Coroner's Finding: Nguyen, Van Tam

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INQUEST INTO THE DEATH OF VAN TAM NGUYEN [2025] SACC 34 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 was found with a knife in his chest while serving a sentence of imprisonment on home detention. The inquest explored the circumstances leading up to him being found by family members.

Held:

1. Van Tam Nguyen, aged 47 years of Parafield Gardens, died at Parafield Gardens on 14 December 2022 as a result of a stab wound to the chest.

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

No recommendations made.

Counsel Assisting: MS R SCHELL Hearing Date/s: 10/09/2025 Inquest No: 20/2025 File No/s: 3089/2022

This judgment contains discussion of suicide and may be distressing to some people There is always help available If you need support, contact Lifeline Australia Call 13 11 14 or Text 0477 13 11 14 or chat online at www.lifeline.org.au/crisis-chat Aboriginal & Torres Strait Islander Support Call 13YARN (13 92 76) Kids Helpline Call 1800 55 1800 MensLine Australia Call 1300 78 99 78

INQUEST INTO THE DEATH OF VAN TAM NGUYEN [2025] SACC 34 Introduction and background 1 Van Tam Nguyen was born on 2 January 1975.1 He commenced using heroin at the age of 20 years and methylamphetamine from 2010.2 He was married for about 30 years and had three children.3 Reason for inquest 2 In March 2020, Mr Nguyen was charged and taken into custody for seven counts of trafficking in controlled drugs, methylamphetamine and heroin.4 3 On 6 May 2021, a Judge of the District Court of South Australia imposed a sentence of 4 years, 6 months and 19 days imprisonment, backdated to March 2020.5 A non-parole period of 3 years, 7 months and 22 days was imposed. Mr Nguyen died while serving that sentence on home detention and his death was a death in custody. An inquest into his death was mandatory in accordance with Section 21 of the Coroners Act 2003.

Mr Nguyen’s incarceration and subsequent release on home detention 4 Mr Nguyen was admitted initially to the Adelaide Remand Centre, transferred to the Yatala Labour Prison on 24 March 2020, Mobilong Prison on 29 May 2020, then to the Cadell Training Centre on 12 October 2021 and to the Pre-Release Centre on 16 November 2021.6 While in custody he was prescribed methadone for opioid dependence withdrawal symptoms. He was also prescribed mirtazapine to assist with insomnia and to improve mood. He had some knee pain and swelling in his right knee due to bilaterial suprapatellar effusion for which he was provided medication and a compression bandage.7 5 On 28 November 2022, Mr Nguyen was released to serve the remainder of his sentence on home detention, living at Parafield Gardens with his wife, son and one of his daughters.8 He attended an intake appointment on 29 November 2022. He said that he was happy to be out of prison and able to spend time with his family.9 He was granted a regular passout to collect his methadone.10 That same day, Mr Nguyen contacted OARS Community Transitions, to which he had been referred for mental health and drug abuse support.11 1 Exhibit C13, page 4 2 Exhibit C13, page 10 3 Exhibit C13, page 10 4 Exhibit C13, page 4 5 Exhibit C13a, page 1; Exhibit C13, page 4 6 Exhibit C9 at [4], [6], [8] and [11]-[12] 7 Exhibit C9 8 Exhibit C3 at [2]; Exhibit C9 at [18] 9 Exhibit C8 at [7] 10 Exhibit C8 at [8] 11 Exhibit C8 at [7]

[2025] SACC 34 State Coroner Whittle 6 In early December 2022, Mr Nguyen was stung by a bee. Following that, he began complaining about being very tired with no energy, not being able to sleep and seeing ghosts when he did sleep.12 He would usually do the cooking but became too tired to do it after the bee sting.13 7 On 13 December 2022, Mr Nguyen attended at Department for Correctional Services (DCS) Community Corrections for an appointment with his supervisor.14 He was polite and presented well. He said that he had arranged for work to commence in the new year.

He requested passouts for 15, 16 and 19 December 2022 for various purposes. Nothing occurred which raised any concerns about Mr Nguyen’s mental health.15 The events of 14 December 2022 8 At about 11:30am on Wednesday, 14 December 2022, Mr Nguyen’s wife and daughter went shopping. At about 4:40pm, his wife called Mr Nguyen and told him that car repairs would cost $1,000 and they spoke about how expensive that was.16 9 Mr Nguyen’s son came home at about 5:20pm or 5:30pm, said hello to Mr Nguyen and then went to his room and played a computer game, using a headset which blocked all outside noise.17 10 Mr Nguyen’s wife and daughter arrived home at about 6pm.18 His wife saw Mr Nguyen sitting on the lounge in the shed and thought he was asleep. She approached him and saw that he had a knife in his chest.19 She called out to her daughter, who was unloading groceries from the car, to call an ambulance. She checked for signs of breathing and a pulse, finding neither.

11 Mr Nguyen’s daughter phoned triple zero but accidentally hung up, then immediately redialled. Mr Nyugen’s daughter also checked Mr Nguyen, finding his body a little bit warm but no signs of breathing.20 12 Paramedics were tasked to attend at 6:06pm,21 arriving at 6:12pm.22 Upon arrival, they were met at the gate by a young woman described as very upset and crying. One of the paramedics stated that she said, ‘Come in, my dad’s been stabbed by my mum’.23 The other described her words as ‘Come quick. My dad’s been stabbed by my mum’.24 Paramedics observed Mr Nguyen and said that upon their arrival, he was clearly deceased, with pale skin and pale lips.25 There was about 300mL of congealed blood on his chest.26 12 Exhibit C4 at [8] 13 Exhibit C4 at [19] 14 Exhibit C8 at [12] 15 Exhibit C8 at [14] 16 Exhibit C4 at [13] 17 Exhibit C3 at [7] 18 Exhibit C5 at [11] 19 Exhibit C4 at [15] 20 Exhibit C5 at [19] 21 Exhibit C6 at [4] 22 Exhibit C7 at [4] 23 Exhibit C7 at [4] 24 Exhibit C6 at [9] 25 Exhibit C6 at [16] 26 Exhibit C6 at [19]

[2025] SACC 34 State Coroner Whittle They put Mr Nguyen on the ground to assess him better but considered resuscitation was futile, given the location of the knife, apparently directly into Mr Nguyen’s heart.27 13 All members of Mr Nguyen’s family say that he never spoke about self-harm.28 Cause of death and involvement of others 14 A post-mortem examination was conducted by consultant senior forensic pathologist Associate Professor Neil Langlois, limited to the chest. Dr Langlois found a stab wound to the left side of the chest with the knife still in situ.29 It had entered between the 5th and 6th left ribs in the mid-clavicular line. The lateral edge of the upper lobe of the left lung had been punctured. The knife had entered the pericardial sac, punctured the lateral anterior apical wall of the left ventricle of the heart and travelled through, penetrating the posterior wall of the left ventricle. There was about two litres of blood within the chest cavity. Dr Langlois found no evidence of any other significant natural disease or other trauma. He concluded that Mr Nguyen’s death was as a result of a stab wound to the chest,30 which I find was the cause of death. Although Associate Professor Langlois could not rule out, on the basis of the post-mortem findings, that another person was involved, he stated, ‘The wound appeared in keeping with having been self-inflicted as the knife remained in the body and there was no evidence of “defence” type injuries’.31 15 At the inquest I received a statement32 from Mr Nguyen’s wife detailing, among other things, how she came home from shopping and found her husband on the sofa in the garage with the knife in his chest. She said she started crying a lot and yelled out to their daughter that something was wrong with her dad and she needed to call the ambulance, which arrived soon afterwards.

16 Mr Nguyen’s daughter provided a statement in which she described being called into the shed by her mother saying there was something wrong, within about 30 seconds of her mother going into the garage. She described calling the ambulance, frantic and confused.

17 A question arising for determination is whether any other person was involved, as the two paramedics reported Mr Nguyen’s daughter said that her dad had been stabbed by her mum.33 Having carefully considered all of the evidence, I am satisfied that if Mr Nguyen’s daughter said that, it was not what occurred.

18 The detective in charge of the investigation, Detective Brevet Sergeant Michaela Tiss, provided a detailed investigation report stating that when spoken to by police, witnesses were highly emotional and attending police considered that the statements to the attending paramedics about ‘mum stabbing dad’ may have been misheard or misinterpreted.

Mr Nguyen’s daughter was reported as having no memory of saying anything to that effect.34 27 Exhibit C6 at [24]; Exhibit C7 at [7] 28 Exhibit C3 at [14] 29 Exhibit C1a, page 1 30 Exhibit C1a, page 2 31 Exhibit C1a, page 3 32 Exhibit C4 33 Exhibit C6 and Exhibit C7 34 Exhibit C13

[2025] SACC 34 State Coroner Whittle 19 CCTV footage from a neighbouring house provides conclusive independent evidence in this regard. It shows Mr Nguyen’s wife and daughter arriving home at 6:03pm. The ambulance records show a triple zero call at 6:06pm,35 that is, within three minutes. When paramedics arrived, six minutes later at 6:12pm, Mr Tran was obviously dead, with what looked to paramedics like about 300mL of congealed blood on his chest and on the lounge underneath him. These are indicators that he had not died in recent moments.

20 I find that Mr Nguyen’s stab wound to the chest was self-inflicted and his wife was not involved his death. If his daughter was not misinterpreted and did express that her mother had stabbed her father, I am satisfied this was a product of her distress and confusion and did not reflect any knowledge on her part of what had occurred.

Conclusions 21 Mr Nguyen had been sentenced by the District Court to a period of imprisonment and, at the time of his death, was lawfully held in custody, in the form of home detention.

22 As to the care provided by Community Corrections who were supervising Mr Nguyen, there were never any concerns raised about his mental health. This is consistent with the evidence of Mr Nguyen’s family that he had never spoken of self-harm. Bearing in mind that he presented no outward mental health issues and in fact requested passouts for future activities in his last appointment, I conclude that there was nothing unreasonable or inappropriate about the supervision given to Mr Nguyen.

23 I find that Van Tam Nguyen, aged 47 years of Parafield Gardens, died at Parafield Gardens on 14 December 2022 as a result of a self-inflicted stab wound to the chest.

24 I make no recommendations.

Keywords: Death in Custody; Home Detention; Suicide 35 Exhibit C17