Finding into death of Diane Bell
Deceased
Diane Bell
Demographics
52y, female
Date of death
2017-06-19
Finding date
2019-06-13
Cause of death
Plastic bag asphyxia and asphyxia in the setting of an irrespirable environment
AI-generated summary
Diane Bell, a 53-year-old woman with delusional disorder and chronic suicidal ideation, died by argon gas inhalation in June 2017. She had been under care of North West Area Mental Health Service with a Community Treatment Order and was receiving multidisciplinary support including psychiatry and psychology. Despite ongoing suicidal thoughts expressed between October 2016 and her death, her treating team managed her as a chronic rather than acute risk. On 2 June 2017, she informed family she had purchased items for suicide; a gas bottle was confiscated. She was reviewed on 13 June and appeared engaged with treatment. She died four days later. The coroner found her mental health care appropriate and multidisciplinary support adequate. Key clinical lesson: the ease of accessing argon gas cylinders without restrictions enabled her suicide method. The coroner's recommendations focused on restricting access to inert gases rather than critiquing clinical management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- chronic suicidal ideation
- delusional disorder with persecution beliefs
- insight into past harm to others following assault incident
- easy access to argon gas cylinders
- ongoing psychological distress from relationship breakdown and intervention orders
Coroner's recommendations
- That the Department of Health and Human Services explore whether the deleterious substances provisions of the Drugs Poisons and Controlled Substances Act 1981 (Vic) might be amended to include the major gases used in inert gas inhalation suicide in Victoria; and whether such an amendment would have any practical impact on Victorians' ability to access these gases for purposes of suicide.
- That the Australian Competition and Consumer Commission expand the scope of its engagement with Australian gas manufacturers, importers and suppliers, to include not only helium but all common gases used in inert gas inhalation suicide, when considering what design modifications could be made to reduce people's ability to use gas cylinders and associated equipment in suicide.
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 —