Owen Robert Hammersley, age 20, died from multiple blunt force injuries sustained in a single motor vehicle crash on Lalla Road, Tasmania. He lost control of his Nissan Navara ute while negotiating a left-hand bend and c…
Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…
Leisl Smith, 23 years old, disappeared on 19 August 2012 after being picked up by James Church from Tuggerah Railway Station. She was never found. The coroner concluded on the balance of probabilities that Church killed …
BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…
A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…
Jay Joseph Harrison, a 47-year-old homeless man with schizophrenia and substance use disorder, died from combined drug toxicity involving heroin, amphetamines, hydroxyrisperidone, and olanzapine. He was found unconscious…
Bryan Pham, 24, died by suicide via train strike on 2 June 2020, two days after release from remand custody. He had schizophrenia, substance use disorder, and was recently incarcerated for assault and FVIO breach. While …
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…
Frederick William Boyle, aged 74, died of congestive heart failure in the setting of influenza A infection, end-stage dementia, and Parkinson's disease while in Port Phillip Prison. He had been transferred from St Vincen…
Hillal Barbour, a 29-year-old man with schizophrenia, was fatally shot by police responding to a domestic violence call. He emerged from his home armed with two knives and advanced towards officers despite their instruct…
A 61-year-old Vietnamese woman died from pulmonary thromboembolism secondary to deep vein thrombosis while an involuntary psychiatric patient. She had been admitted following a suicide attempt and was placed on an Assess…
Manpreet Kaur, a 24-year-old Indian national on a student visa, died of pulmonary and miliary tuberculosis on 20 June 2024 at Melbourne Airport. She had been symptomatic for months, presenting to a GP on 19 May 2024 with…
A 74-year-old man died from pulmonary thromboembolism with deep vein thrombosis 10 days after elective umbilical hernia repair. He received appropriate VTE prophylaxis (mechanical and pharmacological) intraoperatively an…
Wayne Michael Parker, a 60-year-old man with chronic degenerative spinal disease and chronic pain managed with opioid medications, disappeared on 3 June 2023 from Mount Barker, Western Australia. He drove to Mount Magog …
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…
A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while in aged care. Key cl…
Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…
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…
Stephen James O'Connell, aged 74, died by suicide by drowning in the Derwent River on 2 October 2024. He had a significant psychiatric history with previous suicide attempts (1997, 2005) and mental health conditions dati…
Baby H was born at home on 21 September 2022 following an unassisted birth (freebirth) without medical oversight. The mother had received no antenatal care despite being unaware of the actual gestational age. The baby sh…
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