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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
WA2024-07-10

Inquest into the Death of Kevin John KEATH

76y · Male·metastatic prostate cancer with terminal palliative care

Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…

oncologypalliative caresystemdelay
WA2024-07-10

Inquest into the Death of Jason Anthony THOMPSON

54y · Male·metastatic lung cancer with terminal palliative care

Jason Anthony Thompson, a 54-year-old long-term prisoner at Casuarina Prison, died from metastatic lung cancer. He collapsed on 17 February 2023 with suspected opioid overdose but was not transferred to hospital for appr…

emergency medicineoncologydelaynaloxone
WAprison2024-06-12

Inquest into the Death of Alf Deon EADES

46y · Male·head injury complicated by bronchopneumonia, with palliation

A 46-year-old remand prisoner died from traumatic brain injury sustained during a severe prison assault. Critical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress…

correctional healthneurosurgerycommunicationsystem
WAprison2024-02-21

Inquest into the Death of Iain Campbell BUCHANAN

65y · Male·complications, including pneumonia, of traumatic brain injury

A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…

neurosurgeryemergency medicinedelaysystem
WAprison2022-12-13

Inquest into the Death of William Frederick ANDERSON

53y · Male·intracerebral haemorrhage

William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened,…

emergency medicineneurologydelaysystemaspirin
WAhospital2022-11-03

Inquest into the Death of Jeffery William ROONEY

41y · Male·subarachnoid haemorrhage due to rupture of a berry aneurysm of the right interna…

A 41-year-old male prisoner died from subarachnoid haemorrhage caused by rupture of an undiagnosed berry aneurysm while incarcerated. He had a complex medical history including migraines, head injuries, hypertension, and…

neurosurgeryemergency medicineamitriptyline
WAcommunity2022-09-14

Inquest into the Death of Warren Keith MATTHEWS

27y · Male·Head injury

Warren Keith Matthews, aged 27, died from head injury following a motor vehicle collision on Bussell Highway, Western Australia. He was driving a vehicle without registration plates when police attempted to stop him. He …

emergency medicineneurosurgerymethamphetamine
WA2022-02-04

Inquest into the Death of Robert William ROMAN

55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…

A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented with headach…

nephrologyemergency medicinesystemcommunicationaspirin
WA2021-12-21

Inquest into the Death of James Alexander TILBURY

77y · Male·early pneumonia in an elderly man receiving terminal palliative medical care for…

James Tilbury, a 77-year-old long-term prisoner, died from early pneumonia while receiving palliative care for an atypical brain meningioma. He had complex chronic conditions including COPD, prostate cancer, ischaemic he…

palliative careneurosurgerycommunicationsystemdexamethasone
WAprison2021-11-01

Inquest into the Death of Joseph Thomas ROE

50y · Male·subarachnoid and intracerebral haemorrhage in association with a ruptured berry …

Joseph Thomas Roe, age 50, died from a ruptured berry aneurysm causing subarachnoid and intracerebral haemorrhage. He was a prisoner at Casuarina Prison when he called for medical assistance on the night of 17-18 Septemb…

emergency medicineneurosurgerycommunicationsystem
WAhome2021-08-26

Inquest into the Death of Baby E (Name Subject to Suppression Order)

0y · Male·Complications of VATER syndrome and sacrococcygeal teratoma

Baby E was a 7-month-old neonate with VATER syndrome and sacrococcygeal teratoma who died from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in…

neonatologynephrology
WAhospital2020-11-20

Inquest into the Death of Trent Nathaniel ROBERTSON

44y · Male·head and neck injuries with terminal palliative care

Trent Robertson, 44, died from severe head and neck injuries sustained in a high-speed motorcycle crash on 27 May 2018 after evading a brief police traffic stop. Police observed him speeding at 92 km/h in a 60 km/h zone,…

trauma surgeryintensive care
WAhospital2020-04-02

Inquest into the Death of Benedict Chifley David CANDY

66y · Male·bronchopneumonia in a man with invasive sarcoma-like tumour of the head, with te…

Benedict Chifley David Candy, a 66-year-old sentenced prisoner, died from bronchopneumonia complicating invasive sarcoma-like tumour of the head with terminal palliative care. He had a recurrent Merkel cell carcinoma tha…

oncologypalliative caremorphine
WAcommunity2019-01-29

Inquest into the Death of Glenn William STRICKLAND

43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…

Glenn William Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, Western Australia. He failed to nego…

emergency medicinetrauma surgerysystemdelay
WAhospital2017-01-20

Inquest into the Death of Tamika Patricia Carol ULLRICH

23y · Female·chronic hydrocephalus with brain swelling

A 23-year-old registered nurse with undiagnosed chronic hydrocephalus presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketor…

emergency medicinegeneral practicediagnosticcommunicationcelecoxib
WAhospital2016-12-02

Inquest into the Death of Jason Barry WINCHESTER

34y · Male·Complications of head injury sustained in motorcycle crash

A 34-year-old man died from complications of severe traumatic brain injury sustained in a motorcycle crash on 11 November 2013, with death occurring 2.5 months later on 29 January 2014. He crashed while evading a police …

trauma surgeryneurosurgerymethamphetamine
WA2016-10-18

Inquest into the Death of Giovani Wade RYAN

15y · Male·Severe traumatic brain injury resulting from motor vehicle crash

Giovani Wade Ryan, 15 years old, died from severe traumatic brain injury sustained when the stolen panel van in which he was a front seat passenger rolled at high speed on an unsealed intersection. Young intoxicated male…

emergency medicineintensive carealcohol
WA2016-09-29

Inquest into the Death of Troy Allan ROGINSON

35y · Male·head injury in a man with chronic liver disease

A 35-year-old male prisoner with chronic hepatitis C cirrhosis and thrombocytopenia died from traumatic brain injury sustained during an unprovoked assault by another prisoner. A single punch caused him to fall backward …

neurosurgeryemergency medicinemethadone
WAhospital2015-08-12

Inquest into the Death of Helen Christine MacFARLAINE

52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …

A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…

neurosurgeryintensive carecommunicationsystemaspirin

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