Finding into death of Rachael Lee Dixon

IN THE CORONERS COURT COR 2024 002097 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 20081 Findings of: AUDREY JAMIESON, Coroner Deceased: Rachael Lee Dixon Date of birth: 30 July 1970 Date of death: 14 April 2024 Cause of death: 1a: Unascertained Place of death: 69 Fraser Street Clunes Victoria 3370 Keywords: Magic mushrooms, psilocybin, psilocin, toxicity, psychedelic drugs, woodlovers syndrome 1 Amended on 13 August 2025 to correct a minor typographical error.

INTRODUCTION

1. On 14 April 2024, Rachael Lee Dixon was 53 years old when she died at a health retreat in Clunes. At the time of her death, Rachael lived in Ringwood North, Victoria.

2. Rachael was raised on the South Island of New Zealand and during her adolescence completed an electrical apprenticeship. In 1994, Rachael commenced working as an Electrical Engineer for the New Zealand Army before she was medically discharged the following year.

3. In her twenties, Rachael moved to Australia and lived in various states before settling in Victoria. In 1997, she met Richard Mountain (Richard). In 2002, the pair married and in 2003, welcomed their son.

4. In 2004, Rachael and Richard separated however maintained a close relationship and at the time of Rachael’s death, were spending more time together and ‘reconnecting’.

5. Rachael had a passion for fitness and healthy living. Throughout her life she held various jobs including as a myo-therapist and personal trainer. She is fondly remembered as someone who was ‘always happy, laughing and positive’.

Medical History

6. According to Richard, Rachael ‘always struggled with mental health problems’. Rachael attributed her mental ill health to unresolved childhood trauma. There is no evidence that Rachael attended a medical practitioner, had received a diagnosis or was prescribed medication to manage the same. Indeed, Richard recalled that Rachael was averse to pharmaceutical and recreational drugs.

7. As early as 13 years of age, Rachael experienced an eating disorder, specifically bulimia.

Bulimic behaviours continued well into adulthood. On 28 January 2024, Rachael wrote to a friend, ‘I’m punishing myself with bulimic behaviour’. Rachael also struggled with excess alcohol consumption. According to Richard, her ‘drinking of alcohol increased over the years’. Rachael’s son similarly recalled that she drank alcohol when she felt ‘a bit sorry for herself’ and wanted ‘to mask the pain’.

Rachael’s use of psilocybin

8. Even though Rachael was against drugs, Richard believes that she saw ‘magic mushrooms’ as ‘a natural thing’. In the years leading up to her death, Rachael experimented increasingly with magic mushrooms.

9. Psilocybin is the active compound in magic mushrooms. The body converts psilocybin to psilocin, which possesses psychoactive characteristics. According to The Deep Self 28 Day Microdosing Experience, microdosing is ‘the practice of consuming very low, sub-perceptual (sub-hallucinogenic) doses of a psychedelic substance. When integrated into an intentional weekly routine, it has tremendous potential to help you heal and improve your quality of life’.

10. Rachael met Deanne Matthews to ‘learn Reiki and to heal’ approximately eight years before her death.2 On 10 November 2022, Deanne sent Rachael a copy of ‘The Deep Self 28 Day Microdosing Experience’ – a booklet containing journaling prompts and information on microdosing using psilocybin at home which Deanne had advertised as a $500 ‘investment’.

Rachael made annotations in the booklet as early as 20 November 2022.

11. In the booklet, Rachael wrote that her primary goal was ‘no binge drinking alcohol and food’.

She perceived psilocybin as a means to address and resolve her childhood trauma. Evidence indicates that Deanne coached and guided Rachael through microdosing, including on one occasion, instructing her to consume more psilocybin during a microdosing session.

12. Deanne rented a property in Clunes named ‘Soulbarn’ where she held ‘healing sessions’ – which she described as ‘an intimate group of people together [who] consume magic mushrooms for the purpose of dealing’. Participants pay to attend these ‘retreats’ and have either known Deanne for a long time or have been referred to her.

13. During a healing session, Deanne sources the magic mushrooms for the group and grinds them into a powder – to total an ‘approximate weight of 48 grams’. Participants begin the ritual by ingesting blue lotus, to help ‘relax the body in preparation for the journey’. They consume rice with a ‘small sprinkle’ of mushroom and perform a round of breath work.

14. Participants consume the mushroom power, brewed into a tea, in two servings. According to Deanne, the first dose contains between 1 and 3 grams of mushroom powder, ‘depending on how much they want’. Deanne, and her assistant who is also present, also consume a ‘micro 2 I note that Deanne Matthews also uses the name Diane Matthews/Mathews.

amount’. Approximately 90 minutes later, participants are invited to consume a second serving of tea. According to Deanne, during the intervening 90 minutes, she monitors the participants to ‘make sure they are safe, ok and [have] no adverse reaction to the mushroom use’. The second offering is of up to 3 grams – for a total amount of up to 6 grams of mushroom powder.

15. In the eighteen months prior to her death, Rachael attended all sessions Deanne held at Soulbarn – approximately every three months. According to Deanne, Rachael consumed the mushrooms on each occasion ‘without any problem’. However, Richard recalled differently.

According to him, Rachael told him about her most recent experience at Soulbarn: ‘she said that she had had a bad experience. She said that she went to a dark place and didn’t feel great after that consumption of psilocybin’. Rachael believed this was because ‘they had upped her dose of the psilocybin’.

16. Rachael reported positive effects of her psilocybin use. Her son stated: ‘I think they were definitely helping her, she seemed to be getting better. I knew she was getting better because she would stop drinking as much, she would always tell me how relaxed and how much better she felt within herself and about life’.

THE CORONIAL INVESTIGATION

17. Rachael’s 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.

18. 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 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.

19. 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.

20. Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Rachael’s death. The Coronial 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.

21. This finding draws on the totality of the coronial investigation into the death of Rachael Lee Dixon 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.3

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

22. On 13 April 2024, around midday, Rachael left home for a retreat at Soulbarn. According to her son, she was ‘very excited to go to the retreat’. Richard similarly recalled that the week prior, she excitedly told him ‘she thought this was going to be her big breakthrough moment’.

23. At the healing session that evening, in attendance were nine participants (including Rachael), Deanne and her assistant. At the commencement of the session, a fellow participant noticed that ‘Rachael was on a high, she was welcoming others and giving them hugs’. She repeated her intention of: ‘I’m meeting myself, I’m going home’. At approximately 6:15pm, Rachael consumed her first serve of mushroom tea, and at 7:45pm, consumed the second. Rachael drank the tea from a small bowl with a spoon.

24. At approximately 11:30pm, the mushroom’s psychedelic effects were wearing off some of the participants. Deanne’s recollection is as follows: Rachael called out to her and ‘was crying’.

Deanne comforted her and noticed she remained ‘under the effect of the mushroom’.

25. Deanne attempted to lift Rachael to her feet however, she could not walk. Another participant tried to assist Deanne, however, Rachael fell – ‘it was a decent fall’ from approximately 50 centimetres height.

3 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.

26. Deanne took Rachael to a separate area and lay her on a pillow. She instructed her assistant to contact Soulbarn’s landlord. Deanne formed the belief that Rachael ‘needed some fresh air’ and so moved her to the kitchen, opened the back door to let in ‘fresh cold air’.

27. There is little evidence from other participants regarding the events of the evening – noting that they were under the influence of psychedelics at the time. One participant recalls that at approximately 11:20pm, she heard Rachael say ‘help’. This participant consumed a similar amount of mushroom tea as Rachael and stated that she ‘didn’t feel neither good nor bad’.

28. Records indicate that at 11:53pm, Deanne contacted emergency services. According to a transcript of the telephone call, Deanne said: ‘I was holding a ceremony and I don’t think someone, she’s not responding’. When asked ‘do you know what happened to her?’, Deanne replied ‘I don’t know, she was just saying she couldn’t breathe’. Deanne was ‘not too sure’ if Rachael was breathing and was instructed to commence cardiopulmonary resuscitation

(CPR).

29. At 12:02am, a nearby Good Sam responder attended the scene, equipped with a defibrillator.

Upon their arrival, they observed CPR was underway. Deanne remained on the telephone with emergency services when the Good Sam responder attached the defibrillator. On the telephone recording, the defibrillator is heard stating, ‘shock not advised’ on six occasions. Several community members had arrived, including the landlord, who were taking turns performing

CPR.

30. At 12:09am, paramedics arrived at Soulbarn and found Rachael in asystole.4 They continued resuscitation efforts for approximately 30 minutes. At approximately 12:45am, paramedics declared Rachael deceased.

31. Victoria Police members attended the scene. They seized the bowl Deanne used to weigh the mushroom power, and the bowl and spoon Rachael used to drink the tea.

32. On 16 April 2024, members attended Rachael’s house and seized her journal, bedding and clothing. In Rachael’s bedroom, members located a small container with vegetal substance – believed to be mushrooms. Next to the container was The Deep Self 28 Day Microdosing Experience booklet.

4 A form of cardiac arrest in which the heart stops beating entirely.

33. Members accessed Rachael’s text messages and email account and located correspondence between herself and Deanne, dated as early as 10 November 2022.

Identity of the deceased

34. On 14 April 2024, Rachael Lee Dixon, born 30 July 1970, was visually identified by her friend, Deanne Mathews, who completed a formal Statement of Identification.

35. Identity is not in dispute and requires no further investigation.

Medical cause of death

36. Forensic Pathologist Dr Joanne Ho (Dr Ho) of the Victorian Institute of Forensic Medicine (VIFM) conducted an autopsy on the body of Rachael Dixon. Dr Ho considered materials including the Victorian Police Report of Death for the Coroner (Form 83) and post-mortem computed tomography (CT) scan and provided a written report of her findings dated 21 August 2024.

37. The post-mortem examination revealed mild fatty liver disease (‘hepatic steatosis’), uterine fibroids and contraction bands within the heart. Contraction bands signify new and irreversible myocyte injury. It is a non-specific finding and can occur in CPR, where there is trauma to the chest and in recent heart attacks (‘myocardial infarction’).

38. There was subgaleal bruising the left parietal and left temporal regions – bruising under the scalp on the left side of the head. Dr Ho attributed the bruising to a terminal collapse. There were anterior right 4th and 5th buckle fractures and anterior left 2nd to 6th buckle rib fractures.

39. There was no post mortem evidence of any injuries which may have caused or contributed to the death.

40. Toxicological analysis of post-mortem samples identified the presence of psilocin at a concentration of ~ 6 ng/mL.

41. Dr Ho stated that whilst there is a temporal relationship between Rachael’s consumption of the magic mushroom infused tea and her death, deaths purely attributed to psilocin are rare as psilocybin mushrooms have low toxicity – approximately 45 times less potent than lysergic acid diethylamide (LSD). She continued that deaths associated with psilocybin and psilocin were not directly linked to the intrinsic toxicity of the hallucinogen but rather circumstances

of misadventure or suicide while under its effects. Dr Ho concluded that the contribution of psilocin to Rachael’s death ‘cannot be made with any certainty’.

42. Dr Ho stated that there are some causes of sudden and unexpected death whereby no anatomical findings are revealed at post mortem examination – such as cardiac arrhythmias, seizure disorders and metabolic and biochemical derangements. Examination of the brain did not reveal any obvious causes for seizures. Examination of the heart did not show valvular or significant coronary artery disease.

43. C-reactive protein (CRP) and procalcitonin – markers of inflammation and/or infection – were not elevated. Microbiology comprising a blood culture showed Staphylococcus epidermis, likely a post mortem bacterial contaminant. Bilateral lung tissue and swabs showed no bacterial growth and no viruses.

44. Dr Ho provided an opinion that the medical cause of death was 1(a) UNASCERTAINED.

CRIMINAL INVESTIGATION

45. On 18 November 2024, Victoria Police arrested Deanne Matthews in relation to Trafficking in a Drug of Dependence. She was formally interviewed and released pending summons to appear at court.

46. On 13 March 2025, Deanne appeared before the Bacchus Marsh Magistrate’s Court. She was found guilty, received a fine of $3,000 and did not receive a conviction.

47. No other charges have been laid against Deanne.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

1. As noted above, Dr Ho of the VIFM concluded that Rachael’s medical cause of death was unascertained. Dr Ho noted that circumstantially there was a ‘temporal relationship between her death and the consumption of the magic mushroom infused tea’, but that psilocybin has very low intrinsic toxicity and deaths implicating psilocybin toxicity (as distinct from the

drug’s behavioural effects) are very rare, so “the contribution of psilocybin to her death cannot be made with any certainty”.

2. Uncertainty regarding the link between magic mushroom consumption and death is not unique to Rachael’s case. At my direction, the Coroners Prevention Unit (CPU) searched coronial databases and identified 20 deaths in Victoria between 2014 and the time of writing where psilocin was detected in forensic toxicology. In seven of these cases, forensic pathologists and/or coroners explicitly considered the potential link between magic mushroom consumption and death but were unable to determine whether it played a causal or contributory role. In a further five cases, the forensic pathologist and/or coroner implicated behavioural effects of magic mushrooms in the death; in three cases they implicated its toxic effects; and in the remaining five cases, the potential role of mushrooms was not explicitly considered or was considered and excluded.

3. During my investigation, I received correspondence from Dr Simon Beck of the Australian Psychedelic Society, which further highlighted what is still unknown about how magic mushroom use may be linked to death. Dr Beck drew my attention to a toxidrome called ‘wood-lover paralysis’, which is associated with the consumption of certain lignicolous mushrooms containing psilocybin and is characterised by experience of transient weakness.

Dr Beck, together with Caine Barlow, Liam Engel and Monica Barratt, recently published the results of a study reviewing online survey respondents’ reported subjective experiences of weakness following magic mushroom consumption.5 These results serve as a comprehensive and very useful introduction to the toxidrome.

4. The study involved 392 survey respondents (drawn from North America, Europe, Australia and New Zealand), 165 of whom reported experiencing muscle weakness at least once after ingesting psilocybin-containing mushrooms. The onset of weakness was reported to occur anywhere between 10 minutes to 18 hours after mushroom consumption. The weakness usually affected the limbs, and manifested at times, in an inability to stand or walk, difficulty swallowing, or subjective breathing difficulties. In some cases, the weakness came in ‘waves’.

5 Beck SA et al, “’Wood-lover paralysis’: Describing a toxidrome with symptoms of weakness caused by some lignicolous ‘wood-loving’ Psilocybe mushrooms”, Toxicon, vol 264, Sep 2025, 108450.

The duration of the weakness varied, in some cases extending to days after mushroom ingestion. In some cases, falls or other accidents were reported as a result of the weakness.

5. Dr Beck and his co-authors proposed a number of theories as to why wood-lover paralysis may occur, but could not confirm a mechanism for it, noting that there are still many gaps to be filled in our understanding of psilocybin-containing mushrooms and their effects.

6. In Dr Beck’s letter, he shared details of two cases of apparent wood-lover paralysis that he thought may be relevant to understanding the circumstances in which Rachael died. The first case was of a person in New Zealand who experienced weakness and breathing difficulties after consuming magic mushrooms and was subsequently found unresponsive by a friend and could not be resuscitated. The second case was of a person in Australia who developed symptoms consistent with wood-lover paralysis after consuming foraged magic mushrooms, and who required CPR and intubation in an intensive care unit when they lost the ability to breathe spontaneously; they reportedly recovered the next day with no cause identified for their symptoms.

7. Dr Beck commented on these cases: ‘Given the nature of the weakness described, seemingly having the ability to affect skeletal muscle broadly and at times quite severely, as well as the reports of subjective breathing difficulties, it seems reasonable to infer that respiratory depression and potentially respiratory arrest due to muscle weakness may be rare but possible consequences of woodlover paralysis.’

8. I was grateful to Dr Beck and his colleagues for sharing information regarding wood-lover paralysis with me. Having considered the information carefully in the context of Rachael’s death, I agree that the evidence regarding Rachael’s symptoms (particularly her being unable to walk and her loss of spontaneous breathing) appears to be consistent with symptoms linked to the wood-lover paralysis toxidrome. I also noted from witness statements that several other participants in the Clunes mushroom ceremony reported symptoms apparently consistent with wood-lover paralysis, including leg weakness and difficulty swallowing. However, as woodlover paralysis is a toxidrome without a confirmed mechanism and cannot be ascertained forensically, I ultimately determined on the balance of probabilities that I am unable to find

wood-lover paralysis caused or contributed to Rachael’s death. Accordingly, I must accept Dr Ho’s position that a medical cause of death cannot be ascertained.

9. However, I emphasise I have not concluded the mushroom consumption was unrelated to Rachael’s death. Rather, as already discussed, Rachael’s case reflects that we do not know enough at present about the chemistry and pharmacology of magic mushrooms to confirm or exclude that mushroom consumption caused or contributed to her death (whether via woodlover paralysis or another mechanism).

10. Adopting a prevention lens, the possibility that the magic mushroom consumption may have been implicated in Rachael’s death provides a rationale to consider how the risk of future similar deaths occurring might be reduced if the link turns out to be proven. This rationale is bolstered by the fact that forensic pathologists and coroners have on previous occasions, attributed Victorian deaths to the toxic effects of psilocybin and psilocin in magic mushrooms.

I further note Dr Beck and his colleagues’ observation that interest in and the use of magic mushrooms is on the rise in Australia and internationally, driven in part by developments such as Australia legalising the prescription of psilocybin to treat certain conditions on 1 July 2023.

This raises a concerning possibility that Victorian coroners will encounter more deaths in a setting of magic mushroom use in future. Indeed, this may already be occurring: among the 20 Victorian deaths the CPU identified where psilocin was detected in toxicology, only four occurred before 2020; there were two deaths in 2020, then four in 2021, one in 2022, three in 2023, and five in 2024.

11. In examining this prevention question, I considered first the nature of the mushroom consumption in Rachael’s death and the other Victorian deaths identified by the CPU. I noted that in each case the mushroom consumption occurred outside clinical supervision, usually alone or in the company of friends; Rachael was the only individual whose death occurred at a retreat or similar communal setting. I also noted that in all cases where the source of consumed magic mushrooms could be established, the deceased had foraged them or obtained them from an acquaintance.

12. I also considered the use of magic mushrooms from a harm reduction perspective. This perspective proceeds from an understanding that some people will use drugs regardless of any barriers, and therefore interventions need to focus first on preventing or reducing negative impacts of drug use (be they individual, social, legal or other). People have used magic mushrooms for a broad range of reasons for (at least) decades in Australia, despite any laws

prohibiting this, and I am not so naïve as to believe I could propose any interventions that would change this reality.

13. Finally, I considered Dr Ho’s advice that psilocybin-containing mushrooms have low toxicity and in particular that psilocybin itself has very low intrinsic toxicity. This was an important reminder for me to consider proportionality in prevention: that interventions should not cause undue alarm or panic by misrepresenting the risks they are intended to address.

14. I have concluded that at present the most appropriate intervention to consider is user education. People who use magic mushrooms and/or (as in the retreat Rachael attended) facilitate others’ use of magic mushrooms should be aware that, even if rare, harms including deaths have been associated with magic mushroom consumption, and if possible, they should put measures in place to recognise and respond to these harms if they occur. In this respect, my thinking is aligned with Dr Beck and his colleagues, who concluded in their research paper that: ‘Information about WLP [wood-lover paralysis] should be included in education about psilocybin mushrooms, both for consumers and service providers. Growing awareness of WLP effects, which mushrooms are most likely to produce WLP and syndrome management strategies for consumers and carers (e.g. avoid physical tasks, ensure temperature control, etc.) can help control this growing risk and should inform how markets are regulated.’

15. I do not make any formal recommendation in support of my prevention conclusions, because so far as I am aware, no organisation or body could reasonably be said to have the ability to reach and provide education to the diverse people in the Victorian community who might use magic mushrooms. However, I direct that this finding be published on the Coroners Court of Victoria website so that my insights are available to any organisations or individuals who are in a position to consider and disseminate them to those who might be at risk.

FINDINGS AND CONCLUSION

1. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Rachael Lee Dixon, born 30 July 1970; b) the death occurred on 14 April 2024 at 69 Fraser Street Clunes Victoria 3370;

c) I accept and adopt the medical cause of death ascribed by Dr Joanne Ho and I find that Rachael Lee Dixon died from unascertained causes;

2. AND, although I am unable to find to the requisite standard that the consumption of psylocibin caused or contributed to Rachael Lee Dixon’s death, I find that her death occurred in the context of her recent use of illicit drugs.

I convey my sincere condolences to Rachael’s family for their loss.

Pursuant to section 73(1) 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: Matthew Mountain, Senior Next of Kin Dr Simon Beck Detective Senior Constable Clive Martella, Coronial Investigator Signature:

AUDREY JAMIESON CORONER Date: 23 July 2025 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.