Coronial

29 results for domestic violence exposure

VICcommunity2016-12-14

Finding into death of Jake James-Kotsanas

23y · Male·Haemorrhage from incised wounds to the neck and wrists

…isode following acute methylamphetamine intoxication. He had a complex trauma history including childhood domestic violence exposure, paternal heroin overdose witnessed as a teenager, chronic substance use disorder with …

psychiatrytoxicologymethamphetamine
VIChospital2024-11-19

Finding into death of Daniel Surtees

36y · Male·Complications of thermal burn injuries

…6, died from complications of extensive thermal burn injuries (>80% body surface area) sustained during a domestic violence incident. After consuming 14 cans of bourbon at a party, Daniel returned home intoxicated and ar…

plastic and reconstructive surgeryintensive caremorphine
QLDhome2022-06-17

CJ - Non-inquest findings

14y · Male·Hanging

A 14-year-old boy died by hanging after extensive exposure to domestic and family violence and child abuse, primarily from his father. Child Safety Services involve…

paediatricspsychiatrydiagnosticcommunicationcannabis
VIChome2011-10-18

Finding into death of Peter John Griffin

54y · Male·Hanging (self-inflicted), following the death of Lynette Ann Kent from stab woun…

…g relationship breakdown. The finding documents a 10-year relationship characterised by escalating family violence, controlling behaviour, stalking, and threats. Critical clinical lessons include: the GP who treated both…

general practicepsychiatrycommunicationsystem
VIChospital2021-12-13

Finding into death of Baby A

1y · Male·Global cerebral ischaemic injury following cardiorespiratory arrest of unknown c…

…c injury following cardiorespiratory arrest of unknown cause in the setting of detected methylamphetamine exposure. He had multiple healing traumatic injuries (rib fractures, wrist fracture, mesenteric injury, scrotal br…

paediatricsemergency medicinesystemcommunicationmethamphetamine
SA2015-06-24

Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

47y · Male·Toxic effects of phosphine gas

…and preventive lessons: (1) Police failed to investigate or escalate multiple warning signs of escalating violence and suicide risk despite a history of intimate partner violence, stalking, and explicit suicide threats o…

psychiatrygeneral practicediagnosticsystemoxazepam
VIChome2025-05-23

Finding into death of Shirley Annette Kidd

67y · Female·Head injuries

…ces appeared insufficient to address his complex trauma. The coroner identified gaps in specialist family violence recovery services for young people, particularly those who are victim-survivors. Key prevention opportuni…

psychiatrygeneral practicesystemcannabis
VIChome2012-03-08

Finding into death of Selina Cecilia Te Nohu Tilley

45y · Female·Multiple injuries

Selina Tilley, a 45-year-old woman, died from multiple injuries sustained during domestic violence perpetrated by her partner Kenneth Mahoney. Over 15 months, Tilley experienced repeated physical…

communicationsystem
QLDcommunity2021-08-20

Dower, Sarahjane - Non-inquest findings

26y · Female·Neck injury due to stabbing

…iple times over 22 months of treatment; the psychologist did not recognize indicators of intimate partner violence; there was no formal handover to local services when the therapeutic relationship ended; her domestic vio…

psychologypsychiatrydiagnosticcommunicationvenlafaxine
WAhome2020-07-16

Inquest into the Death of CHILD RM

17y · Female·ligature compression of the neck (hanging)

…il 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver disease. Critical gaps were identified in the child prote…

paediatricspsychiatrysystemcommunicationalcohol
QLDcommunity2023-12-21

GREER, Tina

32y · Female·Unknown

…ed by her partner Leslie Sharman who was involved in her coercive and controlling relationship, including domestic violence. The coroner found inadequate responses by Queensland Police (poor investigation of three DV inc…

paediatricsaddiction medicinediagnosticcommunication
QLD2015-03-24

E, aged 14 - Non-inquest findings

14y · Male·hanging

…inal 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 leaving his mother's…

psychiatrygeneral practicediagnosticmarijuana
VIC2015-10-30

Finding into death of Darcey Iris

4y · Female·Injuries sustained in fall from height

…ignificant physical or sexual abuse. The coroner found no breach by treating GPs but noted gaps in family violence training and awareness among healthcare professionals. Key clinical lessons include: GPs are 'stand-alone…

general practicepaediatricscommunication
NSWhome2025-03-04

Inquest into the death of ML

1y · Female·complications of acute bronchiolitis arising from Respiratory Syncytial Virus (R…

…espiratory syncytial virus (RSV) infection in inadequate accommodation following parental separation from domestic violence services. The coroner identified systemic failures in the Department of Communities and Justice …

paediatricscorrectional healthsystemcommunicationmarijuana
VIChospital2016

Finding into death of Zakiya Crystal Lisa Thomas

15y · Female·Hanging

…periences of childhood sexual abuse by her uncle, physical and emotional abuse by her step-father, family violence, and suicidal ideation to multiple agencies. Significant failures occurred: Child Protection closed her c…

psychiatrypaediatricscommunicationsystemcitalopram
WAcommunity2019-02-07

Inquest into the 13 Deaths of Children and Young Persons in the Kimberley Region

Ligature compression of the neck (hanging) in 12 cases; one open finding

…deaths were suicides and one open finding. Common contributing factors included intergenerational trauma, exposure to domestic violence and alcohol abuse, untreated mental health conditions, poor physical health (failure…

psychiatrypaediatricsdiagnosticcommunicationalcohol
NSWcommunity2022-07-15

Inquest into the death of C S

5y · Male·Presumed drowning

…rt that the children were missing despite clear risk factors: LS's recent release from prison, history of violence and mental health issues, drug use, erratic behaviour, and SJ's expressed concerns she would take the chi…

paediatricspsychiatrydiagnosticsystemmethamphetamine
VIChome2020-11-16

Finding into death of Hilton Davis

50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity

…Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental health issues following a 2012 mo…

general practiceforensic medicinecommunicationsystemoxycodone
VIChome2024-11-06

Finding into death of Samantha Joy Fraser

38y · Female·Hanging in the setting of multiple blunt force injuries

…d psychologist, was murdered by her estranged husband Adrian Basham in July 2018 despite an active family violence intervention order. The coronial investigation identified systemic failures in family violence service re…

general practicepsychologydiagnosticcommunicationdiazepam
VIChome2015-05-08

Finding into death of Divesh Sharma

5y · Male·unascertained

…ical lessons include: healthcare professionals seeing both spouses together may miss disclosure of family violence; family violence—including controlling behaviour—was not recognised; CALD communities may lack understand…

rehabilitation medicineneurologycommunicationsystemchloroform

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