trauma sustained after being struck by another dementia-affected resident in an aged care facility. He was assessed overnight at the facility and transferred to hospital the fo…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
0y · Male·Concussive brain injury
A 7-month-old boy died from concussive brain injury caused by intentional head trauma inflicted by his mother's partner in a domestic violence context. The child had multiple bruises, bite marks, and subdural haemorrhage…
0y · Unknown·fatal injuries from dog attack
A 5-week-old infant died from fatal injuries inflicted by the family pet, a dog (American Staffordshire Terrier) named Bully, who attacked him in the family home in early July 2021. About one month before the fatal attac…
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