Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

These findings have been partially de-identified in relation to the name of the deceased and friends by direction of the Coroner pursuant to S.57(1)(c) of the Coroners Act 1995

I, Stephen Raymond Carey, Coroner, having investigated the death of

Ms M;


Find That :

a) The identity of the deceased is 'Ms M' who died at Kingston at a date and time unable to be determined, but in July 2011.

b) The deceased was born in December 1975 and was aged 35 years at the time of her death.

c) The deceased was unemployed and was a single person.

d) The deceased died of the combined effects of drowning and mixed drug (Amitriptyline, Tramadol and Benzodiazepine) intoxication.

Circumstances Surrounding the Death :

The deceased is reported to have suffered depression and anxiety throughout her adult life and also abused alcohol. She moved back to Tasmania from interstate in approximately 2004 and lived with family.  After living there for a few months she then travelled to Hobart where she sought assistance for her alcohol addiction at the Salvation Army Rehabilitation Centre in New Town. It was there that she met 'Mr J' and entered a relationship with him from which the deceased's children, twins, were born in July 2006. Unfortunately, the relationship between the deceased and 'Mr J' was violent and as a result of this and the deceased's continued abuse of alcohol the children were taken into care by Child and Family Services. The deceased's family attempted to assist her for approximately 12 months after this occurred in order that she might have reached a position to be able to regain custody of her children, however this did not occur. When the twins were 18 months old the deceased's parents gained custody of them. The deceased continued to have access to the twins and maintained her endeavours to address her alcohol addiction. However, although she was able to end the domestic relationship with 'Mr J' and with the assistance of her parents establish her own home, her alcohol abuse continued. She had ten admissions to the Royal Hobart Hospital for alcohol related matters including alcohol withdrawal throughout 2010. There were further admissions from 29 to 31 January 2011, 18 to 20 May 2011 14 to 16 June 2011 and again on 30 June 2011. She remained in care at the hospital on that last occasion until 5 July 2011. By this stage she was noted as no longer experiencing alcohol withdrawal and was noted to be in a "good frame of mind". The deceased had, however, been upset on 4 July 2011 as it was the fifth birthday of her twins and she still expressed hope and confidence to be able to reunite with them. Upon her release it was noted that she hoped to be readmitted to Missiondale, a residential alcohol rehabilitation service at Evandale.

The deceased had previously attended Missiondale commencing in February 2011. The Case Manager with responsibility for the deceased reports as follows on the interview conducted upon the deceased's arrival:

"the deceased stated she wished to take part in the program to get her life back together and eventually get her children back. The deceased is self-referred and stated her last drink was a week prior. On the question of self-harm, the deceased stated she had thoughts of self-harm ten years prior but no actions at all 'thoughts only'. The deceased told me of her foot/ankle injury that had not mended properly and required ongoing treatment and medication. She also told me of anxiety attacks in the past that came out of the blue without warning. She was on prescriptions for Endep and Panadeine Forte."

Apparently matters progressed well and when the deceased went home for a weekend visit at the end of May she was "glowing". However, on 17 May when the deceased had not returned from her weekend leave, police were contacted, and she was found intoxicated and taken to hospital. There was further contact with the deceased and arrangements were made that she would return to Missiondale on 11 July 2011.

The deceased was last seen on 9 July 2011 at approximately 3.30pm when a neighbour noticed her return to her home in a taxi with several shopping bags. She was seen to enter her residence. A neighbour, became concerned when she did not see the deceased again and on Wednesday morning, 14 July 2011 she contacted Tasmania Police. Police attended at approximately 9.30am and found the body of the deceased located in the bath clothed in pyjama bottoms, sweat top and socks. The hot water tap was on with water running at a slow rate and the bath was overflowing causing flooding to other areas of the residence. Although there was no bath plug in the bath some stickers and debris had partially blocked it allowing the water to overflow. The residence was checked by the investigating police and found to be secure with no signs of violence or disturbance. I am satisfied that no other person contributed to the deceased's death and that although the precise circumstances are unable to be determined, some form of accident has occurred due to the effects upon her of the medication she has taken. Given her clear plans for the future and her generally positive attitude I am satisfied that the deceased's death was precipitated by an accidental overdose of her medication and her death was a tragic accident.

Before I conclude I wish to convey my sincere condolences to the family of the deceased.

Dated this 21 day of March 2013.


Stephen Raymond Carey