Coroners Act 1995
Coroners Rules 2006
Rule 11

These findings have been de-identified by direction of the Coroner pursuant to S.57(c) of  Coroners Act 1995

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

Mr L



(a) The identity of the deceased is Mr L who died on 26 July 2010 at Moonah in Tasmania.

(b) Mr L was aged 45 years.

(c) Mr L was unmarried and was employed as a stonemason/groundsman.

(d) Mr L died as a result of head and chest injuries following a single vehicle motor accident.

Circumstances Surrounding the Death: 

Mr L was described as a private person who had been involved in a number of relationships some of which did not end well.  There are indications of jealousy and anger management issues affecting Mr L in relation to these relationships which required police involvement, and in respect of the last relationship, the issue of a restraint order.  Also of significance was the extremely high level of debt incurred by Mr L on two personal credit cards.  He was a social drinker but frequently used cannabis.  He did not have a close relationship with his father, who lived in Tasmania, but had an ongoing and close relationship with his two sisters, DD and SB, both of whom reside in Victoria.  His family were unaware of his cannabis use and did not suspect that he suffered any form of depressive illness.  However friends and ex-partners were aware of both of these aspects. 

Mr L was in a relationship with Ms W from approximately January 2010 until April 2010.  During the period of this relationship he is reported by her to have regularly displayed agitation and anger and to have continuously expressed a wish to marry her, stating that if he couldn’t be with her he wanted to die.  Although the relationship was over they did have dinner together on 10 July 2010.  Ms W believes that Mr L may have perceived this as a means of rekindling the relationship as he then started barraging her with telephone calls and SMS texts.  On some days this could be as many as 40-50 and many were abusive in nature.  By mid-July he was attending at her home, and the home of her friends whom she might have been visiting, in an attempt to see her.  On 21 July 2010 she obtained a restraint order against Mr L.  After this time his constant attempts to contact her ceased. 

Mr L was in a relationship with Ms Z from approximately August 2008 until December 2009.  She states that she ended the relationship because she felt he was suffering depression and despite her endeavours he refused to seek professional assistance.  She did not have much contact with him after the relationship ended, but he did visit her on 21 July 2010.  During their time together on that day she recalls him outlining the following:

• He had dug a hole for himself that he couldn’t get out of.  This was referring to an alleged affair he had at work (Ms W).
• He told me he’d quit both jobs he had.  One was at Millingtons at Cornelian Bay Cemetery and the other was as a bottle shop attendant at Cooley’s Hotel in Moonah.
• He made a Will which he was signing on Friday.
• He was sorting out his superannuation beneficiaries.
• He was writing letters to his sisters and possible others.
• He told her that in one of the letters to his sisters he had left a bank cheque that was for his funeral.
• He told me that he thought he was a failure.
• He was having financial problems.  His debt had increased from $30,000 to $40,000 on his credit card.
• He told her that one of his superannuation funds was enough to pay this debt off and another had death benefits with it.
• He told her that he would play golf on Saturday as he didn’t want to let his team down, so he planned to kill himself on Sunday and he was going to do this by gassing himself at 8.00pm on Sunday.
• He would not tell her where he was going to do this, just that it would be somewhere private.
• He made her promise not to call his sisters.

Ms Z reports that she was overwhelmed by these comments and she believed he was serious.  She contacted him again during that night and also throughout Thursday and they met again on Thursday night.  At that meeting he was under the influence of alcohol and cannabis.  She remained in contact with him and on Friday after seeking advice from “Beyond Blue” and “Lifeline” she contacted Tasmania Police.  The police reported back to her that on Friday afternoon 23 July 2010 they had visited Mr L but he did not display sufficient signs of intent to self-harm for them to intervene.  Mr L then contacted Ms Z stating “The police were a nice touch” and he warned her not to contact his sisters otherwise he would act sooner than planned. 

Because of her concerns on Sunday 25 July she contacted Mr L’s sister, D, and told her everything that had happened.  She then went to Mr L’s unit but he ran away from her when she arrived.  Soon after Tasmania Police arrived.  Mr L came back and the group then talked for a significant period of time.  This concluded with Mr L agreeing to a request that he go with police to the Royal Hobart Hospital in order to seek assessment and presumably assistance if required.  The police had come to Mr L’s unit following a call from his sister S who contacted them after her sister D had advised her of the contents of the telephone call she had received from Ms Z.  The police officers had concluded after their discussions with Mr L and Ms Z that there was a risk that he may self-harm and they also located a length of hosing in the boot of his car.  The police officers accompanied Mr L to the Emergency Department at Royal Hobart Hospital and remained with him until released by the Triage Nurse Mr R.  Mr L was given a Triage Category 3 which denotes a recommendation that he be seen by a medical officer within 30 minutes.  He was placed in a seclusion cubicle and underwent initial assessment by Psychiatrist Emergency Nurse Ms W.  She reports as follows:

• He was offered a meal and something to drink but he did not want anything. 
• During the interview he gave no indication of suicidal intent, in fact he was telling me how he planned to go to Adelaide with a male friend to see the friend’s son graduate from the Airforce.
• He was questioned on suicidal ideation and he denied any.
• The story he provided at this time differed from that he had given the police.
• During the course of the evening he enquired how long it would be before he saw a doctor and it was explained that delays were caused by a number of Category 1 patients that needed to be dealt with.
• He repeatedly asked how long it would be before he saw a doctor as he would like to go home as he had to work the next day.
• He was again offered something to eat and drink but he refused.
• A short time later another patient was brought to the area and this required her attention together with numerous other staff including security.
• After this incident was resolved she returned to where Mr L was located but realised he had left the Department. 
• He was not reported missing to police because he was not on an Initial Order and was therefore present as a voluntary patient.
• Mr L did not meet the criteria for being placed on an Initial Order. 

Once Mr L left the hospital he apparently remained under the impression that police would be looking for him.  He took a taxi to his flat and then drove his car to Cornelian Bay and placed it inside the grounds at the Cornelian Bay Cemetery (he held keys to the gate).  He then telephoned a friend, Mr B, who came and collected him and took him to his flat in Lindisfarne.  During their discussions Mr L told Mr B that he was going to commit suicide in a few hours by gassing himself in his motor vehicle at the Kingston Cemetery.  He told Mr B that if police tried to pull him over he was going to unclip his seatbelt and drive into a power pole in order to kill himself.

Mr B then drove them both to a hotel to purchase some alcohol and then to the Cornelian Bay Cemetery.  Mr B at the direction of Mr L then drove Mr L’s vehicle to an area in the vicinity of the Kingston Cemetery whilst Mr L followed in Mr B’s car.  This was to avoid detection as Mr L remained under the impression that police would be looking for him.  In fact Mr L’s exit from the Royal Hobart Hospital had not been reported to police and no action would have been taken by police to locate him.

At the Kingston Cemetery they exchanged cars, continued their discussions during which time Mr L consumed some alcohol and used cannabis.  Mr L said he was going to gas himself at that location as he wanted to be found the next day.  Mr B said he could not talk Mr L out of his plan so he eventually left, returned to his flat and did not advise anyone of what had occurred or what was possibly to occur.

It is assumed that at some stage thereafter Mr L attempted to gas himself in his vehicle as he had outlined.  Although there is no witness as to this, at post mortem he was shown to have greater than normal range saturation (18%) of carboxyhaemoglobin (carbon monoxide).  Normal concentrations are generally less than 10% saturation.  This elevated level of carbon monoxide in the blood stream is possibly as a result of an attempt by Mr L to gas himself which was either unsuccessful or which he for some reason desisted from completing. 

In any event Mr L has then driven his motor vehicle back to Moonah as signals from his mobile phone and SMS messages were traced to him being in that area.  During the night of 25 July 2010 he sent a number of SMS texts to Ms W.  She also made endeavours to contact him on his phone because she had been made aware of his threat to self-harm. 

A Laser motor vehicle driven by a sole occupant was noted to travel through the green signal and turn left from Hopkins Street into Charles Street.  The vehicle was being driven at or about the posted speed limit of 50km/h.  At approximately 2.30am on 26 July police determined that they would intercept this vehicle for the purposes of a random breath test.  Constable Williams was driving the police vehicle and accelerated in order to move within approximately ten metres of this motor vehicle and then activated the police red and blue lights to signal the driver to pull over.  The Laser continued moving below the posted speed limit and turned left into Florence Street.  The police vehicle followed, waiting for the Laser to pull over but it did not do so.  The police vehicle followed behind the Laser which increased its speed as it approached the intersection with Main Road.  Constable Williams said that he was travelling at about 60km/h at a distance 30 metres behind the Laser.  This is corroborated by a glimpse of CCTV vision recorded by the BP Service Station on Florence Street near Main Road, which shows the Laser pass by followed by the police vehicle with emergency warning lights operating.  Constable Williams says that he did not get an opportunity to alert radio dispatch services before the Laser deviated slightly by one metre to the right of the centre line and proceeded through the intersection with Main Road.  Constable Williams is of the view that the driver could have safely turned both left or right at the speed the Laser was travelling as it approached the intersection.  Instead the Laser continued straight ahead and drove into the carpark of the business Zap Fitness, almost directly opposite.  The speed of the Laser was estimated at about 80km/h at this time and Constable Williams thought that the driver intended to park in this carpark and then attempt to abscond.  The Laser however crossed the carpark and crashed head-on into a wall.  CCTV vision recorded the actual crash.  Sergeant Rodney Carrick, an experienced Accident Investigator, conducted a scene analysis and from that determined that the Laser impacted the wall whilst travelling at a speed of 38km/h.  The police vehicle entered the carpark and both Constables Williams and Manning commenced first aid upon the driver.  The police officers observed that Mr L (the driver) was not wearing a seatbelt and that he had suffered visible head and chest injuries.

At 2.33am Constable Williams advised police radio dispatch services that there had been an accident and requested assistance.  An ambulance attended the scene at 2.35am and paramedics commenced treatment.  This treatment was ceased at approximately 2.50am and Mr L was pronounced dead.  Due to the circumstances of this accident, investigators from the Police Internal Investigations Unit were involved and conducted a thorough investigation.

At post mortem Mr L had a blood alcohol reading of 0.025% which is half the legal limit but also present was the active ingredient of cannabis (THC).

I have considered the very detailed police investigation report on this matter and I am satisfied that the circumstances that existed between the time the decision by the police officers to conduct a random breath analysis upon Mr L up until the accident do not amount to a death occurring in the following circumstances:

• Whilst escaping or attempting to escape from ……….police custody; or
• Whilst in the process of police officers attempting to detain a person. 

 (Section 24(1)(d) & (e), Coroners Act 1995).

I therefore do not consider that it was mandatory for me to conduct a formal inquest in relation to this matter.  The police officers lawfully attempted to intercept Mr L on a public street for the purposes of a random breath test and he failed to stop when police signalled for him to do so.  Constable Williams made a decision to follow the Laser until it pulled to the side of the road in order that he could conduct the breath test, or alternatively he could gain the registration number of the vehicle or observe the driver should he flee from the vehicle.  The Laser motor vehicle and police vehicle were traveling at or about the posted speed limit in Charles Street.  There was no indication at that point that Mr L intended to flee and I am advised that in normal circumstances many vehicles fail to stop immediately for police because of such things as seeking a safe place to pull over or being oblivious to the following police vehicle.  The Laser in fact slowed down as it turned into Florence Street at which point it suddenly accelerated, and it was only at that point that Constable Williams thought that the Laser was not going to stop.  It was only a brief time (approximately 6 seconds) from that point until the accident occurred.  I accept that in that short period no decision had been made by Constable Williams as to his possible future course of action and accept that he had formed no intention of seeking to detain the driver save for intercepting to conduct the random breath assessment. Although for a short period this might technically have been a police pursuit, at no time did Constable Williams exercise any control over Mr L. I also accept that given the short duration of the incident Constable Williams had no reason to believe that his actions might have initiated or contributed to Mr L’s decision to drive through the intersection and into the wall.

I conclude that Mr L had previously made a decision to commit suicide on the night of Sunday 25 July 2010.  He gave details of his intention in this regard to Ms Z and to Mr B. This intent is also confirmed by the general tenor of a letter that Mr L sent his sisters (which was received by them on Monday 26 July 2010) which was consistent with being a suicide note. I am unable to say why Mr L was unable to carry out his intention to gas himself in his motor vehicle, but unfortunately (and through no fault of the police officers involved) the attempt by the police to intercept him initiated his other claimed intention, that is to undo his seatbelt and crash his motor vehicle. I find that Mr L deliberately drove his motor vehicle into the wall with the intention of ending his life.

Comments and Recommendations:

It is indeed tragic that this man who had clearly verbalised an intention to commit suicide could not be dissuaded or stopped from that course of action.  His friend Ms Z and the police officers who escorted him to the Royal Hobart Hospital on 25 July 2010 were clearly concerned as to his safety. However he was able to modify his presentation so as to not be adversely assessed by staff at the Royal Hobart Hospital. I do not consider that advising police that Mr L had left Royal Hobart Hospital prior to being assessed by a medical officer would have made any material difference in this case. The police in the circumstances would have had no power to detain him as he at all times was a voluntary patient. In fact it was his stated intention to take action to end his life should he be approached by police. Mr L had clearly decided on a certain course of action and was determined to see it through.

I formally acknowledge that Ms W and more particularly Ms Z did all that they could reasonably have done to assist Mr L. So also did the police officers (Sergeant Burton, Constables McKenzie and Moore) who intervened and managed to persuade Mr L to attend at Royal Hobart Hospital on 25 July 2010.  I also formally determine that the actions of Constables Williams and Manning can in no way be said to have caused the fatal motor vehicle accident. They at all times were acting lawfully and had no way of knowing that Mr L would act in the manner that he did when they sought to intercept him. Any criticism of the actions of those involved in this unfortunate matter must be confined to Mr B who despite being a close friend of Mr L decided to take no action to alert authorities of Mr L’s intentions and more particularly his location at a time when there was at least a prospect of a successful intervention.

Before concluding this matter I wish to convey my sincere condolences to the family of Mr L.

DATED 23 September 2011 at Hobart in the State of Tasmania


Stephen Raymond Carey