Demographics
30y, male
Date of death
2020-06-03
Finding date
2022-11-25
Cause of death
Cyanide poisoning
AI-generated summary
A 30-year-old teacher in regional Victoria died from cyanide poisoning in June 2020. He presented to his GP in February 2020 with atypical features including fear of being poisoned, which raised concerns for possible psychiatric disorder or substance abuse, but no mental health history was disclosed. He was not referred for mental health assessment despite these red flags. In May 2020, he obtained potassium cyanide online from a NSW supplier (Bacto Laboratories) by falsely declaring himself a cleaner on an End User Declaration. The supplier had concerns about the legitimacy of the purchase but proceeded after police contact yielded no response. The coroner found he died by suicide and identified regulatory failures: the NSW supplier failed to verify his authority to obtain Schedule 7 substances, contrary to NSW regulatory requirements. The coroner recommended education programs for Schedule 7 substance suppliers regarding their regulatory obligations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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