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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. Give feedback about this page. Skip to navigation Skip to content Skip to footer. These types of deaths are called reportable deaths. Year of finding All years Clear filters. Clear filters. Back to top. Recognised high risk to spectators in Finke Desert Race by Motorsport Australia and those running the race, failure to mitigate the risk. Child death in care, inherited genetic disorder Batten disease, removed from family due to disability. Application for leave to appear; sufficient interest; police association. Intimate partner homicide, domestic violence, response by police, supervision by Community Corrections, calls. Sixteen year old lost to mental health follow up shortly after being discharged from inpatient unit, died due to high voltage electrocution. Person missing with a dog on a background of small town feud, suspicious circumstances, extensive searches. Three deaths, vehicle crash on Christmas day, unregistered vehicle detected by police and followed, whether deaths in custody. Suicide, death in care, 9 years of age, Aboriginal Placement Principle not adhered to, trauma not assessed and treated. Electrocution of 11 year old boy at a home in a remote Aboriginal community, roof live with 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. Death in custody, ATV rollover, workplace safety at prison. 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. Death in custody, natural cause death, prisoner given leave to die in his community. Deaths of teenage girls in remote Aboriginal communities, high levels of trauma and stress, perfunctory police investigations, little to no assistance from government agencies. 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. Death in custody, prisoner in correctional facility, natural cause death, adequacy of care, treatment and supervision. Death in custody of Correctional Services, natural causes. Sea snake bite, neurotoxic venom, prawn trawler, remote location. Pedestrian run over by vehicle, driver did not provide adequate account, belief that offences have been committed, referral back to Police and DPP. Mental Health, involuntary admission, remained psychotic, non-compliance with Mental Health and Related Services Act in provision of leave, took his own life. Death in custody, prisoner in correctional facility, natural causes. Failure of primary care providers to offer vaccination Pnemovax23 , Failure by hospital to identify sepsis, Failure to identify septic shock, antibiotics commenced too late. Death in care, high risk suicidal patient, involuntary admission to ward not secure , failure to improve security after previous death, poor communication with family. Single vehicle rollover, Kakadu Highway, gravel on bitumen at intersection with unsealed road. Death in custody, foreign national, inadequate health care. 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. Traffic collision between unregistered motorcycle and vehicle, substandard police investigation, referral back to Police and DPP. Defence Force urban operations live fire training exercise, safety mitigation procedures not followed, systemic failure, soldier shot in head. Anxiety, young woman, suicide, NT Mental Health Service, General Practitioners, no adequate history or assessment, no coordinated care, no referral by GP to psychiatrist. Death in Custody, Natural Causes, Communication problems with hearing impaired prisoners, AutoPulse resuscitation devices. Death in care, 17 days old baby, congenital heart defect, expected death, appropriate care and treatment. Nature Park, hot day, short walk, signage obscured by vegetation, boundary fence down, tourists became lost, environmental heat injury. Police investigation, gunshot death, shot in back of neck, safety catch on, investigated as suicide, role of investigative bias. 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. Delay in diagnosis, unexpected death, poor communication with family, no report to Coroner. Employee with mental health issues, treated inappropriately by employer, bullying behaviour, Mental Health Service poor note keeping and stakeholder engagement. 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. Death in Custody, complex mental health presentation, inadequate resources available in Alice Springs. 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. Death of deckhand, dangerous access and egress from vessel, no gangway, regulatory response to death. 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. Death in custody, natural causes, released on bail for payback. 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. Death in custody, likely autoimmune disease, medical treatment appropriate, failure of Correctional Services to notify family of illness until after death. Fall from a tower, no high risk work licence, no harness, non-compliance with Safe Work Method Statement. 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. Death in Custody, Darwin Correctional Precinct, mental health treatment, water intoxication, Olanzapine toxicity. Death in care, natural causes, appropriate care, timeliness of police investigation, Territory Families compliance with request for files. 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. 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. 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. Death in Care, Aboriginal baby, appropriate care and attention, kinship arrangements, sudden death. 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. Vehicle Hijacking and further robbery, firearm, joyriding youth, limited options for apprehension, limited coordination and control of police resources. 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. High risk elective surgery, inadequate medical treatment, inadequate resources at Darwin Private Hospital, inadequate escalation procedure, no internal review, referral to Medical Board. Baby died of traumatic head injury, initial disagreement between medical experts, disagreement resolved, referred back to Police. Delay in provision of autopsy report, delay in Coronial Investigation. Domestic Violence, ten year history of violence, time to consider a different approach. Death at Sobering up Shelter, Police systems non-compliant, failure to record protective custody episodes, no referral for assessment for Alcohol Mandatory Treatment. Death of child in care, expected death due to congenital serious medical conditions, appropriate care and treatment. Death in custody, of natural causes while in prison, care and treatment appropriate. Death in Care, self-harm leading to death, quality of care, Mental Health of deceased and treatment and respon. 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. Accidental death from falling tree branch, dangerous trees, inspection and maintenance of trees, negligence. Death as a result of positional asphyxia, crowd controllers and their training. Violent death, mentally ill offender, indicators of threat, institutional response. Read about the Kumanjayi Walker inquest. Death in Care, Natural causes, Delay in Reporting. Crocodile attack, taken from boat, unsuitability of small and unstable boats in crocodile waters, fishing from bank of river, dangers inherent. Death in Custody, Terminally ill prisoner. Fall in hospital, no falls risk policy, no handover of fall or neurological observations, subdural bleed. Death in Care, compulsory care and treatment in Alcohol rehabilitation centre, Death in mandatory detention. Motor vehicle accident, drink driver, police pursuit, Death in Custody. Death in Custody, Death by natural causes, Treatment and care whilst in Custody. Death by drowning, dangers of alcohol associated with swimming. 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. Accidental death, ultralight aircraft crash, dangers associated with flying such aircraft. Unexpected death by drowning, drainage, secured access to drains, municipal responses thereto. Death of baby in care of foster parent; cause of death undetermined; care and treatment whilst at hospital and in care. Death in Custody, Death by natural causes, care and treatment whilst in Custody. Motor Vehicle Death; Fitness to drive of elderly drivers. Death due to Coronary Artery and Heart Disease. Motor vehicle accident, cyclist death, unregulated pedestrian crossing of multi-lane roadway. Death in care, natural cause death, care and treatment exemplary. Unexpected death, beach drowning, unexplained injuries. Sepsis, necrotising fasciitis, death in medical care. Fatal stabbing, care and treatment for mentally ill persons, schizophrenia. Collision at intersection, multiple deaths, Airservices fire truck, emergency services. Killing of children, suicide, police response to child welfare complaint, grief counsellor. Death in Custody, serving prisoner, terminal illness, care and treatment thereof. Death by natural causes, adequacy of medical care, arsenic poisoning, closure of property. Death in Care, mandatory inquest, No criticism or recommendations. Death in custody, care and treatment whilst in Alice Springs Watch House, alcohol toxicity, positional asphyxia. Motor vehicle accident, rock through windscreen, multiple head injuries. Car accident, collision with truck, methamphetamine, amphetamine, cannabis, heart failure. Pedestrian motor vehicle accident, fatal injury, person held in care. Accidental death by drowning, Public Aquatic recreational area, Supervision and management thereof. Unlawful killing, failings in police investigation with the death, referral back to DPP and Commissioner of Police. Unexpected death of child in care, mandatory Inquest, quality of treatment and care prior to death. Death in custody, Coronary atherosclerosis, cardiac hypertrophy, care and treatment whist in custody. Death in custody, natural causes, adequacy of custodial medical attention, rheumatic heart disease, swine flu. Death in custody, death by self inflicted hanging, care and treatment whilst in custody. Death in custody, natural causes, adequacy of custodial medical attention. Chronic Myocarditis, adequacy of medical treatment, air transfer procedures. Single vehicle roll-over, intoxicated driver, failure to wear seat belt, police pursuit. Unexpected death in hospital, complications arising at birth and treatment thereof, communications between treating medical professionals. Unexpected death of child in care, mandatory Inquest, death from complications arising from neonatal cerebral palsy. Death in custody, attempted apprehension by police, drowning. Mental illness, treatment and care, suicide, after care, counselling for bereaved family. Unexpected Death, myocarditis, remote area health facilities and treatment, aero-medical evacuation. Violent death, foul play, belief as to crime. Unexpected death, subdural haemorrhage. Unexpected death in hospital, difficulty in diagnosing appendicitis in children. Suspicious death; inadequate police Investigation, delay, belief in crime committed. Suicide by hanging, circumstances in relation thereto including alcohol and violence. Motor vehicle crash, police pursuit policy. Death in Custody, natural causes, importance of medical notes. Unexpected baby death, acute heat stress, circumstances unknown, open finding. Death in Custody, use of Taser devices, apprehension of mentally ill persons, apprehension of physically ill persons. Death from bronchopneumonia, 81 year old man, nursing home resident, palliative care. Death in custody, Role of watch house keeper, watch house procedures, risk assessment of intoxicated prisoners. Motor vehicle accident, police pursuit, remote community, liquor restrictions. Death in care, long stay patient at RDH, dehydration, inadequate patient notes. Unexpected death, Dog attacks on live person, Dog attacks on deceased persons, Responsibility of relevant agencies. Aboriginal land Commissioners Court. Child in Care of the Minister, reportable death of child, care received prior to death, problems with relevant government agency. Death of baby interstate but normally resident of Northern Territory, child in need of care, responsibilities of relevant Government agencies. Motor vehicle accident, police pursuit, pursuit policy and training, adequacy and timeliness of police investigation. Unexpected death, recreational drug overdose, police response, ambulance response, medical response. Motor vehicle accident, multiple deaths, driver education, unsealed roads in remote localities. Unexpected hospital death, injuries resulting from a fall, adequacy of patient notes. Death in custody, escapee, Police search, suicide. Intentional self-inflicted hanging, police conveyances, suicide in East Arnhem. Unexpected death in Hospital on admission, Heart disease, Triage, Nursing protocols. Death in Custody and care, restraint by police, positional asphyxia, police training in relation thereto, report of crime committed. Hanging of young person — petrol sniffing — sexual abuse — remote communities - effectiveness of FACS and other government intervention — police delay in coronial investigation. Unexpected death in hospital, obstetric care, non-reporting of death to the Coroner. Death in custody, Police duty of care, Watch House procedures, Medical treatment. Absconding juvenile patient, relevant hospital policy and non-compliance with it, subsequent hospital actions. Motor accident causing severe injury, medical treatment thereof, decision to cease mechanical ventilation consequent on poor prognosis, communication between health professionals and family. Death in Custody, suicidal deceased, police efforts to assist, suicide. Reportable death in hospital, patient fall, medical treatment, hospital nursing. Kalkaringi Court and Katherine Court. Reportable death, preventable death at remote airstrip, patient travel. Nauiyu Nambiyu Govt. Council Building, Daly River. Death in Custody, police responses, Health Worker responses. Motor vehicle accident, quality of police investigation, police registration of motor vehicles. Death in care, Severely disabled young boy, Exceptional and dedicated care by carers. Accidental death by suffocation, petrol sniffing, Opal fuel and inherent dangers. Unexpected death, Electrocution, Electric work at and in remote residential homes, safety practices. Residential swimming pool party, alcohol ingestion, accidental death by drowning. Unexpected death, myocardial infarction coronary heart disease , circumstances involving violence immediately prior to death. Reportable death at Alice Springs Hospital, medically adverse event, hospital resources, preventable death. Death by gunshot, police shooting, crimes committed. Death from drug overdose, prescribed drugs, medical treatment of known drug addict. Unexpected death by natural causes, emergency treatment, Ambulance Service attendance on deceased persons, nil transportation to Hospital. Unexpected death, myocardial infarction, circumstances involving violence immediately prior to death. Unexpected death of child, electrocution, Public Housing maintenance, faulty or dangerous air conditioning units. Deaths resulting from Acute Multiple Drug toxicity, Prescription drugs, Medical treatment prior to death. Road accident death, alcohol affected pedestrian, involvement of motor vehicle driven by police. Septicaemia death, medical treatment both before onset of Septicaemia and afterwards. Death in Custody, Darwin Correctional Facility, care and treatment, natural cause death. Motor vehicle accident, quality of coronial investigation by police, belief as to crimes. Skeletal Remains — traditional Aboriginal burial — identification of remains — open finding. Daly River Darwin Magistrates Court. Motor vehicle fatality, police involvement. Death as a result of stabbing, medical treatment thereafter, possible preventable death. Violent death, domestic violence, parole supervision of violent offenders. Death in Custody, Natural Causes Care and supervision of deceased in custody. Death in Custody, natural cause death, prison supervision of ill inmates. Death in Custody, Federal Agencies and their duty of care to detainees. Death in Custody, police pursuit, motor vehicle accident, police pursuit policy. Death by foul play, Domestic Violence, police conduct in relation to domestic violence restraining order. Coronial Inquest, death in custody, death from self-inflicted wounds, involvement of police, ambulance officers treatment, reception at hospital. Coronial Inquest, death in custody, death from natural causes, medical facilities at the prison. Inquest — Death In Care — security of mental health facility. Motor Accident, pedestrian walking into motor vehicle, death by misadventure. Accidental death, gunshot wound, firearms use. Coroners: Inquest, ambulance service, failure to convey patient to hospital. Inquest, missing person, remote area, police search. Coroners Inquest, death in care, mental illness, observation policy, adequacy of staffing levels. Unexpected death, Drowning, uncertain circumstances concerning death, open finding as to some circumstances concerning death. Unexpected death, crocodile attack, regulation of tour guides, national part safety. Unexpected death, uncertain and suspicious circumstances concerning death, quality of police response, open finding. Resuscitation, administration of carbon dioxide. Violent death, unreliable witnesses, suspected unlawful killing, reference to Commissioner of Police, DPP. Inquest, motor vehicle accident, load restraint, investigation, Accident Investigation Unit. Inquest, St John Ambulance, ambulance dispatch, refusal to send ambulance. Inquest, death at hospital, staffing levels, Bali bombing, Health Insurance Act, production of documents, quality assurance activity. Inquest, open findings, death by gunshot wound, destruction of evidence. Inquest, death from exposure, viewing body after death. Inquest Death by stabbing, referral pursuant to section 35 of the Coroners Act. Death following a physical fight, commission of offences, referral to DPP and Commissioner of Police. Death by drowning, referral pursuant to section 35 of the Coroners Act, open finding. Death by secondary haemorrhage — Unexpected death in hospital — Failure to detect haemorrhaging. Inquest, mental illness, medication regime, observations of carers, discharge after involuntary admission, protocols for administration of clozapine. Inquest, death in care, observation policy. Death in Care - natural causes being pneumonia complicating cytomegalovirus embryopathy. Death in Custody, detention for purposes of protective custody, belief in the commission of crime, duty of care. An inquest into the death of skeletal remains. Public swimming facility, safety aspects. Mental health, involuntary patient, suicide, PAWA facilities security. Disappearance, Missing Persons Inquiry, death, possible crimes in connection therewith. Transport safety — Fatigue management. Discretionary Inquest, reportable death, suspicious circumstances, open finding. Death in custody - police shooting - justifiable homicide - police investigation - police general orders — possible use of non-lethal weapons. Coroners, Inquest, death in hospital, positional asphyxia, hypoxic brain damage, level of care. Death in Custody, belief as to crime committed, Hospital procedures, liason between Police and Hospital staff. Coroners — Inquest — Police — Head injuries undetected. Coronial Inquest, death of infant, jurisdiction, reportable death, doctor patient relationship, medical practitioner. Loss of blood arising from incised wound to the left arm. Ti Tree, haemorrhage due to perforation of the left internal iliac artery, gunshot wound to the abdomen.
Coronial inquests and findings
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Coronial inquests and findings
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