221 results
53y · Male·Hanging
PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoi…
28y · Male·In keeping with Hanging
A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …
84y · Male·The available evidence does not allow for any finding to be made as to the cause…
An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bus…
Male·Gunshot wounds to the head
This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
31y · Male·metastatic alveolar soft part sarcoma
31-year-old man serving a custodial sentence died of metastatic alveolar soft part sarcoma on 25 January 2022. Diagnosed April 2020, the ultra-rare cancer (1 in 10 million incidence) had already metastasised at discovery…
58y · Male·acute myocardial infarction caused by ischaemic heart disease
Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
Deaths from injuries sustained in a mass stabbing attack
This inquest examined deaths resulting from a mass stabbing attack at Westfield Bondi Junction on 13 April 2024. The perpetrator, Joel Cauchi, had treatment-resistant schizophrenia and had ceased antipsychotic medication…
41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…
On 13 April 2024, Joel Cauchi stabbed 16 people at Westfield Bondi Junction, NSW, fatally wounding six: Dawn Singleton, Jade Young, Yixuan Cheng, Ashlee Good, Faraz Tahir, and Pikria Darchia. Cauchi was shot and killed b…
40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …
Joel Cauchi, a 40-year-old man with chronic treatment-resistant schizophrenia, carried out a stabbing attack at Westfield Bondi Junction shopping centre in Sydney on 13 April 2024, killing six people (Dawn Singleton, Jad…
35y · Male·The available evidence does not allow for any finding to be made as to the cause…
A 35-year-old male with extensive mental health history died by intentional self-inflicted means on 13 September 2022 at Vaucluse, NSW. He had multiple psychiatric diagnoses including bipolar disorder, autism spectrum di…
43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…
A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …
55y · Female·acute necrotising bronchopneumonia
MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…
60y · Female·multiple injuries
JF, a 60-year-old woman with recurrent major depressive disorder and a history of suicide attempts, died by suicide at Redhead Headland on 12 February 2024. Despite three prior psychiatric hospitalizations and documented…
43y · Male·methadone toxicity
Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …
70y · Male·death by hanging, self-inflicted
A 70-year-old man died by hanging in prison while serving a sentence for child sexual offences. He had previously attempted suicide in 2017 when initially charged, and was subsequently treated with antidepressants and ps…
37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …
A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…
55y · Male·Complications of alcohol use disorder
Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…
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