Coroner's Finding: Gifford, Paul Douglas

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INQUEST INTO THE DEATH OF PAUL DOUGLAS GIFFORD [2025] SACC 33 Inquest Findings of his Honour State Coroner Whittle 27 November 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a man who took his own life while subject to home detention bail. The inquest explored the adequacy of the support provided by the Department for Correctional Services.

Held:

1. Paul Douglas Gifford, aged 36 years of OB Flat, died at OB Flat on 16 May 2021 as a result of acute neck compression due to hanging.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR M KIRBY Hearing Date/s: 24/10/2024 Inquest No: 37/2024 File No/s: 0983/2021

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INQUEST INTO THE DEATH OF PAUL DOUGLAS GIFFORD [2025] SACC 33 Introduction and cause of death 1 Mr Paul Douglas Gifford was born on 1 March 1985 and died on 16 May 2021 at the age of 36 years.

2 Mr Gifford was found at his home address in OB Flat, near Mt Gambier, hanging by a rope from a tree in the front yard. A post-mortem examination by Dr Cheryl Charlwood, a senior consultant forensic pathologist from Forensic Science SA, confirmed the cause of death as acute neck compression due to hanging.1 3 There were no physical signs or other injury that might suggest any other person was involved in Mr Gifford’s hanging. An injury to the area underneath his chin was apparently caused when he was cut down from his suspended position, striking his chin on another part of the tree.

4 A toxicological analysis of Mr Gifford’s blood revealed the presence of methylamphetamine, amphetamine, and buprenorphine.2 Dr Charlwood opined that the presence of methylamphetamine was not a direct factor in the cause of death, but it may have had some bearing on Mr Gifford’s judgment and mental state at the time of his death.

5 There are no suspicious circumstances surrounding his death.

Reason for inquest 6 At the time of his death Mr Gifford was subject to home detention bail, having been charged with offences relating to drugs trafficking and firearms possession.3 7 As a person subject to home detention bail, Mr Gifford’s death is a death in custody and a reportable death pursuant to section 3(1) of the Coroners Act 2003. As a death in custody, an inquest is mandatory pursuant to section 21(1)(a) of the Act.

8 There are no questions over the lawfulness of the bail agreement or his custody status.

Medical history 9 At the time of his death Mr Gifford was in remission from non-Hodgkin’s lymphoma which was diagnosed in 2015.4 His previous medical and mental health history included a diagnosis of borderline personality disorder and drug induced psychosis. Over the years he also received treatment for drug dependence, depression and anxiety.

10 Mr Gifford’s life was also punctuated with traumatic experiences and difficulties with the law, leading to several convictions and periods of incarceration over the course of his life.

1 Exhibits C2, C2a 2 Exhibits C3, C3a 3 Exhibit C7, annexure PG2 4 Exhibit C9

[2025] SACC 33 State Coroner Whittle 11 In 1998, when he was 13 years old, Mr Gifford was allegedly the victim of sexual abuse by the friend of his biological father. The abuse was never reported to police so no investigation was ever held into the matter.5 It was only disclosed many years later to mental health clinicians.

12 In 2000 he commenced using cannabis, which soon became a daily feature of his life. He progressed to using methylamphetamines on a regular basis in 2003, which developed into an ongoing addiction with daily use.6 13 In 2006 Mr Gifford was imprisoned for the first time, after being convicted of aggravated serious criminal trespass and aggravated robbery. Later in 2006 he was admitted to the Mount Gambier Hospital following a suspected suicide attempt by drug overdose.7 14 In February 2008 Mr Gifford was taken to the Mount Gambier Hospital by police, suffering from what was suspected to be drug induced psychosis. Prior to this, in January 2008, he had attended the Ferrers Medical Clinic in Mount Gambier with his mother, seeking referral to the Mental Health Team. Mr Gifford was reportedly having issues with anger management, depression, mood swings, lack of interests and negative thoughts.8 15 In September 2010, Mr Gifford was assessed by clinical forensic psychologist, Dr Marie O’Neill, following his conviction for aggravated robbery. In a report prepared for the District Court of South Australia,9 Dr O’Neill outlined Mr Gifford’s personal and mental health history. She identified areas of childhood trauma, including the sexual abuse, bullying at school and family separation. Testing conducted in this assessment showed Mr Gifford had elevated levels of anxiety and depression, and that he often felt worthless.

It was noted that he had been abusing alcohol and illicit drugs and had been referred for some services which were reportedly difficult to access in Mount Gambier, where he was living at the time.

16 In November 2011, a psychological report was prepared by forensic psychologist, Mr Richard Balfour, once again for use in court proceedings. Mr Balfour noted an extensive history of drug misuse and childhood trauma, including paternal abandonment and violence, paternal mental illness, and physical and sexual abuse. Mr Balfour also noted a history of high lethality suicide attempts in the past.10 17 In June 2015, Mr Gifford was first registered with Drug and Alcohol Services South Australia (DASSA) in Mount Gambier. His registration came about after his release from custody onto home detention bail, following referral by his mother in relation to heroin use. He failed to attend any further appointments after the initial appointment to assess his suitability for the Suboxone program.11 He was subsequently discharged from the service.

5 Exhibit C6 6 Ibid 7 Ibi 8 Exhibit C9 9 Exhibit C6, Annexure AMS1 10 Exhibit C6, annexure AMS2 11 Exhibit C8

[2025] SACC 33 State Coroner Whittle 18 Also in June 2015, Mr Gifford sought a mental health review through Ferrers Medical Clinic. He was provided a K10 depression scale form to complete, however never returned to complete the care plan.12 At this time Mr Gifford had recently been released from prison following his cancer diagnosis and chemotherapy treatment.

19 In July 2018, Mr Gifford referred himself to DASSA to be assessed for the Medication Assisted Treatment for Opioid Dependence (MATOD) program. He engaged with the program, and his general practitioner was authorised to prescribe methadone or buprenorphine through to September 2019. In October 2019 his engagement with DASSA ended because of his incarceration.13 20 In March 2021, Mr Gifford was again referred to DASSA at Mount Gambier by his Department for Correctional Services (DCS) case manager, Leonie Wookie. He engaged with DASSA on several occasions over the next month, and on 23 April 2021 he attended for his fifth day of Suboxone stabilisation. Further prescriptions were provided to Mr Gifford’s pharmacist, however Mr Gifford did not attend DASSA again after that date. When first referred, Mr Gifford’s clinical opiate withdrawal scale (COWS) score was 0. Over the course of his stabilisation period his score increased to 12 but had started to reduce again by the fifth day.14 21 In March 2021 Mr Gifford completed the K10 assessment receiving a score of 35/50.15 His general practitioner, Dr Tamminedi, described this as showing moderate symptoms of depression and anxiety. Mr Gifford was referred to a local social worker with psychology training, Liz Moriarty. At this appointment Dr Tamminedi observed nothing to suggest Mr Gifford was at risk of suicide, and they planned further assessments and treatment, including changes to medication.16 A mental health care plan had been put in place and Mr Gifford appeared happy with what was planned. Dr Tamminedi was later advised that, although contact was made, Ms Moriarty had no consultations with Mr Gifford prior to his death.

Recent background 22 Mr Gifford had been in an on and off relationship with Amy Hodgson since 2015.

Immediately before that he had been incarcerated for criminal offending but was released to serve his sentence on home detention following his cancer diagnosis.17 23 On 31 August 2020, Mr Gifford was arrested after police located him apparently drug affected in a vehicle at the On the Run service station at Smithfield. A search of his vehicle had allegedly revealed quantities of methylamphetamines, buprenorphine and fantasy, along with cash and scales. He was charged with drugs trafficking offences and remanded in custody. Further drug paraphernalia and drugs were allegedly located at his home address in Craigmore, along with an air rifle. He was released from custody onto home detention bail on 7 September 2020, to reside at his address in Craigmore.18 12 Ibid 13 Ibid 14 Ibid 15 Exhibit C9 16 Ibid 17 Exhibit C4a 18 Exhibit C21a

[2025] SACC 33 State Coroner Whittle 24 On 15 September 2020, Mr Gifford allegedly breached his home detention conditions by absconding from his bail address. The next day he presented to the Lyell McEwin Hospital where he was detained upon an Inpatient Treatment Order (ITO) under the Mental Health Act 2009, with suspected drug induced psychosis. Upon the expiry of the ITO, Mr Gifford was released into police custody and detained at the Port Augusta Prison.

He was again released on home detention bail on 4 March 2021, to reside at his parents’ property at Childs Road, OB Flat.19 25 The OB Flat residence was a large property with shedding and an old church building which was being renovated to live in. Mr Gifford was helping with these renovations but, given its distance from the main house, he required a pass from his correctional services officer, Ms Wookie, to attend the building.

26 Although Mr Gifford’s mother, Anna Spehr, stated that Ms Wookie was obstructive with granting passes, DCS records show that Mr Gifford was granted passes on most occasions when requested. Ms Wookie’s affidavit reveals there was one occasion on 9 April 2021 when a pass to the old church was refused, but this occurred while the suitability of that location was still being assessed. Once the premises had been assessed as suitable, passes were not refused.

27 In my assessment there are no deficiencies with how Mr Gifford was dealt with by DCS.

They assisted him to access services he requested and dealt with his requests for leave appropriately. Special arrangements were made for reporting given the remoteness of his address so that he was not compelled to travel for reporting appointments unnecessarily frequently, allowing for telephone appointments.

28 Mr Gifford’s partner, Amy Hodgson, was staying at the OB Flat address as well, with her belongings in the old church and not in the house. She was spending nights with Mr Gifford. She had recently been approved for a private rental elsewhere and the two had agreed that he would move in with her. Mr Gifford had applied to vary his bail to permit this, but he died before the hearing of the application.

29 Mr Gifford’s relationship with Ms Hodgson was sometimes troubled. Ms Hodgson said they had been doing well but struggled with substance abuse together. Ms Hodgson told police she had begun speaking to Mr Gifford about whether it was a good idea to move in together.

30 Mr Gifford’s mother had a very poor view of the relationship with Ms Hodgson, describing it as toxic.

31 Ms Hodgson admitted to police that she and Mr Gifford used drugs on 15 May 2021, including methylamphetamine that she had sourced for them. Text messages from Mr Gifford’s phone indicated he supported her in this endeavour. No charges are proceeding against her regarding the supply of these drugs. Together they used the methylamphetamine that Ms Hodgson obtained, and Suboxone that Mr Gifford was prescribed.

32 Mr Gifford was experiencing continuing issues with his mental health, drug misuse, and his relationship. It is also clear that professional services were made available to him by 19 Exhibit C7

[2025] SACC 33 State Coroner Whittle his treating medical practitioners, his DCS case manager and his family, but his engagement and commitment to these services was inconsistent.

Mr Gifford’s death 33 At the time of his death, Mr Gifford’s mother and father were not home, having been on holiday in Queensland. They had returned to Adelaide but had not yet travelled back to OB Flat.

34 Ms Hodgson was the last to see Mr Gifford alive. They had been doing well staying off drugs until using drugs together on 15 May 2021. The next day, Mr Gifford began to exhibit strange behaviours. He texted Ms Hodgson in the morning and asked her to go to the old church to look for a SIM card. He then sent her to remove a rope that was hanging from a roof beam in a shed behind the old church, because he did not want his grandmother to find it. Ms Hodgson removed this and put it in her car. They did not talk about why the rope was there. Ms Hodgson knew there had been periods of depression in the past but did not believe Mr Gifford was at risk of self-harm.

35 Later in the day they discussed moving in together, which led to an argument.

Ms Hodgson stated that she felt someone was messing with her head, possibly because of the drugs they had taken. Ms Hodgson told Mr Gifford it might be a good idea for her to be by herself for a while to get her head together. She took off her engagement ring and left it on the table.

36 Later during text or Facebook communications, Ms Hodgson went looking for Mr Gifford and found him in the front yard standing up with a pink rope around his neck tied to a tree branch, leaning forward, strangling himself. He was still responsive, and she struggled with him to get him to stop. Eventually he assisted her to remove the rope from his neck.

She cut this piece of rope into small sections so it could not be used again. She felt that the crisis had passed and that Mr Gifford was not in danger of doing anything else.

37 Ms Hodgson spent a lot of that day delivering furniture to her new premises, going back and forth between the church and the house. She was at the church later that day communicating with Mr Gifford via Facebook and returned to the house as it was dark and she could not find Mr Gifford.

38 At 5:15pm on 16 May 2021, Mr Gifford sent a text message to Ms Hodgson, showing a picture of a pink rope tied to a tree. In the message he professed his love for her and said that now she was gone he had nothing and nobody. He explained his actions and said goodbye to her.

39 Ms Hodgson took a torch and went looking for him outside and found Mr Gifford hanging from the same tree as earlier in the day, but this time he was unresponsive. She called her mother who called an ambulance. Ambulance and police officers who attended noted Ms Hodgson was in a very distressed state.

40 Mr Gifford was certified life extinct at 6:25pm on 16 May 2021.

Conclusions 41 Mr Gifford was a man who struggled with poor mental health and substance abuse. He was a child sexual abuse survivor. He was in and out of prison. He was facing criminal

[2025] SACC 33 State Coroner Whittle proceedings for further alleged serious offending, and he did not want to return to prison, which appeared to be a likely outcome.

42 His engagement with services seems to have fluctuated over the years but appropriate care and treatment was made available to him. DCS provided him access to services for drug and alcohol support, and his general practitioner appropriately referred him to mental health support services.

43 Whilst on home detention bail, after a period of abstinence, Mr Gifford resumed drug use, in breach of his strict conditions of bail, following which there was a crisis in his relationship leading to apparent abandonment of a plan to move in with Ms Hodgson. In the wake of that, he threatened and then attempted suicide, which was prevented by Ms Hodgson. Sadly, when Ms Hodgson thought the crisis had passed, Mr Gifford succeeded in taking his own life.

44 I find that Mr Gifford was a person in lawful custody at the time of his death, being a person on home detention bail.

45 I find that Mr Gifford received appropriate care and assistance from the Department for Correctional Services in relation to his mental and physical health, and his drug misuse issues.

46 I make no recommendations.

Keywords: Death in Custody; Home Detention Bail; Suicide