336 results
32y · Male·Multiple injuries sustained in a fall from a height
AQV, 32, had escalating depression, alcohol use disorder, and suicidal ideation while perpetrating family violence against his partner. In June 2024, following an overdose with suicidal intent in NSW, he underwent a comp…
38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazin…
Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline personality disorder…
17y · Male·Suicide by self-inflicted hanging
RL was a 17-year-old Alice Springs teenager who died by suicide while under Northern Territory mental health services' care. Critical clinical lessons emerged: failure to inform his mother about mental health deteriorati…
53y · Female·Multiple injuries sustained in a fall from height
A 53-year-old woman with delusional disorder and late-onset schizophrenia had progressive psychotic symptoms and suicidal ideation. In May 2024, she declined voluntary hospital admission due to housesitting commitments a…
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
Female·Fulminant hepatic failure due to paracetamol toxicity
A 19-year-old female with anorexia nervosa, borderline personality disorder, and chronic suicidality was admitted to St Vincent’s psychiatric inpatient unit on 28 July 2023. She reported ongoing suicidal thoughts but eng…
38y · Female·Multiple injuries sustained when struck by a train
Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…
33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…
F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…
31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
Male·Gunshot wounds to the head
This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…
41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…
Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…
47y · Female·Acute alcohol and drug (diazepam, paroxetine) toxicity
JBV, age 47, died from acute alcohol and drug toxicity after consuming alcohol combined with prescribed benzodiazepine (diazepam) and SSRI (paroxetine) medications. She had completed rehabilitation treatment for alcohol …
50y · Male·Gunshot wound to the head
A 50-year-old RAAF Flight Sergeant with Major Depressive Disorder and anxiety died from a self-inflicted gunshot wound to the head after police responded to a domestic disturbance. He had received appropriate, evidence-b…
23y · Female·Injuries sustained in a fall from a height
Jacqueline Pringle, 23, died from injuries sustained in a fall from the 60th floor of an apartment after consuming alcohol and MDMA at Crown Casino. She had a complex psychiatric history including major depression, anxie…
51y · Male·Hanging
A 51-year-old man with a complex mental health history and prior self-harm alert died by hanging in a correctional facility after a planned transfer. He requested protective custody following a physical altercation with …
35y · Male·The available evidence does not allow for any finding to be made as to the cause…
A 35-year-old male with extensive mental health history died by intentional self-inflicted means on 13 September 2022 at Vaucluse, NSW. He had multiple psychiatric diagnoses including bipolar disorder, autism spectrum di…
34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…
A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…
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…
62y · Male·Shotgun injury to the head
Kon Maximos, aged 62, died from a self-inflicted shotgun wound to the head on 15 October 2023. He was in acute interpersonal crisis following marital separation, family estrangement over infidelity, and police interventi…
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…
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