Inquest into the death of Dennis Ellis

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Mr Dennis Ivan Clifford Ellis Hearing dates: 12 and 13 October 2022 Date of findings: 13 October 2022 Place of findings: Coroners Court of New South Wales - Lidcombe Findings of: Magistrate Erin Kennedy, Deputy State Coroner Catchwords: CORONIAL LAW – police operations, motor vehicle accident, question of pursuit – vehicle stop File number: 2020/94710 Representation: Counsel Assisting the Coroner: Mr Jake Harris instructed by Mr Gareth Martin, Crown Solicitor’s Office NSW Commissioner of Police: Ms Danielle New instructed by Ms Rebecca Atherton, Office of the General Counsel NSW Police Force Non publication order: Orders made pursuant to s. 74 of the Coroners Act 2009 on 12 October 2022 over certain information in the NSW Police Force Safe Driving Policy and particular portions of the brief wherein that information appears. A copy of those orders can be obtained on request to the registry.

Findings: I make the following findings pursuant to section 81 of the Coroners Act 2009 (NSW): Identity of the deceased: The person who died is Dennis Ivan Clifford Ellis.

Date of Death: On 22 March 2020.

Place of Death: Intersection of Laidlaw Street and Reddall Street, Yass NSW.

Cause of Death: Multiple Blunt Force Injuries.

Manner of Death: Single motor vehicle collision.

Introduction

1. This inquest concerns the death of Dennis Ellis, who died on 22 March 2020 at Yass, at 34 years of age from catastrophic injuries that he sustained when the vehicle he was driving collided with a tree. Just prior to the collision, he had come to the attention of police due to the manner of his driving when he swerved onto the wrong side of the road into the path of a police vehicle. He then drove off at speed and police followed him.

About a minute later, Dennis’s vehicle failed to negotiate a left-hand bend, left the road and collided with a tree at high speed. He died as a result of multiple blunt force injuries.

The nature of an inquest

2. An inquest is required to be held into Dennis’s death, because it appears it was a result of police operations (ss. 23(1)(c) and 27(1)(b) of the Coroners Act 2009).

3. The primary function of an inquest is to identify the circumstances of death. Section 81 of the Coroners Act 2009 requires the coroner holding an inquest to record in writing the fact that a person has died and also record: a. the person's identity; b. the date and place of the person's death; and c. the manner and cause of death.

4. Another purpose of an inquest is found in section 82 of the Act, to consider whether it is necessary or desirable to make recommendations in relation to any matter connected with the death. This involves identifying any lessons that can be learned from the death, and whether anything should or could be done differently in the future, in particular to prevent a death in similar circumstances.

5. This inquest was assisted by the preparation of an extensive brief of evidence together with the giving of oral evidence by several witnesses: a. Officer in charge, Detective Chief Inspector Grey, b. Acting Sergeant Arnold, the offsider in police wagon YASS21, c. Constable Murdoch, the driver of YASS21, d. Sergeant Carroll, the driver of a highway patrol car, and e. Sergeant Peck, Traffic and Highway Patrol Command and member of the Safe Driver – Incident Review Panel, who gave opinion evidence on the actions of the police officers that night

Reflections on the life of Dennis Ellis

6. Dennis was born in Liverpool, NSW and was 34 when he died. He is survived by his parents, Helen and Mark and was their only child. At the time of his death, he was living in the garage of his parents’ property at Murrumbateman, about 20km south of Yass.

7. Dennis’s early life appears to have been generally happy when with his family. His parents say he was a “pretty good child” and a “normal little boy.” He was, however, bullied at school for being overweight and he struggled with schoolwork.

8. The family had an interest in pony trotting, and Dennis developed a passion for it, initially trotting Shetland ponies. He trained at Goulburn TAFE to become a trotting driver. He later worked as a baker and then took up a job in his father’s filter exchange business.

9. Dennis married when he was 20. Dennis and his wife separated after 2 years, and he returned to live in a garage on his parent’s property. During this time, Dennis told his parents he was gay. They were aware of Dennis having a few long-term relationships over the years.

10. Dennis had a lifelong problem with alcohol. His parents report he drank alcohol every day, mainly drinking wine and soda.

11. Dennis’s physical health was relatively good. He was HIV positive, for which he was prescribed medication (Eviplera and Odefsey).

12. He suffered poor mental health, with symptoms of depression and low mood. There are some reports of Dennis engaging in self-harm by taking an overdose of pills in March and June 2016. Records show Dennis was taking an antidepressant, Cymbalta (duloxetine) from at least 2018 until the time of his death.

13. When drinking, Dennis would sometimes become aggressive and violent. Some of Dennis’s previous partners reported that he was violent towards them, and at least one AVO had been taken out against him. Dennis faced charges of assault occasioning actual bodily harm and damage property relating to alleged conduct against one of his former partners in May 2019. Those charges were listed before the Magistrates Court in the ACT on 8 April 2020, two weeks after Dennis’s death.

14. On 10 July 2019, Dennis attended his GP, Dr Bajpe, with depressive symptoms and suicidal ideation, in the context of his recent court matters. He was referred to the Yass Community Mental Health Centre. On 6 August 2019, he was reviewed by psychiatrist Dr Oyekan. It was proposed that he could have a voluntary admission to change his antidepressant medication, but Dennis decided he did not want to proceed with this.

Dennis was referred for a second opinion but did not attend the appointment. He was discharged from the service on 25 September 2019. He attended his GP on 3 October 2019, for another prescription for Cymbalta.

15. In October 2019, Dennis met Ivan and began a relationship, which continued until the time of Dennis’s death. They did not live together but Ivan stayed in the garage with Dennis sometimes at weekends. Ivan lived in Queanbeyan and reported a good relationship with Dennis. He did not report any violent tendencies from Dennis, he was unaware that Dennis was taking antidepressants and he did not know about his pending criminal charges.

16. Dennis met another man, “J”, with whom he occasionally had meetings of an intimate nature. They were intending to meet at a hotel on the night of Dennis’s death. There were some text messages between them on the evening of his death.

17. Overall, his parents described Dennis as a son who was good and productive when he wasn’t intoxicated. They expressed great concern over the level of his drinking and overall management of his mental health, with several suicide attempts.

Events of 22 March 2020

18. During the day on 22 March 2020, Ivan helped Dennis deliver a bed frame, which he had sold on Facebook Marketplace. They drove to the ACT and then to Ivan’s apartment. Dennis appeared to be in good spirits. They returned to Murrumbateman, where Ivan left Dennis at about 4pm.

19. There had been an announcement that day about financial benefits available to people during the COVID pandemic. The family’s business had suffered a significant downturn, and Dennis’s father decided he was going to dismiss Dennis from work, which would allow Dennis to access those benefits and assist the business.

20. During the evening, Dennis had dinner with his parents. The COVID situation was discussed, and the decision to dismiss Dennis. According to his parents, Dennis appeared well. He was drinking from a plastic mug, presumably containing wine, but was not obviously drunk. His mother reported that he had two glasses of wine at dinner.

At around 10pm, Dennis left his parents’ home and went to his property in the garage.

21. Dennis called Ivan a couple of times that evening. At about 9.30pm, Dennis told Ivan that his parents had dismissed him from work. He said he was going to go to Centrelink the following day. Ivan reported that he appeared stressed and sounded like he had been drinking to excess.

22. At 10.38pm, Dennis called his uncle, David. Dennis sounded “chirpy” during the call and said he was “just checking in”.

23. From about 10.51pm, Dennis exchanged several messages with his friend “J”. After about twenty minutes he sent “J” a message saying, “on way”. A couple of minutes later, at 11.13pm, Dennis sent Ivan a text, “Night night long (sic) you.”

24. At some stage around that time Dennis left his parents’ property in his Hyundai. They did not hear the car leave, and they were unaware he had gone until they were contacted by police the next morning.

25. Dennis drove to McDonalds, Yass Valley Way, at the north of Yass near the Hume Highway. He arrived at McDonalds at 11.26pm and ordered food at the drive-thru.

A witness, Melissa Blundell, also went through the drive-thru at McDonalds. She recalls the high beams of the car behind her being flashed repeatedly.

26. Police officers Constable Allan Murdoch and Acting Sergeant Michael Arnold were also at McDonalds. They were on duty in a marked Holden Colorado caged vehicle (marked YASS 21). They met up with Sergeant Matthew Carroll and Senior Constable Daniel Condron, the other unit on duty, who were in a Highway Patrol car (marked STH 255).

They had a coffee. None of the officers saw Dennis at McDonalds.

27. When Ms Blundell left McDonalds, she was followed by a car into Yass. The car again flashed its lights at her and was driving erratically, approaching her quickly, then backing off. At Pollux Street, at the north of Yass, she turned left, and the car swerved around her onto the wrong side of the road, and then sped off. I accept on the balance of probabilities having regard to all the evidence that the car was driven by Dennis.

28. After getting coffee, Constable Murdoch and Acting Sergeant Arnold also drove back south into Yass, heading along Laidlaw Street and over the bridge. Sergeant Carroll and Senior Constable Condron were travelling some distance behind.

29. At about 11.35pm, “J” sent Dennis a text, saying, “Ill (sic) be ready in 10”. There was then a call between them of about 3 and a half minutes. It is not known what they discussed.

The encounter with police

30. The events leading to the collision all occurred on the stretch of road known as Yass Valley Way, which runs about 2km through the centre of Yass in an approximately northsouth direction. The southern aspect of Yass Valley Way becomes Comur Street as it enters the Yass Township, then Laidlaw Street as it crosses the Yass River, and leaves

Yass to the north as Yass Valley Way. The road has a posted speed limit of 50kmph as it travels through the Yass Township, increasing to 70kmph at Orion Street at the northern end of town. At the northern end there is a left-hand bend as the road leaves Yass.

31. At about 11.45pm, police vehicle YASS 21, driven by Constable Murdoch with Acting Sergeant Arnold in the passenger seat, had crossed the bridge at Yass, heading south.

As it approached a roundabout at Comur Street and Rossi Street, Constable Murdoch observed Dennis’s red Hyundai crossing the roundabout. He believed the car was driving at speed. The car crossed the solid white line onto the wrong side of the road and into the path of the police car. Constable Murdoch had to veer to the left to avoid a collision. Neither officer could see the driver, although Acting Sergeant Arnold was able to get the registration number.

32. Dennis’s car continued north, passing the highway car STH 255 driven by Sergeant Carroll, which was heading south. Constable Murdoch performed a U-turn at the base of the bridge and activated YASS 21’s primary lights.

33. Acting Sergeant Arnold contacted police radio and asked for checks on the vehicle. He also asked the highway vehicle to follow them, telling radio, “this might be a pursuit”.

The highway car acknowledged that request.

34. Sergeant Carroll performed a U-turn and followed YASS 21. He then activated his own warning lights, which commenced the In-Car Video recording (ICV), with some footage being back-captured. He accelerated to catch up with YASS 21.

35. Twenty seconds after the last radio broadcast, Acting Sergeant Arnold made the following broadcast: YASS 21: Yass 21 for your info, that car came at us. Um we thought they was on their phone or something on the wrong side of the road.

Now they’re driving on the right side of the road down Laidlaw Street towards the Yass Service Centre.

36. Constable Murdoch continued north and approached a right-hand sweeping bend. At that point, past the takeaway shop, Constable Murdoch could see some taillights in the distance, for a split second or two, before losing sight of them as the turned the bend.

Acting Sergeant Arnold turned off YASS 21’s primary lights.

37. Constable Murdoch continued driving north along Laidlaw Street. They were looking at the side streets, trying to locate Dennis. Constable Murdoch was slowing down at the junctions.

Dennis’s car collides with a tree

38. A witness, Mitch Ballard, was at the Yass Valley Bakery in Irvin Square. He coincidently knew Dennis and had spoken to him about 2 months prior. Mr Ballard heard a car speeding and saw a vehicle “fly” past. He estimated the speed to be 150 to 200kmph.

He then heard a screech of tyres and a loud bang and went to help. He then saw the police cars. Mr Ballard recalled that both police cars had their warning lights illuminated.

39. YASS 21 arrived at the scene of the accident after it had occurred. Acting Sergeant Arnold informed police radio that there had been a collision and asked for an ambulance and fire service. That broadcast commenced 68 seconds after the first broadcast relating to Dennis’s vehicle.

40. Sergeant Carroll arrived, and police approached Dennis’s vehicle, which was emitting smoke. It had apparently collided heavily with a tree located on the outside (right-hand side) of the bend. It was very badly damaged, to the extent that officers could not get access inside the cabin to render help. Dennis, in any event, appeared deceased.

Senior Constable Condron felt for a pulse but could not find one.

41. Paramedics subsequently arrived and confirmed that Dennis had died.

Investigation Autopsy and toxicology

42. A limited autopsy, by way of external examination, CT scan and toxicology, was conducted on 1 April 2020 by Dr Rebecca Irvine. Dr Irvine found the cause of death to be multiple blunt force injuries. These included a severe cranio-cervical injury which severed the spinal cord. It is likely death would have been immediate.

43. Toxicology showed a blood alcohol content of 0.173g/100mL (and a higher reading in vitreous humour) and a nontoxic level of duloxetine.

Pharmacology opinion of blood alcohol levels

44. Dr Judith Perl has provided an expert report. She states that the femoral blood sample is a good indicator of the blood alcohol content at the time of death. A reading of 0.173g/100mL would be expected to have caused “very significant” or “substantial” impairment of driving ability. Cognitive, motor and visual functions, reactions skills,

tracking ability, perception, judgment and decision making, visual scanning and peripheral vision would all be “very significantly” impaired.

45. Dr Perl refers to statistics, which show that blood alcohol content (BAC) readings above 0.150g/100mL increase the risk of crash involvement by 22.1 times. The effects of duloxetine, the antidepressant, are less likely to have contributed to impairment, because Dennis had been taking that drug for over 12 months.

Road side CCTV footage

46. CCTV footage was obtained from various sources and played in the inquest. There is footage from sites along the route of the incident, including the crash itself. The ICV from STH 255, which shows only YASS 21 and not Dennis’s car, was also played in the inquest.

The outcome of the crash scene investigation

47. Senior Constable Chris Warren performed a crash scene investigation. He reports that the bitumen road surface was in good condition, with minor rutting. He observed a tyre mark on the road, commencing 20m south of the centre of Reddall Street at the right-hand side of the left lane. The tyre mark crossed the double white line and went across the road in an anticlockwise arc.

48. There were also tyre marks in the kerb, consistent with having been struck by front and rear tyres. Beyond that, there was extensive damage to a tree. The distance from the commencement of the tyre mark to the area of impact was 80m.

49. Senior Constable Warren’s opinion is that the vehicle “failed to negotiate the bend”, struck the tree, rotated 45 degrees and rebounded back onto the southbound shoulder, facing approximately north.

50. The Hyundai was also examined, and no mechanical defects were identified. The seatbelt was engaged and the airbags were deployed. The tyre tread was adequate.

Of note, there was no visible damage on YASS 21.

What speed was Dennis travelling at the time of impact?

51. Sergeant Derick Fenton performed analysis on CCTV footage to calculate the average speed of the vehicles. Using CCTV footage taken from Yass Earth Movers on Laidlaw Street, he calculated that Dennis was travelling at 141kmph, YASS 21 , at 110kmph and STH 255 at 141kmph, in a 50kmph zone. The ICV records that STH 225 was travelling at 158kmph at one stage.

52. The Hyundai was about 475m ahead of YASS 21 (12.15 seconds). In the footage depicting the collision, the Hyundai’s speed was estimated to be not less than 100.1 kmph (in a 70kmph zone).

Conduct of police on 22 March 2020

53. Sergeant Deborah Peck, of the NSW Police Force Traffic and Highway Patrol Command, has reviewed the incident to consider whether there were any breaches of the NSW Police Force Safe Driving Policy (SDP).

54. Relevantly, the SDP provides the following in relation to traffic stops: a. It is permissible for police to perform a traffic stop or to reduce the distance to an offending vehicle without informing police radio, VKG (SDP 6-1).

b. If operationally or tactically necessary, closing the distance to an offending vehicle may be done without activating warning lights or a siren, provided it is reasonable not to use those warning devices and police take reasonable care

(SDP 6-2).

c. There is a list of criteria to consider when conducting a traffic stop (SDP 6-4).

d. A direction to stop while utilising a police vehicle must be done by activating both warning lights and siren (SDP 6-5).

55. The SDP also defines a pursuit in the following way (SDP 7-1): It is an attempt by a police officer in a motor vehicle to stop and apprehend the occupant(s) of a moving vehicle, regardless of speed or distance, when the driver of the other vehicle is attempting to avoid apprehension or appears to be ignoring police attempts to stop them. A pursuit commences at the time you decide to pursue a vehicle that has ignored a direction to stop.

56. There are guidelines which apply to the commencement and termination of pursuits, and where a pursuit is in progress there are obligations on the driver to communicate certain information to police radio.

57. In Sergeant Peck’s view, Constable Murdoch did not give a formal direction to the Hyundai to stop, and a pursuit was never commenced, according to the terms of the SDP. She also believes that the speed of each of the police vehicles was appropriate in the circumstances.

Analysis of the evidence Actions of the police officers

58. I accept that, on 22 March 2020, Acting Sergeant Arnold and Constable Murdoch met with Sergeant Carroll at McDonalds. They were toward the end of their shift and travelling in marked police vehicle YASS 21 from McDonalds to the police station.

Sergeant Carroll was following them back to the station in a highway patrol vehicle.

Sergeant Carroll admitted being somewhat preoccupied with the coffees that they had just bought. He was a short distance from YASS 21. The first that any officer knew of Dennis was when Constable Murdoch saw him travelling “quick” through the roundabout. It seems Dennis then swerved onto the wrong side of the road directly into the path of the marked police vehicle being driven by Constable Murdoch. The police sign on the roof of the vehicle was illuminated and easily identifiable as a police vehicle.

Constable Murdoch had a clear recollection of illuminating the police sign, given he had no need to be discrete as they returned to the station.

59. Constable Murdoch swerved to the left to avoid a collision, and Dennis was able to straighten up and continue. Dennis then passed the second marked patrol car driven by Sergeant Carroll. Sergeant Carroll was a very experienced highway patrol officer who recalled seeing the car, but nothing about the car drew his particular attention.

I accept at the time Dennis passed him that there was nothing about his driving at that point that was of obvious concern.

60. Constable Murdoch quickly moved to an area where he could make a U turn to follow Dennis, given the very concerning manner of driving he had witnessed. Constable Murdoch gave an account that he was wanting to pull over the vehicle, for the purposes of a stop and potentially a breath test. He said he had little or no communication with Acting Sergeant Arnold. He said that he turned the primary warning lights on and started to gain speed to follow Dennis. He did not make a determination to enter a pursuit; his only intention was to perform a traffic stop. In fact, his evidence was that he would not enter into a pursuit with Dennis.

61. Acting Sergeant Arnold watched as the car driven by Dennis quickly disappeared from sight. He deactivated the lights and called for assistance. The radio transmission was consistent with his account in evidence, that Dennis had moved toward their police car, he was concerned a pursuit might be needed and he, very appropriately, called to have the highway patrol car at hand. This is further evidence that YASS 21 was never going to actively enter into a police pursuit. Sergeant Peck gave evidence that this was very

appropriate and proper action taken by Acting Sergeant Arnold. He was using the excellent resource that he had available. It was her view that a stop was appropriate and necessary in these circumstances, and that activation of the primary lights was also appropriate. She also gave evidence that in some cases, such as here, it can be useful to deactivate lights in a situation where the vehicle is no longer in sight, to ensure that other’s driving behaviour does not become more dangerous if they understand that they are being followed.

62. Constable Murdoch was able to achieve several glimpses of the car in the distance, although he also said that he was concerned to look down side streets in case Dennis had turned off. I accept that he was looking for the car ahead, and was mindful that he needed to check side streets, and as a result did decelerate while undertaking this process.

63. It was evident from the ICV that the road was undulating, and that at times the line of sight between the highway patrol car and YASS 21 was lost.

64. I pause there to highlight that the officers had just witnessed a car driving erratically, onto the wrong side of the road, in a manner that potentially could have caused a serious accident. They were of the view that he was on the phone, or over the legal alcohol limit. I find that it was appropriate for them to attempt to stop Dennis in those circumstances.

65. Sergeant Carroll, a very experienced officer in Highway Patrol, drove his car at a speed that, at times, exceeded 150 km/hr to attempt to catch up to YASS 21 and Dennis. He assessed the surrounding conditions as safe to travel at those speeds before he proceeded. He firstly activated lights, and then, as his speed increased, the siren.

66. The officers were all acting in concert in the interests of protecting the community at that point. No officer had determined that a pursuit was initiated, and as such I accept that no pursuit was actively on foot. They were merely trying to affect a traffic stop at that time. They were not sure that Dennis was aware of their presence nor even that they were following him.

67. I cannot be satisfied that Dennis knew that the officers were following him.

68. The police did reach high speeds, but at that point they were only able to glimpse the car being driven by Dennis. His manner of driving was dangerous at those high speeds, particularly given his level of intoxication, but the police were not able to close the distance to indicate to him that they intended for him to stop. On the evidence of

Sergeant Peck, I am satisfied that the speeds at which Constable Murdoch and Sergeatn Carroll travelled were appropriate in the circumstances.

Actions of Dennis

69. On balance, I am satisfied that Dennis was well over the legal BAC limit. He was upset that he was losing his job and had to make other arrangements. He had driven aggressively earlier, flashing his lights and very close to the rear of Ms Blundell’s car, only to speed off following. This evidence is consistent with the fact that he was known to be aggressive and impulsive sometimes when drinking to excess.

70. I accept that when he came to the roundabout, he was travelling faster than the area permits on the evidence of Constable Murdoch. I accept that his vehicle crossed to the wrong side of the road after passing through the roundabout and travelled directly into the path of marked police vehicle YASS 21, and that Constable Murdoch took evasive action and was able to avoid an accident.

71. Circumstantially, I am able to draw the inference that Dennis did see the police cars;not one, but two marked vehicles. He drove directly into the path of one, and then passed a second, a highway patrol car. He then sped up considerably. The manner and speed at which he drove support the view that he was in a sudden abrupt hurry to move away from the police cars, one of which he had just come to attention for his dangerous manner of driving. He was intoxicated, facing criminal charges in just two weeks’ time, and was outside his home in circumstances that might not have been permitted under the public health orders relating to COVID that applied at that time.

72. In my view, the facts are overwhelming that upon driving into the path of police he decided to avoid interaction by removing himself at speed from the situation. That is not to say he was avoiding a stop, no stop had even yet been determined or indicated, but it is an obvious explanation as to why he suddenly and dramatically accelerated in the manner that he did.

73. I am not satisfied on the evidence that Dennis intended harm to himself on that night.

He had made previous attempts of self-harm, and he had been given news by his father that he would be no longer employed given the COVID situation of his father’s business.

He did express concern about that on the phone to Ivan, however he was not to be left destitute, in fact it was to allow him to access the Government funding.

74. Detective Chief Inspector Grey gave evidence that the marking on the roads were indicative of Dennis trying to take the turn, in that he appeared to try to negotiate the

corner. Detective Chief Inspector Grey also considered there were more obvious trees that might have been used to cause self-harm than the tree with which Dennis’s vehicle collided. He also drove in an arc, not directly at the tree.

75. Dennis was travelling to meet a friend. He had indicated that intention and stopped at McDonalds on the way. He had been driving unnecessarily aggressively prior to coming to police notice, which may also assist in understanding why he reacted to the police as he did.

76. It seems no coincidence that he accelerated considerably after he saw not one but two police cars. I am satisfied that he changed his driving to avoid police. He had many reasons to seek to avoid police, he had just driven towards a police car on the wrong side of the road, he was out in COVID without a proper excuse, he was highly intoxicated and was facing other charges in only 2 weeks’ time.

77. Once he continued on however, I cannot be satisfied that he was even aware of where the police were. On the police evidence they had limited vision or sighting of him once they commenced to follow Dennis. The officers in YASS 21 were not even aware of where the highway patrol car was, and it had lights and then lights and sirens on. That evidence is consistent with the description of this stretch of road which was undulating with various bends, and it was clear that the visibility of each car was limited.

78. I am satisfied on the evidence that Dennis lost control of his vehicle, in a state of considerable intoxication while travelling at speed and hit a tree as a result.

79. There was no causal link between the operation or actions of police and his death. The police at all times acted in accordance with policy and protocol. Dennis lived with combined mental health issues, had great difficulties with alcohol and difficulty in regulating his own behaviour when intoxicated. Tragically, the combination of these factors lead to the collision and his death.

Recommendations

80. As a result of the above findings, I do not consider it necessary or desirable to make any recommendations in this Inquest.

Acknowledgements

81. The Coronial Inquest process commences with the gathering of evidence. Detective Chief Inspector Grey prepared a comprehensive brief after a very thorough investigation.

His diligent work enabled the Inquest to focus on the main issues in question. I thank him for the time and care he has given this matter.

82. The process was also facilitated by the cooperation and engagement of the officers, Constable Murdoch, Acting Sergeant Arnold and Sergeant Carroll, all who showed concern and dismay at the loss of a life that night.

83. I also thank Ms New and Ms Atherton for the considerable preparation and cooperative approach in this process.

84. Finally, to Mr Harris and Mr Martin as the assisting team. The time, care and detailed attention provided assisted me to undertake a careful analysis of the facts of this matter and ensured that the matter could proceed in a respectful yet thorough manner.

Findings required by section 81(1) As a result of considering all of the documentary evidence and the oral evidence heard at the Inquest, I am able to confirm that the death occurred and make the following findings under section 81 of the Act in relation to it: Identity of the deceased: The person who died is Dennis Ivan Clifford Ellis.

Date of Death: On or after 22 March 2020.

Place of Death: Intersection of Laidlaw Street and Reddall Street, Yass NSW.

Cause of Death: Multiple Blunt Force Injuries Manner of Death: Single motor vehicle collision.

Final Remarks To the family and friends of Dennis Ellis, I offer my sincere and respectful condolences for this tragic and difficult loss.

I close this inquest.

Magistrate E Kennedy Deputy State Coroner 13 October 2022