Inquest into the death of Karl MELO-RICHARDS

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CORONER'S COURT OF NEW SOUTH WALES

Inquest into the suspected death of missing person Karl MeloRichards

11 April 2019

11 April 2019

Coroner's Court Complex, Lidcombe

Magistrate Derek Lee, Deputy State Coroner

CORONIAL LAW - missing person, cause and manner of death 2017/392868

Mr T O'Donnell, Coronial Advocate Assisting the Coroner

| find, on the balance of probabilities, that Karl Melo-Richards is now deceased. He died on, or sometime after, 2 September 2016 at Malabar NSW 2036. Karl intentionally inflicted his own death. However the available evidence does not allow for any finding to be made as to the cause of Karl's death.

Table of Contents

IMtrOCUCTION 0... eee cecccctectececesesnsessetsceseessecsecsseessassneneseecsecsecsecseceseesensenssssuaseaesaesaessesaecsecsecueonseneens 1 Why was an inquest held? .

Karl's life

IAONtity eee eectecescesceseseescnensecneccsecssesseassassaesaecesseessessessssesassasassaenseesueessessesseesessssssssssansaeeee Date of death.

Place of death...

Cause of death..

Manner of death

Epilogue

Introduction

1. Karl Melo-Richards was last seen alive on 2 September 2016. In a period of about three hours during that afternoon Karl left his home in Maroubra. His movements and what transpired during this period, and the hours and days that followed it, have not been able to be determined with any precision. After Karl was reported as missing, the police conducted an extensive investigation in an attempt to discover what happened to him.

Despite pursuing multiple lines of enquiry, many unanswered questions still remain about the circumstances in which Karl went missing.

Why was an inquest held?

2. Shortly after Karl was reported as missing, the NSW Police notified the Coroner's Court that he was suspected of being deceased. When the case of a missing person, who is suspected to have died, is reported to a coroner, the coroner must determine from the available evidence whether that person has in fact died. In such cases there will often be very little information, despite extensive enquiries, about what happened to the person after they were last seen alive.

3. If the coroner forms the view that a missing person has died then the coroner has an obligation to make findings in order to answer questions about the identity of the person who died, when and where they died, and what the cause and the manner of their death was. The manner of a person's death means the circumstances in which that person died. If the coroner is unable to answer these questions then an inquest must be held.'

4. In Karl's case, a large amount of evidence was gathered by the police concerning the circumstances surrounding the period leading up to when Karl was last seen alive.

However, none of this evidence was able to reveal exactly what happened to Karl after 2 September 2016. As it has not been possible to answer the questions that a coroner is required to answer, it became mandatory for an inquest to be held.

Karl's life

5. As will be discussed later in these findings, all of the evidence gathered to date suggests, tragically, that Karl is now deceased. Inquests into the deaths of persons, even those persons who are missing and suspected of being deceased, usually only focus on the last moments of a person’s life, or the last moments when they were seen alive. These moments are sometimes measured in weeks or months, but more often they are measured in hours and days. As a consequence, often there is very little known about the (usually) years of life that preceded these final moments. Therefore, it is appropriate at this stage to recognise Karl's life in a brief, but hopefully meaningful, way.

6. Karl was born in 1991 at the Royal Hospital for Women in Randwick to his parents, Vanessa Richards and Miguel Melo. Karl was initially raised in Coogee but following his parents’ separation when Karl was aged two, he later grew up in the Maroubra area whilst living with his mother.

' Coroners Act 2009, section 27.

In accordance with subsequent court orders, living arrangements were made for Karl to spend roughly equal time with both his mother and father each week. In 1994 Ms Richards formed a new relationship with David Lowlett. They later had two children, Kirra and Kai, who were four years old, and 16 years old, respectively, at the time that Karl was reported missing. In 2008, Karl moved in with his father and lived with for 12 to 18 months before eventually moving back to his mother’s home. In 2011 Mr Melo moved to Queensland meaning that Karl only saw his father about three or four times per year.

After school, Karl commenced a plumbing apprenticeship but later changed this to a carpentry apprenticeship. By all accounts Karl enjoyed working in the building industry.

Karl was a keen surfer and spent a great deal of time at Maroubra Beach. Although Karl kept largely to himself and was not known to have many friends, he was considered to be a good friend to those who knew him well.

There can be no doubt that Karl is greatly missed by his family. The fact that there has been much uncertainty surrounding what happened to Karl has inevitably made the sense of loss felt by his family even more upsetting.

What is known about Karl‘s medical history?

There was a family history of depression on the paternal side of Karl's family. When aged 14 or 15 Karl himself first began to display signs of depression which were found to be ongoing. Karl was feeling pressure from high school examinations and casual work he was engaged in at the time. It was also at this time that Karl began to experience suicidal ideation.

Ms Richards has expressed the view that Karl's separate living arrangements with his parents whilst growing up unfortunately created an unstable and disruptive childhood for Karl. This meant that Karl was forced to adapt to two different parenting styles. In Ms Richards’ opinion, this led to Karl developing anxiety and feeling disconnected from both sides of his family.

During the period that Karl was living with his father from 2008 he experienced difficulty sleeping. Mr Melo took Karl to see a general practitioner (GP) who prescribed Karl with medication (temazepam) to treat insomnia. On 2 August 2009 Mr Melo found Karl in a semi-conscious state after Karl had ingested an excessive quantity of temazepam in an apparent self-harm attempt. Karl was taken to hospital for treatment where he was noted to be suffering from suicidal ideation. It was also noted that Karl had been experiencing significant psychological stressors over the preceding month related to low self-esteem, his studies, being unable to surf, not having a girlfriend, and his parents’ separation.

Karl was found to have a major depressive disorder and to be at medium risk of self-harm.

He was prescribed antidepressant medication (quetiapine and mirtazapine) and later discharged with a referral to see a psychologist.

Following discharge, Karl returned to live with his mother. In September 2009 Karl was referred to the Black Dog Institute. Karl's history was noted to be suggestive of unipolar

melancholic depression and he was prescribed another antidepressant (venlafaxine) in addition to his existing medication regime. It was also noted that Karl was experiencing intermittent suicidal ideation at this time.

In January 2010 Karl began undergoing Cognitive Behavioural Therapy (CBT) with a psychologist. It appears that this treatment was positive for Karl as his mother noted an improvement in his functioning, and by April 2010 Karl noted that he was no longer feeling suicidal. During this time, Karl went on an overseas trip with some friends, which appeared to also have a positive effect on Karl, and he was also completing his plumbing apprenticeship.

However, over time it appeared that the mirtazapine was causing negative side-effects. Karl was noted to have what his mother described as “manic-style episodes”? and he began to experience conflicts with his fellow employees, which was out of character. Karl was found to be suffering what was described as a deep depression and sought treatment in the form of brainwave therapy. After a short period of treatment, Karl’s low mood appeared to lift and he returned to his usual self. This period of positivity only lasted a brief time. After a couple of weeks Karl experienced an anxiety episode at work and was taken to hospital where he was admitted to a mental health inpatient unit. During his admission Karl was prescribed further antidepressant medication (citalopram).

lt appears that this change in medication was a positive one for Karl as his mother noted that Karl's level of suicidal ideation appeared to diminish. During this period, Karl moved out his mother’s home and lived for a time with some flatmates, before later living alone for about six months. Following this, Karl returned to live with Ms Richards and Mr Lowlett in Maroubra.

However, by 2012 it appeared that Karl’s condition had declined and he was diagnosed with depression. Throughout 2012 Karl attended his local medical centre on a number of occasions in relation to this depression, ongoing stress and sleeping difficulties. Sometime in 2012 Karl wrote an entry in his diary which read: “To whoever ends up reading this these were my last words. | don’t realy [sic] understand in no matter what state of mind im [sic] in now im [sic] supposed to move forward and live a normal life with having the constant thoughts of harming or killing myself in the back of my head...before | die id [sic] like to make sure...! never thought it [sic] end like this but fuck, here it is...”°

On 16 March 2012 Ms Richards returned home to discover that Karl's car was not there.

She went to South Maroubra beach and saw Karl's car parked there. Ms Richards called Karl on his mobile phone whilst at the same time making her way to the cliffs at the beach. Karl answered his phone and began making his way to find his mother. It became apparent to Karl's mother that Karl was in the vicinity of the cliffs and contemplating self-harm. This incident resulted in another admission to hospital for Karl after which he was discharged on a medication regime of citalopram and quetiapine.

The next several years appeared to be more positive ones for Karl. In about April 2012 Karl formed an intimate relationship with Eveline Mussi. Karl later moved out of home to live with his Ms Mussi for a short period. He was also able to complete his carpentry studies

? Exhibit 1, Tab 3 at [11].

3 Exhibit 1, Tab 9.

(which he had since transferred to), and was working on completing his apprenticeship whilst working for a building company. Karl continued to take citalopram as part of his medication regime although his mother became aware that Karl experimented with varying the dosage from time to time, which tended to affect Karl's level of functioning.

In 2015 Ms Mussi travelled to Brazil for an extended period. As a result, she and Karl decided to remain just friends for that year.

On 24 April 2016 Karl admitted himself to the Psychiatric Emergency Care Centre (PECC) at Prince of Wales Hospital after going to the cliffs at Maroubra and contemplating selfharm. Karl later told his mother that he had stopped himself and instead driven himself to hospital. It appears that Karl's motivation had been partly due to concerns he was experiencing over money owed by him to family members for a recent operation. Whilst admitted, Karl’s condition improved with increased sleep and he reported an abatement of suicidal ideation. Karl was later discharged with a plan to seek follow-up psychological and psychiatric treatment.

Following his discharge Karl returned to live with his mother in Maroubra. Ms Richards noted that Karl took some time to settle back in to everyday life and eventually returned to work. However, Ms Richards also noted that Karl’s behaviour seemed to follow a similar pattern where a return to regular life would trigger an increase in anxiety with resultant depressive episodes. Ms Richards and Mr Lowlett also noted that Karl again had difficulty sleeping during this period, and that his lack of sleep would cause his level of functioning to decline.

Staff from the PECC maintained ongoing contact with Karl during this period. By early May 2016 Karl reported that his mental state had deteriorated and the only thing preventing him from jumping from a height to cause his own death was a fear that he would survive with serious, but non-fatal, injuries. Karl also disclosed having thoughts of ending his own life by motor vehicle collision or through the use of a firearm.

Throughout May 2016 Karl continued to disclose further suicidal ideation, described his mood as low, and that he felt “worthless” and was “tired of being depressed”. Karl indicated that a surfing injury, costly surgery to correct the injury, being unable to work,

and Ms Mussi’s absence overseas were all stressors that were adversely affecting his mental health.

On 24 May 2016 there was a further incident when Karl's mother again noticed that Karl was not at home. Ms Richards made her way to South Maroubra beach to look for Karl whilst at the same time attempting to call him on his phone. She eventually found Karl walking near the cliff edge and moved him away from it back to safety. Following this incident Karl re-admitted himself to the PECC and his dose of venlafaxine was increased.

However, Karl did not like using the medication because of its side effects and he eventually recommenced using citalopram.

Karl was later discharged on 1 June 2016. He later began to exhibit signs of depression again, despite daily contact with, and regular home visits from, staff at the PECC. As his family were concerned that he would leave the house to commit an act of self-harm they

took steps to sleep near the front door to ensure that Karl would not leave the house without one of his family being aware of his absence.

By mid-June 2016 Karl again reported having regular suicidal thoughts involving jumping from a cliff or hanging himself. After Ms Mussi returned to Australia in June 2016 she recalls that Karl told her on several occasions during this period up to 2 September 2016 that he experienced suicidal thoughts every morning.

Karl engaged in treatment with a psychiatrist who he continued to see on a regular basis. It was recommended to Karl that he consider another form of treatment (transcranial magnetic stimulation) available at private mental health care facility. Karl was eventually admitted to this facility in July 2016 and underwent treatment for about six weeks. Shortly before his admission Ms Mussi saw from Karl's phone that he had been conducting research on how to tie knots with a rope.

Once admitted, Karl continued to have suicidal thoughts. He reported continued depression and said that he had considered different ways to end his life. During his admission, Karl was allowed daily leave to spend time with family and friends. During one such leave period Karl went surfing with his father, although he was only able to manage to do so for a short time. On this occasion Karl began to cry and told his father, “Dad, I’m slowly dying, | don't think | can take this anymore” 4

During another period of leave, Karl and Ms Mussi went for a walk along the cliffs at North Maroubra. Karl told Ms Mussi that he had previously visited the cliffs several times and contemplated self-harm, making reference to another person who had inflicted their own death at the same location.

Towards the end of August 2016 it appeared that Karl's condition had improved and he was discharged on 19 August 2016. Plans were made for Karl to see a psychiatrist and seek a referral to a psychologist from his GP. On 22 August 2016 Karl sent is father a text message in which he said that he was feeling a lot better. Later it was reported that Karl was no longer feeling suicidal. However, a diary entry made by Karl on 31 August 2016 (which was his last known diary entry) recorded the following: “My sleep has been gradually getting worse over the last 3 nights to the point where | only got about an hr last night.

This morning my emotions were out of whack to the point where | was in tears and feeling very anxious. | noticed this especially when | tried to go surfing and felt like crying the whole time while | was in the water’ ©

Following his discharge Karl continued to manage his own medication and made attempts to recommence CBT and arrange further sessions with a psychologist. On 30 August 2016 Karl dropped Ms Mussi off at the airport as she was about to embark on another brief overseas trip. Karl told her that he felt sad and upset each time she left.

On the morning of 1 September 2016 Karl told his mother that he planned to speak to Ms Mussi with the intention of telling her that he thought they should see less of each other.

On the same day, Karl was meant to pick up Ms Mussi from the airport but called her and told her that he was not feeling well because he had had little sleep. During the day Karl

4 Exhibit 1, Tab 2 at [49].

5 Exhibit 1, Tab 2 at [65].

attended a clinic to participate in a group talk about building motivation. Karl spoke about feelings of sadness and having difficulty sleeping which was causing him significant distress.

Later that evening Ms Richards rang Karl from work and spoke to him briefly. She returned home at around 10:15pm and saw that Karl was reading downstairs. Ms Richards spoke with Karl for a short time before bidding him goodnight and going upstairs to bed.

What happened on 2 September 2016?

Ms Richards saw Karl the following morning, shortly before he left the house at 7:30am.

Karl told his mother that he was going to speak to Ms Mussi. He later arrived at her home at about 7:35am and they spoke for about 10 or 15 minutes. Karl told Ms Mussi that he needed to deal with his depression without depending on her and that he needed to stop seeing her for a while. However, he mentioned that he and Ms Mussi could go travelling after he felt better. During this conversation Ms Mussi believed that Karl received a message on his phone, although she was unsure whether it was a SMS message or a message received through a social media application. Ms Mussi noticed that Karl immediately covered up the message once he received it. Later, following the report of Karl being missing, Ms Mussi recalled that she was unsure if she saw the message on this day or on an earlier occasion.

n any event, after leaving Ms Mussi, Karl went to a hardware store in Hillsdale at about 8:45am. Once there, Karl was recorded on CCTV footage to purchase a 4.5 metre length of 8mm cotton cord sash rope.

arl later returned home at about 10:00am. For the remainder of the morning, Karl helped his mother with some renovation work that was taking place at their home at the time.

After lunch, Karl sat down to watch some television in the lounge. At some stage, Mr Lowlett and Kai, who were also home that day, left the house to attend an appointment. Mr Lowlett asked Karl if he wanted to join them but Karl declined. At that time Karl's family knew that he would mention if he was experiencing any suicidal ideation, but on this day arl made no mention of any such thoughts. Karl’s mother later left for work at abou 1:450m. Mr Lowlett and Kai left the house at about the same time.

Later that afternoon Kirra returned home at about 4:30pm. She found the front and back doors of the house open, and looked around for Karl but could not find him. Kirra though that nothing was amiss and sat down on the couch. Mr Lowlett returned home about 10 minutes later and asked where Karl was. When Kirra told him that she did not know, Mr Lowlett tried to call Karl on his mobile phone without success. Mr Lowlett noted that Karl's car remained parked outside and that his keys and wallet (containing a modest amount o cash, credit cards, and an Opal travel card) were still at home.

Mr Lowlett left home and drove to the South Maroubra beach car park to search for Karl in the area surrounding the cliffs at Magic Point, but could not find him. Mr Lowlett spoke to some fishermen who had been at the location since about 2:00pm who told him that they had not seen Karl. Mr Lowlett drove to North Maroubra and continued to search the cliffs there for any sign of Karl, without success.

Mr Lowlett called Ms Richards to tell her what had occurred. Ms Richards became extremely upset and called the police to report Karl as missing, with grave concerns that he had left home to harm himself. After Mr Lowlett returned home, he and Ms Richards called Karl's closest friends to see if they had seen Karl. None of them had, and some of them went to search for Karl along the coastline at Maroubra.

Sometime later, Karl's family discovered a length of rope which had been tied around a rafter in the section of the house which was undergoing renovation. One end of the rope had been cut off close to the rafter.

What steps were taken in an attempt to locate Karl?

In the hours, days, weeks and months that followed the report of Karl being missing, numerous steps were taken by the police, Karl’s family, and other persons and organisations in an attempt to ascertain his whereabouts. A summary of these investigative steps is set out below:

(a)

Initial attending police arrived at Karl's home shortly after 6:009m on 2 September 2016 and searched it. A foot search was conducted of South Maroubra beach cliffs and the surrounding area. Checks were also conducted at a local club where Karl was known to use the gym, and at Prince of Wales Hospital.

On 3 September 216 police conducted a further foot search at South Maroubra beach cliffs and the surrounding area with a police dog unit. On the same day members of the Maroubra Surf Life Saving Club conducted a search of Maroubra and Malabar Bay via jet ski. Karl's family and friends also spent much of the day searching for Karl in Malabar Headland National Park (the National Park) and the coastline between Malabar Bay and Maroubra.

On 4 September 2016 Karl's family discovered a noose which had been discarded on top of a bucket which was used to hold rubbish. It was assumed that the noose had been fashioned from the rope Karl had purchased two days earlier. Karl's mother observed that this was out of character for Karl, who was ordinarily an organised person. Ms Richards also believed that it was unlikely Karl would consider using the noose to self-harm at home out of concern that one of his family members would discover him and be traumatised by such a discovery.

On the same day police conducted a foot search of Arthur Byrne Reserve, North and South Maroubra beach, the area around Lurline Bay and Heffron Park. The Police Air Wing was also used to conduct an aerial search over bushland around the Anzac Rifle Range from South Maroubra beach, and then north along the coast towards Coogee beach. Further foot searches of North Maroubra beach, the street's surrounding Karl's home, Malabar, Little Bay and La Perouse were performed. Checks were also conducted with Prince of Wales Hospital, Royal Prince Alfred Hospital, and St Vincent's Hospital.

On 7 September 2016 police again searched Karl's home and Ms Mussi’s home.

On 13 September 2016 police attended Magic Point, a headland south of Maroubra Beach, with Ms Richards, who identified the location as where she had found Karl walking along the cliffs on 24 May 2016. This location is approximately 1.7 kilometres, or about 20 minutes walk, from Karl’s home

On 14 September 2016 police searched a storm drain off Waterside Avenue, Maroubra where human remains had previously been washed up. A foot search was also conducted in this area.

On 16 September 2016 police divers searched an area from Magic Point to Boora Point.

On 28 September 2016, and 16 October 2016 the police Air Wing unit conducted an aerial search over Magic Point and the National Park.

On 12 October 2016 and 20 October 2016 police, utilising a dog unit, trail bikes, and National Parks and Wildlife Service staff conducted a search of the eastern and western sections of the National Park.

On 23 November 2016 police searched the coastline from Magic Point to Boora Point utilising Rescue Squad staff and drones.

On 8 January 2017 police divers conducted a free swim search of 100 metres along the rock shelf at Mistral Point. This was followed by an aerial search over Mistral Point on 14 January 2017.

On 19 and 28 December 2017, following information provided by a member of the public, police conducted a search of an area within the National Park via foot and with the use of trail bikes.

Between 3 September 2016 and 22 August 2017 a number of local, state and national media outlets, and the Maritime Union of Australia, published information relating to Karl and requested persons with any relevant information to contact police. On 11 October 2016 police also performed a letterbox drop of the residences near Karl's home seeking further information. Details regarding the circumstances of Karl going missing were also added to the NSW Police Missing Persons Unit database and to the Australian Missing Persons Register.

The various media releases produced a number of reported sightings of Karl by members of the public. Between 4 September 2016 and 22 August 2017 these reports were investigated by police and either considered to be doubtful, of no investigative value, or eliminated as being possible sightings of Karl.

Unfortunately, none of the above searches was able to yield any information that provided a clear picture as to Karl's whereabouts or what happened after he left home on the afternoon of 2 September 2016.

Apart from the physical searches described above, police also conducted a number of enquiries, commonly referred to as “signs of life checks”. These enquiries are made because it is presumed that in modern society, it would be unusual for a member of the

community to not have some degree of interaction with a number of commonly used organisations as a matter of daily life by, for example, opening or accessing a bank account, or making a claim to Medicare. If such an interaction occurs then there is usually a record kept by the organisation about it. Set out below is a summary of the further checks performed by police:

(a)

Examination of Karl’s mobile phone usage and records revealed that the last location that his phone could be linked to was a cell tower at Maroubra Junction at 2:40am on 2 September 2016. This cell tower covered an area including Karl's home and Magic Point. Records revealed that all calls made to Karl's phone on 2 September 2016 (with the first being at 3:48pm) were forwarded to a message service. This suggests that Karl's phone had been turned off or deactivated sometime after 2:40am. Records further confirmed that Karl’s move service has not been used since 2 September 2016 and was disconnected on 29 December 2017.

Police also conducted an examination of Karl's financial records which revealed that he held two bank accounts with ANZ. The last transaction made by Karl occurred on 30 August 2016 when he used one of his accounts for a purchase at a petrol station in Mascot.

On 5 September 2016 an amount of $120 was deposited into one of Karl’s bank accounts by his father. On 7 September 2016 an amount of $3,641.47 (representing a tax refund) from the Australian Taxation Office, and an amount of $442.60 from Centrelink (representing a government benefit payment) were deposited into Karl's bank accounts. Records revealed that as at 12 October 2016 Karl's bank accounts were in credit to the amount of $4,980.13. Further records revealed that as at December 2017 Karl had not conducted any transactions or claims with either Medicare or Centrelink.

Enquiries with the Department of Immigration and Border Protection (as it then was) revealed that Karl’s passport had not been used to travel offshore, and that no application for a passport in his name had been made after 2 September 2016.

Further checks with a number of airlines revealed that no person using Karl's name had departed Sydney to another domestic airport. Finally, records obtained from a number of taxi companies and rideshare services revealed that no person with Karl's name or address had utilised their services on 2 September 2016.

Police conducted enquiries with a number of persons who were friends or associates of Karl, who had conducted business or other dealings with him, or who some relevant contact with him proximate to the time he went missing. None of these persons was able to provide police with information to advance the investigation.

Police also examined Karl's laptop, his Facebook account and his email accounts. This examination revealed that Karl's last recorded social media and email activity occurred on 30 August 2016. Further, police found no evidence on any of Karl's electronic records that he was planning any travel, or any information that would assist the investigation.

(f} A sample of Karl's DNA, taken from his toothbrush, was collected for comparison purposes. Similarly samples were taken from both Ms Richards and Ms Melo. None of these samples have produced a positive match when compared against samples taken from unidentified human remains.

(g) As part of the investigation an opinion was sought from Professor Rob Brander from the University of New South Wales, an expert in coastal geomorphology, rip currents and beach safety. This opinion was sought because, given the information provided by Ms Richards that she had found Karl walking along the cliffs at Magic Point, and the proximity of the location to Karl’s home, it was hypothesised by investigating police that Karl may have jumped from a height at this location. Professor Brander expressed the view that if Karl had entered the water at Magic Point on 2 September 2016, it is unlikely that his remains would be washed ashore. In support of his conclusion Professor Brander referred to previous studies involving a similar scenario which demonstrated that it was impossible to accurately predict where human remains might be deposited ashore.

(h) Final signs of life checks were conducted by police with a number of government agencies and departments, most recently in March 2019.

Is Karl still alive?

47. A finding that a person is deceased is a finding of great significance and gravity, not only for the family members of that person and the emotional toll that such a finding will invariably bring, but also because such a finding carries with it important legal and administrative consequences. Such a finding is made on the balance of probabilities, but there must be clear, cogent and exact evidence that a person has died before it can be made.®

48. In determining whether Karl is still alive or now deceased, consideration has been given to the following factors:

(a) Since 2 September 2016 the police investigation has not uncovered any positive evidence which suggests that Karl is still alive - every reported sighting has been examined and discounted by police as having any investigative value;

b) Extensive physical searches of locations which Karl is likely to have attended on 2 September 2016 have produced no positive evidence as to his whereabouts;

c) Karl had a lengthy, demonstrated history of suicidal ideation which appeared to intensify at various points in the months leading up to him going missing;

d) All previous mobile phone, electronic, and online activity conducted by Karl ceased on or just before 2 September 2016;

e) Financial transactions involving Karl’s known bank accounts ceased on 30 August 2016 and there has been no attempt made to access a sum of almost $5,000 in these

® Briginshaw v Briginshaw (1938) 60 CLR 336.

accounts, in circumstances where Karl had no demonstrated means to support himself financially from 2 September 2016 onwards;

f) There is no evidence that Karl has embarked on any domestic or international travel after 2 September 2016;

g) Any activity relating to Karl has not appeared on any government database or record held by organisations such as Medicare and Centrelink after 2 September 2016;

h) Karl's family and those closest to him, have not heard from him for more than 31 months; and

i) Karl seemingly left his home in the period between 1:45pm and 4:300m on 2 September 2016, suddenly and unexpectedly, leaving behind his car and personal possessions.

In assessing the above, consideration has also been given to a belief expressed by Karl's mother that Karl may have planned to go missing on 2 September 2016 and travelled to Queensland, possibly due in part to the fact that his father resides there. Part of Ms Richard's belief is based upon reported sightings of Karl in March 2017 by a member of the public. These reports were investigated by police. The person who reported sighting Karl at this time was shown a photo of Karl but unable to state if it showed the same person that she had sighted. Further, a person matching the description given by the reporter was later identified on CCTV footage at a location near the reported sightings. On further investigation this person was eliminated as being Karl.

Consideration has also been given to the fact that Ms Mussi recalls that at one stage she gave Karl a book which was a true story about a professional surfer who was able to travel to many surfing competitions around the world despite having modest finances. Ms Mussi recalls that after Karl read the book he was inspired to do something similar. This raises the possibility that the circumstances of Karl going missing on 2 September 2016 may have been the product of such inspiration.

Further, at one stage during the investigation it was suggested that the message which Karl received on his phone on the morning of 2 September 2016, when he was speaking with Mussi, may have been sent by a person whom Karl was in, or intended to form, a relationship with. This suggestion was based on Karl appearing to conceal the message from Ms Mussi. However, it has subsequently been established from phone records that Karl did not receive a message at this time. This is consistent with Ms Mussi’s subsequent acknowledgement that she may have been mistaken in her recollection of the incident. In any event, there is no other evidence to indicate that Karl was forming, or had formed, a relationship with any other person at around the time he went missing.

It should also be noted that both Ms Richards and Ms Mussi have stated that Karl was not a spontaneous person by nature, that he was typically very organised, and that he would not embark on any endeavour without having planned it in advance. Given what is known about Karl's nature, it would be expected that if Karl had intended to go missing, there would be some evidence of pre-planning or organisation to this effect. To the contrary, the police

investigation has not revealed any evidence of such planning or organisation undertaken by Karl, or any other person who might have been assisting him to do so.

Having regard to all of the above evidence the conclusion that must, sadly, be reached is that it is more probable than not that Karl is now deceased.

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

Having reached a conclusion that Karl is now deceased, a number of questions remain to be answered. The first two questions relate to whether any finding can be made as to the cause and manner of Karl’s death.

As noted above, the evidence gathered during the police investigation establishes that Karl had a lengthy history of suicidal ideation, that such ideation had progressed from mere contemplation to actual self-harm attempts, and that Karl had articulated to others the methods by which such selfharm would be attempted. Further, it is noted that two days before Karl went missing he made a diary entry in which he recorded that he had again been experiencing difficulty sleeping and that this was distressing him greatly. Karl's medical history establishes that inadequate sleep was known to be associated in a decline in his condition and associated depression. Finally, there is evidence that in the period immediately preceding him going missing, Karl took preparatory steps to farewell those closest to him: in August 2016 Ms Richards noticed that Karl was more considerate than usual and always ready to help her; and Karl's conversation with Ms Mussi on 1 September 2016 in which he explained that he needed to see less of her might be interpreted as a farewell gesture.

Of course, the evidence also demonstrates that at times Karl expressed ambivalence about the prospect of self-harm. For example, during his conversation with Ms Mussi on 1 September 2016 Karl made reference to travelling together in the future after a period of separation. Further, Mr Lowlett recalls that whilst Karl used to say that “he couldn’t go on the way it was going”, Mr Lowlett expressed the view that he did not think Karl could end his own life, knowing the pain that it would cause his mother. However, Mr Lowlett equally said that he did not think that Karl could simply leave and not tell his mother, similarly knowing the pain that it would also cause her.

Consideration also needs to be given to the discovery of the rope attached to the rafter and the noose at Karl’s home. On one view this evidence represented a clear preparatory step to self-harm taken by Karl in purchasing the length of rope on 2 September 2016 and then fashioning a noose with it, which was affixed to a rafter before being cut off. On another view, the fact that it was cut off might suggest that Karl had decided to abandon any self-harm attempt due to a concern about the traumatic impact that this would have on his family, particularly if he was discovered by one of his younger siblings. Having regard to Karl's declining condition leading up to 2 September 2016, the purchase of the rope and fashioning of the noose represented, at the least, a physical manifestation of Karl's increasing and repeated suicidal ideation. Whilst Karl may have decided to abandon a particular method of self-harm that afternoon, his actions indicate that contemplation of self-harm in general was still operating heavily on his mind.

Dr Matthew Large, a psychiatrist at Prince of Wales Hospital, examined Karl on 24 and 26 May 2016 and was aware of the community outpatient treatment which Karl received following his discharge. In a statement provided to the police as part of the investigation, Dr Large expressed the opinion that “it is really very likely that Karl has taken his life"? Dr Large’s opinion, the actions regarding the rope taken by Karl on 2 September 2016, and the preparatory steps taken by Karl are all consistent with a conversation that Karl had previously had with Mr Lowlett. In that conversation Karl told Mr Lowlett that he was aware of the pain it would case his mother if he were to self-harm, but also said that “he didn’t know how much fight he had left in him’ ®

Having regard to the above evidence, the conclusion that must be reached is that Karl intentionally caused his own death. There is no evidence to suggest that Karl was the victim of third party involvement or that the circumstances in which he went missing are attended by a degree of suspicion. Therefore, this can be eliminated as a plausible manner of death.

Whilst the possibility of misadventure cannot be entirely excluded (if Karl had, for example, accidentally fallen from a height), the evidence establishes that Karl's previous self-harm attempts were all the result of intentional action, and only terminated prematurely by Karl (such as driving himself to the hospital, or responding to his mother’s intervention); there is no evidence of any previous misadventure. Having regard to these factors, and the above evidence, it is therefore more probable than not that Karl’s death was intentionally selfinflicted.

Having reached this conclusion, the next question is whether any finding can be made as to the cause of Karl's death. It became clear during the police investigation that the possibility that Karl had jumped from a height at a coastal location near his home was raised at the very outset. Karl had made previous references to considering this method of self-harm, he had previously been found at Magic Point, and this was the first location which Ms Richards and Mr Lowlett had travelled to when it had previously been discovered that Karl was missing. On this basis, the evidence would seem to suggest that it is most likely that Karl caused his death by jumping from a height at a coastal location. Such a hypothesis would also be consistent with Karl's body not being found despite extensive land and sea searches, and also consistent with the opinion expressed by Professor Brander.

It can be concluded that, on balance, it is most likely that the mechanism by which Karl intentionally inflicted his own death involved him jumping from a height at a coastal location. Whilst the exact coastal location cannot be identified on the available evidence, it is most likely that it was in the vicinity of Magic Point, Malabar. This is for several reasons.

Firstly, Karl had previously been to the location in March 2012 and May 2016 whilst contemplating self-harm. Secondly, various medical records note that Karl made reference to the location in the context of voicing suicidal ideation. Thirdly, the location was easily accessible from Karl's home, being a short walking distance along a marked path.

The evidence gathered during the investigation established that the distance from the top of the cliffs at Magic Point to the rock shelf below is a distance of approximately 20 to 26.7 metres. There is also evidence, taken from medical literature, which establishes that the critical threshold for a fall from height by an adult is defined to be greater than a height of

7 Exhibit 1, Tab 8 at [5].

8 Exhibit 1, Tab 6 at [11].

64,

six metres, that survivable injuries generally occur below this critical threshold, and that a vertical falling height of more than 27.4 metres is considered to be a non-survivable injury.

However, as discussed further below, the precise location where Karl is likely to have jumped from a height cannot be established on the evidence. Further, in the absence of Karl's body being found and a postmortem examination being performed, it is not possible to reach a conclusion as to the precise cause of Karl's death, even on the balance of probabilities. Using this scenario, it is equally possible that Karl may have sustained fatal injuries after jumping from height, or that he may have sustained incapacitating injuries after the fall and then subsequently drowned in the ocean.

Consideration has been given to the fact that the evidence indicates that Karl may have employed some other means to inflict his own death. The evidence establishes that Karl had previously disclosed contemplated causing his own death by hanging, through a motor vehicle collision, or through the use of a firearm. Indeed, Karl's initial actions taken on 2 September 2016 were to acquire a rope, fashion a noose, and tie it. However, if Karl had employed one of these methods to cause his own, then it would reasonably expected that his body would have been located from the extensive search that was conducted after he was reported missing. The fact that Karl was not found suggests that it is most likely Karl inflicted his own death by jumping from a height.

Ultimately, however, the evidence is not sufficiently cogent to allow for a conclusion to be reached as to the cause of Karl's death.

Where and when did Karl die?

The evidence establishes that when Karl left home on 2 September he left behind his car and any funds which might have assisted with travel. This suggests that it is likely that Karl could only travel to locations within walking distance of his home, and that it would have been difficult for him to travel far beyond the Maroubra area. It is evident that an extensive land, air and sea search of Maroubra and its surrounds failed to locate any sign of Karl.

Having regard to the conclusions reached above as to the mechanism by which Karl inflicted his own death, and accepting the opinion expressed by Professor Brander, it is more probable than not that Karl died at a coastal location in Malabar in the vicinity of Magic Point, although the precise location cannot be determined.

The available evidence also does not allow for a finding to be made as to the precise timing of Karl's death. However, given the sudden circumstances in which Karl went missing, and the time that has passed since then, it can be concluded that Karl must have died on, or sometime after, 2 September 2016.

Findings

Before turning to the findings that | am required to make, | would like to thank Mr Tim O'Donnell, Coronial Advocate, for his assistance with the preparation and conduct of the inquest. The efforts of Detective Senior Constable Lee Jennings conducting a thorough investigation and preparing a comprehensive brief of evidence should also be acknowledged.

69. The findings | make under section 81(1) of the Act are:

Identity The person who died was Karl Melo-Richards.

Date of death Karl died on, or sometime after, 2 September 2016.

Place of death Karl died at Malabar NSW 2036.

Cause of death

The available evidence does not allow for any finding to be made as to the cause of Karl’s death.

Manner of death Karl intentionally caused his own death.

Epilogue

70. On behalf of the coronial team and the NSW Coroner's Court | extend my sincere and respectful condolences to Karl's family. The circumstances surrounding Karl going missing, and the persistent and painful feeling of uncertainty in the years that have passed since, has no doubt caused them immeasurable sorrow and anguish.

71. | close this inquest.

Magistrate Derek Lee

Deputy State Coroner

11 April 2019

Coroner's Court of NSW, Lidcombe