Inquest into the death of Marcellus Tipiloura
Deceased
Marcellus Tipiloura
Demographics
26y, male
Date of death
2003-10-05
Finding date
2005-08-31
Cause of death
Suicidal cut throat
AI-generated summary
A 26-year-old Aboriginal male, Marcellus Tipiloura, died from a self-inflicted cut throat while police and emergency services were attending. He had made threats to kill himself and his wife after consuming alcohol and cannabis, leading his wife to call emergency services. When police arrived and opened a cupboard where he was hiding with a knife, he was incapacitated with OC spray and fell, causing a severe laceration to his throat that severed his trachea. Paramedics administered Midazolam to manage his violent agitation before transport to hospital, where resuscitation efforts failed. The coroner found no fault with police, paramedic, or hospital care. The death was survivable only with immediate medical intervention, which was impossible given his severe self-inflicted injury and uncontrollable behaviour that impeded care provision.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- Self-inflicted laceration to anterior neck
- Complete transection of trachea
- Severe trauma with extensive aspiration of blood
- Violent and combative behaviour interfering with care
- Alcohol intoxication (0.139% BAC)
- Cannabis use
- History of domestic violence and mental health crisis
Coroner's recommendations
- St John Ambulance Service to thoroughly examine Dr P.'s critical comments regarding trauma management protocols to achieve better outcomes in future severe trauma situations, noting that protocols have already been updated since this incident to allow up to 30mg Midazolam instead of the previous 15mg limit
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —