Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Glenn Hay, Coroner, have investigated the death of



I have decided not to hold a public inquest hearing into her death because my investigations have sufficiently disclosed the identity of Mrs M, the date, place, cause of death, relevant circumstances concerning how the death occurred and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999.  I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.


(a) Mrs M died at Unit 32 No. 32 Acton Crescent, Goodwood on 17 September 2011.

(b) Mrs M was born in Hobart, Tasmania on 10 January 1935.  At the time of her death she was aged 76 years. Mrs M was a divorced woman. 

(c) I find Mrs M’s cause of death was the combined effects of incised wounds of the wrist and nitrazepam intoxication. 

(d) I further find the wounds were self inflicted and the nitrazepam was ingested by Mrs M with the express intention of taking her own life.

Relevant Background Material:

Mrs M grew up in Goodwood as one of six (6) children.  When she was 22 she gave birth to her first child.  She then married.  They moved to South Australia where she resided with her husband for a period of approximately 20 years.

Whilst in South Australia she gave birth to her other children.  Mrs M’s marriage broke down in 1990.  She separated from her husband and moved to Hobart.  About ten (10) years ago she moved into a unit in where she has lived by herself ever since.

There is clear evidence Mrs M had been suffering depressive symptoms since about 1996.  During the years she has been prescribed a number of anti-depressant medications, although her willingness to take that medication varied during that time and she was also reluctant to take psychological counselling as advised by her medical practitioner. Her general health appeared to deteriorate after she was involved in a pedestrian accident in 1998. Mrs M was struck by a car which resulted in significant injuries being caused to her left leg.  She was hospitalised for a period of 5 weeks.  As a result of this Mrs M suffered deep depression and she was referred to a clinical psychologist, but attended only a few times as she felt she received no benefit.

In 2003 Mrs M was diagnosed with Laryngeal Carcinoma (throat cancer).  In 2005 she required hospitalisation for an obstruction in her throat.  She was at risk from aspiration from eating and drinking.  As a result of this a tracheostomy tube to afford vocalisation albeit in a husky tone and a percutaneous feeding gastrostomy tube (direct feeding tube into the stomach) were inserted.

As a result of the inserted tubes Mrs M avoided social interaction and found it very uncomfortable when she was in the presence of other persons.  People found it difficult to understand her husky voice.

Mrs M became increasingly depressed through her inability to socialise as well as eat and enjoy solid foods.

Mrs M consulted her general practitioner between 1994 and the date of her death.  On a number of occasions she requested physician assisted suicide and on at least two occasions requested he supply her with the drug Nembutal (a renowned euthanasia drug). It was her view that that this type of euthanasia should be legalised and be available to people such as herself.  Mrs M indicated to the doctor it was her desire to choose the time of her death and she wanted to die on her own terms having the means available to her in order to facilitate this.  The doctor refused her requests, explaining to her that he was opposed to physician assisted suicide.  I make no adverse finding or comment about his advice to her.  From his detailed medical notes it is clear he gave very appropriate caring advice and assistance to his patient over many years.

Mrs M mentioned suicide to family and friends on a number of occasions.  In May 2011 during her annual medical check she outlined to the doctor her frustrations and embarrassment with her poor communication skills, her declining vision and lack of mobility due to osteoarthritis. 

Mrs M’s children live on the mainland.  On Wednesday 14 September 2011 her daughter visited her for the day. Mrs M was excited about the opportunity to spend the day with her daughter.  Her daughter left to go to the airport about 8pm that night.  She rang her mother on the Thursday (15 September) and Friday (16 September).  On the Friday Mrs M seemed fed up with her life and ailing health.

The last person to see the deceased alive was her neighbour Barbara Clifford.  Barbara visited Mrs M on Friday 16 September when she appeared her normal self.  Mrs M was not again seen alive after 16 September.

Circumstances Surrounding Death:

Mrs M’s daughters decided to pay her a surprise visit on Monday 19 September 2011. They arrived at her unit at about 12.30pm.  There was no answer at the front door.  One of the daughter’s obtained the spare key to the unit which was contained in a jar in the back yard. 

The door was unlocked and they entered the unit and unfortunately they found their mother lying on the floor on her side.  It was plainly obvious that she was deceased.  Emergency services were immediately called and Tasmania Police attended.

Ambulance personnel attended and confirmed death and that she had been deceased for some time.  Mrs M was observed by police on the floor in a large pool of blood.  There were several deep cuts on both her wrists.  The bed had been moved towards the bedroom door.  There was also blood in the lounge room, bathroom and kitchen areas.  There was a blood stained pillow, water soaked book and razor blade in the bottom of the shower bay.  It appeared as if “the deceased” had been sitting in the shower a short time before death.

On the counter in the kitchen was a handwritten note.  The note was dated 17 September 2011, it was signed by Mrs M.  The note indicated an intention to take her own life as a result of her ailing health. Mrs M had taken the telephone from its cradle and had cleaned and turned the refrigerator off.

Toxicology testing found the presence of nitrazepam in her body in greater than therapeutic levels and at levels which may prove fatal in some individuals.  The State Forensic Pathologist conducted a post mortem examination and found that Mrs M died from the combined effects of incised wounds of the wrist and nitrazepam intoxication and that she most probably died from an incised wound to the left wrist where she cut her radial artery branch.  I accept those opinions.

Findings and Comments: 

I am satisfied that a full and detailed police investigation has taken place concerning the circumstances surrounding this death. I am satisfied there are no suspicious circumstances.  I further find Mrs M acted alone in consequence of an express desire on her part to take her own life.  It is clear that she planned her death.  It is also clear that from the blood stains in the house that she took initial action in the lounge room, moving to the kitchen where she has attempted to clean up some of the blood by using a bucket and towels.  She has then moved to the bathroom and eventually to the bedroom where she died.

I have concluded the note I referred to above was written by Mrs M on 17 September 2011.  The note in my view should be regarded as a suicide note.

I have further concluded that on 17 September 2011 Mrs M ingested a greater than therapeutic quantity of the drug known as Nitrazepam.  Nitrazepam is a benzodiazepine with anxiolytic, sedative, muscle relaxant and anti-convulsant effects.  The drug is used to treat insomnia.  At some stage, more likely than not after having ingested the drug, Mrs M has cut her left wrist. 

I find Mrs M acted in the manner in which she did in direct consequence of an express desire on her part to bring about her death.  Her health including her mobility was ailing.  She had indicated to other persons an intention to take her own life.  It is sad she chose to do it in a way which did not permit her to pass away calmly and peacefully.

In closing I wish to express my sincere condolences to Mrs M’s family and friends, and especially to her daughters who unfortunately discovered their mother on 19 September.

DATED: 11th May 2012 at Hobart in the State of Tasmania.

Glenn Hay