36 results
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…
50y · Male·Multiple injuries sustained in high-speed motorcycle crash
Donald Ward, aged 50, died from multiple injuries sustained in a high-speed motorcycle crash on 4 March 2023 in Karratha, WA. Ward left a nightclub intoxicated with alcohol (BAC 0.186%) and cannabis, obscured his number …
34y · Male·Gunshot injuries to chest and left shoulder
Joseph Abela, a 34-year-old with chronic paranoid schizophrenia and polysubstance use, died from gunshot wounds inflicted by police during a mental health welfare check on 25 October 2021. Critical clinical failures prec…
26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia
Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…
38y · Male·Multiorgan failure following out of hospital cardiac arrest in a man with methyl…
A 38-year-old Noongar man died from multiorgan failure following out-of-hospital cardiac arrest after being restrained in prone position by police. He had injected methylamphetamine and developed excited delirium, becomi…
26y · Male·ligature compression of the neck (hanging)
Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…
heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…
Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…
39y · Male·Cardiac arrhythmia following violent exertion necessitating physical restraint i…
39-year-old Chad Riley died from cardiac arrhythmia following violent exertion during physical restraint. He presented to hospital intoxicated with methylamphetamine, exhibiting drug-induced psychosis with agitation and …
16y · Male·multiple injuries
A 16-year-old child in state care under a Protection Order (Until 18) was a passenger in a stolen vehicle being driven by his friend. Police attempted multiple vehicle intercepts during a series of evade police driving i…
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,…
22y · Male·gunshot injury to the chest
Hayden Paul Stacey, 22, died from a gunshot wound to the chest inflicted by police constable Lucinda Boon during a mental health crisis incident on 27 May 2018 at Peel Health Campus, Western Australia. Stacey had called …
35y · Male·atherosclerotic heart disease with methylamphetamine effect in a man under physi…
A 35-year-old male with severe pre-existing ischaemic heart disease and recent cardiac arrest (April 2016) presented with increasingly erratic and paranoid behaviour after methylamphetamine use and alcohol consumption. H…
36y · Male·Ligature compression of the neck (suicide by hanging)
A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…
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…
34y · Male·cardiorespiratory arrest during struggle and restraint in a man with methylamphe…
A 34-year-old man with methylamphetamine intoxication (blood level 1.2 mg/L) and focal coronary artery atherosclerosis died from cardiorespiratory arrest during a struggle and restraint by a homeowner and subsequent poli…
63y · Female·disseminated metastatic carcinoma of unknown primary in a woman with multiple sc…
Pamella Rees, a 63-year-old woman with longstanding multiple sclerosis, died on 30 June 2014 from disseminated metastatic carcinoma of unknown primary. Her cancer went undiagnosed despite regular GP contact. In her final…
45y · Male·Gunshot injury to the chest (self-inflicted)
Scott Andrew Blanchard, a 45-year-old Detective Sergeant with the Western Australian Police Gang Crime Squad, died from a self-inflicted gunshot wound while on duty near Kalgoorlie. In June 2015, following a trip to Thai…
28y · Female·ligature compression of the neck
Mary Van Der Walt, a 28-year-old with depression, anxiety, and borderline personality disorder, died by hanging on 21 April 2014. Two police officers responding to her initial '000' call found her unresponsive and pulsel…
45y · Female·multiple organ failure following thermal injuries (severe burns)
Wendy Bearfoot, a 45-year-old DEC (Department of Environment and Conservation) employee, died from multiple organ failure following severe thermal burns (80% of body) sustained in a bushfire burnover on 12 October 2012. …
49y · Male·ligature compression of the neck (hanging)
Barry Matt Stuart, a 49-year-old prisoner at Hakea Prison, died by suicide via ligature compression of the neck in November 2013. Critical clinical lessons include: (1) maintaining psychiatric continuity of care is essen…
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