Coroner's Finding: Christian, Jake Nicholas

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INQUEST INTO THE DEATH OF JAKE NICHOLAS CHRISTIAN [2025] SACC 32 Inquest Findings of his Honour State Coroner Whittle 27 November 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a man who had an overdose of illicit drugs while on home-detention bail. The inquest explored the circumstances leading up to the overdose.

Held:

1. Jake Nicholas Christian, aged 27 years of Victor Harbor, died at Victor Harbor on 6 October 2022 as a result of heroin toxicity.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MS R SCHELL Hearing Date/s: 12/09/2025 Inquest No: 16/2025 File No/s: 2480/2022

INQUEST INTO THE DEATH OF JAKE NICHOLAS CHRISTIAN [2025] SACC 32 Introduction and background 1 Jake Nicholas Christian was born on 30 July 1995.1 He was the eldest child of Andrea Darragh and Brett Christian. His siblings are Eden, Shannon and Thomas.2 Unfortunately, Mr Christian’s father died in 2007. Mr Christian then took on the responsibilities of being the eldest sibling while he was only young himself.3 2 Mr Christian suffered from depression and anxiety4 and struggled to get medication to help him.5 He wanted to be a police officer but struggled to finish year 12. He took on a career in the retail industry6 and was described by his employer at Drakes Victor Harbor to be a good and reliable staff member. 7 3 Mr Christian was drawn to drugs and alcohol from his late teenage years.8 He used cannabis, methylamphetamine and later heroin. Eventually he was an intravenous user.9 He had a number of occasions of detention under the Mental Health Act where intoxication was suspected to have induced mental health episodes.10 4 Mr Christian had a tumultuous relationship with his mother. They often fought and there were instances of violence, but often his mother would not cooperate with police and they would go on living together.11 Mr Christian had no instances of violence involving any other person.12 5 On 20 April 2022, Mr Christian assaulted his mother and she had to call police to protect herself.13 He had pushed, hit and kicked her.14 At the time, there was an intervention order in place which allowed contact but prohibited violence. The intervention order was finalised in September 2020.15 6 Police arrested Mr Christian for assault and for contravention of the intervention order.16 He was granted supervised bail to live at Dover Gardens.17 He was prohibited from contacting his mother, but on one occasion he arrived at home telling her he had nowhere 1 Exhibit C1; Exhibit C4 at [2] 2 Exhibit C4 at [2] 3 Exhibit C5 at [3] 4 Exhibit C12 5 Exhibit C4 at [9] 6 Exhibit C4 at [11] 7 Exhibit C7 at [4] 8 Exhibit C4 at [12] 9 Exhibit C4 at [30]; Exhibit C8 at [9]; Exhibit C9 at [6] 10 Exhibit C20, pages 27-31 11 Exhibit C20, page 16; Exhibit C4 at [17], [18], [20] and [21] 12 Exhibit C20, page 16 13 Exhibit C4 at [15] and [32] 14 Exhibit C4 at [15] 15 Exhibit C20c 16 Exhibit C15 at [6] 17 Exhibit C20d

[2025] SACC 32 State Coroner Whittle else to stay and so she let him stay.18 They started arguing and Mr Christian left before police arrived.

7 Mr Christian was charged with the offences of breaching his bail on 8 July and 15 July 2022, after a friend of Mr Christian’s mother reported his presence on those occasions.

His mother did not assist police, but her friend did.19 Mr Christian was not granted bail by police or by the Magistrate at his first hearing and he spent time in prison.20 8 Notwithstanding that he argued with his mother, and they had a volatile relationship, she says they continued to love each other. Mr Christian’s mother wanted him to get out of prison, so she moved out of her home and lived with her mother in New South Wales, allowing Mr Christian to move into her house on home detention.21 She arranged for a housemate to move in to pay rent to help with the mortgage repayments.

9 Mr Christian was granted home detention on 8 August 2022.22 He had an intake appointment on 10 August 2022.23 Mr Christian reported on a fortnightly basis and was said to be engaged and polite. He was fully compliant and was open with his community corrections officer about his mental and physical health conditions. He was hopeful of engaging with medical and mental health services to commence treatment.24 He was prescribed sertraline and olanzapine and was on a program where he was provided a standard passout for collection of his medication.25 His friends observed him to be doing well during his time on home detention.26 10 While on home detention, Mr Christian was attending work and the gym27 and was generally hopeful for the future.28 He had seen a doctor and was given medication for his anxiety and had indicated that he had given up using drugs and alcohol and was starting to feel better.29 11 In September 2022, Mr Christian was subject to a random drug test and a random breath test.30 No drugs or alcohol were detected. While Mr Christian had previously identified an addiction to cannabis with his corrections officer, he did not disclose a problematic relationship with any other illicit substance or alcohol during his ordered supervision visits.31 12 On 19 September 2022, Mr Christian disclosed to his corrections officer that he had begun to feel ‘cabin fever’ and they discussed reaching out to friends to visit when he felt confined.32 18 Exhibit C4 at [18] 19 Exhibit C20, page 36 20 Exhibit C20, page 5; Exhibit C20e 21 Exhibit C4 at [23] 22 Exhibit C15 at [16]; Exhibit C20f 23 Exhibit C15 at [19] 24 Exhibit C15 at [20] 25 Exhibit C15 at [21] 26 Exhibit C9 at [19]; Exhibit C8 at [20] 27 Exhibit C7 at [16] 28 Exhibit C7 at [20] 29 Exhibit C12 30 Exhibit C15 at [22] 31 Exhibit C15 at [30] 32 Exhibit C15 at [34]

[2025] SACC 32 State Coroner Whittle 13 On 6 September 2022, Mr Christian was referred by his GP for a mental health team review.33 In the weeks preceding his death, Mr Christian’s employer observed that he seemed happier than he had been for some time and was enjoying coming into work.34 The events leading to Mr Christian’s death 14 On 5 October 2022, Mr Christian had an appointment with his corrections officer. He was future-focussed and asked for a passout to visit the bank to talk about taking out a car loan.35 He said that he wanted to speak to the Magistrate at a hearing on 7 October 2022 about removing home detention because of his compliance. He returned home at 2:15pm.36 Later in the night, Mr Christian’s housemate heard him snoring.37 15 At about midnight on 6 October 2022, Mr Christian was found by his housemate slumped on the toilet.38 He was dressed.39 He had an uncapped needle with him.40 A Velcro tourniquet was beside Mr Christian when the scene was secured and impressions of a tourniquet were observed on the deceased’s left arm by police who first attended.41 There was a piece of toilet paper with a spotting of blood on it consistent with having been used to stop blood over an injection point.42 Mr Christian’s housemate called triple zero and commenced CPR until paramedics arrived.43 He was dragged to the open area to allow space to work. A defibrillator was connected, but no rhythm was detected, and shocks were not able to be delivered.44 Paramedics observed lividity and rigor mortis commencing. Mr Christian had a very low body temperature.45 They declared life extinct at 12:22am.46 In Mr Christian’s bedroom, paramedics found the packaging for the syringe.47 A small plastic resealable bag, later determined to contain heroin, was also located.48 Cause of death 16 A post-mortem examination was conducted by senior consultant forensic pathologist Dr John Gilbert, limited to external examination, CT scan and toxicology.49 There were no injuries or illness found on the CT scan. Toxicological analysis of Mr Christian’s blood revealed morphine at a concentration of 0.14mg/L and codeine at 0.023mg/L, as well as the metabolite monoacetylmorphine in the preserved urine.50 Post-mortem redistribution is expected to have altered the results. The forensic scientist, Ms Danielle Butzbach, provided advice that a study of morphine concentrations amongst people who 33 Exhibit C12 34 Exhibit C6 at [16] 35 Exhibit C15 at [39] 36 Exhibit C15 at [43] 37 Exhibit C1a at [8] 38 Exhibit C1a at [10] 39 Exhibit C18 at [9]; Exhibit C1 at [10] 40 Exhibit C13 at [12]; Exhibit C14 at [13] 41 Exhibit C20 at 6; Exhibit 18 at [22] 42 Exhibit C20, page 52 43 Exhibit C1a at [11]; [12] 44 Exhibit C13 at [8]; exhibit C14 at [9] 45 Exhibit C14 at [10] 46 Exhibit C13 at [9]; exhibit C14 at [11] 47 Exhibit C14 at [15] 48 Exhibit C20, pages 6, 50; Exhibit C18 at [26] 49 Exhibit C2a 50 Exhibit C3a

[2025] SACC 32 State Coroner Whittle have died as a result of overdose showed a range of between 0.04mg/L to 5.5mg/L, with a median concentration of 0.24mg/L. She explained that there is a significant overlap between the dosages that can kill people and dosages that users can tolerate.

Conclusions 17 Dr Gilbert concluded that Mr Christian’s death was attributable to heroin toxicity51 and I find that Mr Christian’s cause of death was heroin toxicity. There is no evidence of suicidal intent and I find that this was an accidental overdose.

18 Mr Christian was lawfully in the custody of the Chief Executive of the Department for Correctional Services (DCS) pursuant to his conditions of bail which included home detention and electronic monitoring. This is a death in custody as defined in the Coroners Act 2003 and an inquest is mandatory.

19 Mr Christian was subject to regular appointments with his DCS community corrections officer and he was subject to two random intoxicant tests. They had discussions about his mental health and Mr Christian seemed to be on track with a plan to see a psychiatrist.

His work was going well and he was focussed on the future. There is no criticism to be made of the care afforded to Mr Christian while he was on home detention.

20 I make no recommendations.

Keywords: Death in Custody; Home Detention; Drug Overdose 51 Exhibit C2a, page 2