Inquest into the deaths of Sandra BONEY, Norman BONEY and Roger John ADAMS

STATE CORONER’S COURT OF NEW SOUTH WALES Inquiry Inquest into the deaths of Sandra Boney, Norman Boney and Roger John Adams Hearing dates: 17 October 18 October and 19 October 2016 Date of findings: 22 November 2016 Place of findings: NSW State Coroner Court Glebe Findings of: Deputy State Coroner H Barry File number: 2015/39515; 2015/57255; 2015/90486 Representation: Ms P Dwyer, Counsel Assisting instructed by Ms A Anderhuber (Office of the General Counsel, Department of Justice) Mr C Day Aboriginal Legal Service, representing Mary Miller Mr H Chui representing Western Area Local Health District (instructed by Crown Solicitor’s Office)

Findings: Sandra Boney died on 3 February 2015 at Bourke Hospital. The cause of death was Organising Pneumonia. The manner of death was natural causes.

I find on balance that her admission to hospital was caused by the ingestion of methanol and it was the ingestion of methanol that caused her to become ill and contributed to her death.

Norman Boney died on 14 February 2015 at Dubbo Base Hospital. The cause of death was Organising Pneumonia and a contributing cause of death was alcoholic liver disease. The manner of death was natural causes. I find on balance that his admission to hospital was as a result of ingestion of methanol that caused him to become ill and contributed to his death.

Roger Adams died on 25 March 2015 at Collarenebri Multi – Purpose Medical Service Hospital. The cause of death was Organising Pneumonia complicating and an antecedent condition being liver disease. The manner of death was natural causes. I find on balance that his admission to hospital was as a result of ingestion of methanol that caused him to become ill and contributed to his death.

Introduction: Sandra Boney, Norman Boney and Roger Adams all resided at the Walli Reserve near Collarenebri. In late 2014 early 2015 they each consumed an unknown quantity of moonshine, which is the name given to home-made alcohol crudely distilled.

Sandra, Norman and Roger became ill and each was admitted to hospital between January and March 2015.

In January 2015 Sandra was admitted to Collarenebri Hospital and was returned to country and passed away on 3 February 2015 at Bourke Hospital. She was 40 years of age.

Norman was admitted to Dubbo Base Hospital on 3 February 2015 and passed away on 14 February 2015.He was 46 years of age.

Roger Adams became unwell in February 20145 and was admitted to Collarenebri Hospital. He was later flown to Dubbo Base Hospital and then transferred to Royal

Prince Alfred Hospital for treatment. He was discharged and returned to Walli Reserve but was readmitted to Collarenebri Hospital in March 2015 and treated at Orange Base Hospital but returned to country at Collarenebri where he passed away on 24 March 2015.He was 37 years of age.

Sandra and Norman were siblings. Sandra was in a long-standing relationship with Roger Adams. Notwithstanding the fact that each of these three persons struggled with alcoholism it was not expected that they would die so young.

Sandra is survived by her daughter Elliot Boney. Norman is survived by his daughter Patricia Sullivan.

A number of members of the community and relatives of the three deceased persons attended the inquest. Their grief and sadness was palpable. Sandra, Norman and Roger were much loved and valued members of the community at the Walli Reserve and it is clear that their deaths have had a profound effect on the family and the community.

Lavinia Flick, who was related to and had known Roger all her life, stated in relation to the impact of Sandra’s, Norman’s and Roger’s death upon the community: “The sadness that you feel, there are no words for it” The Inquest: The role of the Coroner as set out in Section 81 of the Coroner’s Act 2009 ( “the Act”) is to make findings as to:

(a) the identity of the deceased

(b) the date and place of the person’s death

(c) the physical or medical cause of death; and

(d) the manner of death, in other words , the circumstances surrounding the death.

This primary focus of this inquest is the manner of death relating to Sandra, Norman and Roger and whether there is evidence sufficient to establish that the consumption of moonshine in any way contributed to their deaths.

The Evidence: Moonshine Moonshine is the name given to home-made alcohol, crudely distilled. Whilst it is not illegal in Australia to purchase a still, it is illegal to distil alcohol without a licence.

Professor Ian Whyte, Director Department of Clinical Toxicology and Pharmacology, Calvary Mater Hospital, NSW provided a written statement and gave oral evidence to the court.

He described the process of distilling and the effects of Methanol poisoning which can be summarised in the following terms: Methanol is a colourless, volatile, flammable, slightly sweet – tasting liquid with a slightly alcoholic odour distinctly different from ethanol. .Methanol can be found in antifreeze or fuel or for stoves or solvent in paints and nail varnishes in many countries. In those countries methanol is used to “de-nature” ethanol (that is a process which renders ethanol unsafe to drink, and therefore makes ethanol solutions exempt from taxes). That is where the term methylated spirits came from, but in Australia because of the recognition of how dangerous it can be, legislation was introduced in 1984 to remove methanol as an allowable agent for denaturing ethanol. Methylated spirits in Australia no longer contains methanol. Consequently methanol poisoning in Australia is a rare event.

The basic principles of distillation-fractional separation by boiling point require the appropriate equipment and techniques to ensure purity. It is easy to get the technique wrong. The distillate is collected in volumes referred to as heads(discarded first fraction), hearts(product) and tails(discarded or redistilled last fraction).. Both the heads and the tails contain increased amounts of methanol.

Altering the production method, for example, by collecting the heads or tails to increase yields, will increase the percentage of unwonted and potentially deadly methanol.

The process of natural fermentation may produce methanol. It is the simplest alcohol and closely related to ethanol, but it is highly flammable and volatile, and highly toxic to humans. Methanol is found in trace quantities in fruit juices and fermented beverages, where it is produced from the hydrolysis of fruit pectins. It has no therapeutic use.

Methanol itself has a relatively low toxicity. It is the body’s metabolism of methanol that is responsible for its transformation to toxic compounds. Methanol is metabolised principally in the liver. The main enzyme responsible for metabolising drinking alcohol (ethanol), is also the primary enzyme involved in the oxidation of methanol to its first metabolite, formaldehyde. Formaldehyde converts to formic acid.

It is the formic acid which causes the damage and leads to toxicity. Methanol disappears quickly from the body but formic acid lasts a lot longer in the body.

Clinical Effects Professor Whyte also explained the clinical effect of methanol on the human body, which is disturbing. A relatively small dose can cause blindness and ultimately death.

Methanol toxicity primarily affects the central nervous system, the eye and the gut.

Methanol is a CNS depressant, and like other alcohols, in high concentration it can cause low blood pressure and reduction in heart function.

The delay between the ingestion of methanol and presentation to a healthcare facility and the co-ingestion of ethanol are the two most important parameters affecting the clinical presentation. Shortly after methanol ingestion the patient may show mild disinhibition, sedation or incoordination attributable to methanol itself. This phase rarely leads the patient to seek medical attention and may be relatively mild in an ethanol tolerant individual.

After a latent, asymptomatic phase of many hours ( 12 -24 but may be as long as 72), patients may complain of visual disturbance, headache, vomiting, dizziness or abdominal pain. The experience of these symptoms is very variable and the coingestion of ethanol typically delays the onset of these symptoms for 24 hours.

Moonshine is also known to contain other toxins including heavy metals such as lead and arsenic. Such toxins can produce symptoms such as anaemia, tachycardia, hypotension, altered mental states, seizures, blood in your urine, vomiting blood, diarrhoea, drowsiness and stomach pain.

Consumption of Moonshine by Sandra, Norman and Roger and the supply of Moonshine by Mary Miller.

There is ample evidence in the brief of evidence prepared in this matter to establish that Sandra, Norman and Roger as well as other members of the Walli Reserve community had been drinking moonshine for a number of months before their deaths.

There is also conclusive evidence that the moonshine was supplied by Mary Miller.

Mary Miller conducted a second hand business in Collarenebri. She resided with her partner, Graham Stewart in Pokataroo, near Collarenebri.

Following the death of Sandra, police attended Mary Miller’s property at Pokataroo on 6 February 2015.Detective Senior Constable Samantha Neader and Senior Constable Shanelle Trevillian and Sargent Lisa Jones conducted a search of the premises. Mary Miller and her partner Graham Stewart were present and consented to that search.

Seized during that search was a number of plastic crates and cardboard boxes of red wine. Some of those bottles had torn labels which were identical to the bottles that had been seized by police after being provided to Sue Jenkins of the Walgett Aboriginal Medical Service, from the Walli Reserve the day before.

In addition, a number of bottles containing homemade ‘rum’ and ‘Tia Maria’ were located at Pokataroo. Mr Stewart acknowledged that he made the alcohol and that the homebrew kit was his.

Ms Miller stated that she assisted Mr Stewart with the manufacture of the homemade beer. She denied selling the homemade alcohol, but claimed that she would use a “barter” system with the residents at Walli Reserve. Ms Miller admitted that she gave a box of wine to Margaret Boney around Christmas time but claimed this was from the supply that she had previously purchased from an auction in Bathurst. Ms Miller had bought the wine at Auction which she claimed had come from a vineyard.

Mary Miller’s denial that she sold homemade alcohol to the residents at Walli reserve is in stark contradiction to the oral evidence given to the court and to statements given by witnesses to health workers and the police.

In oral evidence, Amy Bennett, the niece of Roger Adam, stated that before Christmas 2014, she heard from Margaret Boney about Moonshine being available.

She stated that the” whole of the Reserve was talking about it”. She consumed moonshine at Margaret Boney’s house. Amy understood that the alcohol had been supplied to members of the community by Mary Miller. In addition, Amy purchased a bottle of homemade alcohol from Ms Miller at her shop just before Christmas 2014.

That alcohol was contained in a Bundaberg Rum bottle. Amy paid $50 for the alcohol and drank the contents herself. She claimed the alcohol tasted like methylated spirits and she had pains in her chest the next day.

Additionally, Amy stated that she had drunk some moonshine at Margaret Boney’s house. This was the alcohol that had been purchased by Margaret from Ms Miller.

She told how the alcohol tasted like the “smell of methylated spirits” and after consuming it she developed headaches and pains in the chest that same night. Both her arms went numb “like pins and needles” and she realised that this moonshine was making her feel sick.

Amy had observed Ms Miller attending the Reserve and dropping off boxes of alcohol to the rear of house no.10, Margaret Boney’s house.

Margaret Boney also gave oral evidence. She identified the bottles taken from Ms Miller’s premises by police as being the same in appearance to the bottles of alcohol that were delivered to her house at Walli Reserve in 2014 and 2015. Margaret stated that Ms Miller had sold her alcohol on more than ten occasions. There were about 2 boxes of large bottles and between 10 – 20 boxes of smaller bottles. The alcohol in the larger bottles tasted like “liquorice”, and the contents of the smaller bottles tasted like methylated spirits. Margaret was able to identify this taste because she had consumed methylated spirits in the past.

For the box of larger bottles, Margaret paid $80. The smaller bottles – 24 bottles in a box – cost $100 and one very large black crate containing large bottles cost $150.

Margaret shared this alcohol with Sandra, Norman and Roger. Margaret stated that Ms Miller also delivered bottles of moonshine contained in Coke bottles. These were delivered in plastic bags and cost $80 for about 15 bottles. Sandra, Norman and Roger drank from all these supplies.

Max Boney, Margaret’s son, gave evidence that he had carried a box of homebrew from Ms Miller’s shop in Collarenebri to his mother Margaret’s car. He had seen Ms Miller attend Walli Reserve on 3 -4 occasions bringing bottles of alcohol. He had observed family members consuming the homebrew and noticed them to have “not a normal hangover”. At the time it was not understood that this homebrew could be toxic.

Lavinia Flick told the court that Mary Miller had told her about the availability of moonshine and about her selling it. This conversation took place on Good Friday 2014.Ms Flick stated that Ms Miller said to her: “Ask your brother if he’d like to buy some homemade alcohol for $5.” Ms Flick did not see the alcohol but told her brother about the offer and understood that he purchased some alcohol. In addition, her nephew drank moonshine purchased directly from Ms Miller and slept for 3 – 4 days. He told her it tasted “foul” and “putrid”.

None of this evidence was contested by Ms Miller’s representative and I accept the oral evidence given by Margaret Boney, Max Boney and Lavinia Flick.

The overwhelming and only conclusion is that Mary Miller was in fact selling moonshine (homebrew) to the residents of Walli Reserve during the period 2014 and early 2015.

The Police Response Sandra Boney passed away on 3 February 2015. Prior to this she had been transferred by Ambulance to Collarenebri Hospital on 10 January 2015.

Suzanne Jenkins, from the Walgett Aboriginal Medical Service, visited Sandra in hospital and immediately noticed that one of her hands was shaking, she could not talk or walk and was incontinent. She spoke with Suzanne Mahoney, Health Services Manager at Collarenebri Hospital and both agreed that Sandra was exhibiting symptoms that were not consistent with the stated diagnosis of alcohol withdrawal. After expressing their concerns to the medical officer, Sandra was transferred to Dubbo Hospital for further treatment.

Around 1 February 2015,Ms Jenkins heard rumours from Anthony Shepherd, an Aboriginal Health Worker at Collarenebri Hospital, about the consumption of moonshine.

After Norman became ill on 1 February 2015, with similar symptoms to those exhibited by Sandra, and following Sandra’s death on 3 February 2015, Ms Jenkins attended Walli Reserve and spoke with residents. She was informed about large quantities of homebrew. She collected a number of bottles of the alcohol and contacted Suzanne Mahoney who contacted the police.

Police launched an investigation and attended Walli Reserve on 5 February 2015 where a number of bottles of alcohol (homebrew) were seized.

The contents of those bottles were analysed by the Forensic Science Services Toxicology Unit. A mixture of alcohol and methanol were detected in some of the samples submitted for analysis. The levels of alcohol ranged from 4.2g/100ml to 22g/100ml. The methanol levels ranged from 0.7g/100ml to 2.3g/100ml.

Detective Neader contacted Dubbo Hospital and advised Norman’s treating doctor that both Sandra and Norman may have consumed an unknown quantity of “moonshine” around Christmas and New Year.

As previously stated, Police also attended the premises of Mary Miller on 6 February,2015 and conducted a search of that premises and spoke with Mary Miller and Graeme Stewart.

In addition Detective Neader caused a Media Health Alert to be created and published on the Western Local Health District website, Facebook page and on the New South Wales Police Force website, alerting the community to the possible manufacture and sale of “moonshine” and the dangers associated with the manufacture and consumption of “moonshine”.

The Autopsy Reports and Cause of Death and Expert Opinion Sandra Boney An autopsy report was prepared by Dr Allan Cala, Senior Staff Specialist in Forensic Pathology from the Department of Forensic Medicine, Newcastle, on 10 February 2015.

Dr Cala noted that Sandra Boney died on the 3 February 2015 at Bourke Hospital, the cause of death being Organising Pneumonia.

He further stated that Acute and Organising Pneumonia were identified in each lung and that death was as a result of these conditions. The liver was cirrhotic, the most likely cause for this being alcohol abuse. Toxicological analysis of Sandra’s blood showed no alcohol in antemortem or post-mortem blood samples.

Because the allegation of “moonshine” ingestion was made well after Sandra’s presentation to hospital, by the time of death toxicological analysis was only able to detect medical (in hospital) drugs.

In an expert report prepared by Dr Michael Robertson, Pharmacologist and Forensic Toxicologist, he noted that in the weeks preceding her admission to hospital, Sandra had been ill and not eating. He stated in his oral evidence that if Sandra had ingested any moonshine in the two weeks prior to her hospitalisation it would be likely that any clear evidence of methanol- related toxicity would have disappeared by the time of her hospitalisation. He further stated that chronic daily ingestion of liquor containing both alcohol and methanol can lead to an accumulation of methanol

that will remain largely un-metabolised until such time as the alcohol is excreted from the body such as during periods of abstinence.

Dr Robertson agreed with Dr Cala that because knowledge of the possible ingestion of” moonshine” was made after Sandra’s presentation to hospital; if moonshine had in fact been ingested it would have been metabolised and eliminated from the body within a number of hours of ingestion and therefore any sample collected more than a few hours after ingestion may not be reliable evidence to exclude methanol ingestion.

Paradoxically, according to Prof Whyte, drinking alcohol can prevent the causes of methanol poisoning because ethanol (alcohol) in the bloodstream helps to prevent the formation of formic acid and formaldehyde. According to Dr Joseph Etta, the admitting doctor at Collarenebri Hospital, Sandra’s family had reported that she had not consumed alcohol for one week prior to her admission to hospital. It is possible that Sandra became so unwell in the days prior to her hospitalisation that she limited her alcohol intake thus impacting upon the build- up (and therefore the toxicity) of formic acid.

Dr Robertson noted that Sandra presented with symptoms of altered level of consciousness, shaking, sinus tachycardia and general feelings of illness. All these symptoms can be consistent with methanol poisoning. Notwithstanding the lack of toxicological analysis, Dr Robertson concluded that he did not think methanol toxicity could be excluded as a cause of Sandra’s initial illness and presentation to hospital.

Norman Boney An autopsy report was prepared by Dr Allan Cala on 23 February 2015.

Dr Cala noted that Norman Boney died on 14 February 2015 at Dubbo Base Hospital, the cause of death being Organising Pneumonia and a secondary cause being alcoholic liver disease.

Toxicological analysis of antemortem samples of blood showed no alcohol detected.

Neither chemicals nor drugs were detected and Dr Cala stated that this may be explained by earlier metabolism of alcohol or methanol at low levels.

Toxicological analysis whilst in hospital showed Norman’s methaemoglobin levels varying between 0.7 to 1.9%. Dr Cala stated that this suggests he may have ingested small amounts of methanol at some time earlier but was not sufficiently a high enough blood methanol level to cause death.

Dr Robertson noted that Norman was admitted to hospital with similar symptoms as those exhibited by Sandra. He was admitted with an altered level of consciousness, he was experiencing tremors when mobilising, vomiting, febrile, abdominal distension, tachycardia, anaemic, and hypotensive with an abnormal ECG.

Dr Robertson again concluded that he did not think methanol toxicity could be excluded as a cause of Norman’s initial illness and presentation to hospital.

Roger Adams An autopsy report was prepared by Dr Allan Cala on 30 March 2015.

Dr Cala noted that Roger Adams died on 25 March 2015 at Collarenebri Multipurpose Medical Service Hospital and that the cause of death was Organising Pneumonia complicating, antecedent cause of death being alcoholic liver disease.

Dr Cala stated that toxicological analysis of antemortem blood presumed to have been taken from the deceased at or around the time of admission showed no alcohol; this is not surprising if Roger Adams had become unwell and ceased drinking at least hours prior to admission.

Roger had told Dr Janet Cantley, a locum and Visiting Medical Officer at Collarenebri Hospital, on 20 February 2015, that he had consumed a homebrewed spirit with other friends over the previous four days. He had further stated that he had been drinking the home brew over the last month.

Roger presented with symptoms of vomiting blood, feeling fatigued and blood in his urine. It is also reported that he experienced weakness of his legs and that his vision may have been blurry.

Roger was transferred to Dubbo Base Hospital on 20 February 2015 for further treatment and examination. While being treated at hospital Roger provided a statement to Police on 20 February in which he states that he consumed three bottles of “smallies” port and a couple of days later he felt sick. He further stated that he drank the “grog about two weeks ago but the symptoms started about two to four days ago”.

Roger was transferred to the Intensive Care Unit at Royal Prince Alfred Hospital in Sydney to undergo further treatment and investigation of other possible non – alcohol related causes of liver disease including copper, heavy metal and infectious causes, all of which were negative. His condition stabilised and Roger was discharged from RPA and transferred back to Collarenebri Hospital for discharge on 28 February 2015.

It is reported that Roger consumed a large amount of alcohol when he returned to Walli Reserve and on 19 March he experienced a convulsion and cardiac arrest. He was admitted to Collarenebri Hospital and transferred to the Intensive Care Unit at Orange Base Hospital for treatment.

Upon admission to Collarenebri Hospital, Roger had a blood pH of 7.1 suggesting acidosis, a possible symptom of methanol poisoning although; Dr Robertson states that given his acute state of health, other possible causes of the acidosis were possible.

Again, Dr Robertson concludes that he did not think methanol toxicity could be excluded as a cause of Roger’s initial illness and presentation to hospital on 20 February 2015.

Distilling Spirits In NSW and Australia, it is illegal to distil alcohol. It is illegal to purchase, possess or erect a still over a 5Litre capacity. A still of less than 5Litres may be purchased for the purpose of distilling water or essential oils.

The relevant legislation governing the purchase of a still is the Excise Act 1901(Commonwealth) (the Excise Act).

Section 25 of the Excise Act provides that: “A person who does not hold a manufacturer licence must not intentionally manufacture excisable goods knowing, or being reckless as to whether, the goods are excisable goods.

Section 25(2) of the Excise Act provides that “A person who does not hold a manufacturer licence must not manufacture excisable goods.” “Excisable goods” is defined in the Act as goods in respect of which excise duty is imposed by the Parliament, and includes goods the subject of an Excise Tariff.

Alcohol, (including Spirits) are excisable goods.

The anomaly arises in the fact that a person can possess a 5Litre still for the purpose of distilling water or essential oils and there is no need for a licence. In practice, a person can possess the 5Litre still and can illegally manufacture alcohol; but because there is no licencing requirement ,that activity is likely to remain undetected unless there is a catastrophic event such as in the loss of lives such as those of Sandra, Norman and Roger.

Because of the gap in the legislation, there is the potential for fatal consequences.

Although no evidence was called on this matter, the court is aware of fatalities that have occurred in other States as a result of the ingestion of illegally distilled alcohol.

Recent newspaper articles reveal that in 2013 there were two tragic deaths in Tasmania from suspected methanol poisoning, and three deaths in Queensland.

One way of preventing such an event may be to require that all persons in possession of a still must hold a licence. Another may be to mandate better warnings on the distilling equipment. I intend to send these findings to the Commonwealth Attorney General and to the Commonwealth Minister for Finance, so that they are aware of this inquest and can further consider the issues.

Sale Of spirits Section 7(1) of the Liquor Act 2007(NSW), provides: “A person must not sell liquor unless the person is authorised to do so by Licence”.

Maximum penalty: 100 penalty units or imprisonment for 12 months, or both.

In this case it is a matter for the police, after careful consideration of the evidence available to them, whether charges are laid against any person for the sale of liquor without a licence.

Conclusion Undoubtedly the manufacture of homemade alcohol or “moonshine” can lead to fatalities or permanent manifestations. The expert evidence established that in homemade alcohol, methanol is often present and this is a serious and dangerous problem.

Sandra, Norman and Roger all struggled with alcoholism as evidenced in their medical records and disclosures to Police and medical staff. But, the evidence overwhelmingly supports the fact that prior to the introduction of the “moonshine”, all three were relatively healthy and participating in life on the Reserve. Both Anthony Shepherd and Sue Jenkins knew Sandra, Norman and Roger well. Their deaths were unexpected.

Mr Shepherd stated that he had known the three persons for a long time. Sandra was articulate and liked to chat and was able to walk into town. When she was admitted to hospital, Sandra failed to recognise him and she could not hold a cup, nor take care of herself.

Similarly, before Norman and Roger became unwell, they appeared relatively healthy and happy to chat. Mr Shepherd had seen Sandra and Roger admitted to hospital in the past and was aware how they normally responded to intoxication. Their presentation to hospital in early 2015 was vastly different.

Suzanne Jenkins agreed with the evidence of Mr Shepherd.

Detective Senior Constable Neader knew Sandra, Norman and Roger and stated that Sandra and Norman appeared to be in reasonable health. She was aware of some prior health issues with Roger. The coincidence of these three relatively well individuals dying within a short space of time drove the police investigation.

Detective Senior Constable Neader stated that it was her and Senior Constable Trevillian’s instinct, coupled with the knowledge that “moonshine” may have been supplied to all three persons, that caused them to escalate the investigation into Sandra’s death and then into the deaths of Norman and Roger.

These two police officers took seriously the concerns raised by Ms Jenkins and Ms Mahoney. There is no doubt that the police response in acting quickly; alerting not only the treating medical practitioners involved in Norman and Roger’s care but alerting the community at Walli Reserve and the general public to the dangers of “moonshine” may well have prevented further catastrophic events as a result of the consumption of “moonshine”.

Their response was governed by concern and compassion for the persons who had died and they should be commended for the diligent way in which they conducted this investigation and I intend to send these findings to The Commissioner for Police NSW for his information.

The tragedy of this matter is that not only did three beloved members of the community die but that a contributing factor to the illness that led to their deaths was the ingestion of “moonshine”; that “moonshine” having been supplied by Mary Miller.

Mary Miller was considered by many persons at Walli Reserve to be a friend. That is simply not the case. Mary Miller sold for profit contaminated alcohol to vulnerable members of the community.

Lavinia Flick, in referring to Roger, told the court: “As a member and friend and cousin when he was taken like that, Mary opened her shop the next day after they died like it was nothing”.

It is impossible to disagree with Lavinia’s conclusion: “Mary targeted people with alcoholism – she targeted people with an addiction and disease – it was our people that were affected by it”.

I make the following findings:  Mary Miller manufactured or assisted in the manufacture of “moonshine”.

 Mary Miller sold supplies of the “moonshine” alcohol to Margaret Boney at the Walli Reserve  Margaret Boney shared that alcohol amongst various family members including Sandra Boney, Norman Boney and Roger Adams  Sandra Boney, Norman Boney and Roger Adams were observed to ingest that alcohol over a period of weeks or months.

 The cause of Sandra Boney, Norman Boney and Rogers Adam’s’ illnesses was the consumption of alcohol containing methanol. Consuming the methanol led to them becoming unwell and being hospitalised.

 Sandra Boney, Norman Boney and Roger Adams each had a compromised immunity due to other health issues and methanol poisoning acted on that compromised immunity and contributed to their untimely death.

Formal findings Sandra Boney died on 3 February 2015 at Bourke Hospital. The cause of death was Organising Pneumonia. The manner of death was natural causes. I find on balance that her admission to hospital was caused by the ingestion of methanol and it was the ingestion of methanol that caused her to become ill and contributed to her death.

Norman Boney died on 14 February 2015 at Dubbo Hospital. The cause of death was organising pneumonia and a contributing cause of death was alcoholic liver disease. The manner of death was natural causes.I find on balance that his admission to hospital was as a result of ingestion of methanol that caused him to become ill and contributed to his death.

Roger Adams died on 25 March 2015 at Collarenebri Multi -Purpose medical service Hospital. The cause of death was Organising Pneumonia complicating and an antecedent condition being alcoholic liver disease. The manner of death was natural causes. I find on balance that his admission to hospital was as a result of ingestion of methanol that caused him to become ill and contributed to his death.

Deputy State Coroner Glebe Date