Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

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

I, Robert Pearce Coroner, having investigated the death of

'Ms C'


Find That :

(a) The identity of the deceased person is 'Ms C', born in August 1992  in Victoria;

(b) 'Ms C' died on July 2010 as a result of her taking her own life by hanging in the  northern end of  Tasmania;

(c) The cause of her death is injury caused by hanging;

(d) No other person contributed to the cause of 'Ms C' death.

Circumstances Surrounding the Death:

1. 'Ms C' was aged 17.  She lived with her mother and her father at  Newnham.  She attended Newstead College.  'Ms C' has a younger brother.

2. At about 12 noon on Wednesday 28 July 2010, 'Mr C' returned home from work.  He had arranged with 'Ms C' to take her to lunch.  On entering the rumpus room 'Mr C' found 'Ms C' hanging by her neck from a rope, possibly a dog lead, suspended from a beam running across the ceiling.  There was obvious injury to her neck.  Her father and then intensive care paramedic ambulance officers made prolonged but ultimately unsuccessful attempts to resuscitate her.  I am satisfied that, by the time that she was found, 'Ms C' was already dead.

3. No note was left but there is nothing to suggest the direct involvement of another person in 'Ms C’s' death.  There were no signs of disturbance in the bedroom.

4. Toxicology testing disclosed a greater than therapeutic level of the anti-depressant drug fluoxetine but there is no evidence it directly contributed to the cause of 'Ms C’s' death.

5. I am satisfied that 'Ms C' took her own life.  The coronial investigation revealed a number of additional circumstances that appear to me to point clearly to that conclusion.  At the outset I would point out that these circumstances are viewed with the benefit of hindsight and that there was little to warn her family or friends that she had a serious intention to harm herself.  As is often the case with teenage children, she was not receptive to her mother’s attempts to discuss personal issues with her.

6. 'Ms C' and her immediate family came to Tasmania when she was only young. Her mother’s parents, already lived in Tasmania.  'Ms C' did well at school, was close to her parents and her brother and, although reserved, had many friends and was well liked by everyone.  However, when she was 13 or 14, her mother noticed that she had cut herself and she seemed to be developing an eating disorder.  These issues seemed to resolve and although she became less communicative the behavior her mother now describes was not atypical for a teenage girl.  In 2009 she commenced a relationship with 'Mr S' and she became close to him.  For a range of reasons he even spent time living at the family's home and was employed by 'Mr C'.

7. Later in 2009 'Ms C' disclosed to her boyfriend that, when she was 12, she had been sexually abused by her grandfather.

8. On 14 May 2010 'Ms C' consulted a medical practitioner specializing in the mental health of adolescents.  'Mr S' accompanied her to the appointment.  The doctor assessed her as being moderately to severely depressed and prescribed anti-depressant medication.  He discussed the issue with her and left it to her to decide whether to tell her parents.  At that time she had not yet done so.  He gave no other advice about reporting what she told him and did not report it himself.  The medical practitioner saw her again on three subsequent occasions, May 2010, June 2010 and July 2010.  His report indicates a gradual improvement in her presentation on each occasion and no indication that suicide was likely.

9. In April 2010 'Ms C' told her parents about what she said her grandfather had done, and that she had not previously reported it for concern for her grandmother.  No report was made to police.

10. In May 2010 'Mr S' moved to Queensland to live.  Although he remained in contact with 'Ms C' his absence at a time of such upheaval in her life was no doubt difficult for her.

11. I record that a prosecution against the medical practitioner for failure to report the allegation of sexual abuse was not proceeded with.

Comments and Recommendations:

12. By s28 of the Coroners Act, a coroner investigating a death is required to find, if possible, when and where the person died, how the death occurred, the cause of death and to identify any person who contributed to the cause of death.

13. The primary focus of an investigation is to seek out and record the facts concerning the death of a person.  It is a fact finding exercise of an inquisitorial nature.  The facts which are relevant are those which may enable findings about the matters the Act requires the coroner to, if possible, determine.  It is not the function of an investigation to attribute any moral or legal responsibility or liability for a death or to hint at blame.  It is not a means if apportioning guilt.  A coroner is to determine facts.  The facts, once determined, will speak for themselves and it is for others to, if necessary, draw legal conclusions.

14. Findings do not and should not involve a finding that the person has some criminal or civil responsibility for the death.  However, it is proper that an investigation should identify not only the direct means or mechanism of death but also the circumstances attending the death.

15. I have decided not to hold an inquest into 'Ms C' death.  The investigation has sufficiently disclosed the identity of the deceased person, the time, place, relevant circumstances concerning her death and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act.  No other a person contributed to the cause of 'Ms C's' death within the meaning of that term in the Coroners Act 1995.  I do not consider that an inquest is likely to elicit any further significant and relevant information concerning the issues that I am required to determine.

16. There is no need in this case to make other comment or recommendation.

I convey my sincere condolences to 'Ms C's' family.

DATED: 23 October 2012 at Launceston in the State of Tasmania.


Robert Pearce