Coronial inquests and findings
The Northern Territory's coroner’s office investigates unexpected or suspected deaths on behalf of the community.
These types of deaths are called reportable deaths.
The coroner decides whether to hold a public inquest into a death. This is also called a public court hearing.
After an inquest, the coroner publishes their findings, which sets out their decisions and recommendations.
To find out more about inquests, go to the Northern Territory Government website.
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| Death of | Date commencing | Date of findings | Location | |
|---|---|---|---|---|
| Kumanjayi Jurrah | 29 July 2024 | 15 November 2024 View findingsPDF (3.5 MB) |
Alice Springs Local Court | |
| Toddler R | 31 October 2024 | 31 October 2024 View findingsPDF (222.2 KB) |
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| Roper Highway 4 | 10 October 2024 | 10 October 2024 View findingsPDF (1.7 MB) |
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| Arnhem Highway 2 | 10 October 2024 | 10 October 2024 View findingsPDF (1.8 MB) |
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| Toddler K | 30 August 2024 | 30 August 2024 View findingsPDF (430.8 KB) |
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| Kumanjayi Rabuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk | 19 August 2024 | 19 August 2024 Counsel Assisting's proposed recommendations 19.08.24PDF (178.0 KB) |
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| Kumanjayi Rabuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk | 19 August 2024 | 19 August 2024 Counsel Assisting's submissions in relation to common issues 19.08.24_RedactedPDF (1.2 MB) |
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| Katrina Hawker | 17 June 2024 | 09 August 2024 View findingsPDF (472.9 KB) |
Darwin Local Court | |
| Pine Creek Fatalities | 02 July 2024 | 02 July 2024 View findingsPDF (235.6 KB) |
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| Grace | 13 February 2024 | 27 June 2024 View findingsPDF (1.8 MB) |
Darwin Local Court | |
| Mr Dooley | 16 January 2024 | 12 June 2024 View findingsPDF (508.7 KB) |
Darwin Local Court | |
| Douglass Maggie | 30 May 2024 | 30 May 2024 View findingsPDF (234.4 KB) |
Darwin Local Court | |
| Xysz Tacdliwaazy @Josh Ngalarina | 19 September 2023 | 05 April 2024 Agency response reportPDF (9.8 MB) |
Darwin Local Court | |
| Xysz Tacdliwaazy @Josh Ngalarina | 19 September 2023 | 05 April 2024 View findingsPDF (868.1 KB) |
Darwin Local Court | |
| Shane Tapp | 17 October 2023 | 02 February 2024 View findingsPDF (3.0 MB) |
Katherine Local Court | |
| Delvene Thompson | 31 May 2023 | 06 December 2023 View findingsPDF (695.8 KB) |
Darwin Local Court | |
| Delvene Thompson | 31 May 2023 | 06 December 2023 Agency response reportPDF (20.6 MB) |
Darwin Local Court | |
| Kumanjayi Walker | 22 November 2023 | 22 November 2023 Ruling No 8PDF (4.0 MB) |
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| Baby Croker | 16 May 2023 | 22 September 2023 View findingsPDF (532.6 KB) |
Darwin Local Court | on front page of findings |
| Baby Croker | 16 May 2023 | 22 September 2023 Agency response reportPDF (28.4 MB) |
Darwin Local Court | |
| Nigel Harris | 23 August 2022 | 05 June 2023 View findingsPDF (1.9 MB) |
Alice Springs Local Court | Recognised high risk to spectators in Finke Desert Race by Motorsport Australia and those running the race, failure to mitigate the risk |
| Nigel Harris | 23 August 2022 | 05 June 2023 Agency response reportPDF (13.3 MB) |
Alice Springs Local Court | |
| Kumanjayi Walker | 27 April 2023 | 27 April 2023 Ruling No 7PDF (206.0 KB) |
Alice Springs Local Court | |
| Kumanjayi Holmes | 30 March 2023 | 31 March 2023 View findingsPDF (1.5 MB) |
Alice Springs Local Court | Child death in care, inherited genetic disorder Batten disease, removed from family due to disability. |
| Janelle Pamkal | 14 February 2023 | 15 March 2023 View findingsPDF (208.3 KB) |
Darwin Local Court | Person held in care, CareFlight retrieval, aortic dissection, Chest Pain Pathway |
| Bernard Hector | 17 January 2023 | 24 February 2023 Agency response reportPDF (7.1 MB) |
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| Bernard Hector | 17 January 2023 | 24 February 2023 View findingsPDF (323.3 KB) |
Darwin Local Court | Death in custody, self-inflicted hanging, Local Court ‘At Risk’ Practice Direction, adequacy of care and assessments, access to health services and missed appointments, Aboriginal Mental Health First Aid, prison staffing |
| Kumanjayi Walker | 25 October 2022 | 25 October 2022 Ruling No 5PDF (347.5 KB) |
Alice Springs Local Court | |
| Kumanjayi Walker | 18 October 2022 | 18 October 2022 Ruling No 4PDF (216.2 KB) |
Alice Springs Local Court | |
| Kumanjayi Walker | 29 September 2022 | 14 October 2022 Ruling No 3PDF (450.4 KB) |
Darwin Local Court | |
| Kumanjayi Walker | 09 September 2022 | 13 September 2022 Ruling No 2PDF (286.6 KB) |
Alice Springs | Coronial proceedings; inquests; deaths in custody; inquest following acquittal; objections to evidence; unlawfully obtained evidence; authority to receive evidence under the Coroner’s Act 1993 (NT) |
| Kumanjayi Walker | 26 May 2022 | 19 July 2022 Ruling No 1PDF (199.2 KB) |
Darwin Local Court | Application for leave to appear; sufficient interest; police association |
| Roberta Curry | 17 May 2022 | 10 June 2022 Agency response reportPDF (12.1 MB) |
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| Roberta Curry | 17 May 2022 | 10 June 2022 View findingsPDF (228.3 KB) |
Darwin Local Court | Intimate partner homicide, domestic violence, response by police, supervision by Community Corrections, 000 calls |
| Reginald Roy | 15 March 2022 | 20 May 2022 Agency response reportPDF (9.5 MB) |
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| Reginald Roy | 15 March 2022 | 20 May 2022 View findingsPDF (216.6 KB) |
Darwin Local Court | Sixteen year old lost to mental health follow up shortly after being discharged from inpatient unit, died due to high voltage electrocution |
| Patrick Moriarty | 07 June 2018 | 07 April 2022 View findingsPDF (1.1 MB) |
Katherine Local Court | Person missing with a dog on a background of small town feud, suspicious circumstances, extensive searches |
| S. Wongaway, D. Wongaway and M.Dixon | 07 December 2021 | 07 March 2022 View findingsPDF (1.1 MB) |
Alice Springs Local Court | Three deaths, vehicle crash on Christmas day, unregistered vehicle detected by police and followed, whether deaths in custody |
| Josef Lear | 02 November 2021 | 25 January 2022 View findingsPDF (187.4 KB) |
Darwin Local Court | Death in custody, natural causes |
| Sammy | 22 June 2021 | 25 November 2021 View findingsPDF (274.5 KB) |
Darwin Local Court | Suicide, death in care, 9 years of age, Aboriginal Placement Principle not adhered to, trauma not assessed and treated |
| Brody Wauchope-Dirdi | 12 October 2021 | 24 November 2021 View findingsPDF (503.9 KB) |
Darwin Local Court | Electrocution of 11 year old boy at a home in a remote Aboriginal community, roof live with 240 volts, caused by faulty Power and Water Corporation connection to residence, no earthing of electrical connection and metal roof, no maintenance or inspection over 25 years |
| HD (name suppressed) | 27 September 2021 | 09 November 2021 View findingsPDF (620.0 KB) |
Darwin Local Court | Domestic violence allegations made against serving police officer, inadequate investigations, coercive control ‘red flags’ not recognised |
| Benjamin Watts | 13 April 2021 | 29 April 2021 View findingsPDF (1.0 MB) |
Darwin Local Court | Death in custody, ATV rollover, workplace safety at prison |
| Benjamin Watts | 13 April 2021 | 29 April 2021 Agency response reportPDF (6.3 MB) |
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| Patrick Bloomfield | 09 March 2021 | 01 April 2021 View findingsPDF (1.8 MB) |
Alice Springs Local Court | Remote Aboriginal Community, RBT avoidance, police pursuit, terminated, rolled 5 kilometres later, death in custody, family access to body and scene not facilitated, suspicions of family not allayed |
| Patrick Bloomfield | 09 March 2021 | 01 April 2021 Agency response reportPDF (6.1 MB) |
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| Christopher Malyschko | 09 November 2020 | 15 January 2021 View findingsPDF (804.7 KB) |
Darwin Local Court | Death in custody while under influence of synthetic cannabis ‘Kronic’, failure to adequately respond to ‘Kronic’ by prison management, death contributed to by boredom, failure of educational and entertainment system in new prison, not remedied after 6 years |
| Edgar Forrester | 09 December 2020 | 07 January 2021 View findingsPDF (142.8 KB) |
Alice Springs Local Court | Death in custody, natural causes |
| Robert Curtis | 08 December 2020 | 07 January 2021 View findingsPDF (45.9 KB) |
Alice Springs Local Court | Death in custody, natural cause death, prisoner given leave to die in his community |
| Barbara Francis | 03 November 2020 | 18 December 2020 View findingsPDF (397.2 KB) |
Darwin Local Court | Death of resident in aged care, dementia unit, understaffing, hip protectors, external/agency staff, Delay in ambulance attendance |
| Master W, Miss B and Master JK | 13 October 2020 | 15 December 2020 Agency response reportPDF (6.4 MB) |
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| Fionica James, Katurah Mamarika, Layla Leering | 16 September 2020 | 15 December 2020 View findingsPDF (906.5 KB) |
Darwin Local Court | Deaths of teenage girls in remote Aboriginal communities, high levels of trauma and stress, perfunctory police investigations, little to no assistance from government agencies |
| Master W, Miss B and Master JK | 13 October 2020 | 15 December 2020 View findingsPDF (462.5 KB) |
Darwin Local Court | Volatile substance abuse by children in remote Aboriginal communities, failure of government agencies to assist, unlawful practices by Top End Health Service, previous assurance of compliance not observed |
| Lily Elizabeth Aldridge | 26 October 2020 | 26 October 2020 View findingsPDF (69.0 KB) |
Darwin Local Court | |
| David Loader | 18 August 2020 | 18 August 2020 View findingsPDF (257.6 KB) |
Darwin Local Court | Death in custody, prisoner in correctional facility, natural cause death, adequacy of care, treatment and supervision |
| Ishmael Nawirridj | 30 June 2020 | 17 July 2020 View findingsPDF (300.5 KB) |
Darwin Local Court | Death in custody of Correctional Services, natural causes |
| Ishamel Nawirridj | 30 June 2020 | 17 July 2020 Agency response reportPDF (1.3 MB) |
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| Jonathan Hempel | 09 November 2018 | 03 January 2020 View findingsPDF (1.1 MB) |
Darwin Local Court | Pedestrian run over by vehicle, driver did not provide adequate account, belief that offences have been committed, referral back to Police and DPP |
| Harry Evans | 26 November 2019 | 03 January 2020 View findingsPDF (99.6 KB) |
Darwin Local Court | Sea snake bite, neurotoxic venom, prawn trawler, remote location |
| Lebron Douglas Martin | 08 October 2019 | 22 November 2019 View findingsPDF (298.7 KB) |
Darwin Local Court | |
| Daryl Riley | 12 September 2019 | 27 September 2019 View findingsPDF (43.1 KB) |
Alice Springs Local Court | Death in custody, prisoner in correctional facility, natural causes |
| Linden Kunoth | 10 September 2019 | 27 September 2019 View findingsPDF (824.9 KB) |
Alice Springs Local Court | Mental Health, involuntary admission, remained psychotic, non-compliance with Mental Health and Related Services Act in provision of leave, took his own life |
| Jordan Allen | 11 September 2019 | 27 September 2019 View findingsPDF (969.4 KB) |
Alice Springs Local Court | Mental Health Facility, involuntary patient, “cigarette leave” while still psychotic, took his own life |
| Linden Kunoth | 10 September 2019 | 27 September 2019 Agency response reportPDF (5.1 MB) |
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| Joanne Craig | 27 August 2019 | 20 September 2019 Agency response reportPDF (2.9 MB) |
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| Joanne Craig | 28 August 2019 | 20 September 2019 View findingsPDF (2.0 MB) |
Darwin Local Court | Failure of primary care providers to offer vaccination (Pnemovax23), Failure by hospital to identify sepsis, Failure to identify septic shock, antibiotics commenced too late |
| Daniel Alexander Bleaney | 30 July 2019 | 13 September 2019 View findingsPDF (131.7 KB) |
Darwin Local Court | Death in care, high risk suicidal patient, involuntary admission to ward (not secure), failure to improve security after previous death, poor communication with family |
| Robin Riley, Thomas Turpin, Fabian Andrews, Cassandra Martin | 09 July 2019 | 09 August 2019 View findingsPDF (4.8 MB) |
Darwin Local Court | Single vehicle rollover, Kakadu Highway, gravel on bitumen at intersection with unsealed road |
| Daniel Alexander Bleaney | 30 July 2019 | 13 July 2019 Agency response reportPDF (4.3 MB) |
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| Fazan Khan | 11 April 2019 | 20 June 2019 View findingsPDF (73.0 KB) |
Darwin Local Court | Drug overdose; MDMA; multi-drug toxicity; self administered; dangers of ‘lean’- soft drink mixed with pharmaceuticals. |
| Sean Daniel Collins | 09 April 2019 | 07 May 2019 View findingsPDF (1.6 MB) |
Darwin Local Court | Death in custody, foreign national, inadequate health care |
| Ali Achmadun Djawas | 12 March 2019 | 16 April 2019 View findingsPDF (1.9 MB) |
Darwin Local Court | Elective surgery, lack of information as to risks of surgery, unnecessary surgery, poor communication by Hospital, lack of appropriate discharge procedure and information, anastomotic leak leading to death |
| Xavier Lengyel | 19 March 2019 | 12 April 2019 View findingsPDF (2.8 MB) |
Darwin Local Court | Traffic collision between unregistered motorcycle and vehicle, substandard police investigation, referral back to Police and DPP |
| Jason Challis | 20 November 2018 | 16 January 2019 View findingsPDF (154.1 KB) |
Darwin Local Court | Defence Force urban operations live fire training exercise, safety mitigation procedures not followed, systemic failure, soldier shot in head |
| Julie Frances Morrell | 13 December 2018 | 13 December 2018 View findingsPDF (44.9 KB) |
Darwin Local Court | mechanical (traumatic) asphyxia as result of motor vehicle accident, Humpty Doo Hotel carpark, Arnhem Highway |
| Sabrina Di Lembo | 23 October 2018 | 03 December 2018 View findingsPDF (147.7 KB) |
Darwin Local Court | Anxiety, young woman, suicide, NT Mental Health Service, General Practitioners, no adequate history or assessment, no coordinated care, no referral by GP to psychiatrist |
| Wilfried and Gisela Thor | 06 November 2018 | 26 November 2018 View findingsPDF (2.5 MB) |
Alice Springs Local Court | Nature Park, hot day, short walk, signage obscured by vegetation, boundary fence down, tourists became lost, environmental heat injury |
| Jessica Poulson | 08 November 2018 | 26 November 2018 View findingsPDF (40.2 KB) |
Alice Springs Local Court | Death in care, 17 days old baby, congenital heart defect, expected death, appropriate care and treatment |
| Jeremy aka Lawrence Tunkin | 16 October 2018 | 26 November 2018 View findingsPDF (117.5 KB) |
Alice Springs Local Court | Death in Custody, Natural Causes, Communication problems with hearing impaired prisoners, AutoPulse resuscitation devices |
| Matthew Rosewarne | 18 September 2018 | 10 October 2018 View findingsPDF (128.3 KB) |
Darwin Local Court | Police investigation, gunshot death, shot in back of neck, safety catch on, investigated as suicide, role of investigative bias |
| Henry George Wilson aka Albert Wilson | 21 August 2018 | 21 September 2018 View findingsPDF (145.8 KB) |
Darwin Local Court | Unexpected death in Hospital caused by injury during procedure, not reported to coroner, failure to treat elderly man dying in pain, failure to communicate appropriately with family during treatment and after death |
| David Fensom | 21 August 2018 | 21 September 2018 View findingsPDF (100.5 KB) |
Darwin Local Court | Delay in diagnosis, unexpected death, poor communication with family, no report to Coroner |
| Paula Schubert | 25 June 2018 | 25 July 2018 View findingsPDF (121.2 KB) |
Darwin Local Court | Employee with mental health issues, treated inappropriately by employer, bullying behaviour, Mental Health Service poor note keeping and stakeholder engagement |
| Sasha Green | 17 April 2018 | 21 June 2018 View findingsPDF (206.0 KB) |
Tennant Creek Local Court | Unlawful killing, inexperienced investigators, inadequate investigation, inadequate supervision by senior police, continued inability by some investigators to adequately assess evidence, continuing destruction by police of vital forensic material |
| Naomi Smith | 09 April 2018 | 19 June 2018 View findingsPDF (115.0 KB) |
Darwin Local Court | Death in Custody, complex mental health presentation, inadequate resources available in Alice Springs |
| Asera aka Ezra Young | 19 March 2018 | 06 April 2018 View findingsPDF (109.1 KB) |
Darwin Local Court | Death in custody, police entry to private residence, waking an intoxicated and elderly man, absence of police powers, duty of care not fulfilled, not recognised as custody incident, delayed investigation |
| Daniel Bradshaw | 11 December 2017 | 08 February 2018 View findingsPDF (3.6 MB) |
Darwin Local Court | Death of deckhand, dangerous access and egress from vessel, no gangway, regulatory response to death |
| Vernon Bonson | 22 January 2018 | 07 February 2018 View findingsPDF (79.2 KB) |
Darwin Local Court | Death in custody, hanging from fan in correctional facility, department developing solution to prevent fans holding body weight, recording of reasons for transfer of prisoners within prison |
| Ronnie Nelson | 01 December 2017 | 19 January 2018 View findingsPDF (54.2 KB) |
Alice Springs | Death in custody, natural causes, released on bail for payback |
| Peter Bonnell | 24 October 2017 | 11 January 2018 View findingsPDF (4.4 MB) |
Darwin Local Court | Collision by motorcycle rider with temporary traffic control devices, rider impairment, failure to install traffic control devices in accordance with Australian Standard, report to DP |
| Addison Anthony | 13 November 2017 | 11 January 2018 View findingsPDF (112.7 KB) |
Darwin Local Court | Death in custody, likely autoimmune disease, medical treatment appropriate, failure of Correctional Services to notify family of illness until after death |
| Damien Kyle-Little | 12 October 2017 | 24 November 2017 View findingsPDF (96.4 KB) |
Darwin | Fall from a tower, no high risk work licence, no harness, non-compliance with Safe Work Method Statement |
| Dale Walkinshaw | 16 October 2017 | 21 November 2017 View findingsPDF (85.6 KB) |
Darwin Local Court | Death in Custody, transporting in caged police vehicle, duty of care, bootlace attached to grill of vehicle cage and then around neck, police inability to see what happening in cage, failure by police to mitigate the risks of the poor vision |
| John Roberts | 18 September 2017 | 13 October 2017 View findingsPDF (199.2 KB) |
Darwin Local Court | Death in Custody, Darwin Correctional Precinct, mental health treatment, water intoxication, Olanzapine toxicity |
| Ruby Blitner | 18 July 2017 | 10 August 2017 View findingsPDF (61.6 KB) |
Katherine Local Court | Death in care, natural causes, appropriate care, timeliness of police investigation, Territory Families compliance with request for files |
| Roy Melbourne | 26 June 2017 | 21 July 2017 View findingsPDF (73.8 KB) |
Darwin Local Court | Hanging from fan in correctional facility, failure to install mechanism to prevent fans holding body weight, lack of reintegration systems for some long term prisoners |
| John Munkara | 15 June 2017 | 29 June 2017 View findingsPDF (86.2 KB) |
Darwin Local Court | Death in Police custody, Police Communications failure to pass on request for an ambulance, no facemask in Police vehicle, no treatment under Alcohol Mandatory Treatment scheme, unlawful discharge from assessment facility |
| Edward Laurie | 23 May 2017 | 15 June 2017 View findingsPDF (119.2 KB) |
Darwin Local Court | Long term petrol sniffing, failure to realise objects of the Volatile Substance Abuse Prevention Act, failure to provide a treatment program, failure to follow processes outlined in Act |
| Baby S | 09 May 2017 | 09 June 2017 View findingsPDF (132.3 KB) |
Alice Springs | Death in Care, Aboriginal baby, appropriate care and attention, kinship arrangements, sudden death. |
| Baby S | 09 May 2017 | 09 June 2017 View findingsPDF (132.7 KB) |
Alice Springs Local Court | Death in Care, Aboriginal baby, appropriate care and attention, kinship arrangements, sudden death |
| Heather Fotiades | 10 April 2017 | 05 May 2017 View findingsPDF (117.1 KB) |
Darwin Local Court | Medical practitioners prescribing high dose opioids for chronic non-cancer pain, addiction, failure of system to identify prescription shopping, failure to taper high doses to safer levels, failure of pain specialist to reduce dose despite unsafe levels and knowledge drugs ineffective in relieving p |
| Gabby Wanambi | 16 February 2017 | 07 April 2017 View findingsPDF (128.2 KB) |
Darwin Local Court | Twisted ankle, developed sepsis, not recognised by emergency department in hospital, no attendance by on-call doctor, second death at hospital due to undiagnosed sepsis |
| Ashley Richards | 13 February 2017 | 07 April 2017 View findingsPDF (190.6 KB) |
Darwin Local Court | Vehicle Hijacking and further robbery, firearm, joyriding youth, limited options for apprehension, limited coordination and control of police resources |
| Irene Magriplis | 06 March 2017 | 30 March 2017 View findingsPDF (219.3 KB) |
Darwin Local Court | High risk elective surgery, inadequate medical treatment, inadequate resources at Darwin Private Hospital, inadequate escalation procedure, no internal review, referral to Medical Board |
| Ray Gibson | 14 December 2016 | 13 January 2017 View findingsPDF (142.9 KB) |
Alice Springs Local Court | Death in Custody, natural causes |
| Michael Smedley | 12 December 2016 | 13 January 2017 View findingsPDF (243.4 KB) |
Alice Springs Local Court | Baby died of traumatic head injury, initial disagreement between medical experts, disagreement resolved, referred back to Police |
| Ronnie Beasley | 14 December 2016 | 13 January 2017 View findingsPDF (224.8 KB) |
Alice Springs Local Court | Death in Custody, natural causes |
| Noel Ramage | 09 January 2017 | 09 January 2017 View findingsPDF (40.9 KB) |
Darwin Local Court | accidental drowning |
| Justin Morgan-Parke | 14 November 2016 | 14 November 2016 View findingsPDF (41.7 KB) |
Darwin Local Court | accidental drowning |
| Krista Lloyd | 12 October 2016 | 17 October 2016 View findingsPDF (63.0 KB) |
Darwin Local Court | Delay in provision of autopsy report, delay in Coronial Investigation |
| Natalie McCormack | 08 August 2016 | 21 September 2016 View findingsPDF (204.3 KB) |
Alice Springs Local Court | Domestic Violence, ten year history of violence, time to consider a different approach |
| Wendy Murphy | 08 August 2016 | 21 September 2016 View findingsPDF (207.1 KB) |
Alice Springs Local Court | Domestic Violence, ten year history of violence, time to consider a different approach |
| Jethro Dhamarrandji-Baker | 15 August 2016 | 05 September 2016 View findingsPDF (65.1 KB) |
Darwin Local Court | School sports carnival accident, “Troopy Pull” activity, children too close to vehicle, child run over by vehicle, the distance between the vehicle and the participants was unsafe, failure to prepare a proper risk assessment |
| Marrianne Munkara | 08 June 2016 | 02 September 2016 View findingsPDF (76.0 KB) |
Darwin Local Court | Death at Sobering up Shelter, Police systems non-compliant, failure to record protective custody episodes, no referral for assessment for Alcohol Mandatory Treatment |
| Christopher Murrungun | 10 May 2016 | 02 September 2016 View findingsPDF (114.0 KB) |
Darwin Local Court | |
| Dean Jigili | 06 June 2016 | 11 July 2016 View findingsPDF (60.9 KB) |
Darwin Local Court | Person in Care, psychosis, involuntary admission, absconded from Cowdy Ward, hanging, response from Top End Mental Health |
| Peter Fittock | 13 May 2016 | 29 June 2016 View findingsPDF (45.1 KB) |
Darwin Local Court | Death in Custody, prison death, hanging, care & supervision appropriate |
| Richard Kunia | 22 June 2016 | 22 June 2016 View findingsPDF (36.1 KB) |
Alice Springs Local Court | Death of child in care, expected death due to congenital serious medical conditions, appropriate care and treatment |
| Kevin Steel | 21 June 2016 | 21 June 2016 View findingsPDF (40.2 KB) |
Alice Springs Local Court | Death in custody, of natural causes while in prison, care and treatment appropriate |
| Madeline Downman | 11 April 2016 | 08 June 2016 View findingsPDF (452.9 KB) |
Darwin Local Court | Death in Care, self-harm leading to death, quality of care, Mental Health of deceased and treatment and respon |
| Ryan Harry Donoghue | 18 April 2016 | 03 June 2016 View findingsPDF (2.4 MB) |
Darwin Local Court | Electrocution on fishing vessel, noncompliance with Work Health and Safety legislation, previous coronial recommendations for similar death, confusing regulatory regime, lack of response by regulators |
| Bundy Namarnyilk | 13 April 2016 | 22 April 2016 View findingsPDF (91.5 KB) |
Darwin Magistrates Court | Death in Custody, death in prison, death by natural causes, care & treatment while in custody |
| William Brown | 09 March 2016 | 21 April 2016 View findingsPDF (156.1 KB) |
Darwin Magistrates Court | Accidental death from falling tree branch, dangerous trees, inspection and maintenance of trees, negligence. |
| Styles Isaac King | 16 February 2016 | 18 March 2016 View findingsPDF (291.5 KB) |
Katherine Magistrates Court | Death as a result of positional asphyxia, crowd controllers and their training. |
| Ronald Donaldson | 27 January 2016 | 09 March 2016 View findingsPDF (135.3 KB) |
Darwin Magistrates Court | Violent death, mentally ill offender, indicators of threat, institutional response. |
| Martin Leach | 21 November 2024 | Directions Hearing | Darwin Local Court | Tags |
| Mati Tamwoy | 10 December 2024 | Darwin Local Court | Tags | |
| Wayne Hunt | 21 November 2024 | Directions Hearing | Darwin Local Court | Tags |
| Pukumani Alimankinni | 23 April 2024 | Adj. sine die | Darwin Local Court | Tags |
| Kumanjayi Fly | 14 October 2024 | Part heard - recommencing 3 December | Alice Springs Local Court | Tags |
| Kumanjayi Rabuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk | 20 May 2024 | Submissions and adj. sine die | Darwin Local Court | Tags |
| Judith Smart and Christine Guyula | 19 August 2024 | Adj. sine die | Darwin Local Court | Tags |
| Michael Deutrom | 10 February 2025 | Darwin Local Court | Tags | |
| Toko-Harieta Maki | 21 November 2024 | Directions Hearing | Darwin Local Court | Tags |
| T. Ptjara Clements and Kumanjayi Ptjara | 03 March 2025 | Alice Springs Local Court | Tags | |
| Kumanjayi Johnson | 03 February 2025 | Alice Springs Local Court | Tags | |
| Douglas Johnson | 21 November 2024 | Directions Hearing | Darwin Local Court | Tags |
| Baby G | 09 July 2024 | Adj. sine die | Darwin Local Court | Tags |
| Richard Roe | 21 May 2024 | Written Submissions and Adj. sine die | Darwin Local Court | Tags |
| KM | 11 March 2024 | Adj. sine die | Darwin Local Court | Tags |
| Rayleen Dick, David Hardy and Karen Bading | 08 April 2024 | Submissions and adj sine die. | Darwin Local Court | Tags |
| Kumanjayi Walker | 05 September 2022 | In progress. Read about the Kumanjayi Walker inquest. |
Alice Springs Local Court | Tags |
| Didbala | 11 November 2024 | Adj. sine die | Katherine Local Court | Tags |
| Angus Dixon | 09 October 2015 | 25 November 2015 View findingsPDF (42.3 KB) |
Alice Springs Magistrates Court | Death in Care, Natural causes, Delay in Reporting |
| Zoe Woolmer | 05 October 2015 | 25 November 2015 View findingsPDF (131.6 KB) |
Alice Springs Magistrates Court | Tour groups, risky behaviour, inappropriate tour guide training, photo opportunities at cliff edge, fall from cliff, tour operator’s failures, park authority’s failure to enforce conditions of permit |
| William Scott and Lanh Van Tran | 07 September 2015 | 30 October 2015 View findingsPDF (142.7 KB) |
Darwin Magistrates Court | Crocodile attack, taken from boat, unsuitability of small and unstable boats in crocodile waters, fishing from bank of river, dangers inherent |
| John Angeles | 13 August 2015 | 16 October 2015 View findingsPDF (109.0 KB) |
Darwin Magistrates Court | Death in Custody, Terminally ill prisoner |
| Kerry James Murphy | 25 July 2016 | 01 September 2015 View findingsPDF (84.2 KB) |
Darwin Local Court | Fall in hospital, no falls risk policy, no handover of fall or neurological observations, subdural bleed |
| Virginia Brown | 06 July 2015 | 14 August 2015 View findingsPDF (209.7 KB) |
Alice Springs Magistrates Court | Death in Care, compulsory care and treatment in Alcohol rehabilitation centre, Death in mandatory detention |
| Perry Langdon | 11 August 2015 | 14 August 2015 View findingsPDF (159.7 KB) |
Darwin Magistrates Court | Death in custody, “paperless arrest scheme”; care and treatment whilst in Darwin Watch House, overrepresentation of Aboriginal people in custod |
| Dennis Wurramarrba | 26 May 2015 | 31 July 2015 View findingsPDF (158.0 KB) |
Darwin Magistrates Court | Motor vehicle accident, drink driver, police pursuit, Death in Custody. |
| Clare Harrison | 09 July 2015 | 10 July 2015 View findingsPDF (286.0 KB) |
Alice Springs Magistrates Court | Death in Care; treatment for “Anorexia Nervosa”; Mental Health detention |
| Raymond McDonald | 09 March 2015 | 13 April 2015 View findingsPDF (226.3 KB) |
Darwin Magistrates Court | Death in Custody, Death by natural causes, Treatment and care whilst in Custody |
| Ryan Ashton | 12 March 2015 | 27 March 2015 View findingsPDF (128.4 KB) |
Darwin Magistrates Court | Death by drowning, dangers of alcohol associated with swimming |
| Levi Griffiths | 09 February 2015 | 02 March 2015 View findingsPDF (145.1 KB) |
Darwin Magistrates Court | Intoxicated driver; fleeing scene of collision with pedestrian, fail to report accident to Police or hospital; placing body away from scene, Hells Angels Outlaw Motorcycle club. |
| Victor Campbell | 16 February 2015 | 19 February 2015 View findingsPDF (85.8 KB) |
Alice Springs Magistrates Court | Death in Custody, Alice Springs Correctional Services, natural causes, care and treatment. |
| Desmond Tilmouth | 17 February 2015 | 19 February 2015 View findingsPDF (98.2 KB) |
Alice Springs Magistrates Court | Death in Custody, Alice Springs Correctional Services, natural causes, care and treatment. |
| Anthony Faulkner | 08 December 2014 | 21 January 2015 View findingsPDF (92.4 KB) |
Darwin Magistrates Court | Death in Care, mental Health patient, sudden & unexpected death, heart attack. |
| Neil McNab | 26 November 2014 | 30 December 2014 View findingsPDF (1.6 MB) |
Darwin Magistrates Court | Accidental death, ultralight aircraft crash, dangers associated with flying such aircraft |
| Simone Montgomerie | 29 September 2014 | 01 December 2014 View findingsPDF (118.0 KB) |
Darwin Magistrates Court | Jockey, fall from horse during Darwin cup, horse baulking at crossing; Darwin Turf Club, Thoroughbred Racing NT. |
| Haidar Ali Ikhtiyar | 06 October 2014 | 03 November 2014 View findingsPDF (92.3 KB) |
Darwin Magistrates Court | Death in Federal custody; Detention of asylum seeker; Psychological Care and Treatment; Suicide. |
| Francis Gaykamangu | 13 May 2014 | 03 November 2014 View findingsPDF (65.2 KB) |
Darwin Magistrates Court | Death of young Aboriginal man from coronary artery disease; early recognition/diagnosis of coronary artery disease in young Aboriginal people in particular; connected to Findings in the associated inquest of Dion Daniels |
| Dion Daniels | 09 September 2014 | 03 November 2014 View findingsPDF (244.5 KB) |
Darwin Magistrates Court | Death of young Aboriginal man from coronary artery thrombosis; early recognition/diagnosis of coronary artery disease in young Aboriginal people in particular |
| Richard Baird | 22 September 2014 | 14 October 2014 View findingsPDF (244.3 KB) |
Darwin Magistrates Court | Unexpected death by drowning, drainage, secured access to drains, municipal responses thereto. |
| Baby C | 22 July 2014 | 01 September 2014 View findingsPDF (1.5 MB) |
Alice Springs Magistrates Court | Death of baby in care of foster parent; cause of death undetermined; care and treatment whilst at hospital and in care. |
| Braydon Brown | 09 July 2014 | 01 September 2014 View findingsPDF (292.2 KB) |
Alice Springs Magistrates Court | Bacterial meningitis; need for early intervention; Yuendumu Clinic; CARPA manua |
| Michael Pedersen | 07 July 2014 | 24 July 2014 View findingsPDF (103.8 KB) |
Alice Springs Magistrates Court | Collision between car and motorcycle, Inadequate road markings, Ilparpa Road, Clay Pans. |
| Ryan Smiler | 19 May 2014 | 21 July 2014 View findingsPDF (222.1 KB) |
Darwin Magistrates Court | Death in Custody, Death by natural causes, care and treatment whilst in Custody. |
| Pauline Iris Abbott, Kendrick Oliver and Joy McNamara | 29 April 2014 | 11 July 2014 View findingsPDF (100.3 KB) |
Alice Springs Magistrates Court | Motor Vehicle Accident, Multiple Deaths, Police Involvement |
| Benjamin Wilton | 07 April 2014 | 27 May 2014 View findingsPDF (151.0 KB) |
Darwin Magistrates Court | Motor Vehicle Death; Fitness to drive of elderly drivers |
| Eric Lewis Wobona | 18 February 2014 | 15 May 2014 View findingsPDF (76.7 KB) |
Katherine Magistrates Court | Death due to Coronary Artery and Heart Disease |
| Joshua Stephen Walsh | 03 December 2013 | 19 March 2014 View findingsPDF (190.9 KB) |
Darwin Magistrates Court | Gunshot Suicide, Police Siege |
| Vikki Riley | 14 January 2014 | 23 January 2014 View findingsPDF (84.6 KB) |
Darwin Magistrates Court | Motor vehicle accident, cyclist death, unregulated pedestrian crossing of multi-lane roadway. |
| Miss M | 17 December 2013 | 18 December 2013 View findingsPDF (95.4 KB) |
Katherine Magistrates Court | Death in care, natural cause death, care and treatment exemplary |
| Paul James Du Toit | 18 November 2013 | 04 December 2013 View findingsPDF (68.7 KB) |
Darwin Magistrates Court | Unexpected death, beach drowning, unexplained injuries. |
| Sara Lorraine Hampel | 20 August 2013 | 20 November 2013 View findingsPDF (3.4 MB) |
Darwin Magistrates Court | Sepsis, necrotising fasciitis, death in medical care |
| Gwyyneth Cassiopeia-Roennfeldt | 13 August 2013 | 15 October 2013 View findingsPDF (228.4 KB) |
Alice Springs Magistrates Court | Fatal stabbing, care and treatment for mentally ill persons, schizophrenia. |
| Damien Hughes | 02 September 2013 | 30 September 2013 View findingsPDF (73.6 KB) |
Darwin Magistrates Court | Death in Custody, natural causes |
| Kevin Taylor, Lena Yali and Gregory McNamara | 20 May 2013 | 20 June 2013 View findingsPDF (140.4 KB) |
Darwin Magistrates Court | Collision at intersection, multiple deaths, Airservices fire truck, emergency services. |
| Michael Chisholm, Aaliyaha Webb and Julian Chisholm | 19 March 2013 | 15 May 2013 View findingsPDF (139.8 KB) |
Darwin Magistrates Court | Killing of children, suicide, police response to child welfare complaint, grief counsellor. |
| Jennifer Taylor and Clifford Norman | 26 February 2013 | 22 March 2013 View findingsPDF (700.9 KB) |
Alice Springs Magistrates Court | Motor vehicle crash, death in custody, police general order Emergency Vehicle Driving (EVD) and pursuit driving |
| Peter Clarke | 15 October 2013 | 13 February 2013 View findingsPDF (117.0 KB) |
Alice Springs Magistrates Court | Death in Custody, serving prisoner, terminal illness, care and treatment thereof. |
| Yong Lam Chai | 09 November 2012 | 16 November 2012 View findingsPDF (59.1 KB) |
Darwin Magistrates Court | Death in Custody; Prison care and treatment; Natural Cause Death |
| Name 'N' | 26 October 2012 | 29 October 2012 View findingsPDF (49.0 KB) |
Darwin Magistrates Court | Death in Care, mandatory inquest, No criticism or recommendations |
| Ben James Witham | 28 August 2012 | 29 October 2012 View findingsPDF (113.3 KB) |
Darwin Magistrates Court | Death by natural causes, adequacy of medical care, arsenic poisoning, closure of property. |
| Terrence Daniel Briscoe | 12 June 2012 | 17 September 2012 View findingsPDF (2.7 MB) |
Alice Springs Magistrates Court | Death in custody, care and treatment whilst in Alice Springs Watch House, alcohol toxicity, positional asphyxia |
| Kalotina Galimitakis | 16 July 2012 | 27 August 2012 View findingsPDF (1.2 MB) |
Darwin Magistrates Court | Unexpected death of baby, Hospital Birth, Paediatric Treatment, Communication with parents |
| Rosalyn Ellen O'Neill | 29 May 2012 | 10 August 2012 View findingsPDF (93.8 KB) |
Darwin Magistrates Court | Motor vehicle accident, rock through windscreen, multiple head injuries |
| Geoffrey James Hewitt | 01 June 2012 | 03 August 2012 View findingsPDF (72.8 KB) |
Darwin Magistrates Court | Car accident, collision with truck, methamphetamine, amphetamine, cannabis, heart failure |
| Edward Brown | 13 July 2012 | 13 July 2012 View findingsPDF (55.0 KB) |
Alice Springs Magistrates Court | Death in custody, natural causes |
| Master C | 10 July 2012 | 13 July 2012 View findingsPDF (74.4 KB) |
Alice Springs Magistrates Court | Pedestrian motor vehicle accident, fatal injury, person held in care |
| Azaria Chantel Chamberlain - Appendix A | 24 February 2012 | 12 June 2012 View findingsPDF (7.4 MB) |
Darwin Magistrates Court | Royal Commission of Inquiry into Chamberlain Convictions, Report, Commonwealth Parliamentary Papers (1987), volume 15, paper 192 |
| Azaria Chantel Chamberlain | 24 February 2012 | 12 June 2012 View findingsPDF (73.8 KB) |
Darwin Magistrates Court | CORONIAL LAW -- INQUEST -- CAUSE OF DEATH Reopening of Inquest – fresh evidence – primary duty – standard of proof – cause of death - expansion of traditional verdicts – taken by animal – dingo |
| Lado Stephen Lazorous | 28 March 2012 | 20 April 2012 View findingsPDF (128.4 KB) |
Darwin Magistrates Court | Accidental death by drowning, Public Aquatic recreational area, Supervision and management thereof |
| Michael Condrick | 13 December 2011 | 19 April 2012 View findingsPDF (90.7 KB) |
Darwin Magistrates Court | Unlawful killing, failings in police investigation with the death, referral back to DPP and Commissioner of Police |
| Master F | 26 March 2012 | 26 March 2012 View findingsPDF (87.9 KB) |
Darwin Magistrates Court | Unexpected death of child in care, mandatory Inquest, quality of treatment and care prior to death. |
| Robert Martin Johnson | 25 July 2011 | 07 March 2012 View findingsPDF (189.2 KB) |
Darwin Magistrates Court | Death in Custody, Suicide by Hanging, Care and Treatment of Deceased in Prison |
| Barnabas Naroldol | 24 November 2011 | 04 January 2012 View findingsPDF (660.9 KB) |
Darwin Magistrates Court | Death in custody, Coronary atherosclerosis, cardiac hypertrophy, care and treatment whist in custody |
| Steven Andrew Forbes | 23 September 2011 | 03 January 2012 View findingsPDF (67.8 KB) |
Darwin Magistrates Court | Death in custody, natural causes, adequacy of custodial medical attention, rheumatic heart disease, swine flu. |
| Bird | 21 November 2011 | 25 November 2011 View findingsPDF (65.2 KB) |
Darwin Magistrates Court | Death in custody, death by self inflicted hanging, care and treatment whilst in custody. |
| Daniel Phillips Johnson | 20 September 2011 | 18 November 2011 View findingsPDF (81.3 KB) |
Darwin Magistrates Court | Death in custody, natural causes, adequacy of custodial medical attention |
| Kerisha Slim | 27 April 2011 | 14 October 2011 View findingsPDF (89.5 KB) |
Katherine Magistrates Court | Chronic Myocarditis, adequacy of medical treatment, air transfer procedures |
| Aaron Nathan Stagg | 06 September 2011 | 11 October 2011 View findingsPDF (172.5 KB) |
Darwin Magistrates Court | Death by Hanging, Self-inflicted, Mental Health Issues, Treatment and Care |
| Shechem Wasan-Garlngarr | 12 July 2011 | 23 September 2011 View findingsPDF (101.3 KB) |
Darwin Magistrates Court | Single vehicle roll-over, intoxicated driver, failure to wear seat belt, police pursuit |
| Baby M | 18 July 2011 | 09 September 2011 View findingsPDF (76.1 KB) |
Darwin Magistrates Court | Unexpected death of child in care, mandatory Inquest, death from complications arising from neonatal cerebral palsy. |
| Linda Nha Tran | 06 July 2011 | 09 September 2011 View findingsPDF (130.4 KB) |
Alice Springs Magistrates Court | Unexpected death in hospital, complications arising at birth and treatment thereof, communications between treating medical professionals |
| Stuart Morris | 10 August 2011 | 02 September 2011 View findingsPDF (58.7 KB) |
Nauiyu Nambiyu Council Chambers, Daly River | Death in custody, attempted apprehension by police, drowning |
| Nicholas Edward Spring | 09 June 2011 | 29 July 2011 View findingsPDF (128.8 KB) |
Darwin Magistrates Court | Mental illness, treatment and care, suicide, after care, counselling for bereaved family. |
| Marilyn Lalara | 24 May 2011 | 27 July 2011 View findingsPDF (144.8 KB) |
Alyangula | Unexpected Death, myocarditis, remote area health facilities and treatment, aero-medical evacuation |
| Kumanjai Marshall | 08 July 2011 | 13 July 2011 View findingsPDF (474.5 KB) |
Alice Springs Magistrates Court | Death in custody; natural causes |
| Peter Murphy (Suppression order lifted 19.4.17) | 12 April 2011 | 06 July 2011 View findingsPDF (17.8 KB) |
Alice Springs Family Court | Violent death, foul play, belief as to crime |
| Peter Murphy (Suppression order in place) | 12 April 2011 | 06 July 2011 View findingsPDF (439.8 KB) |
Alice Springs Family Law Court | Violent death, foul play, belief as to crime |
| Leo Kauka Simukka | 16 June 2011 | 24 June 2011 View findingsPDF (66.6 KB) |
Darwin Magistrates Court | Unexpected death, subdural haemorrhage |
| Damon Cabiddu | 15 March 2011 | 01 June 2011 View findingsPDF (127.0 KB) |
Darwin Magistrates Court | Unexpected death in hospital, difficulty in diagnosing appendicitis in children |
| Marlon Aidan Clancy | 22 February 2011 | 13 May 2011 View findingsPDF (109.7 KB) |
Darwin Magistrates Court | Infant death, suffocation, mother/infant co-sleeping |
| Kieffen Owen Raggett | 30 November 2010 | 08 April 2011 View findingsPDF (711.1 KB) |
Borroloola / Darwin Magistrates Court | Suspicious death; inadequate police Investigation, delay, belief in crime committed |
| Dwayne Joseph Berto | 27 January 2011 | 15 March 2011 View findingsPDF (80.5 KB) |
Darwin Magistrates Court | Suicide by hanging, circumstances in relation thereto including alcohol and violence |
| Emma Jane Claridge | 25 October 2010 | 04 February 2011 View findingsPDF (1.5 MB) |
Darwin Magistrates Court | Death in Care, Mental Health treatment, In patient leave, Suicide |
| Deryck Michael Calvert | 09 November 2010 | 23 December 2010 View findingsPDF (773.5 KB) |
Darwin Magistrates Court | Motor vehicle crash, police pursuit policy |
| Kristelle Ruby Mulladad aka Oliver | 10 August 2010 | 29 October 2010 View findingsPDF (109.0 KB) |
Alice Springs Magistrates Court | Unexpected Death, Management of Referrals, Delay in Treatment. |
| Carl Francis Walker | 30 September 2010 | 29 October 2010 View findingsPDF (55.3 KB) |
Darwin Magistrates Court | Death in Custody, natural causes, importance of medical notes |
| Adam Francis Chandler | 30 June 2010 | 10 September 2010 View findingsPDF (89.1 KB) |
Darwin Magistrates Court | Unexpected death, alcohol related deaths in Darwin CBD, Police Watchhouse procedures |
| Michael Aubrey Campbell | 31 May 2010 | 01 September 2010 View findingsPDF (97.2 KB) |
Darwin Magistrates Court | Unexpected baby death, acute heat stress, circumstances unknown, open finding |
| Gottlieb Rubuntja | 18 May 2010 | 11 August 2010 View findingsPDF (193.4 KB) |
Alice Springs Family Court | Death in Custody, use of Taser devices, apprehension of mentally ill persons, apprehension of physically ill persons. |
| Danmirriwuy Yunupingu | 12 May 2010 | 07 July 2010 View findingsPDF (57.0 KB) |
Nhulunbuy Magistrates Court | Unexpected Death, Suicide, Drunkenness, Police Involvement, Liquor Restrictions |
| Desmond Waight | 13 April 2010 | 05 July 2010 View findingsPDF (563.7 KB) |
Darwin Magistrates Court | Death from bronchopneumonia, 81 year old man, nursing home resident, palliative care. |
| Cedric Trigger | 09 March 2010 | 19 May 2010 View findingsPDF (91.7 KB) |
Alice Springs Magistrates Court | Death in custody, Role of watch house keeper, watch house procedures, risk assessment of intoxicated prisoners |
| Zephaniah Namundja | 19 April 2010 | 22 April 2010 View findingsPDF (78.0 KB) |
Darwin Magistrates Court | Motor vehicle accident, police pursuit, remote community, liquor restrictions. |
| Dailyna Byrnes | 25 March 2010 | 16 April 2010 View findingsPDF (74.3 KB) |
Darwin Magistrates Court | Death in care, long stay patient at RDH, dehydration, inadequate patient notes |
| Briony Goodsell | 22 March 2010 | 13 April 2010 View findingsPDF (67.4 KB) |
Darwin Magistrates Court | Crocodile attack, Adequacy of signage, Saltwater Crocodile Management Plan, Public Safety |
| Michael Anthony Hardy and Robert James Roe | 22 September 2009 | 30 March 2010 View findingsPDF (241.1 KB) |
Alice Springs Magistrates Court | Unexpected death, Dog attacks on live person, Dog attacks on deceased persons, Responsibility of relevant agencies. |
| Mohammed Ayubi, Muzafar Sefarali, Mohammed Zamen, Awar Nadar and Baquer Husani | 25 January 2010 | 17 March 2010 View findingsPDF (563.7 KB) |
Darwin Magistrates Court / Darwin Supreme Court | Detention of persons by Australian Defence Force members, violent & unexpected death of asylum seekers, apprehension of illegal entry boat, explosion on boat, rescue of multiple survivors. |
| Baby Kalib (Child 7) | 11 May 2009 | 19 January 2010 View findingsPDF (1.5 MB) |
Darwin Magistrates Court / Alice Springs Magistrates Court | Death of baby interstate but normally resident of Northern Territory, child in need of care, responsibilities of relevant Government agencies. |
| Deborah Leanne Melville | 23 November 2009 | 19 January 2010 View findingsPDF (3.1 MB) |
Aboriginal land Commissioners Court | Child in Care of the Minister, reportable death of child, care received prior to death, problems with relevant government agency. |
| Barbara Malthouse, Nigel Inkamala, Daryl Inkamala, Dion Ngalken, Gordon Murray and Antonia Meneri | 03 November 2009 | 17 December 2009 View findingsPDF (105.6 KB) |
Alice Springs Magistrates Courts | Motor vehicle accident, police pursuit, pursuit policy and training, adequacy and timeliness of police investigation |
| Matthew Winsloe Hinton | 27 October 2009 | 02 December 2009 View findingsPDF (137.8 KB) |
Darwin Magistrates Court | Unexpected death, recreational drug overdose, police response, ambulance response, medical response. |
| Jaron Mamarika, Dwayne Bara, Jaross Amagula and Francene Huddleston | 01 October 2009 | 27 November 2009 View findingsPDF (104.6 KB) |
Alyangula Magistrates Court | Motor vehicle accident, multiple deaths, driver education, unsealed roads in remote localities. |
| Alma June Green | 09 September 2009 | 27 November 2009 View findingsPDF (68.8 KB) |
Darwin Magistrates Court | Unexpected hospital death, injuries resulting from a fall, adequacy of patient notes. |
| Maureen Caroline Thomson | 13 July 2009 | 24 November 2009 View findingsPDF (112.2 KB) |
Darwin Magistrates Court | Unexpected hospital death, communication with patient’s family |
| Clifton Wayne Pamkal | 24 March 2009 | 15 October 2009 View findingsPDF (176.1 KB) |
Darwin Magistrates Court, Bulman (Opening) and Katherine Courts | Death in custody, escapee, Police search, suicide. |
| Danny Borrak Gumana | 12 August 2009 | 28 September 2009 View findingsPDF (185.0 KB) |
Nhulunbuy Magistrates Court | Intentional self-inflicted hanging, police conveyances, suicide in East Arnhem |
| Kenneth William Hill | 16 February 2009 | 30 June 2009 View findingsPDF (79.9 KB) |
Darwin Magistrates Courts | Unexpected death in Hospital on admission, Heart disease, Triage, Nursing protocols |
| Robert Plasto-Lehner and David Gurralpa aka Moscow | 25 February 2009 | 10 June 2009 View findingsPDF (261.3 KB) |
Darwin Magistrates Court | Death in Custody and care, restraint by police, positional asphyxia, police training in relation thereto, report of crime committed. |
| Kunmanara Forbes | 22 April 2009 | 04 June 2009 View findingsPDF (118.8 KB) |
Alice Springs Magistrates Court | Hanging of young person – petrol sniffing – sexual abuse – remote communities - effectiveness of FACS and other government intervention – police delay in coronial investigation |
| Declan McConville | 03 February 2009 | 28 May 2009 View findingsPDF (93.8 KB) |
Darwin Magistrates Courts | Reportable Hospital Death, baby born with shoulder dystocia, ramifications & treatment, critical review. |
| Georgia Rae Tilmouth | 12 November 2008 | 09 April 2009 View findingsPDF (162.2 KB) |
Darwin | Unexpected death in hospital, obstetric care, non-reporting of death to the Coroner. |
| Paul Guarini | 15 December 2008 | 09 April 2009 View findingsPDF (83.9 KB) |
Darwin | Person in care, Mental Health Patient, Suicide, Mandatory Inquest |
| Peter Jacobs | 19 February 2009 | 20 February 2009 View findingsPDF (93.3 KB) |
Darwin Magistrates Court | Death in custody, Police duty of care, Watch House procedures, Medical treatment. |
| Jenissa Ryan | 25 September 2008 | 23 December 2008 View findingsPDF (82.8 KB) |
Alice Springs | Absconding juvenile patient, relevant hospital policy and non-compliance with it, subsequent hospital actions |
| Paulo Melo | 21 October 2008 | 18 December 2008 View findingsPDF (161.5 KB) |
Darwin | Motor accident causing severe injury, medical treatment thereof, decision to cease mechanical ventilation consequent on poor prognosis, communication between health professionals and family |
| Sandra McRae | 16 July 2008 | 29 October 2008 View findingsPDF (144.1 KB) |
Darwin | Unexpected Hospital Death, Pulmonary Embolism as a consequence of Fractures, Care and Treatment Thereof. |
| Rebecka Hans | 08 October 2008 | 10 October 2008 View findingsPDF (97.5 KB) |
Darwin | Death in Custody, suicidal deceased, police efforts to assist, suicide |
| Margaret Winter | 29 April 2008 | 04 September 2008 View findingsPDF (172.6 KB) |
Darwin | Reportable death in hospital, patient fall, medical treatment, hospital nursing |
| Robert Daly | 07 April 2008 | 01 September 2008 View findingsPDF (80.4 KB) |
Nauiyu Nambiyu Govt. Council Building, Daly River | Death in Custody, police responses, Health Worker responses. |
| Peter Limbunya | 13 November 2007 | 01 September 2008 View findingsPDF (168.3 KB) |
Kalkaringi Court and Katherine Court | Reportable death, preventable death at remote airstrip, patient travel . |
| Wayne Walker and Jacqueline Morrison | 26 August 2008 | 26 August 2008 View findingsPDF (82.3 KB) |
Darwin | Death in Custody, police endeavouring to detain, murder / suicide, Police responses thereto |
| Nicholas Konedaris | 05 March 2008 | 13 June 2008 View findingsPDF (93.6 KB) |
Alice Springs Magistrates Court | Motor vehicle accident, quality of police investigation, police registration of motor vehicles |
| Lee Shaun Wurramarrba | 03 June 2008 | 03 June 2008 View findingsPDF (44.8 KB) |
Darwin | Death in care, Severely disabled young boy, Exceptional and dedicated care by carers |
| Kenny Malthouse | 10 December 2007 | 15 May 2008 View findingsPDF (153.2 KB) |
Alice Springs | Accidental death by suffocation, petrol sniffing, Opal fuel and inherent dangers. |
| Aidan Bott | 26 February 2008 | 02 May 2008 View findingsPDF (131.3 KB) |
Darwin Magistrates Court | Unexpected Student Death by accident, Schoolyard Safety, Responsibilities of School Authorities. |
| Darryll Stuart Davis | 23 October 2007 | 02 May 2008 View findingsPDF (133.5 KB) |
Darwin Magistrates Court | Unexpected death, Electrocution, Electric work at and in remote residential homes, safety practices. |
| Billy Martin | 12 February 2008 | 13 February 2008 View findingsPDF (60.0 KB) |
Katherine Court Katherine | Residential swimming pool party, alcohol ingestion, accidental death by drowning |
| John Russell Ralkurra Marika | 29 November 2007 | 02 January 2008 View findingsPDF (43.3 KB) |
Nhulunbuy Court House | Unexpected death, myocardial infarction (coronary heart disease), circumstances involving violence immediately prior to death. |
| Ricky Ryder | 18 September 2007 | 10 December 2007 View findingsPDF (119.7 KB) |
Alice Springs Court House | Reportable death at Alice Springs Hospital, medically adverse event, hospital resources, preventable death. |
| Robert Jongmin | 01 October 2007 | 03 December 2007 View findingsPDF (93.2 KB) |
Wadeye / Darwin Magistrates Court | Death by gunshot, police shooting, crimes committed. |
| Richard Kiel | 12 February 2007 | 13 November 2007 View findingsPDF (72.0 KB) |
Darwin Magistrates Court | Death from drug overdose, prescribed drugs, medical treatment of known drug addict. |
| Angel Blanco-Puerto, Phillip Lindsay, Barry Gaykamangu and Hannu Kononen | 23 April 2007 | 12 November 2007 View findingsPDF (120.7 KB) |
Darwin Magistrates Court | Unexpected death by natural causes, emergency treatment, Ambulance Service attendance on deceased persons, nil transportation to Hospital |
| Kenneth Plummer | 12 June 2007 | 17 August 2007 View findingsPDF (42.5 KB) |
Tennant Creek Court House | Unexpected death, myocardial infarction, circumstances involving violence immediately prior to death. |
| Monica Presley | 26 April 2006 | 28 June 2007 View findingsPDF (89.1 KB) |
Tennant Creek Court House | Unexpected death of child, electrocution, Public Housing maintenance, faulty or dangerous air conditioning units. |
| Erfinna Patricia Lay and John Weston Quirk | 14 November 2006 | 18 May 2007 View findingsPDF (94.9 KB) |
Darwin Magistrates Court | Deaths resulting from Acute Multiple Drug toxicity, Prescription drugs, Medical treatment prior to death |
| Zachariah Foster | 03 April 2007 | 05 April 2007 View findingsPDF (40.2 KB) |
Alice Springs Court House | Road accident death, alcohol affected pedestrian, involvement of motor vehicle driven by police. |
| Jason Donald | 04 December 2006 | 16 March 2007 View findingsPDF (184.8 KB) |
Katherine Court House | Police Pursuit |
| Isabelle Manyita | 31 August 2006 | 12 March 2007 View findingsPDF (133.8 KB) |
Darwin Magistrates Court | Septicaemia death, medical treatment both before onset of Septicaemia and afterwards |
| Patrick Heenan | 05 March 2007 | 09 March 2007 View findingsPDF (152.8 KB) |
Darwin Magistrates Court | Death in Custody, Darwin Correctional Facility, care and treatment, natural cause death. |
| Louisa Turner | 20 February 2006 | 26 February 2007 View findingsPDF (52.2 KB) |
Darwin Magistrates Court | Motor vehicle accident, quality of coronial investigation by police, belief as to crimes. |
| Skeletal remains | 23 October 2006 | 26 February 2007 View findingsPDF (59.5 KB) |
Jabiru Court House | Skeletal Remains – traditional Aboriginal burial – identification of remains – open finding |
| Tracey Karadji | 28 August 2006 | 26 February 2007 View findingsPDF (43.5 KB) |
Daly River Darwin Magistrates Court | Motor vehicle fatality, police involvement |
| Wendy Walangitj Garmu | 25 July 2006 | 10 November 2006 View findingsPDF (47.5 KB) |
Gove | Death as a result of stabbing, medical treatment thereafter, possible preventable death. |
| Jodie Palipuaminni | 18 September 2006 | 23 October 2006 View findingsPDF (303.3 KB) |
Darwin Magistrates Court | Violent death, domestic violence, parole supervision of violent offenders. |
| Freddie Peterson | 27 June 2006 | 02 October 2006 View findingsPDF (147.8 KB) |
Alice Springs Court House | Death in Custody, Natural Causes Care and supervision of deceased in custody |
| Hector Martin | 28 March 2006 | 08 September 2006 View findingsPDF (68.0 KB) |
Darwin Magistrates Court | Death in Custody, natural cause death, prison supervision of ill inmates. |
| Clifford Brown | 02 May 2006 | 29 June 2006 View findingsPDF (68.8 KB) |
Alice Springs Court House | Motor vehicle accident causing death, emergency medical treatment, criminal / coronial investigation, report to the Commissioner of Police & DPP |
| Cynthia Diane Ching | 06 March 2006 | 04 May 2006 View findingsPDF (326.6 KB) |
Alice Springs Court House | Unexpected & accidental death, work place fire, reference to DPP & Commissioner of Police. |
| Alena Rankine | 06 March 2006 | 04 May 2006 View findingsPDF (110.8 KB) |
Alice Springs Court House | Death of a Child in Care Coroners Act 1993 (NT) s12(1)(a), s15(1)(a) |
| Zena Stevens | 14 February 2006 | 28 April 2006 View findingsPDF (259.2 KB) |
Alice Springs Court House | Unexpected Death, Hospital treatment, Remote Area Medical Services, Coronial Investigation |
| Dolly Granites | 20 March 2006 | 22 March 2006 View findingsPDF (179.1 KB) |
Alice Springs Court House | Reportable Death – Natural Causes – Remote Health Care – Inadequate record keeping |
| Muhammad Heri | 18 January 2006 | 03 March 2006 View findingsPDF (47.7 KB) |
Darwin Magistrates Court | Death in Custody, Federal Agencies and their duty of care to detainees |
| David Mather | 05 December 2005 | 18 January 2006 View findingsPDF (61.1 KB) |
Darwin Magistrates Court | Unexpected death, Missing patient, Hospital “Absconding Patient Policy”, Recommendation |
| Damien Wayne | 10 October 2005 | 11 November 2005 View findingsPDF (71.3 KB) |
Alice Springs Court House | Death in Custody, police pursuit, motor vehicle accident, police pursuit policy. |
| Angus Lawrence | 05 September 2005 | 31 October 2005 View findingsPDF (147.5 KB) |
Darwin Magistrates Court | Death heat stroke Defence Force |
| Shareya Shannon | 12 October 2005 | 12 October 2005 View findingsPDF (37.7 KB) |
Alice Springs Magistrates Court | Death of a Child in Care Coroners Act 1993 (NT) s12(1)(a), s15(1)(a) |
| Kumanjay Presley, Kunmanara Coulthard and Kunmanara Brumby | 09 August 2005 | 10 October 2005 View findingsPDF (181.2 KB) |
Alice Springs Court House | INQUEST –substance abuse (petrol), Aboriginal remote area communities, governmental responses thereto. |
| Anne Chantell Millar | 01 February 2005 | 02 September 2005 View findingsPDF (95.8 KB) |
Darwin Magistrates Court | Death by foul play, Domestic Violence, police conduct in relation to domestic violence restraining order. |
| Marcellus Tipiloura | 01 November 2004 | 31 August 2005 View findingsPDF (77.0 KB) |
Darwin Magistrates Court | Coronial Inquest, death in custody, death from self-inflicted wounds, involvement of police, ambulance officers treatment, reception at hospital. |
| Sampson Paii | 05 August 2004 | 26 August 2005 View findingsPDF (83.9 KB) |
Darwin Magistrates Court | Coronial Inquest, death in custody, death from natural causes, medical facilities at the prison. |
| Dale Vincent | 02 August 2005 | 26 August 2005 View findingsPDF (52.2 KB) |
Darwin Magistrates Court | Inquest – Death In Care – security of mental health facility |
| Warren Maminyamanja | 14 March 2005 | 26 August 2005 View findingsPDF (92.2 KB) |
Darwin Magistrates Court | Death in Custody, Prison Medical Services, Duty of Care |
| Kenny Alderson | 15 August 2005 | 19 August 2005 View findingsPDF (40.9 KB) |
Darwin Magistrates Court | Motor Accident, pedestrian walking into motor vehicle, death by misadventure |
| Carlene Coombe | 21 February 2005 | 19 July 2005 View findingsPDF (263.1 KB) |
Darwin Magistrates Court | unexpected death - uncertain and suspicious circumstances concerning death - open finding |
| John Morish | 18 July 2005 | 19 July 2005 View findingsPDF (116.0 KB) |
Darwin Magistrates Court | Accidental death, gunshot wound, firearms use |
| Bradley Abala | 03 May 2005 | 27 June 2005 View findingsPDF (166.4 KB) |
Alice Springs Court House | cause of death was astrocytoma |
| Albert Robbo | 09 May 2005 | 09 June 2005 View findingsPDF (215.1 KB) |
Katherine Court House | INQUEST – investigation of police conduct – dangerous act by driving – report to Director of Public Prosecutions |
| Alison Woods | 06 June 2005 | 06 June 2005 View findingsPDF (102.7 KB) |
Darwin Magistrates Court | Death in Care – Natural Causes |
| Jacky Barakal | 29 October 2004 | 10 May 2005 View findingsPDF (148.4 KB) |
Maningrida Magistrates Court | Inquest, Telephone request for medical assistance – communications problems MANINGRIDA |
| Peter Wiryal | 15 November 2004 | 06 April 2005 View findingsPDF (78.4 KB) |
Darwin Magistrates Court | Death as a result of a Motor Vehicle Accident, police investigation, referral to Commissioner of Police and Department of Public Prosecutions |
| Desmond Mamarika | 30 November 2004 | 01 April 2005 View findingsPDF (81.3 KB) |
Darwin Magistrates Court | Heart disease, public drunkeness & police response to same, seizure and destruction of alcohol by police. |
| Marshall Yantarrnga | 07 February 2005 | 29 March 2005 View findingsPDF (43.4 KB) |
Darwin Magistrates Court | Coroners: Inquest, ambulance service, failure to convey patient to hospital |
| Raymond Curtain, Terrence Westwood, Gerald Thompson, Gregory Westerman, Graham Dearden and Ruth Vincent | 17 March 2005 | 17 March 2005 View findingsPDF (52.3 KB) |
Darwin Magistrates Court | Missing person during Cyclone Tracy |
| George Bukulatpjpi | 16 August 2004 | 03 March 2005 View findingsPDF (37.3 KB) |
Elcho Island | Inquest, missing person, remote area, police search |
| Debbie Douglas | 01 March 2005 | 01 March 2005 View findingsPDF (25.1 KB) |
Darwin Magistrates Court | Death of a Child in Care Coroners Act 1993 (NT) S12(1)(a), s15(1)(a) |
| William Bunting | 27 September 2004 | 01 February 2005 View findingsPDF (115.7 KB) |
Alice Springs Court House | Coroners Inquest, death in care, mental illness, observation policy, adequacy of staffing levels |
| Marie Kirwin | 04 May 2004 | 24 December 2004 View findingsPDF (70.0 KB) |
Darwin Magistrates Court | Unexpected death, Drowning, uncertain circumstances concerning death, open finding as to some circumstances concerning death. |
| Isobel Von Jordan | 30 August 2004 | 22 December 2004 View findingsPDF (58.8 KB) |
Darwin Magistrates Court | Unexpected death, crocodile attack, regulation of tour guides, national part safety. |
| Valerie Wurramurra | 01 June 2004 | 20 December 2004 View findingsPDF (74.9 KB) |
Groote Eylandt Court House | Unexpected death, uncertain and suspicious circumstances concerning death, quality of police response, open finding |
| Nikita Anderson | 18 October 2004 | 14 December 2004 View findingsPDF (78.5 KB) |
Darwin Magistrates Court | Resuscitation, administration of carbon dioxide |
| Roselle Nelson | 26 February 2004 | 10 December 2004 View findingsPDF (36.9 KB) |
Katherine Court House | Violent death, unreliable witnesses, suspected unlawful killing, reference to Commissioner of Police, DPP |
| Jade Lange-Loades, Rory Lange-Loades and Nathaniel Rose | 06 September 2004 | 01 October 2004 View findingsPDF (180.6 KB) |
Darwin Magistrates Court | Inquest, motor vehicle accident, load restraint, investigation, Accident Investigation Unit |
| Stephen Power | 03 August 2004 | 05 August 2004 View findingsPDF (57.7 KB) |
Darwin Magistrates Court | Inquest, St John Ambulance, ambulance dispatch, refusal to send ambulance |
| John Colbert | 19 January 2004 | 02 July 2004 View findingsPDF (55.4 KB) |
Darwin Magistrates Court | Inquest, death at hospital, staffing levels, Bali bombing, Health Insurance Act, production of documents, quality assurance activity |
| Raymond Campbell | 22 March 2004 | 18 June 2004 View findingsPDF (52.3 KB) |
Darwin Magistrates Court | Inquest, open findings, death by gunshot wound, destruction of evidence |
| Gregory Nunggarrgalu | 15 June 2004 | 18 June 2004 View findingsPDF (48.2 KB) |
Nhulunbuy Court House | Inquest, death from exposure, viewing body after death. |
| Craig Matthews | 17 November 2003 | 21 May 2004 View findingsPDF (24.8 KB) |
Darwin Magistrates Court | death on home detention, drug related unlawful killing |
| Isiah Roberts | 19 April 2004 | 21 April 2004 View findingsPDF (221.0 KB) |
Darwin Magistrates Court | Inquest Death by stabbing, referral pursuant to section 35 of the Coroners Act. |
| Mansur La ibu | 16 February 2004 | 19 March 2004 View findingsPDF (65.0 KB) |
Darwin Magistrates Court | Inquest, Unexpected Death, Public Health & Safety of persons held in detention by Federal Agencies, Death in Custody. |
| Maxwell Murphy | 01 December 2003 | 16 February 2004 View findingsPDF (28.9 KB) |
Darwin Magistrates Court | Death following a physical fight, commission of offences, referral to DPP and Commissioner of Police |
| Robert Dalgleish | 17 November 2003 | 11 February 2004 View findingsPDF (87.6 KB) |
Darwin Magistrates Court | Death in Hospital – Death in consequence of complications of gastric band surgery – Failure of Accident & Emergency Department to provide appropriate treatment. |
| Sarah Johnson | 03 March 2003 | 10 February 2004 View findingsPDF (52.0 KB) |
Darwin Magistrates Court | Death by drowning, referral pursuant to section 35 of the Coroners Act, open finding |
| Rita Anderson | 01 September 2003 | 21 January 2004 View findingsPDF (44.9 KB) |
Darwin Magistrates Court | Inquest, Hospital Procedures, Adult Guardianship Board, Police Communications |
| Souzana Afianos | 10 November 2002 | 16 January 2004 View findingsPDF (101.5 KB) |
Darwin Magistrates Court | Death by secondary haemorrhage – Unexpected death in hospital – Failure to detect haemorrhaging. |
| Sunjay Chandra | 08 September 2003 | 19 December 2003 View findingsPDF (73.0 KB) |
Darwin Magistrates Court | Inquest, mental illness, medication regime, observations of carers, discharge after involuntary admission, protocols for administration of clozapine. |
| Sarah Higgins | 08 September 2003 | 19 December 2003 View findingsPDF (62.0 KB) |
Darwin Magistrates Court | Inquest, death in care, observation policy |
| Skye Bree Burnett | 13 October 2003 | 15 December 2003 View findingsPDF (53.3 KB) |
Darwin Magistrates Court | sudden death in an infant with bronchopulmonary dysplasia |
| Owen King | 29 July 2003 | 03 December 2003 View findingsPDF (56.0 KB) |
Alice Springs Court House | natural causes namely lobar pneumonia. |
| Lindsay Ryan | 03 November 2003 | 03 December 2003 View findingsPDF (22.0 KB) |
Darwin Magistrates Court | death in custody, death from natural causes |
| Mark Corbett | 02 June 2003 | 05 September 2003 View findingsPDF (100.2 KB) |
Tennant Creek Court House | death in custody, protective custody, detention in Watchhouse, sobering up shelters. |
| Queenie Michaels | 28 July 2003 | 31 July 2003 View findingsPDF (78.2 KB) |
Alice Springs Court House | Death in Care - natural causes being pneumonia complicating cytomegalovirus embryopathy |
| Annette Kunia | 04 November 2002 | 31 July 2003 View findingsPDF (56.7 KB) |
Alice Springs Court House | Police Pursuit |
| Randil Nuparunya | 28 October 2002 | 20 July 2003 View findingsPDF (48.1 KB) |
Darwin Magistrates Court | death in custody, attempted apprehension |
| Lennie Pinawrut | 26 May 2003 | 17 July 2003 View findingsPDF (41.4 KB) |
Darwin Magistrates Court | Medical, Hospital Procedures |
| Unidentified body | 19 May 2003 | 20 May 2003 View findingsPDF (13.9 KB) |
Darwin Magistrates Court | Unidentified |
| Eric Gaykamangu | 06 August 2002 | 10 April 2003 View findingsPDF (35.9 KB) |
Darwin Magistrates Court | death in custody, protective custody |
| Rita Dandy | 17 June 2002 | 28 March 2003 View findingsPDF (143.4 KB) |
Darwin Magistrates Court | Death In Custody, Section 128 – Police Administration Act, Apprehension and release of severely intoxicated persons |
| Robert John Baxter | 10 February 2003 | 21 March 2003 View findingsPDF (98.1 KB) |
Darwin Magistrates Court | Aircraft Accident - Cessna 210 |
| Reba Lakuwanga | 17 September 2002 | 26 February 2003 View findingsPDF (179.0 KB) |
Darwin Magistrates Court | Death in Custody, detention for purposes of protective custody, belief in the commission of crime, duty of care |
| Skeletal Remains | 17 December 2002 | 17 December 2002 View findingsPDF (129.4 KB) |
Darwin Magistrates Court | An inquest into the death of skeletal remains |
| Sylvester Nawirridj | 24 January 2002 | 27 September 2002 View findingsPDF (83.3 KB) |
Darwin Magistrates Court | violent death, suspicious circumstances, report to Commissioner of Police and Director of Public Prosecutions |
| Graham Murrurkuwuy | 04 March 2002 | 13 August 2002 View findingsPDF (96.1 KB) |
Darwin Magistrates Court | death in custody, death from natural causes, medical facilities at the prison |
| Alfred Firth Thorpe | 22 July 2002 | 06 August 2002 View findingsPDF (52.9 KB) |
Darwin Magistrates Court | death in custody, death from natural causes, prerogative of mercy |
| David Pendergast | 07 May 2002 | 09 May 2002 View findingsPDF (65.1 KB) |
Alice Springs Magistrates Court | Coronial Inquest, death in custody, death from natural causes, medical facilities at the prison. |
| Hayley McCurry-Parriman | 24 April 2002 | 01 May 2002 View findingsPDF (99.5 KB) |
Darwin Magistrates Court | Public swimming facility, safety aspects |
| Luke Peter Littlewood | 05 February 2002 | 12 March 2002 View findingsPDF (124.2 KB) |
Darwin Magistrates Court | Mental health, involuntary patient, suicide, PAWA facilities security |
| Johnno Wurramarba | 18 May 2001 | 19 December 2001 View findingsPDF (373.7 KB) |
Darwin Magistrates Court | Death in Custody Don Dale Juvenile Detention Centre |
| Nathan Wade Brooks | 27 March 2001 | 02 November 2001 View findingsPDF (83.8 KB) |
Darwin Magistrates Court | death by electrocution, work place safety |
| Clive Henry Impu | 03 September 2001 | 19 October 2001 View findingsPDF (194.7 KB) |
Alice Springs Court House | , ischaemic heart disease, prevalence in Aboriginal persons, fail to diagnose. |
| Christopher Limerick | 12 June 2001 | 16 October 2001 View findingsPDF (121.2 KB) |
Tennant Creek Court House | Disappearance, Missing Persons Inquiry, death, possible crimes in connection therewith. |
| Bryan G (aka) Abell Dallos | 05 September 2001 | 15 October 2001 View findingsPDF (178.5 KB) |
Alice Springs Court House | Airport Security Mental Health Involuntary Patient Aviation Investigation |
| George Miller | 07 August 2001 | 12 October 2001 View findingsPDF (158.7 KB) |
Katherine Court House | Death In Custody Section 128 – Police Administration Act |
| Skeletal Remains (Cartier Island) | 10 October 2001 | 10 October 2001 View findingsPDF (67.5 KB) |
Darwin Magistrates Court | SKELETAL REMAINS AT CARTIER ISLAND |
| Blake Harvey | 07 March 2001 | 17 August 2001 View findingsPDF (99.9 KB) |
Alice Springs Court House | fire, death caused by burns, fire safety and regulations |
| Corey Leigh McConville | 17 January 2001 | 23 May 2001 View findingsPDF (73.5 KB) |
Darwin Magistrates Court | Transport safety – Fatigue management |
| William Mason | 23 October 2000 | 04 May 2001 View findingsPDF (74.2 KB) |
Darwin Magistrates Court | Discretionary Inquest, reportable death, suspicious circumstances, open finding. |
| Kheng Hav Eng | 22 March 2001 | 30 March 2001 View findingsPDF (80.6 KB) |
Darwin Magistrates Court | |
| Sebastian Barry Davis | 09 March 2001 | 09 March 2001 View findingsPDF (44.9 KB) |
Alice Springs Court House | Child in Care |
| Matthew Neck, Amanda Bell and Matthew Batson | 04 December 2000 | 09 March 2001 View findingsPDF (140.5 KB) |
Alice Springs Magistrates Court | motor vehicle rollover |
| Eduardo Concepcion | 24 August 2000 | 25 January 2001 View findingsPDF (192.0 KB) |
Darwin Magistrates Court | Death in custody - police shooting - justifiable homicide - police investigation - police general orders – possible use of non-lethal weapons. |
| Skeletal Remains (x15) | 21 December 2000 | 21 December 2000 View findingsPDF (129.9 KB) |
Darwin Magistrates Court | Unidentified Skeletal Remains |
| Ronald Smallwood | 13 December 2000 | 13 December 2000 View findingsPDF (45.5 KB) |
Alice Springs Magistrates Court | death was natural causes, being a disseminated carcinoma |
| Corey Paddy | 08 August 2000 | 01 November 2000 View findingsPDF (79.6 KB) |
Darwin Magistrates Court | Coroners, Inquest, death in hospital, positional asphyxia, hypoxic brain damage, level of care |
| Marcio Jose Lay Nheu | 06 June 2000 | 31 October 2000 View findingsPDF (162.1 KB) |
Darwin Magistrates Court | Death in Custody, belief as to crime committed, Hospital procedures, liason between Police and Hospital staff. |
| Glen Anthony Huitson and Rodney William Ansell | 15 September 2000 | 15 September 2000 View findingsPDF (259.4 KB) |
Darwin Magistrates Court | gunshot wound of the chest and abdomen, multiple gunshot wounds |
| Anthony Mahoney and Jane Mahoney | 02 May 2000 | 11 September 2000 View findingsPDF (225.9 KB) |
Darwin Magistrates Court | Motor Vehicle Accident – Double Fatality – Accident Investigation |
| Francis Kamaranga | 24 July 2000 | 06 September 2000 View findingsPDF (92.9 KB) |
Darwin Magistrates Court | asphyxiation following severe swelling to the larynx due to anaphylactoid reaction. |
| Robert Hodgkinson | 13 June 2000 | 14 June 2000 View findingsPDF (97.9 KB) |
Katherine Magistrates Court | - death in custody - police pursuit – fire extinguishers |
| Trevor Parkyn | 22 May 2000 | 01 June 2000 View findingsPDF (83.1 KB) |
Darwin Magistrates Court | Coroners – Inquest – Police – Head injuries undetected |
| Baby J | 10 April 2000 | 10 April 2000 View findingsPDF (73.0 KB) |
Darwin Magistrates Court | Coronial Inquest, death of infant, jurisdiction, reportable death, doctor patient relationship, medical practitioner |
| Gary Peter Tipungwuti, Patrick Raymond Kerinauia, Noeline Pauantulura, John Gerard Orsto | 21 August 1999 | 24 November 1999 View findingsPDF (1.9 MB) |
Darwin Magistrates Court | self-inflicted hanging, Nguiu community, Bathurst Island |
| Esky Muller | 02 September 1998 | 02 September 1998 View findingsPDF (1.3 MB) |
Alice Springs Court House | Loss of blood arising from incised wound to the left arm |
| Azaria Chantel Loren Chamberlain | 01 January 1995 | 13 December 1995 View findingsPDF (2.8 MB) |
Darwin Magistrates Court | taken by dingo, Ayers Rock, tent |
| T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run) | 10 October 1994 | 20 December 1994 View findingsPDF (8.7 MB) |
Darwin | Fatal accident, Cannonball Run |
| Ganamu Garrawurra | 19 June 1990 | 03 June 1991 View findingsPDF (2.2 MB) |
Galiwinku | death in custody |
| Patricia Slinn, Lesley Ramsay, David James Send, Adrian Martin Durnin and Helen Fuller | 26 November 1985 | 26 November 1985 View findingsPDF (791.6 KB) |
Alice Springs | |
| Azaria Chantel Loren Chamberlain | 14 December 1981 | 10 July 1984 View findingsPDF (23.4 KB) |
Alice Springs Magistrates Court | taken by dingo, Ayers Rock, tent |
| John Ross Jabanardi | 11 December 1981 | 11 December 1981 View findingsPDF (2.7 MB) |
Alice Springs | Ti Tree, haemorrhage due to perforation of the left internal iliac artery, gunshot wound to the abdomen |
| Azaria Chantel Loren Chamberlain | 20 February 1981 | 20 February 1981 View findingsPDF (30.8 KB) |
Alice Springs Magistrates Court | taken by dingo, Ayers Rock, tent |
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