1,963 results
19y · Female·hypoxic encephalopathy as a result of attempted hanging
A 19-year-old woman with psychosis and depression died from hypoxic encephalopathy following attempted hanging while in involuntary psychiatric admission. She was on R15 (15-minute) observation status due to suicide risk…
16y · Male·Gunshot wound to the head
A 16-year-old boy with a 5-year history of depression, multiple suicide attempts, and suicidal ideation died by self-inflicted gunshot wound at school on 1 August 2001. He had been under psychiatric care for 10 months, p…
45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…
Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thioridazine (Mellaril) for appro…
3y · Male·unascertained
Mohammed Tartoussi, aged 3 years 11 months, presented to Bell Street Family Medical Centre on 28 June 2003 with chest pain and mild upper respiratory symptoms. He was diagnosed with mild symptoms and given prednisolone. …
30y · Male·Hypertrophic Cardiomyopathy
Gary John Holcroft, a 30-year-old prisoner at Casuarina Prison Complex, died on 19 September 2001 from Hypertrophic Cardiomyopathy. He had a known heart murmur since childhood and Hepatitis C, and was noted to have eleva…
45y · Male·Bullet wound to the head - self-inflicted
A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…
23y · Male·neck compression due to hanging
A 23-year-old male with drug-induced psychosis died by hanging. He had a long history of substance abuse and behavioural problems, with multiple presentations to hospital and mental health services. In March 2001, he was…
5y · Female·disseminated candidiasis secondary to protein-energy malnutrition
Eliana Diskin, aged 5 months, died from disseminated candidiasis secondary to severe protein-energy malnutrition. After ceasing breastfeeding in late October 2000, her parents fed her exclusively with unfortified rice mi…
27y · Male·propoxyphene toxicity
A 27-year-old man with schizophrenia died of propoxyphene toxicity while in police custody. He ingested a fatal dose of Doloxene capsules prescribed by Dr R. on 27 June 2000. The doctor prescribed 100 capsules to a patie…
24y · Male·hanging
Alexander Varcoe, a 24-year-old Aboriginal man, died by hanging in Yatala Labour Prison while on remand awaiting trial for serious charges. He had a complex history including prior self-harm in 1995-96, alleged prison ra…
28y · Male·Ligature compression of the neck (hanging)
Evan Charles Slater, 28, died by ligature compression of the neck (hanging) in Cell D7, Unit 10 of Hakea Prison on 12 March 2001. He was on remand facing assault and restraining order breach charges stemming from domesti…
43y · Female·neck compression due to hanging
A 43-year-old woman with longstanding depression and previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant…
67y · Male·Aspiration of vomit associated with alcohol intoxication in a man with ischaemic…
Eric Clarence Moody, a 67-year-old man with diabetes, chronic alcoholism, and ischaemic heart disease, died on 6 December 1999 after aspirating vomit while heavily intoxicated with methylated spirits. He presented to Nor…
80y · Male·metastatic carcinoma
Kenneth William Glencross, an 80-year-old prisoner, died of metastatic lung cancer at Mary Potter Hospice on 8 June 2001 while on conditional leave from prison. He was diagnosed with end-stage metastatic lung cancer in M…
0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…
A full-term infant, Matthew Anthony McPhail, was delivered at 9.55 pm on 9 July 2000 at Naracoorte Health Service with no signs of life (Apgar 0). CTG monitoring during labour showed concerning fetal bradycardia episodes…
29y · Male·inhalation of petrol (hydrocarbon inhalation) causing respiratory depression wit…
Three Aboriginal men aged 25-29 years died from petrol inhalation in identical circumstances over 1999-2001, each found face-down in bed with a shaped petrol can sealed to their face. All were chronic sniffers (>10 years…
27y · Male·hydrocarbon inhalation
This inquest involved three deaths from petrol inhalation (1999-2001) on the Anangu Pitjantjatjara Lands. All three deceased were chronic sniffers (10+ years) who died from respiratory depression/asphyxia with distinctiv…
34y · Female·Dothiepin toxicity in a setting of post-natal depression
Debra Smeeton, 34, died on 12 November 1999 from dothiepin toxicity following intentional overdose at home, eight days after giving birth. She had severe post-natal depression after her first child in 1996, requiring hos…
Female·Dothiepin toxicity
Yvonne Carrigg, a woman with recurrent post-natal depression, died from dothiepin overdose three days after psychiatric discharge. Critical clinical failures included: prescribing dothiepin (a cardiotoxic tricyclic antid…
49y · Male·cor pulmonale and chronic bronchitis and emphysema
Graham Murrurkuwuy, a 49-year-old Aboriginal man, died of cor pulmonale and chronic bronchitis/emphysema while imprisoned at Darwin Correctional Centre. He had a long history of smoking and substance abuse. Medical staff…
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