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WAcommunityNew2026-05-27

Inquest into the Death of David GRAY

58y · Male·Gunshot injury to the abdomen

David Gray, 58, deliberately induced police to shoot him as a means of suicide following undisclosed mental health deterioration. On 22 September 2023, he called police anonymously reporting an armed person, then present…

emergency medicineforensic medicine
WAhospital2026-03-26

Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

Sandipan Dhar, 21 months old, died from undiagnosed acute lymphoblastic leukaemia (ALL) complicated by sepsis and pneumonia on 24 March 2024. After three weeks of intermittent fever, he attended his GP three times and wa…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
WA2026-01-08

Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…

cardiologyemergency medicinediagnosticsystem
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…

psychiatryintensive caresystemdelayaripiprazole depot
WAhome2025-12-22

Inquest into the Death of Child LK (Name Subject to Suppression Order)

14y · Male·epilepsy in a boy with Influenza B and COVID-19 infections

Child LK was a 14-year-old Aboriginal boy in state care who died suddenly on 24 August 2023 from an unwitnessed epileptic seizure precipitated by concurrent Influenza B and COVID-19 infections. He had been diagnosed with…

paediatricsemergency medicinecommunicationsodium valproate
WAcommunity2025-12-09

Inquest into the Suspected Death of Eric Donald BRANDRICK

47y · Male·unascertained

Eric Donald Brandrick, aged 47, disappeared from his home in North Fremantle, Western Australia, after 31 December 1989. He had suffered a severe stroke in September 1988 causing left-sided paralysis, visual impairment, …

emergency medicinegeneral medicine
WAhospital2025-12-05

Inquest into the Death of Leslie Charles LINTON

64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis

Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…

cardiologypsychiatryrisperidone
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
WAhospital2025-11-27

Inquest into the Death of Stephen Joseph SCHIPP

58y · Male·complications of oesophageal cancer, with terminal palliative care

Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…

oncologypalliative caresystemdelaychemotherapy
WAcommunity2025-11-05

Inquest into the Death of Child WK (Name Subject to Suppression Order)

8y · Male·Streptococcus pyogenes and parechovirus infection

An eight-month-old boy in state child protection care died from Streptococcus pyogenes and parechovirus coinfection. He presented to regional ED on 2 September with fever and ear infection signs, then 4 September with mi…

general practiceemergency medicineamoxicillin
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…

psychiatrypsychologysystemcommunicationamitriptyline
WAcommunity2025-08-11

Inquest into the Suspected Death of Simon Brian HARRINGTON

34y · Male·unascertained (suspected suicide, but body not located so no post-mortem examina…

Simon Harrington, a 34-year-old man with depression and psychotic features, disappeared on 10 January 2011 after starting a new job that triggered anxiety. He had previously attempted suicide in 2008. His sister Michelle…

psychiatryemergency medicinecommunicationquetiapine
WAcommunity2025-07-09

Inquest into the Death of Travis Barry Mark Kimberly HART

33y · Male·Heat stroke (environmental exposure) in a man with methylamphetamine effect

Travis Hart, 33, died from heat stroke with methylamphetamine effect after abandoning a vehicle during a police intercept in bushland near Kalgoorlie on 25 December 2022. He became separated from companions and was found…

emergency medicineforensic medicinedelaycommunicationmethamphetamine
WAcommunity2025-07-02

Inquest into the Death of Donald Joseph Hemara WARD

50y · Male·Multiple injuries sustained in high-speed motorcycle crash

Donald Ward, aged 50, died from multiple injuries sustained in a high-speed motorcycle crash on 4 March 2023 in Karratha, WA. Ward left a nightclub intoxicated with alcohol (BAC 0.186%) and cannabis, obscured his number …

paramedicineemergency medicinepossibly diagnosticalcohol
WAhospital2025-06-30

Inquest into the death of Houston PEEL

29y · Male·ligature compression of the neck (hanging)

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…

emergency medicinepsychiatrycommunicationdelayolanzapine
WAhome2025-06-24

Inquest into the Death of Leighton Michael WOOD

44y · Male·bronchopneumonia in the setting of combined drug effect

Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…

psychiatrypathologyzuclopenthixol decanoate
WA2025-06-12

Inquest into the Death of Graham John BUTLER

76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…

Graham John Butler, aged 76, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…

correctional healthgeneral medicinebenzydamine
WAcommunity2025-06-09

Inquest into the Death of Joyce Gladis CLARKE

29y · Female·gunshot wound to the abdomen

29-year-old Aboriginal woman (JC) of Ngarlawangga Yamatji Martu descent died from a gunshot wound inflicted by police on 17 September 2019. Four days prior, she was appropriately discharged from Sir Charles Gairdner Hosp…

psychiatryemergency medicinesystemmethamphetamine
WAhospital2025-04-17

Inquest into the Death of Colin Stanley Francis NICHOLSON

69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…

Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…

haematologygeneral practicediagnosticcommunicationparacetamol
WAprison2025-04-10

Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…

emergency medicineneurosurgerydiagnosticcommunicationparacetamol
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