39y · Male·most likely suicide; possibly accidental death from untreated epilepsy or natura…
Martin Page, a 39-year-old man with epilepsy, schizophrenia or Asperger's syndrome, severe obsessive-compulsive behaviours, and intellectual disability, disappeared from his fam…
28y · Male·hanging
Aaron Nathan Stagg, 28-year-old man with likely Asperger's Syndrome and emerging paranoid psychosis, died by hanging on 5 March 2010 after a period of disengageme…
42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…
Andre Walter Bond, a 42-year-old man with schizophrenia, schizoaffective disorder, Asperger's syndrome, and severe obesity, died from upper airway obstruction (choking) on food while dini…
56y · Male·head injuries inflicted by blunt force trauma
…s to kill someone prior to release and had a complex psychiatric history (likely schizophrenia mixed with Asperger's syndrome) that was poorly managed in prison. Multiple systemic failures contributed: inadequate mental …
19y · Male·Hypoxic brain injury due to aspiration of food bolus
Jesse Lee McGann, a 19-year-old with severe autism, Asperger's syndrome, and documented swallowing difficulties, died from hypoxic brain injury caused by aspiration o…
16y · Male·Gunshot wound to the head
A 16-year-old boy with autism spectrum disorder and history of self-harm died from a self-inflicted gunshot wound. He had attended Headspace for mental h…
18y · Male·neck compression due to hanging
Rowan Wheaton, aged 18, died by hanging at supported accommodation in April 2006. He had Aspergers Syndrome diagnosed at age 4, with escalating behavioural and mental health crises from adolescence. Desp…
18y · Female, female, male·Caitlin: suicide by hanging; Talieha: suicide by hanging; William: suicide by tr…
…Centre (BAC) closure in January 2014. Caitlin had complex mental health needs including bipolar affective disorder and PTSD; she lived with her mother and a family member with whom she had a dysfunctional relationship, m…
70y · Female·Gunshot wounds to the head and chest
Marilyn June Burdon, aged 70, was fatally shot by her intimate partner Charles Bisucci on 21 August 2017 in Kew, Victoria. Bisucci subsequently took his own life. Critical systemic failures enabled this preventable intim…
49y · Female and male·Gunshot wound to head inflicted by spouse
Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…
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