Finding into death of Phillip Henry Reidy

IN THE CORONERS COURT COR 2024 3732 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the Death of Phillip Henry Reidy Delivered on: 21 May 2025 Delivered at: Southbank, Victoria Hearing Date: 21 May 2025 Findings of: Coroner Paul Lawrie Representation: Tatjana Frei Hall and Wilcox for the Chief Commissioner of Police Caitlin Akthar of Counsel instructed by Marsdens Law Group for Bacto Laboratories Pty Ltd Counsel Assisting: Ms B. Abeysinghe – Coroners Court of Victoria Keywords: Death in police custody – arrest – suicide – sodium cyanide – Schedule 7 poison – availability of dangerous poison

I, Coroner Paul Lawrie, having investigated the death of Phillip Henry Reidy, and having held an inquest in relation to this death on 21 May 2025 – at Southbank, Victoria find that the identity of the deceased was Phillip Henry Reidy, born on 12 November 1996 and the death occurred on 2 July 2024 at Unit 1, 11 Windridge Way, Kyneton, Victoria 3444 from:

CYANIDE TOXICITY I find, under section 67(1) (c) of the Coroners Act 2008 (‘the Act’) that the death occurred in the following circumstances –

INTRODUCTION

1. On 2 July 2024, Phillip Reidy was 27 years of age when he passed away at his home in Kyneton after consuming sodium cyanide. He had just been arrested by police from Kyneton Police Station for criminal damage arising from a family violence incident.

2. The arrest had been proceeding in a calm and cooperative manner as Mr Reidy gathered himself to go with the police members. He asked to use the bathroom and then suddenly grabbed and swallowed sodium cyanide from a bottle laying nearby.

3. Mr Reidy quickly succumbed to the effects of the poison and collapsed to the floor, where he became unresponsive. Despite the first aid efforts of the police members, and paramedics who attended shortly afterwards, he died at the scene.

4. Mr Reidy’s death occurred whilst he was in police custody. Accordingly, pursuant to section 52(2)(b) of the Act, an inquest is mandatory.

CORONIAL INVESTIGATION AND INQUEST

5. Detective Sergeant Gemma Etherington of the Victoria Police Homicide Squad acted as the Coronial Investigator for the investigation of Mr Reidy’s death and compiled a brief of evidence. The coronial brief included:

(a) statements from Mr Reidy’s mother, previous partners, and associates;

(b) statements from police members and paramedics involved in the events of 2 July 2024 and investigators;

(c) statements and medical records from medical practitioners;

(d) statements and transaction records from Bacto Laboratories Pty Ltd;

(e) police body worn camera (BWC) recordings and CCTV recordings from inside Mr Reidy’s premises;

(f) scene photographs; and

(g) postmortem inspection report from the Victorian Institute of Forensic Medicine and toxicology report.

6. On 29 July 2024, I held an initial mention hearing. I determined subsequently that the matter should proceed in a manner which has come to be called, a ‘summary inquest’.

That is, an inquest where the evidence may be regarded as complete and uncontentious, and where it may be admitted in a summary form without the need to examine witnesses.

This took place on 21 May 2025.

PERSONAL BACKGROUND

7. Phillip Reidy grew up in Woodend as the youngest of three siblings. When he was seven years of age, he was diagnosed with attention deficit hyperactivity disorder (ADHD) and was prescribed Ritalin to manage his behaviour. He was engaged with the Child and Adolescent Mental Health Service until approximately age 15.

8. Mr Reidy attended Kyneton Secondary College but struggled in the school environment and was expelled in Year 8. He was subsequently enrolled at Gisborne Secondary College but never attended and did not continue with any further secondary education.

Later, he completed a Certificate III in Aged Care and a Certificate III in Community Care.

9. Mr Reidy moved out of the family home at age 16 after several family violence incidents where he was identified as the respondent. He was first arrested by police in 2013 after he assaulted a housemate with a knife causing a laceration to their hand.

10. When Mr Reidy was aged 17 to 18 years, he went through a period of extreme weight loss which was resolved after inpatient treatment at Bendigo Hospital. Peter Redding, a consulting psychologist who first saw Mr Reidy in July 2013, considered that he had ADHD and was autistic. Mr Redding noted that Mr Reidy suffered anxiety, obsessive thinking, and had difficulty relating with people.

11. At age 21, Mr Reidy was diagnosed with testosterone deficiency and was prescribed supplementary testosterone by injection every 12 weeks. In addition to this, he began taking supplements to enhance muscle growth, including selective antigen receptor modulators (SARMS) and the amino acid L-Theanine.

12. In about 2019, Mr Reidy became involved in cryptocurrency trading and reported to his family that he had accumulated a significant sum before apparently losing it all in 2021.

In May 2021, he transferred over $96,000 from his own account to an international bank in Florida, USA. It was later revealed that Mr Reidy had fallen victim to an investment scam and the loss of this money, together with the losses from his cryptocurrency trading, created a significant financial and emotional strain upon him.

13. In 2020, Mr Reidy began a relationship with Amintra Amyaem which lasted approximately one year. During this time, he disclosed to Ms Amyaem that he wanted to commit suicide because of his financial losses through online gambling.

14. In 2023, Mr Reidy enrolled in a Diploma of Nursing at Bendigo TAFE but he withdrew from the course halfway through the year. By this stage he had several convictions for contravening Family Violence Protection Orders, and he was concerned that these would affect his ability to gain employment as a nurse.

15. During 2023, Mr Reidy was working through an agency on a part-time or casual basis as a personal care attendant. He provided ‘community care’ to clients in their home and had one to two clients at a time.

16. At the time of his death he was unemployed and receiving Job Seeker payments, as well as financial assistance from his mother as required.

PURCHASE OF SODIUM CYANIDE

17. On 14 July 2023, Mr Reidy initiated an order for 250 grams of sodium cyanide (the order) from Bacto Laboratories Pty Ltd (Bacto) in New South Wales (NSW). Bacto sourced the compound from Chemsupply Australia Pty Ltd (Chem Supply). It was prepared in the form of small blocks of irregular size by the overseas manufacturer, Scharlab.

18. The order included false customer information after Bacto made inquiries of Mr Reidy.

While Mr Reidy used his correct name and his residential address, he purported to be ordering for a company called ‘THX Network’ for the purposes of gold extraction.1 There does not appear to be any company or registered business name in Australia corresponding to ‘THX Network’ (or any similar name).2 Mr Reidy also provided an email address that appeared to correspond to THX Network namely, Phillip@thx.network.

19. The sodium cyanide was shipped to Mr Reidy on or about 29 August 2023.

EARLIER EVENTS INVOLVING THE SODIUM CYANIDE

20. In early 2023, Mr Reidy commenced a relationship with GRW3 and they began living together at his residence in early 2024.

1 Sodium cyanide is used a part of an industrial process to leech gold from ore. Depending on the grade of the ore, typically 250g of sodium cyanide would be consumed in the treatment of approximately 0.5t of ore.

2 An ASIC search reveals only THX Pty Ltd, which was deregistered on 3 May 2020. Otherwise, ‘THX Network’ appears as blockchain based loyalty and rewards platform.

3 Pseudonym Order made 10 October 2024.

21. On 26 March 2024, the pair began arguing at home and GRW decided to leave. GRW packed her belongings and, as she was leaving, took the container of sodium cyanide from a desk drawer. Mr Reidy saw this and grabbed the cyanide from her.

22. On 2 June 2024, Mr Reidy was involved in another argument with GRW whilst at home.

He pushed her backwards, slapped her in the face, and threw her mobile phone to the ground causing it to break. He left shortly afterwards and took GRW’s phone with him to have it repaired. When Mr Reidy returned later that day, he retrieved the container of sodium cyanide from the computer desk, together with a bottle of soft drink, and went outside to his car. GRW followed him. Mr Reidy put some of the cyanide into the drink bottle and shook it up while saying that he had lost everything. Eventually GRW managed to calm him by making him focus on their future plans together. Ultimately, she retrieved the drink bottle from him and tipped out the contents.4

EVENTS OF 2 JULY 2024 Assault on GRW

23. On 2 July 2024, Mr Reidy and GRW were both at home in the morning and had made plans to travel to Woodend to shop and to visit Mr Reidy’s mother. While Mr Reidy was taking rubbish outside from the kitchen he cut his finger on a can in the bag of rubbish.

He blamed GRW for this accident and at 11:08am he slapped GRW’s face. (These events were recorded by an internal CCTV showing the kitchen and meals area of the residence.) He then grabbed GRW by her throat and threw her to the floor.

24. GRW called the manager at the café where she worked and asked for help. The manager then arranged for another employee to collect GRW from the address.

GRW’s report of the assault to police

25. At 12:41pm, GRW attended Kyneton Police Station where she made a written statement in respect of the events of that morning and the previous incidents involving family violence on 26 March 2024 and 2 June 2024. Her statement was taken by First Constable (FC) Ashleigh McKimmie who also took photos of GRW’s neck.

4 CB11-6 – Exhibit 1

26. In this statement, GRW referred to the sodium cyanide in the context of the incident on 2 June 2024: He said he was going to kill himself and got in the car. I went with him and he didn’t kill himself. He did buy a cyanide capsule from the internet to do this. He has had this in his house for a while but I am not sure how long.

27. After the statement was completed, GRW used her laptop computer to show FC McKimmie the CCTV recording of the assault that had occurred on 2 June 2024. FC McKimmie then spoke with Sergeant (Sgt) Michael Delaney, who was the section sergeant for the shift, and provided a briefing concerning the assault which included replaying the CCTV recording. Unfortunately, FC McKimmie inadvertently omitted from the briefing the information concerning the cyanide.

Police attendance to arrest Mr Reidy

28. Senior Constable (SC) Mathew Schubert and Constable (C/) Sam Spirli comprised the crew of the Kyneton divisional van for the afternoon shift.5 At 2:00pm, they were briefed by Sgt Delaney and also shown the CCTV recording. Sgt Delaney tasked them to attend Mr Reidy’s address to arrest him. On speaking with another police member, SC Schubert recalled that he had an unremarkable interaction with Mr Reidy approximately two weeks earlier when Mr Reidy had been the victim of a minor theft. Before leaving the police station, SC Schubert and C/ Spirli performed a check of Mr Reidy on the Victoria Police LEAP database. The only result of note was a warning flag for an active Intervention Order.

29. SC Schubert and C/ Spirli arrived at Mr Reidy’s premises at 2:28pm and activated their body worn cameras. Mr Reidy answered the front door, and after a short conversation just inside the front door, SC Schubert informed him that he was under arrest for criminal damage. SC Schubert then turned Mr Reidy around to place handcuffs on him from behind. He appeared compliant and although he was asking questions, he showed no sign of resistance.

5 Designated ‘Kyneton 303’ or ‘WKY303’

30. C/ Spirli had placed one handcuff on Mr Reidy’s left wrist when Mr Reidy asked if he could use the toilet and get a shirt. SC Schubert permitted this and removed the handcuff.

The time was 2:30:24pm.

31. Mr Reidy walked down a short hallway into a dining area adjacent to a kitchen, and up to a computer desk. The police members followed close behind, but Mr Reidy kept his back to them and picked up from the desk a white plastic bottle containing sodium cyanide.

Still with his back to the police members, he quickly and discretely swallowed some of the compound. The time elapsed from the removal of the handcuff was 9 seconds. Seven seconds later Mr Reidy picked up a bottle of soft drink and drank from it as he walked to the bathroom. All the while neither police member had appreciated what he had done. Mr Reidy began coughing and 19 seconds after ingesting the compound, collapsed to his knees.

32. After a few seconds Mr Reidy managed to walk towards the kitchen bench. He was continuing to cough and show signs of extreme discomfort. He fell to his knees in the kitchen and said, ‘Tell my mum I love her’. When SC Schubert asked what was happening, Mr Reidy said, ‘I’m dying’.

33. As Mr Reidy continued to deteriorate, C/ Spirli inspected the plastic container on the computer desk and discovered that it contained sodium cyanide. He told SC Schubert, who immediately called for urgent medical assistance. Communications were hampered by the fact that SC Schubert’s radio could not effectively transmit from within the premises, although it could receive. This meant that SC Schubert had to repeatedly run outside the house to transmit and then run back to help C/ Spirli.

34. Mr Reidy began coughing blood and losing consciousness. He was placed in the recovery position and the police members attempted to provide first aid. At 2:37pm, they assessed that Mr Reidy was no longer breathing, and they could no longer feel a pulse. SC Schubert immediately began chest compressions, swapping with C/ Spirli at 2:40pm.

35. At 2:42pm, Ambulance Victoria paramedics arrived. On assessment, Mr Reidy was found to be in cardiac arrest with pulseless electrical activity. Six minutes later a second paramedic crew arrived and assisted with the resuscitation efforts. Despite the emergency treatment, Mr Reidy could not be saved, and he was pronounced deceased at the scene by paramedics at 3:22pm.

IDENTITY AND CAUSE OF DEATH

36. On 12 July 2024, Coroner Peterson determined the identity of Mr Reidy’s body based upon fingerprint and other evidence as: Phillip Henry Reidy, born 12 November 1996.

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

38. On 9 July 2024, Dr Joanne Ho, Forensic Pathologist at the Victorian Institute of Forensic Medicine, conducted a post-mortem inspection of Mr Reidy’s body which included CT scan. Various minor injuries were noted but none of these were significant.

39. Analysis of post-mortem blood samples revealed the presence of cyanide at 82 mg/L which is consistent with fatal use.6

40. On 3 September 2024, Dr Ho provided a report of her findings and detailed the cause of death as ‘1(a) CYANIDE TOXICITY’. I accept Dr Ho’s opinion.

MR REIDY’S INTENT

41. On 15 July 2023, Mr Reidy stated to GRW during a WhatsApp exchange: Everything im quitting im gonna watch the world go by and sit at home and do nothing until my cyanide comes in the mail

42. I note that Mr Reidy wrote this the day after he first ordered the sodium cyanide online.

43. At about this time, Mr Reidy also said to his mother that he had purchased cyanide. She did not believe this claim, but Mr Reidy also said to her that he had a ‘way out’ and he would kill himself if she died or if he was arrested again.7

44. The events following the argument and assault upon GRW on 2 June 2024, further reveal Mr Reidy’s plans to use the compound to take his own life.

6 Report prepared by ChemCentre Scientific Division in Western Australia. CB3-5 – Exhibit 1 7 CB5-6 – Exhibit 1

45. I am satisfied that Mr Reidy had the sodium cyanide present and ready for use to end his life at a moment of his choosing. The ready availability of the Coca-Cola on 2 July 2024 was consistent with the method he had employed involving the drink bottle during the threatened suicide one month earlier. I am also satisfied that the soft drink sitting nearby was a considered part of Mr Reidy’s plan and designed to ensure the cyanide salt would react with sure effect.

BRIEFING AND PLANNING FOR THE ARREST

46. In her written statement made on 2 July 2024, FC McKimmie was forthright concerning the briefing she provided to Sgt Delaney and that she had omitted the reference to the cyanide. FC McKimmie explained the reason for the omission, at least as best as she was able to analyse her own thought process at the time. She attributed the mistake to her focus on the family violence issues and criminal offences she considered were evident from the CCTV recording, and her task to prepare a Family Violence Safety Notice. I accept that these circumstances contributed to the omission, and I conclude that this is an instance of human fallibility. The issue serves as a reminder of the importance of the use of a structured briefing process whenever possible to reduce the instances where important information may be overlooked.

47. The omission of the reference to the cyanide in the briefing of Sgt Delaney did have a consequential impact on the briefing that he provided to SC Schubert and C/ Spirli, and the importance of this information is clear. Nonetheless, it is not possible to conclude that SC Schubert and C/ Spirli would have treated Mr Reidy in a materially different manner in their dealings with him between the front door and the moment he ingested the compound. One cannot proceed beyond mere speculation in suggesting that they may have reacted to some sign from Mr Reidy in that brief period and managed to intervene.

48. There is nothing to suggest that the planning by SC Schubert and C/ Spirli was inadequate. They conducted a check of Mr Reidy on the LEAP database and, whilst en route to his premises, discussed the approach they would take with Mr Reidy. They decided that they would proceed directly to arrest without questioning him about the alleged offences, which was reasonable in the circumstances.

POLICE ACTIONS AT MR REIDY’S PREMISES

49. Mr Reidy was arrested just inside his front door at 2:30pm and was in the process of being handcuffed when he asked to use the bathroom and get a shirt. SC Schubert decided to facilitate these requests and removed the one handcuff that had been applied at that point. This appears reasonable. Mr Reidy gave every indication that he was prepared to accompany the police members without any difficulty, and the police members would want to do all they could to maintain his cooperation.

50. The police members stayed close behind Mr Reidy as he walked into the dining area and doubtless would have been very watchful for any threatening behaviour or anything that suggested that he may try to escape. However, there was nothing in his behaviour to suggest either of these responses. Once the handcuff was removed, he moved directly to the computer table where the sodium cyanide lay, but he did so in a manner that was unthreatening and designed to mask his intent. He purposefully used his back to obscure what he was doing, and it took only a moment – indeed, only 9 seconds elapsed between the removal of the handcuff and his ingestion of the compound.

51. Each day police members who are involved in the arrest of a person are required to make tactical decisions based on their continuous assessment of risks. Mr Reidy’s presentation as calm and cooperative would have been a significant feature in the tactical decision making of the police members. Despite the risks involved in removing the handcuff(s), there was nothing unreasonable in this decision. There were also risks involved in persisting with the handcuffing at that moment and refusing Mr Reidy’s straightforward requests. Among these risks was the potential for matters to descend into resistance and physical struggle.

52. It must also be remembered that the use of handcuffs constitutes a use of force which, just as any other means of force which may be used by a police member during an arrest, must be justifiable in accordance with section 462A of the Crimes Act 1958.8 While circumstances justifying the use of handcuffs may be present in many (or most) situations involving arrest, the justification must still be considered by the police member in each instance. The decision by SC Schubert to remove the handcuffs when he did is consistent with the need to consider the justification for the use of handcuffs in each case.

8 Slaveski v State of Victoria & Ors [2010] VSC 441 at paragraphs 131 to 133

53. The BWC recordings are revealing. Mr Reidy moved directly and with well disguised purpose. No criticism should be made of the police members for failing to recognise in those few seconds what he was doing.

54. Once Mr Reidy collapsed on the kitchen floor, the police members did all they could to provide first aid. Both members performed chest compressions in an effort to maintain Mr Reidy until paramedics arrived. I note that ‘rescue breaths’ were not performed as part of the cardiopulmonary resuscitation (CPR), which was fortunate as the only effect would have been to risk the police members to a closer exposure of hydrogen cyanide gas. This is a matter to which I shall return.

AVAILABILITY OF THE SODIUM CYANIDE Overview of the regulatory framework applicable to cyanides

55. The Standard for the Uniform Scheduling of Medicines and Poisons (‘SUSMP’ or ‘the Poisons Standard’)9 is a federal legislative instrument which lists substances according to schedules which are then used uniformly in state legislation.10 Schedule 7 lists dangerous poisons and includes cyanides.11

56. In Victoria, cyanides are ‘not for general sale by retail’ and a licence is required to supply them by wholesale. A permit is needed to obtain or use cyanides for health, research or industrial activities. An application for a licence, permit or authority must be made to the Secretary of the Department of Health.

57. In New South Wales, cyanides are classified as ‘highly dangerous substances’ within Schedule 7 and an authority issued by the Ministry of Health is required to sell, obtain or use cyanides.

58. However, unlike Victoria, the New South Wales legislation provides certain exemptions from the requirements for an authority. These exemptions include supply by wholesale or 9 Also known as ‘Therapeutic Goods (Poisons Standard—February 2025) Instrument 2025’.

10 In Victoria, this is the Drugs, Poisons and Controlled Substances Act 1981 and the Drugs, Poisons and Controlled Substances Regulations 2017. In NSW, this is the Poisons and Therapeutic Goods Act 1966 and the Poisons and Therapeutic Goods Regulation 2008.

11 Specifically, metallic cyanides such as sodium cyanide (NaCN), potassium cyanide (KCN) and others.

use by a person in charge of an institution or facility for scientific research, instruction, analysis or study. It was the ‘scientific use’ exemption that Mr Reidy exploited.

59. In New South Wales, if an exemption is claimed, suppliers should make enquiries to reasonably satisfy the bona fides of such an exemption prior to supply.12 Order, End User Declaration and supply

60. Mr Reidy first ordered the sodium cyanide from Bacto on 14 July 2023 and on 15 July Bacto sent an automated email confirmation of the order.13 Payment was made via PayPal at the time of the order.

61. On 7 August 2023, the Managing Director of Bacto, Phillip Carter, sent an email to Mr Reidy which explained that there had been a delay in supplying the order and that a ‘new’14 End User Declaration (EUD) form was required. The email also included an explanation that the compound was a ‘Highly Dangerous S7 Restricted Product’ such that its acquisition, use or supply required an authority issued by the NSW Ministry of Health. The email also included an explanation of the exception to this requirement as follows: Scientific Institution Exception: an EUD will be required from a scientifically qualified person in charge of a laboratory or department or a person acting under the direct personal supervision of such a person, authorising the scientist to possess and use the above Scheduled Poisons that is required for the conduct of medical or scientific research or instruction or the conduct of quality control or analysis. The EUD will also verify that you agree to the safe use, storage and disposal requirements in accordance with the manufacturers [sic] and all regulatory authority guidelines.15 12 www.health.nsw.gov.au/pharmaceutical/Pages/guide-schedule7.aspx 13 CB43-5 – Exhibit 1 14 The description of the form as ‘new’ does not appear to it being a further form to be completed by Mr Reidy. Rather, it appears to refer to the document having been recently introduced or updated.

15 CB43-9 – Exhibit 1. This explanation is based upon regulation 20 of the Poisons and Therapeutic Goods Regulation 2008 (NSW).

62. Attached to the email was a blank EUD16 and an explanatory document under Bacto’s letterhead and titled, ‘Schedule 7 Poisons’ (explanatory document).17 The explanatory document included the following: It is expected that if a supplier believes that an exemption applies to the supply of a Schedule 7 poison, including a highly dangerous Schedule 7 poison, in one of the above categories of exemption, that some inquiries will be made to reasonably satisfy the bona fides of such exemption prior to supply.

For example, a supplier should be satisfied that the bona fides of a person claiming to be in charge of a facility engaged in scientific research in a scientific establishment are legitimate by making some reasonable basic enquiries of the scientific establishment prior to supply 16 CB43-12 – Exhibit 1 17 CB43-11 – Exhibit 1

63. On 8 August 2023, Mr Reidy sent a short reply email to Mr Carter at Bacto which attached the completed EUD. (Mr Reidy had previously provided a copy of his Victorian driver licence.) A copy of the completed EUD is reproduced below –

64. On its face, the completed EUD should raise serious concerns regarding the authenticity of the information provided. A quick internet search reveals THX Network to be a blockchain based loyalty and rewards platform, but the name has nothing to do with a scientific institution or organisation. The name of the ‘scientifically qualified person’ is given only as ‘Phillip’, and the nominated scientific qualification is incomplete. The ‘Authorisation by supervisor’ purports to be in different handwriting but the name of the supervisor (Robert Smith) does not even match the name of the supervisor given for the declaration (Robert Smithers).

65. I am satisfied that the EUD was completed entirely by Mr Reidy, with critical false information throughout. Moreover, a Google Maps search of the address given by Mr Reidy in the original order reveals the premises as one of three residential units. In no way do the premises appear to belong to, or be the site of, a laboratory or a scientific or commercial organisation.

66. Following the receipt of submissions on behalf of Bacto dated 14 May 2025, a further statement was provided by its Managing Director, Phillip Carter, dated 19 May 2025.18 In this statement Mr Carter explained that in 2020 he sought advice from the NSW Health support line19 to clarify what steps Bacto should take to fulfil its requirements regarding the supply of Schedule 7 poisons to a customer claiming an exemption.

67. Mr Carter stated that he was referred to the relevant NSW Health website which directed that: … a supplier should be satisfied that the bona fides of a person claiming to be in charge of a facility engaged in scientific research in a scientific establishment are legitimate by making some reasonable basic enquiries of the scientific establishment, prior to supply.

68. Mr Carter further stated that he sought advice from the NSW Health support line regarding what would constitute ‘some reasonable basic enquiries’ and he was assisted in compiling a series of questions for this purpose. It was apparently Mr Carter’s initiative 18 Exhibit 2 19 A service provided by the NSW Ministry of Health.

to put these questions in the form that became the EUD and to add the requirement for signing by an ‘authorised supervisor’ and he was helped with the wording by NSW Health.

69. Ultimately, Mr Carter sought advice from the NSW Health support line whether the use of the EUD would be enough to constitute ‘reasonable basic enquiries’ and he was told that it would be. On the basis of this advice, he instituted a new sales procedure requiring completion of the EUD together with proof of identity of the customer by way of a copy of some form of photo ID.

70. I accept that Mr Carter sought and received advice from the NSW Health support line as he has described. I also accept that the advice was the basis for the design of the EUD and the new sales procedure for Schedule 7 poisons. However, it is not the sufficiency of the design of the EUD which is in issue, it is the validity of the information entered upon it by Mr Reidy.

71. Mr Carter also states that verification of the bona fides of a person by a private company is not straightforward. He further suggests that a request for additional information concerning eligibility for the exemption may only practically be answered by the customer making a written statement. I do not accept this to be so. The key issues are whether the customer is who they say they are, and are they authorised by a scientific institution or facility that is itself, genuine?

72. Mr Carter’s contention that a request for a customer’s scientific procedures is likely to be met with concerns regarding confidentiality is beside the point. I would not expect that the obligation to make ‘reasonable enquiries’ requires the supplier to interrogate the scientific institution or facility about its planned use of the substance.

73. Lastly, Mr Carter states that Bacto does not have access to information in the way a government agency may have to verify information, and there is no organisation it can contact to verify the bona fides of a particular customer. I accept this to be the case, but this does not present a bar to checking whether the customer is who they say they are, and are they authorised by a scientific institution or facility that is itself, genuine? In the event that a supplier cannot satisfy itself regarding these basic questions, or there is some real obstacle to the enquiry, the order should not proceed.

74. The gravamen of Mr Carter’s contentions is that Bacto could, in all practicality, do no more than accept the completed EUD at face value. This simply cannot be the case, otherwise the exercise would be meaningless. This position is also at odds with Bacto’s own explanation, accompanying the EUD, that the customer may expect some enquiries will be made.

75. The order was completed on the basis of the completed EUD. The falsity of the document should have been immediately suspected, and even basic enquiries would have shown the document for what it was. Sadly, it seems that the ‘reasonable basic enquiries’ foreshadowed in the explanatory document were not undertaken by Bacto, or at least, not undertaken to a sufficient extent.

COMMENTS I make the following comments connected with the death under section 67(3) of the Act: Inherent dangerousness of sodium cyanide

76. While a wide array of potentially lethal substances is available for sale on the internet with little or no restriction, substances in the nature of sodium cyanide stand apart.

Ingestion of a single block of the pure salt (assuming a weight of a few grams) amounts to many times a lethal dose and is rapidly fatal with no realistic prospect for any meaningful intervention. There is also the risk that it may be used for criminal purposes.

77. The compound reacts in the presence of water to produce hydrogen cyanide gas, although the reaction is slow at room temperature. In the stomach, sodium cyanide reacts in the presence of gastric acid to produce hydrogen cyanide gas far more quickly. In this case, Mr Reidy simultaneously consumed Coca-Cola, which is also acidic20 and would ensure a fast reaction producing hydrogen cyanide.

78. As the police members and paramedics attempted to save Mr Reidy, they were operating in a dangerous environment because of the risk of exposure to hydrogen cyanide gas. For this reason, it is fortunate that the police members did not attempt to deliver ‘rescue breaths’ when performing CPR.

20 The pH of Coca-Cola is approximately 2.5, primarily due to the inclusion of phosphoric acid.

Lack of regulatory uniformity between States and Territories and supplier obligations

79. This case has highlighted a single poison treated differently by the regulations of two States, Victoria and New South Wales. The lack of regulatory consistency is particularly troubling given the realities of modern e-commerce. The sodium cyanide was ordered online by Mr Reidy for delivery to Victoria. Even if the basis for the exemption he claimed had been true, Bacto was delivering the compound into a jurisdiction where the exemption did not operate.

80. In a letter to the Court dated 27 March 202521, Mr Carter advised that Bacto had decided to cease its resale of cyanide and arsenic products and had no plans to reintroduce them for sale in the future. This case was a major factor in Bacto’s decision to remove these products from their portfolio.

81. In the same correspondence Bacto point out that, in addition to their supplier, Chem Supply, there are five other Australian importers of sodium cyanide and other dangerous poisons. Some of these importers have their own networks for domestic resale and the products are available for sale on their websites.

82. In its submissions dated 14 May 2025, Bacto emphasised that the current state-based regulatory approach to the supply of Schedule 7 poisons created inconsistencies and uncertainty for businesses. Bacto also contended that the establishment of a national framework would provide clarity and consistent regulatory oversight with clearer compliance pathways. I agree.

83. It is clear that a nationally unified approach to the regulation of Schedule 7 poisons would bring these very significant advantages. It is confounding that, despite the existence of the Standard for the Uniform Scheduling of Medicines and Poisons, a unified approach to their regulation has not been achieved between states and territories. A nationally uniform approach should be the aim of all jurisdictions, led by the Commonwealth. Whilst this may be a complex exercise, other national regulatory schemes, such as the Heavy Vehicle National Law and Regulations, demonstrate what is achievable.

21 CB44-1 – Exhibit 1

84. In the absence of national uniformity, any organisation supplying sodium cyanide or other dangerous poison bears an onus to ensure regulatory compliance in the state or territory in which they operate, and in the state or territory to which the product is being shipped. Particularly with an order from a new customer, this requires the supplier to take reasonable steps to validate the basis upon which the customer purports to be able to lawfully possess the substance. To satisfy this obligation, in many instances the supplier will need to make proper enquiries of the customer and/or independent sources to verify the information provided.

REMARKS I extend my sincere condolences to Mr Reidy’s family and friends for their loss.

I thank the Coronial Investigator and those assisting for their work in the investigation.

DIRECTIONS Pursuant to section 73(1) of the Act, I direct that this finding be published on the Coroners Court website in accordance with the Rules.

I direct that a copy of this finding be provided to the following: Sandra and Michael Reidy – Senior Next of Kin Chief Commissioner of Police Professional Standards Command – Victoria Police Bacto Laboratories Pty Ltd Department of Health Victoria Ministry of Health New South Wales Department of Health, Disability and Ageing (Commonwealth) Chemistry Australia Limited Detective Sergeant Gemma Etherington – Coronial Investigator

Signature: ______________________________________ Coroner Paul Lawrie 21 May 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 inquest. 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.