Coroner's Finding: de-identified EW

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased and family by the direction of the Coroner pursuant to s 57(1)(c) of the Coroners Act 1995) I, Robert Webster, Coroner, having investigated the death of EW Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is EW; b) EW died in the circumstances set out below; c) EW’s cause of death cannot be determined as his body was never recovered; and d) EW died on 16 August 2022 at Hobart, Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into EW’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Medical records obtained from the Royal Hobart Hospital (RHH);

• Medical records obtained from EW’s general practitioner (GP);

• Affidavit of IJ;

• Affidavit of Berthold Smets;

• Affidavit of Siska Buelens;

• Affidavit of Brianna Doyle;

• Affidavit of Senior Constable Chris Cheeseman;

• Affidavit of Sergeant Melanie Taplin;

• Affidavit of Constable Mathew Goodluck;

• Affidavit of D’Arne Triffett;

• Affidavit of Senior Constable Lucy Brown;

• Report of the forensic pathologist Dr Andrew Reid; and

• CCTV footage and forensic evidence.

Background EW was 18 years of age (date of birth 25 September 2003), single and he resided with his parents, IJ and QB at the date of his death. EW was never married and he had no children.

EW went to primary school at South Hobart Primary School and he then went to Taroona High School. Thereafter, he went to Hobart College for years 11 and 12, and although he did not seem to have a career goal in mind, he was looking towards construction. However, during year 12 he became interested in landscaping. He completed his year 12 education and not long after, that is from February 2022, EW obtained employment with Mr Smets who ran a handyman and landscaping business. EW remained in this employment until the date of his death.

EW was very fit and enjoyed playing sport. A note of the general practitioner of 11 April 2017 indicated EW was very active in riding his mountain bike and playing soccer.

Health EW’s father says his son had no obvious mental health issues as a young child but he often came across as shy and on occasions he exhibited social anxiety. In about year 5 at school this became less of a problem, but it re-emerged when he was in year 9. At that time, not only was he anxious socially but he also became anxious with his schooling. During year 12 EW’s friends, who were more academically minded, were intending to go to university and QB says this seemed to weigh on his son. Also during this year, QB says his son appeared to be concerned about what his future might hold and what his friendships would be. He was very concerned about issues such as climate change, conspiracy theories and other similar topical events. QB believes EW was struggling to make sense of what his place was in the world.

In November 2021, EW and a friend, Siska Buelens, assisted with a PhD study trapping and studying Tasmanian Devils in the Cradle Mountain area. He was away for 12 days and on his return, he spoke initially to his mother and told her that while away he thought he could end his life and that was what he was going to do. He told her the thought gave him the feeling of absolute euphoria. IJ told QB, and thereafter, QB and EW had a long conversation at which time it was suggested he should seek medical advice. Accordingly, in January 2022, EW’s parents took him to the family general practitioner who diagnosed depression and anxiety, and prescribed medication to manage his depression. A mental health plan was also prepared which provided for assistance from a psychologist. EW saw the psychologist on six occasions

between January and August 2022. He advised his parents he liked the psychologist but did not believe he was hearing anything new from him. The advice was that he should eat well, exercise, make an effort with friends and try to push away bad thoughts.

QB says in the two months leading up to his son’s death, EW seemed to be improving as he was more cheerful, but then in the month prior to his death his son’s mood worsened. He was not exercising or taking part in his hobbies or activities. He continued working.

Ms Doyle is a schoolfriend of EW. She heard from mutual friends in January 2022 that EW was not doing so well. The mutual friends had seen him at a party where they came to that conclusion. She therefore reached out to EW and they spoke intermittently by text from March 2022 through to June 2022. During that period, she would send him positive quotes and memes but he did not always respond, however when he did, sometimes he would send back positive messages. He did send some negative messages and she remembers one which was along the lines of “10 people died of suicide every minute”. This message concerned her and therefore she asked to meet him for dinner. They met, at which time Ms Doyle says EW seemed very anxious especially when meeting people and that when he did so, he wanted to leave almost immediately. He indicated it was easier to meet with people one on one rather than in group situations. After this meeting, they continued to message one another. EW indicated he was very depressed and that his medication was not working. About a week or two later, EW tried to end his friendship with Ms Doyle saying to her that he was just like a mutual friend from high school who had bipolar disorder and who was depressed and suicidal. He indicated to Ms Doyle he was backing away from all his friends. At about this time, Ms Doyle’s boyfriend was becoming jealous about the time she spent with EW and so she sent him a message saying she had to back away a little bit, that she knew he had had a crush on her years ago but that she had to be fair to her boyfriend. EW responded that he did not wish to be friends, that he still liked her and wanted to date her. There was no further contact except for a message she received on 7 August 2022 which said, “I don’t like u, im so happy for u , im scared il (sic) replace bella and bring u down again… So that is why i wont let us be friends.” Ms Buelens says on the last full day of work in November 2021, she noticed EW was in a strange mood. She asked him if there was anything wrong and he said that he had made a decision and was now at peace. Later that day she asked him what he meant and he said he did not want to live anymore. He said he did not have hope for the world or his future. Ms Buelens says EW seemed to be content with his decision. They spoke further and during this conversation, he advised her about the method he would use to kill himself and that he had been looking online for ways to do it. He said every time he went for a walk, he was trying to gauge the height of the cliffs nearby because he wanted to die in nature, but he also did

not want somebody to find his body and be traumatised. He mentioned he had a secondary plan, by which he would use a rope but he was still worried about upsetting anyone who found him. He mentioned high places into water in order to avoid being found, such as a cliff, however he did not mention the Tasman Bridge. When they returned to Hobart, she advised him to seek support. Ms Buelens returned to her home in Belgium in January 2022 before returning to Tasmania in July 2022. While away, she and EW spoke often, initially by telephone, but that subsequently became too difficult for EW so they communicated by text.

On her return, she saw him twice; the first time was in a group setting and she says he was really struggling. Their second meeting was around the end of July or early August 2022 at the Botanical Gardens. He said he was really struggling with his thoughts, he was really drained and soon he wanted to go home. They continued to text but not as much as before, and on 16 August 2022, she texted him as it had been quite a few days since they had had contact and he replied by saying that he was busy and had a lot on.

There are no mental health entries in the RHH records.

The GP records indicate EW had been struggling from depression since in or about the beginning of 2021, which was fluctuating, although by July 2022 he advised his general practitioner he had been better in recent times and had benefited from seeing the psychologist. He was keen to continue seeing the psychologist but he did not think his medications were assisting. A mental health review plan was prepared to enable EW to continue to see the psychologist. The appointment with the general practitioner was on 26 July 2022. It is clear what EW was telling the general practitioner was at odds with what he was telling Ms Doyle and Ms Buelens.

Circumstances leading to death Mr Smets, as EW’s employer, knew he was seeking assistance for his mental health but he saw nothing in EW’s presentation to indicate he was sad or angry. It was quite the opposite.

He described EW as happy and euphoric. In particular, there were no issues that arose at work in the week leading up to EW’s death.

He says on 16 August 2022, EW had worked from 7:30am until 3:00pm as they had finished the job for that day. Mr Smets says he noticed nothing unusual or out of the ordinary with EW. He says he seemed to be his usual self. When they finished work for the day, they said goodbye to one another as usual and that they would see each other the next day.

When EW arrived home, his parents were home. QB says his son was not in the best place at that time and he said his son had spent a lot of time recently in his room on Netflix or on YouTube. He came out after dinner but was not very pleasant. He was very cynical or

negative in attitude and demeanour. He told his parents he had been feeling anxious all day at work. QB and EW had a discussion about EW’s attitude and QB concedes he was not particularly patient during their conversation as he had had a bad day himself. QB therefore went to bed quite early but EW remained up with his mother. He subsequently went to bed, but before doing so, he did go to his father’s room where he gave his father a hug.

Some time prior to 10:50pm on 16 August 2022, EW has left his room and the house in a Mazda utility which was registered to his father. He left his mobile telephone behind. He parked the vehicle in the car park at the Botanical Gardens and left the keys to the vehicle on the driver seat and his wallet in the centre console.

Footage obtained from the Tasman Bridge cameras show EW walking alone on the northern pedestrian walkway west to east. He is first seen on the bridge at about 10:53pm. He is alone and is wearing a pair of what look to be blue plaid pattern pyjama pants and a green jacket and hat. He walks calmly along the bridge, glancing around as though checking traffic.

At 11:00pm, he nears the apex of the bridge and he looks around again. At this time, he can be seen holding an electronic tablet in his hands. EW then climbs onto the railing, stands up and dives from the bridge.

Investigation At 7:00am, EW’s parents discover he is not at home and that he had not taken his work boots or lunch bag with him to work that morning. At 7:30am they heard EW’s phone ringing. It was Mr Smets who was looking for EW as he has not turned up for work. IJ and QB left their home to look for EW while Mr Smets left his address and drove from Huon Road towards Leslie Road in case EW had been involved in a crash on the way to Mr Smets’ home.

At 8:00am, EW returned home and contacted police and provided police with details of what had occurred the night before. Details of the vehicle EW was using were subsequently obtained and a “keep a lookout for” was broadcast to the southern police district in relation to the vehicle at 8:32am. At 8:54am police located the vehicle parked and unattended at the Botanical Gardens car park. The vehicle was unlocked and after a search the keys and wallet were located.

At 9:30am a missing person report was generated and a running sheet or log was commenced. At 10:06am a marine unit was tasked to search for EW and was searching the river in the vicinity of the Tasman Bridge. At 11:00am police requested footage from the Tasman Bridge cameras and this was collected at 4:00pm that day. The mobile phone belonging to EW was forwarded to forensic services for examination and while there were

SMS messages and phone calls recorded on the telephone, it did not have internet access.

There is nothing which explains EW’s death in the messages on the phone. The tablet EW was seen holding in the footage has not been recovered. Despite an extensive search of the Derwent River EW has not been found.

Senior Constable Brown is attached to the Missing Persons Unit which is attached to the State Intelligence Service of Tasmania Police. Her duties include reviewing long-term missing person files and as part of that review she, in February 2024, conducted a number of checks with respect to EW. She made checks of all Australian police jurisdictions, 14 of the most commonly used financial institutions, Medicare, Centrelink, the Australian Electoral Commission, Tasmanian Births, Deaths and Marriages, Housing Tasmania, Aurora, Tasmania Mental Health Services, and Australia Border Force amongst others. The attendances on the general practitioner on 26 July 2022 and the psychologist on 18 July 2022 together with the purchase of antidepressant medication on 4 August 2022 were disclosed by the searches, as were bank accounts in EW’s name, the fact that his provisional driving licence expired on 16 February 2024, his last trip into Australia occurred on 8 September 2019 and he had been removed from the electoral roll, marked deceased, on 27 October 2022. There were no matches for EW since the date of his disappearance; that is there is no trace of any activity on his part since 16 August 2022.

Dr Andrew Reid, the forensic pathologist, prepared a report based upon information contained above from Tasmania Police and the contents of the CCTV footage. In that report, Dr Reid notes the contents of the CCTV footage and that EW’s body has not been recovered. He says EW would not have survived a fall from the Tasman Bridge and immersion in the water below. In particular, he says the momentum and impact with the surface of the water, following a fall from the bridge, causes either immediate death from blunt force trauma to the head, neck, trunk and/or limbs or, if injuries are not immediately fatal, death is caused by drowning secondary to physical incapacity, with or without hypothermia due to cold water immersion. He goes on to say it is unlikely EW’s body will be recovered because of the combination of postmortem interval (that is the time that elapsed between 11:00pm on 16 August 2022 and when the search on the river commenced 11 hours later), river/ocean currents, tides and the like. It is possible identified human remains consisting of bones may be discovered in the future and accordingly a DNA sample from EW’s father, which will assist with identification, has been obtained.

I am therefore satisfied, although EW is missing, he is deceased.

I am satisfied there are no suspicious circumstances surrounding EW’s death. I find that he took the action of jumping off the Tasman Bridge alone and with the intention of ending his

life. From the evidence, I am satisfied EW contemplated suicide from as early as November 2021 and this and other evidence on file, which I have highlighted, indicates he had been thinking of ending his life over an extended period of time. EW appears to have been a very private person by nature and it seems that despite the treatment he received and the offers of assistance which were made he was unable to seek the necessary help and support from his family and health professionals. In those circumstances, his death could not have been foreseen or prevented. To his parents, it seems he had been improving since medical assistance had been sought.

I extend my appreciation to investigating officer Senior Constable Chris Cheeseman for his investigation and report.

Comments on Tasman Bridge The Tasman Bridge, one of this state’s most prominent and iconic public structures, continues to be the site of frequent, preventable suicides. It is situated centrally within Hobart, and pedestrians have access to the pathways at all times. The outer barrier is low in height, easy to climb and provides a direct drop into the river at a height that will usually cause death.

In November 2016, Coroner McTaggart handed down her findings following a public inquest into the suicide deaths of 6 people from the Tasman Bridge. She made 7 recommendations to prevent further suicides at this site.1 These included a recommendation that the government formulate a plan for structural modifications to the Tasman Bridge.

In investigating this death, together with 8 other deaths from the Tasman Bridge that are published simultaneously with this finding, the Coroners have commissioned the Coronial Research Officer, Ms Runi Larasati, to conduct a detailed analysis of suicides from the bridge since those the subject of the inquest in 2016.

The report prepared by the Coronial Research Officer (“the Report”) is based upon data from the Tasmanian Suicide Register and should be read with these findings. It is located at: Tasman Bridge Report. The coroners are very grateful to Ms Larasati for the Report which comprehensively outlines facts and issues associated with suicides, suicidal behaviour and suicide prevention at the Tasman Bridge.

The Report provides a helpful summary of progress of the 2016 coronial recommendations relating to preventing suicides on the Tasman Bridge. I acknowledge the work of the Tasman 1 Deaths_from_a_Public_Place.pdf

Bridge Cross Agency Working Group in implementing the recommendations, including enhanced camera surveillance and crisis telephones.

Despite plans made by the government, structural modifications to the bridge have not been made. As described in the Report, the government released its concept design for the Tasman Bridge upgrade in 2022, which included raising the height of its safety barriers alongside transport improvements by widening its pathways. Following detailed assessments, widening the pathways was deemed unfeasible due to structural constraints and budget limitations. Therefore, in 2024, this plan was rescinded.

As of June 2025, the Department of State Growth has indicated that it is conducting community consultations on an amended concept design, which is stated to be “at a very early stage”, with further assessments and tendering process still to take place.2 The Department stated that the project’s primary objective is “to address the significant concerns related to the occurrence of suicides from the bridge”, and noting that pathway improvements will also be delivered.

The current project is jointly funded to $130 million by the Australian and Tasmanian governments. In addition to installing higher safety barriers to prevent suicides, the project scope includes establishing localised passing bays to support transport activities on the bridge. Construction period is expected to commence late 2025 or early 2026 for a period of approximately 12 months.

Without structural modifications to the safety barriers, suicides will continue to occur at this high-risk location. As outlined in the Report, between 1 January 2016 and 30 June 2024, 22 people have died, either by intentionally jumping or falling from the Tasman Bridge.

Additionally, police attend an average of 195 concern for welfare incidents on the bridge each year, including where possible suicidal behaviour of an individual is reported.

The research studies described in the Report provide strong evidence that the installation of appropriate safety barriers on the Tasman Bridge will actually reduce the total number of suicides and not simply result in a substitution of means.

Recommendations Pursuant to section 28 of the Coroners Act 1995, it is appropriate to make the following single recommendation to prevent further suicides from the Tasman Bridge.

2 Department of State Growth, Tasman Bridge Upgrade Project: Project Briefing, 5 May 2025. Provided to the Coroner’s Office on 3 June 2025.

I recommend that the government urgently implement structural modifications to the Tasman Bridge with a key aim of eliminating suicides at the Tasman Bridge.

I convey my sincere condolences to the family and loved ones of EW.

Dated: 30 June 2025 at Hobart, in the State of Tasmania.

Magistrate Robert Webster Coroner