Demographics
30y, male
Coroner
State Coroner Judge John Cain
Date of death
2020-06-03
Finding date
2022-11-25
Cause of death
Cyanide poisoning
AI-generated summary
A 30-year-old teacher in regional Victoria died from cyanide poisoning in June 2020. He presented to his GP in February 2020 with atypical features including fear of being poisoned, which raised concerns for possible psychiatric disorder or substance abuse, but no mental health history was disclosed. He was not referred for mental health assessment despite these red flags. In May 2020, he obtained potassium cyanide online from a NSW supplier (Bacto Laboratories) by falsely declaring himself a cleaner on an End User Declaration. The supplier had concerns about the legitimacy of the purchase but proceeded after police contact yielded no response. The coroner found he died by suicide and identified regulatory failures: the NSW supplier failed to verify his authority to obtain Schedule 7 substances, contrary to NSW regulatory requirements. The coroner recommended education programs for Schedule 7 substance suppliers regarding their regulatory obligations.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT COR 2020 002945 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 *Amended pursuant to section 76 of the Coroners Act 2008 Findings of: Judge John Cain, State Coroner Deceased: Date of birth: Date of death: 3 June 2020 Cause of death: 1(a) CYANIDE POISONING Place of death: Swan Hill, Victoria 3585
was 30 years old when he was found deceased in his rental property in Swan Hill, Victoria.
is survived by his two siblings, and brother, recalled that growing up he and his siblings were ‘very tight knit...and all the siblings were very close to each other’.1
After completing high school at Lakeside Secondary College in Reservoir, went on to study at La Trobe University to become a secondary school teacher. When he completed his studies, commenced employment at Mount Ridley College in Craigieburn before moving to Traralgon and then College. described as a hard worker and as being very self-dependent.
stated that when was working at Mount Ridley College he had been looking after their elderly father and suddenly ‘packed up and left’. was upset with this decision and ‘contact with was very minimal [after] that time’.2
After moved to Swan Hill in January 2020, stated that he had ‘concerns for his mental health and [he] was trying to get him back to Melbourne so that [he] could monitor him’. also recalled that seemed worried and would say that he was not sure if ‘he was imagining things’.3
During the first lockdown of the COVID-19 pandemic, stated that struggled being confined to his apartment and believes that working from home would have been difficult for him.
death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.
The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances 1 Coronial Brief (CB), pg 14. 2 Ibid.
3 CB, pg 5.
are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.
Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.
Victoria Police assigned Senior Constable Stephen Ablett to be the Coroner’s Investigator for the investigation of death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.4
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased
Medical cause of death
4 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.
The post mortem CT scan revealed a fatty liver and small pleural effusions. There was no other significant finding or evidence of skeletal trauma. There were no external injuries or overt evidence of violence or injury contributing to death.5
The toxicological analysis revealed the presence of cyanide, temazepam and oxazepam. The toxicological report stated that cyanide is very potent and acts rapidly to produce hypoxia in high oxygen demanding tissue.6
Dr Bouwer provided an opinion that the medical cause of death was: 1 (a) CYANIDE POISONING.
Circumstances in which the death occurred
described as a ‘very quiet and reserved person at school and [he] kept to himself a lot’.7
Due to the onset of the COVID-19 pandemic, approximately 8 weeks after commenced at College, he was required to work from home and undertake remote learning. Mr stated that during the remote learning period the ‘leading teachers would conduct welfare checks on the other teachers on a regular basis. This was done by either a phone call, text or email’.8 Mr stated that there were no warning flags raised and did not show any signs of mental health issues.
On 22 February 2020, attended the Swan Hill Primary Medical Centre where he was seen by Dr Ernan Hession. On first presentation, Dr Hession assessed him as being atypical and queried whether if his presentation represented a psychiatric disorder or possible substance abuse. mentioned a fear of being poisoned at school and requested a copy of Dr Hession’s 5 CB, pgs 58 – 62.
6 CB, pgs 63 – 68.
7 CB, pg 20.
8 Ibid.
notes about him. He did not reveal any past mental health history to Dr Hession. Dr Hession ordered base line blood tests and asked to return for review. 9
On 14 May 2020, again attended Dr Hession complaining of sleep issues. He felt that these were due to being out of routine as a result of the COVID lockdown. He appeared as rational and non-distressed on this occasion and was prescribed melatonin with a short-term use of Temazepam.10
was last seen alive by his neighbour at 7am on 2 June 2020, leaving his residence in his vehicle. His whereabouts after this time are not known.
On 3 June 2020, Mr a member of the College social welfare team arrived at work and was informed that had not arrived for work or called in sick.
Mr and another member of the social welfare team attended home address. They knocked on the front door numerous times with no response but observed that car was in the driveway. Mr obtained entry via an unlocked window and upon entering the residence, located lying face down at the bottom of the stairwell. Mr stated that was stiff and blue in colour and non-responsive. Emergency services were contacted.11
At or around 11:20am, police and paramedics arrived on scene, and was declared deceased.
The attending police located an empty bottle of Temazepam in the kitchen and a cardboard box marked ‘Toxic.’ An invoice taped to the bottom revealed that had ordered potassium cyanide online from Bacto Laboratories Pty Ltd in New South Wales. The contents had been delivered on 2 June 2020. The bottle had been opened and was next to a drink bottle in the kitchen sink. No suicide note was located.12 9 CB, pg 37.
10 CB, pg 37.
11 CB, pgs 16 – 17.
12 Summary of incident by Senior Constable Stephen Ablett, undated.
FURTHER INVESTIGATION Investigation by Victoria Police
Following death, Victoria Police commenced an investigation to confirm how was able to acquire the potassium cyanide from Bacto Laboratories. Bacto Laboratories supplies laboratory equipment, laboratory consumables and chemicals to consumers.
It was established that had placed an order for 250g of potassium cyanide from Bacto Laboratories on 6 May 2020.
On 4 June 2020, police contacted Mr Phillip Carter, Managing Director of Bacto Laboratories and statements were subsequently obtained from employees outlining the circumstances around the sale and supply of potassium cyanide to
On 15 June 2020, Mr Carter wrote to Senior Constable Ablett and provided the following information:
• ‘potassium cyanide is…a precursor/reagent used in illicit drug manufacturing and is listed as a Category III precursor in the ‘Code of Practice for the Supply Diversion into Illicit Drug Manufacture…drug precursors are a regular problem for us, and we are always trying to monitor this possible problem’
• Potassium cyanide is branded Scharlau and imported by Chem Supply and kept in their South Australia warehouse.
• When we ordered this product…a message appeared on the screen saying it was a restricted product. As it is listed in the ‘Code of Practice for The Supply Diversion Into Illicit Drug Manufacture’ and our staff followed our procedures requesting the customer fill in a ‘Drug Precursor [End User Declaration]’ and supply a copy of his identification’.
• Mr Carter also stated that Bacto Laboratories, ‘often cancel orders or refer orders to the police before we supply goods’.13
• In her statement to police, Ms Cherie Marshall, Director of Bacto Laboratories stated that at the time placed his order, the potassium cyanide was out of stock.
• On 18 May 2020, Mr completed an End User Declaration (EUD) with Bacto Laboratories. stated on the EUD that he was a cleaner and required the product for use in a cleaning task.
• Ms Marshall called Parramatta Police Station about an unrelated matter and spoke to a police officer in the drug investigation unit. Ms Marshall advised the police officer that she, ‘had a bad feeling about this customer using potassium cyanide for cleaning’14. Bacto Laboratories did not hear back from the drug investigation unit and subsequently processed order.
• initially provided Bacto Laboratories with his Australia Passport Number and Bacto Laboratories requested a complete copy of passport or driver’s licence.
provided this documentation to Bacto Laboratories quickly which was considered to be unusual. An employee of Bacto Laboratories stated that it can often take a number of days for people to supply documentation.15
• On 22 May 2020, Bacto Laboratories purchased the potassium cyanide from their supplier, Chem Supply Ptd Ltd in South Australia. An End User Statement (akin to an EUD) was completed between Chem Supply Pty Ltd and Bacto Laboratories.16
• On 28 May 2020, Bacto Laboratories shipped the potassium cyanide to .17 Code of Practice for Supply Diversion into Illicit Drug Manufacture
‘The Code of Practice for Supply Diversion into Illicit Drug Manufacture’18 (the Code) offers best practice principles to assist companies in the prevention of diversion of legitimate industrial chemicals into illicit drug manufacture.
The Code was first developed in 1994 by Chemistry Australia and Science Industry Australia in partnership with law enforcement bodies. It was most recently updated in October 2008.
14 CB, pg 23.
15 CB, pg 30.
16 Schedule L – End User Statement dated 22 May 2020 at CB, p 75.
17 Dangerous Good Shipping Document at CB, p 79; Bacto Laboratories Packing Slip dated 28 May 2020 at CB, p 78.
18 https://chemistryaustralia.org.au/Library/PageContentVersionAttachment/9be9d383-1118-4153-baa94e3145b3f959/code_of_practice_for_supply_diversion_into_illicit_drug_manufacture.pdf
• Protect against the diversion of chemicals and scientific equipment into the illicit production of drugs.
• Cooperate with government and law enforcement agencies in the controlled delivery of chemicals and scientific equipment destined for the use in the illicit production of drugs, where this is expected to lead to the apprehension and conviction of criminal involved in such trade or production.
• Educate and train staff and where practical end users of the precursor drug chemicals as to the issues involved and procedures to be adopted.
• Category 1 – ‘Lists chemicals that required an End User Declaration (EUD) with each purchase and may be sold to ‘account customers’ and customers that are prepared to open an account.
• Category 2 – ‘Lists chemicals and apparatus that require an EUD when sold to nonaccount customers’.
• Category 3 – ‘Lists chemicals and apparatus that may be used in the illicit production of drugs. Purchases from this list should alert companies and organisations to seek further indicators of any suspicious orders or enquiries. No official reporting is required for items on this list unless considered warranted.’
Relevantly, ‘compliance with the Code is voluntary, and compliance with the Code will not ensure compliance with current legislative requirements. The relevant legislation in each jurisdiction must be consulted’.19 19 https://chemistryaustralia.org.au/safetyenvironment/code_of_practice_for_supply_diversion_into_illicit_drug_manufacture#:~:text=The%20Code%20of%2 0Practice%20for,chemicals%20into%20illicit%20drug%20manufacture.
Having considered the above information and available evidence, the focus of my investigation then turned to the policies and procedures in place to monitor and sale and acquisition of potassium cyanide in Victoria and New South Wales.
Sale and acquisition of potassium cyanide in Victoria and New South Wales Victoria
Cyanide is classified as a Schedule 7 poison in the ‘Standard for the Uniform Scheduling of Medicines and Poisons’. In Victoria, a permit is required to purchase or obtain a Schedule 7 poison for industrial, educational, advisory or research purposes in Victoria.20 The Victorian Department of Health website contains a link that can be used to apply for such a permit.21
Pursuant to Section 13 of the Drugs, Poisons and Controlled Substances Act 1981 (Vic)22, persons authorised to possess a poison or controlled substance include any registered medical practitioner, pharmacist, veterinary practitioner, dentist, an authorised officer who needs to perform functions imposed by the Act, or any person employed or engaged by a declared testing facility.
• a permit that may involve organisations providing health services;
• a licence to supply to wholesale (and possible manufacture); and
• a permit for other purposes (that may involve organisations performing research or industrial activities).
• the responsible person ordering cyanide;
• storage of the cyanide;
• security measures at the facility where the cyanide will be stored; and 20 Victorian Department of Health, ‘Schedule 7 substances requiring a permit’, https://www.health.vic.gov.au/drugsand-poisons/schedule-7-substances-requiring-a-permit.
21 Victorian Department of Health, ‘Licence and permits to possess (& possibly supply) scheduled substances’, https://www.health.vic.gov.au/drugs-and-poisons/licences-and-permits-to-possess-possibly-supply-scheduledsubstances.
22 http://classic.austlii.edu.au/au/legis/vic/consol_act/dpacsa1981422/s13.html.
• destruction of any unwanted cyanide.
The responsible person named on the application must either be a registered Australia health practitioner or have a qualification that includes significant studies in chemistry and/or human health.
To confirm whether had a permit to purchase cyanide in Victoria, the Court contacted Mr Tim Bownas, Acting Assistant Chief Officer for Licences and Permits and Health Practitioner Compliance, Medicines and Poisons Regulation, Department of Health. Mr Bownas stated that cyanide is primarily used for electroplating and permits are mainly requested by either jewellers or universities and permits are rarely issued to individuals. Mr Bownas confirmed that did not hold a permit for the purchase of cyanide in Victoria.
New South Wales
• the policies and procedures in place to monitor the sale and acquisition of potassium cyanide in NSW;
• the requirements to be met for a person to apply for and be granted a permit to acquire potassium cyanide in NSW; and
• the obligations on companies in NSW to confirm if a persons hold a permit to acquire potassium cyanide when receiving and fulfilling an order.
On 9 August 2022, the Court received a letter from Mr Bruce Battye, Director Pharmaceutical Regulatory Unit, Deputy Chief Pharmacist, Legal and Regulatory Branch at the NSW Ministry of Health.
Mr Battye stated that in NSW, akin to Victoria, cyanides are classified as “highly dangerous substances” included in Schedule 7, and under the provision of clause 20 of the Poisons and Therapeutic Good Regulation 2008 (the Regulation). A person cannot supply, obtain or use cyanides unless that person holds an authority issued under Part 8 of the Regulation.
In this case, where purchased the potassium cyanide for domestic or non-domestic industrial use, the end user and the supplier of the potassium cyanide are both required to be authorised.
Applications for an authority to obtain and use cyanides must be submitted on an Application for an Authority or Renewal of an Authority to Obtain Cyanide and applications are processed in accordance with Standard Operating Procedure, ‘Issue of Authority to Obtain and Use Cyanide.
Mr Battye stated that when applying for an authority, an applicant must provide details of:
• What the cyanide-based product will be used for;
• How the cyanide-based products are to be stored to prevent unauthorised access;
• How the cyanide-based products are to be stored when not in use, and the manner of disposal of spent solution; and
• Whether the cyanide-based products will be obtained for re-supply to another person.
The applicant is also required to have qualifications, formal training, or demonstrated experience in the handling of cyanides by including a copy of a signed Certificate of Training and Competence, or Statement issued by an education institution. They are also required to provide details on their experience in the handling of cyanides.
Mr Battye confirmed that these requirements have not changed since September 2013.
A letter is subsequently issued to the applicant and an authority document is signed off by the Director Pharmaceutical Regulatory Unit which is valid for up to 3 years.
Mr Battye stated that suppliers of cyanide are required to confirm if a person holds an authority to obtain and use cyanides when receiving and fulfilling an order. This includes the purchaser surrendering their authority to the supplier when obtaining the substance.23
As in this case, when an exemption for an authority does not apply, a supplier must not supply a Schedule 7 substance to any person unless they hold an authority to supply the substance and the purchaser holds an authority to obtain the substance.
23 See clause 20(3) of the Poisons and Therapeutic Good Regulation 2008.
• there have been no key changes to these policies and procedures since the date of death; and
• has never applied or been issued with an authority to obtain potassium cyanide in
Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was , born ; b) the death occurred on 3 June 2020 at Swan Hill, Victoria, 3585, from CYANIDE POISONING; and c) the death occurred in the circumstances described above.
I am satisfied that death was the intended consequence of the deliberate ingestion of potassium cyanide and that he intentionally took his own life.
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death: Acquiring potassium cyanide
I do not make any criticism of or wish to comment on the appropriateness of the regulatory framework in NSW that monitors the sale and acquisition of Schedule 7 substances. However, I am concerned with the ease in which was able to obtain the potassium cyanide and what appears to be noncompliance with the regulatory framework by Bacto Laboratories.
I consider that it may be appropriate for the Pharmaceutical Regulatory Unit of the NSW Ministry of Health to consider developing and implementing education programs or initiatives intended for suppliers of Schedule 7 substances to remind them of their obligations as set out in the current regulatory framework. In doing so, the Pharmaceutical Regulatory Unit of the
NSW Ministry of Health may also wish to consider liaising with Chemistry Australia and Science Industry Australia in relation to the currency and applicability of the Code.
I am cognisant of the fact that it is not within the jurisdiction of this Court to comment on any legal issues which may arise from the sale of potassium cyanide by Bacto Laboratories to I am of the view that these issues would more appropriately be investigated by the NSW Police Force and the Pharmaceutical Regulatory Unit of the NSW Ministry of Health.
A copy of this finding will be provided to the NSW Commissioner of Police and NSW Ministry of Health and to consider these issues further.
Suicide rates in Victoria
Unfortunately, the annual frequency of suicides occurring in the state of Victoria has been steadily increasing for the past decade.
Regrettably, there are no reliable tools or methods for predicting suicide. While there are some factors known to increase suicide risk, the majority of people with these risk factors do not suicide. It is difficult to assess which people with identified suicide risk factors may suicide, and if they might suicide in the short term. Predicting suicide is even more difficult in people who experience suicidal ideation in response to external stressors, as it can be difficult to predict when a stressor may occur and whether the person will experience suicidal ideation in response. Suicide attempts in such people tend to be impulsive and unpredictable.
Clearly, more needs to be done to address the increasing suicide rate in Victoria and Australia more generally. This is an issue that was carefully considered by the Mental Health Royal Commission. The Royal Commission report and recommendations was tabled in the Victorian Parliament on 2 March 2020. Many of the findings and recommendations are directed at providing greater support and assistance to people at risk of self-harm. The Victorian Government has agreed to implement all of the recommendations. It is anticipated that these initiatives will reduce the number of deaths that occur by suicide COVID-19 Impact on Suicide Rates in Victoria
The December 2021 Monthly Suicide Data Report produced by the Coroners Court of Victoria, shows that there were 713 Victorian suicides in 2020 and 683 Victorian suicides in
The May 2022 Monthly Suicide Data Report shows that there were approximately 288
Victorian suicides from January – May 2022. These numbers are comparable to previous years, which were 700 suicides in 2019 and 703 in 2018.24
Whilst it appears that the onset of the COVID-19 pandemic has not precipitated an increase in Victorian suicides, the pandemic and the measures implemented by governments to halt its spread have caused psychological distress for many Victorians and have been an important contextual factor in individual Victorians’ decisions to take their own lives. In case, the COVID-19 situation may have embedded itself as a stressor in his life and interacted/exacerbated other stressors.
In addition, in 2021 the Coroners Court of Victoria partnered with researchers from several institutions to generate early insights into the ways that COVID-19 might be acting as a stressor in Victorian suicides. Initial police reports for all suspected Victorian suicides during the first 11 months of the pandemic were reviewed, and the researchers found evidence of an explicit link between COVID-19's impacts and the decision to suicide in 60 cases (approximately 9.5% of all suspected Victorian suicides during the period). The research has been published in the Australian and New Zealand Journal of Public Health.25
The researchers identified three recurring sets of themes pertaining to COVID-19 in the deaths.
a) The first theme was that COVID-19, and its consequences adversely affected the individual's sense of self: restrictions on social interactions and movement interrupted familiar patterns of everyday life, and there was increasing worry about one's physical and mental health.
b) The second theme was the effect on the individual's relationships with others, through loss of social activities and community connectedness, an increased sense of loneliness, and strain on familial and intimate relationships.
c) The third theme was the effect on the individual's relationships with institutions, as people were displaced from their usual residential and employment and other contexts, 24 Coroners Court Monthly Suicide Data report May 2021. Published 20 January 2022 at p 3.
Dwyer J, Dwyer J, Hiscock R, et al., "COVID-19 as a context in suicide: early insights from Victoria, Australia", Australian and New Zealand Journal of Public Health 2021, Published 12 July 2021 https://onlinelibrary.wiley.com/doi/epdf/10.1111/1753-6405.13132
were forced to deal with social support services, and experienced interruptions to healthcare.
As the researchers have recognised, COVID-19 has been a significant stressor for some - eroding our sense of agency, affecting our general wellbeing, and impeding our connections with others. Our experiences in coping and dealing with the pandemic will be analysed over the coming months and years to determine what went well and what could have been done better. This information will be crucial in informing future government policy and allocation of resources to support our recovery and build our resilience.
The Coroners Court of Victoria will continue to assist this task by regularly publishing updated suicide statistics and relevant findings where appropriate I convey my sincere condolences to family for their loss.
Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: , Senior Next of Kin Bruce Battye, Director Pharmaceutical Regulatory Unit, Deputy Chief Pharmacist, NSW Ministry of Health Commissioner Karen Webb APM of the New South Wales Police Force Senior Constable Stephen Ablett, Coroner’s Investigator Signature:
JUDGE JOHN CAIN STATE CORONER Date: 25 November 2022 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a
coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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