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QLDcommunity2026-08-11

Inquest into the death of James Michael Watson

34y · Male·Multiple gunshot wounds

James Michael Watson, aged 34, died from multiple gunshot wounds sustained during a police altercation outside the Greek Club in South Brisbane on 11 October 2022. He had long-standing mental health issues and polysubsta…

forensic medicinetoxicologymethamphetamine
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
QLDhome2025-10-10

Inquest into the death of AB

31y · Male·Hanging

31-year-old male with borderline personality disorder, alcohol use disorder, and history of self-harm died by hanging. He had multiple presentations to emergency services and mental health services from March to July 202…

psychiatrygeneral practicesystemcommunicationalcohol
QLDcommunity2024-11-04

Inquest into the death of Damon Paul William Savage

27y · Male·Multiple gunshot wounds

Damon Savage, 27, died from multiple gunshot wounds during a police response to a domestic violence incident. He had called police while assaulting his partner, armed himself with two large knives, advanced towards offic…

psychiatryemergency medicinecommunicationsystemmethamphetamine
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…

general practiceobstetricscommunicationsystemmethamphetamine
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
QLDcommunity2023-12-21

GREER, Tina

32y · Female·Unknown

Tina Louise Greer, 32, disappeared on 18 January 2012 and is presumed deceased, killed by her partner Leslie Sharman who was involved in her coercive and controlling relationship, including domestic violence. The coroner…

paediatricsaddiction medicinediagnosticcommunication
QLD2022-06-03

Kermode, Jesse Aaron

24y · Male·Gunshot wounds to the chest and abdomen

Jesse Aaron Kermode, 24, died after being shot by police at Ipswich Railway Station on 16 September 2018. He had a longstanding history of treatment-resistant schizophrenia and substance abuse, with repeated documented p…

psychiatryaddiction medicinemethamphetamine
QLDhome2022-01-18

Lewis, Daniel Patrick

36y · Male·Gunshot wounds to the chest and abdomen

Daniel Lewis, aged 36, died from gunshot wounds after police responded to a domestic violence call. Lewis had a history of brain injury from age 11, substance abuse, mental health issues including PTSD and drug-induced p…

psychiatryemergency medicinecommunicationsystemalcohol
QLDhome2021-02-17

T, an eight week old infant - Non-inquest findings

<1y · Male·Sudden infant death syndrome category II (SIDS) - accidental asphyxiation due to…

An 8-week-old infant died from SIDS category II, likely due to accidental asphyxiation when the mother fell asleep and slumped forward over him. The infant was born to a mother with a 12-year history of heroin addiction …

neonatologypaediatricssystemcommunicationheroin
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…

psychiatryemergency medicinediagnosticcommunicationalcohol
QLDhospital2018-07-30

Matthew Douglas McLachlan - Non-inquest findings

28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…

Matthew McLachlan, a 28-year-old paraplegic with chronic pain from spinal cord injury, died from mixed drug toxicity while hospitalized for urinary tract infection treatment. He was receiving fentanyl patches, oxycodone,…

infectious diseasesemergency medicinecommunicationsystemfentanyl
QLDhome2018-05-21

House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith

Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…

Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…

general practicepain medicinediagnosticmedicationfentanyl
QLDhome2016-11-30

LAMH - non-inquest findings

31y · Female·Mixed drug toxicity

A 31-year-old woman with long-standing opioid dependence enrolled in the Queensland Opioid Treatment Program died from mixed drug toxicity, with toxic levels of Fentanyl and other drugs in her system. A general practitio…

general practiceemergency medicinemedicationdiagnosticfentanyl
QLD2016-05-09

Blutcher, Micheal Wayne

31y · Male·accidental overdose of fentanyl

Micheal Blutcher, aged 31, died from accidental fentanyl overdose in custody at Capricornia Correctional Centre Farm after injecting fentanyl extracted from a transdermal patch. The fentanyl was smuggled into the low-sec…

emergency medicinetoxicologysystemdelayfentanyl
QLDcommunity2016-01-18

Kumeroa, Shaun Basil

42y · Male·gunshot wounds to the chest and abdomen

Shaun Basil Kumeroa, aged 42, died from gunshot wounds during a police siege in Brisbane. Following a family dispute resolution conference regarding custody of his daughter, Mr Kumeroa assaulted his ex-partner and became…

general practicepsychologybuprenorphine/naloxone
QLDhome2015-04-24

Lievesley, Tamiya Calais

<1y · Female·Morphine toxicity

Tamiya Calais Lievesley, a six-month-old infant, died from morphine toxicity on 2 March 2004. She ingested a fatal dose of morphine, likely administered by one of her parents who were both morphine-dependent. The coroner…

paediatricsgeneral practicemedicationdiagnosticmorphine
QLDhospital2013-01-18

Ryan, Adam Trent

30y · Male·asphyxia due to hanging (suicide)

30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…

psychiatrygeneral practicecommunicationdocumentationsertraline
QLD2012-12-14

Mitchell, Herbert John

50y · Male·Global hypoxic brain injury suffered during cardiac and respiratory arrest cause…

Herbert Mitchell, a 50-year-old man with alcohol dependence, was arrested for public drunkenness after being found extremely intoxicated at a shopping centre. Initially taken to an alcohol diversion centre but removed du…

emergency medicineintensive carediagnosticsystemalcohol
QLDhome2012-12-06

Bramble, Julie Anne

50y · Female·septicaemia

Julie Anne Bramble, a 50-year-old woman with alcohol dependence and recent drug use, died from septicaemia on 1 April 2011 at her home in Bundaberg. Over 4-5 days prior to death, she developed progressive symptoms includ…

emergency medicineparamedicinedelaycommunicationmethamphetamine

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