Inquest into the death of DO

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of DO Hearing date: 7 November 2023 Date of findings: 7 November 2023 Place of findings: NSW Coroners Court - Lidcombe Findings of: Magistrate Elizabeth Ryan, Deputy State Coroner Catchwords: CORONIAL LAW – death as a result of fall from a height - – the manner of death – was police response appropriate.

File number: 2022/358360 Representation: Counsel Assisting the inquest: E Sullivan of Counsel i/b the NSW Crown Solicitor The Commissioner of NSW Police: M Short of Counsel i/b the Office of General Counsel Findings: Identity The person who died is DO.

Date of death: DO died on 25 November 2022.

Place of death: DO died at Ben Buckler Point, North Bondi NSW.

Cause of death: The cause of DO’s death is multiple blunt force injuries.

Manner of death: DO died as a result of a fall from a height, carried out with the intention of taking his own life.

Findings in the Inquest into the death of DO

Non-publication orders Orders have been made pursuant to sections 75(1) and (2) of the Coroners Act 2009 (NSW) [the Act] in relation to non-publication of the deceased’s identity and the identity of his relatives. A copy of these orders is on the Registry file.

Introduction

1. Section 81(1) of the Act requires that when an inquest is held, the Coroner must record in writing his or her findings as to the date and place of the death and its cause and manner.

2. In addition, pursuant to section 82 of the Act, the Coroner may make recommendations in relation to matters which have the capacity to improve public health and safety in the future, arising out of the death in question.

3. These are the findings of an inquest into the death of DO.

4. Pursuant to section 75 of the Act, in these findings DO’s identity has been concealed with the use of a pseudonym, as have the identities of members of his family and his girlfriend.

Overview

5. DO was only 27 years old when he died on the night of 25 November 2022. He jumped from the cliff edge at Ben Buckler Point in North Bondi and fell onto the rock shelf below. He suffered unsurvivable injuries and was pronounced deceased soon afterwards.

6. An inquest into DO’s death is mandatory. This is because the circumstances amount to a death which occurred ‘as a result of’ a police operation. Section 27 of the Act requires that such deaths be the subject of an inquest. This is to ensure that the circumstances of the person’s death, including the conduct of involved police officers, is independently scrutinised.

7. In this case, police officers in the area responded quickly to a call for help from a bystander. Four officers arrived on the scene within seconds of DO jumping to his death. It is likely that their arrival was a contributing factor to his death, providing a causal connection (but far from the only causal connection) to his death.

8. I will state at this point that notwithstanding this connection, the evidence establishes that the involved police officers were not responsible for DO’s death and did what they could to try to prevent it. As will be seen, there is no basis for criticism of their actions.

Findings in the Inquest into the death of DO

Issues

9. The issues examined at inquest were as follows: a) What was the manner of DO’s death?

b) Were the actions of the attending police officers in accordance with NSW Police Force policy and procedure?

DO’s life

10. DO was a Colombian national who was born in the city of Pereira. His parents are CB and CP. He has a sister and two brothers.

11. DO was intelligent and he worked hard at school. He successfully completed law studies and then worked as a solicitor in Pereira. He met his girlfriend SD in April

12. Soon afterwards, the couple decided they would travel together to Australia to study and work. They began to make plans and to save money.

13. Tragically, DO’s death took place only four days after he and SD arrived in Sydney to start what they hoped would be a new chapter in their lives.

14. DO’s family live in Colombia. His parents, his sister and his brothers attended the inquest by way of AVL and were ably assisted by Spanish interpreter, Ms Abigail Pita.

SD’s brother, Alejandro, also appeared by AVL.

14. At the close of the evidence, DO’s mother spoke lovingly of her son. He was, she said, a beautiful person who had been full of aspirations and positivity. She and her family are heartbroken that they will not see him grow old and achieve his dreams.

The evidence

15. The evidence at inquest consisted of a detailed brief compiled by the officer in charge of the coronial investigation, Detective Sergeant Daniel Poole. Detective Poole also gave oral evidence at the inquest.

The events of 23 and 24 November 2022

16. DO and SD arrived in Sydney on the night of 21 November 2022 on six-month visas.

They were met at the airport by SD’s friend, Santiago Moncado. He had offered them temporary accommodation in a North Bondi apartment he shared with two other people.

17. In her statement, SD said that at first DO appeared to share her happiness in having finally reached Australia. The next evening, they sat on Bondi Beach to watch the sunset and to discuss plans for work. DO recorded a video to send to his mother and his sister.

Findings in the Inquest into the death of DO

18. The following day, however, Mr Moncado noticed that the couple had been arguing and that SD appeared unhappy. In her statement, SD said that she and DO spent time that evening discussing difficulties in their relationship and what they might do to improve things.

19. That day, DO had also contacted a longstanding childhood friend, Jhon Cruz. Jhon had been living in Sydney since 2019. DO told Jhon that he had been feeling stressed, disconnected and ‘a little sad’. They arranged to meet up the following day.

20. DO also texted his mother and his sister in Colombia, admitting to feeling alone and having thoughts of killing himself.

21. By the evening of 24 November 2022, SD and Jhon were each deeply worried about DO.

22. During the afternoon, SD messaged DO that she needed some space and time on her own. Later, DO sent her a photo of the ocean and a message that he was going to end his life. Panicked, SD and Mr Moncado drove to a number of coastal areas trying to locate DO. SD also rang DO’s sister GO in Colombia to tell her what was happening.

23. In the meantime, Jhon was also trying to find DO. Soon after 6.00pm that day, DO messaged Jhon that ‘I feel very sad, I’m feeling alone, I’m so stressed’. He followed this with the words: ‘It’s going to be a beautiful ending’.

24. Jhon got into his car and drove to the Bondi area, trying to contact DO as he drove. At about 7.50pm, he found DO on a cliff ledge at Dover Heights. DO was sitting on the ocean side of a steel safety barrier. It was a dark evening with heavy gusts of wind.

25. Overcoming his own fear of heights, Jhon climbed over the safety barrier to sit with DO on the cliff ledge. He managed to persuade him to come away from the edge and talk to him.

26. DO told his friend that he felt alone, and disclosed that six years ago his best friend had taken his own life. DO said he had been thinking about suicide often, telling Jhon that he didn’t want ‘to keep living more than 27 years. I already made the decision and if I’m not doing it today, it is going to be happening soon’.

27. Jhon spoke with DO for a long time, trying to reassure him that he had friends who could help him to build a happy future for himself. Eventually he was able to persuade DO to get into his car. They decided it would be best for DO to stay at his (Jhon’s) place that night. DO thanked Jhon for saving his life.

28. Later, Jhon and DO returned to Mr Moncado’s apartment where he and SD had been staying. Here, DO collected some belongings for the night. SD was shocked to hear from Jhon that he had recovered DO from a cliff edge. As they left, she asked Jhon to take care of DO and to speak with her the following morning.

Findings in the Inquest into the death of DO

The events of 25 November 2022

29. DO was up early the following morning to start a new job in a nursey. Jhon farewelled him with these words: ‘My friend, … today is going to be a good day. It is the first day of your new job and it is a physical job so hopefully you’re feeling good. I will be here for you, and I will look at psychologists and hopefully we can find a solution’.

30. But later that evening it was clear that DO was very unhappy. He met up with SD at the northern end of Bondi Beach and she told him that she needed space and that he needed to focus on his mental health.

31. Following their conversation, DO hugged and kissed SD goodbye and then ran away to sit on a grassy hill. At around 10.06pm, SD rang Jhon to say that she and DO had broken up and to ask if DO could stay with him for another night. Whilst she was on the sand looking at the sea, DO appeared behind SD yelling and asking who she was talking to and if there was someone else.

32. DO then walked and ultimately ran in a northerly direction along the beach. SD followed him along the shore. At some point, DO stopped and shouted to SD, ‘why do you want to see what I am going to do?’ SD then followed DO through a park and up some stairs but struggled to keep up with him. It was dark and she occasionally lost sight of him. She was in the meantime making desperate phone calls to Jhon and to DO’s sister.

At Ben Buckler Point

33. When SD caught up with DO, he was sitting at the edge of a cliff at a spot known as Ben Buckler Point. This is the northern headland of Bondi Beach. It overlooks a rock shelf some twenty to thirty metres below. A metal safety barrier separates the public footpath from the cliff edge.

34. DO was on the cliff side of the metal barrier. SD climbed over the barrier to join him.

In tears, she begged him not to end his life, but he told her that if someone appeared, he would jump faster than they could get to him. At this, SD took hold of the front of DO’s t-shirt and tried to tie herself to him. DO however told her that this was ‘the perfect way to go’.

35. This scene was witnessed by Ms Emily Wolf from the window of her nearby apartment.

At about 10.30pm that night, she saw SD and DO standing on the ocean side of the barrier. SD was holding DO’s t-shirt and pulling him towards her and away from the cliff edge. Ms Wolf could hear SD screaming and crying.

36. Seriously concerned, Ms Wolf rang 000 and told the operator: ‘there’s a couple and she’s screaming at him, and she’s like … I think she is trying to get him not to jump … I need someone to come quickly’.

Findings in the Inquest into the death of DO

37. Ms Wolf’s call was made at 10.34pm and resulted in a police broadcast. At 10.39pm, a nearby police vehicle with call sign ODIN 10 acknowledged the broadcast. The vehicle with its four officers arrived at Ben Buckler Point within one minute, deactivating their lights and siren as they approached.

38. From the cliff edge, SD could see the word ‘Police’ on the side of ODIN 10 as it approached. Suddenly, DO pulled his t-shirt over his head and ran to the edge of the cliff, leaving SD holding his t-shirt.

39. At almost the same time, one of the officers attached to ODIN 10, Constable Madeng Dut, saw DO look towards the police vehicle. Constable Dut jumped from the moving vehicle and sprinted towards the cliff edge, yelling ‘Wait, stop!’ He and his colleagues describe seeing DO push SD away, removing his t-shirt, then jumping over the cliff edge.

40. Ms Wolf also observed this terrible sequence of events. She saw DO turn his head towards the approaching police vehicle, then turn towards the ocean, run to the cliff edge and jump off.

41. Constable Dut and his colleague Constable Jack Owens ran to the cliff edge and attempted to find a way down to the rock shelf where DO had fallen. They called his name, telling him they would come and get him, but DO was not responsive. Noting the treacherous conditions, their supervising sergeant directed them to return and await the arrival of the Police Rescue squad.

42. Police Rescue officers reached DO soon afterwards, but there were no signs of life.

The post mortem examination

43. A post mortem examination was performed by forensic pathologist Dr Istvan Szentmariay. He concluded that DO died as a result of multiple blunt force injuries.

44. Toxicology testing did not detect any alcohol, medications or illicit drugs in DO’s post mortem blood sample.

The manner of DO’s death

45. The evidence is clear that DO’s fall was the result of an intention to end his own life.

46. On 24 November 2022, DO had texted his mother and his sister, disclosing that he had been thinking about killing himself. This state of mind was also evident in his actions and words that evening, during his conversation with his friend Jhon at the cliff edge at Dover Heights.

47. Furthermore, the statements of SD, Emily Wolf and the attending police officers regarding DO’s actions at Ben Buckler Point evidence a clear intention on his part to jump from the cliff edge. His actions were clearly the result of a deliberate decision.

Findings in the Inquest into the death of DO

48. As for why DO made the tragic decision to end his own life, the coronial investigation could uncover little as to his mental health history. His sister mentioned that he had previously seen a psychologist for anxiety and to assist him to stop smoking. SD too mentioned that he occasionally got anxious and stressed, but not to any significant degree.

49. Perhaps more significantly, what DO disclosed to Jhon on the night of 24 November 2022 suggests that he was deeply affected by the suicide death of a friend some years previously. In addition, it is evident that in the days leading up to DO’s death he was distressed by the breakdown of his relationship with SD.

50. No doubt the above were all factors in DO’s decision. Ultimately, it is not possible to know what his underlying reasons were. This must be a source of additional pain for his family, who struggle to understand how their much-loved son and brother could have taken such a tragic and final step.

Did the actions of police officers contribute to DO’s death?

51. This question can be answered briefly. The evidence indicates that the arrival of the police vehicle at Ben Buckler Point that night acted as a trigger for DO to take his final steps.

52. However, as described in paragraphs 23 and 26 above, it is apparent that DO had been contemplating suicide for some time. As he commented to his friend Jhon the night before: ‘I already made the decision and if I’m not doing it today, it is going to be happening soon’.

53. Furthermore, there can be nothing to criticise in the police’s actions as they approached the scene. They were responding to a call for help and this was consistent with their duty to keep members of the public safe, including DO. They took care not to activate the vehicle’s lights and siren, so as not to heighten the emotions of the person in need of help.

54. None of the police officers had any opportunity to engage directly with DO. Nor did they have time to do anything to prevent his movements, other than to run forward in the vain hope of reaching him before he jumped.

Did the involved police officers respond appropriately?

55. I accept the submissions of Counsel Assisting that the response of the involved police officers was in all ways appropriate. They responded immediately to the crisis, arriving within a minute of acknowledging the call on police radio. They did what little they could to try to prevent DO from jumping. Afterwards, officers Dut and Owens attempted to reach DO to give aid, meanwhile seeking to reassure him. The conditions however were treacherous and they were directed to await the arrival of a specialist team.

Findings in the Inquest into the death of DO

56. These actions are worthy of acknowledgement, and I join with Counsel Assisting and with DO’s mother in expressing appreciation for the efforts of these police officers.

57. As noted by Counsel Assisting, two other responders showed particular compassion and sensitivity to SD that night. Distraught and in deep shock, she was comforted by Constable Helen Walker. A Spanish-speaking NSW Ambulance paramedic Emil Banayos also spent time with her, explaining what was happening and breaking to her the terrible news that DO had not survived.

58. All involved officers acted in accordance with NSW Police Force policies and procedures. Given the circumstances, they could not have acted in any way which would have prevented DO’s tragic death.

59. I also adopt the submission of Counsel Assisting that DO’s friend Jhon Cruz did his utmost to help DO, providing comfort and support, and persuading him to come away from the cliff ledge the previous night. SD too did all she could to stop DO from jumping to his death on the night of 25 November 2022.

Conclusion

60. I will conclude by expressing my sincere sympathy to DO’s family for the loss of their beloved son and brother. They will always grieve for DO, but I hope that time will bring them a measure of peace.

61. I thank Counsel Assisting Ms Sullivan and Ms Kohler of the NSW Crown Solicitor’s Office for their excellent assistance and the Officer in Charge, Detective Sergeant Poole, for his careful and comprehensive investigation.

Findings required by s81(1) As a result of considering all the documentary evidence and the oral evidence heard at the inquest, I make the following findings.

Identity The person who died is DO.

Date of death: DO died on 25 November 2022.

Place of death: DO died at Ben Buckler Point, North Bondi NSW.

Cause of death: The cause of DO’s death is multiple blunt force injuries.

Manner of death: DO died as a result of a fall from a height, carried out with the intention of taking his own life.

Findings in the Inquest into the death of DO

I close this inquest.

Magistrate E Ryan Deputy State Coroner Lidcombe Date 10 November 2023 Findings in the Inquest into the death of DO