RECORD OF INVESTIGATION INTO DEATH (WITHOUT HOLDING AN INQUEST)

Coroners Act 1995
Coroners Rules 2006
Rule 11

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

Ms F

WITHOUT HOLDING AN INQUEST

FIND THAT:

a) The identity of the deceased is Ms F who died at a precise time unable to be determined but at some time between late on the night of 7 March 2011 or early morning of 8 March 2011.

b) Ms F was born in Hobart and was aged 32 years at the date of her death.

c) Ms F was an unemployed person, and single without dependents.

d) The body of Ms F has been unable to be found, however given the circumstances of this matter I determined that the likely cause of death was extensive blunt traumatic injury and/or drowning following a fall from height.

e) Although I am unable to determine with absolute certainty, it is highly likely that Ms F died as a result of action she took to end her life, by jumping from the Tasman Bridge.

Circumstances Surrounding the Death:

Ms F is described as a person who had difficulties throughout her adult life and more recently had demonstrated clear signs of depression and anxiety.  Ms F is described as someone who was “a loner” and who had a history of abusing alcohol and more recently cough syrup medication in order to achieve “a high”.  Ms F had struggled in her endeavours for higher education and also for employment.  She is reported as having difficulties in maintaining concentration.  In recent times before her disappearance Ms F had been living with her parents who noted in the period leading up to her disappearance that she had suffered the loss of a relationship she had developed with an overseas student, who advised her that he did not wish to maintain the relationship upon his return home.  Also Ms F received advice from Centrelink that she was required to repay $7,000 that had been paid to her. 

Approximately three weeks prior to the date of her disappearance Ms F had attempted suicide when on 15 February 2011 she was admitted to the Royal Hobart Hospital having been discovered by her mother with a plastic bag over her head which was connected to a barbecue gas bottle.

At that time she is reported as presenting to the Royal Hobart Hospital with two months of depressive symptoms, apathetic, unmotivated and withdrawn.  She had decreased sleep, no loss of weight, ruminated on the past and had suicide ideas for the last three weeks before admission.  She presented as being ambivalent about living and there was mention of a recent relationship breakup.  She remained a patient for two weeks up until 2 March 2011 and appeared to respond well to anti-depressant medication.  It was noted that her suicide ideas resolved at least two days prior to discharge but she had undergone a neuropsychological assessment which showed poor attention and memory deficits thought to be secondary to her long term poly-substance use (cannabis, alcohol and cough syrup).  Upon discharge from the Royal Hobart Hospital she was transferred to the care of the Southern District Adult Community Mental Health Service with a discharge plan which included follow up with her general practitioner for medications and with the Drug and Alcohol Service and a mental health package for psychological sessions.  On 4 March 2011 the Adult Community Mental Health Service left appointment details on Ms F’s telephone when there was no answer.  Subsequent telephone contact on 4 March 2011 with Ms F’s mother revealed that Ms F was reluctant to use this Service and had deleted their message and said that she would not attend the appointment.  Ms F’s mother is reported to have advised that a private sector follow up would be used for Ms F’s psychological care and that her mood was improved.  Ms F was reported as being apparently compliant with her medications.  Later that day telephone contact was made by the Service with Ms F who advised that her mood was 7/10 and she stated that she had no serious mental health concerns.  She was non-committal about the psychiatric appointment that had been given to her and was unable to meet on that day, however it was agreed that she would be given a reminder call on 7 or 8 March 2011 about the psychiatric appointment that had previously been given to her.  This reminder call was made on 8 March 2011 subsequent to Ms F’s disappearance. 

In accordance with the discharge arrangements made upon Ms F’s release from the Royal Hobart Hospital Dr W, general practitioner, had provided advice to Ms F’s mother that he was happy to see her upon discharge to ensure ongoing care and specialist psychiatric input.  Ms F’s mother called Dr W on 4 March to advise that Ms F had been discharged from hospital and that she was keen to attend her psychiatric out-patient appointment that had been scheduled for 10 March.  Dr W received another telephone call from Ms F’s mother on 7 March informing him that Ms F was now refusing to see the psychiatrist or to attend him.  He was contacted on the following day to advise of Ms F’s disappearance.

On 6 March 2011, on a Saturday night, Ms F had been out with friends socialising at the Brisbane Hotel.  She was described by friends on this evening to be bright and “almost normal”.  The next morning she met a long-time friend, Mr G, for coffee at approximately 10.00am and they stayed in company with each other for 2-3 hours.  Mr G stated that by the way she was acting throughout this time he did not have any concerns for her wellbeing, however she did appear “a little quiet” but he assumed that this was because of her medication.  He later that day telephoned Ms F commenting to her how much he had enjoyed their time together and suggesting they do that more often.  Mr G again stated that during this phone call Ms F appeared fine and he had no reason to feel concerned for her wellbeing.

Ms F was last seen by her father at approximately 9.30pm on 7 March 2011 at their residence.  She had been watching television and she remained up after he went to bed.  Mr F described his daughter on this particular night to be “zoned out” and as if she didn’t really want to talk.  This same night at approximately 11.45pm another friend of Ms F’s, Mr M, was riding his pushbike from North Hobart to Sandy Bay when he believes he saw Ms F walking down Macquarie Street near the intersection of Murray and Macquarie Streets in Hobart.  He describes that he is certain it was Ms F, that he waved to her but she did not acknowledge his wave and appeared somewhat startled by seeing him. 

At approximately 2.30am on 8 March 2011 Ms F’s mother went out to the living room of their home and found a note that had been left by her daughter on the kitchen table which appeared to be a suicide note.  It read:

 “I’m afraid I’ve broken my promise, by the time you read this I’ll be gone off the Tasman Bridge.  I continue to feel numb on the inside despite feeling the effects of the anti-depressants.  Care for myself and others is absent.  Tried to pretend, hoping that I could fake it but it hasn’t worked.  I’ve tried caring towards others but it’s not there anymore.  Everything awkward and clumsy, and I realise what I’ve done last night is a selfish act.  However, I’ve always been a selfish person.  It’s always been a streak in my personality.  I know what I’ve done will cause pain to you.  However I’m not prepared to be alive feeling like a zombie just to prevent others from feeling pain.  From my perspective I’m already dead on the inside anyway.”

Police were immediately contacted and an investigation commenced given the concern for Ms F’s welfare.  These endeavours continued throughout the early hours but at approximately 7.00am personal items were located at the apex of the Tasman Bridge which were identified as belonging to Ms F.  Marine Police were dispatched and a search conducted of the immediate area around the Tasman Bridge however no body was located.  Since that date Police investigations have confirmed that bank records and phone records in the name of Ms F have not been activated.  Family and friends have been contacted on a number of occasions to date and confirm that there has been no contact with Ms F.  A detailed Police investigation has been conducted and I am satisfied based upon that investigation that in all likelihood Ms F is deceased, having taken her own life by jumping from the Tasman Bridge.

Comments & Recommendations:

As noted in my findings an inference has been made that Ms F jumped from the Tasman Bridge.  There is no direct evidence as to that fact. I therefore repeat the comments I made in a recent matter that involved a similar circumstance.

 “Although there are cameras affixed to the Tasman Bridge they are primarily for vehicular traffic flow management and operate on a “real time” basis with no recording.  In order to secure evidence of pedestrian incidents on the bridge and also to provide a means for possible emergency service intervention, it is recommended that consideration be given to:

• ensuring that the cameras affixed to the Tasman Bridge can monitor pedestrian as well as vehicular traffic;
• provide a 24 hour recording capability from those cameras which is held for a reasonable period (at least one week) to allow access for investigation purposes not only for pedestrian incidents but also vehicular accidents;
• provide a capability for a 24 hour, 7 day a week monitoring of the “real time” camera transmission to allow an ability for a timely intervention if a pedestrian is noted to be acting dangerously, inappropriately or suspiciously on the Tasman Bridge.  Possible facilities where such a monitoring system could be established might include the Police Radio Room, Hobart Police Station Enquiry Office, or Tas Ports Control Room.”

It may be possible that such monitoring might provide a chance that a life may be saved and would also in tragic cases such as this provide certainty of what occurred.

Unfortunately even with the care, love and support of her family and with access to appropriate medical assistance Ms F, obviously due to her very poor mental health state felt this action by her was her only option.


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


Dated: 30 September 2012 at Hobart in the State of Tasmania.

 

Stephen Carey
CORONER