Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

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

I, Stephen Raymond Carey, Coroner, having investigated a death of Mr D

Find that:

(a)               The identity of the deceased is Mr D;

(b)               Mr D died in circumstances described in this finding;

(c)               Mr D died as a result of carbon monoxide intoxication due to inhalation of car exhaust fumes;

(d)               Mr D died in March 2014 in southern Tasmania;

(e)               Mr D was aged 60 years at the time of his death;

(f)                Mr D was divorced and he was employed at the date of death; and

(g)               No other person contributed to Mr D's death.

Circumstances Surrounding the Death:

Mr D had an unloving stepfather and his mother committed suicide when he was approximately 9 years of age. He thereafter had many years staying with relatives of his stepfather and apparently was not loved or wanted by them. 

From approximately 1975 he is recorded as being an industrial chemist, in the late 1990s he worked in the financial industry as a financial futures trader, and from 2007 until his death he was employed by a Commonwealth Government-owned corporation in various aspects of that business. 

He was married on 27 November 1998 and divorced on 11 March 2002.  During that period his former wife, Ms G, reports that Mr D suffered depression and was receiving psychiatric care in that regard.  She also reports that he had many conflicts with neighbours usually triggered by barking dogs and that these incidents resulted in police intervention.  When they met, Ms G explains that they had a common interest in motorbikes and this interest was shared with two long term friends, EB and HM.  Ms G identifies Mr D's loss of his employment within the finance industry and a long period of unemployment as causing a worsening of his depression and she noted his behaviour became erratic and difficult. 

After the dissolution of his marriage and the property settlement that went with that, Mr D purchased a unit in northern Sydney. He thereafter isolated himself and appeared to only engage with EB, who would accompany him on motorcycle rides on weekends.  EB reports that Mr D made a decision to change his lifestyle and relocate somewhere cheaper and initially looked to Adelaide, however he proceeded to move to Tasmania, buying property in southern Tasmania.  This decision was perhaps influenced by his friend HM living in that general area, who reports that although he continued to be reclusive and to live a private life, he engaged actively in landscaping his property and also continuing with his love of motorbikes, working on same and riding them. 

After his move to Tasmania he regained employment with the Government-owned corporation with whom he had been employed whilst living in New South Wales prior to his move.

HM hoped that with the renewed interest in developing his new residence and also with the gaining of employment that Mr D would become more settled and relaxed.  However, this apparently was not the case as he continued to display difficulty in controlling his anger and to normalise his observations. 

Dr O reports that Mr D had been a patient of his practice since October 2009 with a working diagnosis of depression.  Treatment in this regard included anti-depressant medication and referral to a psychologist.  HM comments that Mr D had difficulty engaging socially with others and he believed this was not assisted by his need for anti-depressant medication but additionally the fact that he was consuming alcohol to an excessive level.  He comments that his alcohol use would sometimes cause Mr D to say and do things inappropriately.  EB also comments upon Mr D's struggle with depression which he believed led to excessive consumption of alcohol.  Both HM and EB commented upon reports from Mr D as to his unhappy work environment where he felt alienated and at times ostracised by those with whom he worked. 

Matters appear to have deteriorated for Mr D in early 2013 when, acting on information, Tasmania Police attended his home and seized computer equipment in respect of an investigation relating to offences of child exploitation and bestiality.  On one occasion during the course of this investigation Mr D has impulsively, and whilst affected by alcohol, driven his motor vehicle to the local police station.  During the course of that journey he was intercepted by police and as a result was charged with driving with an excessive blood alcohol content and also using an unregistered and uninsured motor vehicle.  Due to the manner in which he behaved whilst with the police, following his apprehension, he was taken to the Royal Hobart Hospital where he remained for a week in the psychiatric ward.  His anti-depressant medication was altered during this period due to the apparent ineffectual results being achieved from maximum dosage of his then prescribed medication.  Mr D became frustrated with the delay in concluding his drink driving matters, his mental health apparently was further impacted as he is reported to have increased his alcohol consumption even further.  During this period the investigation in relation to the pornography matters continued.  Mr D appeared at the Hobart Magistrates Court initially in March 2013; however the matters were adjourned until June 2013 at which time he pleaded guilty to the driving charges.  An application was made for a restricted licence and this was adjourned until July 2013.  At this time he was convicted and a licence disqualification of 6 months was imposed with an adjournment as to the hearing of the restricted licence application as Tasmania Police indicated they required a representative from Mr D's employer to be available for cross-examination as to the basis asserted by Mr D for the grant of a restricted licence.  When this matter was heard in September 2013 the representative from the employer was unable to give definitive evidence as to whether Mr D would lose his employment following the disqualification for 6 months.  The Magistrate hearing the matter requested further evidence from the employer.  At this time Police Prosecution advised that they had a letter from the Registrar of Motor Vehicles requiring Mr D to have liver function tests to comply further with their licencing requirements, in addition to his application for a restricted licence, in that the Registrar needed to be satisfied Mr D was medically fit to drive a motor vehicle given his level of medication for depression with anti-depressants, including the Seroquel.  There were further delays in obtaining the necessary evidence from the employer and the matter was not finalised until December 2013.

Mr D's barrister reports that Mr D was frustrated by this process, however he was ultimately more concerned about the pornography charges and how these would affect his employment and whether or not he could be imprisoned as a result of those matters.  Mr D was initially proceeded against with a summons for those matters with his first appearance in October 2013.  Initially the child exploitation charge was proceeded with by way of an indictable offence, however in November 2013 that initial complaint was withdrawn and another complaint substituted which dealt with the child exploitation material as summary offences rather than indictable crimes under the Criminal Code.  Mr D pleaded guilty to these charges in February 2014 and the matter was adjourned for facts and sentence before a Magistrate in March 2014.  At that time, in respect of the proceedings in the Magistrates Court in March 2014, Mr D's barrister reports that:

"He was anxious before Court but did not tell me then that he was contemplating suicide that day.  A medical report from Dr Jim Blacket, Clinical Director of Mental Health and Statewide Services of Tasmanian Health Organisation was obtained for His Honour .… .  This letter was tendered to the Court along with a plea in mitigation that Mr D had suffered depression, prior to these charges and as a result of these charges.  The report only made reference to notes of one previous hospitalisation in March/April 2013 for suicide ideation following being investigated for the current charges.  His Honour heard submissions from defence counsel that Mr D had clinical depression for many years along with chronic alcoholism and he required further details of this, asking for a pre-sentence report and any other reports which made reference to his alcohol treatment and attendance at counsellors.  His Honour wanted these reports as he was not satisfied that the medical report was comprehensive enough to cover the issues canvassed by defence in the plea in mitigation.

His Honour heard submissions from Police Prosecutor Ms McCulloch who asked that Mr D be placed on the sex offenders register and for Mr D to be sentenced on the basis that this was not just a glancing view of the material but that he had copied the material to DVD and that the material had been watched on a number of occasions by Mr D, particularly the most serious material, a video clip of a 10 year old girl performing fellatio on an adult male.  Mr D was concerned that on previous adjournments His Honour had not ordered a pre-sentence report when police requested one, but after this sentencing hearing he needed to consider his sentencing options.  Whilst in Court Mr D began to visibly shake at the Bar Table and was mumbling and muttering under his breath."

During these proceedings, Mr D also noted the presence of a reporter from the Australian Broadcasting Corporation (ABC) and expressed concern that he would lose his job as soon as the proceedings were reported. 

Mr D's barrister stated that after the Court proceedings Mr D was visibly upset; apparently he believed that the Magistrate was considering a jail term despite reassurance by his barrister that the pre-sentence report would give the Magistrate a number of non-custodial options in respect of sentencing.  Mr D was reported as visibly shaking whilst outside the Court and he was offered advice from his barrister to go to his doctor or to the hospital if he was feeling unwell or considering self-harm.  Before they left the Court building his barrister noted the ABC journalist situated outside the Court building together with a cameraman and she warned Mr D that they may be waiting for him to film him.  Mr D is reported to have said at this time words to the effect that he "wanted to end it" and that "this was the end of it".  As he left the building, Mr D approached the ABC journalist and it is apparent he made some reference to killing himself.  The ABC reporter offered to provide Mr D with the telephone number of appropriate support services and his barrister reiterated to Mr D that he should proceed to the hospital or go and see his doctor.  Although there was commonality in the evidence from his barrister and the ABC reporter as to the fact that Mr D was upset and that he had threatened to self-harm, his barrister says that she requested that the matter not be reported whereas the ABC reporter states that his barrister did not seek to influence him about not reporting the case.  The ABC reporter says that he discussed the matter with his senior editors and it was decided to run the story on radio at the 1:00pm news service.  Evidently there was discussion between the reporter and his senior editor after Mr D's barrister had expressed her concerns to the reporter following the news report.  A decision was made by the news editor to "pull" the story.  This was a decision taken as a precautionary matter given the concern for Mr D following the comments he had made after his Court appearance.  Following this decision of the afternoon in March 2014, there was no further broadcast of the details of the Court appearance by Mr D, although the story remained on the applicable website for a further period of time. 

Earlier that afternoon Mr D's barrister had also contacted SG at Statewide Mental Health Division of the Department of Health and Human Services, the person whom she had previously requested the medical report from in relation to the plea of mitigation provided on behalf of Mr D.  SG undertook to make enquiries as to any contact made by Mr D.  Later that afternoon an employee of the Department of Health and Human Services advised Mr D's barrister that they had been unable to contact Mr D and therefore his barrister contacted the police radio room at approximately 5:00pm to pass on her concerns as to Mr D's welfare.  Senior Constable K Keygan and Constable C Carr made a number of endeavours to locate Mr D during the course of their shift that night.  They initially attended his address at 7:20pm and found nobody present and also the absence of his motor vehicle.  In the course of their patrol they checked for signs of Mr D's vehicle at a number of locations in their area including the car parks of local hotels and the car park of his workplace.  During the evening repeated attempts were made to contact Mr D on his mobile and home phone.  At approximately 10:00pm Senior Constable Keygan telephoned Mr D's barrister and was advised that Mr D had previously attempted suicide by "gassing" in his vehicle. Accordingly, whilst on patrol south from Hobart, they once again checked his address and searched inside the house through an open sliding door but located nothing of concern save for the mobile phone identified as Mr D's on the kitchen bench.  They continued their patrol and searched public access waterfront areas in southern Tasmania.  Upon their return to the police station a further inspection was made of Mr D's residential address without success.  Later that morning police investigations continued with checks made of the Launceston and Hobart airports for Mr D's vehicle together with a similar check at the Bass Strait ferry terminal at Devonport.  Federal Police were involved in searching passenger booking details noting that there were no flights booked in the name of Mr D in the relevant period.

On the following day, Mr Robert Clarke and his partner Ms Suzanne Lowe were travelling on a highway in southern Tasmania. Having parked at a reserve, they alighted from their vehicle and they walked through the reserve area towards the waterfront where Mr Clarke noted a small white vehicle parked at the end of a rough track on the headland.  Upon closer inspection he noted a male person in the vehicle.  Ms Lowe contacted the emergency number "000" for police with this report being logged at 12:07pm.  They had observed that the engine of this vehicle was still running and there was a plastic pipe connected to the exhaust pipe of the vehicle and entering the rear passenger door window of the vehicle.  Mr Clarke approached the vehicle, opened the driver's door, turned off the ignition and then Ms Lowe, a registered nurse, checked the male occupant for signs of life.  She could not rouse the occupant and noted that there were signs that he was in rigor.  Police attended soon after.  The first attending officer was Constable Ml Buick who observed a white sedan parked on a slightly elevated area of the foreshore.  It was noted that there was a rough, rocky track which led from the highway for approximately 50m to the position of the vehicle.  As he approached the vehicle, Constable Buick observed a length of black plastic pipe connected to the exhaust pipe of the vehicle and the driver's door was open which allowed him to observe a male person seated in the driver's seat, slumped across the front passenger seat.  He carried out appropriate checks confirming that this person was deceased.  Inside the car he observed two 750ml bottles of Jack Daniels whiskey, one empty, one full.  He observed a number of empty blister packs of prescription medications as well as white tablets which were unpacked and sitting on the front passenger floor.  He noticed a knife and sharpening stone in the passenger foot well and a piece of paper sitting on the dash in front of the instrument cluster.  The empty foils of medication and the tablets found were identified as Seroquel.  The note which was propped in front of the instrument panel was referred to in the writing as a "will and testament". 

Further police officers attended the scene and a full investigation was commenced, with one of the attending officers identifying the deceased person as Mr D based upon previous dealings with him.  When Mr D was removed from the motor vehicle, it was noted that he had some injuries to his body in the form of rather shallow lateral cuts to both wrists and one similar cut to the neck.  It appeared that these had been self-inflicted.  There were no other injuries of significance identified or any sign of the intervention of any other person.

At post-mortem the wounds to Mr D's neck, right anterior forearm and left anterior wrist were noted and described as superficial with none having penetrated the subcutaneous tissue or caused substantial underlying injury.  It was also noted that there was a pink colouration of the body consistent with the inhalation of car exhaust fumes, there were pill fragments in the stomach and toxicology revealed a lethal carbon monoxide level of 61% and an elevated level of Quetiapine and a low level of alcohol.  He was also found to have had a 60% stenosis of two coronary arteries; however it was not thought that this would have been a cause of death but may have contributed.

Insofar as the possible contributions to his mental state were concerned, it was recorded that Mr D underwent a laparoscopic right hemi-colectomy in December 2010 (for colon cancer) and then underwent 12 courses of chemotherapy.  At post-mortem, the forensic pathologist could not identify any anastomoses and there were no obvious adhesions, recurrent adenocarcinoma or metastatic carcinoma and it was thought unlikely that the carcinoma played any significant role in the death, although it was noted that given his history of depression, Mr D may still have had concerns regarding the possibility of recurrence.

Comments and Recommendations:

I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity of Mr D, the date, place, cause of death, relevant circumstances concerning how his death occurred and the particulars needed to register his 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 significant information further to that disclosed by the investigations conducted by me.

It is apparent that Mr D expressed concerns after his court appearance about the possibility that the publication of his conviction upon the pornography charges could lead to the loss of his employment and also, I infer, cause him significant embarrassment generally.  The balancing of the competing principles of ensuring the maintenance of the general public interest in having an open and transparent justice system as opposed to the personal welfare of persons convicted of offences is a complex issue going beyond my role in this case.  The publication that occurred may have contributed to the decision taken by Mr D to self-harm but I am not persuaded that this of itself led to that decision.  The action taken to discontinue the publication of the story was appropriate given the level of anxiety expressed by Mr D.  However, he also was affected by a concern that he might face imprisonment, his employment may be lost and also an overall frustration of the delay in finalising his prosecution.  Perhaps it was even a realisation of the nature and gravity of his offences and the possible direct and indirect consequences of his conviction that overwhelmed him.

Before I conclude this matter, I wish to convey my sincere condolences to Mr D's family and friends.

DATED: 22 March 2015 at Hobart in the State of Tasmania.

Stephen Raymond Carey
CORONER