Coronial
VICcommunity

Finding into death of Gerald Vanderwerf

Deceased

Gerald Vanderwerf

Demographics

56y, male

Coroner

Coroner Audrey Jamieson

Date of death

2016-09-23

Finding date

2018-09-18

Cause of death

unascertained; presumed suicide by unknown means

AI-generated summary

Gerald Vanderwerf, a 56-year-old man with a 40-year history of severe depression, suicidal ideation, and multiple suicide attempts, disappeared from the Grampian Ranges on 23 September 2016. The coroner found on the balance of probabilities that he intentionally ended his own life in the bush. Key clinical lessons include: Mr Vanderwerf disclosed suicidal attempts only retrospectively after resolution; treating psychiatrist never saw him in crisis; he repeatedly withdrew from treatment; he minimised symptoms due to shame about unemployment and psychiatric history; and he declined multiple offered support services including case management and group therapy. The combination of profound personality disturbance, impaired emotional literacy, social withdrawal, financial stress, and intermittent treatment engagement created vulnerability to suicide. Earlier recognition of crisis points, enhanced safety planning, involuntary treatment consideration during high-risk periods, and more assertive engagement (rather than passive referral) to support services may have altered outcomes.

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

Specialties

psychiatrygeneral practicepsychology

Error types

communicationsystem

Drugs involved

lamotriginelithium carbonatequetiapinesertralinethyroxine sodiumtemazepam

Contributing factors

  • severe depression with 40-year history
  • multiple previous suicide attempts
  • personality disturbance with primitive psychotic components
  • impaired emotional literacy
  • social isolation and withdrawal
  • unemployment and financial stress causing shame
  • pattern of treatment engagement and withdrawal
  • minimisation of symptoms
  • non-disclosure of suicidal ideation until resolved
  • refusal of offered mental health support services
Full text

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 2017 5810

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Inquest into the Death of: GERALD VANDERWERF

Delivered At: Coroners Court of Victoria

65 Kavanagh Street

Southbank 3006 Distributed On: 18 September 2018 Hearing Date: 18 September 2018 Finding Of: AUDREY JAMIESON, CORONER

Police Coronial Support Unit Senior Constable Jayme Gurishic

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I, AUDREY JAMIESON, Coroner having investigated the death of GERALD VANDERWERF

AND having held an inquest in relation to this death on 18 September 2018

at MELBOURNE

find that the identity of the deceased was Gerald Vanderwerf

born on 28 April 1960

and the

death occurred on or about 23 September 2016

at an unknown location in the Grampian Ranges, Victoria.

from:

1(a) UNASCERTAINED CAUSES

in the following summary of circumstances:

On 23 September 2016, Gerald Vanderwerf checked out of the Goldfields Comfort Inn in Stawell, Victoria. He subsequently disappeared and has not contacted family and friends.

Victoria Police discovered his locked vehicle at the Borough Huts Campground parking lot

in the Grampian Ranges.

On 16 November 2017, I received a request from Detective Senior Constable (DSC) Slagian Radoievici to treat the disappearance of Gerald Vanderwerf as a “suspected death” within the meaning of section 52(1) of the Coroners Act 2008 (Vic) (the Act). A “suspected death” is included in the definition of “death” in section 3 of the Act. Consequently, a Coronial

Investigation was held into the death of Gerald Vanderwerf.

DSC Radoievici was my Coronial Investigator’ and compiled the coronial brief, which included inter alia statements from the Victoria Police investigation into Mr Vanderwerf’s disappearance, in order to assist me in determining whether it was appropriate to complete a

Finding in relation to his death.

On 18 September 2018, a Summary Inquest was held into the death of Gerald Vanderwerf.

' A Coroner’s Investigator is a police officer nominated by the Chief Commissioner of Police or any other person nominated by the coroner to assist the coroner with his/her investigation into a reportable death. The Coroner’s Investigator takes instructions and direction from a Coroner and carries out the role subject to the direction of a Coroner.

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BACKGROUND AND CIRCUMSTANCES

Gerald Vanderwerf was 56 years of age at the time of his disappearance. He was divorced and had no children, Mr Vanderwerf was a qualified carpenter but was unemployed and lived off his diminishing savings and periodic Centrelink payments. At the time of his disappearance, Mr Vanderwerf lived alone in a rental apartment in St Kilda, Melbourne.

Mr Vanderwerf was of Dutch decent and bom in Canada. He was the second of five siblings and had three brothers and one sister. When he was approximately five years of age, Mr Vanderwerf’s family immigrated to San Jose, California where he attended a small Christian school. When he was 15 years of age, he re-enrolled into a larger public school.

Mr Vanderwerf attributed the onset of mental ill-health to the difficulties associated with commencing at a new school, as well as the development of severe acne on his face and

back.

At approximately 18 years of age, Mr Vanderwerf began using cocaine. He also experienced severe suicidal ideation for the first time and he placed the barrel of a gun in his mouth.

Mr Vanderwerf did not reveal these facts to anyone until many years later.

In his mid-twenties, Mr Vanderwerf apparently investigated the physical logistics of shooting himself with a gun and later attempted to end his own life by carbon monoxide poisoning.

In 1985, Mr Vanderwerf met Karen Safris (née Sullivan) from whom he hid his mental illhealth until they became engaged after approximately five years of dating. Mr Vanderwerf and Ms Safris shared common interests, including a love of outdoor fitness including hiking,

walking, and bike riding.

During the course of his marriage, Mr Vanderwerf’s mental ill-health became more pronounced. He began medical treatment for depression in 1991, at his wife’s behest.

Mr Vanderwerf was prescribed sertraline and lithium in a combined anti-depressant medication. He continued to take his prescribed medication for one year when he trialled a break from pharmacological treatment, At that time, he experienced an extreme bout of depression and attempted to end his own life. Consequently, he recommenced Sertraline and

continued to take it for 15 years.

In 1996, Mr Vanderwerf and Ms Safris separated; they divorced in 1997. He believed that

his mental ill-health played a large role at the end of their marriage. Sometime later, he

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experienced debilitating depression; he was unable to leave the home and sometimes unable

to get out of his bed for protracted periods of time. :

In 2006, Mr Vanderwerf attempted suicide by carbon monoxide poisoning, he also consumed a number of sleeping pills. Subsequently, Mr Vanderwerf sold the home he had shared with Ms Safris. It was in a state of disorder as he had begun the renovation process

but was unable to complete it.

After selling his home, Mr Vanderwerf immigrated to Australia where his brother Mark Vanderwerf had been living. During the first three months, he travelled around Australia using his brother’s camping gear. Mr Vanderwerf was sponsored by his employer

and therefore able to remain in the country.

Mr Vanderwerf lived in a bungalow in the backyard of the Ripponlea home Mark shared with his wife Janelle. They became increasingly aware of his depression as he tended to withdraw from those around him and sleep for the vast majority of the day. They were able

to encourage Mr Vanderwerf to discuss his experiences and feelings on some occasions.

In 2007, Mr Vanderwerf commenced a relationship with Maree Germech which ended amicably at Mr Vanderwerf’s volition, after approximately four years. In 2009, Mr Vanderwerf moved into his rental apartment in St Kilda, Melbourne.

There were periods during Mr Vanderwerf’s life when he experienced mental health. During these times, he would engage in the outdoor activities he had always enjoyed; he was very fit and often went hiking in the Grampians. He would also socialise with Ms Germech, who remained a good friend, and they would see movies together. Mr Vanderwerf would play chess in the botanical gardens and enjoyed yoga. He had a few close friends who did not know each other well. Mr Vanderwerf also felt very close with Mark and Janelle’s sons and

doted on them.

Medical Treatment in Australia

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In 2010, Mr Vanderwerf began consulting General Practitioner Dr Jenny Jobst. After five sessions, Dr Jobst became aware of his mental il] health and created a treatment plan for his depression. In early May 2012, Dr Jobst referred Mr Vanderwerf to Psychiatrist and Psychotherapist Dr Martin Day.

On 14 May 2012, Mr Vanderwerf consulted Dr Day for the first time and they continued to meet regularly until 15 August 2014. During this time, Mr Vanderwerf’s mood stabilised

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and his therapy was generally focused on his personal circumstances; he was still

unemployed and living on his dwindling life-savings.

Over time, Dr Day became aware that Mr Vanderwerf would paint a euphemistic picture of his mood which was not as well managed as it had initially appeared. Consequently, he changed the goals of Mr Vanderwerf’s treatment to general support and decided to

reconsider more ambitious changes to his patient’s personal circumstances at a later time.

On 13 September 2012, Mr Vanderwerf began to consult Psychiatrist Dr Barbara Kulijewicz. He disclosed that he had experienced increasingly frequent bouts of depression since the age of 31 and that he had seen multiple clinicians in an effort to curb his symptoms. Despite efforts to find the correct pharmacological treatment, Mr Vanderwerf’s mood continued to fluctuate. Occasionally, he was non-compliant with medication and/or

attendance.

Dr Kulijewicz determined that Mr Vanderwerf minimised his symptoms out of embatrassment; he also found unemployment and need of financial support a source of shame. Mr Vanderwerf indicated to Dr Kulijewicz that he had kept his unemployment a secret for two years, only to reveal it out of fear that he would face financial troubles similar

to those which had triggered his attempted suicide in 2006.

On 15 August 2014, Mr Vanderwerf ended his first course of treatment with Dr Day, apparently frustrated with his lack of progress. He told Dr Day that ‘/ove not therapy’ was the answer to his mental health issues. Dr Day’ stated that the first course of Mr Vanderwerf’s treatment? identified that he had a ‘profound disturbance of personality structure, with primitive psychotic components’. Dr Day also identified that Mr Vanderwerf had impaired ‘emotional literacy’ and struggled to connect other people’s emotions and his own. Dr Day commented that Mr Vanderwerf would often undergo self-imposed periods of

isolation.

Dr Day and Dr Kulijewicz both indicated that they learned of Mr Vanderwerf’s suicidal ideation and intentions after the fact and when these feelings were resolved. Dr Kulijewicz commented that she had never seen her patient in a crisis point but learned about these

instances retrospectively.

? Between 14 May 2012 and 15 August 2014.

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On 4 May 2015, Mr Vanderwerf recommenced his consultations with Dr Day.

Dr Kulijewicz recommended this course of action when it became apparent that

Mr Vanderwerf was re-exhibiting symptoms of mild depression.

During the following year of treatment with Dr Day,? Mr Vanderwerf was offered access to a number of practical life-aids. Mr Vanderwerf was often either lacklustre in his approach to utilising these referrals or reticent to use them at all. Amoung a number of other referrals, he

declined to use the following: a. Mental health case management through public or private systems for assistance with daily living tasks; b. Group therapy sessions; and c. Double general practitioner appointments when other clinicians were on breaks.

Between 4 May 2015 and 22 August 2016, Mr Vanderwerf withdrew from treatment with Dr Day on a number of occasions. During these times, he would experience suicidal

thinking, recover to a degree and then return to therapy.

On 20 May 2016, Mr Vanderwerf returned to therapy with Dr Day after a four month absence. He revealed that he abandoned a suicide attempt during March that year.

Mr Vanderwerf said that he took the train to Stawell and stayed there for two nights. On the third day he took a taxi to the nearby camping area at Halls Gap. He attached a noose to a secluded tree and sat on the branch to which the rope was fastened and put the noose around his neck. Mr Vanderwerf then told his doctor that he climbed down the tree and returned to

Melbourne.

Mr Vanderwerf also revealed to Dr Day that he had endured another abandoned suicide attempt on 23 April 2016. He said that he had prepared for this event by consulting different health practitioners, seeking a supply of sleeping tablets. Mr Vanderwerf said that he returned to Halls Gap on 23 April 2016 with a bottle of whisky, multiple temazepam‘ tablets

and six to eight grams of quetiapine.’ He reported poor recollection of the next events,

3 Between 4 May 2015 and 22 August 2016.

  • Temazepam is a drug of the benzodiazepine class. It may assist with insomnia by interacting with chemicals in the brain which may cause sleep problems when unbalanced.

3 Quetiapine is atypical antipsychotic drug which is used in the treatment of schizophrenia, bipolar disorder and major depression. Quetiapine may have a sedative effect but it is not recommended for aiding sleep.

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however, Mr Vanderwerf did remember waking in the bush after possibly spending the night

outside. He was delirious, barefoot and in a state of undress.

  1. Dr Day stated that Mr Vanderwerf would only return for treatment after the suicidal ideation had resolved. Dr Day said that his patient suffered a pattern of commencing treatment, withdrawal from treatment, suicidal ideation and return to treatment.

  2. At the time of his disappearance, Mr Vanderwerf was prescribed:

a. Lamictal® 100mg chewable tablets nocte;

b. Lamictal 200mg chewable tablets 1 nightly;

e. Lithium carbonate’ 250mg tablets 2bd with food;

d. Seroquel XR* 400mg modified release tablets 1 nightly; and e. Thyroxine sodium’ 50mczg tablets 1 daily.

Missing Person Report

  1. At approximately 5.00am on 24 September 2016,'* Jeff Vanderwerf received an email from his brother. At this time, Jeff resided in California in the United States of America.

Mr Vanderwerf had written to Jeff to inform him that his truck was parked at the Borough Huts parking lot, south of Halls Gap. The emai! read like a “suicide note” and mentioned who should receive the benefit of his assets once his ‘expenses (were) cared for...’

  1. At 3.36am on 25 September 2016, Jeff messaged Janelle and asked if she had received the email; she had not. Jeff forwarded the email to Janelle who read it and immediately became concerned and contacted Mark."

  2. Mark contacted St Kilda Police Station and reported Mr Vanderwerf missing. It was quickly

established that Mr Vanderwerf’s truck was parked near Borough Huts parking lot, south of Halls Gap, and that this was his last known location.

® Lamictal (lamotrigine) is an anticonvulsant medication which is used in the treatment of epilepsy. It may also be used to treat acute depressive episodes in bipolar disorder.

7 Lithium carbonate is an inorganic compound which may be used to treat mania episodes in bipolar disorder.

5 Seroquel is quetiapine; please see above n 4.

® Thyroxine sodium is manufactured from the thyroid hormone and is used to treat hyperthyroidism.

10 This was the local time in Jeff's location.

1 Mark and Janelle separated prior to Mr Vanderwerf’s disappearance.

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At approximately 10.00am on 25 September 2016, Leading Senior Constable (LSC) Kellie Harris of Halls Gap Uniformed Police received notice to attend the Borough Huts parking lot to determine if Mr Vanderwerf was with his vehicle. She was unable to locate the vehicle. LSC Harris returned to the Halls Gap Police Station, conducted a LEAP search and

found that the details she had been provided for the vehicle were incorrect.

At approximately 12.00pm, LSC Harris retumed to the Borough Huts parking lot and located Mr Vanderwerf’s Hilux utility; the doors were locked and a steering wheel bar was

visible through the closed windows.

POLICE INVESTIGATION

The circumstances of Mr Vanderwerf’s disappearance have been the subject of investigation by Victoria Police. Police obtained statements from his family, friends and medical

practitioners. No evidence suggests direct third party involvement was identified.

Investigation of Events Prior to Disappearance

During the course of the investigation, Victoria Police leamt of Mr Vanderwerf’s movements prior to his disappearance through various investigative means, including a

review of his bank account statements.

Victoria Police ascertained that Mr Vanderwerf went to Bunnings Warehouse in Port Melbourne on 18 September 2016. He purchased a 3.7 metre to 6.5 metre extendible, straight, aluminium ladder. He also bought two marine quality ropes. At that time,

Mr Vanderwerf visited his storage facility nearby and removed unknown items.

On 19 September 2016, Mr Vanderwerf travelled to Stawell. He stopped at a Caltex petrol station in Ararat and CCTV footage shows that an aluminium ladder was affixed to his vehicle’s roof. At approximately 2.20pm, Mr Vanderwerf checked into the Goldfields Comfort Inn.

On 20 September 2016, Mr Vanderwerf purchased approximately $60.00 of unknown items from Woolworths in Stawell. On this day Mr Vanderwerf also emailed Jeff to request his postal address. My investigator informed me that Victoria Police believe this was to send his

apparent “suicide note” by post, in case his email failed.

At an unknown time on 21 September 2016, Mr Vanderwerf withdrew cash from an ANZ ATM in Halls Gap. At 4.12pm, Mr Vanderwerf purchased a fluorescent yellow 12 litre dry

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bag from Stawell. Sports Scene. The retailer recalls seeing a car matching the description of

Mr Vanderwerf’s utility at the front of the store, with a ladder on the roof.

On 22 September 2016, Mr Vanderwerf purchased three rolls of plastic marking tape from David O. Jones Hardware in Stawell. One roll of tape was a lime green colour which matched the colour of the tape observed on a disused walking track during the third search.

At 1.10pm, Mr Vanderwerf installed a program on his email account called “Gmail delay” which allowed him to select the date and time an email would be received. He also received

an email response from Jeff.

On 23 September 2016, Mr Vanderwerf checked out of the Goldfields Comfort Inn. At approximately 2.00pm, a local resident observed a tall man matching Mr Vanderwerf’s description. The man wore a baseball cap on and was walking south on Grampians Road which is approximately eight kilometres south of the Borough Huts. The resident described

the individual as ‘on a mission’.

Investigation of Property

AA,

When Victoria Police inspected Mr Vanderwerf’s car, they found it to be incredibly clean; there was no dirt under the wheel wells or tyres. The utility contained a number of his personal possessions which were packaged and labelled for distribution to friends and family.

Police officers noted that the fuel gauge showed the tank was 25 percent filled. DSC Radoievici informed me that there were possibly hundreds of kilometres of driving unaccounted for, if Mr Vanderwerf filled his fuel tank to capacity at the Ararat Caltex on the way to Stawell. My investigator postulated that this may represent times that Mr Vanderwerf

drove to different areas near the Borough Huts, possibly to conceal the rope and ladder.

Victoria Police also inspected his apartment in St Kilda shortly after his disappearance and identified that he had packaged and labelled his possessions as he had in the Hilux utility.

The Victoria Police E-Crime unit inspected Mr Vanderwerf’s laptop, telephone and GPS.

The E-Crime Unit identified that Jeff received the email about the location of Mr Vanderwerf’s utility approximately 48 hours after the email had actually been sent. .

Mr Vanderwerf had visited the website for “Gmail Delay” a number of times prior to downloading the application.

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The GPS unit revealed that Mr Vanderwerf had walked along the Cathcart Memorial Track

along Mt Rosa prior to his disappearance and that he went “off track” at two locations.

Mr Vanderwerf had 11 recorded phone calls in the month of September: a. On 13 September 2016, he contacted his friend Chris Pappas at 11.39pm;

b. On 15 September 2016, he contacted Breeanna McGrath and an insurance company;

and

c. On 18 September 2016, he contacted a company that sells prepaid mobile phone

cards and a 1800 number.”

Searches for Mr Vanderwerf

There have been four search operations since Mr Vanderwerf was reported missing.

On 25 September 2016, a search was conducted within a 500 metre radius of his vehicle at the Borough Huts parking lot, as well as most of the roads and walking tracks in the area.

The search was controlled by the Duty Sergeant for Victoria Police Search and Rescue, Acting Sergeant (AS) Nicole Bath. The initial search involved over sixty searchers, including: local police, Search and Rescue, the Dog Squad, Victoria Police Air Wing and

Parks Victoria personnel.

On 28 September 2016, the search was suspended due to weather.

Between 17 October 2016 and 19 October 2016, the second search took place. This involved

local State Emergency Services members and concentrated on Cathcart Memorial Track.

On 12 December 2016, another two-day search was commenced. The searchers comprised of Victoria Police Search and Rescue members, local State Emergency Services volunteers, the Police Mounted Branch and Victoria Police Air Wing. The search area included areas of interest around Mt. Rosea in the Grampian Ranges. The Air Wing searched twenty

kilometres south of Borough Huts for one kilometre either side, without success.

On this occasion, searchers located green fluorescent tape along a disused walking track.

Searchers noted that the majority: of trees around Jimmy Creek Campground,” off Grampians Road, Mafeking are Stringy Bark. The stump of the tree can extend upward of

four to six metres before branching out, making the movement of a ladder through the bush

12 1-800-869-3557 which seems to be associated with “Wells Fargo” a bank in the United States of America.

3 Approximately twenty seven kilometres south of Mr Rosea.

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extremely difficult. The bushland at this location is very thick and relatively steep, particularly along Cathcart Memorial Track.

Despite their efforts, Victoria Police and other search and rescue personnel were not able to locate Mr Vanderwerf. Mr Vanderwerf has not contacted any persons known to him since

his disappearance.

Recent Investigations & “Proof of Life” Checks

DSC Radoievici took over the Missing Person investigation in relation to Gerald Vanderwerf on 9 September 2017. After receiving a direction to assist me in my investigation into the disappearance and suspected death of Gerald Vanderwerf, he completed a number of recent enquiries in order to determine whether Mr Vanderwerf had

re-located to a new location. The enquiries identified that Mr Vanderwerf: a. Had not legally changed his name; b. Did not have a new, connected, or used telephone number; c. Received a final payment from Centrelink on 18 August 2016; d. Had two accounts with the ANZ Bank which held $33.56 and $118.06 respectively; e. Had not been documented emigrating from Australia since his disappearance; and f. Had no record of contact with interstate police forces since his disappearance,

Between 20 November 2017 and 23 November 2017, DSC Radoievici organised the fourth and most recent search for Mr Vanderwerf’s body. Cadaver dogs were brought in from Queensland Police to assist. This search area had been narrowed down to a specific area

near Mt. Rosea in the Grampian Ranges. Mr Vanderwerf’s remains have not been located.

During the investigation, Dr Day opined that it was more likely Mr Vanderwerf elected to end his own life, in a manner of his choosing as opposed to re-starting his life elsewhere.

Mr Vanderwerf’s family and friends reached the same conclusion. Janelle stated that it would be characteristic of Mr Vanderwerf to quietly end his life in the bush in an effort to avoid their distress. Mark also believed Mr Vanderwerf had ended his life this way to cause less stress to his family, but that his disappearance had been difficult for all involved.

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SUMMARY INQUEST

  1. On 18 September 2018, an Inquest into the disappearance and suspected death of Gerald Vanderwerf was held. There has been no new evidence identified in relation to the

investigation since the compilation of the Coronial Brief.

FINDING

Gerald Vanderwerf’s prolonged absence of contact with any persons, together with the totality of the evidence of the circumstances surrounding his disappearance, supports a Finding on the balance

of probabilities that he is deceased.

The evidence before me is demonstrative of Gerald Vanderwerf’s mental ill health, previous suicidality, and his methodical actions between 13 September 2016 and 23 September 2016.

The available evidence is sufficient to make a Finding on the balance of probabilities that

Gerald Vanderwerf entered the bush in the Grampian Ranges with the intention to end his own life.

On the balance of probabilities, I find that Gerald Vanderwerf is deceased, in circumstances where

I find that he has intentionally ended his own life at an unknown location in the Grampian Ranges.

I find that he died on or about 23 September 2016.

Iam unable to make a finding as to the cause of his death.

Pursuant to section 77(3) of the Coroner Act 2008 (Vic), the investigation into the disappearance and suspected death of Gerald Vanderwerf may be reopened if any new facts and circumstances

come to light.

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Pursuant to section 73(1) of the Coroners Act 2008 (Vic), 1 order that this Finding be published on

the internet.

I direct that a copy of this Finding be provided to the following:

Mark Vanderwerf Janelle Vanderwerf

Detective Senior Constable Slagian Radoievici

Signature: | pr — | — |

AUDREY JAMIESON CORONER

Date: 18 September 2018 ———

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