Inquest into the death of Natasha Lechner

STATE CORONER’S COURT OF NEW SOUTH WALES

/ quest into the death of Natasha Lechner

“2- 4 4May 2023, Lismore e Courthouse

NSW State Cr Coroner's Court, Lidcombe _

Findings of: State Coroner, Magistrate Teresa fey ‘Sullivan

ee

Catchwords: ORONIAL LAW — Kambo frog — death following application of frog poison — unnecessary death -

: vulnerable person- delay in getting help -Triple 0 call File number: 2019/77661

Representation: ‘ ounsel Assisting the Coroner: ‘Dr P Dwyer SC.

Instructed by M Wail (Crown Solicitor’s Office) Findings: : he identity of the deceased - The person who died is

Natasha Lechner

Date of death - Natasha died on 8 March 2019

Place of death - Natasha died in Mullumbimby, New Sou

Wales ‘Cause of death - The cause of Natasha’s death was Kambo frog toxin

Manner of death — Natasha died after participating in a Kambo ceremony Recommendations:

a eee

sudden cardiac arrhythmia following the administration of

Table of Contents

ITPOCUCTION ...cccceccecccceeecsececseccececcseeceeeeeecseeenteceaececesescsesansesenseeesireccoieeeecnnadenpeetnnneess 1 The purpose of an inquest and the role of the Coronet... eee eee terete 1 Factual Background «0.0... ccc eeeceeeneeenereeeetees we a2 Kambo Ceremony on 8 March 2019.

What is KaMmb0? 00.0.0... eceeeee cece cece cece tenner neeeereecceeeeeeeeannnnnnregrses Did Kambo contribute to Natasha’s death? ...

Legal Status occ cece cence cee cre terre ent tneernerneerreesseeneneeseeneris ery ens) Findings required by s81(1) 15.

The Coroners Act in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of Natasha Lechner

Introduction

4. This is an inquest into the death of Natasha Lechner who was 39 years old when she died. Natasha passed away after a ‘Kambo’ ritual ceremony, which is based on a traditional South American ritual in which proponents use the poison of the giant Kambo ‘monkey’ frog, in a process they believe will have healing properties.

The ritual involves the deliberate burning of a recipient’s skin in small dots over parts of the body, and the application of frog toxin onto the exposed burns to

cause a reaction, which almost always involves vomiting.

2. The inquest into Natasha's death was held at Lismore Courthouse for three days, commencing on 2 May 2023. A brief of evidence containing three volumes of documentary material was tendered and oral evidence was adduced from

various witnesses.

3. A list of issues was prepared by counsel assisting prior to the hearing of the inquest. The issues which this Inquest explored included, but were not limited to: a. What was the most likely cause of Natasha’s death?

b. What are the legal and ethical issues surrounding use of ‘Kambo’?

c. With respect to the power to make recommendations pursuant to s82 of the Act: i. Is there a need for greater education with respect to the dangers of Kambo use?

ii. Is there a need for greater regulation over the use of Kambo

and/or practitioners training others in the use of Kambo?

The purpose of an inquest and the role of the Coroner

4. This inquest is a public examination of the circumstances of Natasha death. The

primary function of this Court is to explore the circumstances in which Natasha's

death occurred and to identify opportunities to prevent deaths in similar

circumstances.

The role of a Coroner, as set out in s. 81 of the Coroners Act 2009 (NSW) (‘the Act’), is to make findings as to: i. The person's identity, and ii. The date and place of the person’s death, and iii. The manner of the death, and

iv. The medical cause of the death

At this inquest, the identity of the person who has passed away, along with the date, time and place of the death are not in issue.

The Coroner has the power to make recommendations under section 82 of the Act, where it is necessary or desirable to do so, in relation to any matter connected with the person’s death which is the subject of the inquest. This power allows the Coroner to focus on whether anything should or could have been done to prevent the death and recommend any changes to prevent a similar death

from occurring in the future.

Factual Background

After careful consideration of the brief of evidence tendered at the hearing and the oral evidence of the witnesses who appeared, | make the following findings in relation to the factual background of the inquest.

Natasha Lechner

Natasha, called ‘Tash’ by those close to her, was born alongside her twin brother Christian, two months premature, on 14 December 1979 at Wollongong Hospital.

Natasha enjoyed a close relationship with Christian and they spoke often.

Her father, Frank Lechner, described Natasha as an “old soul in a young body”.

At an early age she showed incredible wisdom and had many creative interests

including poetry, storytelling, music and spirituality. She shared these interests

with many friends and enjoyed learning new things from others. It is clear

Natasha was deeply loved by her mother, father, brothers and friends.

Before settling in the Northern Rivers region, Natasha had lived in Wollongong, and in Sydney and had also travelled overseas. At the time of her death, Natasha was living in a share house in Mullumbimby, and had been there for about one year, after responding to an advertisement on social media. One of her

housemates was Kelly Green who had also previously worked with Natasha.

Ms Green described Natasha as “very smart and she loved learning new things”.

For many years, Natasha had suffered from a range of chronic health issues which caused her significant pain. In 2009, she was diagnosed with lumbar degenerative disc disease, which was operated on in 2010. This surgery provided some pain relief, however in 2014 Natasha experienced a recurrence of severe back pain, radiating to her legs. At the time of her death, Natasha was morbidly obese, weighing 120 kilograms.

In February 2019, Natasha was declared medically unfit for work due to chronic pain caused by her spinal condition. Previously, she had worked as a hairdresser, having started an apprenticeship at the age of 15. She had also

completed a beautician’s course.

Natasha’s Interest in Kambo

Natasha had been interested in alternative medicine for many years. In around 2015 she became aware of Kambo and its purported healing properties. Prior to her death, Natasha tried Kambo and found it beneficial to her. Ms Green estimated that Natasha had used Kambo on about six occasions before she decided to do the training. During the training Kambo was administered in five sessions, and Natasha had likely administered it to herself once since coming

back from training.

At autopsy, the forensic pathologist recorded sixty-one round lesions on Natasha's body, that were consistent with burn marks sustained during the Kambo ceremony process. There were five fresh lesions; forty-one partially

healed round lesions and _ fifteen fully healed round lesions.

In January 2019, Natasha participated in a two-week basic level training course in Kambo, held at a retreat north of Kyogle in New South Wales. It was run by the International Association of Kambo Practitioners (or IAKP) and around 13

people participated in the course.

The JAKP was founded and run by Ms Karen Darke, who designed the course outline used by teachers. Ms Darke appears to have qualifications in psychology or counselling, but not in medicine and there is no evidence to suggest that the IAKP has had assistance from toxicologists or medical practitioners in the

development of their training materials.

There were three individuals associated with the IAKP who taught the course attended by Natasha: Laurel Hefferon, Andy Copeman and Sarah Jane Morrison (also known as Aisha Priya). The ‘lead trainer’ for the course was Ms Morrison, who had first attended a basic two-week Kambo training course run by the IAKP in Poland in June 2015.

The IAKP training course involved both theory and practical sessions, including the application of Kambo onto participants in five separate sessions. During each session, multiple ‘points’ of Kambo were applied. Natasha had around four points of Kambo during her first session and the number of points then increased by

one or two points per session.

Around four participants failed to complete the course and were sent home.

However, Natasha did pass and she told her brother Christian that she was proud

of this achievement because it was rigorous program.

It is clear Natasha took her role as a Kambo ‘practitioner’ seriously. After passing the course, Natasha performed a ceremony on one of her friends. Before doing

so, she gave an in-depth overview of the process involved and what was going to happen. Natasha also informed her friend of medical warnings associated with

the treatment.

In 2014, Natasha met Victoria Sinclair through a friend at her workplace. At that time Ms Sinclair was advertising herself as, amongst other things, a Kambo practitioner. She uses the name ‘Maestra Victoria’ and describes herself as a “spiritual teacher’. Her website refers to her as a “transpersonal (eco) psychologist, trauma and postcolonial specialist and plant medicine practitioner, working on a High Priestess Level of initiation, ordained through several lineages and acknowledgments and in terms of shamanic initiation and training she worked prolifically in the Free Party Scene in Europe since 1990s and has been journeying and working extensively in Central and South America and Australia since 2006”.

Ms Sinclair gave evidence that she trained in Kambo in Mexico in 2014 and this involved a five-day intensive course, one-on-one with a Kambo teacher. She said that she was taught about various safety measures, including making sure there was first aid on hand in the event of an adverse event and phoning paramedics if necessary. Ms Sinclair was also taught about the risk of hyponatremia, a potentially life-threatening side effect of Kambo caused by excessive consumption of water, where the concentration of sodium in the blood becomes abnormally low.

Prior to March 2019, Ms Sinclair performed Kambo ceremonies on Natasha three to four times. In return, Natasha would pay Ms Sinclair money or provide other favours like accommodation at her house. Ms Sinclair was more experienced than Natasha and it is not surprising that Natasha regarded her as a teacher, as

well as a friend.

Kambo Ceremony on 8 March 2019

In March 2019, Ms Sinclair was visiting Australia from Ireland. She was staying with Natasha at her house in Mullumbimby and intended to continue her travels after around 5 days.

31,

A few days prior to Ms Sinclair's arrival, Natasha had informed her housemate Ms Green that she was feeling “really off’. It was not uncommon for Natasha to

feel lethargic and suffer headaches and period pain on a regular basis.

At around 9:30am on 8 March 2019, Natasha, Ms Sinclair and Ms Green were at Natasha’s house in Mullumbimby. Ms Green left to get a coffee and to give Natasha and Ms Sinclair some space to undertake the Kambo ceremony, which she knew they had planned.

Before commencing the Kambo ceremony, both Natasha and Ms Sinclair used ‘Sananga’, thought by its proponents to be a ‘plant medicine’. {t is administered as an eye-drop and is often used in association with Kambo in traditional South

American tribal settings.

Victoria Sinclair voluntarily participated in a formal recorded interview with NSW Police. She was forthcoming about the Kambo ceremony and the fact that they had “paired” that day - meaning that Natasha had administered the Kambo onto Victoria, and then they swapped roles and she administered it to Natasha. Ms Sinclair told police that Natasha had sourced the Kambo from her teacher.

Natasha had asked Victoria to administer the points of Kambo “in a line down her heart” but she (Ms Sinclair) decided to “raise them a little bit from the main heart area which would be the most sensitive” and asked Natasha to select “safer

places” like the arm.

At around 9:45am, Ms Sinclair was administered Kambo by Natasha. Ms Sinclair vomited soon afterwards, as was expected with the ceremony. She quickly recovered and her ritual concluded without issue.

Some time after that, Natasha and Ms Sinclair swapped roles and Ms Sinclair administered the Kambo secretions to Natasha. In preparation for the ritual, Natasha drank 1.5 litres of water from a bottle she had filled beforehand.

Ms Sinclair prepared the ‘Kambo Stick’, and using a lit incense candle, burnt a series of circular wounds onto Natasha, removing the top layer of her skin as she did so. Specifically, five circular wounds were made. Three wounds were in a vertical line below the clavicle and above the sternum and two were on the inner left wrist. Ms Sinclair administered the Kambo onto the wounds. | heard evidence from Ms Sinclair that the five points were requested by Natasha and were not

unusual or in excess of prior Kambo ceremonies they had conducted together.

Natasha appeared to feel faint quite quickly, however she did not purge. She lay down on the floor for around two minutes until she sat up, grabbed Ms Sinclair's arm and said "something's not right" or “this isn’t good” before she lost

consciousness.

Natasha started to make murmuring noises and her eyes were glazed. Ms Sinclair gave evidence that she “was holding her up” and “trying to bring her around” “maybe for about for 10 minutes”, as she believed that Natasha was “processing something” and that if she was going to purge, she did not want her to choke.

Ms Sinclair then decided to lie Natasha down into the recovery position and she

wiped off the Kambo secretions from the wounds before attempting to revive her

. with water by pouring it over her head. Ms Sinclair noticed goosebumps on

Natasha's skin and decided to massage her extremities because she thought Natasha was getting cold. Natasha’s lips turned blue and she saw that she wasn't

responding very well, so Ms Sinclair turned her over and commenced CPR.

Ms Sinclair also attempted to access Natasha’s mobile phone to request an ambulance, but she did not normally use mobile phones and was not able to access it. Further, as Ms Sinclair explained in oral evidence, because she was nota resident of Australia, she did not know the correct number to call emergency services. She did not run outside the house to get help.

Ms Green arrived home at around 11:10am and heard Ms Sinclair yelling Natasha's name. She ran into the sunroom and saw Natasha on her side,

39,

foaming at the mouth. Ms Green immediately turned Natasha over and

commenced CPR before contacting Triple 0 on her mobile at 11.16am.

At 11:21am, paramedics attended at the house. Natasha was not breathing at all and attempts to revive her were unsuccessful. Sadly, it was clear that she had

already passed away before the paramedics arrived.

At 12.25pm, police officers from Tweed Heads attended and a crime scene was established at 12.40pm, meaning police took over the scene from NSW Ambulance. Officers attending noted the strange burn marks on Natasha caused by the Kambo ceremony.

The risks of Kambo

What is Kambo?

A.

Kambo is the secretion taken from the Giant Monkey Frog (Phyllomedusa bicolor), a frog native to the Amazon rainforest. Traditionally, these secretions were used by tribes in the West Amazon and Peru regions as an ancient ritual for luck, war, purification and the treatment of ailments. The practice has spread to other parts of the world. Individuals from places like the USA, Europe and Australia have co-opted Kambo and have incorporated it into a wide range of

different alternative medicine ceremonies.

There is no peer-reviewed research to support the health benefits of Kambo and the TGA and the Australian Medical Association reject claims that it has any medicinal purposes. In short, there is no clinical research supporting the

purported therapeutic benefits of the Kambo ceremony.

The frog secretion is harvested in the Amazon by directly obtaining it from the back of a live frog. The frog is tied by each leg with string and agitated, encouraging the secretions, which are then scraped from the frog and dried onto

small sticks.

In contemporary western settings, Kambo is typically applied during a ceremonial ritual for the purposes of “healing”, “cleansing” or “detoxifying” a person. The ceremony begins by burning the top layer of a participant’s skin with a small stick.

Small amounts of the frog secretion are then placed onto the open wounds.

The secretions are composed of multiple substances including several highly concentrated bioactive peptides. It is possible that other chemicals are contained within the secretions which have not yet been identified and very few of them

have been tested in human based scientific studies.

These peptides cause immediate and intense pharmacological effects such as: hypotension, flushing, palpitations, nausea, vomiting, bile secretion and facial swelling. Upon application of the frog secretion, a participant often quickly vomits.

Participants often drink a large amount of water before the ceremony to assist

with the purging process.

The secretions of the frog are sourced outside of Australia. They are allegedly collected by the Indigenous tribes within the Amazon region of South America and provided to practitioners of Kambo frog medicine. It is possible that there may be regional variations and other environmental and human factors that result in a variation in peptides and other chemicals produced by the frogs. They may also be something quite different to what has been allegedly sold as Kambo,

particularly with increasing demand from Westerners.

Physiological effects of Kambo include nausea, a sensation of increased strength, heightened senses, hypotension, dizziness, swelling of the face and throat, burning sensation, incontinence, sweating, euphoria and loss of

consciousness.

Medical contraindications

According to the IAKP, medical contraindications of doing Kambo include a history of stroke, esophageal weakness, heart bypass surgery, enlarged heart,

implanted cardioverter defibrillators, pericardial effusion, congestive heart

disease, excessive fluid in the heart sac, heart valve replacement surgery, organ transplant, blood clots, serious mental health conditions, low blood pressure that requires medication, Addison’s disease, if you're currently undertaking chemotherapy or radiation therapy within four weeks of Kambo or if you are pregnant or lactating. In addition, there are increased risks for those who have consumed certain prescription and dangerous drugs before using Kambo. It is unclear whether these contraindications identified by the IAKP are supported by

peer reviewed medical research.

Medical risks

While there is no credible research about the medicinal benefits of Kambo, there are clear and identified risks that are underestimated by some of its proponents.

There is a risk of death, liver damage, heart attack, stomach pain and damage

to the stomach walls and esophagus.

As | noted above, Sarah Jane Morrison (aka Aisha Priya), was one of the trainers on the Kambo course that Natasha participated in. Ms Morrison provided a

written statement for the inquest and gave oral evidence.

In her written statement, she set out a list under the topic of “Risks Discussed”

with the participants on the course. They were as follows:

e Risks associated with fainting and low blood pressure;

e Risks associated with electrolyte imbalance (hyponatremia), including signs and symptoms of Hyponatremia and what action to take;

« Risks associated with swelling;

e Risks associated with infections on the burn site;

e Risks associated with an increase in the heart rate or respiratory distress;

e Risks associated with burns and the depth of burning and if Kambo entered the blood stream. Students are taught to ensure there are no signs of blood at the burn site. If there is blood at the site, the Kambo should not be placed on that burn site.

¢ Students are taught in the event that Kambo enters the blood stream, an ambulance must be called by the practitioner immediately.

e Death is discussed as a risk if the water guidelines and first aid are not adhered to or if a client is contraindicated and does not disclose this or does

not know they have a medical condition (emphasis added).

The way in which this last bullet point is framed is telling. It advises of risk of death, but only in three particular circumstances — 1) where the “water guidelines and first aid are not adhered to” or 2) “if a client is contraindicated and does not disclose this” or 3) the participants “does not know they have a medical condition”.

That information is not complete and does not properly advise participants of the true risk of engaging with Kambo, even for healthy people. It is clear from the available literature, and the two cases that have recently come to my attention as State Coroner, that death can occur even where there is no pre-existing condition or at least not one that could possibly be identified beforehand.

Did Kambo contribute to Natasha’s death?

On 13 March 2019, an autopsy was performed by pathologist, Dr Lorraine Du Toit-Prinsloo, and she prepared a report dated 15 May 2019. Dr Du Toit-Prinsloo was unable to determine the cause of Natasha’s death at the time of her report, but she wrote about the circumstances surrounding Natasha’s death and the tisks of Kambo. She noted that there were five round acute reddish lesions on Natasha’s body, 41 partially healed lesions to the body and 15 healed round lesions. She highlighted other known cases of death after the administration of

Kambo written about in international literature.

At inquest, | heard oral evidence from a number of experts - Professor Mark Adams, Head of the Department of Cardiology at the Royal Prince Alfred Hospital; Associate Professor Darren Roberts, Consultant Toxicologist and Medical Director of the New South Wales Poisons Information Centre and Dr

Lorraine Du Toit-Prinsloo, Forensic Pathologist.

Professor Roberts provided a detailed overview of the history and composition of Kambo. He told the court that Natasha’s death was likely to be as a result of an acute cardiac event and that the temporal association of Kambo to Natasha’s death was an important factor. Professor Roberts identified the fact that there have been other deaths of this nature linked to Kambo and written about in

international scientific literature.

Professor Adams also opined that Kambo played a role in triggering the cardiac event suffered by Natasha, given the temporal proximity and because there had been previous instances of adverse cardiac events for people using Kambo.

Professor Adams noted that Natasha’s mode of sudden death was preceded by a feeling of impending problems and he identified cardiac arrhythmia leading to a cardiac arrest or profound hypotension leading to cerebral hypoxia, followed

by a respiratory arrest as likely causes of death.

On the basis of the expert opinions of Professor Roberts and Professor Adams, and the surrounding circumstances, | am satisfied on the balance of probabilities that Natasha died as a result of an adverse cardiac event, triggered by the administration of Kambo, which involves scraping poisonous secretions onto burns in the body.

The role of Victoria Sinclair

In 2019, Natasha made the decision to participate in the Kambo teacher training and she was clearly very interested in the process. She was a clever, independent women who was searching for a way to cure herself from a

debilitating condition she was suffering.

Consistent with her interest in Kambo, on 8 March 2019, Natasha decided to “pair” with Ms Victoria Sinclair in administering Kambo to each other. That meant that each was in a position, not only of administering the secretions, but of

helping the other if something went wrong.

If something had gone wrong for Ms Sinclair, Natasha had her phone available to her and would no doubt have called Triple 0 immediately. Unfortunately, Ms Sinclair did not have her own phone and had not made any preparation for how she would get expert medical attention if something went wrong for Natasha, as it tragically did. It is obvious that she, like many other persons who advocate for Kambo use, seriously underestimated the potentially fatal effect for users, even

those with contraindications.

1 cannot know whether earlier medical intervention would have saved Natasha, but it is obvious that the earlier the arrival of the ambulance, the better the chance they had of assisting her. It is a great shame that Ms Sinclair had not thought that

through beforehand, and was not equipped to call for emergency medical care.

What are the legal and ethical issues surrounding the use of

Kambo?

Legal status

At the time of Natasha’s death, Kambo was a largely unregulated substance in Australia. In March 2019, Kambo was not listed as a prohibited substance under the Drug Misuse and Trafficking Act 1985 (NSW) and its possession was not unlawful under that legislation.

jn part due to Natasha’s death and other reported concerns, Kambo drew the attention of regulators including the Commonwealth Department of Health and the Therapeutic Goods Administration (TGA).

In 2019, a delegate of the Secretary of the Commonwealth Department of Health sought to have Kambo included in the Poisons Standard, following reports of harm resulting from its use. Accordingly, on 24 December 2020 a notice was published pursuant to regulation 42ZCZK of the Therapeutic Goods Regulations 4990 (Cth) which, among other things, invited members of the public to make submissions concerning the proposed amendment. in response to the notice,

submissions were made by the Australian Medical Association as well as the

International Association of Kambo Practitioners. | have had the benefit of

reviewing same of this material which is contained in the brief of evidence.

In March 2020, the Advisory Committee on Chemicals Scheduling and the Advisory Committee on Medicines Scheduling provided their advice as to the

scheduling of Kambo under Poisons and Therapeutic Gaods Regulations.

On 20 July 2021, the TGA published a “Notice of interim decisions to amend (or not amend) the current Poisons Standard” which publicised the TGA’s decision to include Kambo in Schedule 10 of the Poisons Standard from 1 October 2021.

Following the enactment of the Poisons Standard October 2021 (Cth), Kambo has been included in Schedule 10 of the Poisons Standard effective from 14 October 2021. As a result, it is classified as a substance of “such danger to

health as to warrant prohibition on sale, supply and use”.

Accordingly, pursuant to regulation 128P of the Poisons and Therapeutic Goods Regulation 2008 (NSW) (‘PTG Regulation”), the manufacture, supply or use of Kambo is prohibited unless a person is expressly authorised to do so in accordance with Part 8 of the PTG Regulation.

It is noteworthy that in certain South American countries, Kambo has become

illegal outside of its traditional cultural use.

Had that reform not already occurred | would have made a recommendation for the manufacture, supply and use of Kambo to be illegal. While regulators must balance risk of harm with personal liberties, it appears to me that a number of vulnerable people are drawn to using Kambo in circumstances where those who administer it may hold themselves out as part of a healing profession, and yet lack training in basic first aid. Like Ms Sinclair, those persons may not prepare themselves for what to do in an emergency.

| note that | do not have any power to make recommendations that bind Ms

Victoria Sinclair, who is not an Australian citizen and does not practice in this

country. Without wishing to insinuate blame or shame, it is, as | have said earlier, extremely regrettable that Ms Sinclair had not equipped herself with the number for Triple 0 or given further consideration to what she would do in the event of an

emergency. Vital time was lost before Triple 0 was called.

74, | note that Ms Sinclair gave oral evidence that she no longer administers Kambo to others. At the time of inquest, however, she continues to advertise herself as an experienced Kambo practitioner. A copy of these findings will be emailed to Ms Sinclair and | urge her to reflect upon them, and to educate herself and others as to the risks of Kambo. Those risks now include being prosecuted for the illegal manufacture, use or supply of Kambo. More importantly, this inquest, and the inquest into the tragic death of Jarrad Antonovich, have highlighted the risk of serious illness and death from the use of Kambo, and the importance of

accessing urgent medical attention.

Findings required by s81(1)

75. Asa result of considering all of the documentary evidence and the oral evidence given at the inquest, | am able to confirm that the death occurred and make the following findings in relation to it.

The identity of the deceased - The person who died was Natasha Lechner Date of death - Natasha died on 8 March 2019 Place of death - Natasha died in Mullumbimby, New South Wales

Cause of death - The cause of Natasha’s death was sudden cardiac arrhythmia following the administration of Kambo frog toxin

Manner of death — Natasha died after participating in a Kambo ceremony

Recommendations

76.. Pursuant to s 82 of the Coroners Act 2009, Coroners may make

recommendations connected with a death.

77. For the reasons articulated above in paragraph [72], it is not necessary for me to make any recommendations.

Concluding remarks

| again express my deepest sympathies to Natasha's family, friends and loved ones.

It was clear to those present in the courtroom that she was deeply loved by all. She was a gentle, bright and kind woman, and her death is a great loss to her family and

friends, and to the broader community.

| close this inquest. Li Magistrate Teresa O’Sullivan

NSW State Coroner Date 23 February 2024