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
Xysz Tacdliwaazy @Josh Ngalarina 19 September 2023 05 April 2024
View findings PDF (868.1 KB)
Darwin Local Court
Shane Tapp 17 October 2023 02 February 2024
View findings PDF (3.0 MB)
Katherine Local Court
Delvene Thompson 31 May 2023 06 December 2023
View findings PDF (695.8 KB)
Darwin Local Court
Kumanjayi Walker 22 November 2023 22 November 2023
View findings PDF (4.0 MB)
Ruling No 8
Nigel Harris 23 August 2022 05 June 2023
View findings PDF (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
Kumanjayi Walker 27 April 2023 27 April 2023
View findings PDF (206.0 KB)
Ruling No 7
Alice Springs Local Court
Kumanjayi Holmes 30 March 2023 31 March 2023
View findings PDF (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 findings PDF (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
View findings PDF (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
Bernard Hector 17 January 2023 24 February 2023
View findings PDF (7.1 MB)
Agency response report
Kumanjayi Walker 25 October 2022 25 October 2022
View findings PDF (347.5 KB)
Ruling No 5
Alice Springs Local Court
Kumanjayi Walker 18 October 2022 18 October 2022
View findings PDF (216.2 KB)
Ruling No 4
Alice Springs Local Court
Kumanjayi Walker 29 September 2022 14 October 2022
View findings PDF (450.4 KB)
Ruling No 3
Darwin Local Court
Baby Croker 16 May 2023 22 September 2022
View findings PDF (532.6 KB)
Darwin Local Court on front page of findings
Kumanjayi Walker 09 September 2022 13 September 2022
View findings PDF (286.6 KB)
Ruling No 2
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
View findings PDF (199.2 KB)
Ruling No 1
Darwin Local Court Application for leave to appear; sufficient interest; police association
Roberta Curry 17 May 2022 10 June 2022
View findings PDF (228.3 KB)
Darwin Local Court Intimate partner homicide, domestic violence, response by police, supervision by Community Corrections, 000 calls
Roberta Curry 17 May 2022 10 June 2022
View findings PDF (12.1 MB)
Agency response report
Reginald Roy 15 March 2022 20 May 2022
View findings PDF (9.5 MB)
Agency response report
Reginald Roy 15 March 2022 20 May 2022
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (187.4 KB)
Darwin Local Court Death in custody, natural causes
Sammy 22 June 2021 25 November 2021
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (1.0 MB)
Darwin Local Court Death in custody, ATV rollover, workplace safety at prison
Benjamin Watts 13 April 2021 29 April 2021
View findings PDF (6.3 MB)
Agency response report
Patrick Bloomfield 09 March 2021 01 April 2021
View findings PDF (6.1 MB)
Agency response report
Patrick Bloomfield 09 March 2021 01 April 2021
View findings PDF (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
Christopher Malyschko 09 November 2020 15 January 2021
View findings PDF (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 findings PDF (142.8 KB)
Alice Springs Local Court Death in custody, natural causes
Robert Curtis 08 December 2020 07 January 2021
View findings PDF (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 findings PDF (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
View findings PDF (6.4 MB)
Agency response report
Fionica James, Katurah Mamarika, Layla Leering 16 September 2020 15 December 2020
View findings PDF (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 findings PDF (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 findings PDF (69.0 KB)
Darwin Local Court
David Loader 18 August 2020 18 August 2020
View findings PDF (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 findings PDF (300.5 KB)
Darwin Local Court Death in custody of Correctional Services, natural causes
Ishamel Nawirridj 30 June 2020 17 July 2020
View findings PDF (1.3 MB)
Agency response report
Harry Evans 26 November 2019 03 January 2020
View findings PDF (99.6 KB)
Darwin Local Court Sea snake bite, neurotoxic venom, prawn trawler, remote location
Jonathan Hempel 09 November 2018 03 January 2020
View findings PDF (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
Lebron Douglas Martin 08 October 2019 22 November 2019
View findings PDF (298.7 KB)
Darwin Local Court
Daryl Riley 12 September 2019 27 September 2019
View findings PDF (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 findings PDF (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
Linden Kunoth 10 September 2019 27 September 2019
View findings PDF (5.1 MB)
Agency response report
Jordan Allen 11 September 2019 27 September 2019
View findings PDF (969.4 KB)
Alice Springs Local Court Mental Health Facility, involuntary patient, “cigarette leave” while still psychotic, took his own life
Joanne Craig 27 August 2019 20 September 2019
View findings PDF (2.9 MB)
Agency response report
Joanne Craig 28 August 2019 20 September 2019
View findings PDF (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 findings PDF (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 findings PDF (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
View findings PDF (4.3 MB)
Agency response report
Fazan Khan 11 April 2019 20 June 2019
View findings PDF (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 findings PDF (1.6 MB)
Darwin Local Court Death in custody, foreign national, inadequate health care
Ali Achmadun Djawas 12 March 2019 16 April 2019
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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
Jeremy aka Lawrence Tunkin 16 October 2018 26 November 2018
View findings PDF (117.5 KB)
Alice Springs Local Court Death in Custody, Natural Causes, Communication problems with hearing impaired prisoners, AutoPulse resuscitation devices
Jessica Poulson 08 November 2018 26 November 2018
View findings PDF (40.2 KB)
Alice Springs Local Court Death in care, 17 days old baby, congenital heart defect, expected death, appropriate care and treatment
Wilfried and Gisela Thor 06 November 2018 26 November 2018
View findings PDF (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
Matthew Rosewarne 18 September 2018 10 October 2018
View findings PDF (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
David Fensom 21 August 2018 21 September 2018
View findings PDF (100.5 KB)
Darwin Local Court Delay in diagnosis, unexpected death, poor communication with family, no report to Coroner
Henry George Wilson aka Albert Wilson 21 August 2018 21 September 2018
View findings PDF (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
Paula Schubert 25 June 2018 25 July 2018
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (54.2 KB)
Alice Springs Death in custody, natural causes, released on bail for payback
Addison Anthony 13 November 2017 11 January 2018
View findings PDF (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
Peter Bonnell 24 October 2017 11 January 2018
View findings PDF (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
Damien Kyle-Little 12 October 2017 24 November 2017
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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
Ashley Richards 13 February 2017 07 April 2017
View findings PDF (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
Gabby Wanambi 16 February 2017 07 April 2017
View findings PDF (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
Irene Magriplis 06 March 2017 30 March 2017
View findings PDF (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
Michael Smedley 12 December 2016 13 January 2017
View findings PDF (243.4 KB)
Alice Springs Local Court Baby died of traumatic head injury, initial disagreement between medical experts, disagreement resolved, referred back to Police
Ray Gibson 14 December 2016 13 January 2017
View findings PDF (142.9 KB)
Alice Springs Local Court Death in Custody, natural causes
Ronnie Beasley 14 December 2016 13 January 2017
View findings PDF (224.8 KB)
Alice Springs Local Court Death in Custody, natural causes
Noel Ramage 09 January 2017 09 January 2017
View findings PDF (40.9 KB)
Darwin Local Court accidental drowning
Justin Morgan-Parke 14 November 2016 14 November 2016
View findings PDF (41.7 KB)
Darwin Local Court accidental drowning
Krista Lloyd 12 October 2016 17 October 2016
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (114.0 KB)
Darwin Local Court
Dean Jigili 06 June 2016 11 July 2016
View findings PDF (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 findings PDF (45.1 KB)
Darwin Local Court Death in Custody, prison death, hanging, care & supervision appropriate
Richard Kunia 22 June 2016 22 June 2016
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (135.3 KB)
Darwin Magistrates Court Violent death, mentally ill offender, indicators of threat, institutional response.
Kulum 16 January 2023 Directions Hearing Darwin Local Court Tags
Nigel Harris 23 August 2022 Part Heard - Recommencing 2023 Alice Springs Local Court Tags
Damilia Holmes 24 August 2022 Vacated - New date set for 2023 Alice Springs Local Court Tags
Kumanjayi Walker 29 March 2022 Directions Hearing - Those seeking leave to appear. Darwin Local Court Tags
Kumanjayi Walker 05 September 2022 In progress.
Read about the Kumanjayi Walker inquest.
Alice Springs Local Court Tags
Kumanjayi Walker 26 May 2022 Directions Hearing Alice Springs Local Court Tags
Kumanjayi Walker 15 August 2022 Directions Hearing Darwin Local Court Tags
Glen Dooley 16 January 2023 Directions Hearing Darwin Local Court Tags
KM 16 January 2023 Directions Hearing Darwin Local Court Tags
01 January 2016 Tags
Ngeygo Ragurrk 26 June 2023 Part Heard - Recommencing 30.10.23 Darwin Local Court Tags
Patrick Moriarty 06 April 2022 Part Heard - Recommencing 2022 Katherine Local Court Tags
Pukumani Alimankinni 23 April 2024 Resuming Darwin Local Court Tags
Kumanjayi Fly 14 October 2024 Alice Springs Local Court Tags
Kumanjai Brogus 28 February 2024 Directions Hearing Alice Springs Local Court Tags
Bernard Hector 26 July 2022 Adjourned -new date set for 2023 Darwin Local Court Tags
Baby G 09 July 2024 Darwin Local Court Tags
Anthony Rubuntja 28 February 2024 Directions Hearing Alice Springs Local Court Tags
Mati Tamwoy 16 February 2024 Directions Hearing Darwin Local Court Tags
Katrina Hawker 18 June 2024 Darwin Local Court Tags
Richard Roe 21 May 2024 Darwin Local Court Tags
Kumanjayi Walker 27 May 2024 Alice Springs Local Court Tags
Kumanjayi Walker 22 February 2024 Part Heard Alice Springs Local Court Tags
Baby G 14 December 2023 Directions Hearing Darwin Local Court Tags
KM 11 March 2024 Darwin Local Court Tags
Pukumani Alimankinni 19 March 2024 Part Heard Darwin Local Court Tags
Kumunjayi Ptjara 11 December 2023 Directions Hearing Darwin Local Court Tags
Rayleen Dick, David Hardy and Karen Bading 08 April 2024 Darwin Local Court Tags
Karen Bading, Raylene Dick, David Hardy 24 November 2023 Directions Hearing Darwin Local Court Tags
Kumanjayi Walker 27 February 2023 Part Heard - Recommencing Alice Springs Local Court Tags
Kumanjayi Walker 31 July 2023 dates vacated to recommence in Oct 2023 and Feb/March 2024 Alice Springs Local Court Tags
Kumarn Rubuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk 28 April 2023 Directions Hearing Darwin Local Court Tags
Kumarn Rubuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk 30 October 2023 Adj. sine die Darwin Local Court Tags
Kumanjayi Walker 23 October 2023 Vacated Alice Springs Local Court Tags
Kumarn Rubuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk 05 June 2023 Directions Hearing Darwin Local Court Tags
Kumarn Rubuntja 21 August 2023 Part Heard - Recommencing 30.10.23 Alice Springs Local Court Tags
Kumanjayi Walker 26 February 2024 Part Heard Alice Springs Local Court Tags
Miss Yunupingu 14 August 2023 Part Heard - Recommencing 30.10.23 Darwin Local Court Tags
KM 14 December 2023 Directions Hearing Darwin Local Court Tags
Mr Dooley 16 January 2024 Adj. sine die Darwin Local Court Tags
KM 20 October 2023 Directions Hearing Darwin Local Court Tags
Grace 13 February 2024 Adj. sine die Darwin Local Court Tags
Kumanjayi Haywood 13 June 2023 Part Heard - Recommencing 30.10.23 Alice Springs Local Court Tags
Angus Dixon 09 October 2015 25 November 2015
View findings PDF (42.3 KB)
Alice Springs Magistrates Court Death in Care, Natural causes, Delay in Reporting
Zoe Woolmer 05 October 2015 25 November 2015
View findings PDF (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 findings PDF (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 findings PDF (109.0 KB)
Darwin Magistrates Court Death in Custody, Terminally ill prisoner
Kerry James Murphy 25 July 2016 01 September 2015
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (128.4 KB)
Darwin Magistrates Court Death by drowning, dangers of alcohol associated with swimming
Levi Griffiths 09 February 2015 02 March 2015
View findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (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 findings PDF (100.3 KB)
Alice Springs Magistrates Court Motor Vehicle Accident, Multiple Deaths, Police Involvement
Benjamin Wilton 07 April 2014 27 May 2014
View findings PDF (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 findings PDF (76.7 KB)
Katherine Magistrates Court Death due to Coronary Artery and Heart Disease
Joshua Stephen Walsh 03 December 2013 19 March 2014
View findings PDF (190.9 KB)
Darwin Magistrates Court Gunshot Suicide, Police Siege
Vikki Riley 14 January 2014 23 January 2014
View findings PDF (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 findings PDF (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 findings PDF (68.7 KB)
Darwin Magistrates Court Unexpected death, beach drowning, unexplained injuries.
Sara Lorraine Hampel 20 August 2013 20 November 2013
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Darwin Magistrates Court Sepsis, necrotising fasciitis, death in medical care
Gwyyneth Cassiopeia-Roennfeldt 13 August 2013 15 October 2013
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Alice Springs Magistrates Court Fatal stabbing, care and treatment for mentally ill persons, schizophrenia.
Damien Hughes 02 September 2013 30 September 2013
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Darwin Magistrates Court Death in Custody, natural causes
Kevin Taylor, Lena Yali and Gregory McNamara 20 May 2013 20 June 2013
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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
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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
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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
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Alice Springs Magistrates Court Death in Custody, serving prisoner, terminal illness, care and treatment thereof.
Yong Lam Chai 09 November 2012 16 November 2012
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Darwin Magistrates Court Death in Custody; Prison care and treatment; Natural Cause Death
Name 'N' 26 October 2012 29 October 2012
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Darwin Magistrates Court Death in Care, mandatory inquest, No criticism or recommendations
Ben James Witham 28 August 2012 29 October 2012
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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
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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
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Darwin Magistrates Court Unexpected death of baby, Hospital Birth, Paediatric Treatment, Communication with parents
Rosalyn Ellen O'Neill 29 May 2012 10 August 2012
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Darwin Magistrates Court Motor vehicle accident, rock through windscreen, multiple head injuries
Geoffrey James Hewitt 01 June 2012 03 August 2012
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Darwin Magistrates Court Car accident, collision with truck, methamphetamine, amphetamine, cannabis, heart failure
Edward Brown 13 July 2012 13 July 2012
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Alice Springs Magistrates Court Death in custody, natural causes
Master C 10 July 2012 13 July 2012
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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
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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
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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
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Darwin Magistrates Court Accidental death by drowning, Public Aquatic recreational area, Supervision and management thereof
Michael Condrick 13 December 2011 19 April 2012
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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
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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
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Darwin Magistrates Court Death in Custody, Suicide by Hanging, Care and Treatment of Deceased in Prison
Barnabas Naroldol 24 November 2011 04 January 2012
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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
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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
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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
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Darwin Magistrates Court Death in custody, natural causes, adequacy of custodial medical attention
Kerisha Slim 27 April 2011 14 October 2011
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Katherine Magistrates Court Chronic Myocarditis, adequacy of medical treatment, air transfer procedures
Aaron Nathan Stagg 06 September 2011 11 October 2011
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Darwin Magistrates Court Death by Hanging, Self-inflicted, Mental Health Issues, Treatment and Care
Shechem Wasan-Garlngarr 12 July 2011 23 September 2011
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Darwin Magistrates Court Single vehicle roll-over, intoxicated driver, failure to wear seat belt, police pursuit
Linda Nha Tran 06 July 2011 09 September 2011
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Alice Springs Magistrates Court Unexpected death in hospital, complications arising at birth and treatment thereof, communications between treating medical professionals
Baby M 18 July 2011 09 September 2011
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Darwin Magistrates Court Unexpected death of child in care, mandatory Inquest, death from complications arising from neonatal cerebral palsy.
Stuart Morris 10 August 2011 02 September 2011
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Nauiyu Nambiyu Council Chambers, Daly River Death in custody, attempted apprehension by police, drowning
Nicholas Edward Spring 09 June 2011 29 July 2011
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Darwin Magistrates Court Mental illness, treatment and care, suicide, after care, counselling for bereaved family.
Marilyn Lalara 24 May 2011 27 July 2011
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Alyangula Unexpected Death, myocarditis, remote area health facilities and treatment, aero-medical evacuation
Kumanjai Marshall 08 July 2011 13 July 2011
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Alice Springs Magistrates Court Death in custody; natural causes
Peter Murphy (Suppression order in place) 12 April 2011 06 July 2011
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Alice Springs Family Law Court Violent death, foul play, belief as to crime
Peter Murphy (Suppression order lifted 19.4.17) 12 April 2011 06 July 2011
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Alice Springs Family Court Violent death, foul play, belief as to crime
Leo Kauka Simukka 16 June 2011 24 June 2011
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Darwin Magistrates Court Unexpected death, subdural haemorrhage
Damon Cabiddu 15 March 2011 01 June 2011
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Darwin Magistrates Court Unexpected death in hospital, difficulty in diagnosing appendicitis in children
Marlon Aidan Clancy 22 February 2011 13 May 2011
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Darwin Magistrates Court Infant death, suffocation, mother/infant co-sleeping
Kieffen Owen Raggett 30 November 2010 08 April 2011
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Borroloola / Darwin Magistrates Court Suspicious death; inadequate police Investigation, delay, belief in crime committed
Dwayne Joseph Berto 27 January 2011 15 March 2011
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Darwin Magistrates Court Suicide by hanging, circumstances in relation thereto including alcohol and violence
Emma Jane Claridge 25 October 2010 04 February 2011
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Darwin Magistrates Court Death in Care, Mental Health treatment, In patient leave, Suicide
Deryck Michael Calvert 09 November 2010 23 December 2010
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Darwin Magistrates Court Motor vehicle crash, police pursuit policy
Kristelle Ruby Mulladad aka Oliver 10 August 2010 29 October 2010
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Alice Springs Magistrates Court Unexpected Death, Management of Referrals, Delay in Treatment.
Carl Francis Walker 30 September 2010 29 October 2010
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Darwin Magistrates Court Death in Custody, natural causes, importance of medical notes
Adam Francis Chandler 30 June 2010 10 September 2010
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Darwin Magistrates Court Unexpected death, alcohol related deaths in Darwin CBD, Police Watchhouse procedures
Michael Aubrey Campbell 31 May 2010 01 September 2010
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Darwin Magistrates Court Unexpected baby death, acute heat stress, circumstances unknown, open finding
Gottlieb Rubuntja 18 May 2010 11 August 2010
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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
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Nhulunbuy Magistrates Court Unexpected Death, Suicide, Drunkenness, Police Involvement, Liquor Restrictions
Desmond Waight 13 April 2010 05 July 2010
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Darwin Magistrates Court Death from bronchopneumonia, 81 year old man, nursing home resident, palliative care.
Cedric Trigger 09 March 2010 19 May 2010
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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
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Darwin Magistrates Court Motor vehicle accident, police pursuit, remote community, liquor restrictions.
Dailyna Byrnes 25 March 2010 16 April 2010
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Darwin Magistrates Court Death in care, long stay patient at RDH, dehydration, inadequate patient notes
Briony Goodsell 22 March 2010 13 April 2010
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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
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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
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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.
Deborah Leanne Melville 23 November 2009 19 January 2010
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Aboriginal land Commissioners Court Child in Care of the Minister, reportable death of child, care received prior to death, problems with relevant government agency.
Baby Kalib (Child 7) 11 May 2009 19 January 2010
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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.
Barbara Malthouse, Nigel Inkamala, Daryl Inkamala, Dion Ngalken, Gordon Murray and Antonia Meneri 03 November 2009 17 December 2009
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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
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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
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Alyangula Magistrates Court Motor vehicle accident, multiple deaths, driver education, unsealed roads in remote localities.
Alma June Green 09 September 2009 27 November 2009
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Darwin Magistrates Court Unexpected hospital death, injuries resulting from a fall, adequacy of patient notes.
Maureen Caroline Thomson 13 July 2009 24 November 2009
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Darwin Magistrates Court Unexpected hospital death, communication with patient’s family
Clifton Wayne Pamkal 24 March 2009 15 October 2009
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Darwin Magistrates Court, Bulman (Opening) and Katherine Courts Death in custody, escapee, Police search, suicide.
Danny Borrak Gumana 12 August 2009 28 September 2009
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Nhulunbuy Magistrates Court Intentional self-inflicted hanging, police conveyances, suicide in East Arnhem
Kenneth William Hill 16 February 2009 30 June 2009
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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
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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
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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
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Darwin Magistrates Courts Reportable Hospital Death, baby born with shoulder dystocia, ramifications & treatment, critical review.
Paul Guarini 15 December 2008 09 April 2009
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Darwin Person in care, Mental Health Patient, Suicide, Mandatory Inquest
Georgia Rae Tilmouth 12 November 2008 09 April 2009
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Darwin Unexpected death in hospital, obstetric care, non-reporting of death to the Coroner.
Peter Jacobs 19 February 2009 20 February 2009
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Darwin Magistrates Court Death in custody, Police duty of care, Watch House procedures, Medical treatment.
Jenissa Ryan 25 September 2008 23 December 2008
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Alice Springs Absconding juvenile patient, relevant hospital policy and non-compliance with it, subsequent hospital actions
Paulo Melo 21 October 2008 18 December 2008
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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
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Darwin Unexpected Hospital Death, Pulmonary Embolism as a consequence of Fractures, Care and Treatment Thereof.
Rebecka Hans 08 October 2008 10 October 2008
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Darwin Death in Custody, suicidal deceased, police efforts to assist, suicide
Margaret Winter 29 April 2008 04 September 2008
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Darwin Reportable death in hospital, patient fall, medical treatment, hospital nursing
Peter Limbunya 13 November 2007 01 September 2008
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Kalkaringi Court and Katherine Court Reportable death, preventable death at remote airstrip, patient travel .
Robert Daly 07 April 2008 01 September 2008
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Nauiyu Nambiyu Govt. Council Building, Daly River Death in Custody, police responses, Health Worker responses.
Wayne Walker and Jacqueline Morrison 26 August 2008 26 August 2008
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Darwin Death in Custody, police endeavouring to detain, murder / suicide, Police responses thereto
Nicholas Konedaris 05 March 2008 13 June 2008
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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
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Darwin Death in care, Severely disabled young boy, Exceptional and dedicated care by carers
Kenny Malthouse 10 December 2007 15 May 2008
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Alice Springs Accidental death by suffocation, petrol sniffing, Opal fuel and inherent dangers.
Darryll Stuart Davis 23 October 2007 02 May 2008
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Darwin Magistrates Court Unexpected death, Electrocution, Electric work at and in remote residential homes, safety practices.
Aidan Bott 26 February 2008 02 May 2008
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Darwin Magistrates Court Unexpected Student Death by accident, Schoolyard Safety, Responsibilities of School Authorities.
Billy Martin 12 February 2008 13 February 2008
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Katherine Court Katherine Residential swimming pool party, alcohol ingestion, accidental death by drowning
John Russell Ralkurra Marika 29 November 2007 02 January 2008
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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
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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
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Wadeye / Darwin Magistrates Court Death by gunshot, police shooting, crimes committed.
Richard Kiel 12 February 2007 13 November 2007
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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
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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
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Tennant Creek Court House Unexpected death, myocardial infarction, circumstances involving violence immediately prior to death.
Monica Presley 26 April 2006 28 June 2007
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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
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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
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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
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Katherine Court House Police Pursuit
Isabelle Manyita 31 August 2006 12 March 2007
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Darwin Magistrates Court Septicaemia death, medical treatment both before onset of Septicaemia and afterwards
Patrick Heenan 05 March 2007 09 March 2007
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Darwin Magistrates Court Death in Custody, Darwin Correctional Facility, care and treatment, natural cause death.
Tracey Karadji 28 August 2006 26 February 2007
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Daly River Darwin Magistrates Court Motor vehicle fatality, police involvement
Skeletal remains 23 October 2006 26 February 2007
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Jabiru Court House Skeletal Remains – traditional Aboriginal burial – identification of remains – open finding
Louisa Turner 20 February 2006 26 February 2007
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Darwin Magistrates Court Motor vehicle accident, quality of coronial investigation by police, belief as to crimes.
Wendy Walangitj Garmu 25 July 2006 10 November 2006
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Gove Death as a result of stabbing, medical treatment thereafter, possible preventable death.
Jodie Palipuaminni 18 September 2006 23 October 2006
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Darwin Magistrates Court Violent death, domestic violence, parole supervision of violent offenders.
Freddie Peterson 27 June 2006 02 October 2006
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Alice Springs Court House Death in Custody, Natural Causes Care and supervision of deceased in custody
Hector Martin 28 March 2006 08 September 2006
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Darwin Magistrates Court Death in Custody, natural cause death, prison supervision of ill inmates.
Clifford Brown 02 May 2006 29 June 2006
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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
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Alice Springs Court House Unexpected & accidental death, work place fire, reference to DPP & Commissioner of Police.
Alena Rankine 06 March 2006 04 May 2006
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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
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Alice Springs Court House Unexpected Death, Hospital treatment, Remote Area Medical Services, Coronial Investigation
Dolly Granites 20 March 2006 22 March 2006
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Alice Springs Court House Reportable Death – Natural Causes – Remote Health Care – Inadequate record keeping
Muhammad Heri 18 January 2006 03 March 2006
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Darwin Magistrates Court Death in Custody, Federal Agencies and their duty of care to detainees
David Mather 05 December 2005 18 January 2006
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Darwin Magistrates Court Unexpected death, Missing patient, Hospital “Absconding Patient Policy”, Recommendation
Damien Wayne 10 October 2005 11 November 2005
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Alice Springs Court House Death in Custody, police pursuit, motor vehicle accident, police pursuit policy.
Angus Lawrence 05 September 2005 31 October 2005
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Darwin Magistrates Court Death heat stroke Defence Force
Shareya Shannon 12 October 2005 12 October 2005
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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
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Alice Springs Court House INQUEST –substance abuse (petrol), Aboriginal remote area communities, governmental responses thereto.
Anne Chantell Millar 01 February 2005 02 September 2005
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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
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Darwin Magistrates Court Coronial Inquest, death in custody, death from self-inflicted wounds, involvement of police, ambulance officers treatment, reception at hospital.
Dale Vincent 02 August 2005 26 August 2005
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Darwin Magistrates Court Inquest – Death In Care – security of mental health facility
Sampson Paii 05 August 2004 26 August 2005
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Darwin Magistrates Court Coronial Inquest, death in custody, death from natural causes, medical facilities at the prison.
Warren Maminyamanja 14 March 2005 26 August 2005
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Darwin Magistrates Court Death in Custody, Prison Medical Services, Duty of Care
Kenny Alderson 15 August 2005 19 August 2005
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Darwin Magistrates Court Motor Accident, pedestrian walking into motor vehicle, death by misadventure
John Morish 18 July 2005 19 July 2005
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Darwin Magistrates Court Accidental death, gunshot wound, firearms use
Carlene Coombe 21 February 2005 19 July 2005
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Darwin Magistrates Court unexpected death - uncertain and suspicious circumstances concerning death - open finding
Bradley Abala 03 May 2005 27 June 2005
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Alice Springs Court House cause of death was astrocytoma
Albert Robbo 09 May 2005 09 June 2005
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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
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Darwin Magistrates Court Death in Care – Natural Causes
Jacky Barakal 29 October 2004 10 May 2005
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Maningrida Magistrates Court Inquest, Telephone request for medical assistance – communications problems MANINGRIDA
Peter Wiryal 15 November 2004 06 April 2005
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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
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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
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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
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Darwin Magistrates Court Missing person during Cyclone Tracy
George Bukulatpjpi 16 August 2004 03 March 2005
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Elcho Island Inquest, missing person, remote area, police search
Debbie Douglas 01 March 2005 01 March 2005
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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
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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
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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
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Darwin Magistrates Court Unexpected death, crocodile attack, regulation of tour guides, national part safety.
Valerie Wurramurra 01 June 2004 20 December 2004
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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
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Darwin Magistrates Court Resuscitation, administration of carbon dioxide
Roselle Nelson 26 February 2004 10 December 2004
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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
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Darwin Magistrates Court Inquest, motor vehicle accident, load restraint, investigation, Accident Investigation Unit
Stephen Power 03 August 2004 05 August 2004
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Darwin Magistrates Court Inquest, St John Ambulance, ambulance dispatch, refusal to send ambulance
John Colbert 19 January 2004 02 July 2004
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Darwin Magistrates Court Inquest, death at hospital, staffing levels, Bali bombing, Health Insurance Act, production of documents, quality assurance activity
Gregory Nunggarrgalu 15 June 2004 18 June 2004
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Nhulunbuy Court House Inquest, death from exposure, viewing body after death.
Raymond Campbell 22 March 2004 18 June 2004
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Darwin Magistrates Court Inquest, open findings, death by gunshot wound, destruction of evidence
Craig Matthews 17 November 2003 21 May 2004
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Darwin Magistrates Court death on home detention, drug related unlawful killing
Isiah Roberts 19 April 2004 21 April 2004
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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
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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
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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
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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
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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
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Darwin Magistrates Court Inquest, Hospital Procedures, Adult Guardianship Board, Police Communications
Souzana Afianos 10 November 2002 16 January 2004
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Darwin Magistrates Court Death by secondary haemorrhage – Unexpected death in hospital – Failure to detect haemorrhaging.
Sunjay Chandra 08 September 2003 19 December 2003
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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
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Darwin Magistrates Court Inquest, death in care, observation policy
Skye Bree Burnett 13 October 2003 15 December 2003
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Darwin Magistrates Court sudden death in an infant with bronchopulmonary dysplasia
Owen King 29 July 2003 03 December 2003
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Alice Springs Court House natural causes namely lobar pneumonia.
Lindsay Ryan 03 November 2003 03 December 2003
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Darwin Magistrates Court death in custody, death from natural causes
Mark Corbett 02 June 2003 05 September 2003
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Tennant Creek Court House death in custody, protective custody, detention in Watchhouse, sobering up shelters.
Queenie Michaels 28 July 2003 31 July 2003
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Alice Springs Court House Death in Care - natural causes being pneumonia complicating cytomegalovirus embryopathy
Annette Kunia 04 November 2002 31 July 2003
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Alice Springs Court House Police Pursuit
Randil Nuparunya 28 October 2002 20 July 2003
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Darwin Magistrates Court death in custody, attempted apprehension
Lennie Pinawrut 26 May 2003 17 July 2003
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Darwin Magistrates Court Medical, Hospital Procedures
Unidentified body 19 May 2003 20 May 2003
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Darwin Magistrates Court Unidentified
Eric Gaykamangu 06 August 2002 10 April 2003
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Darwin Magistrates Court death in custody, protective custody
Rita Dandy 17 June 2002 28 March 2003
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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
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Darwin Magistrates Court Aircraft Accident - Cessna 210
Reba Lakuwanga 17 September 2002 26 February 2003
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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
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Darwin Magistrates Court An inquest into the death of skeletal remains
Sylvester Nawirridj 24 January 2002 27 September 2002
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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
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Darwin Magistrates Court death in custody, death from natural causes, medical facilities at the prison
Alfred Firth Thorpe 22 July 2002 06 August 2002
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Darwin Magistrates Court death in custody, death from natural causes, prerogative of mercy
David Pendergast 07 May 2002 09 May 2002
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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
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Darwin Magistrates Court Public swimming facility, safety aspects
Luke Peter Littlewood 05 February 2002 12 March 2002
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Darwin Magistrates Court Mental health, involuntary patient, suicide, PAWA facilities security
Johnno Wurramarba 18 May 2001 19 December 2001
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Darwin Magistrates Court Death in Custody Don Dale Juvenile Detention Centre
Nathan Wade Brooks 27 March 2001 02 November 2001
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Darwin Magistrates Court death by electrocution, work place safety
Clive Henry Impu 03 September 2001 19 October 2001
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Alice Springs Court House , ischaemic heart disease, prevalence in Aboriginal persons, fail to diagnose.
Christopher Limerick 12 June 2001 16 October 2001
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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
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Alice Springs Court House Airport Security Mental Health Involuntary Patient Aviation Investigation
George Miller 07 August 2001 12 October 2001
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Katherine Court House Death In Custody Section 128 – Police Administration Act
Skeletal Remains (Cartier Island) 10 October 2001 10 October 2001
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Darwin Magistrates Court SKELETAL REMAINS AT CARTIER ISLAND
Blake Harvey 07 March 2001 17 August 2001
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Alice Springs Court House fire, death caused by burns, fire safety and regulations
Corey Leigh McConville 17 January 2001 23 May 2001
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Darwin Magistrates Court Transport safety – Fatigue management
William Mason 23 October 2000 04 May 2001
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Darwin Magistrates Court Discretionary Inquest, reportable death, suspicious circumstances, open finding.
Kheng Hav Eng 22 March 2001 30 March 2001
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Darwin Magistrates Court
Matthew Neck, Amanda Bell and Matthew Batson 04 December 2000 09 March 2001
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Alice Springs Magistrates Court motor vehicle rollover
Sebastian Barry Davis 09 March 2001 09 March 2001
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Alice Springs Court House Child in Care
Eduardo Concepcion 24 August 2000 25 January 2001
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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
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Darwin Magistrates Court Unidentified Skeletal Remains
Ronald Smallwood 13 December 2000 13 December 2000
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Alice Springs Magistrates Court death was natural causes, being a disseminated carcinoma
Corey Paddy 08 August 2000 01 November 2000
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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
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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
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Darwin Magistrates Court gunshot wound of the chest and abdomen, multiple gunshot wounds
Anthony Mahoney and Jane Mahoney 02 May 2000 11 September 2000
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Darwin Magistrates Court Motor Vehicle Accident – Double Fatality – Accident Investigation
Francis Kamaranga 24 July 2000 06 September 2000
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Darwin Magistrates Court asphyxiation following severe swelling to the larynx due to anaphylactoid reaction.
Robert Hodgkinson 13 June 2000 14 June 2000
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Katherine Magistrates Court - death in custody - police pursuit – fire extinguishers
Trevor Parkyn 22 May 2000 01 June 2000
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Darwin Magistrates Court Coroners – Inquest – Police – Head injuries undetected
Baby J 10 April 2000 10 April 2000
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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
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Darwin Magistrates Court self-inflicted hanging, Nguiu community, Bathurst Island
Esky Muller 02 September 1998 02 September 1998
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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
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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
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Darwin Fatal accident, Cannonball Run
Ganamu Garrawurra 19 June 1990 03 June 1991
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Galiwinku death in custody
Azaria Chantel Loren Chamberlain 14 December 1981 10 July 1984
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Alice Springs Magistrates Court taken by dingo, Ayers Rock, tent
John Ross Jabanardi 11 December 1981 11 December 1981
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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
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Alice Springs Magistrates Court taken by dingo, Ayers Rock, tent

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