Video detailing Police response
Coroners Act 1996 [Section 26(1)] Coroner’s Court of Western Australia RECORD OF INVESTIGATION INTO DEATH Ref: 66/19 I, Michael Andrew Gliddon Jenkin, Coroner, having investigated the disappearance of Nathan James GAUNT with an inquest held at the Albany Coroner’s Court, 184 Stirling Terrace, Albany on 5 November 2019 find the death of Nathan James GAUNT has been established beyond all reasonable doubt, and the identity of the deceased person was Nathan James GAUNT and that death occurred on or about 22 October 2018, at sea in the vicinity of The Gap, Albany in the following circumstances: Counsel Appearing: Sergeant L Housiaux assisted the Coroner. Table of Contents INTRODUCTION .................................................................................................. 2 THE DECEASED .................................................................................................. 4 Background ............................................................................... 4 The deceased’s comments about ending his life .......................... 6 DISAPPEARANCE ................................................................................................ 8 The events of 22 October 2018 ................................................... 8 The deceased’s vehicle is located ................................................ 9 THE SEARCH .................................................................................................... 11 Initial enquiries at the scene .....................................................11 The search begins .....................................................................12 The search continues ................................................................13 Comments regarding the search ................................................15 POLICE INVESTIGATION ................................................................................... 16 Forensic evidence ......................................................................16 The deceased’s mobile phone.....................................................17 Other enquiries by police...........................................................18 Conclusion reached by police ....................................................18 HAS DEATH BEEN ESTABLISHED? ................................................................... 19 CAUSE AND MANNER OF DEATH ...................................................................... 20 CONCLUSION .................................................................................................... 22 Inquest into the death of Nathan James GAUNT (F/No: 828/2019) page 2. INTRODUCTION 1. Nathan James Gaunt (the deceased) was born in Albany, on 7 August 1993. 1 For the reasons I have set out below, I find that his death occurred on or about 22 October 2018 as a result of immersion in water (drowning). 2. On 4 July 2019, the Acting State Coroner determined that on the basis of the evidence contained in a police report with respect to the deceased’s disappearance, that he had reasonable cause to suspect that the deceased had died and that his death was a “reportable death”.2 3. Accordingly, pursuant to section 23(1) of the Coroners Act 1996 (WA), the Acting State Coroner directed that the suspected death be investigated.3,4 In accordance with that direction, I held an inquest into the suspected death of the deceased, in Albany on 5 November 2019. Members of the deceased’s family and his friend attended the inquest. 4. The following witnesses gave oral evidence at the inquest: i. Acting Senior Sergeant Andrew Dunn (Police investigator); ii. Senior Constable Matthew Ward (Forensic officer); iii. Mr Khai Nunn (the deceased’s friend);and iv. Acting Inspector Craig Wasley (District officer). 5. The documentary evidence at the inquest included a report into the deceased’s disappearance and suspected death, prepared by the Western Australia Police, 5 forensic evidence and statements from the deceased’s family and his friend. Together, the Brief comprised two volumes. 6. The inquest focused on the circumstances surrounding the deceased’s disappearance and the question of whether he took his own life.
7. The deceased’s vehicle was located on 22 October 2018 on rocks near a carpark in the vicinity of The Gap, a tourist attraction in Albany. The Gap is located approximately 2.6 kilometres west of Sharp Point and is comprised of a spectacular channel in the 40 metre high coastal granite coastline of the Torndirrup National Park. A viewing platform allows visitors to look directly down at the ocean below
THE DECEASED Background 8. The deceased was born at the Albany Regional Hospital on 7 August 1993. He had a sister and a brother and attended school in Albany, where he completed Year 11. He lived with his parents until he was about 18 or 19 years of age, when he moved out on his own for 12 months, before moving back to live with his parents. In January 2018, the deceased went to live with his sister, Ms Natalie Gaunt. 8,9 9. The deceased was employed as a courier driver at the time of his disappearance and had previously worked at a poultry farm. He drove a white Nissan Navarra utility.10 10. The deceased was said to have been self-conscious about his size and to have struggled to lose weight, despite exercising regularly. In July or August of 2018, the deceased started a new diet, having first consulted with his doctor.11,12,13 11. The deceased was single and was said to have struggled with female relationships. According to Ms N Gaunt, the deceased had not had any previous serious relationships.14 12. Mr Khai Nunn, who gave evidence at the Inquest, said he met the deceased in primary school and described the deceased as his best friend. Mr Nunn also said that he was the deceased’s only real friend, outside of family and work colleagues.15 13. Mr Nunn said the deceased led what he would describe as a “normal” type of lifestyle and seemed “generally happy” with his job. He said the deceased was very intelligent, but had an “odd” or “slightly weird” personality. Mr Nunn also said that the deceased was frustrated about living in Albany and was bored with his life there.
14. Although Mr Nunn had moved from Albany to Perth in 2010, he kept in daily contact with the deceased, and the deceased came to stay with him in Perth from time to time.17,18 15. Ms N Gaunt, described the deceased as a “typical Aussie bloke”. She said he was a private person, and was nice, humble, respectful and protective. He had a cheeky and funny personality. Mr Nunn agreed with this description of the deceased.19,20 16. Mr Nunn said the deceased was a deep thinker, who tended to over think things. The deceased would sometimes express concerns that “the government” was following him. Mr Nunn says he used to joke with the deceased about this, and considered it to be a funny part of the deceased’s character.21 17. As far as Mr Nunn was aware, apart from some previous cannabis use, the deceased did not take illicit drugs, nor did the deceased drink much alcohol. Mr Nunn said he was not aware of the deceased having been diagnosed with any form of mental health condition, including depression. 22,23 However, Mr Nunn said that in his view: As I have said, I think that he [the deceased] was pretty lonely. This, I think, was because of his smart, intelligent and slightly weird personality, which some people don’t always take to.24 18. The deceased enjoyed riding his motorbike, fishing and going four-wheel driving in his utility. He also enjoyed playing video games and was active on social media.25 19. In October 2018, the deceased injured his right ring finger at work and had some time off work. He seemed unhappy because he “couldn’t do things around the house”.
20. On 20 October 2018, the deceased went to a party with his sister. Mr Nunn said he received a few “drunk texts” from the deceased, who seemed to be enjoying himself. Mr Nunn thought it was good that the deceased was out socialising.27 At the party, the deceased poured out a drink because he hadn’t seen it prepared and the next morning, he complained that his drinks had been spiked. Ms N Gaunt thought that the deceased had merely had too much to drink.28,29 21. The last time Mr Nunn saw the deceased in person was when the deceased came to see him in Perth three weekends before he disappeared. Mr Nunn said the deceased enjoyed these visits to Perth as he was frustrated with his life in Albany and “felt trapped”. Mr Nunn said the deceased’s mood was absolutely fine and “everything seemed normal” and the deceased’s mood was “absolutely fine”.30 The deceased’s comments about ending his life 22. At the Inquest, Ms Shirley Gaunt, the deceased’s mother, took issue with a comment in the police investigation report that the deceased had spoken of The Gap as a place where he could take his life. She said the comments had been taken out of context and had been made during “a general family conversation”. 31 23. Mr Nunn said that over the previous 10 years, the deceased had made “throw away” comments about taking his life on about four occasions. The deceased made these comments in a “tongue in cheek way”, and Mr Nunn did not take the remarks seriously.32 24. The deceased had said that he “might as well drive his car off the cliffs at Sharp Point”. The deceased also said he would load up his car and take his dog if he “did it”. The last time the deceased made comments like this to Mr Nunn, was sometime in 2017
25. In his statement, Mr Nunn made the following observation with respect to the deceased’s comments about the Gap: Again, I did not take this seriously. It may have been on his mind, but I never thought that he would go through with something like this and actually end his life. To my knowledge, Nathan was - had been fine recently. There’s nothing he had said to me that made me concerned about his welfare. He has had no breakups or rejections.34 26. In his statement, the deceased’s father, Mr Charles Gaunt said: Nathan has never made any self-harm comments to myself, but has made general comments in the past to me. He would make a general comment, words to the effect, “if anyone wanted to disappear in the Albany area, the quickest way out is off The Gap, Salmon Holes or off the top of Bluff Knoll”. The last time I recall Nathan saying this was about three to four years ago. He made similar comments a few years before that.35 27. Ms N Gaunt thought that the deceased may have shown signs of obsessive compulsive disorder and that for the first three months of 2018, the deceased was suffering with “concealed anxiety”, although he was “happy and relaxed” for the last few months prior to his disappearance. Mr Nunn said that at times, the deceased seemed generally anxious.36,37,38 28. Ms N Gaunt made the following comment about her brother: I find it hard to believe that he took his own life, but I am coming to accept it. He didn’t have any enemies and didn’t mix with dangerous people. I don’t know of any reason why anyone would want to harm Nathan.
DISAPPEARANCE The events of 22 October 2018 29. Sometime between about 5.30 am and 6.00 am on 22 October 2018, Ms N Gaunt heard a vehicle start up and leave home. Presumably this was the deceased, because only Ms N Gaunt and her son and the deceased lived at the house and when she got up at about 7.10 am, the deceased and his vehicle were gone.40 30. It was later noticed that although 22 October 2018 was a workday, when he left home, the deceased’s work clothes remained neatly folded in his drawers and both pairs of his work boots were in his bedroom. 41 31. Police obtained closed-circuit television (CCTV) footage from the Little Grove General Store located on Frenchman’s Bay, adjacent to the Torndinup National Park. The CCTV footage captured the deceased’s vehicle driving past the store in the direction of The Gap at 6.48 am on 22 October 2018.42 32. Road traffic counters located on the entrance road at The Gap record hourly statistical information about the number and types of vehicles passing over them. When the data was subsequently analysed, it showed that the first vehicle recognised of the type driven by the deceased, had crossed the counters between 8.00 am and 9.00 am on 22 October 2018.43 33. It is about a 12 minute drive from the deceased’s home to the Little Grove General Store, and a further eight minute drive from there to the carpark at The Gap.44 34. It is unclear what the deceased was doing from the time he left home before 6.00 am and 6.48 am when his car was seen on CCTV passing the Little Grove General Store, and between 6.48 am and 8.00 am, which appears to be the earliest time he can have driven on the entrance road to The Gap.
The deceased’s vehicle is located 35. At about 9.25 am on 22 October 2018, Ms Selena Jeffrey, a tourist visiting The Gap with her husband, noticed the deceased’s car stuck on rocks leading to The Gap. At first, she thought the vehicle was in that position for some kind of advertisement or promotion, but later, it appeared to her as if the driver had attempted to drive “towards the edge”
36. As Ms Jeffrey walked towards the viewing platform at The Gap, she noticed two areas of dried blood on the platform’s handrail. Ms Jeffery said one of the areas of blood was “the size of my hand” and that “it was a significant amount of blood to notice”. Ms Jeffrey also saw “a small pool of blood” about 1.5 to 2 metres from the top of the handrail down onto the rocks.47 37. Ms Jeffrey and her husband spoke to another couple whilst they were at The Gap. That couple said the deceased’s car had not been there the day before when they had visited. Neither Ms Jeffrey, nor her husband, nor the couple they spoke to at the Gap, reported the matter to the Police at that time.
38. Ms Jeffrey did report what she had seen to police on 25 October 2018, after watching a television news report about the deceased’s disappearance.49 39. At about 12.15 pm on 22 October 2018, Mr John Russell, was visiting The Gap with his wife. He saw the deceased’s car “up on rocks” and noticed the vehicle’s front skirt, number plate and one of its driving lights had been damaged. The keys were in the ignition and the windows and doors were closed.50 40. As Mr Russell and his wife walked towards the metal walkway leading to The Gap, he saw a plastic case on the left side of the walkway, with what appeared to be the base of a hobby knife protruding from it.51 41. Mr Russell took photographs of the deceased’s car and later told staff at the Albany Visitor’s Centre what he had seen. Mr Russell subsequently attended the Denmark Police Station on 23 October 2018, and handed over the photographs he had taken.52 42. At 3.43 pm on 22 October 2018, Ms Tanya Lewis, who worked at the Albany Visitor’s Centre, rang police to advise them of what she had just been told by Mr Russell.
THE SEARCH Initial enquiries at the scene 43. At 3.44 pm on 22 October 2018, ten minutes after Ms Lewis contacted police, First Class Constable Cameron Fyfe and Senior Constable Ward were dispatched to The Gap to conduct enquiries and arrived at 3.52 pm.54 44. Officer Fyfe saw the deceased’s vehicle stuck between two large rocks. There was no one in the vehicle, which was unlocked, and the keys were in the ignition. Officer Fyfe tried to operate the vehicle’s dash-cam but was unable to do so.55 It appeared to Officer Ward as if an unsuccessful attempt had been made to drive the vehicle over the surface of the rocks.56 45. A member of the public alerted Officer Fyfe to the fact that there was blood on the handrail of the viewing platform at The Gap. He saw the blood on the handrail and also identified blood droplets leading from the handrail towards the ocean.57 46. Officer Fyfe declared the area a protected forensic area and moved members of the public away.58 Meanwhile, Officer Ward took some photographs and examined the scene. He identified the plastic case observed earlier by Officer Fyfe and noticed blood staining on the container and on a scalpel blade underneath the container. Another scalpel blade was located a short distance away between two rocks.59 47. Officer Ward identified a blood trail from the handrail of the viewing platform at The Gap, onto the rock surface below leading towards the cliff face. He collected samples of the blood he identified and seized the plastic container and scalpel handle.
48. Meanwhile, police made various attempts to locate the deceased. There was no answer when they rang his mobile, no record of him presenting at Albany Hospital within the previous two days and the deceased’s employer confirmed that he had not reported to work. The last activity on the deceased’s Facebook account was at 9.10 am on 21 October 2018, when the deceased mentioned his hangover. 61 The search begins 49. The Officer in Charge of the Albany Police Station, Sergeant Andrew Dunn (a qualified marine search mission controller) took control of the search. Two sea rescue vessels were deployed to The Gap at 5.16 pm on 22 October 2018, and a fixed wing aircraft began searching the area by 5.35 pm. Prior to last light, the aircraft pilot was able to search the coast one nautical mile east and west of The Gap. Neither the aerial search, nor the search by the rescue vessels found any sign of the deceased.62,63 50. Police obtained “drift predictions” from the National Search and Rescue Mapping program known as SARMAP, which incorporates factors including wind speed, current and object size. The SARMAP information, which was received at 6.36 pm and passed on to rescue personnel, was that a person floating in the ocean would drift close to the shoreline in an easterly direction.64 51. Police consulted with Dr Paul Luckin, a consultant anaesthetist based in Queensland, who is also an expert in search and rescue operations. Dr Luckin advised that the deceased’s “time frame for survival” was up to 10 hours if he was in the ocean and an indefinite period on land, assuming access to food, water and shelter.65 52. Meanwhile, police sought assistance from the Albany unit of State Emergency Service (SES) and teams arrived at The Gap at 7.15 pm.
53. An SES vertical rescue team abseiled down the cliff face at The Gap and found blood on rocks just below the cliff edge, consistent with other blood leading to that area. Meanwhile, another SES team conducted foot patrols of the surrounding area, until the patrols were suspended due to bad light at 8.05 pm. 68 54. An SES dog was deployed and indicators from the dog led from the deceased’s vehicle to the cliff edge at The Gap. The vertical rescue team continued their efforts until 8.46 pm, using artificial light. 69 The search continues 55. Over the following four days, police coordinated an extensive air, sea and land search in an unsuccessful attempt to locate the deceased. The following resources were deployed: i. Fixed-wing aircraft: at 6.30 am on day two of the search, a Cessna aircraft with two police spotters on-board, began searching the coast, east and west of The Gap. The search took four hours and extended to Bald Head, approximately 10 nautical miles from The Gap.70,71 ii. Rotary-wing aircraft: on day two, the RAC rescue helicopter assisted with land and sea searches and searched the area in the vicinity of The Gap between 9.08 am and approximately 1.00 pm.72,73 iii. Rescue vessels: rescue vessels from the Albany Volunteer Marine Rescue Service conducted sea searches on days two, three and four of the search and assisted police divers on day five. The vessel tracking data shows that these searches were extensive and detailed.
iv. SES foot patrols: teams of SES members conducted extensive land searches and searched visually out to sea on days two and three of the search. Mapping data showed that the teams searched over 44 hectares of scrub in the vicinity of The Gap. Possibility of detection calculations by the teams (based on factors including: lighting, terrain, vegetation and weather) gave a score of between 82 - 100%.76,77,78 iv. Police drone: a police drone equipped with video recording equipment was deployed on days four and five of the search. The drone took a number of photographs and assisted police divers on day five of the search.79,80 v. Police divers: although police divers had been considered during the initial stages of the search, it was not until day five that sea conditions were safe enough to deploy divers.81,82,83 56. The deceased’s timeframe for survival (assuming immersion in the ocean) had expired at the end of the first day of the search.84 Given that no trace of the deceased had been found despite an extensive search, following consultations with the deceased’s family, the search for the deceased was officially concluded at 2.34 pm on 26 October 2018.85,86,87 57. Acting Senior Sergeant Dunn said that in his opinion, all of the resources that he requested were made available to him.88 Acting Inspector Wasley was also satisfied that sufficient resources had been allocated to the search.
Comments regarding the search 58. Despite an extensive land, air and sea search that extended over five days, the deceased could not be located. I am satisfied that every effort was made to locate the deceased as soon as police became aware he was missing. 59. In this case, the first recorded sighting of the deceased’s abandoned vehicle at The Gap was at 9.25 am on 22 October 2018. At that time, blood was seen on the viewing platform handrail and on rocks leading to the cliff edge. Had that information been relayed to police soon after those observations, there is at least a possibility that the search for the deceased may have had a different outcome. 90. 60. Acting Inspector Craig Wasley agreed that members of the public should be encouraged to immediately report all unusual sightings to police. Police can then evaluate the information received and determine what action to take. 91 61. In this case, as soon as police received information about the deceased’s vehicle being found at The Gap, their response was timely, efficient and professional.92 The resulting search for the deceased was detailed and comprehensive. The fact that no trace of the deceased was found, strongly suggests that he was lost at sea. 62. Acting Inspector Wasley noted that since the deceased’s disappearance, another two people had gone missing at The Gap. The body of one person had been recovered, but the other person was still missing. He said that a number of strategies had been considered to address this issue, including restricting access to The Gap after sunset and erecting signs displaying the numbers for crisis services.93 63. Acting Inspector Wasley also said that consideration was also being given to installing a CCTV camera at The Gap, which may assist in identifying possible incidents as they occur. A CCTV camera may also act as a deterrent to people considering using The Gap as a place to take their lives.
POLICE INVESTIGATION Forensic evidence 64. Police collected the following samples at the scene for DNA analysis by PathWest Laboratory Medicine WA (PathWest):95,96 i. Blood found on the top aspect of the railing on the western side of viewing platform handrail at The Gap; ii. Blood found on rocks near the cliff edge at The Gap and on the rock cliff surface; iii. Trace samples from the grip portion of a scalpel blade and a scalpel found near the viewing platform; and vi. Blood found on a plastic case containing scalpel blades. 65. The blood samples were analysed against DNA collected from personal care items known to have been used by the deceased, namely his toothbrush, razor and comb.97,98 DNA testing by PathWest confirmed that all of the samples collected by police at The Gap (i.e.: i. – iv. above), matched the deceased’s DNA. 99 66. As Senior Constable Matthew Ward, a police forensic investigator with 27 years of experience, put it: So most importantly, the blood yielded a single profile to a single individual, and all of the blood yielded…that same single profile, and when compared to…the DNA from Nathan’s toothbrush, comb and razor, that single profile matched those items
67. Police also tested a cigarette butt found on the western side of the viewing platform at The Gap. The cigarette butt had been seized as a precaution because of its proximity to the viewing platform. However, when analysed, the DNA profile on the cigarette butt was unknown and did not match the deceased’s DNA. 101 68. A baseball cap found by police on rocks between the deceased’s vehicle and where the scalpel blades were found, was also seized for DNA analysis. Shortly after the baseball cap had been seized, police noticed numerous other caps and hats at The Gap. In view of the blustery conditions at that location, this is unsurprising. In any event, when analysed, the DNA profile on the baseball cap was unknown and did not match the deceased’s DNA. 102 69. Numerous “trace samples” were taken from surfaces inside and outside the deceased’s vehicle. DNA analysis of those samples did not assist police with their enquiries.103 70. For the sake of completeness, I note that a video taken at the scene showing the blood spots I have referred to and the deceased’s vehicle was played at the inquest. 104 71. After viewing the video footage at the inquest, Ms N Gaunt thought she saw a lunchbox in the rear of the deceased’s vehicle that she did not recognise. However, the item was identified at the inquest by the deceased’s brother, Mr Justin Gaunt, as an air compressor container.105 The deceased’s mobile phone 72. As noted, police called the deceased’s mobile number at 3.56 pm on 22 October 2018 without success. Subsequently, by using movement and location information in the form of “pings” to the deceased’s mobile phone, police determined that it had been switched off, or had become otherwise disabled, at 6.01 am on 22 October 2018
Other enquiries by police 73. Other than scheduled debits, there were no personal transactions on the deceased’s NAB bank account after 22 October 2018.107,108 Enquiries with Australian Border Force confirmed there was no record that the deceased had left Australia, as at 24 December 2018.109,110 Since 22 October 2018, there has been no contact from the deceased.111 74. The deceased was last seen by his GP on 12 October 2018. On that occasion, he presented following an injury at work to his finger. The deceased had seen his GP on two previous occasions, but neither of these consultations related to mental health issues.112 Conclusion reached by police 75. At the inquest, Acting Senior Sergeant Dunn said that after considering all of the evidence: My conclusion is the same as it was at the time of writing the report, and that is that he leaped from The Gap and took his own life.
HAS DEATH BEEN ESTABLISHED? 76. In my view, the evidence establishes, beyond all reasonable doubt, that the deceased died on or about 22 October 2018 in the vicinity of The Gap at Albany. 77. In reaching that conclusion, I have relied on the following facts: i. The deceased left home in his vehicle between 5.30 am 6.00 am on 22 October 2018; ii. CCTV footage shows the deceased’s vehicle heading in the direction of The Gap at 6.48 am on 22 October 2018; iii. The deceased’s vehicle almost certainly travelled along the access road to The Gap sometime between 8.00 am and 9.00 am on 22 October 2018; iv. The deceased’s vehicle was found abandoned on rocks at The Gap, at about 9.25 am on 22 October 2018; v. The deceased’s blood was found on rocks leading to the viewing platform at The Gap, on the viewing platform handrail and on rocks leading the cliff edge. In addition, blood consistent with the blood found on the rocks at the edge of the cliff was found 1.5 – 2 metres down the cliff face; vi. The deceased’s DNA was detected on a scalpel blade and handle and his blood was found on a plastic container located at The Gap; vii. An SES dog gave indicators between the deceased’s vehicle and the edge of the cliff at The Gap; viii. The deceased’s timeframe for survival after entering the water was approximately 10 hours and an extensive land, sea, and air search over five days failed to find any trace of him; and ix. Since 22 October 2018, there has been no contact of any kind from the deceased.
CAUSE AND MANNER OF DEATH 78. I have concluded that the deceased cut himself with a scalpel blade and then jumped from The Gap in order to take his life. I am further satisfied that the deceased subsequently died from immersion in the ocean. 79. In reaching my conclusion as to the manner and cause of the deceased’s death, I have relied on the matters referred to in paragraph 73 above and the following facts: i. On approximately four occasions prior to his death, the deceased had made “throw away” comments to his friend Mr Nunn about ending his life by driving his car off Sharp Point; ii. On several occasions, the deceased made “general comments” to his father that if a person wanted to disappear in the Albany area, the quickest way out is to go off The Gap, Salmon Holes or Bluff Knoll; iii. The deceased was frustrated and bored with his life in Albany and had, on occasions, seemed anxious; iv. The deceased had few friends outside his family, was self-conscious about his weight and was lonely; v. The deceased left his work clothes and both pairs of his work boots in his bedroom when he left home on 22 October 2018; vi. To his sister’s knowledge, no one had any reason to harm the deceased; vii. The DNA profile from the blood samples collected at The Gap were from a single person, namely the deceased, and not a mixed profile. In my view, this makes it far more likely that the deceased’s blood loss came from self-inflicted wounds, rather than as a result of a violent struggle with some unidentified person;
viii. The absence of any cogent evidence that any other person was with the deceased prior to the time he arrived at The Gap, or during the time he was there on 22 October 2018; and vi. The fact that there has been no contact from the deceased since 22 October 2018. 80. Having carefully considering all of the available evidence, I have concluded that the deceased deliberately took his life. I therefore find that his death occurred by way of suicide.
CONCLUSION 81. The deceased was a dearly loved son, brother and friend. He was 25 years of age when he disappeared at The Gap in Albany on 22 October 2018. 82. There are no eye witnesses to the deceased’s final moments, and so the exact sequence of those events must remain a mystery. 83. However, when considered as a whole, it is my view that the evidence in this case, leads to the inescapable conclusion that the deceased died on or about 22 October 2018, after he entered the ocean from the cliff edge at The Gap with the intention of taking his life. 84. Exactly what caused the deceased to act as he did will never be known. Quite obviously, the loss of a young person in these circumstances is an unspeakable tragedy. 85. The grief and pain felt by the deceased’s family members and his friend must be all the more acute, because, apart from some “throw away” comments, the deceased does not appear to have given any clue as to what he intended to do. Sadly, it is not uncommon for those contemplating taking their lives to give no prior warning of their indication to do so. MAG Jenkin Coroner 27 November 2019