Coronial
VICcommunity

Finding into death of Adrian James Keatley

Deceased

ADRIAN JAMES KEATLEY

Demographics

48y, male

Coroner

Coroner John Olle

Date of death

2013-02-08

Finding date

2013-11-15

Cause of death

hanging

AI-generated summary

Adrian Keatley, aged 48, died by hanging at a roadside location. Police had contact with him the day before his death at the same location but had no welfare concerns. A suicide note was found at the scene. The post-mortem revealed incidental findings of liver cysts of uncertain significance and a hydrocele. This case highlights the importance of thorough risk assessment during police welfare checks, particularly when individuals are found in isolated locations with vehicles present over extended periods. Enhanced mental health screening and engagement with support services may have been beneficial, though the coroner did not identify specific preventable failures in clinical care.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Contributing factors

  • suicide
  • possible underlying health issues (liver cysts)
Full text

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 / 0578

FINDING INTO DEATH WITH INQUEST ~

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: ADRIAN JAMES KEATLEY

Delivered On: 15 NOVEMBER 2013

Delivered At: Level 11, 222 Exhibition Street Melbourne 3000

Hearing Dates: 15 NOVEMBER 2013

Findings of: JOHN OLLE, CORONER

Police Coronial Support Unit Leading Senior Constable Tracey Ramsey

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I, JOHN OLLE, Coroner having investigated the death of ADRIAN KEATLEY

AND having held an inquest in relation to this death on 15 November 2013

at MELBOURNE CORONERS COURT

find that the identity of the deceased was ADRIAN JAMES KEATLEY

born on 20 September 1964

and the death occurred between 7 February and 8 February 2013

at Intersection of Luptons Track and Tynong North Road, Tynong North 3813

from: 1 (a) HANGING

in the following circumstances: L. Adrian Keatley was aged 48 years at the time of his death. He lived at 2 Edney Court, Noble Park.

  1. The coronial brief has fully addressed the tragic circumstances of death Mr Keatley.’

  2. At inquest a summary of evidence was read by my assistant. I am satisfied the summary is

an accurate reflection of the material contained in the inquest brief.

Post mortem medical examination

  1. On 11 February 2013, Dr Melissa Baker, Forensic Pathologist at the Victorian Institute of

Forensic Medicine, performed an examination on the body of Adrian James Keatley.

5. Dr Baker found the cause of death to be hanging.

6. Dr Baker commented:

“According to details outlined in the Victoria Police Report of Death Form No. 83, over the two days preceding the deceased’s death, his vehicle was reported by passers-by as a suspect vehicle at the intersection of Tynong North Road, Camp Road and Lupton’s Track, Tynong North. Police spoke to the deceased at 18:22 hours on 7th February 2013 at this location. Police had no concerns for his welfare, but suggested he camp at a designated camping ground. At 08:00 hours on 8th February 2013, a witness discovered the deceased’s car on Tynong Road North

adjacent to Lupton’s Track facing in a southerly direction. The deceased had hitched

' Copy of the coronial brief will remain on the court file

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a red octopus strap around his neck securing the other end to a roll bar on the back of his vehicle’s cabin. He has then hung himself. There are no other signs of violence.

A search of the deceased’s vehicle revealed car keys, a wallet, last Will and suicide note. The deceased was found lying on his side with the octopus strap still attached

to his neck and the roll bar.

External examination revealed a red octopus strap around the deceased’s neck with

an underlying ligature mark. No other injuries were identified.

Post mortem CT scan revealed a right sided hydrocele and multiple cysts in the liver.

Cysts were not identified in other organs. The cysts in the liver may represent multiple cystic metastases, however a primary tumour is not visible and there is no evidence of lymphadenopathy. A post mortem examination would be necessary in

order to determine the nature of the cysts.””

  1. In all the circumstances, I am satisfied Mr Keatley died in circumstances of suicide.

Finding

I find the cause of death of Adrian Keatley to be hanging.

I direct that a copy of this finding be provided to the following: The Family of Adrian Keatley

Signature:

? Dr Bakers post mortem report

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