Inquest into the death of Sharon Bell

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Sharon Bell Hearing dates: 17 to 19 December 2018 Date of findings: 7 February 2019 Place of findings: NSW State Coroner’s Court, Lidcombe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – cause and manner of death, end stage liver disease, hepatic encephalopathy, methadone toxicity, blunt force head injury File number: 2013/163122 Representation: Mr T Edwards, Counsel Assisting, instructed by Ms T Howe (Crown Solicitor’s Office) Mr M Hunter for Mr T Bell Findings: I find that Sharon Bell died on 24 or 25 May 2013 at Seven Hills NSW

2147. The cause of Sharon’s death was cardiorespiratory arrest in a person with blunt force head injury, end-stage liver disease with hepatic encephalopathy, and respiratory depressant drug use. Both natural and non-natural causative features were present at the time of Sharon’s death. However, the available evidence does not allow for a finding to be made as to the precise mechanism of death.

Table of Contents

1. Introduction 1.1 In the early hours of the morning on 25 May 2013 Sharon Bell was found collapsed in the hallway of her home with no signs of life. Sharon’s family members had visited her only a few hours earlier. The subsequent postmortem examination and coronial investigation into the last hours of Sharon’s life raised a number of questions regarding what happened to Sharon and how she came to be found on the floor of her home.

2. Why was an inquest held?

2.1 Under the Coroners Act 2009 (the Act) a Coroner has the responsibility to investigate all reportable deaths. This investigation is conducted primarily so that a Coroner can answer questions that they are required to answer pursuant to the Act, namely: the identity of the person who died, when and where they died, and what was the cause and the manner of that person’s death. All reportable deaths must be reported to a Coroner or to a police officer.

2.2 When any of the above questions cannot be answered then an inquest is required to be held. In Sharon’s case, the medical and physical evidence raised a number of possibilities regarding both the cause and the manner of Sharon’s death. The manner of a person’s death usually relates to the circumstances leading up to, and surrounding, a person’s death.

2.3 As part of the coronial investigation, opinions were sought from a number of medical experts in an attempt to answer the questions relating to the cause and manner of Sharon’s death. These experts were called to give evidence during the inquest, along with other witnesses who saw and spoke to Sharon in the days leading up to her death.

2.4 The inquest sought to gather this evidence in an attempt to provide Sharon’s family and friends with answers as to what happened to Sharon during the final hours of her life.

3. Sharon’s life 3.1 Inquests and the coronial process are as much about life as they are about death. A coronial system exists because, as a community, we recognise the fragility of human life and place enormous value on how precious it is. Recognising the impact that a death of a person has, and continues to have, on the family and loved ones of that person can only serve to strengthen the resolve we share as a community to strive to reduce the risk of preventable deaths in the future.

3.2 Understanding the impact that the death of a person has had on their family only comes from knowing something of that person’s life and how the loss of that life has affected those who loved that person the most. Therefore it is extremely important to recognise and acknowledge Sharon’s important life. It is hoped that the brief words below do so in a meaningful and respectful way.

3.3 Sharon was born in 1959, being the oldest daughter to Reginald and Yvonne Pittman. Sharon had four sisters: Gloria, Tracey, Kelly and Jody. Sharon’s family was based in Sydney’s western suburbs and after moving to different locations over a period of time they eventually settled in the Blacktown

area. Sharon attended Blacktown High School until Year 9 and it was around this time that she began displaying rebellious behaviour.

3.4 Whilst she was a teenager, Sharon met Terrence (known as Terry) Bell and the two later formed a relationship. Over the years the relationship was a somewhat turbulent, on again-off again one, with Sharon and Terry often separating, only to later reconcile. During one period of reconciliation Sharon learned that Terry had a 2½ year old son from another relationship that he had formed whilst he and Sharon were separated. Terry’s son was also named Terry, and so he was known as “Terry boy”.

Sharon had much love to give Terry boy and cared for him as if he were her own son.

3.5 Sharon’s caring nature was evident in other ways too. During the earlier period of her relationship Sharon cared for two children who belonged to one of Terry’s cousins. Later, sometime in 2007, Sharon fostered another child from Terry’s side of the family. Again, Sharon raised all these children as her own.

3.6 Sharon shared a close relationship with her mother and sisters, all of whom loved her deeply. There is no doubt that they mourn her devastating loss and miss her enormously. This was readily apparent during the course of the inquest.

4. Sharon’s medical history 4.1 Sharon had a past history of using illicit drugs and consuming alcohol heavily. Terry also had a similar history of drug and alcohol use. He had also previously been diagnosed with schizophrenia and had been admitted to hospital for treatment on a number of occasions.

4.2 Sometime during their relationship Sharon and Terry later moved into a house at Doonside before later returning to their own house in Seven Hills. This appeared to be a positive period for Sharon as she appeared to not be using illicit drugs and was focused on looking after the children in her care.

4.3 Sadly, the children were later removed from Sharon’s care by the Department of Community Services (as it then was) on two occasions. Each time, these events adversely affected Sharon’s well-being: Sharon’s mother, Ms Pittman, noticed that Sharon began to drink alcohol more heavily and use illicit drugs and prescription medication. During the same periods, Ms Pittman observed that Sharon’s physical health declined and she complained of liver problems and poor circulation in her legs.

4.4 Sometime in late 2011 or early 2012 Sharon was found at home, slumped over on a couch and not breathing. Emergency services were called and Sharon was taken to hospital where she remained for about a week. Although Sharon later recovered and was eventually discharged, it became evident that she had suffered some neurological damage as a result of the incident. Ms Pittman also noticed that after Sharon returned home from hospital she was very slow in her thinking and movements, unstable on feet, and required a walking frame to assist with her mobility.

4.5 In the period following her discharge from hospital Sharon was able to remain drug and alcohol free for about two months. However, in late September 2012 and early 2013 Sharon experienced two tragic events when both her father and her sister, Gloria, passed away. Their deaths deeply affected Sharon and Ms Pittman observed that following these two heartbreaking events over a matter of months, Sharon’s alcohol use increased.

5. What happened on 22 May 2013?

5.1 Bayram Boyraz was a friend of Terry boy and knew both Sharon and Terry. Mr Boyraz often went to Sharon’s house, roughly every one to two weeks, to check on her well-being as he was aware that her health was declining. At about 10:00am or 11:00am on 22 May 2013 Mr Boyraz went to Sharon’s house at 8 Hayes Road, Seven Hills to check on her. At the time, Sharon lived at the house with Terry and two friends of hers, Barry Stoneham and Ann Marie Thomas. Mr Stoneham and Ms Thomas had only moved into the house several weeks earlier and shared one of the bedrooms in the house.

5.2 When Mr Boyraz arrived at Sharon’s house he went inside. He found Terry in the living room and immediately saw that Terry was not himself: he was holding a knife in his hand and talking to the TV.

Mr Boyraz also saw Sharon sitting on the lounge nearby and it appeared to him that she was worried by Terry’s behaviour.

5.3 After some time Terry eventually put the knife down. Mr Boyraz picked it up and placed it under the lounge in order to hide it from Terry. Mr Boyraz only stayed at the house for about 15 to 20 minutes.

As Terry’s behaviour was making him uncomfortable Mr Boyraz left the house in order to speak to Sharon’s sister, Jody.

5.4 Mr Boyraz later returned home. Several hours later he received a call from Sharon who asked him to come to her house, without saying why. When Mr Boyraz returned to Sharon’s house he found her sitting on the lounge and reportedly saw that Sharon had swollen lips and cheeks, black eyes and blood on her shirt. Mr Boyraz formed the view that Sharon had been assaulted and asked her what happened. Sharon looked in the direction of Terry who was standing nearby. Mr Boyraz asked Sharon if he should call an ambulance and Sharon told him yes. Mr Boyraz noticed that Terry started shaking and appeared to be having some type of seizure-like episode whilst he was standing up. Mr Boyraz asked Terry if he was alright and helped him to sit down.

5.5 Mr Boyraz called Triple Zero and asked for an ambulance to attend Sharon’s house. In a subsequent statement which he made to the police Mr Boyraz said that he informed the Triple Zero operator that Sharon could not breathe and that it appeared that Sharon had been assaulted. The transcript of the Triple Zero call, however, contains no reference made by Mr Boyraz (or anyone else) to Sharon having been assaulted. In evidence during the inquest, Mr Boyraz agreed that he did not tell the Triple Zero operator, or the paramedics who subsequently attended Sharon’s house, that she had been assaulted by Terry.

6. What happened on 23 May 2013?

6.1 At about 2:50am on 23 May 2013, paramedics Luke Frost and Ian Bird received a call requesting their attendance at 8 Hayes Road, Seven Hills in response to a patient who was experiencing shortness of breath. They arrived at about 2:56am. Upon entering the house they saw Sharon and Terry. When Paramedic Frost asked who the subject of the call was, Terry indicated towards Sharon. Paramedic Frost helped Sharon into the back of the ambulance and asked why she had called for an ambulance.

Sharon said that she had done so for Terry.

6.2 Paramedic Frost returned to the house to ask if Terry needed an ambulance. Terry confirmed that he did not and so Paramedic Frost returned to the ambulance. Once there, Paramedic Frost asked

Sharon if she wanted to go to the hospital, and Sharon said that she did. After Sharon departed in the ambulance Mr Boyraz, who was still at the house, returned home.

6.3 On the way to the hospital Sharon told Paramedic Frost that she had been assaulted the previous night and that her legs were sore from her previous cellulitis condition. Paramedic Frost performed a limited assessment, during which he noted that Sharon had redness to both of her lower legs (which was consistent with cellulitis) but did not see any injuries on her. Paramedic Frost also took a set of observations which included measuring her blood pressure and other vital signs.

6.4 According to an electronic medical record created by Paramedic Frost it was noted: “On examination [patient] alert and well perfused ambulant with walking aid. Stable enroute”.1 In a section titled Secondary Survey it was noted, “Left & Right Lower Leg erythema/reddening; no other abnormalities detected”.2 6.5 The ambulance arrived at Blacktown Hospital emergency department at about 3:12am. CCTV footage records Sharon being taken into the hospital in a wheelchair by hospital staff at 3:18am. Sharon was triaged in the emergency department by registered nurse (RN) Navneeta Reddy. On examination, RN Reddy noted that Sharon was extremely vague and so it was difficult to obtain a history from her.

Triage notes recorded by RN Reddy note the following: “[On examination] dry oral mucosa. Abnormal speech – normal for [patient]…Lower leg black and hard with blisters. Dry blood on face noted. [History]: methadone program”.3 6.6 Dr Gopinath Betarayappa later spoke to Sharon in the emergency department waiting room as Sharon refused to be assessed inside and wanted to leave the hospital. Contemporaneous notes made by Dr Betarayappa record the following: “I tried to get Sharon inside for assessment but she refused. Although appears to have some sedative (slurred speech), she states her speech is usually like this. Oriented to time, place and person, has the capacity to make her decision – no grounds to force her against her wish to assess. Called taxi by herself and left the department…I see no grounds to hold her against her wish in the dept”.4 6.7 CCTV footage records Sharon standing up from her wheelchair and exiting the hospital at 4:01am.

6.8 John Softley was working as a taxi driver early in the morning on 23 May 2013. At around 3:00am Mr Softley accepted a radio booking for a passenger at Blacktown Hospital. Mr Softley parked near the emergency department and saw Sharon appear a short time later, walking whilst pushing a wheelchair to steady herself. Mr Softley helped Sharon into the taxi and a nurse passed him a note with Sharon’s home address in Seven Hills. CCTV footage depicts Sharon getting into the taxi at 4:05am. Whilst in the taxi Sharon gave Mr Softley directions to drive her to Mr Boyraz’s home instead of her own home.

6.9 Upon arrival at Mr Boyraz’s home, Mr Softley helped Sharon out of the taxi and she asked him to help her to a nearby fence so that she could steady herself. Once he had done so, Mr Softley heard 1 Exhibit 1, Tab 30.

2 Exhibit 1, Tab 30.

3 Exhibit 1, Tab 70, page 431.

4 Exhibit 1, Tab 70, page 434.

Sharon loudly calling out to someone, and noted that Sharon was able to stand up by holding on to the fence herself. Mr Softley left the area a short time later.

6.10 Sometime around 4:00am or 4:30am Mr Boyraz was asleep at his home when he heard his name being called out from the front of his house. He walked outside and found Sharon there. Mr Boyraz helped Sharon inside the house. Although Sharon had some trouble speaking she told Mr Boyraz that she wanted Terry out of the house because he was scaring her. Sharon told Mr Boyraz that Terry was “talking crazy” and that he was saying things like, “You are going to die tonight, Sharon”.5 6.11 Given Sharon’s demeanour and the fact that Mr Boyraz was aware that Sharon had never previously had reason to visit him at his home Mr Boyraz formed the view that Sharon was legitimately frightened. Mr Boyraz helped Sharon into his car and drove her back to her home in Seven Hills. Once there, Mr Boyraz called Triple Zero and waited for the police to arrive.

7. Attendance of the police on 23 May 2013 7.1 Senior Constable Lauren Martin and Constable Luke Favre responded to the job broadcast over police radio requesting officers to attend Sharon’s home. They arrived at about 6:45am and saw Sharon seated in the front passenger seat of a car that was parked in the driveway, with Mr Boyraz standing nearby. Both Senior Constable Martin and Constable Favre saw that Sharon had what appeared to be dried blood under her nose but noted that she had no obvious injuries to her face.

Constable Martin also noted that Sharon smelt strongly of alcohol, that she appeared to be under the influence of alcohol or a drug, and that her clothes were heavily soiled with stains.

7.2 Senior Constable Martin asked Mr Boyraz what had happened. According to Senior Constable Martin, Mr Boyraz told the police officers that he had picked Sharon up from hospital and brought her home.

Senior Constable Martin asked Sharon what was going on and why she had been at hospital. Sharon only replied, “Yeah”, and Senior Constable Martin noticed that Sharon’s speech was slow and slurred.6 Senior Constable Martin then asked Mr Boyraz whether Sharon had told him why she was at hospital. On the account provided by Senior Constable Martin, Mr Boyraz replied, “No, she didn’t tell me. Terry is in the house and he needs to go see mental health or something. He’s out of control”.7 Senior Constable Martin asked Mr Boyraz what Terry had done and if he had seen Terry hurt, or threaten, himself or anyone else. Mr Boyraz said that he had only heard Terry yelling.

7.3 Senior Constable Martin and Constable Favre knocked on the front door. Terry appeared a short time later. Constable Favre asked Terry what had happened and if he could tell the police what the yelling was about. Terry replied that nothing had been going and that he had been sleeping. Constable Favre then asked Terry if he knew why Sharon went to hospital. Terry replied that Sharon had a fall in the lounge room the previous day and said, “She’s been falling a lot lately. I have been tryin’ to look after her. She finds it hard gettin’ up ya know”.8 Terry went on to tell Constable Favre that he had not harmed anyone, or had no thoughts of harming himself. Terry also told Constable Favre that he had a mental health case worker who he knew to contact if he needed help. During this interaction Senior Constable Martin found Terry to be “calm and able to hold regular conversation” and not displaying 5 Exhibit 1, Tab 46 at [20].

6 Exhibit 1, Tab 8 at [6].

7 Exhibit 1, Tab 8 at [6].

8 Exhibit 1, Tab 8 at [6].

any behaviour that indicated that he was intoxicated or in need of immediate mental health intervention.9 7.4 After speaking with Terry, Senior Constable Martin and Constable Favre went back outside to see Sharon. Terry joined them and helped Sharon back into the house. At the front door Senior Constable Martin asked Sharon how she got the blood on her face. Sharon replied, “I fell on the floor trying to get off the lounge yesterday”.10 Constable Favre noted that Sharon pointed to the lounge room as she said this. Mr Boyraz went inside the house, telling the police officers that he would stay for a while to help Sharon and Terry. Senior Constable Martin and Constable Favre left the scene a short time later. Subsequently, Senior Constable Martin created an entry in the NSW Police computer aided despatch system noting, “Attended location and spoke to each party. No evidence of mental health issues. No one wanted to report any other matters”.11 7.5 My Boyraz’s recollection of some of the events of 23 May 2013 is somewhat different to that of the two attending police officers. According to Mr Boyraz he told the officers that he was worried about Sharon and believed that Terry had assaulted her. In evidence during the inquest Mr Boyraz said that he was sure that he told the police officers this and that Sharon wanted Terry to be removed from the house. Mr Boyraz went on to explain that he tried his best to have the police officers remove Terry and that he (My Boyraz) became angry when they informed him that Terry was not going to be removed. Mr Boyraz said that he also told the police that Terry needed to attend a mental health facility for assistance.

7.6 In evidence Constable Favre said that Mr Boyraz made no mention that he was scared for Sharon.

Instead, Constable Favre recalls that Mr Boyraz only mentioned that he believed Terry was out of control and in need of treatment at hospital. Constable Favre was asked whether he made his own independent enquiry about whether Terry required any form of treatment for an apparent mental health condition. Constable Favre explained that this was why he and Senior Constable Martin went inside the house to speak with Terry: in order to make sure that he has not behaving in any way which warranted detention under the provisions of the Mental Health Act 2007 (the Mental Health Act). Constable Favre went on to explain in evidence that he considered the criteria which might have resulted in Terry’s detention and formed the view that Terry did not meet any of the criteria at the time.

7.7 Constable Favre went on to indicate that during his attendance at Sharon’s home, he did see that she had dried blood on her cheeks near her nose. However, Constable Favre said that he did not notice that Sharon had black eyes or any swollen facial features. Ultimately Constable Favre said that he reached the conclusion that Sharon had returned home from hospital only a few hours before the arrival of police, and although she appeared in poor physical health she was happy to go inside and remain at the house. In conclusion Constable Favre said that he and Senior Constable Martin investigated the issue raised by Mr Boyraz, namely that Terry was possibly suffering from an acute mental disturbance which might warrant detention under the Mental Health Act. Constable Favre explained that the investigation which he and Senior Constable Martin conducted indicated that Terry was calm and lucid, and that detention was not warranted.

9 Exhibit 1, Tab 8A at [6].

10 Exhibit 1, Tab 8 at [8].

11 Exhibit 1, Tab 8A at [8].

7.8 Senior Constable Martin similarly agreed that Mr Boyraz made no mention of any belief that Terry had assaulted Sharon. She said that she had a clear recollection that Mr Boyraz maintained that he had no knowledge of what had happened to Sharon before she had appeared outside his home some hours earlier. Senior Constable Martin said further that at no time did Mr Boyraz make any mention of Sharon having been assaulted by Terry. Senior Constable Martin explained that having regard to the entirety of the information that she had been provided with, and gathered whilst at Sharon’s house, she did not consider the incident to be domestic violence related. Senior Constable Martin also explained that, like Constable Favre, she had considered the provisions of the Mental Health Act in relation to Terry. Ultimately, Senior Constable Martin formed the view that it was not appropriate to exercise any powers available under that Act.

8. Further events on 23 May 2013 8.1 Following the departure of the police officers, Amarjit Hothi, a taxi driver, received a call to pick up Sharon from her home at around midday. When he arrived he saw Sharon make her way to the taxi using her walking frame. Mr Hothi went to place the walking frame in the boot of the taxi whilst Sharon stood near the rear passenger door with her hands on the taxi.

8.2 After loading the frame Mr Hothi went back to help Sharon into the taxi and noticed that she had fallen to the ground and was lying on her back on the concrete driveway. Mr Hothi did not witness the fall but saw that the taxi door remained closed. Mr Hothi helped Sharon into a sitting position and asked if she was able to get up. Sharon said that she could not and so Mr Hothi sought the help from a male person who came from the house (believed to be Terry) to help Sharon to get to her feet.

8.3 Sharon asked to be taken to the shops but Mr Hothi declined to do so as he felt that Sharon was at risk of falling again. Mr Hothi retrieved Sharon’s walking frame from the taxi and told the male person that instead of Sharon going to the shops herself, he (the person believed to be Terry) could collect anything from the shops that Sharon needed.

9. What happened on 24 May 2013?

9.1 Mr Stoneham saw Sharon sitting outside the house at about 11:00am on the morning of 24 May

2013. Sharon told him that she was going to the shops and left some time later. Mr Stoneham next saw Sharon at about 4:30pm when she returned home with some groceries. Terry was home at the time and Mr Stoneham noted that he appeared fine as he went about preparing dinner for himself and Sharon.

9.2 Ms Thomas arrived home at around sometime between 7:00pm and 8:00pm. Ms Thomas spoke to Sharon and noticed that she had bruises on the left side of her neck and breasts. She described them as “horrible looking and really dark and purple”.12 Ms Thomas noticed that Sharon did not appear to be herself and asked her what had happened. Ms Thomas recalls Sharon mentioning something about a taxi and then said to ask Terry. Ms Thomas and Mr Stoneham later retired to their bedroom at about 8:30pm.

12 Exhibit 1, Tab 45 at [10].

9.3 At about 9:45pm Ms Pittman, Sharon’s sister, Jody, Sharon’s nephew, Braydan, and his girlfriend arrived at Sharon’s house. Jody had earlier been told by Mr Boyraz that Sharon had fallen over into the gutter and had been unable to get up. Accordingly, Jody made arrangements to pick up her mother so that they could visit Sharon and check on her. When Jody and the others arrived at Sharon’s house Terry came to the front door. Ms Pittman noted that Terry was behaving erratically and that he said that the police were coming “to shoot ya”.13 When Ms Pittman asked where Sharon was Terry said that she was asleep on the lounge.

9.4 Ms Pittman went inside and found Sharon lying on a lounge chair. Sharon had difficulty sitting up and needed to be helped by Braydan. At some stage Jody noticed that Sharon was wearing a hospital bracelet and pointed this out to Ms Pittman. Ms Pittman asked Sharon when she had been at hospital and Sharon told her that she did not know. Ms Pittman noticed that Sharon had bruising around her breasts and that one of her breasts appeared to be swollen. Jody whispered to her mother to look at Sharon’s face, and Ms Pittman saw that Sharon had bruising around her neck to her jaw line, that her cheeks appeared to be puffed and swollen and that she had a small graze under her chin. Jody asked Sharon what happened to her and Sharon whispered, “He done it”, looking towards Terry.14 When Ms Pittman asked if Sharon had called the police Sharon said that she had not because she was “old school”.15 Ms Pittman immediately asked Terry if he had hit Sharon. He replied, “No, I wouldn’t hit my queen”.16 Ms Pittman then asked how Sharon had received her bruises and Terry did not reply but instead began to quote some poetry.

9.5 Jody used her mobile phone to take photos of Sharon’s face and body. As she did so she saw bruising to the inside of Sharon’s right leg. As she tried to move Sharon’s leg to take a photo, Sharon moaned in pain. This caused Jody to comment that it appeared that Sharon had been kicked.

9.6 At this time, Ms Pittman noticed that Terry was becoming agitated as he was walking around the lounge room and saying things like people were going to kill him, he was ready to die, and that funeral things were in his room. Ms Pittman attempted to persuade Terry to attend a local mental health facility but Terry refused to do so and said that someone there was going to kill him.

9.7 Ms Pittman was later able to sit down with Sharon in the kitchen and asked her again if Terry had hit her. Sharon again replied that he had. Ms Pittman asked if Terry had done this before and Sharon told her that she had been to stay with Mr Boyraz temporarily and that Terry had made her sign a piece of paper when she left.

9.8 Ms Pittman told Sharon that she and Jody would pick her up the next day to take her to hospital to seek assistance with her walking. Ms Pittman helped Sharon back to the lounge room and tried to get Terry to go to bed. However, Terry refused to do so and began to become agitated.

9.9 After some further negotiation, Ms Pittman was eventually able to successfully get Terry to go to bed. Whilst Terry was in his room Sharon told her mother and sister that she had not been drinking for two days “because of the way Terry’s been carrying on”.17 After noticing the bruises to Sharon’s breasts, Jody asked how that had occurred. Sharon replied, “Terry bashed me” and said that it had 13 Exhibit 1, Tab 38 at [26].

14 Exhibit 1, Tab 39 at [10].

15 Exhibit 1, Tab 38 at [37].

16 Exhibit 1, Tab 38 at [37].

17 Exhibit 1, Tab 39 at [13].

happened in a chair and indicated that she had been “knocked out”.18 Ms Pittman asked Sharon if she was OK. Sharon said that she was and Ms Pittman and the rest of Sharon’s family decided to leave. In evidence during the inquest Jody said that she wanted to take Sharon home with her but that Sharon was reluctant to leave. She described Sharon as being scared and that it appeared as though Terry had “something over her”. Ms Pittman and Sharon’s other family members left the house at about 11:15pm.

10. What happened on 25 May 2013?

10.1 At about 1:00am on 25 May 2013 Mr Stoneham woke up to go to the bathroom. He opened his bedroom door and immediately saw Sharon lying on her back in the middle of the hallway, wearing the same clothes that he had seen her in earlier in the evening. Mr Stoneham woke up Ms Thomas, told her what had happened, and asked her to wake up Terry so that he could help Mr Stoneham pick up Sharon. Ms Thomas went to look for Terry and found him sitting in the lounge room. Ms Thomas told Terry that she thought Sharon was dead and asked for his help. Terry only mumbled something but was otherwise unresponsive and did not move. In evidence Ms Thomas described Terry as not being engaged at all, that he was not himself and that it appeared he could not comprehend anything that Ms Thomas was saying.

10.2 Mr Stoneham returned to Sharon and pushed her shoulder, telling Sharon to wake up and get up. Mr Stoneham put his hand on Sharon’s cheek and noticed that it was very cold. He felt for a pulse and could not find one. He immediately told Ms Thomas to call an ambulance and she did so.

10.3 NSW Ambulance paramedics arrived at the house a short time later at 1:53am. They noticed that Terry was walking around the house, mumbling and frothing at the mouth. On assessing Sharon they found her to be cold to the touch with no signs of life. One of the paramedics, Daniel Hollis, formed the opinion that Sharon had been “deceased for quite some time”.19 Paramedic Hollis noted that Sharon had dried vomit around her mouth and that she had obvious signs of lividity on her body. An ECG monitor was connected to Sharon which indicated that her heart rhythm was in asystole and had no signs of electrical activity. Accordingly, the paramedics decided not to attempt to revive Sharon as it was apparent that she was already deceased.

11. What were the results of the initial postmortem investigation 11.1 Sharon was later taken to the Department of Forensic Medicine in Glebe where Dr Kendall Bailey, forensic pathologist, performed an autopsy on 26 May 2013. Dr Bailey noted that:

(a) Sharon had fragments of foreign material, believed to be plasterboard, in her hair;

(b) She had multiple areas of bruising on her face, breasts, upper arms and buttocks, with a large area of bruising present on the posterior scalp (but with no overlying abrasion or laceration of the skin);

(c) There was subdural and subarachnoid haemorrhage with areas of old and new contusions noted on the surface of the brain; 18 Exhibit 1, Tab 39 at [13].

19 Exhibit 1, Tab 33 at [7].

(d) Brain examination revealed recent (possibly several hours before death) and remote blunt force head injuries with severe hepatic encephalopathy (neurological disease caused by metabolic disturbance caused by liver failure);

(e) There was marked liver cirrhosis and gallbladder disease; and

(f) Toxicological examination revealed a concentration of methadone within the reported high, and potentially fatal, range, together with a non-toxic concentration of diazepam (a benzodiazepine class drug used to treat anxiety and alcohol withdrawal) and analgesic medication.

11.2 In an autopsy report dated 26 June 2014, Dr Bailey opined that the concentration of methadone found in Sharon’s blood was difficult to interpret. This was due to the fact that because Sharon was a chronic user of methadone (as a result of her history of illicit drug use) her individual tolerance to the drug could not be measured, and because the concentration overlapped between toxic and non-toxic ranges. However, Dr Bailey noted that whilst the concentration of diazepam was well within the reported non-toxic range, the combination of diazepam and methadone would likely have had a synergistic effect in causing depression of brain function.

11.3 Dr Bailey also opined that:

(a) Whilst there was an impressive degree of diffuse bruising these injuries were not a significant contributing factor to Sharon’s death, and that Sharon had an increased risk of bleeding, even from minor trauma, due to her advanced liver disease;

(b) Sharon’s recent brain injuries were mild and focal and unlikely, in isolation, to have resulted in coma or death;

(c) Whilst hepatic encephalopathy may result in impaired consciousness, coma or death, the degree of associated swelling in Sharon’s case may have been insufficient to cause death.

(d) Hepatic encephalopathy, head injury and the use of methadone and diazepam all may individually cause impaired consciousness and decreased respiratory drive, the combined effect of which may be fatal.

11.4 Ultimately, Dr Bailey opined that the cause of death was the combined effects of end stage liver disease (with hepatic encephalopathy) and blunt force head injury in a person using methadone and diazepam.

12. What was the cause and manner of Sharon’s death?

12.1 It is evident that the autopsy report raised three factors that might have caused, either in isolation or combination, Sharon’s death. In order assist in determining whether one or more of these factors is more likely that than the other(s) to have caused Sharon’s death, consideration needs to be given to a report co-authored by Dr Michael Rodriguez, a neuropathologist who was involved in the initial postmortem investigation. In addition, as part of the coronial investigation, further opinion was sought from two independent experts:

(a) Professor Michael Besser AM, a consultant neurosurgeon; and

(b) Professor Johan Duflou, a consultant forensic pathologist.

12.2 Consideration of each of the three factors is discussed in more detail below.

(a) Blunt force head injury 12.3 Both Dr Bailey and Dr Rodriguez were of the opinion that Sharon’s recent blunt force head injuries were unlikely, on their own, to have caused Sharon’s death. Similarly, Professor Besser expressed the opinion that whilst the blunt force head injuries likely contributed to Sharon’s death, they would most likely have not been lethal in isolation.

12.4 Professor Duflou was of a similar view to the other experts. He noted that there was no suggestion that Sharon’s remote head injuries did not directly cause or contribute to death. It was possible that they may have had only indirectly contributed to death by causing Sharon to have a propensity to fall which, if she had done so, could have caused her to suffer the more recent blunt force head injuries.

However, with regard to these more recent head injuries Professor Duflou noted that there was healing and bleeding around the time of death but not of a severity typically associated with death.

In conclusion, Professor Duflou opined that “there is little evidence for the constellation of injuries to the head, including the intracranial contents, to have directly caused death in this case”.20 12.5 Conclusion: The totality of the medical evidence establishes that the recent blunt force head injuries suffered by Sharon were unlikely, in isolation, to have caused her death. It is most likely that the injuries played a causative role, in combination with Sharon’s other co-morbidities, in causing her death.

(b) End stage liver disease with hepatic encephalopathy 12.6 Dr Rodriguez noted that whilst hepatic encephalopathy may result in impaired consciousness, coma or death, the latter is usually secondary to marked cerebral oedema (brain swelling) and intracranial hypertension (high blood pressure). In Sharon’s case it was noted that whilst there was some brain swelling it was to a lesser degree than what is typically seen in persons with fatal intracranial hypertension.

12.7 Professor Besser also noted that whilst severe hepatic encephalopathy was present, and may result in deceased levels of consciousness, there was no evidence of this in Sharon’s case. In particular, Professor noted that Sharon was conversing and engaging with her family members who had visited her only hours before she was found unresponsive. Further, Professor Besser explained that whilst brain swelling was present, there was no herniation (a potentially fatal side effect where the brain is displaced due to pressure caused by swelling). This indicated that although there was a degree of raised intracranial pressure, it was insufficient to be fatal.

20 Exhibit 1, Tab 67, page 12.

12.8 Similarly, Professor Duflou agreed with the other experts that it was unlikely that hepatic encephalopathy caused Sharon’s death due to the absence of severe brain swelling associated with herniation. Like Professor Besser, Professor Duflou also noted that Sharon was conscious, talking and, to limited extent, mobile when she was last seen alive on the evening of 24 May 2013. This recent history proximate to the time when Sharon was discovered in the hallway of her home was inconsistent with an altered level of consciousness that would expect to accompany hepatic encephalopathy.

12.9 Conclusion: The clinical evidence established that Sharon had features of end stage liver disease and hepatic encephalopathy which produced a degree of intracranial pressure and resulting brain swelling. However, the swelling was not of a degree to have caused brain herniation which would have been potentially fatal. Further, the observations made of Sharon engaging with her family members several hours before she was found to be unresponsive is inconsistent with hepatic encephalopathy independently causing Sharon’s death.

(c) Methadone and diazepam levels 12.10 Due to her past illicit drug use, Sharon had been prescribed, and was using, methadone at the time of her death. Professor Besser considered that “the most significant acute factor is likely to be the very high blood level of methadone found on toxicology which was, of itself, potentially fatal”.21 Professor Besser noted that at the very least the high methadone level would have caused a marked decline in Sharon’s level of consciousness and that this was already compromised by her hepatic encephalopathy. Professor Besser considered it likely that the recent brain contusions also contributed to a decreased level of consciousness.

12.11 Professor Duflou also highlighted that interpretation of the toxicology results from the autopsy was difficult. Ultimately Professor Duflou concluded that whilst it was possible that Sharon overdosed on methadone, given the high concentration, the witnessed observations of her on the evening of 24 May 2013 do not support this conclusion. That is, there was no evidence of somnolence, snoring, or pronounced sedation. Further, Professor Duflou opined that given the lividity present it suggested that Sharon had been deceased for a longer rather than shorter period and that therefore it was likely that she died closer to 11:15pm on 24 May 2013. If this was the case then it made methadone and diazepam overdose as the sole cause of death very unlikely due to these drugs causing respiratory depression and then death over a period of hours.

12.12 Conclusion: The evidence established that the blood level of methadone was at a potentially lethal level. However, interpretation of what this level meant in Sharon’s case is problematic. This is because Sharon may have developed a tolerance for methadone due to her past use of it. In turn, this meant that whilst the high blood level of methadone found in Sharon’s case might be independently fatal for a naïve user, it might not have been for a chronic user of methadone such as Sharon.

21 Exhibit 1, Tab 66, page 7.

12.13 However, the evidence established, at the least, that the level of methadone would have likely contributed to some alteration of Sharon’s level of consciousness, but not to the extent that it would have proved to be fatal on its own. This is because the observations of Sharon in the hours before her death demonstrated no evidence of sedation which would ultimately prove to be fatal. Instead, the evidence established that the concentrations of respiratory depressant drugs contributed, with the other comorbidities, to Sharon’s death.

(d) Final conclusions 12.14 Professor Besser agreed with Dr Bailey’s opinion that the cause of Sharon’s death was multifactorial; he considered that each of the three factors identified above played a causative role, in combination, in causing Sharon’s death.

12.15 Professor Duflou opined that “the cause of death is best given as cardiorespiratory arrest in a person with blunt force head injury, end-stage liver disease with hepatic encephalopathy, and respiratory depressant drug use, acknowledging that it is not possible to isolate any specific single cause for the cardiorespiratory arrest, and that no specific mechanism has been identified in this case”.22 In evidence Professor Duflou explained that his opinion as to cause of death differed slightly to that of Dr Bailey’s because he did not necessarily give sole or combined attribution to the features present.

This is because whilst all of the above features were present it was possible that they did not all contribute to Sharon’s death.

12.16 Professor Duflou explained his reasoning with the following example. He opined that it is more likely than not that if Sharon struck the back of her head against the wall to the extent of causing the scalp injury and recent intracranial pathology she would have suffered a period of decreased consciousness. During this time, it is also reasonably possible that Sharon may have had decreased respiration due to one or more of the following factors: airway blockage, her pre-existing neurological abnormalities, her obesity, her pulmonary disease, her liver disease with associated hepatic encephalopathy, the effects of the acute blunt force head injury, and the effects of high levels of methadone and benzodiazepines. This decreased respiration, given the pre-existing pathology, could have precipitated cardiorespiratory arrest and death.

12.17 However, Professor Duflou emphasised that the example above was only a possibility and that “there is no medical, death scene or autopsy based objective evidence which elevates this to anything more than a reasonable possibility”.23 Professor Duflou also noted that he could not exclude the possibility that Sharon “had a terminal collapse as a result of all the above but excluding the recent intracranial injuries sustained, and that as a result of that terminal collapse her condition deteriorated to the extent that she had a cardiorespiratory arrest, with the recent injuries playing effectively no role in the death”.24 22 Exhibit 1, Tab 67, page 15.

23 Exhibit 1, Tab 67, page 21.

24 Exhibit 1, Tab 67, page 21.

12.18 The totality of the evidence established that Sharon had a number of comorbidities, each of which could have played a causative role in her death. Whilst features such as Sharon’s high blood methadone level could be independently fatal, it is more likely that these features operated in combination leading to a decreased level of consciousness, reduced respiratory drive, cardiopulmonary arrest and, ultimately, death. The example provided by Professor Duflou demonstrates the difficulty in reaching a conclusion, even on balance, as to whether any one of the causative features was more prominent that the others and, indeed, whether all of the features, or only some of them, played a causative role in Sharon’s death.

12.19 To this extent, the cause of Sharon’s death is best described as being cardiorespiratory arrest in a person with blunt force head injury, end-stage liver disease with hepatic encephalopathy, and respiratory depressant drug use.

12.20 It is not possible, from the available medical evidence, to determine with any certainty which of the possible causative factors actually contributed to Sharon’s death. As Professor Duflou explained, Sharon may have suffered a terminal collapse independent of the recent blunt force injuries observed postmortem. Further, the presence of both natural (end stage liver disease with hepatic encephalopathy) and non-natural (blunt force head injury and drug use) causes of death means that it is not possible to distinguish one type of cause of death from the other. Therefore, the manner of Sharon’s death is attributable to both natural and non-natural causes.

13. Were Sharon’s blunt force head injuries the result of accidental or non-accidental injury?

13.1 According to Mr Boyraz, he saw Sharon on the evening of 22 May 2013 to have injuries which were consistent with her being assaulted. Indeed, Mr Boyraz formed the view that this is what happened to Sharon and therefore made a call to Triple Zero to seek assistance for Sharon. It should be noted that although Mr Boyraz formed this belief, the contemporaneous evidence and Mr Boyraz’s own acknowledgment in evidence during the inquest establishes that he never explicitly informed anyone of his belief.

13.2 The evidence given by the paramedics who attended to Sharon as a result of the Triple Zero call and the subsequent observations of Sharon that were made when she was taken to Blacktown Hospital are inconsistent with Mr Boyraz’s observations. The paramedic and hospital evidence established that Sharon only had lower leg reddening (consistent with cellulitis) with no other abnormalities detected. Certainly, the paramedic and hospital evidence did not identify that Sharon had any injuries consistent with having been assaulted.

13.3 However, the observations made by Sharon’s family members on the evening of 24 May 2013 are consistent with Sharon having been assaulted. Sharon was noted to have bruising to her face, breasts and right leg. When questioned about these injuries, Sharon indicated that they had been caused by Terry.

13.4 It is against this background, that Sharon’s recent blunt force head injuries need to be considered.

The observations made by Sharon’s family members on the evening of 24 May 2013 raises a direct question as to whether the recent blunt force head injuries observed at autopsy were the result of

accidental injury (such as from a fall) or the result of non-accidental injury (such as from an assault or episode of interpersonal violence).

13.5 In considering this question it should be noted that the evidence establishes that it is more probable than not that the injuries observed by Sharon’s family on the evening of 24 May 2013 were inflicted, and not accidental, injuries. Further it is more probable than not that the injuries were inflicted as a result of an episode of interpersonal violence involving Terry. This is due to a number of reasons.

Firstly, when asked what had happened to her on 24 May 2013, Sharon specifically nominated Terry as being responsible. Secondly, the evidence regarding the history between Sharon and Terry (prior to May 2013) established that their relationship was marred by past incidents of domestic violence.

Thirdly, the evidence established that at least between 22 May 2013 and 24 May 2013 Terry’s mental health was deteriorating to the extent that he was observed to be behaving erratically on several occasions. However, even though the evidence allows for the above conclusion to be reached regarding the non-accidental nature of the injuries observed on 24 May 2013, it is not possible to reason, from this alone, that the recent blunt force head injuries observed postmortem were also non-accidental.

13.6 One reason for this is because there is little evidence as to the mechanism by which the recent blunt force head injuries were occasioned, and even less evidence as to the mechanism by which the injuries observed on 24 May 2013 were occasioned. As to the latter, although Sharon nominated Terry as having caused them, she did not disclose to her family members, or anyone else, how they allegedly occurred. More importantly, the available medical and expert evidence is unable to distinguish between whether the recent blunt force injuries represent accidental or non-accidental injuries. Finally, it should be remembered that Sharon had been observed by independent witnesses to be unsteady on her feet on 2 May 2013 and to have actually fallen due to this unsteadiness on 23 May 2013.

13.7 In evidence given during the inquest Dr Bailey explained that it was not possible to determine if the bruises to Sharon’s head had been accidentally inflicted (such as from a fall) or not (such as from an assault). Dr Bailey also explained that it was not possible to differentiate between a bruise caused by a person coming into contact with an object, as opposed to an object or part of another person’s body striking a person (such as with a punch or kick).

13.8 Dr Rodriguez also explained that Sharon’s recent blunt force head injuries may have resulted from numerous causes including falls or assaults. Dr Rodriguez explained that “based on an examination of the brain and its coverings alone it is not possible to determine how each injury in isolation or collectively was sustained”.25 Like Dr Bailey, Dr Rodriguez explained that it was not possible to determine if Sharon’s head injuries had been accidentally inflicted or not. Similarly, Dr Rodriguez noted that it was not possible to determine if the injuries were the result of Sharon’s head striking an object or an object (or part of a person’s body) being used to strike Sharon’s head.

13.9 Dr Rodriguez went on to explain that determining the age of these injuries is imprecise and the timing of associated reactive changes varies between individuals and is affected by numerous factors. However, the findings at autopsy suggested that the subarachnoid haemorrhage and contusions were recent, possibly occurring several hours prior to death. More specifically, Dr 25 Exhibit 1, Tab 5, page 5.

Rodriguez opined that the recent blunt force head injuries were consistent with both a fall or an assault on 24 and 25 May 2013. However, as Dr Rodriguez regarded the recent blunt force head injuries as being most likely less than 36 hours old, the injuries were not consistent with a backwards fall on cement at about midday on 23 May 2013. Therefore, whilst Dr Rodriguez’s opinion eliminates the recent blunt force head injuries as being caused by the unwitnessed fall that Sharon experienced in the driveway to her home when she was in the process of getting into a taxi on 23 May 2013, it does not provide further clarification as to whether the injuries were caused accidentally or nonaccidentally on either 24 May 2013 or 25 May 2013.

13.10 Like Dr Rodriguez, Professor Besser considered that the recent blunt force head injuries could have been sustained either by falls or assaults and that they were consistent with these having occurred on 24 and 25 May 2013. In relation to the backwards fall on cement at about midday on 23 May 2013, Professor Besser considered that if the large occipital scalp haematoma was due to this fall then it may have resulted in a contre-coup recent injury (an injury located on the opposite side of the site of a trauma) to the frontal and temporal lobes some 36 hours prior to death. However, Professor Besser noted that that the neuropathology suggested that the brain contusions and haemorrhages occurred less than 36 hours prior to death, making this timeframe inconsistent with a backwards fall on cement on 23 May 2013. To this extent, the opinion expressed by Professor Besser was consistent with that expressed by Dr Rodriguez, as already noted above.

13.11 In relation to the recent head injuries, Professor Duflou noted that the large bruise to the back of Sharon’s head was likely sustained when her head struck the plasterboard wall in the hallway, likely as a result of a backwards fall. However Professor Duflou explained that he could not say for certain whether the fall was accidental (as the result of losing balance) or attributable to some interpersonal violence (in the form of a shove or push).

13.12 Professor Duflou also noted that the intracranial injuries (subdural haemorrhages, subarachnoid haemorrhages, frontal and temporal contusions, and limited intraventricular haemorrhage) could have been sustained as a result of one or more falls, or as a result of an assault, or a combination of the two. Professor Duflou explained that this set of injuries could all reasonably be the result of one or more assaults in the hours before death on 24 and 25 May 2013, as well as due to a fall as a result of Sharon’s inherent instability and propensity for falling.

13.13 Finally, it should be noted that when NSW Ambulance paramedics and police arrived at Sharon’s home on 25 May 2013, it was noted that Terry was suffering from the effects of a suspected clozapine overdose. As a result, Terry was conveyed to Blacktown Hospital and admitted for treatment. On the morning of 28 May 2013 a medical team reviewed Terry. He told them that he had been brought to hospital by police and said, “They say I have assaulted my wife, which I don’t remember”. When Terry was asked about some police officers who were at the hospital at the time Terry replied, “I might have done something silly. I think my wife is dead. She was preparing to die.

Now I want to die. I have lost one thing I loved”.26 However later during the review Terry told the medical staff that Sharon “used to drink heaps of alcohol” and “had falls”27, and denied hitting Sharon.

26 Exhibit 1, Tab 71, page 86.

27 Exhibit 1, Tab 71, page 87.

13.14 Having regard to the above, there is no reliable evidentiary basis upon which a conclusion could be reached that in his discussion with medical staff on 28 May 2013 Terry was making an admission that he had assaulted Sharon on 24 or 25 May 2013. Although Terry referred to the fact that he might have done something “silly”, he initially said that he had no recollection of assaulting Sharon and, later, denied hitting her.

13.15 Conclusion: The available evidence does not allow for a finding to be made as to whether Sharon’s recent blunt force head injuries were the result of accidental or non-accidental injury. The circumstances leading to the discovery of Sharon in the hallway of her home in the early hours of 25 May 2013 were not witnessed. Although there was a documented history of domestic violence between Sharon and Terry, and that it is more probable than not that the injuries which Sharon’s family observed on 24 May 2013 were non-accidental in nature and likely the result of an episode of interpersonal violence involving Terry, an evidentiary nexus cannot be drawn between these matters and Sharon’s recent blunt force heard injuries.

13.16 Further, the combined opinion of all the medical experts is that it is not possible to identify the mechanism by which the recent blunt force injuries were occasioned. They injuries are equally consistent with an accidental event such as a fall, as well as with a non-accidental event such as an episode of interpersonal violence involving a strike in the form of a punch or kick. Further, the evidence also leaves open the possibility that the injuries could have been the result of a combination of both mechanisms; for example, Sharon may have been intentionally pushed or shoved and then stumbled, causing her to accidentally strike her head on an object. In this regard the available physical evidence does not assist in resolving the question of mechanism. The evidence of plasterboard on the hallway floor and in Sharon’s hair only point to Sharon’s head coming into contact with the hallway wall (and being one possible cause of her recent blunt force head injuries), but does not establish the manner in which this occurred.

14. Findings pursuant to section 81 of the Coroners Act 2009 14.1 Before turning to the findings that I am required to make, I would like to acknowledge, and express my gratitude to, Mr Troy Edwards, Counsel Assisting, and his instructing solicitor, Ms Tracey Howe of the Crown Solicitor’s Office. Their assistance during both the preparation for inquest, and during the inquest itself, has been invaluable. I would also like to thank them both for the sensitivity and empathy that they have shown in this matter. I also thank Inspector Jason Pietruszka for his efforts during the complex investigation into Sharon’s death and for compiling the comprehensive initial brief of evidence.

14.2 The findings I make under section 81(1) of the Act are: Identity The person who died was Sharon Bell.

Date of death Sharon died on 24 or 25 May 2013.

Place of death Sharon died at Seven Hills NSW 2147.

Cause of death The cause of Sharon’s death was cardiorespiratory arrest in a person with blunt force head injury, end-stage liver disease with hepatic encephalopathy, and respiratory depressant drug use.

Manner of death Both natural and non-natural causative features were present at the time of Sharon’s death.

However, the available evidence does not allow for a finding to be made as to the precise mechanism of death.

15. Epilogue 15.1 It is most distressing to know that whilst Sharon had much love and care to give to others, and was much loved by her family, she was found alone in the early hours of the morning on 25 May 2013.

15.2 On behalf of the NSW State Coroner’s Court and the counsel assisting team, I offer my deepest heartfelt sympathies, and most respectful condolences to Sharon’s mother and sisters, and Sharon’s other family members, for their most tragic loss.

15.3 I close this inquest.

Magistrate Derek Lee Deputy State Coroner 7 February 2019 NSW State Coroner’s Court, Glebe