Coronial
WAother

Inquest into the Death of Thomas Francis LEVINGE

Deceased

Thomas Francis Levinge

Demographics

73y, male

Coroner

Coroner King

Date of death

2013-10-07

Finding date

2015-03-17

Cause of death

Unknown (possibly impact with water, drowning, injury, exhaustion, dehydration, hypothermia, or attack by predatory animal)

AI-generated summary

A 73-year-old man with recent cognitive decline jumped from a cruise ship in Western Australia, resulting in death. Clinical lessons include recognising that cognitive impairment and depression may manifest as behavioural changes rather than explicit complaints. The deceased had undiagnosed memory loss that distressed him deeply, feared dementia given family history, but did not discuss concerns with his long-term doctor. Early identification of cognitive changes, particularly in elderly patients experiencing distress about memory loss, and proactive assessment for depression and suicidality could have enabled intervention. Healthcare providers should maintain low threshold for cognitive screening in older adults with lifestyle changes and should explore psychological wellbeing when patients show anxiety about memory or health concerns.

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

Error types

diagnostic

Drugs involved

temazepam

Contributing factors

  • Recent cognitive decline and memory loss not discussed with healthcare providers
  • Distress about memory loss and fear of developing dementia
  • Lack of medical assessment of cognitive changes despite 20-year doctor-patient relationship
  • Possible undiagnosed depression or suicidal ideation
Full text

Coroners Act 1996 [Section 26(1)] Western Australia

RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref No: 8/15 I, Barry Paul King, Coroner, having investigated the suspected death of Thomas Francis Levinge with an inquest held at Perth Coroners Court, Court 51, CLC Building, 501 Hay Street, Perth, on 3 March 2015, find that the death of Thomas Francis Levinge has been established beyond all reasonable doubt and that death occurred on or about 7 October 2013 in the waters of Prince Frederick Harbour from an unknown cause in the following circumstances: Counsel Appearing: Mr J T Bishop assisting the Coroner TTaabbllee ooff CCoonntteennttss

CONCLUSION AS TO HOW DEATH OCCURRED AND THE CAUSE OF Inquest into the suspected death of Thomas Francis Levinge – 623/2014

IINNTTRROODDUUCCTTIIOONN

  1. At about 6.00 pm on 7 October 2013 Thomas Francis Levinge (the deceased) disappeared after he jumped off the stern of a cruise ship in Prince Frederick Harbour in the Kimberley region of Western Australia. He was 73 years old.

  2. The evidence of a survival expert, Dr Paul Luckin, indicates that the deceased was unlikely to have survived the fall of 12 to 14 metres to the ocean and that, if the deceased had survived the fall, he would not have survived until midday on the following day.

  3. On 10 June 2014 this Court received an email request from the deceased’s daughter Maria Levinge for an inquest into the assumed death of her father.

Ms Levinge explained the circumstances of the deceased’s disappearance and identified a subsequent investigation by Senior Constable Steve Williamson of the Western Australia Police.

  1. Under section 23 of the Act, where a person is missing and the State Coroner has reasonable cause to suspect that the person has died and that the death was a reportable death, the State Coroner may direct that the suspected death of the person be investigated. Where the State Coroner has given such a direction, a coroner Inquest into the suspected death of Thomas Francis Levinge – 623/2014

must hold an inquest into the circumstances of the suspected death of the person and, if the coroner finds that the death of the person has been established beyond all reasonable doubt, into how the death occurred and the cause of death.

  1. On 17 June 2014 the State Coroner considered that she had reasonable cause to suspect that Mr Levinge had died and directed that the suspected death be investigated.

  2. On 3 March 2015 I held an inquest into the deceased’s suspected death. The evidence adduced was the report1 of Senior Constable Williamson and brief oral evidence from him.2

TTHHEE DDEECCEEAASSEEDD

  1. The following information was primarily obtained from statements provided by the deceased’s family.3

  2. The deceased was born in 1940 in County Longford in Ireland. After finishing his education he went to London to look for work and met his wife to be, who was also Irish. They married in 1962 and had three daughters.

1 Exhibit 1, Tab 2 2 ts 5 - 8 3 Exhibit 1, Tabs 8 and 25 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

  1. In 1972 the deceased and his family immigrated to Australia where the deceased set up a successful business selling automotive paints.

  2. The deceased loved living in Australia, including the opportunities for bushwalking and camping. He was a keen golfer and joined golf clubs where he played every Saturday. He was extremely fit and healthy, rising early each day and going for walks in the nearby bush. He enjoyed nature and wildlife and he liked to fix things.

  3. The deceased was a devoted family man, working hard to provide for his family. He was quick witted, intelligent and proud, including being proud of his daughters, who all obtained university degrees, and of his two loving grandchildren.

  4. The deceased was a devout Catholic. He was active in the local church and was a member and twice president of the local branch of the Catenian Association, which raised money for charity.

13. The deceased sold his business in about 2000.

He worked part-time with the new owners for about 10 years before retiring completely in about 2010.

  1. During his semi-retirement the deceased was able to play golf twice a week and he and his wife were able to travel more, especially on cruise ships of which they had Inquest into the suspected death of Thomas Francis Levinge – 623/2014

grown particularly fond. They had been on several cruises through Asia. Their favourite ship was the Sun Princess.

  1. In the last two or three years before he disappeared the deceased began to lose his short term memory function, leading to difficulty performing day to day tasks such as fixing things or operating electronic equipment. He became less able to play card games that he had played since childhood, and he could no longer concentrate long enough to play 18 holes of golf.

  2. The deceased’s loss of memory function apparently distressed him deeply, possibly because there was a history of dementia in his family which he feared he would also develop. He did not talk about it with his wife or his daughters, and he did not complain of memory loss to his doctor of over 20 years.4

EEVVEENNTTSS LLEEAADDIINNGG UUPP TTOO TTHHEE DDEECCEEAASSEEDD’’SS DDIISSAAPPPPEEAARRAANNCCEE

  1. The Levinges booked onto a Sun Princess cruise leaving Fremantle for Sydney on 29 September 2013. The deceased was looking forward to the voyage and was in good spirits. However for some days after the cruise had 4 Exhibit 1, Tab 7 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

commenced, the deceased had trouble remembering how to find their stateroom.5

  1. Nonetheless the Levinges were enjoying the cruise. They had made a group of new friends with whom they socialised each evening in the Regency dining room. The deceased was always telling jokes and chatting amiably with whoever he met. During the day the Levinges engaged in several activities together, but would also do things apart, depending on what entertainment was available on the ship.6

  2. On 7 October 2013 the Levinges had breakfast together and carried out their usual activities during the morning.

They had lunch at the Horizon Court restaurant and stayed there until about 4.30 pm. The ship stopped at about 5.00 pm in the waters of Prince Frederick Harbour to enable the passengers to watch the sunset at about 5.30 pm, and the Levinges went on deck where they stayed until the sun had set.7

  1. At 5.30 pm the Levinges went to their stateroom to get ready for dinner. While there they had a disagreement about where to eat dinner. The deceased wanted to eat at the Regency dining room, but Mrs Levinge did not want to get dressed up to eat there after being windblown from being on the deck in the afternoon.

5 Exhibit 1, Tab 8 6 Exhibit 1, Tab 8 7 Exhibit 1, Tab 8 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

As Mrs Levinge was not particularly hungry, she suggested that the deceased go to the Regency on his own and she would meet him later at a show at the theatre.8

  1. The deceased left the stateroom in casual attire rather than dressed for dinner. In the hallway nearby he was seen by a stateroom steward, Ricky Delos Santos, to whom he had spoken several times since the cruise began. The deceased greeted Mr Santos who replied, ‘Enjoy your dinner,’ and the deceased thanked him.9

  2. Mrs Levinge went to the Horizon Court restaurant for a light dinner and later went to the theatre, but the deceased did not show up. Mrs Levinge went back to the stateroom and thought that the deceased might be there, but he was not. She then went to listen to singing as she normally did after dinner and stayed there until about 9.45 pm. The deceased was not in the stateroom when she returned, so Mrs Levinge took a temazepam tablet and went to sleep.10

  3. The deceased was still not in the stateroom when Mrs Levinge woke up the next morning. She thought that he may have slept on deck under the stars as he sometimes did, but as time went on and she could not 8 Exhibit 1, Tab 8 9 Exhibit 1, Tab 9 10 Exhibit 1, Tab 8 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

find him, she began to worry.11 She sought help from the ship’s crew who arranged for the deceased’s name to be called over the public address system several times over the next two hours, but the deceased did not appear. The ship’s crew conducted a search of the ship without success.12

  1. Ship’s crew also went around the ship with pictures of the deceased asking passengers if they had seen him.

A passenger stated that he believed that he had seen the deceased at 9.00 am that morning having breakfast in the Horizon restaurant. CCTV recordings from 6.00 pm the previous night to 11.00 am that morning were reviewed, but the deceased was not seen on the recordings.13

  1. At about 11.10 am on 8 October 2013 the Sun Princess notified the Rescue Coordination Centre of the possibility that the deceased had been lost overboard. By 2.00 pm on 8 October 2013 the ship had returned to its position at 9.00 am to search for the deceased in the sea. Three aircraft and a Royal Australian Navy ship joined in the search, but the deceased was never found.14

  2. On 19 October 2013 a Ship Security Officer on board the Sun Princess reviewed CCTV recordings from earlier on 7 October 2013 and discovered that seconds before 11 Exhibit 1, Tab 8 12 Exhibit 1, Tab 12 13 Exhibit 1, Tab 12 14 Exhibit 1, Tab 5 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

6.00 pm that evening the deceased was recorded climbing over the railing at the stern of the ship and jumping into the sea.15 The deceased’s identity was confirmed by Maria Levinge.16

CCHHAANNCCEESS OOFF SSUURRVVIIVVAALL

  1. At about 5.00 pm on 8 October 2013, Dr Paul Luckin was consulted by the Australian Maritime Safety Authority in relation to the deceased’s likely life expectancy. Dr Luckin considered that, had the deceased jumped from the ship at 9.00 am that morning, it was likely that he had died at or very soon after the fall from injuries caused when entering the water.

Dr Luckin thought that, if the deceased had survived the fall, the survivability until the end of daylight was a maximum of 40% and that survival until daylight on 9 October 2013 was not possible.17

  1. When later asked by Mr Bishop for a further opinion about the deceased’s chances of survival if he entered the water at 6.00 pm on 7 October 2013, Dr Luckin said that he believed that the probability of survival until daylight was very low, possibly 10%. He did not believe that the deceased could have survived until midday on 8 October 2013.18 15 Exhibit 1, Tab 10 16 Exhibit 1, Tab 23 17 Exhibit 1, Tab 6 18 Exhibit 1, Tab 24 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

  2. After it was known that the deceased had entered the water 15 hours earlier than originally thought, a drift analysis using a computer based program was conducted by water police officers to ascertain the possibility that he had been able to reach land in Prince Frederick Harbour.19

  3. The results of the analysis indicated that, if a person were floating on the surface without the assistance of swimming, there was a 1.2% chance that the person would make landfall on Murrara Island approximately two hours after entering the water. After four hours, there was a 10% chance of the person making landfall on a small islet and a 1.4% chance of making landfall on Murrara Island.20

FFUURRTTHHEERR IINNVVEESSTTIIGGAATTIIOONNSS

  1. Police intelligence analysts reviewed the deceased’s Medicare and Centrelink records and determined that the deceased had not had any medical treatment or received any Centrelink payments since September 2013.21 19 Exhibit 1, Tab 4 20 Exhibit 1, Tab 4 21 Exhibit 1, Tab 2 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

  2. The deceased has not been in contact with any member of his family since he last spoke with Mrs Levinge on 7 October 2013.

CCOONNCCLLUUSSIIOONN AASS TTOO WWHHEETTHHEERR DDEEAATTHH HHAASS BBEEEENN EESSTTAABBLLIISSHHEEDD

  1. In my view the foregoing evidence establishes the death of the deceased beyond all reasonable doubt.

CCOONNCCLLUUSSIIOONN AASS TTOO HHOOWW DDEEAATTHH OOCCCCUURRRREEDD AANNDD TTHHEE CCAAUUSSEE OOFF TTHHEE DDEEAATTHH

  1. The CCTV recording shows the deceased deliberately and without hesitation climbing over the railing at the stern of the Sun Princess and jumping into the ocean. While it is tempting to speculate as to the reasons for his actions, there can be little doubt that the deceased was aware of their likely consequence. On that basis I infer that he intended to end his life.

35. I find that death occurred by way of suicide.

  1. The evidence relating to the cause of death is inconclusive. Dr Luckin considered that the deceased may have died from injury suffered from impact with the water or from drowning. Drowning may have resulted from injury or from exhaustion, dehydration or hypothermia.22 I assume, given the relevant location, 22 Exhibit 1, Tab 6 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

that other possibilities may include attack by a predatory animal.

37. In these circumstances I find that the cause of death is unknown.

B P King Coroner 17 March 2015 Inquest into the suspected death of Thomas Francis Levinge – 623/2014

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