Coroner's Finding: Constantine, Matthew Keith

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INQUEST INTO THE DEATH OF MATTHEW KEITH CONSTANTINE [2025] SACC 4 Inquest Findings of her Honour Coroner Giles 31 March 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of Matthew Keith Constantine who took his own life whilst subject to home detention in March 2022.

Held:

1. Matthew Keith Constantine, aged 33 years of Adelaide, died at the Royal Adelaide Hospital on 20 March 2022 as a result of hypoxic-ischaemic encephalopathy due to hanging with resuscitation.

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

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 28/02/2025 Inquest No: 04/2025 File No/s: 0639/2022

11 12 13 14 15 16 This judgment contains discussion of suicide and may be distressing to some people There is always help available If you need support, contact Lifeline Australia Call 13 11 14 or Text 0477 13 11 14 or chat online at www.lifeline.org.au/crisis-chat Aboriginal & Torres Strait Islander Support Call 13YARN (13 92 76) Kids Helpline Call 1800 55 1800 MensLine Australia Call 1300 78 99 78

INQUEST INTO THE DEATH OF MATTHEW KEITH CONSTANTINE [2025] SACC 4 Introduction and cause of death Matthew Keith Constantine was born on 2 November 1988 in Victoria.1 He died at the Royal Adelaide Hospital on 20 March 2022 at the age of 33 years.

A pathology review was undertaken at Forensic Science South Australia by Dr Alexandra Yuill, medical practitioner, and discussed with Dr Stephen Wills, forensic pathologist.

The cause of death provided in the report of that review was hypoxic-ischaemic encephalopathy due to hanging with resuscitation.2 I so find.

Reason for inquest At the time of his death Mr Constantine was on a curfew under supervision of Adelaide Community Corrections following his release from Mobilong Prison in December 2021.

During curfew hours he was required to reside at 1566/160 Carrington Street, Adelaide.

Mr Constantine’s cause of death arose while he was at that location in compliance with his curfew, and therefore his death was a death in custody in accordance with the Coroners Act 2003. Thus, an inquest into Mr Constantine’s death was mandatory.

Background and medical history Mr Constantine was born to Janine and Keith Constantine. He was the youngest of three brothers. The family resided in Victoria.

His mother described him as a very healthy and sporty child who was good at fixing things.

When he was 16, he commenced work as a sheep shearer in New South Wales. It was around this time that his mother noticed he appeared to be using illicit drugs.3 Some years later Mr Constantine advised a treating practitioner, Dr Benny Tang, that he had in fact commenced intravenous drug use at age 14 years.4 During his teens he commenced a relationship which lasted four years. His mother explained that once this relationship ended, he started to ‘go off the rails’ and began to get into trouble with the police.5 He later had another long-term relationship resulting in two children, born in 2015 and 2016.6 The family resided together in Hamilton, Victoria until that relationship came to an end and Mr Constantine then lived at Merino, Victoria and Mount Gambier, South Australia.

1 Exhibit C7 at [3] 2 Exhibit C1 3 Exhibit C7 at [5] 4 Exhibit C10, page 1 5 Exhibit C7 at [6] 6 Exhibit C7 at [7]

[2025] SACC 4 Coroner Giles Mr Constantine attempted the methadone program in 2020, but found it ineffective in controlling his addiction, and he continued illicit drug use whilst on the program.7 Mr Constantine suffered from anxiety and depression and was prescribed mirtazapine 30mg at night for this.

Imprisonment leading to supervision by Community Corrections In 2021 Mr Constantine was charged with numerous offences in Mount Gambier, including non-residential trespass and theft, breaching bail and driving offences. He received a head sentence of imprisonment for 12 months and 2 weeks with a non-parole period of 8 months.8 Mr Constantine was housed at the Yatala Labour Prison from May 2021 before his transfer to Mobilong Prison in October 2021.9 He had a medical consultation in October 2021 where he denied suicidal ideation.

A Parole Report was prepared on 22 November 2021. Mr Constantine was noted to be remorseful for his offending and had developed some insight and victim awareness.10 He was noted to have been prescribed medication for anxiety while in prison.11 He said he had gone into a downward spiral when he stopped working after injuring his knee, and that his offending was related to drug use.12 It was noted that he had never been monitored by the High Risk Assessment Team while in prison.13 Mr Constantine was assessed as having a tendency to react impulsively.14 Mr Constantine was granted parole and released from custody on 12 December 2021.15 His parole conditions included condition 23, a curfew, which was to be enforced by condition 25, electronic monitoring.16 Whilst he was subject to electronic monitoring he had freedom of movement, such that he did not require ‘pass outs’ to leave his residence outside of his curfew hours.17 He was placed under the supervision of Community Corrections and individual weekly appointments were scheduled.18 Referrals to wraparound services were made. He commenced counselling, which he reported he found useful, but subsequently disengaged with, prior to re-engaging.19 He also visited Dr Benny Tang on 15 December 2021 and was prescribed Suboxone to deal with his opiate addiction.20 As Mr Constantine had no release accommodation available to him in South Australia, he was initially assisted with accommodation in a men’s shelter, before moving into 7 Exhibit C10, page 2 8 Exhibit C8, Annexure A 9 Exhibit C9 at [10], [12] 10 Exhibit C27, page 1 11 Exhibit C27, pages 1, 9 12 Exhibit C27, page 5 13 Exhibit C27, page 7 14 Exhibit C27, page 11 15 Exhibit C9 at [14] 16 Exhibit C28 17 Exhibit C8, Annexure A 18 Exhibit C8 at [7] 19 Exhibit C8 at [12] and [19]-[20] 20 Exhibit C10, page 2

[2025] SACC 4 Coroner Giles accommodation at Carrington Cottages on 22 December 2021. He expressed that he wanted to visit his family, but he was not allowed to leave South Australia.21 He reported to his mother that he was unhappy in his accommodation.

Circumstances leading to Mr Constantine’s death Mr Constantine commenced a relationship with Kylie-Anne Taylor on 26 January 2022.22 Ms Taylor lived in Waikerie and would travel to Adelaide to visit Mr Constantine as much as possible. Mr Constantine would also travel to Waikerie, although due to his curfew, he was restricted in how long he could spend there.23 Ms Taylor was arrested in February 2022. Mr Constantine had applied to serve his curfew period at her home in Waikerie but, due to her arrest, this request was not approved.24 He became frustrated, and they began to argue.

At around this time Ms Taylor suffered a miscarriage and Mr Constantine became emotional and upset when he found out. He attended for a supervision appointment where he expressed a sense of grief and loss but presented as forward focused and spoke about future plans of residing with his girlfriend.25 On 16 March 2022 Mr Constantine called his mother to apologise for everything he had put her through.26 He asked her to find his children and FaceTime him so he could see them. She was not able to find them.27 On 17 March 2022 Mr Constantine spent the day with Ms Taylor. He returned home in compliance with his curfew and Ms Taylor then went to visit a friend. Mr Constantine found out and became angry because he thought she was associating with people who had been responsible for her arrest.28 Mr Constantine spent about 20 minutes talking to a fellow resident in the garden.

Mr Constantine said that he had been having a hard time since leaving prison and was upset that he had not seen his girlfriend and family in a while.29 Ms Taylor said that she found out Mr Constantine tried to hack into her Facebook account, and she messaged him about it. Mr Constantine denied it. Ms Taylor blocked him, messaged him ‘we’re done’ and did not answer his calls.

At 12:22am on Friday 18 March 2022 Mr Constantine called a mutual friend, Kathleen Jarman, to try to attempt contact with Ms Taylor, but was unsuccessful.30 After being advised that Ms Taylor would not speak with him, he sent Ms Jarman two videos. The first video depicted him wrapping a strap around his neck and moving a chair to a 21 Exhibit C7 at [15] 22 Exhibit C6 at [2] 23 Exhibit C6 at [3] 24 Exhibit C6 at [4] 25 Exhibit C8, Annexure A 26 Exhibit C7 at [17] 27 Exhibit C7 at [18] 28 Exhibit C6 at [7] 29 Exhibit C4 at [5]-[6] 30 Exhibit C5 at [13]-[14]

[2025] SACC 4 Coroner Giles doorway.31 The second video depicted him standing on the chair with the strap around his neck.32 In the video, Mr Constantine says ‘Fuck yous. See yous. I can’t live without her. I’m done’. Ms Jarman called triple zero. She messaged Mr Constantine saying ‘stop it’ and he replied, ‘Yeah watch this good bye Kathy’.

Mr Constantine posted on social media that he was going to hang himself. SAPOL officers attended in order to conduct a welfare check at 12:50am.33 They were initially unable to enter the building and commenced breaking in shortly before another resident opened the door.34 SAPOL officers went to Mr Constantine’s room and forced it open, which had the effect of dislodging Mr Constantine who was hanging from the door with a strap around his neck.35 Constable Cleggett cut the strap free and Senior Constable Blieden commenced CPR.36 Paramedics then arrived and took over CPR with assistance from the SAPOL officers.37 A return of spontaneous circulation was achieved, and Mr Constantine was taken to the Royal Adelaide Hospital.

Toxicological analysis of Mr Constantine’s blood upon arrival at hospital found no alcohol, however methylamphetamine and amphetamine were detected.

At the Royal Adelaide Hospital Mr Constantine was intubated and ventilated. There was increasing myoclonic jerking and so Mr Constantine was paralysed with rocuronium.38 He was in metabolic and respiratory acidosis. Mr Constantine’s acidosis was able to be corrected, and his respiration returned to normal. A CT scan showed no fractures and no acute brain abnormalities. However, this scan was too early to be able to detect the consequences of the period of low oxygen to Mr Constantine’s brain.39 Mr Constantine remained in the Intensive Care Unit for two days but showed no meaningful neurological recovery. He was profoundly unresponsive with no response to any stimuli.40 In the afternoon of 19 March 2022 blood gas testing showed that there was stable respiratory function and no medical cause for his unconscious state.41 It was then observed that Mr Constantine had stopped triggering the ventilator, a signal that he had stopped breathing as a result of brainstem damage.42 Medical staff conducted clinical brain death testing on the morning of 20 March 2022.

31 Exhibit C5 at [17] 32 Exhibit C5 at [18] 33 Exhibit C12 at [3] 34 Exhibit C12 at [6] 35 Exhibit C12 at [8] 36 Exhibit C11 at [13] and Exhibit C12 at [9] 37 Exhibit C16 at [11]-[13] 38 Exhibit C3 at [8]; Rocuronium is a muscle relaxant 39 Exhibit C3 at [13] 40 Exhibit C3 at [15] 41 Exhibit C3 at [22] 42 Exhibit C3 at [23]

[2025] SACC 4 Coroner Giles Life was declared extinct at 10:45am on 20 March 2022.

Conclusion and recommendations I find that Mr Constantine made the decision to take his own life on 18 March 2022.

I further find that Mr Constantine was lawfully detained at the time his cause of death arose.

In all of the circumstances, I make no recommendations.

Keywords: Death in Custody; Parole; Suicide; Hanging