73 results
35y · Male·self-inflicted gunshot wound to the head
Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…
67y · Male·Congestive cardiac failure
Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and comple…
45y · Male·Environmental exposure and dehydration
A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…
Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…
Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…
17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…
Didbala, a 17-year-old Aboriginal girl with complex mental health conditions including psychosis, bipolar disorder and suspected FASD, died by hanging at a CASPA residential care house in Katherine on 3 October 2022. She…
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…
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
19y · Male·gunshot wounds to chest and abdomen
Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man, died from gunshot wounds to his chest and abdomen at Yuendumu Police station on 9 November 2019. This coroner's report focuses on systemic failures in policing, youth…
Female·Domestic violence homicides: Miss Yunupiŋu—stab wound to chest; Ngeygo Ragurrk—b…
This landmark coronial finding examines four domestic violence deaths of Aboriginal women in the Northern Territory—Miss Yunupiŋu (2018), Ngeygo Ragurrk (2019), Kumarn Rubuntja (2021), and Kumanjayi Haywood (2021)—all ki…
13y · Female·Self-inflicted single gunshot wound to the chest
Grace, 13, died from a self-inflicted gunshot wound using an unsecured .308 Winchester rifle stored in her parents' bedroom. She had disclosed suicidal thoughts to a school counsellor in September 2021, but this disclosu…
22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)
A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block, they wer…
34y · Male·Multiple blunt force injuries from motor vehicle crash (pedestrian struck)
A 34-year-old Indigenous male with schizophrenia and psychosis living in 24/7 supported care wandered from his care home on 3 February 2024 and was struck by a motor vehicle on Stuart Highway while walking in poor light …
20y · Female·Stab wound to the left mid-anterior of the chest in the context of multiple othe…
A 20-year-old Aboriginal woman was fatally stabbed by her intimate partner during an escalating domestic violence relationship. She sustained a stab wound to the chest perforating her heart, causing cardiac tamponade and…
35y · Female·aortic dissection with associated acute aortitis
A 35-year-old Aboriginal woman with schizoaffective disorder presenting with acute psychosis and chest pain was appropriately referred for psychiatric assessment and retrieval. CareFlight transport was timely and the rec…
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…
16y · Male·Consequences of high voltage electrical injury due to mental disorder/psychosis
Reginald, a 16-year-old Aboriginal boy with first episode psychosis, intellectual disability, and fetal alcohol spectrum disorder, was admitted to the Youth Inpatient Unit and improved significantly with inpatient care. …
9y · Female·suicide by hanging
A 9-year-old Aboriginal girl died by suicide while in out-of-home care. She had been removed from her Aboriginal parents at 10 months of age and placed with non-Aboriginal carers despite legislation requiring Aboriginal …
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…
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 …
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