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NT2026-03-19

Inquest into the death of Bradley Murdoch

66y · Male·metastatic adenocarcinoma (palliated) from an unidentified primary tumour

Bradley John Murdoch, a 66-year-old prisoner serving a life sentence for murder, died in the palliative care unit of Alice Springs Hospital from metastatic adenocarcinoma on 15 July 2025. He had presented to the correcti…

oncologypalliative carecarboplatin
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
NT2024-06-12

Inquest into the death of Mr Dooley

37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia

Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …

cardiologygeneral practicediagnosticcommunicationatorvastatin
NTcommunity2024

Inquest into the death of Domestic violence victim (Bush Camp, Karama)

47y · Female·Multiple blunt force injuries

A 47-year-old Aboriginal woman died from multiple blunt force injuries sustained during a prolonged violent attack by her domestic partner at a bush camp in Karama, NT on 17 January 2022. She had a documented history of …

forensic medicineemergency medicinecommunicationsystemalcohol
NT2023-02-24

Inquest into the death of Bernard Hector

31y · Male·self-inflicted hanging

Bernard Hector, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Centre on 30 August 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearan…

psychiatrycorrectional healthcommunicationsystem
NTcommunity2023

Inquest into the death of Toddler R

3y · Male·Disseminated Staphylococcus aureus infection

A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethar…

general practicepaediatricsdiagnosticdelayparacetamol
NThome2021-11-09

Inquest into the death of Holly Davidson

38y · Female·Subdural haemorrhage in the context of chronic alcoholism due to post-traumatic …

Holly Anne Davidson, a 38-year-old police officer, died from a subdural haemorrhage sustained 3-5 days before her death. She had been in a coercive, controlling, and violent relationship with her police officer partner f…

emergency medicinepsychiatrydiagnosticsystemparacetamol/codeine/doxylamine
NTaged care2021-01-07

Inquest into the death of Robert Curtis

61y · Male·end stage renal failure, in the context of type 2 diabetes mellitus and chronic …

Robert Curtis, a 61-year-old Aboriginal man with end-stage renal disease, end-stage liver disease, and poorly controlled diabetes, was imprisoned for driving while disqualified on 4 February 2019. He fell in the prison s…

nephrologypalliative carefentanyl
NThospital2021-01-07

Inquest into the death of Edgar Forrester

56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…

Edgar Forrester, a 56-year-old Aboriginal man, died of aspiration pneumonitis secondary to oesophageal squamous cell carcinoma with metastases while in custody. He presented with progressive dysphagia from September 2019…

general practicecardiologydiagnosticdelay
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …

paediatricspsychiatrydiagnosticcommunicationalcohol
NT2020-08-18

Inquest into the death of David Loader

58y · Male·carcinomatosis from unknown primary

David Kevin Loader, a 58-year-old life prisoner, died from metastatic cancer of unknown primary in January 2020. He presented with multiple episodes of back, abdominal, shoulder and rib pain between July and November 201…

general practiceoncologysodium valporate
NT2019-09-27

Inquest into the death of Daryl Riley

42y · Male·ischaemic heart disease due to coronary artery atherosclerosis and left ventricu…

Daryl Jabangardi Riley, a 42-year-old Aboriginal prisoner, died of ischaemic heart disease due to coronary artery atherosclerosis and left ventricular hypertrophy while playing pool in the recreation room at Alice Spring…

cardiologygeneral practicediagnosticcommunication
NThospital2019-09-20

Inquest into the death of Joanne Craig

57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection

Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 1…

emergency medicinegeneral practicediagnosticcommunicationondansetron
NT2019-05-07

Inquest into the death of Sean Daniel Collins

32y · Male·self-inflicted hanging

Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…

general practicepsychiatrydiagnosticcommunicationsertraline
NTcommunity2018-12-03

Inquest into the death of Sabrina Di Lembo

19y · Female·self-inflicted hanging

Sabrina Di Lembo, a 19-year-old law student, died by suicide after experiencing anxiety and panic attacks during exam preparation. Over nine weeks, she had 17 medical contacts but received inadequate assessment, no detai…

general practicepsychiatrydiagnosticmedicationvenlafaxine
NThome2018-07-25

Inquest into the death of Paula Schubert

53y · Female·self-inflicted hanging

Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…

psychiatrygeneral practicecommunicationsystemrisperidone
NThospital2018-01-11

Inquest into the death of Addison Anthony

35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…

A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…

emergency medicineintensive carecommunicationdiagnosticdicloxacillin
NT2017-10-13

Inquest into the death of John Roberts

37y · Male·water intoxication and olanzapine toxicity in association with schizophrenia

A 37-year-old Aboriginal male prisoner with a long history of treatment-resistant schizophrenia died at the Darwin Correctional Precinct. He was on high-dose olanzapine (15mg twice daily) and zuclopenthixol when he devel…

psychiatryemergency medicineolanzapine
NThospital2017-08-10

Inquest into the death of Ruby Blitner

7y · Female·respiratory failure from severe scoliosis due to Murray Valley encephalitis

Ruby Blitner died from respiratory failure secondary to severe scoliosis caused by Murray Valley encephalitis acquired at age two. Her clinical course involved progressive respiratory compromise, recurrent aspiration pne…

paediatricsinfectious diseases
NThome2017-06-09

Inquest into the death of Baby S

0y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest as a consequence of…

A 7-month-old Aboriginal female, Baby S, died from hypoxic-ischaemic encephalopathy caused by respiratory viral infection and pneumonia with cardiac arrest. She was in care of Territory Families after removal from her mo…

paediatricsforensic medicine

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