Inquest into the disappearance and suspected death of Kenneth Klees

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the disappearance and suspected death of Kenneth Klees Hearing dates: 2 August 2022 Date of findings: 2 August 2022 Place of findings: Coroner’s Court of New South Wales Findings of: Magistrate Carolyn Huntsman, Deputy State Coroner Catchwords: CORONIAL LAW – human remains, Mollymook beach, missing person, cause and manner of death File number: 2021/0056941 Representation: Solicitor Assisting the Coroner, Senior Constable Kai Jiang, Findings: I make the following findings pursuant to s81 of the Coroners Act 2009 NSW: Identity – Mr Kenneth KLEES Time of Death – Between 1 and 26 February 2021 Place of Death – Kiama area, NSW Cause of Death – Unascertained.

Manner of Death – Unable to be determined, open finding Recommendations Nil Non-publication orders: Nil

JUDGMENT Introduction 1 These reasons for decision are provided for the findings made at an Inquest into the death of Mr Kenneth Klees. He was reported missing on 9 February 2021, after not having been seen or heard from since he left his home on 1 February 2021. Unfortunately, he was confirmed deceased when part of his remains were located at Mollymook beach on 26 February 2021. At the time he went missing Mr Klees had just turned 37 years of age. He is survived by family members who cared for him greatly.

2 I would like to begin these reasons for decision by expressing my deep condolences to the family and friends of Kenneth for their loss. Kenneth’s family members include his parents, Mrs Janet Klees and Mr Richard Klees, and his siblings, Catherine, Stephen and Peter, and Peter’s wife Eleanor and their children.

3 It is important to acknowledge that sudden and tragic deaths continue to be felt by family members for several years, with considerable impact on the lives of the deceased’s loved ones.

The Coroner’s role 4 Under the Coroners Act 2009 (the Act), a Coroner has the responsibility to investigate all reportable deaths. Reportable deaths are defined under Section 6 of the Act and include deaths which have not occurred naturally, such as in the present case.

5 The coronial investigation is conducted primarily to make formal findings as to the following five aspects of the reportable death, pursuant to s81 of the Act: (1) the identity of the person who died; (2) the date and (3) place they died, and what was the (4) cause and the (5) manner of that person’s death. The inquest

investigates the facts and circumstances of a death and in certain cases will examine changes that could be made to prevent similar deaths in the future.

6 It is important to recognise that the coronial process 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. Even the with the passage of time, it is expected that families will wish to grieve and attempt to cope with their enormous loss in private. An unfortunate aspect of the coronial process and inquest is that it can require a family to re-live distressing memories, and to do so in public. I again express my condolences to Kenneth’s family for their loss.

Evidence at the inquest 7 The coronial investigation precedes the inquest. During the investigation considerable evidence, in the form of witness statements, expert opinions/reports, photographic evidence, medical records are obtained by, and provided to, the Coroner, in the form of a brief of evidence. A report as to the cause of death is provided by the forensic pathologist (autopsy report). In the case of the investigation into the death of Kenneth, extensive evidence was obtained and contained within the brief. The evidence included statements from family members, witness statements by investigating police, CCTV footage and still images taken from CCTV footage, bank records, expert witness statements (including an expert certificate by forensic biologist as to DNA results), and statements from witnesses at Mollymook beach.

8 The evidence in the brief of evidence was very clear and did not require questioning of witnesses. For this reason, the officer in charge of the police investigation, Senior Constable Kristy Hogg, was the only witness required to give oral evidence at the inquest. Her statement summarised the evidence in the brief, and she also provided her opinion, after consideration of all the evidence, as to what may have happened to Kenneth, this will be further detailed below.

About Kenneth 9 Whilst the inquest inquired into the circumstances of the Kenneth’s death, while alive he was connected with family, friends and work colleagues. Kenneth was born on 31 January 1984, to mother, Mrs Janet Klees and father, Mr Richard Klees. Kenneth has three siblings, one younger sister, Catherine, one younger brother, Stephen, and an older brother, Peter. The evidence, including things said by Kenneth during medical appointments, indicates Kenneth felt close to his brother, Peter.

10 Kenneth had always resided with his parents at their family home in the suburb of Ingleburn NSW. This is also where he attended primary and high school. He reported to his general medical practitioner that he was bullied at school and as a result had self-esteem issues. In a statement to police his mother said that her view was that Kenneth went through high school wanting to be a little bit different to the mainstream of school. She also thought he liked to keep to himself. Family reported to police that Kenneth was a very pleasant and personable person – he had a friendly nature and was able to connect with anyone and talk to anyone about anything. Peter says that Ken had a very analytical mind and a great understanding of anything mechanical. Peter told police that Ken took great pride in his job and paid great attention to detail in everything that he did. Peter said he was always very impressed by Ken’s ability to connect with people around him and Kenneth always spoke highly of his friends.

11 Peter thought that Kenneth was like any other kid when he was growing up, he loved machines and electronics. Peter left the family home when he was 15 years of age and at this time Kenneth would have been about 12, so there were a few years with not much contact, however as adults they had regular contact.

Peter told police that before Covid he would catch up with Kenneth every two or three weeks on the weekend – they would go out for a meal, usually in the Newtown area of the inner City of Sydney. During the pandemic they saw each other less.

12 After school, Kenneth attended TAFE in Ultimo. From around 2017, he was employed by HyQuest water solutions at Warwick Farm and worked as a welding machine assembler. For the four years before his death Kenneth had been continuously employed at the HyQuest water solution plant.

13 Kenneth was not married and had no children. He was described as someone who kept to himself. Medical notes recorded that Kenneth loved art and had a limited social circle.

14 Kenneth appears to have perceived, as recorded in medical notes by his general practitioner, that he had had a history of relationship difficulties with partners leaving him for various reasons. The medical notes of his general practitioner indicated Kenneth was distressed by the breakdown of a relationship in 2015.

15 He had previously expressed, to his general medical practitioner, that he was wishing to move out of his parents’ home and wanted more training at work, however he is recorded in clinical notes as stating that it had been difficult due to self-doubt and over analysing things.

16 On 1 February 2021, the day after celebrating his 37th birthday, Kenneth left his parents’ house and did not return. He was last sighted on the same day on CCTV footage viewed by police, walking in the general direction of the Kiama blowhole. On 9 February 2021, Kenneth was reported as a missing person to Campbelltown Police. On 26 February 2021, human remains were found on the sand at Mollymook Beach. After DNA comparison, it was confirmed the remains were Kenneth’s.

Medical history 17 Kenneth did not drink alcohol and was not a smoker. There was also no evidence of any substance abuse. He was allergic to Augmentin tablets. In 2014 Kenneth was diagnosed with Diabetes Mellitus Type 2. He was registered with the National Diabetes Services. There is a family history of diabetes.

18 Kenneth was also suffering from high cholesterol, Obesity, type II diabetes/ Hyperlipidaemia (was prescribed Lipidil), Diarrhoea, Obsessive-Compulsive Disorder (also since 2014), and mild lower leg erythematous. In terms of mental health, he was diagnosed with depression, but there had been no identification of a risk of self-harm or suicide – the notes of both his counsellor and his general practitioner record that there was no evidence of any thoughts of self-harm.

19 Kenneth’s mother was not aware of his mental health issues. However, his brother Peter knew of Kenneth’s struggles with his mental health. Peter, told police that he was aware that Kenneth was seeing a psychologist/social worker at Campbelltown Medical Centre: “I know that Ken had been told that he had depression and anxiety – and had previously been prescribed antidepressants, I don’t know if he was actually taking them, over the years we had spoken at great depth various strategies around self soothing and self-care through exercise, and asking for help and talking about feelings when things were difficult. I also know that Ken had an obsessive-compulsive disorder that manifested in the form of hoarding and cluttering. I think that Ken’s way of dealing with his depression and anxiety was to go and spend time with his friends and connect – I think unfortunately during the pandemic his world got quite small and had lost some of it his protective factors”.

20 The medical notes also revealed that Kenneth spoke with his general medical practitioner about an issue that he had with hoarding, although he was working on this issue and thought he was making some progress.

21 A review of the medical records produced in the brief reveal the following history:

• In 2014 he was diagnosed with type 2 diabetes.

• On 14 May 2014, Kenneth was placed on a GP Care Management Plan that was part of the Enhanced Primary Care Package, which is a program which encouraged structured multidisciplinary care for patients who have at least one chronic condition for 6 months or more. A review was conducted every 6 months.

• In July 2014, Kenneth also saw an ophthalmologist, who found early keratoconus and corneal astigmatism, but no signs of diabetic retinopathy.

• In 2015 he discussed a relationship breakup with his general practitioner

(GP).

• On 8 February 2016, Kenneth was referred to see a psychiatrist due to low self-esteem issues. But it appears he did not make an appointment to see any psychiatrist.

• In April 2020 while attending the GP for treatment of cellulitis he told his GP that he had stopped his medications four years ago and was not taking any medication. The GP noted that he looked depressed but that there were no self-harm thoughts.

• On 6 April 2020, referrals were made under the GP Care Management Plan, for Kenneth to see exercise physiologist, podiatrist, dietician, endocrinologist and psychologist, for the purpose of weight management, control of blood sugar level, cholesterol and blood pressure. However, the records indicate that Kenneth did not follow up or make appointments regarding these referrals. The records also indicate that he had also stopped his medications since 2016, but he was willing to resume.

• On 6 May 2020, Kenneth was diagnosed with long term depression. He told the GP he felt it was worse since diagnosis of his diabetes. A GP Mental Health Care Plan was developed.

• On 20 June 2020 his poor glycaemic control was noted by his GP. On 24 June 2020, Kenneth was again seen by ophthalmologist, who noted very poor control of his blood sugar level, and Kenneth was advised regarding the importance of controlling blood sugar level to prevent diabetic retinopathy changes.

• On 10 July 2020, he participated in his first psychology session with Ms Parasher (a counsellor/social worker/Consultant Mental Health Practitioner), who noted that Kenneth presented with symptoms of PTSD, depression, anxiety, and panic attack disorder. Kenneth reported some childhood abuse and trauma, and stated that he was unable to deal with the trauma. Kenneth stated that he was struggling with life. He felt displaced, isolated, angry, upset, distressed, depressed, low and flat in mood, and had lost his direction in life.

• Kenneth attended four counselling/mental health sessions after July 2020, with the last one completed on 27 November 2020, and a further session scheduled on 5 February 2021, which was intended to be the last session. However, Kenneth did not attend that last session.

• Kenneth last saw his GP on 2 November 2020, attending for right leg cellulitis. The GP noted he had previously presented with this condition in May 2020, and it made him depressed. He was prescribed Bactrim for the condition. The GP recorded “he is not compliant with his medication” and explained that he was stressed at work. The GP again discussed referrals to dietician and podiatrist. Kenneth is recorded in the notes as reporting that he was seeing Angela for depression and anxiety “stated it is helping him” and next scheduled appointment with Angela (Ms Parasher) was 27/11/20.

Events leading up to death 22 In 2020, Janet had noticed that Kenneth wanted to make changes to his life.

He was known to periodically go on an “adventure” on his own without notifying his parents. Janet did not bother him too much as that was her way of not interfering with his life as an adult.

23 In January 2021, the week leading up to Kenneth’s disappearance, Janet noticed that he kept to himself and stayed in his room a lot more. However, Janet just thought that it was Kenneth being an adult and wanting his own time.

24 On 31 January 2021, the family went out and had dinner at the Rashay’s at Campbelltown to celebrate Kenneth’s 37th birthday. Peter, Stephen, his wife and their two children were present at a birthday celebration during the afternoon and on the evening Kenneth, Peter and his parents attended Rahay’s at Campbelltown. The family did not notice anything odd about Kenneth. Peter drove Kenneth to the function in Campbelltown and found him to be his usual self and they chatted about various things, this is detailed in Peter’s statement to police. When asked, Kenneth said that he had a good birthday. After returning home, Kenneth bid his mother good night before he went to sleep.

25 Around 6am on 1 February 2021, Janet heard Kenneth leave the house and thought that he went to work as usual. Janet and Richard went to Bowral for the day and when they returned, they noticed that Kenneth’s car was still at home.

Janet assumed that he was on one of his occasional adventures and did not worry too much about it.

26 On 3 February 2021, Janet was contacted by Kenneth’s manager at work and was informed that he has not attended work. When going through his room, she found Kenneth’s phone on his bed and his watch was also left in the room.

Janet contacted Peter and tried to access Kenneth’s phone to obtain further information however they were unsuccessful. The family contacted Kenneth’s friends, but no one had seen or heard from him.

27 On 4 February 2021, Janet received a phone call from Ms Parasher’s practice regarding Kenneth’s upcoming counselling appointment. Janet became worried but assumed that Kenneth would return in a week’s time. Unfortunately, by 8 February 2021, Kenneth still did not return, and no one had further information as to his whereabouts. On 9 February 2021, Janet attended Campbelltown Police Station and reported Kenneth as a missing person.

An investigation was conducted following the missing person’s report 28 Police were informed that Kenneth had been missing since 1 February 2021.

He had left on foot without his phone but had his wallet with him which contained his bank card. He was last seen wearing a navy-blue collared shirt, black shorts,

black shoes with white socks and black sunglasses. He did not carry any bags or had anything else with him.

29 Police attended Kenneth’s home address and spoke to Janet to obtain more details. They looked through Kenneth’s room but did not find anything suspicious or of assistance. Police noted that the room was very messy, but they were informed that it had always been messy. Police were also informed later that when cleaning out Kenneth’s room, his parents found a few small bottles of alcohol which they thought he did not drink.

30 An initial risk assessment indicated that Kenneth was at a medium risk of harm.

Janet was not aware that Kenneth was suffering from any mental health issues.

She found some medications at home however they all appear to be old. It was suspected that Kenneth was not taking his medications.

31 Police were alerted to the fact that Kenneth had an appointment to see Ms Parasher on 5 February 2021. After enquiries, Police were informed that Kenneth did not attend that appointment, nor did he call in to cancel or reschedule. The risk level was reassessed, and he was deemed to be at a high risk of self-harm.

32 Police spoke to Ms Angela Parasher and were informed that she has not seen Kenneth since 27 November 2020. She had 4 sessions with him. The last time she saw Kenneth, he has left in good spirits and was believed to be going well.

There were no concerns regarding risks of suicide or self-harm identified by Ms Parasher. No medications were prescribed for his mental health conditions.

33 Police attended the HyQuest water solution plant at Warwick Farm where Kenneth has worked for the last 4 years. His manager and work colleagues were spoken to. They were aware that Kenneth suffered from depression and anxiety. The manager had often accommodated Kenneth’s absence from work when he dealt with those conditions. Police were informed that Kenneth appeared to have been in a “slump” in the few weeks prior to his disappearance

and was thought to be suffering from an episode of depression. Kenneth had not been to work since 29 January 2021.

34 Police identified that Kenneth had a storage unit with Kennards Hire at Campbelltown. On attendance, Police found that the storage unit was locked and secured with passcode. Police were informed that it has not been accessed since 23 December 2020.

35 Police requested the CCTV footage from Rashay’s at Campbelltown where Kenneth had celebrated his 37th birthday with his family the day before his disappearance, however no footage was available. Police were advised that no one noticed anything strange about Kenneth at the birthday dinner.

36 All of Kenneth’s family members and friends were contacted and spoken to by Police. No one had any contact from him after 1 February 2021. A statement was obtained from Janet.

37 Police accessed and reviewed footage from CCTV cameras around Ingleburn.

At 6:41am on 1 February 2021, Kenneth was identified in the footage to be walking slowly along Macquarie Road, Ingleburn, with his head down. He appeared to be despondent. His movements were traced to the Ingleburn railway station. Unfortunately, Kenneth did not have an Opal card registered to him, so Opal records could not be obtained.

38 On 11 February 2021, Police were provided the following outline of Kenneth’s movements, on 1 February 2022, as captured by City Rail CCTV cameras:

• At 6:45am on 1 February 2021, Kenneth entered the Ingleburn railway station

• He boarded a citybound train

• He alighted the train at Mascot, then re-entered the same train

• He then got off at Central railway station and again went back into the train

• He travelled around the city circle 4 more times

• At 9:08am on the same day, Kenneth was observed to board a train at Central railway station and got off at Hurstville railway station

• He then caught a southbound train at Hurstville and arrived at Kiama railway station at 11:04am

• He was seen walking tapping off at Kiama railway station and walking towards Railway parade, and Tarralong Road towards the beach at Kiama 39 Other CCTV footage of the local Council (Kiama) captured images of Kenneth walking in the streets of Kiama in the general direction of the Kiama blowhole and also using a CBA bank ATM.

40 It is unclear as to why Kenneth went to Kiama on 1 February 2021. He has no known family, friends or associates in or around the Kiama area.

41 Police viewed the CCTV footage provided by Kiama Council and identified Kenneth leaving the railway station and walking down Manning Street and he appeared to have headed towards the Kiama blowhole. He was alone and was not carrying anything. Police have conducted enquiries with the local accommodation options in Kiama and found no records of Kenneth having stayed at any of them.

42 Police observed on CCTV that Kenneth had used a CBA bank ATM. His bank accounts records were obtained and showed that he last withdrew $200 cash at 1:37pm on 1 February 2021 at a CBA bank ATM in Kiama. There were no further bank activities after this withdrawal apart from automatic transfers into

his other NetBank saving accounts. This was the last confirmed sighting of Kenneth.

43 On 11 February 2021, Police disseminated Kenneth’s photos on the Facebook page of the local Police area commands around Kiama to appeal for public information and for local Police to keep a lookout for him. On 25 February 2022, an informant contacted Crime Stoppers and provided information of a sighting a male in Rhodes who he believed was Kenneth. The sighting was at about 1:30pm on 25 February 2021. Police examined a photo supplied by from City Rail, of this male, it was determined that the male depicted was not Kenneth.

On 23 February 2021, further information was received by Crime stoppers, of possible sighting of a male with similar appearance, but different clothing, to that of Kenneth near the Anglican Church on Terralong Street in Kiama at around 11am on 22 February 2021. Enquiries were made with the Anglican Church and Police were informed that no one matching Kenneth’s description was seen at the location.

44 Police made enquiries with all local hospitals at the Kiama and Ingleburn areas.

However, there were no records of Kenneth being admitted within the relevant time. His Medicare records were accessed and no claims for medication or visits to doctors or hospitals were made since 25 January 2021.

45 On 22 February 2021, Police Airwing Unit conducted an aerial search for Kenneth along the coastline of Kiama, which focused on the waterline and cliff lines between the bare bluff and Bombo Headlands. However, the search did not locate anything of interest. The assistance of divers was requested to search the vicinity of the Kiama blowhole. However, it could not be completed due to weather conditions and availability of Police divers.

46 On 25 February 2021, Police attended Kenneth’s home address again and collected DNA samples from his clothing and pillowcase. Police also contacted his dentist and obtained his dental records. However, the records indicate that he had not seen the dentist since 4 October 2017.

47 About 6:30pm on 26 February 2021, a witness observed something she described as a piece of “blubber” and initially thought it to be whale fat, whilst she was taking a walk with her family along the Mollymook beach. A statement was later obtained from the witness and her uncle regarding the finding of the item. The exact GPS coordinates of the location where the item was found was recorded as -35.32473 latitude and 150.48080 longitude, which was on the sand on the north-eastern end of Mollymook beach (south coast NSW) near the staircase.

48 Police were contacted and upon arrival, the location where the item was found was declared a crime scene. Photographs were taken in situ of the item before retaining it as an exhibit.

49 Upon further inspection, it was believed that the item was a piece of human remains, due to observation of what appeared to be muscle tissues on one side and a belly button on the other. The remains were taken to Milton Hospital Emergency Department and after consultation with doctors, it was confirmed to be human remains. As a result, the remains were transported to the morgue.

On 3 March 2021, the DNA profile from the human remains found on Mollymook beach, was matched to the DNA sample collected from Kenneth’s pillowcase.

50 The location on Mollymook beach and its surroundings were forensically examined. A canvass was completed, and a co-ordinated search of the Mollymook beach was conducted. No further human remains were found.

51 Reverse drift study was conducted, and two diagrams were provided by the Police Marine Area Command which, despite potential inaccuracy, did provide a possible indication that the human tissue found may have originated from the Kiama blowhole area. It must be noted that the NSW Marine SAR Coordinator advised that the modelling and diagram produced are “highly inaccurate” and to be used as an indication only, as they were predicated around the movement of whole bodies in open water, not a piece of human remains from the shoreline.

It must be noted that there is no evidence of the day that the remains washed

up on Mollymook beach so it is possible that this occurred before the date they were found.

52 On 20 March 2021, a report was prepared and submitted to the Deputy State Coroner about the evidence of identification of the human remains - Deputy State Coroner Ryan, on the information in the report was satisfied, on the balance of probabilities, based on the DNA match and other relevant information set out in the report, that the human remains found at Mollymook beach on 26 February 2021 belonged to Mr Kenneth Klees, who had been missing since 1 February 2021.

53 The cause of Kenneth’s death was recorded as unascertained in the Autopsy report completed by the Forensic Pathologist Dr Elsie Burger on 20 July 2021 due to limited material available.

Findings 54 The findings detailed below are based on the evidence, which I have set out above.

55 I am satisfied that the identity of the deceased, whose remains were located on Mollymook beach, is Mr Kenneth Klees. I note he was reported missing not long before the location of his remains, and police had been investigating his disappearance. I am satisfied of the identity of the deceased on the basis of all the evidence, and having regard to the DNA match of the remains with DNA obtained from Mr Klees’ belongings.

56 As it was Mr Klees who died, then the time of his death, which was unwitnessed, must have been between 1 and 26 February 2021, which is the period between the time Kenneth was last seen on CCTV, and the time the remains were found.

57 The death was unwitnessed, and as detailed above, the circumstances are not known, despite extensive police investigation. I find it to be established on all the evidence, on the balance of probabilities, that the death occurred in the Kiama area. This was the area where Kenneth was last seen and where he

last accessed a bank account. He was not seen anywhere after that time – in this context I note that Kenneth travelled to Kiama by public transport and was not seen to depart from Kiama by public transport. Also he was alone, and reportedly knew no-one in Kiama, so there is no reason to believe he departed from Kiama in someone’s motor vehicle. For all these reasons I find that Kenneth’s death occurred when he was in the Kiama area, and that due to tidal drift his remains were located on Mollymook beach.

58 The cause of death cannot be ascertained from the remains, as no injuries or disease process, contributing to the death can be ascertained.

59 As Coroner I am required to make a finding on the balance of probabilities as to the manner of death. I have considered the view of the investigating officer that the death may be due to suicide. I note there are grounds for this view, given the history of depression, and the evidence indicating a likely deterioration in Kenneth’s mental health in the weeks prior to his disappearance, and the fact that close to the time that Kenneth was last seen, he is seen on CCTV to be appearing disoriented. Given the presence of the cliffs and ocean in the Kiama area, and the evidence of poor mental health at that time, it is a distinct possibility that the Kenneth jumped from a cliff into the ocean with intention to end his own life. The manner of death would then be self-inflicted. However, I cannot exclude the equally strong possibility that he accidentally fell, leading to his death. It is quite possible, noting Kenneth had poorly controlled blood sugar levels, that he may have felt unwell and accidentally fallen into the ocean. The manner of death, if by accidental fall, would be misadventure.

60 There is no basis for concluding that the death was due to foul play or third party actions. In CCTV footage Kenneth is seen to be alone. In addition, despite a detailed and thorough police investigation, there is no evidence of anyone who would wish to do him harm, and no evidence of any person who possessed a motive to do so. Further, Kenneth’s bank accounts and property have not been accessed or used after his disappearance.

61 Having regard to all of the evidence, for reasons detailed, I have insufficient evidence to determine the manner of death. It is possible that the manner of death was self-inflicted but it is also possible that the manner of death was misadventure. Given insufficient evidence I am unable to find the manner of death and therefore I make an open finding.

62 The formal findings that I make, pursuant to s82 of the Coroners Act, for the reasons above detailed, are:

(i) Identity – Mr Kenneth KLEES (ii) Time of Death – Between 1 and 26 February 2021 (iii) Place of Death – Kiama area, NSW (iv) Cause of Death – Unascertained

(v) Manner of Death – Unable to determine - Open finding Closing 63 I acknowledge and express my gratitude to the Coronial Advocate and Solicitor Assisting the Coroner, Senior Constable Kai Jiang, for his assistance both before and during the inquest. I also thank the investigating Police Officers, and in particular the Officer in Charge, Senior Constable Kristy Hogg, for her work in the Police investigation and compiling the evidence for the inquest.

64 On behalf of the Coroners Court of New South Wales, I offer my sincere and respectful condolences to the family of Kenneth Klees.

I close this inquest.

Magistrate Carolyn Huntsman Deputy State Coroner Coroners Court of New South Wales