Inquest into the death of Marcellus Tipiloura

26y · Male·Suicidal cut throat

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.