2,604 results
15y · Female·toxicity to heroin
Krisinda Carmen Smart, aged 15, died from heroin toxicity on 20 January 2008. She was a child in care of the Department of Human Services subject to a Custody to Secretary Order. In the days before her death, there were …
18y · Male·acute neck compression due to hanging
Shane Blunden, aged 18, died by hanging in Yatala Labour Prison on 19 September 2011. He was a remanded prisoner with an extensive history of self-harm, including cutting, swallowing batteries and razors, and a previous …
37y · Male·Unascertained (death in custody)
Craig McMillan, 37-year-old male with chronic schizophrenia, died of undetermined cause (death in custody) after being transported by police divisional van to hospital. Despite documented tachycardia from Risperidone, th…
35y · Male·serotonin syndrome
Nicholas Moorby, a 35-year-old male, was found deceased at home in Lynbrook, Victoria on 11 April 2013, having last been seen alive on 9 April 2013. The coroner determined he died from serotonin syndrome. Moorby was pres…
49y · Male·cardiac hypertrophy (longstanding heart disease) complicated by chronic renal fa…
Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 m…
59y · Female·head injury
Ms Athiel Deng, a 59-year-old Sudanese refugee, was fatally assaulted by her son Majang Ngor during an acute psychotic episode induced by cannabis and methamphetamine use. Ngor had a documented first psychotic episode in…
18y · Female·Multiple injuries due to impact by train
KJ was an 18-year-old girl who died by suicide by train on 30 November 2012, six months after a suicide attempt. She had a complex trauma history, including childhood sexual abuse aged 6, and subsequently developed depre…
29y · Male·Injuries sustained in a fall from a height
A 29-year-old man with chronic paranoid schizophrenia died from injuries sustained after jumping from the EJ Whitten Bridge. He had a 5-year history of psychiatric illness with recurrent psychotic episodes despite treatm…
53y · Male·metastatic pancreatic cancer
Joseph Mallia, a 53-year-old man incarcerated at Barwon Prison, presented with left flank pain and haematuria in November 2011. A CT scan in January 2012 identified concerning pancreatic duct distension suggesting possib…
53y · Female·hanging
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…
18y · Male·combination of blunt force injuries to chest and head from falling onto train ro…
An 18-year-old with depression and recent psychological trauma jumped from a railway bridge intending suicide. He struck a destination board and fell onto a train roof instead of in front of it. During a police rescue op…
27y · Male·hanging
Dalvir Singh, a 27-year-old Indian national, died by hanging in immigration detention on 13 February 2014. He had attempted suicide in police custody 16 days earlier but this critical information failed to reach detentio…
72y · Female·Hanging
Chang Ying Xu, a 72-year-old Chinese-speaking woman with severe spinal cord compression, chronic pain, and depression, died by hanging during respite care at an aged care facility. While her depression history and multip…
14y · Male·hanging
A 14-year-old Aboriginal boy died by suicide by hanging at his school. He had experienced childhood trauma including neglect, domestic violence, and parental separation. He was living with his paternal grandmother after …
33y · Male·Gunshot wound to the head
A 33-year-old man with paranoid schizophrenia, polysubstance dependence (amphetamines/cannabis), and chronic suicidal ideation died from a self-inflicted gunshot wound to the head. He had been prescribed risperidone and …
45y · Male·Complications of heat stroke in a man with schizophrenia
Christopher Dokos, a 45-year-old man with schizophrenia on Clozapine treatment, died during the extraordinary January 2014 Victorian heatwave. He had multiple heat-vulnerability risk factors: mental illness, antipsychoti…
50y · Female·Complications of heat stroke in a woman with schizophrenia
A 50-year-old woman with long-standing schizophrenia treated with clozapine died from complications of heat stroke during an unprecedented Victorian heatwave. She and her partner were not contacted by mental health servi…
29y · Female·Multiple injuries due to fall from height
A 29-year-old woman with rapidly deteriorating mental health presented to Ipswich Hospital ED triaged as ATS Category 3 requiring assessment within 30 minutes. Multiple systemic and clinical failures delayed appropriate …
68y · Male·bronchopneumonia with underlying Chronic Obstructive Pulmonary Disease
Robert Gordon Britten, a 68-year-old forensic patient under the Mental Health (Forensic Provisions) Act 1990, died of bronchopneumonia with underlying chronic obstructive pulmonary disease at Macquarie Hospital. He had b…
smoke inhalation and burns from deliberately-lit fire (primary cause varies by i…
Fourteen elderly residents died in a deliberately-lit fire at Quakers Hill Nursing Home on 18 November 2011, set by drug-dependent nurse Roger Dean to destroy evidence of medication theft. Dean had worked while visibly i…
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