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NSWhome2026-04-21

Inquest into the death of Michael

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 …

emergency medicineparamedicinesystemcommunicationvenlafaxine
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …

psychiatryforensic medicinecommunicationsystemdiazepam
NSWcommunity2026-03-25

Inquest into the death of Jesse Riley

31y · Male·Status epilepsy secondary to cerebral cavernoma

Jesse Riley, a 31-year-old with undiagnosed cerebral cavernoma, experienced status epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggre…

paramedicineemergency medicinecommunicationsystemdroperidol
NSWpolice custody2026-03-20

Inquest into the death of Phillip Walton

48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…

Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…

emergency medicineparamedicinediagnosticcommunicationclozapine
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 3

Multiple penetrating knife wounds with hemorrhagic shock and traumatic cardiac a…

On 13 April 2024, Joel Cauchi, with inadequately managed treatment-resistant schizophrenia, stabbed six people to death and injured ten others at Westfield Bondi Junction shopping centre in Sydney. The coroner found Cauc…

emergency medicineparamedicinesystemcommunication
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

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…

psychiatrygeneral practicecommunicationsystemclozapine
NSWhospital2025-12-22

Inquest into the death of Shane McMillan

40y · Male·Acute methylamphetamine toxicity

Shane McMillan, aged 40, died from acute methylamphetamine toxicity while in police custody. He was arrested for domestic violence offences on 1 December 2022 and presented to Orange Health Service twice that day with su…

emergency medicinetoxicologymethamphetamine
NSWhospital2025-12-19

Inquest into the death of JBO

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). …

emergency medicinecardiologycommunicationsystemamiodarone
NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…

psychiatrycorrectional healthsystemcommunicationmethadone
NSWhome2025-09-04

Inquest into the death of Baby MA

0y · Female·Unascertained

An unnamed full-term baby was found deceased at Edmondson Park on 19 February 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's existence. Po…

obstetricsemergency medicinedelay
NSWhome2025-08-28

Inquest into the death of KBS

1y · Male·Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrh…

A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib fractures, extensive bruising, and patterned…

paediatricsforensic medicinecommunicationsystemcannabis
NSWhome2025-06-18

Inquest into the death of Hillal Barbour Interlocutory Application Decision

Male·Gunshot wounds to the chest and lower abdomen

Hillal Barbour died from gunshot wounds sustained during a police response to a 000 call reporting welfare concerns. Officers responded to reports that Hillal was holding a shovel and following his mother. When police ar…

paramedicine
NSWhome2025-05-09

Inquest into the death of Malcolm Brown

33y · Male·sharp force injuries of the neck

Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 following a NSW Police operation.…

psychiatrytoxicologycommunicationdelaymethamphetamine
NSWcommunity2025-04-04

Inquest into the death of RD

7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis

A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172 and 168 bpm) on 15 Sep…

emergency medicineparamedicinediagnosticcommunicationparacetamol
NSW2025-03-25

Inquest into the death of Bernard Greenwell

84y · Male·haemoperitoneum due to ruptured abdominal aortic aneurysm

Bernard Greenwell, an 84-year-old male, died from rupture of an abdominal aortic aneurysm (AAA) while in custody at Cessnock Correctional Centre. He experienced sudden-onset severe left groin pain at 11:30am on 25 April …

emergency medicinevascular surgery
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

Fiona Turnbull, a 59-year-old woman with chronic schizophrenia on clozapine, died from multiple injuries after falling from her third-floor balcony on 12 October 2017 during a psychotic relapse. The death occurred shortl…

psychiatryemergency medicinedelaycommunicationclozapine
NSWhome2024-12-09

Inquest into the death of Jet Gallagher

19y · Male·In keeping with hanging

A 19-year-old male with depression and anxiety died by hanging at his home on 5 March 2021, hours after police and ambulance attended him in the early morning of 4 March following his brother's emergency call. Jet had co…

paramedicinepsychiatrycommunicationdiagnosticdiazepam
NSWhome2024-11-28

Inquest into the death of Michael Peachey

27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…

Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…

emergency medicinepsychiatryproceduralcommunicationdroperidol
NSW2024-10-24

Inquest into the death of Fiona Goodberg

36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…

Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…

psychiatrygeneral practicediagnosticcommunicationescitalopram
NSWcommunity2024-07-08

Finding into death of Jesse Lee Christopher EDWARDS

20y · Male·Prone restraint asphyxia in the setting of alcohol intoxication and centripetal …

Jesse Edwards, a 20-year-old Yorta Yorta and Mutthi Mutthi man, died from prone restraint asphyxia following a physical altercation outside a nightclub in Swan Hill. He was restrained face-down by a security officer for …

forensic medicineemergency medicineproceduralalcohol

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