Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

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

Mr B



(a) The identity of the deceased is Mr B who died at the Royal Hobart Hospital on 13 February 2012.

(b) Mr B was born in Queensland on 26 April 1945 and was aged 66 years at the time of his death.

(c) Mr B was a retired person.

(d) Mr B died as a result of hypoxic brain damage due to insulin intoxication.

(e) I am satisfied based upon the investigation conducted that Mr B died as a result of action he took to end his own life.

Circumstances Surrounding the Death:

Mr B was a long-time member of a  community Club in New Norfolk, and had for some years been the Treasurer of that Club.  Mr B had been retired for a number of years and his wife understood that they were financially comfortable, however she did not have any insight into their financial situation as Mr B handled those matters himself.

During the investigation conducted in this matter it was ascertained that:

• Mr B held two credit cards with the National Australia Bank totalling a debit outstanding of $45,137.75.
• Mr B held a credit card with Westpac totalling an outstanding debit amounting to $25,448.29.
• Mr B held an American Express credit card with an outstanding debit owing of $4,657.03.
• Mr B held a Commonwealth Bank credit card with an outstanding balance amount of $2,429.07.
• Mr B in a letter to the Vice President of the Club admits to embezzling an amount in the vicinity of $35,000 from the Club.

Mr B’s wife reports that in the period before his death Mr B had told her that they had approximately $820,000 in investments and superannuation funds and based upon this she had advised her husband that she would seek to retire from her employment in or about November 2012.  Mr B gave no indication that they had any financial problems.  She states:

 “It was not until after his death that I became aware of overdue credit card debts to the amount of approximately $70,000 in his name and outstanding accounts for rates, utilities and other services.  Supposed investments other than some personal savings and super in my name no longer existed and he had withdrawn the final balance from his superannuation fund account.”

The Vice President of the Club, provided details of his endeavours over the months leading up to the death of Mr B to have him make available the financial records and details of the Club.  It is apparent that these endeavours had been underway for a number of months and on each occasion that he raised the topic, Mr B would have an explanation justifying further time before providing the requested details.  Towards the end Mr B had advised that the records had been provided to an auditor, although he was unable to provide the name of that person.  Mr B also provided advice to the Vice President that he had medical advice from his doctor not to talk about the Club’s business for a period of two weeks.  On the weekend prior to his death Mr B had undertaken to deliver the books of account to the President of the Club that weekend.  On Sunday 5 February 2012 the Vice President visited Mr B, noting that he had not complied with his undertaking to provide the books of account. 

Following that visit Mr B had dinner with his wife and she observed nothing untoward about his behaviour that evening or the following morning before she left for work.  Later that morning Mrs B received a telephone call from her husband advising that he had gone out in order to collect some books of account relating to the Club.  When Mrs B returned home that evening at approximately 5.45 pm, she noted that her husband was not at home but that he had left a note confirming that he had gone to Sandford with the Club’s financial papers and would be home late.  Mr B did not return home that evening and did not answer telephone calls made by his wife throughout the night.  Mr B was notified to Tasmania Police on the morning of Tuesday 7 February to be a missing person.

On Wednesday 8 February 2012 Mr B’s motor vehicle was located on a dirt track on the northern side of the Tyenna Bridge on Gordon River Road, National Park by a Mr G.  Mr G discovered the vehicle apparently “bogged” and he observed Mr B in the front seat.  Despite Mr G’s endeavours he could not get a response from Mr B who was noticed to have vomit on his top and body fluids protruding from his nose and mouth.  Mr G contacted emergency services and Constable L was the first to arrive at the scene.  He observed Mr B to be slumped forward, unconscious and his breathing was very laboured.  Constable L made further contact to emergency services and a short time later two ambulance crews arrived at the scene, one via vehicle the other via helicopter.  Mr B was stabilised before being transferred into the rescue helicopter and flown to the Royal Hobart Hospital.

On arrival at the Royal Hobart Hospital it was determined the deceased had taken approximately 600 units of insulin, he was transferred to the Intensive Care Unit of the hospital with a diagnosed hypoglycaemic brain injury.  On Saturday 11 February 2012 Mrs B and other members of the family were informed by doctors that Mr B had no neurological response and the family made the decision that Mr B’s artificial ventilation assistance be discontinued.  Mr B was transferred to a ward at the hospital where he died at approximately 4:45pm on Monday 13 February 2012. 

Mr B left a total of five notes at the time of his death, and although there is some difficulty deciphering his writing they all contain a consistent theme of Mr B expressing a lack of self-worth, a wish that he had taken action sooner than he did and an apology for what he had done.  Given his financial situation at his death, it is tragic to note that in a letter to his wife, Mr B outlines that there was in fact no money set aside for them contrary to his advice to her in the past and a comment that he had used money to gain acceptance by his peers. 

Mr B was suffering from Type 2 diabetes and his medication in that regard included injected insulin. 


It is apparent from this investigation that for perhaps a number of years Mr B had spent money at such a level that he found himself in significant financial difficulties and had also apparently embezzled funds from the Club.  In the months leading up to his death it must have become clear to him that he could no longer maintain the secrecy as concerted efforts were being made on behalf of the Club to obtain financial records and he was receiving numerous letters of demand in respect of his private credit card debts.  It is tragic that Mr B apparently felt that due to his low self-esteem and lack of confidence that he needed to purchase friendship and influence.  This conduct led to the overwhelming financial situation that he found himself in and for which he apparently could see no way out other than the taking of his life. 

Before concluding I wish to convey my sincere condolences to the family of Mr B.

Dated: this 27 day of August 2012 at Hobart in the State of Tasmania.


Stephen Carey