332 results
57y · Male·Right acute subdural haematoma following a fall
Gary Desmond Frost, a 57-year-old man with intellectual disability, dementia, and schizophrenia, died from a right acute subdural haematoma following a fall while in supported residential care. He experienced multiple fa…
38y · Male·asphyxiation by ligature
A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotic…
20y · Female·Plastic bag asphyxia with inhalation of helium
A 20-year-old woman with a history of depression, anxiety, and self-harm died by helium inhalation asphyxia. She had been treated by her GP with antidepressants and mental health referral to a psychologist but never disc…
42y · Male·ligature compression of the neck (hanging)
Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…
45y · Female·Compression of the neck in circumstances of hanging
Jessica Morgana Wilby, aged 45, a highly accomplished Principal In House Solicitor at the Coroners Court of Victoria with extensive qualifications and excellent performance record, took her life by hanging on 7 September…
46y · Male·cause of death cannot be determined
Trevor Besgrove, a 46-year-old man with complex mental health issues including borderline schizophrenia, depression, and a history of trauma and substance use, was found deceased in his Bicheno home after an estimated tw…
31y · Male·Combined Drug Toxicity (amitriptyline and metoclopramide)
Bo Zhao, a 31-year-old business owner, died from combined drug toxicity (amitriptyline and metoclopramide) in a hotel room on 28 February 2019. He was facing serious criminal charges for fraud involving millions of dolla…
21y · Male·heroin toxicity
A 21-year-old man died from heroin toxicity while on home detention bail. He had been engaged in a methadone program and psychological treatment for heroin addiction, PTSD, depression and anxiety since June 2015. Despite…
44y · Male·compression of the neck consequent upon hanging
A 44-year-old man with a 42-year history of intimate partner violence died by hanging. He had recently separated from his wife and was enrolled in a 18-week men's behaviour change program, having completed 17 of 18 sessi…
29y · Male·Incised injury to the neck
Benjamin Browne, 29, died from a neck laceration sustained during acute behavioural disturbance in August 2018. He had diagnosed major depression with anxiety, prescribed mirtazapine but attended only two psychology sess…
31y · Female·drowning, deliberately self-inflicted with intention of ending life
Maria Rebekah Wright, a 31-year-old woman with severe borderline personality disorder and chronic suicidality, died by drowning at Howrah Beach, Tasmania on 14 August 2017. She had been discharged from Royal Hobart Hospi…
43y · Male·Gunshot wound to the head
Gregory Allen Floyd, aged 43, died from a self-inflicted gunshot wound following the killing of his partner Ora Holt. In the months preceding the deaths, Mr Floyd exhibited delusional beliefs that Ms Holt was having affa…
39y · Female·gunshot wound to the head
Ora Holt, aged 39, was shot and killed by her partner Gregory Floyd on 25 April 2017 in Wangaratta, Victoria. Floyd exhibited escalating coercive, controlling and abusive behaviour throughout late 2016 and early 2017, in…
51y · Male·hypoxic-ischemic encephalopathy due to hanging
Darren Brandon died by hanging in prison on 10 June 2018, two days after arriving at Melbourne Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and histo…
29y · Male·Shotgun wound to the head
Robert James Lawrence, a 29-year-old man with complex mental health needs including ADHD, depression, anxiety, Tourette's syndrome, and borderline personality traits, died from a self-inflicted shotgun wound. He held a C…
48y · Female·Ligature compression of the neck (hanging)
Tania Marie Hodgkinson, a 48-year-old Aboriginal woman, died by suicide via ligature compression while remanded at Bandyup Women's Prison on 23 March 2017. She had been admitted with heroin withdrawal symptoms, grief fro…
Female·Hanging
This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…
43y · Male·bronchopneumonia and brain swelling following ligature compression of the neck (…
Bret Lindsay Capper, 43-year-old male remanded in custody at Hakea Prison, Western Australia, died on 14 January 2016 from bronchopneumonia and brain swelling following ligature asphyxiation by hanging. He had antisocial…
34y · Male·neck compression due to hanging
A 34-year-old male on home detention bail died by hanging. He had a history of mental health issues, depression, and prior suicide threats, but did not disclose these to correctional services staff. In the 24 hours befor…
44y · Male·Hanging
Colin Wayne Blair, a 44-year-old Aboriginal man with a history of mental illness and substance use, died by hanging in the High Dependency Unit of Brisbane Correctional Centre on 13 November 2015. He was on hourly observ…
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