Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Christopher P. Webster, Coroner, have investigated the death of

Blake Marcus NEWTON


I have decided not to hold a public inquest hearing into his death because my investigations have sufficiently disclosed the identity of Mr Newton, the time, place, cause of death, relevant circumstances concerning how his death occurred and the particulars needed to register his 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.

I Find:

a) Blake Marcus Newton (Mr Newton) was born in Launceston in Tasmania on 27 February 1938 and was aged 73 years at the time of his death.   Mr Newton was married with three adult children and his occupation was a retired manager. 

b) Mr Newton died on or about 18 June 2011 at an area known as the Waterworks Reserve in South Hobart.

c) I find that Mr Newton died due to environmental cold exposure (hypothermia).   A significant contributing factor was Alzheimer’s dementia.


Following his retirement, Mr Newton experienced progressive cognitive decline over the last ten years of his life.   The decline initially manifested as a language disorder that was followed by a progression of cognitive decline.  Over several years, his decline was clinically variously classified as ‘frontotemporal dementia’ syndrome and ‘sematic dementia’.  Extensive neuropsychological testing and neuroimaging studies failed to definitively classify his form of progressive dementia.   His progressive dementia was similar to Alzheimer’s disease but manifesting as major speech disorder in the first instance. 

In the last couple of years, as a result of progression of his language disorder, Mr Newton was mute.   Obsessive and repetitious behavioural changes were also evident and to a lesser extent memory decline.   Mr Newton’s condition was managed by his general practitioner, specialist geriatrician and the devoted care of his wife and family.

Circumstances Surrounding the Death:

Mr Newton would routinely (on an almost daily basis) go for walks for around two hours, largely around the Sandy Bay and Waterworks Reserve area.  In evidence provided to this investigation, Mr Newton had not previously had any significant problems with disorientation or getting lost on his walks and he tended to take a specified route. 

Just prior to midday on Saturday 18 June 2011, Mr Newton left his home to undertake his walk.   His wife was of the understanding he was going to the Waterworks Reserve.  Mr Newton’s family became concerned that he had not returned home by mid afternoon.   They attended the Waterworks Reserve and on failing to locate Mr Newton contacted Tasmania Police concerned for his welfare. 

A missing person investigation was immediately coordinated by Tasmania Police.  By late afternoon, an extensive search plan was initiated involving over 50 members.  This included deployment of members of Tasmania Police Search and Rescue and State Emergency Service (SES).   The rescue helicopter was also deployed and the media released information for public assistance.   The focal point was the Waterworks Reserve, surrounding properties and the Sandy Bay area.

The temperatures overnight in the Waterworks Reserve were recorded as low as 2 degrees Celsius, with frost and ice at ground level.  

The search operation continued on Sunday 19 June 2011 and Monday 20 June 2011.  The operation involved extensive police resources and additional experienced volunteers from walking clubs. 

Shortly after midday on Monday 20 June 2011, a search was being conducted of the tree line area approximately 200 metres behind properties with frontage to Waterworks Road, South Hobart.    Mr Newton’s body was located partially concealed by a tree.  There were no suspicious circumstances.

A post-mortem examination was conducted by Forensic Pathologist, Dr Donald Ritchey.  Dr Ritchey determined the cause of Mr Newton’s death as environmental cold exposure (hypothermia).   A significant contributing factor was Alzheimer’s dementia. 

Dr Ritchey reported that hyperthermia occurs when the core body temperature falls sufficiently low for homeostatic mechanism to fail.   Hypothermic individuals often become delirious and engage in ‘burrowing behaviour’ and frequently undress (a condition called paradoxical undressing).  In Dr Ritchey’s opinion, Mr Newton likely died on the day that he went missing despite that his body was not discovered for an additional two days. 

On finding Mr Newton’s body, investigating police also documented observations that are consistent with both burrowing behaviour and paradoxical undressing as reported by Dr Ritchey. 

Findings, Comments and Recommendations:

In considering Mr Newton’s declining cognitive ability, especially in the weeks prior to his death, I find that it is likely that Mr Newton has become disoriented and lost in previously familiar surroundings whilst undertaking his routine walk.   In a state of confusion, due to his language disorder, Mr Newton would have been unable to call out for assistance.   Mr Newton’s survivability assessment in cold weather conditions would be dire. 

I acknowledge that Mr Newton’s family have raised their concern for his welfare at the earliest possible opportunity.   I am satisfied that the response by Tasmania Police, including search coordination, was timely and appropriate.   Unfortunately, despite all efforts, Mr Newton who was significantly impacted by his cognitive condition has succumbed in the environmental conditions presented at the time.  

I wish to highlight that it was not foreseen in this case that Mr Newton was at risk of going missing.  In fact, Mr Newton went for long walks as a daily activity and had no previous significant issues.   However, GPS tracking technology may have application and potential benefit for individuals facing similar cognitive decline and could be considered by families and health care professionals in consultation with the individual on a case by case basis.

I conclude by conveying my sincere condolences Mr Newton’s family.

DATED: 13 April 2012 at Hobart in the State of Tasmania.


Christopher P Webster