Inquest into the death of BG

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of BG Hearing dates: 29 May 2020 Date of findings: 5 June 2020 Place of findings: Coroner’s Court of New South Wales at Lidcombe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – intentionally self-inflicted death, cause and manner of death File number: 2018/14053 Representation: Mr D Welsh, Coronial Advocate Assisting the Coroner Findings: BG died on 11 or 12 January 2018 at Newtown NSW 2042. The cause of BG’s death was neck compression. BG died as a result of actions taken by him with an intention to end his life. BG’s death was therefore intentionally self-inflicted.

Non-publication orders: Pursuant to sections 74(1) and 75(1) of the Coroners Act 2009 the publication of any matter (including the publication of any photograph or other pictorial representation) which identifies any of the following persons is prohibited:

1. BG

2. Any relative of BG

3. GK

Table of Contents

1. Introduction 1.1 BG, a Nepalese national who had immigrated to Australia, was previously in a casual relationship with Amelia Blake, a young lady from England who was on a backpacking trip to Australia. On 12 January 2018, both Amelia and BG were tragically found deceased in BG’s home. The police investigation into the deaths indicated that Amelia had died as a result of actions taken by BG, and that BG had subsequently taken further actions to intentionally end his own life.

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 Section 27(1)(a) of the Act provides that an inquest must be held if it appears to a coroner that a person has died, or might have died, as a result of homicide. In this case, the evidence gathered during the police investigation that took place established that BG had taken actions to cause Amelia’s death on 9 January 2018. This meant that Amelia died as a result of homicide which made an inquest into her death mandatory. Due to the relationship between Amelia and BG, and the proximity of their deaths to one another, it was considered expedient to also hold an inquest into BG’s death.

2.3 In this context it should be recognised at the outset that the operation of the Act, and the coronial process in general, represents an intrusion by the State into what is usually one of the most traumatic events in the lives of family members who have lost a loved one. At such times, it is reasonably expected that families will wish to grieve and attempt to cope with their enormous loss in private. That grieving and loss does not diminish significantly over time. Therefore, it should be acknowledged that both the coronial process and an inquest by their very nature unfortunately compels a family to re-live distressing memories several years after the trauma experienced as a result of a death, and to do so in a public forum.

2.4 It should also noted at the outset that although the evidence gathered during a coronial investigation may give rise to the appearance that a person has died as a result of homicide, such a conclusion (if one is eventually made) does not impose any criminal liability on any person. Indeed, section 81(3) of the Act precludes a coroner from making a finding that indicates, or in any way suggests, that a criminal offence has been committed by any person.

3. BG’s life 3.1 Inquests and the coronial process are as much about life as they are about death. A coronial system exists because we, as a community, recognise the fragility of human life and value enormously the preciousness of it. 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 BG’s life in a brief, but hopefully meaningful, way.

3.2 BG was born in Nepal in 1987 to his parents, SKG and BhG. BG has two siblings, including a sister who immigrated to Australia in 2009.

3.3 In 2010 BG met his wife, SG, whilst attending a rehabilitation centre in Kathmandu for treatment of a history of illicit drug dependency. After forming a relationship BG and his wife later married in 2011.

Following completion of his rehabilitation, BG opened his own rehabilitation centre to assist others dealing with issues of drug dependency. However the centre was later forced to close due to financial considerations.

3.4 On 11 October 2014 BG and his wife immigrated to Australia, arriving in Sydney, following the grant of a student visa to BG’s wife. BG himself was issued with a dependent visa that was associated with his wife’s visa. BG and his wife initially lived in Strathfield before later moving to Redfern. BG found employment as a kitchen hand with a catering company, and subsequently secured a role as a chef with the Fogo Brazilia restaurant (the restaurant) in Chippendale in March 2016.

3.5 At the conclusion of the evidence in the inquest, BG’s sister, SS-G, shared with the Court some memories of her brother. She described BG as a sensitive young man with a big heart, who often gave his time and much of himself to others. She said that she fondly remembers BG’s smile and, together with the rest of her family, deeply feels BG’s loss.

3.6 Given the distressing circumstances in which BG died, it is evident that his death has traumatically affected those closest to him, particularly those family members in Nepal from whom BG has now been permanently physically separated.

4. The relationship between Amelia and BG 4.1 It was while working at the restaurant that BG met Amelia Blake, who was also a restaurant employee at the time. Amelia was a 22-year-old young lady from England who had arrived in Sydney in April 2017 on a backpacking trip. Amelia began working at the restaurant in July 2017.

4.2 After meeting Amelia and BG developed a friendship which later progressed to a casual sexual relationship by mid to late August 2017. As this relationship continued it became apparent that BG was intent on pursuing a more serious relationship than Amelia, and wished to progress their relationship more quickly. During Amelia’s stay in regional Victoria between September and December 2017 she remained in contact with BG using WhatsApp, and arrangements were made for Amelia to live with BG in his unit at 3/85 King Street Newtown for two weeks upon her return to Sydney, before she travelled to Vietnam.

4.3 There is documentary evidence from Amelia’s diary that she was uncertain about the nature and extent of her relationship with BG. On 2 and 5 December 2017, Amelia wrote in her diary that she was considering a relationship with BG, but was unsure about the level of her commitment given her desire to also continue travelling. On 14 and 18 December 2017 Amelia wrote that the relationship between herself and BG was experiencing unspecified difficulties, which caused her to have doubts about continuing the relationship.

5. BG’s other relationships 5.1 In late 2016 BG and his wife separated, resulting in BG moving out and into his own accommodation in Marrickville. It appears that this separation was the combination of difficulties within the relationship from about June 2016. These difficulties were a product of BG’s frequent gambling and socialising with work colleagues, often into the early hours of the morning. Following their separation BG and his wife only had a limited contact with one another on the two occasions; once in early 2017 and again in April 2017.

5.2 The evidence establishes that BG was actually in a number of concurrent relationships at the time that he was seeing Amelia. It appears that around December 2016 BG formed relationships with Maria (Ines) Newman and GK, both of whom worked at the restaurant. Initially, both Ms Neumann and Ms GK believed that they were in exclusive relationships with BG from December 2016.

GK 5.3 BG’s relationship with Ms GK continued up until June 2017 when it seems to have ended. Ms GK resigned from the restaurant at about the same time as she was apparently upset by the breakdown in the relationship. However, it appears that BG and Ms GK continued to have an intermittent casual sexual relationship from June 2017 until December 2017. Around this time, Ms GK became pregnant to BG but subsequently terminated the pregnancy without initially informing BG.

5.4 On the evening of 15 December 2017, Ms GK informed BG about the terminated pregnancy when she was visiting him in Newtown. According to Ms GK this disclosure angered BG causing a verbal altercation which escalated into a physical altercation. This altercation resulted in Ms GK being allegedly pushed onto a bed and then allegedly sexually assaulted by BG. Following this incident, Ms GK left the unit. Several days after this incident BG sent Ms GK a message in which he reportedly apologised for what had occurred. Ms GK did not make any report of this incident to police at the time. It was not until police spoke to Ms GK about the deaths of BG and Amelia that Ms GK made a disclosure regarding the events of 15 December 2017.

Maria Newman 5.5 BG and Ms Newman began a casual sexual relationship in about September 2016 which became more serious in February 2017 when Ms Newman moved into BG’s unit in Newtown. The relationship continued until August 2017 when it encountered difficulties due to BG borrowing money from Ms Newman, which he claimed was for university fees. At around this time, Ms Newman was informed by some of BG’s work colleagues that they were owed money from BG which they had been experiencing difficulty in recovering.

5.6 By September 2017, Ms Newman suspected that BG was involved in another relationship and reportedly “emotionally checked out” of her relationship with BG.1 In around mid-December 2017 Ms Newman was informed by a friend that BG was dating Amelia. Ms Newman subsequently confirmed this report with other employees of the restaurant, including Ms GK. At around the same time, Ms GK discovered that BG had also been in a concurrent relationship with Ms Newman.

1 Exhibit 1, page 20 at [47].

6. BG’s finances 6.1 The evidence establishes that one of the contributing factors to the breakdown in the relationship between BG and his wife was BG’s frequent gambling activities. At the time of their separation BG was reportedly in debt to the amount of about $9,000. This evidence is consistent with the observations of BG’s sister who reported that after BG’s arrival in Australia he frequently contacted her with requests for money.

6.2 The evidence also establishes that between 4 January 2018 and 11 January 2018 BG made multiple cash withdrawals of relatively large amounts of money from automatic teller machines (ATM), usually at the Marlborough Hotel in Newtown or from a Commonwealth Bank ATM on King Street, Newtown. Up until 8 January 2018 these withdrawals were made from BG’s own account. Some of these transactions are summarised below:  A withdrawal of $1,900 on 4 January 2018;  A withdrawal of $1,000 on 7 January 2018;  A total withdrawal of $700 on 8 January 2018;  Total withdrawals of $2,500 from BG’s own account (including a further attempted withdrawal of $200), and $2,500 from Amelia’s account on 9 January 2018.

6.3 Many of the above transactions were made in the early hours of the morning and in circumstances where BG was subsequently recorded on CCTV footage in the gaming room area of the Marlborough hotel, and also at The Star Casino. Indeed, BG was well known to an employee of the Marlborough Hotel who worked in the gaming room area who noted that BG would regularly attend the hotel three to four times per week to use the poker machines. The hotel employee noted that on the evening of 8 January 2018 BG reported having spent $3,000 on the poker machines and continued to gamble in an attempt to recover his losses.

7. Events leading up to 12 January 2018 7 and 8 January 2018 7.1 On 7 January 2018 Amelia and BG had breakfast in Newtown before travelling to Obelisk Beach for the day.

7.2 In the early hours of the morning on 8 January 2018 Amelia and BG attended Royal Prince Alfred Hospital after Amelia had been experiencing pain in her right iliac fossa since 6 January 2018. Despite attempting to treat the pain with analgesia, Amelia was experiencing increased pain together with periods of nausea. Following examination, Amelia was sent home with instructions for a general practitioner to follow up any possibility of a urinary tract infection, and advised to take paracetamol and ibuprofen as required.

9 January 2018 7.3 During the afternoon of 9 January 2018 Amelia and BG went to Watsons Bay before returning to Newtown at around 8:19pm. At 8:28pm Amelia and BG went to a supermarket where CCTV footage relevantly recorded that Amelia appeared well, with no apparent facial injuries. At 8:33pm after

leaving the supermarket, Amelia and BG walked to BG’s unit via Longwood Street, Newtown. This is the last occasion that Amelia is seen on CCTV.

7.4 A resident of a neighbouring unit to BG’s saw Amelia in the kitchen/living room area using what appeared to be a computer screen at what the neighbour believed was about 8:00pm. BG was also seen walking around the unit at this time.

7.5 At about 8:40pm Amelia sent her mother a WhatsApp message in response to a comment made by Mrs Blake to a photo that Amelia had sent of herself earlier in the day whilst at Watsons Bay. At about 8:47pm Amelia sent another WhatsApp message to Ms Whitworth. The two had been discussing their upcoming trip to Vietnam since about 6:23pm earlier that evening. According to Ms Whitworth, the 8:47pm message appeared to be abruptly end the conversation between herself and Amelia, which Ms Whitworth considered to be unusual and out of character for Amelia. Amelia’s phone records subsequently showed that her phone was using data from 8:33pm but ceased at 8:48pm.

10 January 2018 7.6 At 2:23am on 10 January 2018 BG went to the Marlborough Hotel and withdrew $1,000 from Amelia’s account, followed by a second withdrawal of $1,000 from Amelia’s account. BG later left the Marlborough hotel at 3:08am and a short time later transferred $500 from Amelia’s savings account to her personal account. Following this, BG went to an ATM on King Street Newtown and withdrew $500 from Amelia’s account and $500 from his own account. BG returned to the Marlborough Hotel and remained in the gaming room until about 4:00am.

7.7 At 11:49am and 11:52am two messages were sent from Amelia’s WhatsApp account to her mother’s and Ms Whitworth’s WhatsApp accounts, respectively. The messages referred to Amelia being in pain (referring to her previous presentation to hospital) and to postponing her flight to Vietnam until 12 January 2018. Upon receiving the message Ms Whitworth formed the view that the message had not actually been sent by Amelia. This is because the message was in broken English, it contained an emoji symbol which Amelia was not known to use, and because the content of the message was inconsistent with previous conversations between Amelia and Ms Whitworth.

7.8 At 12:17pm Ms Whitworth received another message from Amelia’s WhatsApp account containing a photo of Amelia in a hospital bed. Upon receiving this message, Ms Whitworth again considered it to be unusual because Amelia had earlier that week sent her a similar photo (via Snapchat) of herself wearing the same clothes. Ms Whitworth received two further messages from Amelia’s WhatsApp account at 12:19pm and 12:46pm. Again, Ms Whitworth considered these messages to be unusual because they were in broken English, they contained expressions which Amelia was not known to use, and because they were inconsistent with the manner in which Amelia had previously conversed with Ms Whitworth.

7.9 At around the time of this last WhatsApp message to Ms Whitworth, BG contacted Ms Newman and made arrangements to meet in Dee Why later that afternoon at around 3:00pm. Amelia’s phone records indicate that data from her phone was being used in Cremorne, which is consistent with the bus route taken by BG from Newtown to Dee Why. These records also establish that data from Amelia’s phone was later used in Dee Why at around 4:35pm.

7.10 During BG’s meeting with Ms Newman she noted that BG was behaving in an unusual manner and that he repeatedly told Ms Newman how much he loved her. Ms Newman also saw that BG received a number of private phone calls following which he made reference to “stuff about his past”, and which appeared to have made him unsettled.

7.11 At about 6:00pm BG and Ms Newman returned to Ms Newman’s home during which time Ms Newman asked if BG had met with Amelia. BG replied, “Yes I hope she will be OK”.2 When Ms Newman asked why he responded in this way BG replied, “She is going through some problems”.3 Upon returning to Ms Newman’s home BG and Ms Newman had sexual intercourse, and BG again repeatedly told Ms Newman that he loved her. Following this, as BG was preparing to leave, Ms Newman enquired about his future plans. BG replied that there would not be any plans, which prompted Ms Newman to enquire whether he was voicing suicidal ideation. BG replied, “No it’s not my plan, there are some people waiting for me”.4 Following this BG began to cry, and went on to say, “There may have been some things I have done wrong…”. When Ms Newman asked him to stay with her, BG replied, “I can’t, I have to go back, I’m just sorry that it will hurt you and scared [sic] that you will be sad”.5 When Ms Newman sought to explain that he could seek assistance BG replied, “There’s no way of getting out… They’re waiting for me. If something happens to me don’t come to my funeral”.6 7.12 At 6:17 PM Amelia’s mother replied to the earlier message sent from Amelia’s WhatsApp account. In response to this, at 7:06pm, a message was sent from Amelia’s WhatsApp account to her mother. It should be noted that this message, like the earlier messages sent to Ms Whitworth, was also written in broken English and contained similar emoji symbols which Amelia was not known to use.

11 January 2018 7.13 BG later went to sleep at Ms Newman’s apartment before waking up at about 2:00am on 11 January 2018, telling Ms Newman that he had to return home. Ms Newman walked with BG to a bus stop and before he left told him to seek assistance and to respond if she contacted him via text message. BG replied, “If I’m able to read the message I will. If by Saturday you don’t hear anything call my landlord to check the apartment”.7 BG subsequently provided his landlord’s phone number to Ms Newman before boarding a bus. Travel records and CCTV footage indicate that BG caught a bus and then a taxi back to Newtown. At 5:57am BG was captured on CCTV footage walking along Longdown Street Newtown towards his home. This is the last occasion that BG is seen on CCTV.

7.14 Later on 11 January 2018 Ms Newman became concerned for BG’s welfare following their conversation and his unusual behaviour. Ms Newman attempted to contact BG without success. Ms Newman then contacted BG’s work colleagues, his landlord and BG’s family members, eventually speaking to BG’s sister.

2 Exhibit 1, page 46 at [137].

3 Exhibit 1, page 46 at [137].

4 Exhibit 1, page 46 at [140].

5 Exhibit 1, page 46 at [140].

6 Exhibit 1, page 46 at [140].

7 Exhibit 1, page 48 at [145].

8. The events of 12 January 2018 8.1 At around 5:30pm on 12 January 2018 Ms SS-G spoke to the landlord for BG’s unit, Quinton Chen. Ms SS-G told Mr Chen that she had not spoken to her brother in four weeks and was concerned for his welfare. Following this conversation Mr Chen agreed to attend the unit to check on BG.

8.2 Shortly after 5:30pm Mr Chen attended BG’s unit noting that the front door was closed and locked.

Mr Chen knocked on the door several times and called out BG’s name. After receiving no response, Mr Chen entered the unit and found BG lying face up on the ground with no signs of life, and with his hands tied together with plastic cable ties. Mr Chen immediately contacted emergency services.

8.3 Initial attending police arrived on the scene at about 6:00pm. BG was found lying on his back, dressed in a t-shirt, boxer shorts, and socks, with his hands bound together at the wrists with plastic cable ties. It was also noted that BG’s ankles were tied together and that there were a number of cable ties around his neck. A number of cable ties which had been fastened end-to-end were also noted to be hanging from the cross beam of a door frame.

8.4 Inside a bedroom police found Amelia lying on the floor under a blanket, dressed in her underwear and a black singlet, with no signs of life. Attending paramedics subsequently pronounced both Amelia and BG to be life extinct.

8.5 From the subsequent police examination of the scene an amount of blood was found within the kitchen area, together with a bloodstained tissue that had been wrapped in bubble wrap and left in the kitchen garbage bin. Subsequent forensic testing identified the blood stains as belonging to Amelia.

9. What was the cause of BG’s death?

9.1 BG was later taken to the Department of Forensic Medicine in Sydney. On 17 January 2018 Dr Sarita Maistry, forensic pathologist, performed a postmortem examination. The autopsy revealed imprint abrasions with bruising corresponding to the dimension and pattern of the cable ties around BG’s neck. Bilateral conjunctival petechial haemorrhages and minor abrasions to the right elbow and both knees were also identified. There was no other external evidence of trauma. Dr Maistry ultimately opined that BG’s death occurred from the compression due to ligature strangulation (from the multiple cable ties) and possible suspension at some point (hanging).

9.2 Having regard to the autopsy findings and the opinion expressed by Dr Maistry the cause of BG’s death was neck compression.

10. When did BG die?

10.1 The available evidence indicates that the last time BG was captured on CCTV footage was at about 6:04am on 11 January 2018, after BG returned home after visiting Ms Newman. Further evidence establishes that between 7:57am and 8:03am on 11 January 2018 Amelia’s phone was used to access cloud data. Having regard to the circumstances described above, it is most likely that by this time Amelia was already deceased, having died on the evening of 9 January 2018 as a result of actions taken by BG. This conclusion is supported by:

(a) an absence of any data activity on Amelia’s phone after 8:48pm on 9 January 2018;

(b) the unusual text messages sent from Amelia’s WhatsApp account to her mother and Ms Whitworth on 10 January 2018, which appear to have actually been sent by BG who was using Amelia’s phone at the time; and

(c) mobile phone records which indicate that Amelia’s phone was in the vicinity of the Northern Beaches area on 10 January 2018 consistent with BG visiting Ms Newman at the time, and therefore his possession and use of Amelia’s phone at the time.

10.2 Ms Newman attempted without success to contact BG a number of times on 11 January 2018 after he left her home. Whilst it is evident that BG eventually returned home after being captured on CCTV footage at 6:04am, the precise events between this time and when BG and Amelia were later discovered at about 5:30pm on 12 January 2018 is unclear. It should be noted that mobile phone records establish that there was data activity on BG’s mobile phone at 9:39am on 12 January 2018 for a period of almost five minutes. However, it is not evident whether this activity was a result of BG’s use of the phone, or a result of automated data download.

10.3 Having regard to the above, the available evidence establishes that BG died on either 11 or 12 January 2018.

11. What was the manner of BG’s death?

11.1 The police investigation did not identify any physical or forensic evidence to suggest that any person, other than Amelia, had accessed BG’s unit at around the time of his death. There were no signs of forced entry to the unit and also no evidence to suggest that any third party was involved in BG’s death. This is supported by forensic evidence which identified only BG’s fingerprints on the cable ties and their packaging.

11.2 Given the gravity of a finding that a person has intentionally inflicted their own death it is wellestablished that such a finding cannot be assumed, but must be proved on the available evidence.

There is clear evidence that a number of stressors associated with different aspects of his life were operating on BG in the period leading up to 9 January 2018. In particular:

(a) BG was experiencing considerable financial difficulties. His rent was in arrears and he owed significant amounts of money to a number of family members, friends, work colleagues, and financial organisations. Indeed, it appears that BG had accumulated debts totalling about $43,950 by 9 January 2018. Following the discovery of BG’s body, police located a handwritten note itemising names and amounts of money which appeared to be a list of BG’s creditors.

(b) BG’s financial difficulties led to increased gambling behaviour. He was a frequent patron of the gambling room at the Marlborough Hotel, and was also known to frequent other establishments for the purposes of gambling, often into the early hours of the morning. The evidence establishes that between 4 and 10 January 2018 BG gambled almost $11,000 on poker machines.

(c) BG was encountering difficulties in his various relationships. Amelia had previously expressed uncertainty about the seriousness of her relationship with BG. Further, probably by September

2017 and certainly by at least December 2017, both Ms Newman and Ms GK had discovered BG’s infidelity. In addition Ms GK’s termination of her pregnancy had angered and upset BG leading to the alleged incident involving Ms GK on 15 December 2017. Of course, throughout these relationships BG remained married to his wife and although there had been limited contact between them following their separation, it appears that this was at times weighing heavily on his mind. On 12 December 2017 BG contacted his wife via Facebook Messenger to apologise for “everything”, and expressed a desire to right past grievances.8

(d) BG was likely concerned about his visa status. He may have considered that his financial difficulties, the deterioration of his various relationships, and the incident involving Ms King on 15 December 2017 would place his visa, and ability to remain in Australia, in jeopardy.

11.3 In addition to the above, BG’s conversations with Ms Newman on the evening of 10 January 2018, and again in the early hours of the morning on 11 January 2018, are consistent with expressions of suicidal ideation (despite BG’s denials to Ms Newman). Having regard to the evidence which establishes that Amelia died on 9 January 2018 as a result of actions taken by BG, his subsequent conversations with Ms Newman are consistent with expressions of culpability. Understood in this context, it is evident that BG’s responsibility for Amelia’s death was also an operating factor on his actions after he returned home on 11 January 2018. The location of the cable ties on BG’s wrists and on the cross beam of the doorframe, the circumstances in which both Amelia and BG were found, and the autopsy findings suggestive of the compression due to ligature strangulation and/or hanging are all consistent with an intentional act of self-harm.

11.4 Having regard to all of the above, the conclusion that must be reached is that there is sufficiently clear and cogent evidence to establish that BG died as a result of actions taken by him with an intention to end his life.

12. Acknowledgments 12.1 Before turning to the findings that I am required to make, I would like to acknowledge, and express my gratitude to Durand Welsh, Coronial Advocate, for his considerable assistance during both the preparation for inquest, and during the inquest itself. I also thank and commend Detective Senior Constable Adam Packer and his team of investigators for conducting a thorough investigation and for compiling a comprehensive brief of evidence.

13. Findings pursuant to section 81 of the Coroners Act 2009 13.1 The findings I make under section 81(1) of the Act are: Identity The person who died was BG.

Date of death BG died on 11 or 12 January 2018.

8 Exhibit 1, page 59 at [201].

Place of death BG died at Newtown NSW 2042.

Cause of death The cause of BG’s death was neck compression.

Manner of death BG died as a result of actions taken by him with an intention to end his life. BG’s death was therefore intentionally self-inflicted.

14. Epilogue 14.1 It is evident that BG was troubled by many aspects of his life in the days and weeks leading up to his death. Tragically, this resulted in BG taking action not only to intentionally end his own life, but also to end Amelia’s life.

14.2 On behalf of the Coroner’s Court of NSW, I offer my deepest heartfelt sympathies and most respectful condolences to BG’s parents and siblings, and the rest of his family for their enormous loss.

14.3 I close this inquest.

Magistrate Derek Lee Deputy State Coroner 5 June 2020 Coroner’s Court of NSW