189 results
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
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…
46y · Male·Complications of ligature compression of the neck (hanging)
Sean Theo Winmar, a 46-year-old Aboriginal man, died by suicide on 11 August 2022 while on an interim supervision order after his release from prison. He had depression, substance use disorder, and chronic suicidal ideat…
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…
14y · Female·ligature compression of the neck (hanging)
Child RK, aged 14, died by suicide while in Department of Communities care at a therapeutic residential group home on 20 April 2022. She had Complex PTSD from childhood trauma and presented multiple times to emergency de…
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…
54y · Male·unascertained cause
Guido Michel, a 54-year-old electrician with longstanding mental health issues including depression, ADHD, and previous suicide attempts, disappeared in late January 2022 after entering State Forest near Flint, WA with c…
60y · Male·Unknown; likely suicide but natural causes or accident cannot be excluded
Wayne Michael Parker, a 60-year-old man with chronic degenerative spinal disease and chronic pain managed with opioid medications, disappeared on 3 June 2023 from Mount Barker, Western Australia. He drove to Mount Magog …
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…
Male·unascertained
Nicholas Pavlidis disappeared in October 2015 after last being seen alive on 14 October 2015. His abandoned vehicle was reported to police on 24 October 2015 in Yanchep bushland, but initial police response treated it as…
2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despi…
29y · Male·ligature compression of the neck (hanging)
Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…
44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…
David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…
58y · Male·unascertained
Peter James Guidera, a 58-year-old man with a history of depression, suicidal ideation, and previous suicide attempts, disappeared on 8 May 1998 from Narrogin, Western Australia, shortly after receiving a distressing pho…
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…
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…
45y · Male·atherosclerotic heart disease
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…
50y · Male·ligature compression of the neck (hanging)
Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…
22y · Male·Immersion in water (drowning) in a man with combined drug effect
Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…
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