Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

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




a) The deceased is Gary Robert Casely (Mr Casely) who died at a precise time unable to be determined but subsequent to 9.45pm on 27 August 2011 and before 11.30am on 28 August 2011 at Bilton Lodge, 61 Cadbury Road, Claremont.

b) Mr Casely was born on 5 July 1962 and was aged 49 years.

c) Mr Casely was a single person who was unemployed.

d) Mr Casely died of natural causes however the precise manner of death cannot be determined and has been classified as an unexpected death in a man with schizophrenia and post-traumatic seizure disorder.

Circumstances Surrounding the Death:

At the age of 13 years Mr Casely was struck by a motor vehicle after alighting from a school bus.  As a result of this he suffered a significant brain injury.  It took a great deal of time for him to regain his speech and mobility but he remained intellectually impaired and his emotional development ceased at that time.  He also suffered epilepsy for which he required medication.  In his mid to late twenties he was diagnosed as schizophrenic which also required ongoing medication.  He did however manage to live independently but did require some support in that regard.  His sister, Ms Joanne Ring reports that he was “….pretty disgruntled and unhappy with life” and that in the past he had attempted suicide.  In May 2011 he required a period of hospitalisation suffering myocarditis which had occurred as a result of a trial he undertook with a new drug, Clozapine in respect of his schizophrenia. 

Mr Casely was residing at Bilton Lodge an accommodation facility at Claremont.  He had in recent months formed a relationship with another resident, Ms Sarah McLeod.  On the evening of Saturday 27 August 2011 they apparently had a disagreement or argument and he became agitated and was noted walking around the housing complex refusing to talk to anyone.  Another resident at that time, Mrs Carol Bell, recalls that about 9.45pm that night Ms McLeod came to her room in an upset state.  Ms McLeod said she had been arguing with Mr Casely and that he was refusing to talk with her.  Ms Bell noted Mr Casely walking about the complex, she spoke to him and he stated he did not want to talk to Ms McLeod and that he did not want to “go out with” her anymore.  Ms Ring spoke with him by telephone that night and reports that he seemed “stressed” as he had broken up with his girlfriend.

The following morning both Ms McLeod and Ms Bell attempted to raise Mr Casely by knocking on his door but there was no response and his door was locked.  At approximately 11am Ms Ring arrived to pick up her brother as previously arranged and as he was not waiting in the car park where he normally did she also went to his room but could not raise him.  She approached the accommodation centre manager who used a key to enter Mr Casely’s room with Ms Ring.  They found him lying on his bed and he appeared to be dead.  The accommodation manager checked and he had no pulse and was not breathing.  An ambulance was called and paramedics attended but no resuscitation endeavours took place as it was confirmed that Mr Casely was dead.  Police were advised and an investigation conducted which disclosed that there were no suspicious circumstances in relation to his death.

A post mortem did not disclose any clear cause of death and toxicology tests disclosed that prescribed medication was present, however the level of Valproic Acid (an anti-epileptic agent) was at sub-therapeutic level.

The forensic pathologist, Dr Ritchey, concludes that the cause of death was unexpected death in a man with schizophrenia and post-traumatic seizure disorder.  He comments that possible mechanisms of death include a cardiac arrhythmia complicating recent clozapine myocarditis or seizure complicating remote head injury.

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

Dated: 20th day of July 2012 at Hobart in the State of Tasmania.


Stephen Raymond Carey