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NSW2025-01-16

Inquest into the death of Tammy Michelle Shipley

47y · Female·hyponatraemia arising from primary polydipsia and complications of schizoaffecti…

Tammy Michelle Shipley, a 47-year-old Aboriginal woman with chronic schizoaffective disorder and bipolar disorder, died in custody on 20 December 2022 from hyponatraemia arising from primary polydipsia. She was arrested …

psychiatryemergency medicinediagnosticcommunicationbuprenorphine
NSWcommunity2024-12-19

Inquest into the death of Logan Losurdo

20y · Male·Unascertained - cause of death could not be determined due to advanced decomposi…

Logan Losurdo, aged 20, was last seen leaving Magenta Shores at 1:10am on 26 November 2021 after consuming significant quantities of alcohol and cocaine throughout the evening. He made a call to '0' at 2:18am with backgr…

cocaine
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
NSWcommunity2024-12-18

Inquest into the death of Olivia Gilffillan

23y · Female·unascertained

Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She …

psychiatryemergency medicinesystemclozapine
NSW2024-12-18

Inquest into the death of Stephen John Burt

23y · Male·Drowning

Stephen John Burt, aged 23, was found deceased in January 1985, with drowning as the cause. His remains were unidentified for 36 years until 2021. Critical failures included: catastrophic incorrect sequencing of fingerpr…

forensic medicinecorrectional healthdiagnosticcommunication
NSWhome2024-12-12

Inquest into the death of Ms K

43y · Female·suffocation

Ms K, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car va…

general practicepsychologycommunicationsystemalcohol
NSW2024-12-12

Inquest into the death of Mr S

57y · Male·Hanging

A 57-year-old male inmate died by hanging at Long Bay Correctional Centre in January 2018. Although he had been psychiatrically assessed as experiencing major depression with psychotic features and was recommended by a p…

psychiatrycorrectional healthcommunicationsystemfluoxetine
NSW2024-12-11

Inquest into the death of Terry Grady

59y · Male·Hanging

Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…

psychiatrycorrectional healthsystemdelaydesvenlafaxine
NSWhome2024-12-09

Inquest into the death of Jet Gallagher

19y · Male·In keeping with hanging

A 19-year-old male with depression and anxiety died by hanging at his home on 5 March 2021, hours after police and ambulance attended him in the early morning of 4 March following his brother's emergency call. Jet had co…

paramedicinepsychiatrycommunicationdiagnosticdiazepam
NSWhome2024-12-04

Inquest into the death of HB

1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…

A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…

paediatricsemergency medicinesystemcommunication
NSW2024-12-03

Inquest into the death of Simon Cartwright

41y · Male·Septicaemia secondary to chronic peptic ulcer disease

Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…

psychiatrygastroenterologydiagnosticsystempantoprazole
NSWmental health2024-12-03

Inquest into the death of Cyril Levitsky

37y · Male·unascertained

Cyril Levitsky disappeared from Callan Park Hospital in 1970 while under treatment for schizophrenia. He was never found, though an unidentified male body discovered nearby in December 1970 may have been him. Despite ext…

psychiatrysystemdelay
NSWhome2024-11-28

Inquest into the death of Michael Peachey

27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…

Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…

emergency medicinepsychiatryproceduralcommunicationdroperidol
NSWcommunity2024-11-26

Inquest into the death of Andrew Chee Quee

51y · Male·gunshot wound to the chest

Andrew Chee Quee, 51, died from a gunshot wound sustained during a police confrontation at Bay Street, Rockdale, on 20 April 2020. He had a longstanding history of depression, substance abuse, and suicidal ideation. On t…

psychiatrypsychologyalcohol
NSWcommunity2024-11-14

Inquest into the disappearance and suspected death of Peter Claux

Male·Unascertained

Peter Dorian Claux disappeared from Bournda National Park, NSW, sometime between 24 May and 2 June 2022. Despite search and investigation, his body was never located. The coroner held an inquest into the disappearance an…

NSWhome2024-11-08

Inquest into the death of Chi Khanh Huynh

52y · Male·Significant blunt head trauma suffered from an assault inflicted by known person…

Chi Khanh Huynh, a 52-year-old man with long-standing drug dependencies and prior head trauma from a September 2018 scooter accident, died following a severe assault by Cheng Chia involving multiple punches and elbow str…

forensic medicinetoxicologymethamphetamine
NSWhome2024-11-08

Inquiry into the fire at Yankees Gap Road Bemboka

On 15 August 2018, a hazard reduction burn on private property at Yankees Gap Road, Bemboka (NSW) breached containment and spread uncontrolled into national parkland, burning approximately 19,664 hectares, destroying at …

communicationsystem
NSW2024-11-07

Inquest into the death of Elizabeth Britton

Non-accidental blunt force head injury

This is a coronial inquest into the death of Elizabeth Britton, with a hearing in September 2024 and findings released in November 2024 by Deputy State Coroner Carmel Forbes. The inquest was held at Lismore and Byron Bay…

NSWhome2024-11-04

Inquest into the death of MR

4y · Female·hypoxic brain injuries

A 4-month-old girl died from hypoxic brain injury following an unexplained, unnatural restriction of oxygen on 13 May 2017. She was found unresponsive at home and despite resuscitation, suffered irreversible brain damage…

paediatricspathologydiagnosticdelay
NSW2024-10-31

Inquest into the death of AB

34y · Male·Incision/stab wound to the neck

A 34-year-old male remandee died by self-inflicted neck wound while in custody at Metropolitan Remand and Reception Centre. He had been discharged from Risk Intervention Team management following a self-harm incident 7 d…

psychiatryemergency medicinediagnosticsystem
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