Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Robert Pearce, Coroner, having investigated the death of

Mr S.

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

Find that :

(a) Mr S died in March 2011 at Corrina;

(b) Mr S  was aged 66 years;

(c) Mr S died following ingestion of the drugs Temazepam and Sertraline, which most likely in combination with the effect of heart disease, led to his death in a manner that cannot now be precisely determined;

(d) No other person contributed to his death.

Circumstances Surrounding the Death :

Mr S, a retired teacher, lived at Burnie with his wife.  In March 2011 Mrs S became concerned when her husband left home at about 10.30 am and did not return.  She notified her family and the police.  Mr S had a history of suffering from depression and they were concerned for his welfare.  Mr S’ son, who lives in Victoria but had travelled to Tasmania, prepared an email poster and photo of his father and his car.  It was circulated to places they thought he might have gone.

During the evening of the following day, 30 March 2011, Mr S’s car was seen at Corinna in western Tasmania in the car park of a nearby wildlife park.  The manager and an employee of the park found Mr S lying on the ground next to the open driver’s door of the car.  He was alive but he was cold and his breathing was irregular and shallow and a pulse could not be located.  Resuscitation measures were undertaken and an ambulance called.  However Mr S’s condition deteriorated and he was dead by the time the ambulance arrived.

A post mortem examination revealed no injury or disease that would account for his death except that he had ischaemic heart disease involving 50% stenosis of the coronary artery.  Subsequent analysis disclosed the presence of Temazepam, a benzodiazepine used in the treatment of anxiety disorders, and Sertraline, an anti depressant agent.  Temazepam was present in a high therapeutic concentration.

I sought advice from the Director of Statewide Forensic Medical Services, Dr Christopher Lawrence, about the cause of Mr S’s death.  According to Dr Lawrence:

  • it is unusual to see a death caused predominantly by Temazepam, the only drug present in high concentration;
  • generally the coronary artery disease from which Mr S suffered would not, on its own, have caused his death;
  • Mr S may in some undetermined way been exposed to car exhaust although there is no evidence from the scene or the vehicle of how this may have occurred;
  • Mr S may somehow, before falling to the ground, have been in a position that resulted in asphyxia, although this is unlikely;
  • there were no physical signs typically found after the development of hypothermia;
  • the most likely cause is the combined effects of a mixed drug toxicity, arising from the presence of Temazepam and Sertraline, and ischaemic heart disease.

Some circumstances suggest the possibility that Mr S may have deliberately taken his own life.  He had a history of depression and had made previous attempts.  However the evidence of his death does not support such a finding.  His manner when seen by his pharmacist on the previous day was unremarkable, there was no note or other recent suggestion of such an intention, and the nature and quantity of the drugs he ingested did not suggest a concerted effort at self harm.  The door of his car was open when he was found.

I do not consider that a public inquest is likely to elicit any further facts relevant to the issues I am required to determine.  For those reasons I have decided not to hold an inquest.

Comments & Recommendations :

I see no need to make any formal comment or recommendation.

I convey my condolences to Mr S’s family.

DATED:  7 November 2011 at Launceston in Tasmania

Robert Pearce