A 60-year-old man remanded in custody died from pulmonary tuberculosis complicated by severe COPD. Key clinical issues included: delayed diagnosis (TB not suspected at intake despite respiratory symptoms), patient's refu…
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
A 57-year-old man with schizophrenia and schizoaffective disorder died by hanging in prison on 4 August 2024. He had been receiving antipsychotic treatment via injection (paliperidone) but ceased antipsychotic medication…
A 58-year-old man with a 20-year history of chronic depression killed his 15-year-old son before taking his own life. Critical clinical failures included: incomplete handover of medical records when a new GP took over th…
On 7 September 2023, Lachlan Bowles (age 25) fatally shot his workmate Terry Czernowski (age 44) at Moylan Grain Silos in Kellerberrin, Western Australia without apparent provocation. Terry died from multiple gunshot wou…
Sacha Timothee Louis Lefebvre, aged 52, died from complications of chronic cardiac failure with ischaemic heart disease and chronic anaemia whilst sleeping rough at Hawthorn Library. He had multiple chronic conditions in…
Adam Troy Shepley, aged 30, died in police custody following restraint after climbing onto roofs while displaying drug-affected and paranoid behaviour. Post-mortem examination revealed an unascertained cause, likely a ca…
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
A 62-year-old woman driving on the Tasman Highway in Tasmania was affected by sun glare while approaching a blind left-hand curve. She shielded her eyes with her left hand, causing her vehicle to cross double white centr…
Daina Louise Clark, aged 48, died from complications of early onset dementia at a specialist disability accommodation facility in June 2025. She had been diagnosed with early onset dementia in 2019 with an expected lifes…
Ian Robert Cameron, a 73-year-old man with multiple disabilities including motor neuron disease, epilepsy, and intellectual disability, died at home in specialist disability accommodation from complications of pyelonephr…
A 14-year-old boy riding an illegally high-powered e-scooter (capable of 40-50 km/h) collided with a utility vehicle at a residential intersection. The e-scooter exceeded legal speed limits and age restrictions under Vic…
A 69-year-old man with a history of atrial fibrillation, chronic kidney disease, congestive cardiac failure, and Fragile X Syndrome presented to the Emergency Department with dyspnea following an unwitnessed fall. He was…
Jesse Riley, a 31-year-old with undiagnosed cerebral cavernoma, experienced status epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggre…
This inquest concerns the disappearance and suspected death of Gavin Cheng, a 29-year-old man last seen on 29 October 2023 in North Bondi, NSW. Gavin had a documented history of schizophrenia diagnosed in 2015, with peri…
Mr Lifa Faafete, aged 69, died from advanced cholangiocarcinoma while in remand custody at Metropolitan Special Programs Centre. He was appropriately transferred to Prince of Wales Hospital on 22 March 2025 for symptom m…
An 85-year-old man died of aspiration pneumonia in a prison healthcare setting while receiving palliative care. He had experienced a stroke two years prior resulting in cognitive decline and required assistance with all …
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