Coroner's Finding: Tanti, Greg Anthony

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INQUEST INTO THE DEATH OF GREG ANTHONY TANTI [2025] SACC 5 Inquest Findings of her Honour Coroner Giles 31 March 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a 43-year-old man who took his own life in 2021.

The inquest examined the treatment provided at Noarlunga Hospital and by the Department for Correctional Services in the lead up to death.

Held:

1. Greg Anthony Tanti, aged 43 years of Huntfield Heights, died at Huntfield Heights on 19 September 2021 as a result of compression of the neck in keeping with hanging.

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

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 28/02/2025 Inquest No: 03/2025 File No/s: 2014/2021

11 12 13 14 15 16 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 GREG ANTHONY TANTI [2025] SACC 5 Introduction and cause of death Mr Tanti was born on 1 September 1978 in Victoria and died on 19 September 2021 at the age of 43 years.

Dr Neil Langlois, consultant forensic pathologist at Forensic Science South Australia, conducted an external examination with CT scan and toxicology, from which he concluded Mr Tanti’s cause of death was ‘compression of the neck in keeping with hanging’.1 I so find. Analysis of Mr Tanti’s blood revealed the presence of cannabinoids.

Reason for inquest At the time of his death Mr Tanti was on a court-ordered home detention sentence which had been imposed on 13 September 2021.2 Thus, this was a death in custody requiring a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

Background and medical history Mr Tanti’s father William emigrated to Australia from Malta. His mother Theresa is of Maltese background and was born in Australia.

Mr Tanti was the second of four children. He had an older sister and a younger brother and sister. The family relocated to Adelaide in the 1980s.

Mr Tanti suffered from seizures and was diagnosed with epilepsy at age 13, for which he was prescribed sodium valproate.3 He began illicit drug use as a teenager, and this continued throughout his life.

Mr Tanti was a self-employed tiler. He had previously worked as a fibreglasser, a crash repairer at the Mitsubishi factory, and in the mines at Roxby Downs.

Mr Tanti was married in 2002 and had two sons born in 2002 and 2005. During the marriage Mr Tanti had attempted to hang himself.4 In about 2008 the marriage broke down.

Mr Tanti reportedly suffered from anxiety and depression but chose not to take medication due to concerns about mixing it with his epilepsy medication.

In 2014 Mr Tanti had a seizure whilst driving and crashed into a stobie pole. This resulted in a stay in an intensive care unit.5 Following this accident he had to declare bankruptcy 1 Exhibit C2 2 Exhibit C21a 3 Exhibit C8 at [9] 4 Exhibit C8 at [13]; Exhibit C1 at [8] 5 Exhibit C8 at [10]

[2025] SACC 5 Coroner Giles as he was unable to pay the substantial loan on the vehicle, as well as the fees for the ambulance and the stobie pole.

Mr Tanti was detected drug driving on 26 March 2018 and 28 April 2018.6 In early 2021 Mr Tanti commenced a relationship with Jessica Priest. Ms Priest described the relationship as on-again off-again.7 There was some drug use in the relationship and Mr Tanti was charged with driving unauthorised following a drug driving disqualification on 5 January 2021.

In about April 2021, Mr Tanti suffered a seizure and knocked his head while at work. He refused to go to hospital in an ambulance as he had no insurance. His sister was called, and she drove him to the Emergency Department herself.8 While at the hospital, Mr Tanti started to get aggressive and chose to leave the hospital.

Mr Tanti moved out of his parents’ house on 3 June 20219 and began sleeping in his car.

He then spent some time couch surfing. Mr Tanti befriended Jason Gallas, who allowed him to move into his unit at Huntfield Heights.

Supervision by the Department for Correctional Services On 17 June 2021 Mr Tanti was arrested in respect of another charge of driving unauthorised following a drug driving disqualification. He was granted supervised bail later that day.10 This was the first time he had ever been supervised by the Department for Correctional Services.

On 18 June 2021 Mr Tanti presented to the Noarlunga Community Correctional Centre for an intake interview for his supervision.11 During that meeting he said that his problems commenced 11 years earlier when he separated from his wife and lost contact with his boys. He said they had since reconnected. He stated that his car and tools were impounded, and he needed to pay $500 for a drug test to get his licence. He said that without his tools and car, he could not work to get the money for the test. He felt he was in a vicious cycle. His corrections officer noted that he ‘was visibly distress[ed], nearly crying and breathing fast’. He was referred to the Offenders Aid and Rehabilitation Service (OARS).

On 5 July 2021 his corrections officer was advised by OARS: ‘He scored extremely high in his mental health screening due to having no fixed address.’ 6 Exhibit C21 7 Exhibit C7 at [3] 8 Exhibit C1 at [3] 9 Exhibit C1 at [5] 10 Exhibit C11 at [4] 11 Exhibit C11 at [5]

[2025] SACC 5 Coroner Giles A further email from OARS on 30 July 2021 said: ‘Nothing appears easy for Greg at the moment, I will continue to work with him on his drug issues.’12 Admission to hospital in August 2019 On 3 August 2019 a friend of Mr Tanti’s called SAPOL, reporting that Mr Tanti had abandoned his car, dog and belongings. SAPOL officers located the car and phone, which contained a text message Mr Tanti had sent to one of his sons saying: ‘I want you to always remember that I love you and your brother with all my heart and everything that I am. You boys are my world … no matter what you hear or anyone says I always will and have loved you …’13 Mr Tanti was then located by SAPOL officers in a park. He was taken to the Noarlunga Hospital by SA Ambulance officers who had detained him under a care and control order after they arrived to find him restrained by SAPOL. He denied any overdose.

Mr Tanti presented to the triage nurse at 3:44pm. He was accompanied by two mentors.

He reported that he had had an argument with his son the day prior which made him teary and frustrated. He then woke up on that morning and realised he had not been paid. He called the bank who were unhelpful. He said he felt as if this was the straw that broke the camel’s back. He did not know how to cope, so he went out to source drugs. He had sent messages to his support worker and family, telling them that he no longer needed his belongings, and a missing person’s report was made. On the way to see his drug dealer he changed his mind and rang his mentor, Dan.

Dr Malgosia Kowalski recorded the following in the medical notes: ‘Patient admits to suicidal thought Denies that he had any suicidal intention when he sent his messages Messages intent was that he was “walking away” from everything Denies any active suicidal plans Protective factors - sons and letting Dan down … Feels safe in contacting Dan if any troubles Has DASSA appointment with psychologist in 2 weeks Collateral from Dan: Has organisation called “Second Chances” - is Greg’s mentor but initially met him as a friend Feels as if messages were a suicide note - but confident that patient has not used drugs and has no current suicidal intent Has safeguarded him by referring for suicidal counselling Has reiterated hotlines/contacts that he can contact if feeling unsafe Verbal agreement with Greg that he will not let him down Will accompany Greg home.’14 12 Exhibit C23 13 Exhibit C21, pages 15-16 14 Exhibit C26

[2025] SACC 5 Coroner Giles Dr Kowalski concluded that this was a situational crisis and Mr Tanti had good supports in place. Dr Kowalski lifted the care and control order, discharging Mr Tanti home with his mentor at 5:51pm, with a plan for him to follow-up with Drug and Alcohol Services South Australia (DASSA) in two weeks. In all of the circumstances, I find the decision to discharge Mr Tanti at this time was reasonable.

Admission to hospital on 12 September 2021 In the early hours of 12 September 2021, SAPOL responded to a 000 call from Jason Gallas, Mr Tanti’s housemate, in relation to an argument he had had with Mr Tanti.

Mr Gallas told SAPOL officers that Mr Tanti had threatened to ‘rip his head off’.15 Mr Gallas said that Mr Tanti was dangerous when he had been drinking and taking drugs.

SAPOL took Mr Gallas to his father’s house and told him to contact Corrections about having Mr Tanti moved to another address. They returned to the unit to speak to Mr Tanti who said everything was fine.16 Later that afternoon, Ms Priest called 000. She said that Mr Tanti had sent photos of pills in a bowl saying, ‘I’ve had enough, I’m going to take this’. Mr Gallas also called SAPOL.

Police attended at Mr Tanti’s house and Ms Priest was present. She smashed a window and entered the property. Mr Tanti was lying in his bed. He was difficult to wake. There was a small knife within arm’s reach which was removed.17 Mr Tanti had froth around his mouth.18 He said that he was fine and he promised Ms Priest that he had not taken anything.19 He said that he had wanted to end his life, but had had second thoughts and had thrown the medication away.20 Paramedics attended and detained Mr Tanti for a mental health assessment.

Mr Tanti was taken to the Noarlunga Hospital by SA Ambulance on 12 September 2021 where he was triaged at 3:04pm. He was seen by Dr Gabrielle Mond. Dr Mond recorded the following history, inter alia, at 4:11pm: ‘Last night got into an argument with friend (didn’t want to disclose details), then emptied his blister pack of sodium valproate and paracetamol into a Tupperware container and went for a walk along the river. He sent a photo of the tablets to his friend and said he was going to kill himself.

He states he did not take the medications but threw them all into the water, and he was just telling his friend this for attention … Denies feeling suicidal … Denies any previous suicide attempts/self-harm Adamant that he is not feeling suicidal and this was all situational which has now resolved Has a partner, Jess, who he feels is supportive Wants to go home and go to sleep.’21 15 Exhibit C13 at [6] 16 Exhibit C13 at [9] 17 Exhibit C15 at [8] 18 Exhibit C6 at [13] 19 Exhibit C7 at [6] 20 Exhibit C15 at [10], [13]; Exhibit C14 at [10] 21 Exhibit C26

[2025] SACC 5 Coroner Giles Dr Mond recorded: ‘Contacted Jess (partner), with his consent; states that she has not known Greg for long.

Confirmed the above story and that Greg denied the overdose to her. She contacted the police after receiving the text with the photo and as she was unable to get into his house.

States he has been under increased stress recently, particularly as he has a court hearing tomorrow. Unsure about his past psychiatric history but states he had been down recently.

Doesn’t recall any previous suicide attempts. She feels that keeping him in hospital would “do more harm” as he hates being in hospital.’ Dr Mond concluded: ‘No ground to ITO - has capacity and denying any suicidal ideation. D/w mental health nurse Jess who has provided mental health resources.’ Dr Mond ordered blood tests, including for paracetamol, and an ECG. The blood sample was taken at 4:07pm. She set the plan: ‘If above NAD - home with OP mental health support. Given Mental Health Services emergency phoneline, walk in centre info. Advised to make GP appointment for mental health care plan.’ At 5:49pm Dr Mond took a set of observations. At 6:08pm the paracetamol result was returned with a low result, below normal use. Mr Tanti was then discharged at 6:20pm.

Dr Mond recorded a diagnosis of ‘organic mood [affective] disorder, unspecified’.

In light of the circumstances, in particular Mr Tanti’s denial of suicidal ideation and his assertion that he had not in fact taken the medication, Dr Mond’s decision to discharge at this time in accordance with the abovementioned plan was reasonable. I do observe that his denial of previous suicide attempts could have quickly been established to be misleading, as the 3 August 2019 records would have been easily accessible given the presentation was at the same hospital. However, Mr Tanti’s partner did provide information that she did not recall any previous suicide attempts. It is also noteworthy that Dr Mond did not actually discharge Mr Tanti until she had received the test result for paracetamol, which showed a very low level, consistent with Mr Tanti’s account that he had not taken the pills shown in the messages.

The following morning on 13 September 2021, a consultant, Dr Damian Townsend, rang Mr Tanti for a welfare follow-up. Dr Townsend made the following record: ‘History noted Rang Greg this morning Feels well Not drowsy or flat I note is on valpro which wasn’t known at time Denies any thoughts of suicide or self-harm, feels well in mental state and in self Remorseful and regretful of picture sent I would expect clinical syndrome if valpro toxic (drowsiness-->coma) However pertinent to check level Added on. I will chase

[2025] SACC 5 Coroner Giles Still has valpro to take for regular dose for epilepsy management Has booked appt for mental health follow up Will seek help via provided resources emergently if mental state changes.’22 Contrary to that note, the prescription of sodium valproate was known on the previous day, but his sodium valproate level was not checked at that time. Following that phone call Dr Townsend requested a sodium valproate level check using the blood sample taken the day before.

Later that day, Mr Tanti attended at the Christies Beach Magistrates Court. He was sentenced in respect of the two counts of driving unauthorised following a drug driving disqualification and granted a home detention sentence of two months and 13 days.23 The sodium valproate test result was received at 6:43pm on 13 September 2021. It showed a valproate level of 1604 µmol/L as compared to the normal range of 300 to 600 µmol/L.

Dr Townsend reviewed the result. He rang Mr Tanti and spoke to the corrections officer who was present with Mr Tanti at his residence conducting the intake for the home detention sentence.24 Dr Townsend said he wanted Mr Tanti to return to Noarlunga Hospital Emergency Department as his test results were dangerous.25 The corrections officer provided Dr Townsend with the Intensive Compliance Unit’s phone number so that he could advise the team leader of such. Dr Townsend rang the number and asked for Corrections to escort Mr Tanti to hospital, after which he was told Mr Tanti would only be allowed to leave his residence if he was taken by ambulance. Following this, Dr Townsend arranged for an ambulance and called Mr Tanti again to inform him.26 The corrections officers completed the induction process and subsequently left the residence.27 Dr Townsend then made the following notes at 10:11pm: ‘Valpro level resulted 1604 3 x upper limit normal Rang Greg Alert No slurring States feels well Currently home D officers with Greg They cannot escort to ED Greg admitted maybe he did take some extra valpro yesterday. Time of ingestion and quantity uncertain.

He needs repeat assessment in hospital given this new information 22 Exhibit C26 23 Exhibit C23 24 Exhibit C10 at [5] 25 Exhibit C9 at [5] 26 Exhibit C10 at [6] 27 Exhibit C9 at [8]

[2025] SACC 5 Coroner Giles He cannot get to hospital any other way I have called SAAS with his consent to assess and transfer to ED for assessment Needs tox review +/- mental health.’28 Mr Tanti was transported by SA Ambulance to hospital and presented to the triage nurse at 11:55pm on 13 September 2021. He was not drowsy. Following his presentation a blood sample was taken at about 12:30am. An ECG and blood gas tests were conducted just before 1am. Other general observations were normal.

Mr Tanti was examined by Dr Jordan Anderson who made the following notes at 2:55am on 14 September 2021: ‘Gregory was asked to represent to ED by Dr D Townsend regarding Valproate toxicity.

Had overdose from 3 days ago When I met him he was upset, as he had been told that he would only be waiting for an hour, and wanted to go home Bloods had already been taken.

Discussed with Consultant Dr Tri He is able to go home - he has someone home with him We will chase bloods Called the Home detention service to notify that he had been in ED He has agreed to call ED in the morning as a welfare check.’29 Dr Anderson recorded a diagnosis of ‘sequelae of poisoning by drugs, medicaments and biological substances’. Mr Tanti spoke to Community Corrections and obtained permission to walk home. He was discharged at 2:55am on 14 September 2021. The blood test result did not detect any sodium valproate.

According to the records, a mental health examination of Mr Tanti did not take place during this presentation. Given it was discovered he had in fact taken medication in excess of prescriptions despite his denial the day prior, it would have been prudent for another mental health examination to have occurred at this time. However, any supposition as to what a mental health examination at that time may have revealed would be purely speculative. I also note it would have been difficult to facilitate considering Mr Tanti’s annoyance at waiting and his desire to go home.

Mr Tanti had reported he had someone at home with him which provided some level of safeguarding. Additionally, there was a plan in place for Mr Tanti to call the Emergency Department in the morning for a welfare check. I therefore conclude that, in all of the circumstances, it was reasonable to have discharged him at this time. Furthermore, I note Mr Tanti did not take his life for another week following this discharge.

On 14 September 2021 Mr Tanti was directed to attend at Community Corrections in order to complete his home detention sentence intake process. With the imposition of 28 Exhibit C26 29 Exhibit C26

[2025] SACC 5 Coroner Giles this sentence, Mr Tanti had been upgraded from a Level 3 supervisor, who had supervised him while he was on supervised bail, to a more experienced Level 4 supervisor.

Mr Tanti walked to Noarlunga and met with the corrections officer newly assigned to supervise his home detention sentence, Daniel Mannix. Mr Mannix was aware that Mr Tanti had mental health issues, and he noted that Mr Tanti was ‘a bit down’ during the intake interview. Mr Tanti explained his recent hospital admission resulted from his overdosing the previous weekend, having suffered a meltdown pending his court hearing on 13 September 2021 as he thought there was a chance of him going to prison instead of being placed onto a court ordered home detention sentence. Mr Tanti also expressed his concern to Mr Mannix about not being able to finish his current tiling job as it would mean he would lose $1,800 in pay.30 He was talked through the process of having employment approved during a home detention sentence. Mr Mannix stated in his affidavit that Mr Tanti did not present as someone who was at risk of self-harm.31 Ms Priest observed Mr Tanti was more depressed and fidgety after commencing home detention. She described him as being ‘on edge’.32 On 15 September 2021, Mr Tanti was advised that his employment application was approved. Mr Mannix gave Mr Tanti a pass out for the following day so that he was able to finish his tiling job.33 On 16 September 2021, Mr Tanti requested another pass out for the next day which was also approved.34 Ms Priest said that Mr Tanti ‘seemed to be good’ during this period. He was working and ‘seemed to be very happy’.35 However, Ms Priest’s observations did not coincide with Mr Gallas’, who stated in his affidavit that Mr Tanti had shown him some rope around this time, saying ‘he didn’t want to be here anymore’.36 Mr Gallas stated he talked Mr Tanti out of it, after which he seemed to be fine.

Circumstances leading to Mr Tanti’s death On 18 September 2021 Mr Tanti had a disagreement with Mr Gallas, accusing him of sleeping with Ms Priest. Ms Priest stated that Mr Tanti jumped off a wall and hurt his ankle.37 He went to his bedroom and slammed his door.38 Ms Priest left, and Mr Gallas went to the unit of a neighbour, Ashley Stoeckel. He told Mr Stoeckel he was scared of Mr Tanti and wanted to stay there for the night instead of going home. During the night Mr Tanti sent text messages to Mr Gallas saying things like ‘mates don’t do that’.39 30 Exhibit C11 at [7] 31 Exhibit C11 at [8] 32 Exhibit C7 at [4] 33 Exhibit C11 at [10] 34 Exhibit C11 at [12] 35 Exhibit C7 at [9] 36 Exhibit C6 at [10] 37 Exhibit C7 at [10] 38 Exhibit C6 at [16] 39 Exhibit C6 at [18]

[2025] SACC 5 Coroner Giles Mr Tanti messaged Ms Priest saying: ‘And sorry I’m going through something I never have before and don’t know how to deal with it or what I’m going through …’40 The following morning, on 19 September 2021, Mr Gallas responded to Mr Tanti: ‘Hey mate, I’m at Ashley’s and Mel’s house. I aint no dog, I’m a good mate, I’m kind hearted. I would never do that to a friend.’41 Mr Gallas phoned SAPOL to report the argument and asked them to remove Mr Tanti from his unit.

Senior Constable Webber and Constable Hedges attended and spoke to Mr Tanti. Their interactions were recorded on body cam. I have viewed this footage. Mr Tanti informed the SAPOL officers he was trying to find an alternative home detention address.42 He said he had called the home detention office, but they had not answered. Mr Tanti said, ‘I don’t want him scared of me’. He said he did not want to get locked up, to which Senior Constable Webber replied, ‘Trust me, we will try and avoid it as best we can’.

It is clear from the footage that Mr Tanti was upset about the situation. He is seen to become emotional during this conversation, particularly when he expressed that he does not wish to get ‘locked up’ again. The SAPOL officers were pleasant and professional towards Mr Tanti. They expressed understanding for the situation Mr Tanti was in.

The officers then spoke to Mr Gallas who said he did not want Mr Tanti to be arrested.43 He said he was happy to give Mr Tanti some time to find a new place to live.44 The officers then re-attended on Mr Tanti to relay this information to him.45 This interaction was not recorded on body cam, however I have no reason to believe that this interaction was anything but courteous and understanding on the part of the SAPOL officers, as their previous recorded interaction with Mr Tanti had been.

The officers have reflected on their dealings with Mr Tanti. They say he was a bit teary and emotional, but made no comments about self-harm, and so no mental health assessment was considered necessary.46 Throughout their encounter with Mr Tanti his words and actions simply did not raise concerns for his welfare.47 Ms Priest visited Mr Tanti and then left for a doctor’s appointment.48 At about 11am Mr Gallas asked Mr Stoeckel to go to his unit and retrieve some essential items including bread, milk, cheese and ham. Mr Stoeckel went over with his brother.

They took some items from the fridge. They called out to ask Mr Tanti where the ham 40 Exhibit C7, Annexure A at [6] 41 Exhibit C6 at [18] 42 Exhibit C17 at [5]; Exhibit C16 at [6] 43 Exhibit C16 at [10] 44 Exhibit C16 at [11] 45 Exhibit C17 at [9] 46 Exhibit C17 at [5] 47 Exhibit C16 at [5] 48 Exhibit C7 at [11]

[2025] SACC 5 Coroner Giles was. Mr Tanti replied that there was no ham. He said to make sure they brought the milk back.49 He did not appear to be upset at all50 and there was no unusual vibe.51 While at the doctor’s, Ms Priest received text messages from Mr Tanti. He said: ‘Your better off without me and I belong in jail Goodbye Jess you know I love you always will wish you the best’ and ‘It’s better for everyone including my boys if I’m just not here anymore’ She replied: ‘Life is not all about YOU .. grow the fuck up hey’52 She tried to ring Mr Tanti, but he did not answer. She rang Mr Gallas.

At about midday Mr Gallas asked Mr Stoeckel to go back to the unit again as Mr Tanti was no longer answering his phone. Mr Stoeckel and his brother went to Mr Gallas’ unit once more, returning the milk. The front door was locked this time. They called out and did not receive a response. They returned home and Mr Gallas immediately called

SAPOL.

Senior Constable Webber and Constable Hedges attended again, arriving at about 12:30pm. As Mr Gallas’ house keys were inside the unit, he gave Ms Priest permission to smash the window to gain entry. She was just entering when SAPOL arrived. Once inside Ms Priest began screaming ‘Greg, Greg, Greg’53 and opened the front door, saying ‘He’s hung himself’.54 Detective Brevet Sergeant Batty also attended the unit, arriving at about 1:30pm, to carry out his investigation duties. The officers located Mr Tanti hanging by an 8mm blue and white nylon rope that had been fastened around a beam in the ceiling above the manhole.55 There was a dining chair nearby which Mr Tanti appeared to have stepped off of.56 Detective Batty was of a similar height to Mr Tanti. He was able to stand on the chair and easily reach the beam the rope was tied around.57 SA Ambulance paramedics attended and declared life extinct at 12:35pm.

49 Exhibit C5 at [6] 50 Exhibit C4 at [9] 51 Exhibit C5 at [7] 52 Exhibit C7, Annexure A, pages 13-14 53 Exhibit C16 at [18] 54 Exhibit C17 at [16] 55 Exhibit C16 at [22] 56 Exhibit C18 at [18]; Exhibit C19, page 4 57 Exhibit C18 at [19]

[2025] SACC 5 Coroner Giles A suicide note was later found in Mr Tanti’s vehicle58 directed to his sons in which he wrote: ‘I’m nothing and always have been nothing but a waste of oxygen’ and ‘I want to apologise for the pain Ive caused to doing this but in the end just like me you will see that you were always going to be better off without me in your lives.’59 The evidence demonstrated that Mr Tanti took his own life by hanging.

Community Corrections internal review Community Corrections carried out an internal review of Mr Tanti’s case following his death. During that review it was noted that no Suicide Self Harm Warning Screen was entered following the corrections officer becoming aware that Mr Tanti had been taken to hospital in relation to an overdose.

This was said to have been due to multiple factors: the hospital visit was very brief, Mr Tanti was able to get himself to and from the hospital, and then to his Corrections intake appointment the following morning; and that Mr Tanti was assessed as being future focused given he was speaking about employment and obtaining housing. It was also noted that the corrections officer had allayed Mr Tanti’s immediate fears about losing his work and that Mr Tanti was actively engaging with OARS’ counselling.

It was unfortunate timing that Mr Tanti was transferred from one corrections officer to another when transitioning from supervised bail to the home detention sentence as the new officer did not have any prior experience with Mr Tanti. It is likely that more time would have given the opportunity for greater recognition of the severity of Mr Tanti’s situation.

In any event, the officer involved was not presented with a patently suicidal man.

Although the red flag of the hospital admission for overdose was brought to his attention, he made an assessment that Mr Tanti was future focused and that he had counselling supports in place that he was actively engaging with. The officer actively supported Mr Tanti by gaining a quick approval for him to continue working, which appeared to be Mr Tanti’s most significant concern at the time of the intake interview.

In all of the circumstances, there is no criticism to be made of that assessment and those actions.

58 Exhibit C8 at [21] 59 Exhibit C21d

[2025] SACC 5 Coroner Giles Conclusion and recommendations I find that Mr Tanti was in the lawful custody of the Department for Correctional Services at the time of his death, serving a court ordered home detention sentence.

I find that the care provided to Mr Tanti by the Noarlunga Hospital was appropriate in the circumstances.

I do not make any recommendations in this matter.

Keywords: Death in Custody; Home Detention; Suicide; Hanging