Coroner's Finding: Marshall, Benjamin Laurence
Deceased
Benjamin Laurence Marshall
Demographics
31y, male
Date of death
2019-10-05
Finding date
2025-08-22
Cause of death
asphyxia due to self-inflicted hanging
AI-generated summary
Benjamin Marshall, aged 31, died by self-inflicted hanging in October 2019, over two years after discharge from the Royal Australian Navy. He suffered from Bipolar Affective Disorder (BPAD), a genetic condition not causally related to his naval service, though initially misdiagnosed while serving. Key clinical lessons: recruitment processes that identify unsuitability should not be disregarded—Marshall was assessed as psychologically unsuitable twice before recruitment; the RAN should not have posted him to a high-stress seagoing role given his deteriorating mental state and repeated training failures; and early recognition and accurate diagnosis of BPAD (typically in early 30s rather than 20s) are challenging but critical. Marshall received appropriate medical and mental health support during service (124 appointments with various providers) and appropriate transitional management post-discharge. His refusal to engage with post-discharge mental health support and alcohol abuse, combined with the high suicide risk in BPAD, rendered prevention difficult despite best efforts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- bipolar affective disorder (undiagnosed during naval service)
- alcohol abuse
- poor engagement with mental health treatment post-discharge
- social isolation
- failure to engage with vocational rehabilitation opportunities
- recruitment decision to enlist despite prior psychological unsuitability assessments
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