Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Glenn Hay, Coroner, have investigated the death of



I have decided not to hold a public inquest hearing into her death because my investigations have sufficiently disclosed the identity of Mrs N, the date, place, cause of death, relevant circumstances concerning how the death occurred and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999.  I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.


(a) Mrs N died on 25 September 2011 in the waters of the River Derwent at Bridgewater in Tasmania.

(b) Mrs N was born in Tasmania on 16 April 1950.  At the time of her death she was aged 61 years.  The deceased was a married woman without any dependants.

(c) I find the deceased died of drowning.

(d) I further find the cause of death to be a direct result of an act of misadventure.

Relevant Background Material:

Mrs N was aged 61 years and lived with her husband, Mr N at their home in Brighton.  Mrs N was Mr N’s carer.  Mrs N had three adult children by a previous relationship which broke down in the early 1990s.  She had been married to Mr N for a period of 18 years.  Mrs N maintained contact with all of her three children.

Until approximately 4 months prior to her death she worked one day per week, on a voluntary basis, for the Uniting Church at Gagebrook. 

The evidence presented before me clearly indicates Mrs N initially was a sociable and outgoing person.  Mrs N however lost a lot of weight.  Her weight loss was quite noticeable and she became self-conscious of it.  This led to her becoming quite reclusive and not wanting to leave the confines of her home.

Mrs N has a long-standing recorded history of depression in which she suffered ongoing battles with low mood and anxiety.  In 2010 she was prescribed anti-depressant medication in the form of Efexor.  This was changed to Avanza in 2011.  The latter medication was to assist with sleep, weight gain and mood stabilisation.  In July 2011 Mrs N attended her general practitioner at Greenpoint Medical Services.  She presented with depressive symptoms and a psychology referral was arranged to provide extra support.  During the course of the consultation suicidal ideation was also identified.

In addition to depression, Mrs N was treated for problems with her bowel and bladder together with low back and hip pain.  These problems were of a concern in the last two years of her life.

Circumstances Surrounding Death:

On Sunday 25 September 2011 Mrs N was last seen by her husband at her home address at about 9.45am.  Mrs N indicated an intention of going to church.  Her husband left the residence shortly after this time.  There was nothing in Mrs N’s demeanour or manner that gave her husband any concern for her welfare and/or safety.

Throughout the day Mr N attempted to contact Mrs N via mobile phone without success.

I find Mrs N has left her residence a short time after her husband left.  She was driving her mother-in-law’s car, a white Toyota Corolla sedan registered number FJ-0466.  Mrs N drove to Bridgewater and then along Boyer Road in a westerly direction.  Approximately 2.16kms from the Midland Highway she parked her car on the gravel verge on the northern side of the road.  This is in the vicinity of 194 Boyer Road

The parking manoeuvre was observed by a nearby resident who was in his garden.  Mrs N’s vehicle was initially observed outside the driveway to 194.  The resident, Mr J observed the vehicle in the middle of the road and then it parked on the gravel verge.  A person, who Mr J believes was female, got out of the driver’s door and walked around the front of the vehicle. 

From available evidence it is clear that it is not unusual for vehicles to be parked on the verge in this area.  It is close to the River Derwent and is a popular fishing spot and is also utilised by persons walking their dogs.  Nearby are picnic tables and benches.

At approximately 2.30pm that afternoon Mr T was walking his dogs along the track adjacent the river.  He observed a dark coloured cardigan on a picnic bench adjacent the River Derwent.  About 3.45pm Mr T noticed the clothing was still there.  He looked at it and it consisted of a cardigan with a pair of prescription glasses and a set of keys under it.  The picnic bench and these items were in close proximity to the deceased’s motor vehicle.

The find was reported to Police.  On arrival of police it was found that Mrs N’s motor vehicle was locked and secure.  The keys on the picnic bench opened the car.  Mrs N’s handbag containing personal items and money was located on the front seat of the motor vehicle.

Enquiries were then made with her husband and children.  Mrs N had not been seen or heard of by them since morning.  Police (Marine and Rescue Services) were requested to attend the scene and conduct a water search for the deceased.

At approximately 6.30pm that afternoon (25 September 2011) Mrs N was located in the water of the Derwent River approximately 100 metres north west of where her possessions were located and approximately 50 metres off-shore.  She was floating face down in the water.  It was obvious she was deceased

Mrs N was taken aboard a police vessel and transported to the Bridgewater boat ramp.  Once at the ramp Mrs N was identified by her family and then conveyed to the Royal Hobart Hospital mortuary.

Findings and Comments: 

I am satisfied that a full and detailed police investigation into the circumstances surrounding this death has been carried out.  There are no suspicious circumstances.

I am satisfied the person Mr. J saw get out of the motor vehicle was Mrs N.  She was in the motor vehicle by herself.  Why she stopped at this location one can only speculate.  Unfortunately, there is no direct evidence as to what occurred at the water’s edge.

Mrs N has ended up in the water.  Some family members believe Mrs N has intentionally gone into the water with the express intention of taking her own life.  Unfortunately and notwithstanding a history of depression, I do not believe there is sufficient available cogent evidence for me to make this consideration a finding of fact.

On the morning of her death there is no evidence from her husband to suggest that she was not herself.  She did not leave any type of note that could be construed as a suicide note.  Her cardigan was neatly folded on the bench, her reading glasses were under the cardigan as was a set of car keys.

Notwithstanding the previous depression and suicidal ideation the evidence is also consistent with Mrs N walking along the water’s edge near the picnic bench and falling in to the water and not being able to get out.  The evidence presented indicates Mrs N was unable to swim.

Toxicological testing of Mrs N’s blood, inter alia, identified the presence of the drugs mirtazapine and metoclopramide.  Both these drugs are prescription medication. They can cause drowsiness and dizziness.  I have no doubt in combination the side effects of these drugs could well be enhanced.  As to whether the identified drugs had any effect on Mrs N is pure conjecture.

Having carefully considered the available evidence I do not believe that I could properly make a finding of suicide to the exclusion of the possibility Mrs N accidentally fell into the water and was unable to get out.

The Pathologist, Doctor Ritchey, indicates that he found pulmonary congestion and oedema and watery fluid in Mrs N’s stomach, both non-specific findings that are frequently seen in individuals who have drowned.  He states that drowning is a diagnosis of exclusion.  In this case I have concluded that it is highly likely, and therefore find, Mrs N has died of drowning.

Having regard to all the available evidence and the comments I alluded to above I believe the appropriate finding is one of death by misadventure.

In closing, I wish to express my sincere condolences to Mrs N’s family and friends.

Dated: 18 July 2012  at Hobart in the State of Tasmania.


Glenn Hay