Deceased
David Benjamin Ingram
Demographics
44y, male
Coroner
Deputy State Coroner Linton
Date of death
2021-09-24
Finding date
2025-06-06
Cause of death
unascertained - may have been injury from fall, drowning, or predation from marine life
AI-generated summary
David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depression, and previous suicidal ideation, managed with olanzapine since July 2020. Medical records were not disclosed to his employer or ship's officers during induction. In his final days, David exhibited paranoid thoughts, believing he had been drugged, despite no evidence of this and reportedly good crew relations. He became unwell and withdrawn in his last shift, then disappeared in the early morning hours. Footprints found later suggested he went overboard from a precarious area. Clinically, the case highlights the importance of: (1) assessing mental health risk before offshore work, (2) communicating psychiatric diagnoses to occupational health when relevant to safety, (3) recognising decompensation in patients with psychotic illness, particularly when medication compliance is uncertain, and (4) ensuring crew awareness of mental health support resources and escalation protocols.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
[2025] WACOR 22 (S) JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA CORONER : SARAH HELEN LINTON, ACTING STATE CORONER HEARD : 17 FEBRUARY 2025 DELIVERED : 6 JUNE 2025 FILE NO/S : CORC 3539 of 2023
DECEASED : INGRAM, DAVID BENJAMIN Catchwords: Nil Legislation: Nil Counsel Appearing: Senior Constable C. Robertson assisted the coroner Case(s) referred to in decision(s): Nil
[2025] WACOR 22 (S) Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Acting State Coroner, having investigated the disappearance of David Benjamin INGRAM with an inquest held at the Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth, on 17 February 2025, find that the death of David Benjamin INGRAM has been established beyond all reasonable doubt and that the identity of the deceased person was David Benjamin INGRAM and that death occurred on or about 24 September 2021 in the Indian Ocean approximately 30 nautical miles offshore from Exmouth, Western Australia, as a result of an unknown cause in the following circumstances:
David Ingram (David) was last seen alive in the early hours of the morning on 24 September 2021. At that time, he was working as a deckhand on board a commercial cargo vessel that was operating off the coast of Exmouth.
David had been working an early morning shift on the ship’s bridge and was relieved from duty at around 3.00 am. He was seen elsewhere on the ship at around 3.45 am, carrying his laptop computer. It was assumed he had then returned to his cabin to sleep, but the next morning he could not be located. A thorough search of the vessel found no sign of him, but shoe prints were found towards the back of the ship that the crew believed suggested David had gone into the ocean from the back of the vessel. A search of the ocean following the path the vessel had taken was conducted, but no sign of David was found.
David’s disappearance was investigated by officers from the local Dampier Police Station, then later by officers from the WA Police Missing Persons Unit. On the basis of the information provided by the WA Police in relation to David’s disappearance, I determined that pursuant to s 23 of the Coroners Act 1996 (WA), there was reasonable cause to suspect that David had died and his death was a reportable death. I therefore made a direction that a coroner hold an inquest into the circumstances of the suspected death.1
I held an inquest at the Perth Coroner’s Court on 17 February 2025. The inquest consisted of the tendering of documentary evidence compiled during the police investigation conducted into David’s disappearance, as well as hearing evidence from the investigating officer from the Missing Persons Unit and one of the ship’s officers.
At the conclusion of the inquest hearing, I indicated that I was satisfied that David was deceased, but the exact circumstances of his death remain unclear. I have set out below a summary of the information that was before me to assist me in reaching my conclusion that David is deceased, and what limited information is known about how he potentially met his death.
David was born on 27 December 1977 in Bega, New South Wales. He was one of three children and he grew up with his parents, Maria and Ian, and two sisters, Michelle and Rosalynd (Rosie), in New South Wales. David’s mother passed away in 2010 but his father and two sisters are still alive and they provided significant information to the police following his disappearance.2
By all accounts, David’s early life was unremarkable. He was generally a happy child, with a good sense of humour. He got on well with his family and enjoyed surfing with his friends at the beach north of Narooma, where they lived above an 1 Section 23 Coroners Act Direction of Deputy State Coroner.
2 Exhibit 1, Tab 6.
[2025] WACOR 22 (S) ‘Arts and Crafts’ store run by his parents. Unfortunately, for various reasons the family had to move from Narooma to Canberra. David was said to have been unhappy and unsettled in Canberra, as he missed the beach and his Nanna, who still lived there. He returned there often for holidays.3
After finishing school, David studied at the Canberra Institute of Technology and qualified as a chef. He served his apprenticeship in various places along the south coast, from Narooma to Murramarang, before moving to Byron Bay. He eventually became tired of kitchen work and he decided to pursue his love of surfing and diving more professionally.
David began a new life making films of his surfing adventures. From the years 2004 to 2012, David walked and filmed a documentary along the coast of Australia from Sydney to Perth under the fictional name ‘Benjamin Safari’.4 He eventually ‘killed off’ this character in 2013, which led to some media coverage that caused concern for his welfare, but David later explained it as, effectively, a prank gone wrong.5
David also completed a number of marine qualifications over the years and gained work in the maritime industry on charter boats and gas tankers, interspersed with times working in cafes as a chef across Australia.6
David was married in 2005 but the marriage did not last and the couple did not have any children before the marriage ended. He was in a number of other relationships, including one that lasted for a few years, but he did not marry again and never had children. He continued to live a peripatetic lifestyle, moving jobs and towns and sometimes working offshore, as well as travelling overseas for holidays, but he always kept in regular contact with his family by text or phone call.7
David last visited his family on the Sunshine Coast in August 2019 and he continued to keep in regular contact with them after he returned to Western Australia. David had a plan to buy a block of land in Margaret River and develop it with some ‘tiny houses’ to rent out so he could generally live sustainably. He also wanted to buy a yacht. He was working offshore on boats to earn the money he needed to fulfil these dreams. In the meantime, he was living frugally on a friend’s property in Quindalup in WA’s Southwest when not away working. He had begun tending to some beehives, which he enjoyed a lot. He was also seeing a new lady, Milena, and seemed happy with how their relationship was progressing, although it was early days.8
4 Exhibit 1, Tab 6.
5 Exhibit 1, Tab 6.
6 Exhibit 1, Tab 6.
7 Exhibit 1, Tab 6.
8 Exhibit 1, Tabs 6 to 8.
[2025] WACOR 22 (S) receiving regular treatment from general practitioners and psychiatrists for symptoms of anxiety, depression and hallucinations that were thought possibly related to undiagnosed paranoid schizophrenia. David had reported feelings of paranoia, believing that others were out to harm him, as well as feelings of hopelessness.
Additionally, he had a history of substance abuse and reported previous suicidal thoughts and suicide attempts. It was to address these mental health issues that David saw a GP in July 2020.9
When he saw the GP on 20 July 2020, David had just returned from working offshore for 8 weeks. He reported he had become increasingly concerned his shipmates were out to get him but told his doctor he felt it was likely that it was all in his head.10 He was feeling very anxious but had no thoughts of self-harm. The GP commenced him on the anti-psychotic medication olanzapine. When he saw the GP a few days later, he reported he felt much better while taking the olanzapine, although it made him sleepy.11
David was referred to a psychiatrist for urgent psychiatric review and saw the psychiatrist on two occasions in August 2020. On the first occasion, he described a long history of anxiety and indicated he had self-medicated often throughout his life, using cannabis for a long time, as well as trialling amphetamine based pills and LSD.
He was started on an antidepressant, escitalopram, along with the olanzapine, with a planned review in two weeks. At the second appointment, David reported an improvement in his symptoms and general mental health while taking the olanzapine medication, saying it made him calmer and less anxious, including no longer thinking people were ‘out to get him’. He had stopped taking the antidepressant, escitalopram, as he didn’t think it helped. The psychiatrist gave him a six month prescription for olanzapine on 20 August 2020 (with a recommendation he keep trying the antidepressant regularly for a month before deciding on its utility). He did not see the psychiatrist again.12
The psychiatrist wrote to the GP and advised he had given David a letter to show his employer noting that he was prescribed olanzapine for his anxiety. However, the psychiatrist observed that David’s “thoughts were and are paranoid and he has had many psychotic episodes in his life”.13 It was noted by his GP that David seemed reluctant to be given a formal psychiatric diagnosis, so although schizophrenia was suspected, he never received a formal diagnosis.
David was last prescribed olanzapine on 3 February 2021. His six month prescription provided by his psychiatrist had run out, so he obtained another six month script from his GP. If he was taking it as prescribed, it would have run out in August 2021, the month before his disappearance, but after his disappearance some of the medication was found in his cabin, which suggests he wasn’t fully compliant with his dose.14 David’s GP later advised police that stopping the medication abruptly 9 Exhibit 1, Tab 3 and Tab 32.
10 Exhibit 1, Tab 32.
11 Exhibit 1, Tab 32.
12 Exhibit 1, Tab 31 and Tab 32.
13 Exhibit 1, Tab 31.
14 Exhibit 1, Tab 32.
[2025] WACOR 22 (S) shouldn’t have had an adverse effect, but “obviously any psychotic symptoms that were held at bay by the medication can then recur”.15
David’s family were also aware David had some joint-related injuries, particularly his knees, which was consistent with a medical note that he had sustained a posterior cruciate ligament rupture following a surfing incident.18
David had worked on different boats over the years and, as he had mentioned to family members and his doctors, it had not always been a happy experience, depending upon the crew. He had recounted incidents of racial abuse and ‘gaslighting’. This had prompted him to look for a different position with a new crew.19
The Maersk Mover was a Danish flagged ship but its home port at the time was Dampier, WA.20 David’s friend Timothy Schiffermuller (Mr Schiffermuller) had been working on the Maersk Mover as an Integrated Rating or general hand from April 2021. Mr Schiffermuller had known David for many years and knew David had previously worked for another shipping company and had experienced some racism and bullying. Mr Schiffermuller mentioned to David that they might have a position come up on the Maersk Mover and David seemed keen. Mr Schiffermuller recommended David for the job and David was put in contact with the ship’s recruiting team, who arranged a contract. David was informed of the possibility of six months’ work and he was signed up to start rostered shift on the Maersk Mover on 18 September 2021.21
David last saw his new girlfriend Milena in person on 17 September 2021 before leaving to travel to Perth to go on the ship. She recalled he had seemed increasingly stressed before going on this last work trip and he told Milena he was hoping this would be the last time he would ever have to work on the ships. He also told Milena he thought “it was a fairly dangerous mission this time due to the ship being much 15 Exhibit 1, Tab 32.
16 Exhibit 1, Tab 7 [39].
17 Exhibit 1, Tab 7 [40].
18 Exhibit 1, Tab 7, Tab 8 and Tab 31.
19 Exhibit 1, Tab 7, Tab 31 and Tab 32.
20 Exhibit 1, Tab 3.
21 Exhibit 1, Tab 13 and Tab 18.
[2025] WACOR 22 (S) smaller”22 and jokingly said to her that he hoped he would make it back safely. For the first time he then opened up to Milena about the unhealthy work environment he had experienced while working on boats. He told her that the oil and gas industry was tightly controlled by a small group of people and he felt it was very hierarchical on the ships and he often found it hard to get on with the crew. He also mentioned that racism was rife on the ships and that he had suffered from it due to his skin colour. David said he had tried to keep his head down and not engage, but the racial abuse had affected him negatively. He was worried he might have to endure it again, although he was going to a new ship. David seemed reluctant to leave, but before he left he talked in positive terms about his plans for his return, so his mindset was generally positive.23
David last had contact with his sister Michelle on Friday, 17 September 2021. He told her he was starting a new job that day on a different ship with his friend. He was happy about the change as he would be able to work alongside his friend and he was hopeful it would be a less stressful work environment than his previous experience on boats. She was happy for him, but she recalled he indicated he was feeling a little nervous as it was a three week long shift.24
David commenced on board the Maersk Mover on Saturday, 18 September 2021.
The rest of the crew had been with the ship since 2 September 2021. They picked up David and another person, Daniel Willey (Daniel), in Dampier to increase the crew numbers (known as up-manning) for the next task of moving the rig. Daniel had worked on the ship before, so David was the only new crew member.
David met the Captain, Drew Paskin, and the Chief Officer, Shane Broad, on the bridge on arrival and he presented as well. The Captain mentioned the possibility of six months of work, depending on contracts, and David seemed interested in the prospect.25
At that time, the Second Officer was Jonathon Ross (Mr Ross), and it was his role to conduct an induction with David. The induction included a general induction and deck induction, as well as a safety induction that involved familiarising him with the safety equipment and fire equipment and safe ways to exit various areas of the vessel. Mr Ross gave evidence that the “[f]irst and last step on board a vessel is safety”.26 Mr Ross also informed David of the vessel policies, including the fact it was a ‘dry boat,’ meaning no one was allowed to consume any drugs or alcohol on board. Some of this was done by way of an induction video David was able to watch in his cabin, and some was done verbally.27
Mr Ross also checked David’s paperwork and a checklist for any medical issues was conducted. Mr Ross gave evidence that he told David (as he told all employees) that with any medical or mental health concerns, if David didn’t feel comfortable telling 22 Exhibit 1, Tab 8 [26].
23 Exhibit 1, Tab 8.
24 Exhibit 1, Tab 7.
25 Exhibit 1, Tab 17.
[2025] WACOR 22 (S) him, then he could raise them with the Chief Officer, and any conversation would be kept confidential. Mr Ross also mentioned that there is “an air of confidentiality on board a ship, because you live with each other, … and you’ve got to be able to trust each other,”28. He reassured David that you can always talk to someone and know they will respect your privacy. In addition, if there was anything personal he felt he could not disclose to anyone on board, the employee psychological support program information was on a pamphlet in his room.29 David did not mention to Mr Ross that he was taking any medication or have any relevant medical history that he wished to share.30 The Chief Officer and Captain were not made aware of any issues arising from that part of the induction process, and David did not raise any medical concerns with them at any stage.31
Mr Ross recalled that during the induction David mentioned he had never been on anchor handling before and seemed a little bit worried. Mr Ross said he reassured him that he had been hired as an “extra pair of hands,”32 which meant he was effectively surplus to the general crew requirements, and he could learn on the job without too much pressure being placed on him. Mr Ross gave evidence that even experienced crew members can be a little bit apprehensive starting on a new vessel, and although David seemed “a little bit extra nervous”33 as he hadn’t done the particular kind of physical work before, there was nothing that seemed unusual about his nervousness in the circumstances.34 Mr Ross was on a different shift to David, so he didn’t see David much after the induction.
David last communicated with his father that day, 18 September 2021. He mentioned he was on the Maersk Mover doing a rig shift and that his friend Mr Schiffermuller from Margaret River had helped him to get the job after recommending it to David on the basis that they were a good crew. It was a positive conversation as David seemed happy about the new role. His father was very proud of him and congratulated him on his new job. That was the last time they communicated with each other. Reflecting back on their conversation, David’s father could think of nothing that would suggest why he might have gone ‘man overboard’ only a few days later.35
The crew worked on two teams of 12-hour shifts, one team working from midnight to midday and the other team from midday to midnight. They would have the other 12 hours off to do as they pleased. In addition, during the normal crew shift, they would have break for their breakfast, lunch and dinner. The lunch break would normally be for one hour, and they could choose to go and lay down in their cabin, if they wished. David’s allocated shift pattern was 12 am (midnight) to 12 pm (midday). 36
30 Exhibit 1, Tab 19.
31 T 40 – 41; Exhibit 1, Tabs 17 to Tab 19.
35 Exhibit 1, Tab 6.
36 Exhibit 1, Tab 18.
The ship set sail at midnight on 19 September 2021, and David commenced his first shift at that time. David met up with Daniel and he also handled some of David’s induction and other paperwork. They then worked together for part of a watch shift on the bridge, with David performing the task of ‘lookout’. Daniel recalled they spoke about surfing and general talk, and it was generally “a good watch”.37 He later saw David again on the deck and thought David appeared to be handling his duties well and showed good common sense. David appeared to be a quiet, reserved person, but showed no sign that anything was wrong.38
David was generally rostered on the same shift as two other crew members, Maui Whaitiri (Mr Whaitiri) and Jesse Smith (Mr Smith). Both these men had already been working on the vessel for a number of months. They all seemed to get on well. Mr Smith recalled David seemed quiet but keen to learn. Mr Whaitiri also recalled David was very interested in the work and picked things up quickly. He spoke to David about work and surfing during their shifts and thought that David generally seemed fine in his first few days. David mentioned he enjoyed fishing and had brought a handline with him on board, but he didn’t mention any immediate plans to fish.39
It was the impression of other crew members that David would have been “in a really good, comfortable position” having a good friend on board with him. His friend had also recommended him to come on at a time when he was an additional staff member, so there was less pressure on him to learn the ropes quickly. David was rostered to work on the opposite shift to his friend, so they didn’t interact much on the ship, but he was there for support if needed. From their brief conversations, Mr Schiffermuller understood that everything was going well and David did not seem upset or unhappy in the first few days of work. He recalled David commented that it was easier work than he had expected, although he was struggling a little with his sleep (noting he was working the midnight to noon shift) and was only getting a few hours sleep before waking up. He also mentioned he was using the gym.
Mr Schiffermuller last saw David on the ship on 23 September 2021 just before David started his shift at 11.45 pm. He does not appear to have observed anything unusual about David at that time.40
David’s last communication with a family member was a text message to his sister Rosie sent on 21 September 2021. He mentioned that he had found the crew of young men good so far. He did not mention having any safety concerns or personal issues in the message.41
David’s last communications with Milena were on 20 and 21 September 2021. He indicated in a message on 20 September 2021 that the crew were good so far. The next day he sent two pictures of the ship and they discussed how it was much smaller than the previous ship he had worked on, with a crew of only about 15 people. That 37 Exhibit 1, Tab 16 [11].
38 Exhibit 1, Tab 16.
39 Exhibit 1, Tab 14 and Tab 15.
40 T 50; Exhibit 1, Tab 13.
41 Exhibit 1, Tab 7.
[2025] WACOR 22 (S) was their last exchange. Milena sent more messages to David over the following days but did not receive a reply.42
Cormac was aware that David had not liked working on ships in the past due to his negative interactions with other crew members. He had told Cormac that in previous roles he had been exposed to racist behaviour and didn’t always feel safe on board ship. In about June or July 2021, when David was working on a different vessel, he told Cormac he was concerned people from the ship wanted to harm him and he felt there were lots of places on the ship where it would be easy for someone to tip him overboard without anyone seeing. He told Cormac “in case anything happened”43 to him and he disappeared. Noting his medical history, it is possible David may have been experiencing some paranoid thoughts not grounded in reality, but it is equally possible that he did experience racially targeted behaviour that caused him to fear for his safety. Cormac certainly took his expressed concerns at face value. However, it is relevant that this conversation related to a different vessel and crew to the Maersk Mover.44
Cormac received a Facebook message from David on 21 September 2021. In the message, David mentioned he was back at sea on a new boat up off Exmouth. David said his good friend had got him the job and he described the crew as “much better”.45 The messages show they had a relatively ordinary exchange about what was happening in their lives. There was nothing in the messages to raise any concern about David’s safety or mental health. David kept working in the industry, despite his concerns, to earn money to pursue his other interests. Cormac was aware that while on the ships, David was often working on his laptop trying to edit his film footage from his long walk across the country, and Cormac understood David was nearly finished.46
David spoke to the Chief Officer on 22 September 2021 and queried why he was rostered to leave the vessel on 9 October 2021 as he had understood he finished his roster on 7 October 2021, when the rest of the crew finished. The Chief Officer checked with the Captain, Drew Paskin, who advised that David’s contract actually ended on 30 September or 1 October, earlier than the rest of the crew, as he was an additional crew member. The Chief Officer passed this information back to David, who appeared ok with this end date.47
David worked a shift from midnight to midday on 23 September 2021. As well as doing the lookout shifts until sunrise, David, Mr Whaitiri and Mr Smith had done general work on the boat, such as washing and cleaning. They then had the afternoon/evening off. No one is aware what David was doing while off shift, as his time was his own, but it was assumed he was in his cabin resting.48 42 Exhibit 1, Tab 8.
43 Exhibit 1, Tab 11 [68].
44 Exhibit 1, Tab 11.
45 Exhibit 1, Tab 11 [121].
46 Exhibit 1, Tab 11.
47 Exhibit 1, Tab 17.
48 Exhibit 1, Tab 17.
Cormac was not aware at the time, but David emailed him three times on 23 September 2021 from the Maersk Mover. Due to intermittent Wi-Fi signal from the vessel, it’s not clear exactly what time the emails were sent.49 The emails went to an old email address, so Cormac only saw them sometime later when he checked the old account. The content of these emails was alarming, and very different to the tone of the messages a couple of days before.50 I have set out the exact text of the emails below, with the first two sent close in time together, possibly around 4.00 am, and the last email an hour or so later at around 5.00 am. The first email had the heading ‘Stitch Up’:51 Cormac I’ve been drugged pretty much since I got on, got a huge dose today, my heart was about to jump out of my chest I think it’s speed but I’m not sure I’ll be in contact everyday, I’m going to try to get off which may be difficult sorry to put you through this I’m on the maersk mover somewhere nth west of Exmouth I don’t know that you should do anything … we have a new guy coming I believe, my guess is he’ll be the enforcer hopefully I can get off then Look I don’t know what to do? Any ideas? If I loose my shit I have to pay for the repatriation which could be like 20k + which I don’t have. I’d have to say this is the biggest pickle I’ve ever got into …
By the time Cormac saw the messages David had already gone missing. It was unusual for David to email him, and Cormac had never received an email of this nature from David before, but the syntax and grammar sounded like him. The first two emails did not make a lot of sense to Cormac, but the reference in the third to repatriation costs did reference back to their earlier phone conversation in July, when David told him that the crew have to foot the bill for their removal from the ship via helicopter if they are found to be drug or alcohol affected while on board. Cormac passed the emails on to the police and David’s family.52
A crew member from the Maersk Mover confirmed at the inquest that David would not have been expected to cover his expenses to be evacuated from the ship early if it was due to a medical issue. Crew were informed that they would incur the expense if they were removed from the vessel for breach of a policy, such as being found intoxicated or being involved in a fight, and it is possible David had become concerned that it might also apply if he was unwell, but this was not the case.
However, it seems this misconception did prey upon David’s mind prior to his disappearance.53
50 Exhibit 1, Tab 11.
51 Exhibit 1, Tab 11 and Tab 29.
52 Exhibit 1, Tab 11 and Tab 17.
David worked with the Second Officer, Daniel, between 2.00 am to 3.00 am. Daniel recalled that David sat down next to him on the bridge and Daniel tried to strike up a conversation, but it was hard and David was quite abrupt in response. He then stood up suddenly and walked with some hast to the port side windows, rested his forearms on the window rails and stared out to sea, before he began pacing between the port and starboard sides, stopping to lean and look out on each side as he moved back and forth. Daniel thought David’s behaviour was a little odd but he didn’t say anything to him. After a while, David came back in and got a drink. Daniel tried to talk to David again, but David only gave short, brief answers in response. Daniel could sense that something was wrong, but didn’t know what it was and David did not divulge anything personal. When he finished his shift at 3.00 am, David left without speaking to him, which was unusual.54 Mr Smith, on the other hand, recalled that David seemed fine at the 3 am handover.55
The Chief Officer, Shane Broad, came to relieve Daniel on the bridge at 4.00 am. On the way there, at about 3.45 am, he saw David on the first level up from the mess deck, between C and D deck. He recalled David was wearing a long sleeve polo shirt and denim jeans and he was carrying his laptop. David was holding his laptop out in front of him as he was walking, but it was closed, which Mr Broad thought was a little odd. As they passed each other, they both said ‘Hi” then kept walking. The Chief Officer didn’t sense anything wrong at that time56
David was due to return to replace Mr Smith again at 5.00 am, but he did not return.
Mr Smith called David and Mr Whaitiri over the radio. Mr Whaitiri responded and said he didn’t know where David was, so he offered to come and take over instead of David. Mr Whaitiri relieved Mr Smith just after 5,00 am. At the end of their watch, they both went to breakfast. Neither had seen David since 3.00 am and they did not see him in the mess for breakfast. They were all due to meet in the changerooms at 8.00 am, but David did not present as scheduled. Mr Smith and Mr Whaitiri thought David must have slept in, so they went to David’s cabin, but he wasn’t there. They returned to the mess and changeroom then the deck, in case they had missed him, but when they didn’t find him, they called the bridge at 8.20 am and informed Daniel that they couldn’t find David. They were told to have a further look, so they checked all the cabins on C deck and D deck (a total of about 68 rooms), without finding any sign of David.57
55 Exhibit 1, Tab 14 and Tab 15.
56 Exhibit 1, Tab 17.
57 Exhibit 1, Tab 14 and Tab 15.
[2025] WACOR 22 (S) searching all the cabins. They also ran into the Captain while he was on his way to breakfast, and they informed the Captain that David was missing. The Captain went to the bridge and spoke to Daniel, who advised the Captain that he believed David was missing. The Captain called David’s name over the ship’s PA system. When David didn’t present, the Captain called a muster a short time later, at about 8.30 am.
All of the ship’s crew turned out for the muster on the aft deck except David.
Following a head count, the Captain advised the crew that David was missing and the whole crew then conducted a full search of the ship. It took about 30 minutes to search the ship, which was very large and many of the cabins empty. The process was completed a few times to make sure it was thorough.58
Crew members acted as lookouts on shift for 32 hours, but none of them saw any sign of David in the water.60
A large two-day air and sea search was conducted, coordinated by the AMSA JRCC with the Maersk Mover as the lead vessel and many other vessels involved, as well as aircraft, but there was no sighting of David. Detective Senior Constable Paul Ayton confirmed at the inquest that all records indicate the search was very thorough and there was a lot of assistance provided from the various people in the area.61 The weather conditions were favourable to the search, and with the amount of boats and aircraft involved, it was felt that if David had been on the surface of the water in the locations searched, he would have been very visible.62
Dr Paul Luckin (Dr Luckin), a doctor with considerable experience in estimating windows of survivability in missing person cases, was consulted as part of the search. Dr Luckin indicated that based on the known information, there was little chance he would have still been alive by first light on the morning of 24 September 2021, and no chance he was still alive in the water by midday of the same date. The AMSA Response Centre Manager approved a cessation of the search from that time, as there was no further chance of survival.63 58 T 57 - 59; Exhibit 1, Tabs 14 to 16.
59 Exhibit 1, Tab 14, Tab 15 and Tab 17.
60 Exhibit 1, Tab 14 and Tab 15.
61 Exhibit 1, Tab 3.
63 Exhibit 1, Tab 4 and Tab 5.
The search was officially called off on 25 September 2021 and the Maersk Mover ended the search at midday on that date and returned to Dampier. At about 1.30 pm that day, as they were heading in to port, a crew member, Michael Parker, advised the Chief Officer that as the crew were getting out the mooring lines out ready to tie up at the port he had located a whole lot of footprints at the Whaleback area on the port aft of the vessel. The Chief Officer stated that no one should ordinarily go to that location when at sea, and no one would monitor or watch that space. The Captain went to the area and looked at the footprints. His first thought was that “they shouldn’t be there. There is no reason to stand on that section of the whaleback”.64 The Captain took several photographs of the footprints using his mobile phone so that he could later provide photographs of the footprints to police for their investigation. Unfortunately, as it was not known what footwear David was wearing, they could not be forensically compared. However, they appeared to be slip on shoes, not work boots, which it was possible David may have been wearing.65 One of the crew members who found the footprints told police there “were a few like someone had hesitated and then a footstep on the edge as if someone had pushed off”.66
The area was included in the initial search for David, but given it was not an area usually in use and they were looking for a person at that stage (with the thought David may have had a medical event or been injured), not footprints, it was not noticed at that time.67
Mr Ross confirmed at the inquest that the whaleback area was not part of the induction but would have been included as part of the familiarisations done with David by the Chief Integrated Rating, who was David’s supervisor on board. Mr Ross said he was confident it would have been covered with David as any opening on a boat is a big concern, because a person can fall directly into the water, so Mr Ross was certain David “would have been run through all of that”.68 Mr Ross also explained that there is a procedure for putting the nets up in that area, so David would have had to be run through the safety aspects of that area for that purpose. It is also information that is included in the paperwork that was given to David and he signed as part of the induction. There is also a safety line on the back of the boat and safety plaques to warn of the inherent danger.69 Mr Ross made the comment in his evidence that everything they do on a vessel like that is dangerous, so “[e]verything you do is safety first, and caring for your mates”.70
The area where the footprints were found was described as a spot sufficiently precarious that “if you step on it, you will fall off”71 and it was slippery as well, so it was an obvious ‘man overboard’ risk. It was also not well lit during the night. Mr Ross explained that for these reasons, if you were going in that area to work and the safety net was not in place, you would wear a personal flotation device and use the buddy system, as the risk that you might fall was high. However, he reiterated that 64 Exhibit 1, Tab 18 [58].
65 T 14; Exhibit 1, Tab 17.
66 Exhibit 1, Tab 21.
67 T 62 – 63; Exhibit 1, Tab 22.
[2025] WACOR 22 (S) there was no work-related reason for David to go to that area, particularly on his own in the early hours of the morning.72
Responsibility for the ongoing missing person investigation was then transferred to the Missing Persons Unit on 8 February 2022. Officers from the Missing Persons Unit conducted an extensive inquiry into David’s history, speaking to many family members, friends and work colleagues of David.75
Detective Senior Constable Paul Ayton had carriage of the investigation and he obtained a significant amount of background information about David’s life prior to him joining the Maersk Mover. Based on the information obtained from his family and friends, Detective Senior Constable Paul Ayton was able to provide the Court with a very comprehensive understanding of the interesting and varied life that David had lived up to that time. The medical records obtained in the investigation also provided some additional personal information about David’s mental state that he had not shared with his family in detail.76
Detective Senior Constable Paul Ayton was aware of the concerns that David may have been targeted or bullied in previous roles, but his investigation found no formal evidence of complaints or any witnesses to such incidents. Similarly, he found no evidence that David had been the subject of any adverse incidents with other crew members on the Maersk Mover. The crew members were interviewed by police and they all described morale on board as generally good and they thought David had been settling in well. Based upon the medical information, and the comprehensive enquiries into his former employment and most recent employment, Detective Senior Constable Paul Ayton concluded that David held a genuine belief that he was subjected to bullying and racial harassment when at sea, but it was likely his beliefs were delusional and connected to an undiagnosed mental illness.77
When David first joined the Maersk Mover, he appeared to be reasonably well.
The Captain of the ship told police he did not have a lot of ‘hands on’ contact with David, but he saw him a few times in the mess and he was seen eating meals with the 72 T 64; Exhibit 1, Tab 19.
73 Exhibit 1, Tab 17.
74 T 66 – 69, 82 – 83; Exhibit 1, Tab 19.
75 Exhibit 1, Tab 3.
[2025] WACOR 22 (S) other crew and seemed fine. There was nothing unusual about his behaviour that stood out. At one stage, the Captain asked Mr Whaitiri, who was part of David’s team, how David was going and Mr Whaitiri’s comments were all positive. The Captain did not receive any negative comments about David or his work. He understood David was happy to stay on board and he was unaware of David having any issues being on board or with his crewmates.78
However, the evidence of Daniel, as well as the emails sent to David’s friend Cormac, indicate he became unwell in the last few days on the vessel, but unfortunately he does not appear to have confided in anyone onboard, including his good friend, and the people working with him did not know him well enough to realise what was happening.
The Captain advised the police that the crew had searched David’s cabin on the day he was identified as missing, but they did not remove anything from the room and left it as they found it. Crew members mentioned David had a mobile phone and laptop with him on board, but these items were not seen in his room and a search of the ship did not locate either item, which suggests they were with David when he disappeared. This is consistent with the Chief Officer seeing David carrying his laptop at the last time he was seen.79
Detective Senior Constable Paul Ayton advised that some of David’s olanzapine medication had been found in his cabin. Based on his prescription and dosage (noting he had five repeats prescribed), it was calculated that if he had been compliant with his medication regime he should have finished the medication on 19 June. However, there were two boxes of 28 tablets found in his cabin, and they were confirmed to be his third and fourth repeat. This indicated that David had not been taking his medication as prescribed, so he would not have been receiving the full benefit. 80
The crew had checked and confirmed that no lifejackets, flotation devices or other life-saving appliances were missing from the vessel.81
It was clarified that there was no reason for David to have been working on deck in the dark at the time he was last seen. When not doing his watch shift at that time of the morning, he would generally have been doing a task referred to as ‘pegging’, which was basically cleaning inside. He might also have gone to his cabin to rest, which was not unusual. Given he was an extra person on the shift, if he wasn’t around it would not have raised any early alarm as there were other people who could fill this duty and the rest of the duties were not essential at that time of the morning.82 78 Exhibit 1, Tab 18.
79 Exhibit 1, Tab 18.
David was described by all who knew him as a considerate, kind, thoughtful young man with a good sense of humour and a passion for life. He was close to his family and a had a wide circle of friends spanning across the world. He enjoyed many hobbies but didn’t belong to any particular groups or organisations, enjoying doing things on his own or with his friends.83
Michelle indicated in her statement in May 2024 that she believed David’s disappearance was due to a horrible accident, rather than any choice on his part to deliberately disappear. Michelle theorised it was possible he had been using his laptop while sitting on the edge of the boat and accidentally fell into the ocean. He often used his laptop to work on his movie about his walk across Australia.84
David’s most recent intimate partner, Milena, told police in a statement that she was concerned David might have died due to an accident that was covered up or because of racism, given his previous experiences, although I note this was a new ship with a different owner and a new crew, and his final messages were all positive in this regard. Milena expressed her opinion that she did not believe David would have deliberately taken his own life as he was looking forward to coming home to her, his bees and the life he was making in the south west. Milena expressed her belief that David would want to be remembered as kind and interesting, slightly mysterious and self-sufficient. Milena accepted that David could have been struggling with mental health issues, but she believed he was generally in a positive state of mind about the future and had never given her any reason to think he might deliberately harm himself.85
However, David’s previous long-term partner, Grace, did recall conversations with David where he spoke openly about having previously contemplated suicide in his younger years. David didn’t go into specifics, but she was aware he had experienced racial abuse throughout his life that had affected him deeply. They had a difficult breakup but remained friends. Grace recalled that David did seem to become more guarded over time. When they had met for lunch in February 2021, he was more withdrawn than usual and she felt he had put walls up and didn’t want to discuss personal things with her anymore. Unlike other significant people in his life, Grace believes it is very likely David might have taken his own life, based upon his earlier conversations with herself and a mutual friend about suicide. She feels his disappearance is consistent with the way he liked to portray himself as a mystery to others, and the fact that he considered the ocean to be a place of peace and respite from the world.86
Police also spoke to David’s ex-wife, Adare. They divorced in late 2010/early 2011 and had little contact from that time, but in the time they were together she did not recall David ever talking about suicide or self-harm. She described David as someone with a heart of gold, who would tell people what he thought and stand up 83 Exhibit 1, Tab 6 and Tab 7.
84 Exhibit 1, Tab 7 and Tab 8.
85 Exhibit 1, Tab 8.
86 Exhibit 1, Tab 9.
[2025] WACOR 22 (S) for what was right, which could lead him into conflict, but not as someone who would try to harm himself or others.87
Other friends of David spoke about his dream to finish his films about his walk and his hope he might be able to sell the finished product to fund further adventures in the future.88
Cormac, who seems to have been the last person that David tried to contact, is a journalist and he believes David may have emailed him because he wanted his situation recorded with someone he trusted and to preserve the information in writing, noting David had a few months earlier told him on the phone of his concerns for his safety. When Cormac became aware David had gone missing, he was concerned David’s expressed fears had been realised. While he was aware of David faking his own death in the past, he did not at any stage think this was a realistic possibility. He put the previous incident down to a publicity stunt/a way of ‘killing off’ his character as David was ending his walk, and Cormac believes David liked his family and friends and life in general too much to fake his death and start again somewhere else. Cormac does believe, however, that it is possible David took his own life, possibly while his mental health was compromised, which he believes is consistent with the tone of the emails David sent to him immediately before he disappeared.89
Proof of life checks were completed throughout Australia and familial DNA from a number of family members was obtained to assist with checks on the unidentified remains database. None of them matched David.90
88 Exhibit 1, Tab 11.
89 Exhibit 1, Tab 11.
90 Exhibit 1, Tab 3.
Accordingly, I am satisfied beyond reasonable doubt that David Ingram died around the time of his disappearance on 24 September 2021 in the ocean offshore from Exmouth.
I am unable to reach a finding as to the cause of death, as David may have died from an injury sustained in the fall from the vessel, due to drowning or due to predation from marine life. There are too many possibilities for me to be satisfied that one is more likely than another. The cause of death must, therefore, remain unascertained.
As to the manner of death, I am satisfied from the evidence before me that David was likely in an impaired mental state at the time. He was experiencing paranoid thoughts and was indicating he wanted to leave the vessel. There is also some significance to the date, noting he had previously ended the life of his ‘adopted persona’ on the same date some years before. However, there is nothing before me to show that David had formed a definite intention to end his life. No note that could be described as a ‘suicide note’ was found and his cabin had appeared like he had just got up and gone to do a shift, so there was no suggestion of a planned disappearance. Accordingly, I make an open finding as to the manner of death.
This inquest was directed as David is a missing person believed deceased and the evidence explored the circumstances of his disappearance, but this finding is also a record of David’s life. Although he was only 44 years old at the time of his death, he had lived a full life and was still actively pursuing his life goals through passion and hard work. His family were very proud of the steps he was taking to follow in his father’s, and grandfather’s, adventurous footsteps pursuing a living outdoors. Sadly, David died before all of his dreams came to fruition, but he will be remembered by his family as “an adventurer, a surfer, and a humble and kind man”.92 S H Linton Acting State Coroner 6 June 2025 92 Exhibit 1, Tab 7 [54].
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…
Sean Theo Winmar, a 46-year-old Nyungar Aboriginal man, died by hanging at The Beacon residential facility on 11 August 2022. He was subject to an interim post-sentence supervision order (HRSO Act) following release from…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.