Inquest into the death of HC

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of HC Hearing dates: 19 March 2025 Date of Findings: 24 March 2025 Place of Findings: Coroners Court of New South Wales, Lidcombe Findings of: Magistrate David O’Neil, Deputy State Coroner of NSW Catchwords: CORONIAL LAW – missing person –overboard from boat –search –not possible to survive – File number: 2024/80118 Representation Coronial Advocate: Ms Amanda Chytra Non-publication orders Non-publication order made pursuant to s 75(2) of the Coroners Act 2009 and/or the incidental powers of the Court apply in this matter and are available on the Court file.

Findings: The identity of the deceased The person who died was HC.

Date of Death HC died on 17 January 2024.

Place of Death HC died in the Tasman Sea between Australia and New Zealand.

Cause of death Unascertained Manner of Death HC died as a result of actions taken by her with the intention of ending her life.

Introduction 1 HC was 64 years of age when she disappeared from the Majestic Princess in the early Hours of 17 January 2024.Inquest 2 An inquest was held on 19 March 2025.

3 An inquest is a public examination of the circumstances of death. It provides an opportunity to closely consider what led to the death. It is not the primary purpose of an inquest to blame or punish anyone for the death. The process of holding an inquest does not imply that anyone is guilty of wrongdoing. Despite this there may nevertheless be factual findings which necessitate an adverse comment or criticism to be made.

4 The primary function of an inquest is to identify the circumstances in which the death occurred, and to make the formal findings required under s 81 of the Coroners Act 2009 (NSW) (the Act); namely:

(a) the person’s identity;

(b) the date and place of the person’s death; and

(c) the manner and cause of death.

5 In the case of a missing person the first question is whether the evidence has established that the person has passed.

6 Another purpose of an inquest is 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, to prevent a death in similar circumstances.

Coronial Investigation 7 Prior to holding the inquest, a detailed coronial investigation was undertaken and a brief of evidence was prepared by the Officer in Charge (OIC) Detective Senior Constable Phillip Taylor. The brief included witness statements and CCTV footage which focused significantly upon the initial search for HC.

8 All the documents in the brief of evidence have been considered in making the findings detailed below Background 9 HC was born in Budapest, Hungary on 11 August 1960. She escaped as a refugee and ended up in Connecticut in the United States of America, where she met her husband. HC had two children. The couple divorced in 1992.

Tragically, HC's daughter passed away in 2006, leaving her in a state of deep depression for a year. Towards the end of her life, HC was estranged from most of her extended family.

10 In 2014, HC underwent knee replacement surgery which caused complications due to the replacement being too long. HC began to experience hip issues as a result and, due to her gait being impacted, she ended up having both knees and hips replaced over a period of several years. After these surgeries, HC required a cane to walk and was in significant pain, requiring medication.

11 After her daughter's death, HC's mental health declined. She spiralled into depression and told people that she did not want to live anymore. The grief coupled with the physical pain that she was in caused her to express suicidal ideation. Her son moved into the house next door to his mother in 2017 to try and help her, but she had difficulty accepting assistance. As the years went on, HC's mental health seemed to decline further. HC was in a significant amount of debt at the time of her death.

Love of cruises on board ship 12 HC had a deep love for cruising. Her son said that his mother enjoyed the idea of going to bed one day and waking up in another country, and every day being an adventure. She enjoyed shows and laying out in the sun by the pool. Her son told police that his mother had, for many years, been telling him that she would take her life on a cruise. She would often tell him before departing on a cruise that it would be her last and she would not return. Her son explained that his mother seemed to enjoy playing mind games around the idea that she was not returning.

The Majestic Princess 13 At the time of her disappearance, HC had been a passenger on the Majestic Princess cruise ship for approximately three months. The Majestic Princess is a British Royal-class ship operated by Princess Cruises. The ship was launched in 2017 and has a length of 330 metres. It has a capacity of 3,560 including a crew of 1,346. It has 19 decks, houses 1,780 passenger cabins and 757 crew cabins. At the time HC went missing, the Majestic Princess was on a 14-day cruise from New Zealand, which was due to end at Circular Quay Overseas Passenger Terminal on 18 January 2024.

14 During the cruise, HC was staying in a premium deluxe balcony room. HC was well known amongst the crew as she'd been aboard for so long and they had become accustomed to seeing her riding her red, motorised scooter around the ship. When HC wasn't using her scooter, she used two walking sticks to help

her walk. She would use these on occasions her scooter couldn't be accommodated, such as certain shore trips. HC was required to disembark when the Majestic Princess arrived in Sydney on 18 January, as per visa requirements, and she was not returning to the ship. She had told crew members that she did not want to leave.

HC fails to disembark 15 Around 6 or 7pm on 16 January, when the ship was on its journey to Sydney, HC asked a crew member whether he had some disembark luggage tags for her luggage, as she was packing her belongings. At 8pm on 17 January 2024, a crew member knocked on HC's door to clean her room. She did not answer, so he opened the door and went in to clean. He noticed that her ocean medallion and her passport were on top of the dresser table with three to four bags of luggage with disembark tags inside the wardrobe.

16 An ocean medallion is a device given to passengers that can be worn around the neck attached to a lanyard or around the wrist. Each medallion holds the passenger's unique digital identity which is encrypted and communicates with thousands of sensors on board and in the port. It enables cabin doors to be unlocked and for the guest to pay for onboard services. The crew carry smart devices and the medallion helps them know if occupants have left their cabin or may be inside.

17 The crew member did a quick clean of the room and did not notice anything that raised concern. About 7am on 18 January, the Majestic Princess berthed at the Overseas Passenger Terminal in Circular Quay. All passengers were required to disembark. About 8.30am, the crew member returned to HC's cabin and knocked on the door. Upon receiving no response, he opened the door to the cabin and went inside. He noticed the room was the same as he had left it the previous night.

18 HC's scooter, passport and ocean medallion were in the room and her luggage was packed. The crew member became concerned because none of the items had moved since the previous day, so he called his supervisor. The captain and security officer were immediately notified and it was established that HC had not disembarked as per her visa requirements.

A search commences 19 The missing persons routine and search pattern was initiated. The crew systematically looked for HC in designated areas. There were no CCTV cameras that captured the outside of HC's cabin. Security reviewed the ship's CCTV cameras and confirmed that HC was last seen at guest services at about 10.30pm on 16 January.

20 HC's information was accessed and showed that her cabin door was opened from the inside at 1.04am, 17 January. After the initial search of the ship was completed, Australian Border Force confirmed that HC had not disembarked through customs and a report was made to the New South Wales Police Force's marine area command.

21 Sydney Water Police and the marine area command detectives took carriage of the investigation and search. Marine search and rescue coordinator, Sergeant Ryan Spong, coordinated the search efforts from the marine area command search and rescue coordination room with a team of five detectives and another sergeant from the marine area command dispatched to the Majestic Princess. The Australian Maritime Safety Authority joint rescue coordination centre was notified. 17 officers from the Public Order and Riot Squad operational support group were also called in to assist with a coordinated search of the ship. The OIC gave evidence that he was very impressed by the approach to the search and the manner in which it was conducted.

22 The search initially focused on HC's cabin, as there was a working theory that HC may have gone overboard from her balcony, as her mobility scooter and walking aids were still in her room. At that point of the search, it was believed that HC's mobility was very limited without those walking aids.

23 HC's cabin was sealed so that it could be searched by police and to preserve any evidence. HC's luggage had been placed in a secure staff area and was searched by police. It was found that three of the luggage tags had handwritten notes on them. The notes were all similar and gave instructions to send the luggage to HC's son, and that he would pay for it.

Footage located of HC going overboard 24 At 4pm on 19 January 2024, Captain Foster contacted police to advise that they had located footage of HC going overboard from the promenade deck, deck 7, below lifeboat number 1. It was clear from the footage that HC had deliberately climbed over the railing and jumped into the water.

25 The time HC went overboard was 1.10am on 17 January 2024. The ship's position was halfway between Australia and New Zealand in the Tasman Sea.

The ship's speed was 18.6 knots; wind conditions NNS 10 knots. The location HC went overboard was two decks below her cabin and on the starboard side of the ship - the opposite side to her cabin.

26 HC's last movements were backtracked through CCTV. Although there are approximately 500 CCTV cameras on the Majestic Princess, not all of the public areas are covered. The Majestic Princess does not currently have an automatic man overboard detection system. Information provided by Wes Demory, Senior Director of Fleet Services for Princess Cruises, is that although a number of the Carnival brands have tested automatic detection systems, there are currently none that have been found to be effective due to the very high number of false alerts.

HC’s final movements before jumping off the ship

27 CCTV footage established that, at approximately 5pm on 16 January, HC attended the restaurant for a booking she had made the day prior. She ordered a large amount of food and left at about 7pm on her scooter. Around 10.30pm, HC attended the reception area of deck 5 and spoke with guest services about an overcharge on her account for drinks. This charge was rectified and HC left about 15 minutes later. This was the last time any of the crew spoke with HC.

28 The door lock records for HC's cabin show that, at 11.36pm on 16 January, HC's guest card was accepted and the room door was opened and then closed.

At 11.58pm, the door was opened from the inside and then closed again. At 1.04am on 17 January 2024, the door was opened from the inside again and then closed. HC's medallion was left inside the room at this stage.

29 HC was then captured on CCTV footage exiting the lift onto the promenade deck. She was walking with a single walking stick. Then she was seen walking out onto the outdoor deck near lifeboat 1. HC stopped, placed her walking stick on top of a cabinet, and climbed over the railing and underneath lifeboat 1. She then moved out of view of the camera. She is then captured on camera from the side of the ship, going overboard and into the water.

Prospects and duration of survival in the sea 30 Survival expert, Dr Paul Luckin, was consulted to establish a timeframe for survival. Dr Luckin is a recognised medical advisor to the AMSA and is recognised as such by the National Search and Rescue Council. Dr Luckin's opinion is that HC would not have survived the first minutes after entering the water. Her limited mobility would've rendered it practically impossible for her to keep afloat in the water.

31 The conditions at the time were 2 to 2.5 metre swells and 46 knot winds. The sea water temperature would have caused her to rapidly become hypothermic.

Exhaustion and dehydration were also factors to be considered. Dr Luckin also noted that even if HC were located, she would not be able to climb into a raft

dropped to her. The only chance of survival would have been a vessel on scene to lift her from the water.

Search area of 13,000 nautical miles 32 As part of the search effort, drift modelling had been conducted, based off the ship's last known location when HC's cabin door was last opened. The search area was calculated to be 13,000 nautical miles, which was too vast to enable an effective search. I am satisfied this was a reasonable and appropriate decision in the circumstances. The search had continued until 2.22pm on Friday 19 January 2024, when it was then suspended.

Did HC die at sea?

33 I formally determined on 12 June 2024 that HC had passed away on 17 January

2024. I accept the evidence of survival expert, Dr Paul Luckin that HC would not have survived the first minutes after entering the sea.

34 It is not possible to determine the medical cause of HC's death, in that it is not possible to know if the impact from the jump, or a medical episode as a consequence of the shock of jumping into the cold and rough water, or marine animal predation, caused or contributed to HC's death.

35 What is clear is that HC intended to end her own life. She had a history of expressing that she would take her own life. She had a history of expressing that she would take her own life during a cruise on a ship. HC made quite elaborate arrangements in relation to her belongings, even to the extent of indicating payment by her son. Her actions leading up to and jumping from the ship were clearly intentional.

Formal findings 36 I have determined that there is no requirement for any recommendations in this inquest as there are no systemic issues arising.

37 Before expressing the formal findings required by statute, I would like to acknowledge and express my gratitude to Ms Chytra, Coronial Advocate, for her assistance both before and during the inquest. I also thank the officer in charge, Detective Senior Constable Phillip Taylor, for his investigative efforts and for compiling the brief of evidence

FINDINGS UNDER S 81(1) OF THE CORONER'S ACT ARE: Identity: The person who died was HC.

Date: HC died on 17 January 2024.

Place: HC died in the Tasman Sea between Australia and New Zealand.

Cause of death: Unascertained Manner of death: HC died as a result of actions taken by her with the intention of ending her life.

Conclusion 38 On behalf of the Coroner's Court of New South Wales, I offer my sincere and respectful condolences to HC's family members and loved ones. In particular I offer condolences to and thank HC’s son for his assistance to the OIC and for attending the inquest by AVL.

I close this inquest.

Magistrate David O’Neil Deputy State Coroner 24 March 2025

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