294 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…
60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…
David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospita…
42y · Male·Ligature compression of the neck (hanging)
Brian Kealy, aged 42, died by suicide via hanging at Hakea Prison on 2 August 2024 while on remand. He had complex mental health needs including probable schizophrenia, anti-social personality disorder, and polysubstance…
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…
30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…
Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…
14y · Male·epilepsy in a boy with Influenza B and COVID-19 infections
Child LK was a 14-year-old Aboriginal boy in state care who died suddenly on 24 August 2023 from an unwitnessed epileptic seizure precipitated by concurrent Influenza B and COVID-19 infections. He had been diagnosed with…
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…
64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis
Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…
16y · Male·complications of ligature compression of the neck (hanging)
A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…
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…
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…
34y · Male·unascertained (suspected suicide, but body not located so no post-mortem examina…
Simon Harrington, a 34-year-old man with depression and psychotic features, disappeared on 10 January 2011 after starting a new job that triggered anxiety. He had previously attempted suicide in 2008. His sister Michelle…
21y · Male·unascertained
Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent behavior, died on 9 November 2022 at Joondalup Health Campu…
48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…
Monique Gomez, 48, died from a spontaneous intracerebral haemorrhage during hospitalization for stroke rehabilitation and treatment of schizoaffective disorder. An initial ischaemic stroke resulted from non-compliance wi…
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…
29y · Male·ligature compression of the neck (hanging)
Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…
44y · Male·bronchopneumonia in the setting of combined drug effect
Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…
29y · Female·gunshot wound to the abdomen
29-year-old Aboriginal woman (JC) of Ngarlawangga Yamatji Martu descent died from a gunshot wound inflicted by police on 17 September 2019. Four days prior, she was appropriately discharged from Sir Charles Gairdner Hosp…
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