Inquest into the disappearance and suspected death of Gaida COOTE

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STATE CORONER’S COURT

OF NEW SOUTH WALES Inquest: Inquest into the disappearance and suspected death of Gaida Coote Hearing dates: 14 October 2016

Date of findings: 28 October 2016

Place of findings: State Coroners Court, Glebe

Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: Coronial Law- Missing Person -Search and Rescue Operation File number: 2015/167231 Representation: Sgt Paul Bush - Coronial Law Advocate - Advocate assisting

the Coroner Findings: On the balance of probabilities, I find that Gaida Coote is dead. She died on or in the days shortly after 3 December 2014.

Gaida died in or close to the Ku-ring-gai Wild Flower Garden at St Ives, NSW.

lam unable to determine the exact cause or manner of

Gaida’s death.

Recommendations:

To Ku-ring-gai Council,

That the Council consider implementing an RSVP system for all bush volunteer activities, so that supervisors can

account for all volunteers who are expected to attend.

That the Council consider trialling high visibility clothing

for volunteers working in bush areas.

To the Minister of Police and the NSW Commissioner

of Police

That consideration is given to mandating an educational package for all police when the new “Missing Persons — Standard Operating Procedures” are introduced.

Specifically, police should be reminded that there is no “waiting time” necessary when a missing person is

reported.

This decision has been prepared without the benefit of a transcript.

IN THE STATE CORONER’S COURT GLEBE

NSW

SECTION 81 CORONERS ACT 2009

REASONS FOR DECISION

1. This inquest concerns the disappearance and suspected death of Gaida Coote.

Introduction

2. Gaida Coote was 84 years of age at the time of her disappearance. She lived alone in the St Ives area and had close contact with both her adult daughters. Prior to

her retirement she had worked as a manager at Douglas Hanley Moir laboratories.

3. | Gaida was passionate about nature and was reportedly physically fit and active.

She loved walking and one of her favourite activities was to volunteer for a bush care group affiliated with Ku-ring-gai Council that conducted weed clearing and other maintenance within the Ku-ring-gai Wild Flower Garden. The garden is set

in 123 hectares of bushland and is accessed via Mona Vale Road, St Ives.

4. Gaida was adventurous and loved travel. She had recently been to Kakadu National Park, Port Douglas and China with her daughter, Karen. The last trip was in September 2014. At that time, Karen noticed that Gaida found travelling more difficult than she had previously and that she developed a urinary tract infection

which caused her some discomfort and possible confusion.

The role of the Coroner and the scope of the inquest

The role of the Coroner in a case such as this is to make findings as to whether the nominated missing person is actually dead and, if that can be established, to make

further findings as to the date and place of death and in relation to the manner and cause of the person’s death.! In addition, the coroner may make recommendations in relation to matters that have the capacity to improve public health and safety in

the future

The inquest received a significant amount of documentary material including statements, search logs, photographs and maps, Oral evidence was called from the investigating officer Senior Constable Sarah Ireland and from Robert Kidd, Manager, Corporate Risk and Assurance, Ku-ring-gai Council. The court also heard

briefly from Gaida’s daughters.

When was Gaida last seen?

Gaida last saw her daughter Karen on 28 November 2014 when Karen took photographs from the China trip over to Gaida’s house. Karen noticed Gaida seemed quiet and “not quite herself’. Karen spoke to her mother by telephone on 30 November and again on 2 December and she noticed that Gaida was “definitely getting quieter and not talking very much”, She was also concerned that Gaida was becoming confused.’ This is consistent with other reports made to police after

Gaida’s disappearance.”

Gaida’s other daughter Anne saw Gaida on the afternoon of 2 December 2014. She then spoke to her mother about 8.50am on 3 December 2014 but did not observe

anything unusual. This phone call is the last confirmed contact.

Later investigations revealed that Marilyn Mason, the co-ordinator of the bush

care group, had sent an email on Monday 1 December to a number of recipients,

' Section 81, Coroner's Act 2009 (NSW)

Section 82, Coroner's Act 2009 (NSW)

• Statement of Berenice Karen Aspden, Exhibit 1, Tab 4, paragraph [12]

‘In relation to this issue, see her GP’s statement at Exhibit 1, Tab 28.

• See for example reports from Ruth Kofsky about her contact with Gaida on 2 December

2014. Statement of Ruth Kofsky, Exhibit 1, Tab 9

including Gaida, advising them that there was a bush care session planned for 3 December 2014. People were asked to meet at 8.55am. Police later found Gaida’s diary indicating an entry for “bush care” that day. CCTV footage obtained froma neighbour indicates that a car that is likely to have been Gaida’s left the vicinity of

her home around 9.14am on 3 December 2014.

When was Gaida’s disappearance reported to police and was the initial response

appropriate?

Anne Coote called her mother on the morning of 4 December 2014 as they had developed a habit of checking in with each other every day. There was no answer.° She was not able to not make contact with her mother throughout the day, despite trying several times. When her mother did not arrive for dinner at Anne’s house by 7.30pm as had been planned, Anne became concerned and she drove to her mother’s house to check on her welfare. Anne immediately noticed that her mother’s car was not in the driveway, there were no lights on and she found that Gaida’s cats were not in the house, which was in itself unusual.’ Anne made

inquiries with family and friends, but nobody had heard from Gaida.

At approximately 8.20pm on 4 December, Anne went to Chatswood Police station and reported her concerns to Constable Luke Petley.® Constable Petley states that he was told that Anne had last seen her mother around 4pm on 3 December 2014.

’ This is clearly incorrect and I think he is likely to be mistaken in relation to his memory of that detail, given the other evidence before me. In fact, by the time this report was made, Gaida had not been seen or spoken to for almost 36 hours. In response to Anne’s report, Constable Petley created a “Keep a Lookout For” job on the CAD system. This apparently contained a record of her number plate. It appears that Constable Petley told Anne “it was too early to complete a Missing

Person report”.!”

® Statement of Gaida Anne Coote, Exhibit 1, Tab 5, paragraph [9]

” Statement of Gaida Anne Coote, Exhibit 1, Tab 5, paragraph [11]

• Statement of Constable Luke Petley, Exhibit 1, Tab18, paragraph [5]

° Statement of Constable Luke Petley, Exhibit 1, Tab18, paragraph [6]

' Statement of Senior Constable Sarah Ireland, Exhibit 1, Tab 2, paragraph 21

This response was both incorrect and inadequate. By that time it was already clear that the length of Gaida’s disappearance was entirely out-of-character and very concerning. She had missed an appointment for dinner with her daughter, her cats were unfed, she had not been in contact with other friends or relatives, and she had not been at home that morning when electrical work had been scheduled.'' A little probing would have indicated that she had been unwell and “not herself” lately. She was 84 years old and still a regular bushwalker. It was summer. She was not known for irregular habits or unpredictable behaviour. It is not clear why a full missing persons report was not taken and an immediate investigation

launched.

The inquest was supplied with the NSW Police Force’s “Missing Persons - Standard Operating Procedures”.” It is abundantly clear that there is no time limitation that needs to expire before a report can be taken. The circumstances here make it clear that Anne’s report should have been taken immediately. This is something all police should have known. However it appears to remain a common misconception, held by both community members and police, that a missing person report cannot be taken straight away. Further education in this regard may

be required.

Delay can have critical consequences in an investigation such as this. We now know that it is likely Gaida went missing in bushland on a day that has been described as “extremely hot and dry”."* She was 84 years of age and may have

been confused. Her survival may have depended on a quick response time.

When did the search commence?

The following day Ann returned to her mother’s house and there was still no sign of Gaida. She contacted Gordon Police Station this time and was told that they

would send a car to Gaida’s house to take a statement. It appears that after waiting

'' Constable Petley was aware of this fact: see his statement at Exhibit 1, Tab 18, paragraph 7.

• Missing Persons -Standard Operating Procedures, NSW Police Force (version 3, June 2014)

'S Statement of Wendy Grimm, Exhibit 1, Tab 16, paragraph [5]

for two hours, Anne travelled to Gordon Police Station, where a full report was

finally taken.

Later that day Ann recalled that Gaida sometimes did volunteer work at the Wild Flower Gardens. About 4pm she contacted Samantha Burton, a Garden employee to see if staff could check the gardens for Gaida’s car. It only took about ten

minutes for the car to be located.

Unfortunately, while Gaida had been invited to the weeding session, there was no RSVP system in place. She had not attended a group session for some months and did not always attend when it was hot. It appears that she was not expected to attend that day.'* Gaida was also known to arrive late sometimes and join the group after they had commenced.’ On 3 December 2014 one of the members of the group had actually noticed a small white car parked at Cunningham’s Rest when she returned from weeding and she had informed Sarah Burton of the car, as it was unusual in such extreme heat. At this time Sarah Burton had no reason to believe Gaida or anyone else was missing, but as a precaution she asked another employee to check the area. Unfortunately, it appears the wrong car park was checked and consequently no car was found.'® Tragically, Gaida’s car remained unnoticed until Anne contacted Sarah Burton the next day and the car was

eventually discovered.

The police were immediately informed of the whereabouts of the car and a search commenced. Sergeant Burvill took control that afternoon and contacted the dog unit to attend. Police Air was contacted but was unable to assist immediately due to the severe electrical storms tracking towards the area. Foot patrols commenced and police were assisted by volunteers and staff from the Wild Flower Gardens.

Around 8.10pm as the light began to fade and adverse weather was approaching, police called off the search for the evening. Staff from the wildflower gardens

continued into the night.

'* Statement of Sarah Burton, Exhibit 1, Tab19, paragraph [7]

'® Statement of Senior Constable Sraha Ireland, Exhibit 1, Tab 2, paragraph[15] see also the statement of Patricia Chadwick Tab 13.

'° Statement of Sarah Burton, Exhibit 1, Tab 19

The conduct of the search

21,

A full scale search of the area was undertaken from 6 December until 11 December. | have reviewed the search records and | am confident it was conducted in accordance with the best practice guidelines set out in the National

1,7

Land Search Operations Manual. © While it should have commenced the previous

evening, I am at least satisfied that once it began, it was thorough.

The search commenced around the Phantom Falls area, as this was deemed to have the highest possibility of detecting Gaida, given where her car had been found and where it is thought she was headed. The second day concentrated on the bushland surrounding the Wild Flower Garden and between Ku-ring-gai Creek.

From there new areas were covered and the initial areas were searched again.'®

Data maps were retained and reviewed. This continued until 11 December 2014.

Itis important to note that some of the area searched was rough terrain.

Challenges included both heat and rain. High temperatures created a harsh environment and heavy downpours during the period are likely to have washed

away important evidence.

I do not intend to review each aspect of the search. The detailed taskings and search areas are clearly outlined in the search records which form part of the brief of evidence. Many kilometres of rugged land were covered in case Gaida had become confused or lost. Scores of people were involved over a number of days, with assistance from the SES, the Rural Fire Service, National Parks and Wildlife Service, Council employees, volunteers from the Australian Plant Society and Bush Care Group as well as numerous local residents. The search co-ordinators sought the assistance of a number of specialised Units including Police Air, the Rescue and Bomb Disposal Unit (RBDU) and the dog squad. Ground, air and water searches

took place.

'? See statement of Senior Constable Clinton Simpson, Exhibit 1, Tab 25 '8 For further detail of the areas covered, see statement of Senior Constable Clinton Simpson, Exhibit 1, Tab 25

24,

A decision to call off the immediate search on 11 December 2014 was based on the view that Gaida could not possibly have survived in the bush for that long under the harsh conditions she would have faced. It was by all accounts a difficult decision and advice was sought from a survivability expert, Dr Paul Luckin. It was his expert opinion that there was no longer any hope that Gaida could be found

alive.!”

In the following months the Dog Squad and RBDU used the search area for training and conducted numerous extra searches. No remains have ever been found.

During the initial search gardening shears and a bucket were found, but it could not be confirmed that the items belonged to Gaida.”” There was further searching using unmanned aerial flights during 2015 and on August 15 2015, further searches were undertaken including some areas of thick bushland that had not

been previously checked.

Unfortunately, despite these extensive searches, no evidence of Gaida has been found. I have considered the matter carefully and reviewed the daily search logs in some detail. | have carefully considered the way the search was conducted and reviewed its co-ordination. | have looked at the sections of the National Land Search Operations Manual provided to the inquest and assessed compliance to those principles and procedures. I have examined the resources available to the search co-ordinators and other staff and have satisfied myself as to their qualifications and experience. At the end of the day, | am of the firm view that the search was properly planned and executed. | was impressed by the dedication

shown by all those involved.

Is Gaida dead?

The last confirmed contact with Gaida was on the morning of 3 December, when she spoke with her daughter, Anne. It is likely that Gaida left her home soon afterwards and travelled to the Wild Flower Garden to commence her volunteer work. She parked her car at Cunningham’s Rest car park and has not been seen

again. It is highly likely she commenced walking on a path into the bush. It is

'° Senior Constable Sarah Ireland, Evidence at Inquest 14/10/16

?° Statement of Detective Senior Constable James Hammond, Exhibit 1, Tab 3

unclear what happened next. She may have walked beyond the Wild Flower

Garden and into the National Park.

27. Extensive inquiries made by police”! indicate that there has been no subsequent administrative activity that might indicate Gaida is still alive. There is, for example, no relevant bank or commercial activity. Her disappearance was widely featured in the media and on Crime Stoppers. No useful information was forthcoming. More importantly, Gaida’s family and friends have had no contact. Given the close relationships she had, it is inconceivable that she would not have contacted her

loved ones, if she were able to.

28. For completeness, it should be stated that there is certainly no evidence to suggest that Gaida may have committed suicide. There is no evidence of depression. In my view, suicide can be safely ruled out. Despite investigation there is also no evidence that Gaida’s disappearance was suspicious or that she may have met with

random foul play.

29. Gaida was 84 years of age and although she was a strong walker there is some evidence that she may have been suffering from a urinary tract infection or other illness at the time of her disappearance. If injury or illness hampered Gaida she would have had little chance of survival if she became confused, lost or somehow incapacitated in bushland given the particularly extreme weather conditions at

that time.

30. All the available evidence points to a tragic encounter with bad weather and rugged terrain. It is noteworthy that there was significant rainfall and storm activity during December 2014 and it is certainly possible that her body may have

been washed to another location along the nearby creeks and waterways.23

*! Senior Constable Sarah Ireland, Evidence at Inquest 14/10/16. See also Statement of

Detective Senior Constable James Hammond, Exhibit 1, Tab 3

*” For completeness Police investigated some leads in relation to possibilities of foul

play, see Statement of Senior Constable Sarah Ireland. No reliable evidence was found.

Statement of Detective Senior Constable James Hammond, Exhibit 1, Tab 3, paragraph

[23]

Given the seriousness and finality of finding that a person is dead, proof of this issue “must be clear, cogent and exact” before a finding can be made”". The evidence in Gaida’s case certainly reaches this threshold. While her body has never been located, I am of the view, on the balance of probabilities, that it is

comfortably established that Gaida is indeed dead.

Where and when did Gaida die?

There is really no way of knowing with any certainty exactly where and when Gaida died. However, on the balance of probabilities, | accept that it occurred on or soon after 3 December 2014. I am also satisfied, to the requisite standard, that Gaida has perished somewhere in or near to the Ku-ring-gai Wild Flower Garden.

While she may have walked beyond the Garden itself, she is likely to have died

somewhere in the surrounding bushland.

What was the cause and manner of Gaida's death?

Without her body or any direct evidence of her death it is impossible to determine exactly what caused Gaida’s death or to determine how she died. However, as | have stated, I am able to safely exclude suicide and foul play. I am satisfied, on the balance, that her death may be classed as misadventure or accident or may have

been caused by a sudden health crisis of some kind.

What changes have been made by Ku-ring-gai Council following Gaida's

disappearance?

34,

Ku-ring-gai Council has conducted a significant internal review of their volunteer policies and procedures following Gaida’s disappearance. Among the Council documents tendered at the inquest was an internal memo from Patrick Corrigan, St Ives Precinct coordinator,” from 16 December 2014 which indicated two changes had already been made. Firstly a lock up protocol was extended to include

a daily drive around the loop road to ensure that there are no cars parked off the

*4 See Briginshaw v Briginshaw (1938) 60 CLR 336, Inquest into the Suspected Death of Tegan Lee Lane (State Coroner Abernathy, 15 February 2006) >? See exhibit 1, Volume 2, documents subpoenaed from Ku-ring-gai Council.

37,

road in that area. Secondly the expansion of “way finding signs” was to be made a

priority to assist those who may become lost or disoriented.

At the inquest, Mr Robert Kidd from Ku-ring-gai Council also gave useful evidence” about other steps which have been taken. Mr Kidd has recently been involved in updating Council policy and procedure in relation to the engaging of volunteers, among other tasks. The volunteer relationships have been formalised

and a new application form system has been introduced.

Specifically, various new volunteer procedures at the Wild Flower Garden have been introduced. There are new sign-in / sign-out requirements and supervisors are to monitor who is attending each session. Lock-up protocols have been streamlined and carparks are to be checked prior to the park closing each day. Mr Kidd indicated that he was happy to look at a structured RSVP system for volunteer activities. He also foreshadowed that CCTV points would be extended in

During the inquest, Gaida’s daughter suggested that volunteers should wear high visibility vests as a further safety requirement and Mr Kidd said he was happy to

take that suggestion to Council.

Overall, | am satisfied that the Council have completed an appropriate review of volunteer bush activities and that a number of improvements have already been

made,

Findings made pursuant to section 81 of the Coroner’s Act 2009 (NSW)

On the balance of probabilities, I find that Gaida Coote is dead. She died on or in the days shortly after 3 December 2014.

Gaida died in or close to the Ku-ring-gai Wild Flower Garden at St Ives, NSW.

Iam unable to determine the exact cause or manner of Gaida’s death.

*6 Paul Kidd, Evidence at inquest 14/10/16

Recommendations pursuant to section 82 of the Coroner’s Act 2009 (NSW)

42. For reasons set out above | make the following recommendations: To Ku-ring-gai Council

43. That the Council consider implementing an RSVP system for all bush volunteer activities, so that supervisors can account for all volunteers who are expected to

attend.

44, That the Council consider trialling high visibility clothing for volunteers working

in bush areas.

To the Minister of Police and the NSW Commissioner of Police

45. That consideration is given to mandating an educational package for all police when the new “Missing Persons - Standard Operating Procedures” are introduced.

Specifically, police should be reminded that there is no “waiting time” necessary

when a missing person is reported.

Conclusion

46. Finally, | offer Gaida’s family my sincere and heartfelt condolences. I thank them

for participating in this inquest.

47. Iclose this inquest

CMC MUNA

Magistrate Harriet Grahame Deputy State Coroner

28 October 2016