Inquest into the death of JBO

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of JBO Hearing dates: 12-14 November 2025, Port Macquarie Local Court Date of findings: 19 December 2025 Place of findings: Lidcombe Coroner’s Court Findings of: Deputy State Coroner, Magistrate Hosking Catchwords: CORONIAL LAW – cause of death – suspected cardiac arrhythmia File number: 2023/242570 Representation: Counsel Assisting: Donna Ward SC and Rachel Thampapillai, instructed by Penelope Smith, Crown Solicitor’s Office Family of JBO: Emma Sullivan, instructed by Danielle Captain-Webb, Legal Aid NSW CD: Chanel Beesley, instructed by Jonathon Paff, North Coast Criminal Law Findings: Identity of deceased: JBO Date of death: 28 July 2023 Place of death: Casino and District Memorial Hospital, Casino NSW 2470 Cause of death: Cardiac arrythmia (first confirmed as ventricular fibrillation) of unascertained cause.

CULTURAL WARNING Aboriginal and Torres Strait Islander readers are advised that these findings may contain the name of a deceased Aboriginal or Torres Strait Islander person. Readers are warned that there may be words and descriptions that may be culturally distressing.

Manner of death: JBO’s cardiac arrythmia commenced shortly after JBO recorded evidence of a suspected breach of an APVO made for her protection.

Publication orders: Non-publication orders apply to the evidence in this inquest. A copy of the orders made by Deputy State Coroner Hosking can be obtained from the Court Registry.

FINDINGS Introduction 1 These are the findings of an inquest into the circumstances of the passing of JBO born on 19 April 1996.

2 JBO past ‘forever 27’ on 28 July 2023 at Casino and District Memorial Hospital, Casino NSW 2470 (the Hospital). She was a much loved mother, daughter, niece, sister, grandchild and friend.

3 JBO was a First Nations woman who grew up in the Bundjalung region with her family all around her. She lived in Casino. She was loved and valued by her family, many of whom attended the inquest. Their loss is deep and enduring. I express my sincere condolences to each and every person impacted by JBO’s tragic passing.

4 JBO was described by her family members as a healthy and active young woman who was ‘full of life and energy’. She was a bubbly person, outgoing, a talker, constantly giggling and making jokes and having a yarn. She could get anything from her grandfather with just one phone call.

The role of the coroner 5 The role of the coroner is to make findings as to the identity of the nominated person and in relation to the place and date of their death. The coroner is also to address issues concerning the manner and cause of the person’s death1. A coroner may make recommendations, arising from the evidence, in relation to matters that have the capacity to improve public health and safety in the future2.

6 This inquest was held on the basis that JBO’s manner and cause of death was not sufficiently disclosed3.

1 s 81 Coroners Act 2009 (NSW) (the Act).

2 s 82 of the Act.

3 s 27(1)(d) of the Act.

The issues examined at the inquest 7 It was clear before the inquest that the person who had died was JBO and that she died on 28 July 2023 at the Hospital.

8 The issues examined at the inquest related to the cause and manner of JBO’s death, including: (1) What was the cause of JBO’s death?

(2) Whether there was a causal link between JBO seeing CD on 28 July 2023 and the medical events leading to JBO’s death?

The evidence 9 A two volume brief of evidence was tendered to the Court along with a supplementary statement of JBO’s mother. Written and oral evidence was adduced from: (1) Professor Mark Cook, Neurologist and Epileptologist, report dated 1 October 2025 (2) Professor Anna Holdgate, Emergency Medicine Specialist, report dated 15 June 2024 (3) Professor Mark Adams, Cardiologist, report dated 29 October 2024.

10 I am also grateful for the heartfelt family statement read on behalf of JBO’s parents by her loving Aunts and the words of her grandfather.

Background 11 I’m grateful to the Assisting team for their preparation of, and the participants input to, the detailed chronology of relevant events which is annexed and marked A. I will refer to only the most salient aspects of the chronology in the body of my findings.

The assault (23 June 2023 – 28 June 2023) 12 The assault to be described below was not perpetrated in isolation. Some of the background as between JBO and CD and their broader families is set out in the chronology at Annexure A. The additional interactions described in the chronology were in evidence. Notwithstanding that I will be limiting my discussion in these findings to the incident occurring on 23/24 June 2023, I acknowledge that history and have taken it into account.

13 Arising from the assault on JBO, CD was convicted of: (1) assault occasioning actual bodily harm in the company of others and sentenced to a fourteen month intensive corrections order.

(2) stalk/intimidate intending to cause fear or physical or mental harm in relation to a video recorded after the assault for which she was sentenced to a 6 month intensive corrections order.

(3) contravention of the APVO for which she received a 6 month conditional release order.

14 On 23 June 2023, JBO attended a fundraiser at Casino Returned Servicemen’s Club (the Club). She was excited to be going out and had bought new clothes for the event, something she did not do often.

15 JBO attended the Club at around 8:30 pm. The event had about 300 people attending with 23 employees and 6 security staff working.

16 The events described below were largely captured on video and the footage was tendered in the inquest.

17 At around 11:56 pm JBO went into the female bathroom. She saw SD (CD’s sister) standing in the first room where the sinks were located. JBO went through the door into the next room where the toilets were located and heard SD say, ‘Come in now, she is here on her own.’

18 JBO then heard CD yell ‘Get the fuck out here JBO.’ 19 At least one other woman was also present with SD and CD.

20 Whilst in the toilet cubicle, JBO tried to use her phone to ring someone for help but her phone battery was flat.

21 On the video footage it can be seen that CD was preparing for something even whilst JBO was in the toilet cubicle. CD was clapping and pepping herself up.

She handed her phone to another woman whilst SD was recording events on a mobile phone.

22 JBO then walked out of the room in which the toilets were located and walked straight through the room with the sinks in it in order to get out of the female bathroom. She later told Police she knew something was going to happen.

23 JBO opened the door and CD grabbed the back of her hair and pulled her to the ground. She heard CD say, ‘talk about my son, talk about my son.’ This is also audible on the recording.

24 CD is seen punching down to JBO whilst JBO was on the ground. JBO was kicking up trying to get away and also grabbed CD’s hair. At one point CD fell to her knees and pulled JBO’s head up by the hair and punched JBO’s head.

25 JBO heard other voices yelling ‘Rip her CD, rip her.’ 26 Eventually some women came in and intervened.

27 A third party witness intervened. The witness stepped over a bin that had fallen over during the attack and stood over JBO to stop the others hitting her. Trying to reassure JBO she said, ‘security is coming, security is coming.’ 28 Another witness saw two girls on the floor fighting, one of whom she recognised to be CD. She told AC, who worked at the Club and was on duty that night, that there was a fight in the women’s bathroom.

29 In her statement JBO was understandably not sure what happened after the assault was over. She recalled a female security guard picking her up and helping to carry her down the stairs. She was given a bag of ice and asked if she needed anyone to be called to pick her up.

30 It was probably AC and TW who were the first club employees to come and help JBO. Neither of these women were security guards but each were working at the function that night. AC and TW are sisters and each of them had known JBO since High School. They helped JBO get down the stairs with assistance from the club supervisor who then went back to the Mirage room and closed the bar down.

31 According to AC, JBO said, ‘help me, I am going to die.’ 32 Security found CD and began to escort her out.

33 AC said that as CD was being escorted out, she walked past JBO and said something like ‘I am not done with you’. AC thought that JBO then stood up and started walking towards CD before a women came out from behind the reception desk to try and stand in the middle. AC said that one of the security guards was also trying to get CD out the front door of the Club when JBO started walking towards CD.

34 On 24 June 2023 at about 12.09am, CD was ejected from the Club.

35 SB, JBO’s Aunty, was at the function. She saw JBO with her arm around a security guard, blood coming out of her mouth, nose and eye. JBO told SB that CD had bashed her. SB said, ‘I was screaming at the security guards to call the police and ambulance.’ JBO was crying for her mum in this moment. SB rang JBO’s mum, brother and sister and told them to take her to the Hospital. SB also asked the workers for an ambulance.

36 Triple 0 was called at 12.11am by an employee of the Club to request an ambulance. A separate call was made to the police to report the incident and request police assistance.

37 By 12:15 am (within 4 minutes of the ambulance operator picking up the call) an ambulance unit was assigned to the job. The two paramedics who needed to attend were on call. They had to separately travel from their residences into Kyogle and meet at the ambulance station which they did at 12:30 am. They then left together for the job in Casino in vehicle 4522. By the time they arrived at the Club, JBO had already been taken to the Hospital by her brother.

38 Someone took JBO to the lounge area out the back of the Club.

39 AC came back to JBO, sat with her awhile and helped JBO put her phone on charge. AC also tried to call people from her own Facebook account to see if someone could come and pick JBO up, but no one answered.

40 Meanwhile a message had reached JBO’s family, via SB.

41 JBO’s brother received a phone call from his sister in Queensland, telling him that JBO had been assaulted by CD. He drove to the Club but at first security would not let him in (presumably because they were trying to shut the function down by this time.) 42 He was eventually able to get in and found his sister with 3 Club workers with her.

43 JBO’s brother and SB took JBO to the Hospital arriving before 12.54am.

44 JBO was safely at the Hospital before the Ambulance even arrived at the Club.

45 JBO was triaged at the Hospital at 12.54am. Notes from her initial assessment recorded:

Initial assessment – face swelling with the appearance of haematomas developing 1cm laceration near her left eye JBO’s bottom lip had swelling and a haematoma Glascow Coma Score 15/15 Pupils were equal and reactive Reported a headache and her left ankle was painful Temperature 36.9 Pulse 113 bp, Blood pressure 104/72mm HG Respiratory rate 20/min Oxygen saturation 99% room air

GCS 15 Neurological obs Normal 46 JBO had a video call with Dr Clark at 1.15am, his notes recorded: Call started at 1:21 and concluded at 1:47 am Alert and oriented, multiple soft tissue injuries to face, swelling and bruising to left lateral upper lid with a small punctate superficial eyelid laceration, bruise and swelling to right cheek just inferior to orbit. EOM normal, no entrapment, no signs of ocular injury, GCS 15 no focal neuro deficit, 2 small lacerations to lips, not gaping, not crossing vermillion border, superficial abrasions to right cheek as well, no increased WOB, abdo SNT on self palpation, left ankle mild lateral swelling, no deformity, some tenderness no malleoli, no foot swelling Clinical impression: eyelid laceration, lip laceration, soft tissue injuries to face and ankle.

Management plan: simple analgesia as needed, clean wounds with saline, steri-strip left eyelid laceration, crutches as unable to weight bear, will return in the morning for xrays of the left ankle and foot. there is a Dr on site in the morning who can examine the patient and decide on more advanced imaging – in particular, CT facial bones, clinically does not think there is an orbital fracture …return immediately if headache, vomiting or confusion…feels safe to go home with family.

47 Notwithstanding JBO’s distressing injuries, given their nature, a hospital admission was not required. JBO was discharged at 2.14am on 24 June 2023.

She was encouraged to return if her condition deteriorated or she had further concerns.

48 While JBO was at the Hospital, her brother’s girlfriend, KA could hear CD and others yelling outside JBO’s home, ‘JBO, get out on the fucking road.’ This was supported by SB who was on the phone to KA at the time.

49 JBO’s mother called police at 1:14am. The CAD entry for this call said that JBO had been bashed at a nightclub and was now in hospital and groups of possible POIs for assaulting JBO were outside JBO’s home address looking for her again.

50 Around 1.40am a police vehicle, Alstonville 18, drove past the address but by then it was quiet. Police did a few laps of the neighbourhood to be sure that nothing was happening.

51 Meanwhile, sometime after CD was evicted from the Club she recorded another video in which she seems to say, ‘JBO you slut, you dying by the fucking morning.’ 52 JBO contacted Police at 12.50pm to report the assault and Police attended at 3pm to talk to her. Their interview was cut short as JBO was to return to the Hospital at 4pm.

53 At 4pm, JBO returned to the Hospital for a physical examination and to document her injuries. She reported an ongoing headache, nil vomiting. There was visible bruising and swelling to the left side of her face. Standard observations were taken and the results were within normal limits. Dr Bonecki noted: …assaulted yesterday mainly head injury. No loc [loss of consciousness] can remember incident. Has been having difficulty concentrating since event and headaches, no vomiting, s/b police today and requesting medical review documentation of injury.

On exam: Productive cough Respiratory rate: 20 brpm Oxygen saturation: 97% Systolic blood Pressure: 112 mmHg Diastolic Blood Pressure: 70mmHg Peripheral Pulse Rate: 96 bpm Temperature Oral: 37.6 DegC Alert: oriented Speech: normal No localising neurological findings tender over left trapezius No bony spinal tenderness Tender over forehead and right cheek

Bruising around both eyes Steristrip in situ left outer eyer

PERLA No diplopia No numbness, teeth or gums Tender angle left jaw No trismus Good rom Scratch marks right lower cheek 54 JBO was discharged with information regarding signs and symptoms to look out for after a head injury and was given ibuprofen and paracetamol. She was advised that there was no X-Ray available in Casino at that time.

55 JBO become aware of the existence of the video of the assault and the video of the later threat from CD at about 4.30pm via her sister in law.

56 On 25 June 2023, Police attended on JBO at 10am and it was agreed that JBO would provide a statement at the Police station that afternoon. Senior Constable Clissold also attended the Club and obtained a copy of the incident report and requested the CCTV.

57 When JBO attended on Police that afternoon, she was able to provide the video footage of the assault and the subsequent footage of the threats made against her. An Apprehended Personal Violence Order (APVO) was taken out by Police naming JBO as the person in need of protection and CD as the defendant.

58 The APVO conditions included a condition that CD not reside or enter the street on which JBO lived. CD was subsequently charged and granted bail. While some of her bail conditions mirrored the APVO condition, her bail conditions did not preclude her from entering the street on which JBO lived.

Subsequent treatment and events leading up to JBO’s death 59 On 26 June 2023, JBO had a telehealth appointment at 10:15 am with Dr Katherine Hawkins at Bulgarr Ngaru Medical Aboriginal Corporation, Casino.

The appointment was conducted via a video call. Dr Hawkins encouraged JBO to come into the clinic in person but JBO indicated she was too afraid to do so

after the assault. The notes from this consultation with Dr Hawkins say that JBO was ‘crying a lot, feeling very tearful, very anxious, hypervigilant, and had difficulty sleeping.’ 60 Dr Hawkins and JBO talked about psychological supports from NSW Victim Services (phone counselling) or Northern Rivers Community Gateway (trauma support).

61 Dr Hawkins observed significant bruising and swelling to JBO’s face as well as black eyes. JBO also had swelling around her left temple and complained of pain on opening and closing her jaw. She had pain in her left ankle. JBO said she did not want analgesia and declined a short-term prescription of benzodiazepines to help her sleep4.

62 Dr Hawkins ordered a CT of JBO’s facial bones and an OPG x-ray. An OPG xray examines the upper and lower jaws and the teeth. Dr Hawkins thought there was no need for an ankle x-ray if JBO’s ankle continued to improve. A follow up appointment was scheduled for Friday 30 June 2023.

63 JBO went and had a CT of her face and OPG X-ray of her jaws and teeth later that day at North Coast Radiology. There were no acute injuries or fractures identified on x-ray or CT.

64 Dr Hawkins called JBO the next day, 27 June 2023, to check in with JBO and explain the results of the X-ray and CT. Dr Hawkins explained there were no fractures seen and that soft tissue healing can take several weeks.

65 On 28 June 2023, CD attended the street on which JBO lived for the purpose of obtaining personal belongings. She did this with the agreement of the police supervisor involved in her bail decision as they were not aware of the APVO condition preventing her from being on the street. CD was observed in the street by members of JBO’s family who raised it with Police.

4 JBO’s family confirmed she did not like taking medication.

66 Acting Inspector Leigh Hawdon later explained in an email dated 30 June 2023: It was a very unfortunate set of circumstances and miscommunication between Officers at Casino. Personal Violence Order was served on CD whilst she was in custody. Those conditions, particularly not to enter [redacted street], the Supervisor was not aware of. The Supervisor upon granting strict conditional bail, victim protection was part of that bail, not to approach or contact the victim in any way unless that contact is through a lawyer. Upon being released on conditional bail, CD made a request to the Supervisor to briefly return to [redacted street] to pick up some belongings. As a result of the investigation, I have spoken personally to JBO and apologised in regard to miscommunication on the evening and that no further action at this stage will be taken. I have informed JBO that I have reiterated to Officers at Casino the differing bail conditions and conditions of the personal violence order and that any matters in the future whereby JBO or family members require Police assistance that it will be treated as a matter or [sic] priority.

67 CD knew that she could not return to the street where JBO lived because at around 9pm she sent an SMS to her sister that said, amongst other things ‘can’t be in [redacted street] anymore fml’.

68 On 30 June 2023, JBO had her follow up telehealth consult with Dr Hawkins.

JBO again said she had difficulty sleeping and was again too fearful to attend the medical practice in person. JBO did say that her ankle pain was improving and she was able to mobilise with crutches. She still had ongoing facial pain but it was also improving. JBO said her neck felt stiff and sore. Dr Hawkins thought this seemed consistent with a whiplash type injury as JBO had her head pulled back by her hair during the assault.

69 JBO became tearful with Dr Hawkins when they were discussing her difficulties with sleeping due to feeling anxious and afraid. JBO hadn’t made contact with a counsellor yet and needed some assistance with this. Dr Hawkins was to discuss this with KD and she also offered to refer JBO for social work support.

They also discussed JBO staying off social media for a while.

70 JBO went to Queensland to get away from Casino. It is not clear when this occurred. There is no reference to her being in Queensland in Dr Hawkins notes from 30 June. NSW Police called in to check on JBO on 2 July 2023 and her brother told them that JBO had gone to Queensland. So, it appears she left for Queensland at some stage between 30 June 2023 and 2 July 2023.

71 On 3 July 2023, Dr Hawkins again contacted JBO by telephone to check in.

JBO said she was visiting her sister in Queensland as she needed to get out of town for her mental health. JBO said she was feeling like she was being watched in Casino as ‘everyone had seen the video’ on social media. She also said that the person who assaulted her was out on bail.

72 JBO told Dr Hawkins that she was herself staying off social media (as they had discussed during JBO’s last appointment) but that her family and friends were advising her of what was being said on social media.

73 JBO confirmed that KD had been in touch to help JBO with accessing counselling and they were trying to work out the best option for her.

74 On 10 July 2023, Dr Hawkins attempted to call JBO for a planned appointment, but JBO did not answer. Dr Hawkins left a message offering a further appointment but did not hear back.

75 On 14 July 2023, Dr Julia Chiu from Bulgarr Ngaru Medical Aboriginal Corporation Casino called JBO because her son was on her phone call list.

JBO thought the appointment was for her and so Dr Chiu offered her an appointment and said that she would call back in a few minutes. JBO indicated she was fine with this but did not answer when Dr Chiu called back a few minutes later.

76 Dr Chiu left a message for JBO and tried again to speak with her later that day.

The notes from this event record a plan to arrange an appointment for the following week with KH5. This appointment didn’t occur.

77 In her affidavit, JBO’s mother stated that while JBO was in Queensland she complained about constant headaches and was forgetful. There was an incident where JBO couldn’t find something while they were in the car, she was sweating and stressed, when her mother pulled the car over JBO got out and took her clothes off. This was out of character for JBO who her mother 5 Presumably a reference to Dr Katherine Hawkins.

describes was a very private person. This ‘QLD incident’ will be discussed below in relation to the interpretation of this conduct by the medical experts.

78 The precise timing of JBO’s return from Queensland remains uncertain. It is understood she only stayed for a couple of days before she wanted to go back home to Casino.

Events of 27 July 2023 79 The day before JBO died, another of JBO’s brothers, BBO, was attacked by OA. OA was the partner of one of CD’s sisters.

80 OA also attended JBO’s house, he was banging on the door demanding to be let in. JBO and her mother were sitting against the door to prevent him from coming in.

81 The ‘COPS’ Event for this incident states that OA assaulted BBO and that both JBO’s aunt and JBO spoke to police about the assault. BBO himself did not wish to report the assault but police obtained video recordings of the assault and charged OA with affray. He was charged on 28 July 2023, that is the day after the incident. He was later convicted.

82 When police spoke to JBO on 27 July 2023 about the attack on her brother, they said they would attend the family home the next evening to speak with BBO and the family. Tragically, JBO died the following afternoon before any home visit by police could take place.

JBO’s death on 28 July 2023 83 JBO was in the car with her mum and her son, driving home from Coles. They stopped to pick up her dad on the way. JBO and her son were in the back seat.

84 As JBO’s mother was driving towards their street, JBO told her mum she could see CD’s car parked outside CD’s sister’s place (she lived on the same street

as JBO and her family). JBO knew that CD wasn’t allowed on their street because of the APVO.

85 JBO’s mother kept driving towards their house.

86 JBO was tapping on the back of her mum’s seat telling her to turn around and turn back so she could get a photo of CD to give to police. JBO’s mother turned around and drove along their street and saw CD.

87 JBO had her dad’s phone. She made a recording which was tendered to the court.

88 JBO is heard to say to her mum ‘Go slow too’ then ‘Yep I got her, I got her’.

89 Then JBO collapsed and dropped the phone but the recording continued.

90 We can hear on the recording JBO’s parents’ distress as they tried to get her to wake up as she was driven immediately to the Hospital.

91 As they arrived at the Hospital. JBO’s mum was blasting the horn on the car to attract attention as they drove up to the ED.

92 JBO’s dad ran into the Hospital and told staff that JBO had a seizure and became unresponsive 5-10 minutes prior to their arrival outside the ED.

93 The Hospital notes record ‘JBO found in back seat, lying down with agonal respirations and unresponsive, centrally cyanosed … CPR commenced.’ 94 Those notes also referred to JBO being centrally cyanosed. This means that JBO had a bluish tinge, also probably because she wasn’t getting enough oxygen. This is consistent with her mother telling the Hospital staff on the recording ‘she’s turning blue’.

95 JBO had 29 cycles of CPR but didn’t respond to resuscitation efforts. JBO received four defibrillation shocks to try and re-start a normal heart rhythm but

this didn’t work. JBO received multiples doses of adrenaline to try and resuscitate her and an endotracheal tube was inserted to help with her breathing but this didn’t work. JBO was administered amiodarone but this didn’t work.

96 Dr Iravan Sahgal6, spoke to her father and said that all medical options had been exhausted. Dr Sahgal also consulted with another senior doctor at Lismore Base Hospital before recommending that resuscitation attempts should cease.

97 JBO’s father was with her when resuscitation attempts ceased after 1 hour and 5 minutes of what is described as high-quality CPR.

98 JBO’s time of death was recorded as 1:48pm.

99 What happened next was very distressing to JBO’s family.

100 JBO was moved from the Hospital to Lismore too quickly. Her grieving family were not able to spend enough time with her. Some relatives had not arrived at the Hospital before she was moved. Particularly in circumstances where her death occurred in such tragic circumstances and was such a shock, this was further traumatising for her family.

101 After she died, JBO’s family’s access to her was also limited in that they were not able to touch her body. I apologised to JBO’s family for appropriate provisions not being made for them.

102 It was explained to JBO’s family that part of the reason this occurred was because of the shocking and not immediately ascertainable nature of JBO’s death.

6 The senior doctor working on JBO, a specialist emergency doctor.

103 In their report to the Coroner, Police identified JBO’s death as suspicious. There is no criticism of the NSWPF for doing this. The connection between JBO seeing CD and her physical response was unexplained.

104 Further, at that time it was not known if CPR attempts to try and resuscitate JBO were appropriate. JBO was left as she had been when CPR attempts ceased. This was so that the doctor performing the autopsy could record the evidence of medical intervention that had been attempted but which had failed.

The conditions on JBO’s family having access to her after her passing may be explainable while also being factors which aggravated the trauma suffered by her family.

105 I acknowledge the statement of JBO’s Aunt: As an Aboriginal person when we grieve and mourn it is important for us to touch our loved ones and say our final goodbyes. I was not able to do this and to this day it deeply affects me. This is the first time that a family member has passed where we have not been able to touch and smell them and say our final goodbyes.

106 I understand that the Northern NSW LHD is in the process of drafting a policy that that will say what hospitals in that district should do after a person in the hospital has died, and how those hospitals can care for the deceased person.

A copy of these findings are to be provided to the Northern NSW LHD so that they may consider the impact to grieving families of access to a loved one being limited as this may assist in guiding them as their policy is being drafted.

Autopsy 107 A forensic post-mortem examination was conducted on JBO on 3 August 2023 by Dr Alison Ward. Unfortunately, despite the thorough internal examination, no significant pathologies or injuries were revealed. Further, neuropathology examination of the brain also revealed no significant pathological abnormalities.

108 Dr Ward concluded that JBO’s cause of death was ‘unascertained.’ She commented that the cause of death may have been due to a functional rather

than a structural cardiac disease. She identified abnormalities of the cardiac conduction system, including channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT syndrome) as possibly causing JBO’s death. While these disorders can cause a fatal cardiac arrythmia resulting in sudden death, Dr Ward confirmed that they do not cause structural or microscopic abnormality evident in a post-mortem examination.

109 Dr Ward’s opinion is not inconsistent with the additional expert opinions obtained in the course of the inquest which will be discussed in more detail below.

Expert evidence Professor Cook 110 In his report, Professor Cook opined that the assault on JBO resulted in a concussion. While initially described as a mild concussion, he acknowledged in his evidence that the incident in QLD was suggestive of a more serious concussion injury.

111 Having the benefit of the video footage from when JBO collapsed in the car with her son and parents, Professor Cook opined that JBO’s presentation was not consistent with epilepsy. He considered her collapse was caused by a serious cardiac arrythmia.

112 Professor Cook opined that JBO’s: …cardiac event may have been precipitated by extreme emotional stress, superimposed on a background of anxiety and trauma following the assault.

113 Professor Cook considered that JBO potentially suffered from a stress-induced syndrome such as Takotsubo cardiomyopathy. He acknowledged that other inherited arrythmia syndromes could also be provoked by stress but these are difficult to diagnose retrospectively (and via post-mortem).

A/P Holdgate 114 A/P Holdgate opined that JBO died from a fatal cardiac arrythmia resulting in cardiac arrest from which she could not be resuscitated.

115 A/P Holdgate also ruled out a seizure.

116 A/P Holdgate opined that it is most likely that JBO: …experienced a rhythm such as ventricular tachycardia which resulted in very low cardiac output resulting in her collapse associated with abnormal respiratory effort and seizure-like activity. This rhythm further deteriorated to ventricular fibrillation which caused a complete loss of cardiac output resulting in cardiac arrest.

117 In relation to causes of the abnormal cardiac rhythm, A/P Holdgate opined that

JBO: …may have had an underlying and undiagnosed abnormality of the electrical conduction system in her heart such as long QT syndrome and Brugada syndrome. In the presence of stress, the associated surge in adrenaline may worsen or expose underlying conduction abnormalities resulting in abnormal electrical conduction in the heart causing arrythmias and cardiac arrest.

Conditions such as long QT and Brugada are often asymptomatic until an acute event occurs such as syncope or cardiac arrest.

118 A/P Holdgate considered it less likely that JBO suffered from Takotsubo syndrome because it typically presents with chest pain and failure of the heart pump rather than a primary arrhythmia. It is A/P Holdgate’s view that there would have been evidence of the effect of Takotsubo syndrome on the heart at the post-mortem.

119 A/P Holdgate opined that JBO’s death was most likely due to a fatal cardiac arrythmia triggered by severe emotional distress.

A/P Adams 120 A/P Adams opined that JBO’s death was most likely due to a cardiac arrythmia triggered by severe mental stress in the setting of having an underlying predisposition to developing an arrythmia.

121 A/P Adams also considered Takotsubo syndrome to be an unlikely contributing factor given there was no evidence of that syndrome present on autopsy. He considered an underlying arrhythmogenic disorder such as long QT syndrome to be more likely.

Issues 122 The participants to the inquest had helpfully agreed about the chronology of significant events leading up to JBO’s passing. As such, closing submissions focused on the issues identified for consideration in the inquest, being: (1) What was the cause of JBO’s death?; and (2) Whether there was a causal link between JBO seeing CD on 28 July 2023 and the medical events leading to JBO’s death?

123 I acknowledge that not all potential matters causing or contributing to JBO’s passing were explored or excluded in the inquest.

124 JBO went into ventricular fibrillation (VF) sometime after she saw CD on 28 July

2023. This was the rhythm first detected when JBO arrived at the Hospital with her parents.

125 A/P Adams, expert cardiologist, suggested that JBO may have first gone into ventricular tachycardia (where the ventricles in the heart are beating too quickly). That is certainly a possibility but as ventricular tachycardia leaves no sign that doctors can look for on autopsy, we just don’t know if that was the actual pathway that led to VF in this case.

126 A/P Holdgate explained that VF is a ‘shockable rhythm’. This means that medics can try and get a patient in this state back into a regular heart rhythm by using the cardiac paddles to apply a shock to their heart. This was attempted repeatedly at the Hospital with JBO and sadly it did not work. A/P Holdgate’s evidence was that sometimes if someone has already been in VF for too long, it will be too late for the paddles to work.

127 There is such little time to get to someone with VF and try and save them. A/P Holdgate said if someone is already in hospital and hooked up to a heart monitor and goes into VF and the hospital can get to them quickly, then the paddles might work. Despite the swift action on the part of JBO’s parents in getting her to the Hospital, she was unable to be saved.

128 At the Hospital JBO further deteriorated. Her heart went from VF into ‘pulseless electrical activity’. In essence, JBO’s heart didn’t respond to treatment despite best efforts from a team led by an experienced emergency medicine specialist.

129 Consistent with the views expressed by Dr Ward in her post-mortem examination report, AP Holdgate and AP Adams confirmed that the rhythm JBO was experiencing was due to an electrical disturbance in her heart. That disturbance could be monitored when she was alive and hooked up to machines at the hospital, but once she passed and her heart stopped producing electrical activity, there was nothing to see (including on a post-mortem examination) in the heart to show what had previously gone wrong with the electrical cardiac rhythm.

130 At the time of her death, JBO was suffering from the emotional and psychological consequences of her assault in the Club; the videos featuring her circulating amongst her community and the assault on her brother by OA the day before she died.

131 These factors likely contributed to an adrenaline surge which peaked on seeing CD on the day of her death. This was the trigger for JBO’s collapse. This is clear from the footage she took on her father’s phone. Having each watched the footage, each of the experts opined that a temporal connection exists.

132 This adrenaline surge was a physiological response which on this day likely triggered the cardiac arrhythmia which ultimately resulted in JBO’s death.

133 That said, the adrenaline surge on its own does not explain why JBO fell into an arrythmia this day.

134 AP Adams said that there is still so much that medical science has to learn about channelopathies leading to arrythmia.

135 I cannot rule in or rule out the possibility that JBO had a predisposition to VF which, together with an accumulation of stressors in the background and the presence of CD on her street, contributed to JBO’s collapse.

136 Any predisposition may have been genetic or it may have been individual and without a genetic cause. If JBO had a predisposition it may have been long QT or Brugada syndrome or another cardiac channelopathy.

137 Prof. Cook thought that Takotsubo cardiomyopathy best fit JBO’s clinical picture. AP Adams and AP Holdgate thought this less likely because JBO wasn’t complaining of chest pain prior to collapse and there were none of the signs one might see in the heart if someone had experienced Takotsubo for a period of time. Prof. Cook ultimately indicated he would defer to AP Adams and AP Holgate such that the evidence ultimately was not persuasive in relation to Takotsubo cardiomyopathy.

138 While it seems likely that JBO suffered an underlying predisposition to developing an arrythmia, the evidence adduced at the inquest does not enable a concluded view including as to the precise nature of the predisposition.

139 I find that JBO died from cardiac arrythmia (first confirmed as ventricular fibrillation) of unascertained cause. JBO’s cardiac arrythmia commenced shortly after JBO recorded evidence of a suspected breach of an APVO made for her protection.

Concluding remarks 140 I will close by conveying to JBO’s family, friends and community, my sympathy for the tragic loss of their beautiful JBO.

141 I thank the Aboriginal Coronial Information and Support Program social worker, Nicolle Lowe for her invaluable work. The Court always relies on her great assistance and is grateful to receive it.

142 I thank the Assisting team for their outstanding support in the conduct of this inquest.

143 I thank the officer in charge, Detective Sergeant Michael Martin, for his work in conducting the investigation and compiling the brief of evidence which was supplemented by the Assisting team.

Statutory findings required by s 81(1) 144 As a result of considering all the documentary and the oral evidence heard at the inquest, I make the following findings: Identity The person who has died is JBO Place of death JBO died at Casino and District Memorial Hospital Date of death 28 July 2023 Cause of death Cardiac arrythmia (first confirmed as ventricular fibrillation) of unascertained cause.

Manner of death JBO’s cardiac arrythmia commenced shortly after JBO recorded evidence of a suspected breach of an APVO made for her protection.

I close this inquest.

Magistrate R Hosking Deputy State Coroner Lidcombe

---

Annexure A – Chronology Date Time Event Source 19 April JBO born (JBO aged 27 when she died) Report of Death 1996 to the Coroner, Tab 1, p 6 26 May 2014 JBO’s daughter is born 25 May 2020 JBO’s son is born 9 April 2023 5:47pm COPS EVENT E77437849 COPS EVENT E77437849, Tab JBO’s sister called police “people driving past yelling out threat[en]ing to get people to come bash infts sister [JBO] – owner of the veh[icle] is [KD] (approx. 30 year old) her younger sister [CD] was driving the veh[icle]” 9 April 2023 6:03pm COPS EVENT E77437849 COPS EVENT E77437849, Tab “2 [Females] that were yelling out to informant have prev[iously] physical[ly] bashed inf[ormant] and informant is scared – informant calling for ETA of pol[ice] – PO have now left” 9 April 2023 7:14 pm COPS EVENT E77437849 COPS EVENT E77437849, Tab Police attended between 7:14 and 7:22 pm “At the above T/D the Vics were in the front yard of their residence at the above LOC. The PNs drove past the VICs enticing them to a physical fight, The VICs ignored the PNs and went inside to contact police.

Police attended where the VICs told them that they were unsure why the PNs wanted to fight however they had been assaulted by them in the past, so they didn’t want it to happen again.

Police advised the two to apply for a personal violence order at Court and inform police if there are any further issues. Nil threats or offences detected” 10 April 1:49 pm COPS Event E93322418 CAD LOG 2023 10/4/23, Tab 85 Call to 000

COPS EVENT “POIS HAVE TURNED UP AA WANTING TO FIGHT – NK E93322418, Tab

WEAPONS – POS ARE [CD] AND [CA] NFD- POIS KNOWN TO HAVE KNIVES” 10 April 1:56 pm COPS Event E93322418 CAD LOG 2023 10/4/23m Tab 85, Police arrived on scene at JBO’s home address p 26 People of interest were no longer at the scene COPS entry COPS entry E93322418, Tab “There is a history between the Victim and the PN. At times they’re the best of friends and other times the worst enemies.

Of recent the Victim and the PN have been on bad terms and as such there has been several incidents of the PN inviting the Victim to fight.

One of which occurred on the evening on the 9th of April and another during the day of 10th of April.

Both of these occasions occurred when the PN is alleged to have driven past the Victims house and have invited the Victim to fight.

On both these occasions nil offences have occurred and the Victim has been given the advice of applying for a personal violence order through the Courts.” 10 April 5:45 pm COPS Event E93322418 COPS entry 2023 E93322418, Tab Call from JBO’s sister “Around 6 pm on Monday the 10th of April the Victim attended Coles at Casino During this time the PN was also at Coles, The Victim alleges that the PN has walked up to her and has begun to call her out for a fight. Nil threats other then inviting the Victim to engage in a physical fight.

Around 6:30 pm the Victim attended Casino Police Station wishing to report the matter. The Victims version changed several times and Police advised the Victim that she should seek to apply through the Court for a personal violence order (which she had been advised on two prior occasions, one of which with an officer emailing the Victim the steps to apply).

Police attended Coles Casino in order to review the CCTV, which however had nil CCTV covering the incident. Nil Coles staff witnessed the incident.

There was one witness to the event who[se] details remain unknown however that witness stated she only heard the two parties arguing and couldn’t make out what was said and that the parties left after a short time.

Nil offences, Record only. Advice given in regards to PVO application.” 9 May 2023 1:58pm CAD ENTRY CAD Entry, Tab Call from JBO’s sister at 1:58 pm “Inft sister [JBO] has 19041996 has been abused by nbour [CD] 21-23 old – POI was trying to fight inft sister. Nil confrontation.

NWS – NPI, Prev history of physical and verbal abuse from PO – ongoing for weeks. POI poss IP. Chks OTW.

Police attended on scene at 3:47 pm 10 May 2023 Around CAD ENTRY CAD entry, Tab 4:11- 92 Informant – JBO 4:17pm 4:11 pm record

“Details: Inft Daughter [JBO’s daughter] 8 yr old has been bashed by another little girl and came home crying – inft yelling at the child – inft just kept yelling at TZ as well and not answering questions then used some very colourful language and terminated – chks OTW” 4:17 pm record “Details: Inft 8 year old daughter [JBO’s daughter] has been bashed by [DD] 10 years old and [TBR] 11 years old – Inft Curr AA – POIs Curr at [address] with [DD’s] Mother …. NWS – Regular History – Chks OTW – Ambos declined” Police attended on scene at 4:22 pm and did a welfare check Police attended on scene at 5:45 pm Friday Fundraiser being held at Casino Returned Servicemen’s (RSM) Club 23 June 2023 23 June Afternoo JBO getting ready to go out - KA remembers JBO’s Statement of KA, 2023 n brother telling JBO to change her clothes because she might get Tab 15 [4], p 76 into a fight tonight. JBO said “I am not going out looking for fights.

I am just going out to have a good time.” 23 June 8:30pm JBO attended the RSM Club, located on Canterbury Street for a Statement of NG, 2023 fundraiser for a local rugby league team. Tab 32 [11] – [13], p 162 Event had 300 people. The doors opened at 9:30 pm to the Mirage room. There were 23 employees and 6 security staff.

There was a lock out imposed at 11 pm.

23 June 11.56pm JBO was cornered in the toilets by CD, JM and SD. NSW Police Facts 2023 Sheet, Tab 67, p JBO walked to the door CD pulled her hair back and JBO fell to the floor A silver bin was knocked over Video of assault Multiple punches to the head in toilets (Electronic CD was holding JBO down on the ground – punching continuously Material Tabs 3 JBO tried to kick up and 4) Women came in and intervened – JBO held onto the woman’s leg 23 June Observed female on the floor with about 3 or 4 other females. Statement of TF, 2023 Stepped over a bin that had fallen on the floor…stood over the Tab 19 [8] – [11], female on the ground to stop the others hitting her and said pp 121 – 122 “security is coming, security is coming” Statement of BH, Saw a girl on the floor and her head covered in blood. CD was Tab 20 [8] & [11], punching the girls head. Heard the girl on the floor say ‘Help’ pp 123 – 124 Statement of JK, Tab 21 [11] – [12],

p 126 Saw CD run and grab girl who was running towards the door. CD pulled her back, grabbing her by the hair. Saw CD smack the girl Statement of RL, a couple of times in the head. The girl was on the ground Tab 22, p 128 Statement of Saw two girls fighting on the floor. The one on the floor had blood SBA, Tab 23 [12] on her face. “I tried to physically pull them apart but it didn’t do – [13], p 131 much. There was another person trying to separate them.” Statement of TS, Left the bathroom and told AC who works at the RSM “there is a Tab 24 [18], p 133 fight in the bathroom” “I said to one of the security guards I know ‘JKE, there is blood in there’.” 23 June 11:56 – JBO attempted to call someone for help, but her phone was flat. Statement of 2023 12:01 am CD repeatedly kicked and punched JBO in the face and body. JBO, Tab 18 [10] – [14], p 117 Saturday 24 June 2023 24 June 12:01am CD and JM walked out of the female toilets NSW Police Facts 2023 Sheet, Tab 67, p 24 June After JBO said “…I remember a female security guard jumping on top Statement of 2023 of me. She said my name a few times. She picked me up and JBO, Tab 18 [18 – 12:01am helped carry me down the stairs and walked me out to the lounge [21], p 118 down stairs.”… “She gave me a bag of ice and asked if I needed anyone to be called or picked up.” 24 June SB saw JBO with arm around security guard, one shoe on, Statement of SB, 2023 dragging her foot, walking towards the foyer… “I was screaming at Tab 25 [12] – [18], the security guards to call the police and the ambulance”… [21] & [24], pp [JBO]grabbing hold of [SB], security guard and another person 136 – 137 present when girl walked past and said “I am going to kick the cunt out of you [JBO]”…”that’s what you get slut”…security locked the doors…[SB] rang ]JBO’s] mum and sister and brother telling them to take her to the hospital…kept asking the workers for an ambulance…[JBO’s brother] arrived and was let inside to pick up [JBO], [SB] and [SB’s] daughter and go to the Hospital 24 June JBO walking towards AC (AC worked at the Club and was a friend Statement of AC, 2023 of JBO’s since school), dragging her leg and saying “[AC], help Tab 26 [20 ] – me, I am going to die”, said it 3 or 4 times…said “I got double [22], p 141 banked in the toilets” Observed to be bleeding from her eye, nose and maybe lip, blood on her singlet

24 June TW (AC’s sister) went up to JBO with AC and ED (Club Statement of TW, 2023 supervisor) trying to tell JBO we needed to get her Tab 27, pp 147 & downstairs…”When I saw [JBO’s] face I just wanted to get her out 149 of there. ED and I walked JBO down the stairs and security came and assisted.” “When I was talking with [JBO] she kept saying she should have stayed home. She said something about an ongoing feud between family. I just tried to keep her calm” 24 June ED (Club Supervisor) helping her staff helping woman down Statement of ED, 2023 steps. “It was horrible. She had blood coming out of her face. After Tab 29, p 153 I got about halfway down the stairs I went back into the Mirage Room and closed the bar down. When we took her downstairs we had to keep away from other people who were yelling at her from the top of the stairs” 24 June NG (Club Manager) hears a female yelling and sees security Statement of NG, 2023 escorting a female out the front doors of the Club, later told her Tab 32 [19], p 163 name was CD 24 June 12:09am CD left the street outside and was picked up by someone Statement of NG, 2023 Tab 32 [23], p 164 24 June JBO was sitting on a seat in the corner downstairs – she had Statement of SS, 2023 blood all over her face Tab 36 [6], p 173 24 June 12:11am The Club Event Co-ordinator of the fundraiser, MS, called Triple Statement of MS, 2023 000 and asked for an ambulance. MS also called the Casino Tab 30, p 156 (app.) Police Station to report the incident and request police assistance.

MS said “JBO sat under the electronic screens in the foyer. I looked at her and I was in disbelief of her injuries. I called 000 and asked for an ambulance saying that she had head injuries and she was conscious. I also made a call to Casino Police station. I don’t recall if this was before or after JBO came down the stairs…[ the call was diverted to Lismore then Casino then Lismore Police].

I told them where I was from Casino RSM and told them we need assistance, as I had a feeling that there was going to be a drama with the exiting of the event.” Statement of JKE, JKE (security guard) was speaking with two females and JBO – Tab 31 [10] – [11], JKE told them not to leave as they had called an ambulance for p 160 her. Someone took JBO to the lounge area out the back 24 June 12.11am 000 call, phone pick up Statement of 2023 Brent Armitage, Tab 39 Annexure A 24 June 12.15am Ambulance unit assigned (two on call paramedics in the Kyogle Statement of 2023 area assigned from their homes) Brent Armitage, Tab 39 Annexure A

24 June 12.30am Two paramedics met at Kyogle station and then left for the job in Statement of 2023 vehicle 4522 Brent Armitage, Tab 39 [8], p 180 24 June AC later went back and sat with JBO and put her phone on to Statement of AC, 2023 charge Tab 26 [35] p 142 24 June JBO said in her statement “RSM staff walked me out a back door Statement of 2023 and I was picked up by my brother, as they were very concerned I JBO, Tab 18 [22] may get assaulted again…my brother immediately took me to – [23], p 118 Casino Memorial Hospital” 24 June JBO’s brother arrived to collect JBO, security guards had the door Statement of JB, 2023 barricaded…”I pretty much had to force myself in there as the Tab 14 [8] & [10] security guard was not going to let me in.”…found JBO inside with p 73 3 RSM workers 24 June 12:17am NG saw police arrive at the RSM Club around 12:17am and Statement of NG, 2023 interact with the crowd and two men were tasered out the front. Tab 32 [23] & [25], p 164 24 June 12:35am NG states that the police start to leave Statement of NG, 2023 Tab 32 [26], p 165 24 June 12.53am Ambulance unit arrived but at 1253 advised by Police they needed Statement of 2023 paramedics at Casino Police Station as they had relocated Brent Armitage, patients from the RSM Club to the Police Station, Ambulance unit Tab 39 Annexure were told that the original patient (JBO) had been taken to hospital A via private vehicle. Ambulance attend Police Station as requested by police.

When the ambulance arrived, someone said the female had been Statement of taken out the back and had already gone to hospital. Richard Phillips, Tab 35 [12] p 172 MS said “I am not sure what time but the ambulance arrived and Statement of MS, parked out the front. I walked back into the main bar area and Tab 30, p 157 JBO had gone. AC and TW said she had gone in a car and left.” MS said “There was a hole [sic] lot of drama outside. We let the Statement of MS, first lot of people outside the doors and closed the doors to Tab 30, pp 157 - prevent a stampede of people and chaos. There was a lot of 158 people gathering. There were a few angry ones. The police acted, pepper spray which made the crowd more reactive. The people inside were becoming hostile so I just opened the doors. The Ambulance that was there treated the people who had been sprayed by police.” 24 June 12.54am JBO’s vital signs recorded at Casino Memorial Hospital Hospital records 2023 on 24 June 2023, Tab 45 pp 205 – 24 June 12:54am JBO spoke with Registered Nurse AS. Statement of AS, 2023 Tab 43 Triage form, Tab 40, p 191

Per AS triage form entry at 00.54 “was assaulted at a night club by 2 people, punched & kicked in the face, hair pulled & drug abound [sic] th [sic] [query “dragged around the”] floor scratched on the face, swelling haematomas & 1 cm laceration to L) eye.

Headache. No LOC, PEARL P=3. L) ankle pain no swelling” 24 June 1am AS undertakes Emergency Nursing Assessment Statement of AS, 2023 (approx.) Tab 43 [8] – [9], Initial assessment – face swelling with the appearance of pp 200 – 201 haematomas developing 1cm laceration near her left eye JBO’s bottom lip had swelling and a haematoma Glascow Coma Score 15/15 Pupils were equal and reactive Reported a headache and her left ankle was painful Temperature 36.9 Pulse 113 bp, Blood pressure 104/72mm HG Respiratory rate 20/min Oxygen saturation 99% room air

GCS 15 Neurological obs Normal 24 June While they were at the Hospital, JBO’s family were on the phone Statement of SB, 2023 to JB’s girlfriend, who was at JBO’s home address and could Tab 25 [28], p 137 hear CD and her family yelling out…calling out for JBO, wanting to fight her KA at home at JBO’s home address when she heard CD yelling Statement of KA, out from the front of the house, “[JBO], get out on the fucking Tab 15 [12] – [13] road”… & [23], pp 76 – 77 KA later sees 4 police cars drive past the house (after JBO’s mum told KA she was going to call the police) but none of the police cars stopped 24 June 1:15am Commencement of video call with Dr Ryan Clark. Dr Clark Statement of AS, 2023 completed a full assessment of JBO before a plan of care was Tab 43 [13] – [14], decided in consultation with JBO and JBO’s Aunty. He advised pp 201 – 202 them of wound care and signs of head injury and that she should come back to the emergency department if she develops a headache, vomiting or confusion.

Progress Notes, Tab 41 pp 194 – Call started at 1:21 and concluded at 1:47 am Alert and oriented, multiple soft tissue injuries to face, swelling and bruising to left lateral upper lid with a small punctate

superficial eyelid laceration, bruise and swelling to right cheek just inferior to orbit. EOM normal, no entrapment, no signs of ocular injury, GCS 15 no focal neuro deficit, 2 small lacerations to lips, not gaping, not crossing vermillion border, superficial abrasions to right cheek as well, no increased WOB, abdo SNT on self palpation, left ankle mild lateral swelling, no deformity, some tenderness no malleoli, no foot swelling Clinical impression: eyelid laceration, lip laceration, soft tissue injuries to face and ankle.

Management plan: simple analgesia as needed, clean wounds with saline, steri-strip left eyelid laceration, crutches as unable to weight bear, will return in the morning for xrays of the left ankle and foot. there is a Dr on site in the morning who can examine the patient and decide on more advanced imaging – in particular, CT facial bones, clinically does not think there is an orbital fracture …return immediately if headache, vomiting or confusion…feels safe to go home with family 24 June 1:25am All police had left the scene. Statement of NG, 2023 Tab 32 [26], p 165 24 June 2:14am JBO was discharged and left the Emergency Department Statement of 2023 Annette Scofield, JBO did not want to take any analgesia so RN Schofield applied Tab 43 [15] – [19], cool packs to her ankle and face for pain. Management. Cleaned p 202 the laceration to left brow, applied steri-strips JBO insisted she wanted to go home – gave encouragement to return to ED for further assessment if her condition deteriorated or if they had any concerns According to Hospital Records by Schofield “PLAN: reviewed by Progress Notes, My Emergency Doctor, gave analgesia, fitted and educated on Tab 41, p 194 crutches, mild head injury fact sheet explained and understood, discharged with family to return in am for further review and order for xray of ankle” 24 June 3:01am JBO sent an SMS to AC “Thank you so much sis for everything let Statement of AC, 2023 you sister know I thank her as well much appreciated i’m fine Tab 26 [42] – [45] know [sic] thanks again x” p 143 AC “I hope you are okay please be safe. If you need anything you give us a yell. I am sorry I could not do more to help.x” JO “Its ok you had other jobs to attend to I could have happened to anyone, but it was me tonight but for ever being safe I am just glad it was someone who knew me and knew how to come at me.

Thanks (praying hands emoji) xx next time I see out I am going to cuddle you thank you so much I am off to sleep now (laughing emoji)” AC “If you need anything at all please let us know I will give you a big cuddle when I see you next too. I hope you wake up feeling okay xx”

24 June 3:00pm Senior Constable Leizsha Clissold attended JBO’s home and JBO Statement of SC 2023 provided police with her version of the assault and took Clissold, Tab 69 photographs of her injuries. and 7 Photographs of [JBO], Tab 70 24 June 4:00pm JBO goes back to Casino Hospital Hospital records 2023 on 24 June 2023, Triaged by RN Cowie at 1558 “Representation from yesterday Tab 45, p 206 post assault. Was seen yesterday and has had police statement today. Request to have physical examination and documentation of injuries. Headache ongoing since last night. Nil vomiting.

PeARL, bruising/swelling left side of face” Standard observations taken and within normal limits JBO seen by Dr Barbara Ursula Bonecki.

“assaulted yesterday mainly head injury. No loc [loss of consciousness] can remember incident. Has been having difficulty concentrating since event and headaches, no vomiting, s/b police Statement of Dr today and requesting medical review documentation of injury” Barbara Ursula Bonecki, Tab 46 [5] – [7] pp 212 – On exam

• Productive cough Hospital records on 24 June 2023,

• Respiratory rate: 20 brpm Tab 45 p 209

• Oxygen saturation: 97%

• Systolic blood Pressure: 112 mmHg

• Diastolic Blood Pressure: 70mmHg

• Peripheral Pulse Rate: 96 bpm

• Temperature Oral: 37.6 DegC

• Alert: oriented

• Speech: normal

• No localising neurological findings tender over left trapezius

• No bony spinal tenderness

• Tender over forehead and right cheek

• Bruising around both eyes

• Steristrip in situ left outer eyer

- PERLA

• No diplopia

• No numbness, teeth or gums

• Tender angle left jaw

• No trismus

• Good rom

• Scratch marks right lower cheek Advised X ray not available in Casino at this time – Family have Statement of Dr decided to get her seen in AMS on Monday to organise X ray, CT Barbara Ursula Bonecki, Tab 46 JBO was discharged from hospital with information regarding [9] – [12] p 213 signs and symptoms to look out for after a head injury and was given a take home pack of ibuprofen and paracetamol.

24 June 4:30pm JBO’s sister-in-law AR sent two videos via text message to JBO Statement of 2023 which showed JBO being assaulted and CD threatening her. JBO, Tab 18 [30] p 119 Video tabs (Electronic Material) Sunday 25 June 2023 25 June 10:00am Police attended JBO’s home address to speak with JBO to obtain Statement of SC 2023 a statement. JBO gave a statement and a mud map of the Clissold, Tab 69 upstairs toilets’ were the assault took place. JBO identified CD as [15], p 310 the one who assaulted her and the video that was recorded of the assault.

Statement of JBO, Tab 18 [31] – [33] p 119 25 June 10:55am Police attended RSM Club and spoke with the Duty Manager Statement of SC 2023 Phillip REID, who provided a copy of the Incident Log #6997302 Clissold, Tab 69 that was completed by staff member - MS in relation to the [16], p 311 assault. They also requested a copy of the RSM Club CCTV footage that covered before and after the incident.

25 June 1:45pm JBO attended Casino Police Station with KDA, AD, KDA’s Statement of SC 2023 motherAD’s mother, to give a signed statement to police about the Clissold, Tab 69 assault. [18], p 311 25 June 5:00pm Police received RSM CCTV footage of the stairs and foyer, Statement of SC 2023 timeline of the CCTV footage in relation to the assault in the Clissold, Tab 69 female toilets, a copy of the RSM Membership details of CS, and [25], p 312 a copy of the RSM Visitor details of JBO.

25 June 6:10pm A Provisional Apprehended Violence Order (AVO) was taken out Provisional 2023 against CD for the protection of JBO. Apprehended Personal Violence Conditions 1,2,11 Order, Tab 57 Condition 11 – Not to reside or enter the street of JBO’s home address

AVO not served upon CD until 28 June 2023 Monday 26 June 2023 26 June 10.15am JBO attended a telehealth appointment with Dr Katherine Hawkins Statement of 2023 (entry in (Consultant General Practitioner), at Bulgarr Ngaru Medical Katherine progress Aboriginal Corporation, Casino. Hawkins, Tab 47 notes) [9], [11], [13] & Consultation via video chat on phone. Dr Hawkins encouraged [14], pp 214 – 215 JBO to attend consult in person but JBO said she was too afraid to come in after the assault.

A discharge summary from Casino Hospital was reviewed and stated that JBO would be attending the AMS for further imaging recommending CT orbits, OPJ X-ray and ankle X-ray.

Dr Hawkins observed significant bruising and swelling to JBO 's face, as well as bilateral black eyes. She had swelling around her left temple, pain on opening and closing her jaw, and pain in her left ankle. JBO declined analgesia and short-term benzodiazepines to assist with sleep. Dr Hawkins subsequently ordered a CT facial bones (which includes orbits) and OPG x-ray.

Per medical records: “Psychological: Patient reports she is crying a lot, very tearful, feeling very anxious, hypervigilant, difficulty sleeping Consultation Management: notes of Dr

1. CT facial bones – rule out fracture Katherine Hawkins (26 June

2. OPG x-ray – rule out jaw fracture 2023), Tab 49 p

3. Ankle – likely soft tissue injuries – No x-ray for ankle at 221 present if continues to improve

4. Offered psychological supports - NSW Victim Services (phone counselling) or Northern Rivers Community Gateway (trauma support) – [KD] to assist with accessing.

5. Declined offer of diazepam to assist with sleep – doesn’t like to take tablets

6. Follow up booked for Friday.” 26 June JBO had a CT and an OPG X-ray (dental X-ray) of the upper and CT and X-Ray 2023 lower jaw and no acute injuries or fractures were identified. Report, Tab 50 pp 222 – 223 No facial fracture or sinus fluid level. No orbital collection or emphysema. No mandibular fracture. Normal articulation of the temporomandibular joints. Prominent mucosal thickening in the frontal, ethmoid and maxillary sinuses with mild mucosal thickening in sphenoid sinus. There is prominent mucosal thickening and polyposis in the naval cavity with no nasal septal deviation or septal spur. No skull base fracture.

27 June JBO had a follow-up telehealth consultation with Dr Hawkins, Dr Statement of 2023 Hawkins called JBO to check in and to talk about the results of the Katherine x-ray and CT. No fractures seen on CT facial bones or OPJ, Hawkins, Tab 47 discussed soft tissue healing can still take several weeks [19] p 215 Consultation notes of Dr Katherine Hawkins, Tab 51 p 226 28 June 5:00pm CD attended Casino Police Station and was cautioned and Statement of 2023 arrested for the assault upon JBO. Constable David Richardson, Tab 59 [4] – [6], p 242 A Court Attendance Notice issued requiring CD to attend Casino Court Attendance Local Court on the 7 September 2023. H78678869 Sequence 1 Notice – Assault occasioning actual bodily harm, Sequence 2 Assault H78678869, Tab occasioning actual bodily harm in custody, Sequence 3 Stalk or 64 p 269 intimidate intending to cause fear of physical or mental harm (personal violence offence) Statement of service of AVO, Provisional AVO (made on 25 June 2023) served on CD Tab 58 p 241 In contrast to Provisional AVO, Police bail did not impose a Bail variations, condition preventing CD from entering the street of JBO’s home Tab 66, p 271 address Submission of [CD apparently asked Police to return to the street of JBO’s home Noelene Hickling, address to briefly pick up some belongings, Police Supervisor Tab 12, Annexure involved in bail decision apparently agreed, not aware of condition A, p 51 in Provisional AVO that prevented CD from entering the street] 30 June Further telehealth consult with Dr Hawkins regarding ongoing Statement of 2023 ankle, neck and facial pain. JBO reported difficulty sleeping. JBO Katherine again said she was too fearful to attend in person. Hawkins, Tab 47 [20], p 215 Ongoing ankle pain – but managing to walk unassisted by crutches now, neck pain ongoing, some ongoing facial pain but it is improving Consultation Ongoing difficulty with getting to sleep, waking during sleep, starts notes of Dr cry out of the blue, does not want medication, had not yet manage Katherine to make contact with counselling – needs some assistance with Hawkins (30 June same – will discuss with AHW KD, Staying off social media, Will 2023), Tab 52, p think about referral for social work support 227 Email from Leigh Hawdon, Acting Inspector, NSW Police to NH re Submission of breach AVO by CD NH, Tab 12, “It was a very unfortunate set of circumstances and Annexure A, pp miscommunication between Officers at Casino. Personal Violence 56 – 57 Order was served on [CD] whilst she was in custody. Those

conditions, particularly not to enter [street of JBO’s address], the Supervisor was not aware of. The Supervisor upon granting strict conditional bail, victim protection was part of that bail, not to approach or contact the victim in any way unless that contact is through a lawyer. Upon being released on conditional bail, [CD] made a request to the Supervisor to briefly return to [address] to pickup some belongings. As a result of the investigation, I have spoken personally to [JBO] and apologised in regards to miscommunication on the evening and that no further action at this stage will be taken. I have informed [JBO] that I have reiterated to Officers at Casino the differing bail conditions and conditions of the personal violence order and that any matters in the future whereby [JBO] or family members require Police assistance that it will be treated as a matter or [sic] priority.” 2 July 2023 10:00am Police attended JBO’s home address to follow up with JBO and Statement of SC were advised by JBO’s brother that she had gone to Queensland. Clissold, Tab 69 [26] – [28], pp 312 Police obtain statement from TW and DD – 313 3 July 2023 12.04pm Dr Hawkins contacted JBO by phone to check in, JBO was in Statement of Queensland with sister. JBO said the negativity on social media Katherine was impacting her mental health, so Dr Hawkins offered a further Hawkins, Tab 47 appointment but did not hear back. [24], p 215 Per medical records “some ongoing neck and ankle pain in Consultation particular, psychologically – really struggling. Is up in QLD at notes of Dr present, staying with sister. Had to leave the town as was feeling Katherine “down”. Was feeling like being watched in Casino as “everyone Hawkins (3 July had seen the video” on social media. Person who assaulted her is 2023), Tab 53, p out on bail. Has restrictions on not being able to come down her 228 street, family not allowed to harass her etc. However states ongoing negative things being posted on social media by person’s family members. [JBO] is trying to stay away from social media herself – but family and friends are advising her of what is being said. Finding this very distressing and compounding distress and trauma from the events. …[KD] has been in touch to help with accessing some counselling – currently trying to work out which option will suit the best.” 5 July 2023 7:00pm Police attended the RSM Club and showed staff a number of Statement of SC photographs from the recording of the assault and the CCTV Clissold, Tab 69 footage, staff able to identify SD, CC and JK in the photographs, [29], p 313 obtained CCTV footage affidavit on behalf of club 10 July 2023 Dr Hawkins attempted to call JBO for a planned appointment but Statement of JBO didn’t answer. Dr Hawkins left a message offering a further Katherine appointment Hawkins, Tab 47 [26] p 216 10 July 2023 3:30 pm Police took a statement from ED, spoke with RL, JK. Statement of MB, Tab 34

Police had a conversation with MB. She told police SD recorded the fight, MB gave Police permission to take a photograph of her messenger page of the video CD had sent 14 July 2023 2.07pm Dr Julia Chu from at Bulgarr Ngaru Medical Aboriginal Corporation Consultation speaks to JBOas Leondre was on phone call list. “She thought notes of Dr appointment was for her. Offered her an appointment and that I Katherine would call her back in a few minutes. She was fine with this. Did Hawkins (14 July not answer when I called back. Recorded msg left. Will try again 2023), Tab 55, p later today. Tried again. No answer. Will arrange appt for next 230 week with KH” 18 July 2023 11:25am Police obtained a statement from RL, TF and BH Statement of SC – 4:30pm Clissold, Tab 69 [34] – [36], p 314 27 July 2023 Around COPS EVENT E 527082992 COPS EVENT E 3:40pm 527082992 (Tab Informant – [NB] 94) “About 3:40 pm on Thursday 27 July 2023, the victim [BB] was walking along Fredrick Street Casino with his cousin [JR] (witness). Near the corner of Frederick and Waratah Street, Casino (near Madison Meats) a vehicle being driven by [SDR] pulled up beside the victim and witness. [OA] then jumped out of the vehicle and approached the victim. [OA] then made a comment to the victim about [CD] and [JBO]. At this time, the victim and witness started running. [OA] has chased the victim, caught up to him and hit him. The victim fell to the ground, as a way of pretending he was hurt, though [OA] continued to assault him, by ‘booting’ (kicking) him in the head a number of times. At this time, both the victim and the witness observed [SDR] recording the assault on a mobile phone. The victim and witness then ran from the scene.

About 3:49 pm, the victim called his sister [JBO] and told her what happened. [JBO] spoke with the victim about reporting the assault to police, though the victim stated that he does not want to report it.

A short time later, police received a call from the INF [NB]. She stated that she had received a call about her nephew being assaulted by [OA] and his partner over the stuff that happened between [JBO] and [CD]. She stated that her nephew did not want to report the assault due to ramifications.

Police then tried calling the victim, though there was no answer.

Police then called the victim’s mother [LB] and left a message.

Police eventually made contact with [JBO] who told police about what happened. [JBO] stated the victim is terrified of [OA] and told her, “He will keep going and going and will probably kill me.” Police advised [JBO] that they were willing and needed to take action. Police encourage[d] [JBO]to speak with the victim again about speaking with police. Police advised [JBO] that police would attend their home tomorrow night and speak with the victim and family. Police also advised [JBO] that i[f] anything else occurred,

to report it to police and if they managed to get a copy of the recorded assault, to keep a copy” Police obtained the video footage which showed the assault on BB. Both OA and SDR were arrested and charged.

28 July 2023 Around JBO took a video of CD outside a house on the street of JBO’s Statement of LB, 12:15- home address as proof that CD was breaching a condition on her Tab 13 [21] – [30], 12:25 AVO not to enter the street. pp 70 – 71 28 July 2023 Around JBO suffered a seizure or panic attack [as described in notes] and Statement of LB, 12:15- her parents took her to Casino Memorial Hospital. Tab 13 [38] – [42], 12:25 p 71 Hospital records on 28 July 2023, Tab 60, p 246 28 July 2023 12:30 JBO presented with cardiac arrest with a brief period of ventricular Autopsy Report, fibrillation which deteriorated to pulseless electrical activity arrest. Tab 2, p 13 She was unresponsive to all resuscitation efforts, with treatment being withdrawn after 1 hour and 5 minutes of active CPR.

Hospital records Per Hospital records “[JBO] found in back seat, lying down, with on 28 July 2023, agonal respirations and unresponsive, centrally cyanosed…CPR Tab 60, p 246 commenced. On arrival in resus palpable output so CPR paused briefly whilst monitoring placed on her. After monitoring placed, no palpable output felt, CPR recommenced, arrest button pressed and anaesthetics REG, CNS and VMO attended to control airway, COACHED algorithm run and continued throughout resuscitation efforts. ALS procedure followed, pt intubated with minimal interruption to CPR by anaesthetics. Initial rhythm noted to be VF – shocked on 4-5 occasions, given 300mg amiodarone…VF deteriorated to PEA after approx. 15 minutes, bedside US showed no pericardial effusion and no pneumothorax…large amount of blood suctioned from ETT – intubation was not traumatic.

Difficulties oxygenating throughout and low tidal volumes on ventilator, Massive pulmonary event likely caused hypoxia/collapse” 28 July 2023 12:38 pm CPR commenced Hospital records on 28 July 2023, 28 July 2023 12:41 pm Coached shocked VF Arrest Tab 60, p 248 28 July 2023 12:43 pm L)ACF PIVC inserted isats done BSL 5.0 28 July 2023 12:45 pm Coached shocked – Adrenaline 1 mg given, Amioderone 300 mg given 28 July 2023 12:47 pm Coached shocked 28 July 2023 12:51 pm Coached shocked adrenaline 1 mg given 1L N/SALINE Stat ETT inserted 28 July 2023 12:54 pm Coached shocked

PIVC R) hand inserted sats 78% 28 July 2023 12:56 pm Coached non shockable PEA adrenaline 1 mg given sats 85% 28 July 2023 12:58 pm Coached non shockable sats 87% 28 July 2023 1:00 pm Coached non shockable sats 68% BP 140/35 28 July 2023 1:02 pm Coached non shockable – adrenaline 1 mg given sats 85% 28 July 2023 1:04 pm Coached non shockable 28 July 2023 1:05 pm R) radial ART line inserted ABG DONE 28 July 2023 1:06 pm Coached non shockable – adrenaline 1 mg given co2 25 sats 89% 28 July 2023 1:09 pm Coached non shockable 28 July 2023 1:10 pm Ventilator attached 28 July 2023 1:12 pm Coached non shockable rhythm sats 75% etco2 18 adrenaline 1 mg given 28 July 2023 1:15 pm Coached non shockable etco2 24 bedside cardiac US attended by doctor 28 July 2023 1:17 pm Coached non shockable 1 mg adrenaline given co2 27 sats 56% 28 July 2023 1:19 pm Etco2 13 sats 69% Second bag of N/Saline stat 28 July 2023 1:21 pm Coached non shockable 28 July 2023 1:23 pm Coached non shockable sats 80% 28 July 2023 1:25 pm Coached non shockable, 1 mg adrenaline sats 66% etco2 39 28 July 2023 1:27 pm Coached non shockable co2 20 sats 74% 28 July 2023 1:29 pm Coached non shockable 28 July 2023 1:31 pm Coached non shockable etco2 14 sats 60% 28 July 2023 1:33 pm Coached non shockable 1mg adrenaline given sats 72% 28 July 2023 1:35 pm Coached non shockable 28 July 2023 1:37 pm Coached non shockable, US heart, 1 mg adrenaline given 28 July 2023 1:40 pm Coached non shockable sats 77% etco2 27 28 July 2023 1:42 pm Coached non shockable sats 72@ etco2 9 Family arrived brought into bedspace 28 July 2023 1:45 pm Coached non shockable sats 73% 28 July 2023 1:47 pm Coached non shockable 28 July 2023 1:48pm JBO’s time of death recorded.

RIP with family consent and in attendance 28 July 2023 3.02pm Staff at Bulgarr Ngaru learn that JBO died. Consultation notes of Dr Dr Hawkins included note in medical records Katherine “A gentle soul, gone too soon. Hawkins (28 July May she rest in peace.”

2023), Tab 56, p 28 July 2023 6:30pm Senior Constable CLISSOLD given a mobile phone belonging to Statement of SC CD that had been seized by police. This contained a video of the Clissold, Tab 69 assault. [37] – [38], p 314 28 July 2023 Report of death to Coroner completed by NSW Police Report of Death to the Coroner, Tab 1 28 July 2023 Report of death of patient to Coroner reported by Casino Hospital, Report of Death opinion as to cause of death ?PE/pulmonary haemorrhage, of a Patient to the Specific issues which need to be addressed at autopsy: cause of Coroner, Tab 7 death 3 August 8:20 am Post mortem examination – as no cause of death has been Autopsy report, 2023 ascertained and given the deceased’s young age, the cause of Tab 2, pp 15 – 16 death may be due to a functional rather than a structural cardiac disease such as abnormalities of the cardiac conduction system, including channelopathies.

Body – overweight body habitus, no external injuries Post Mortem CT – diffuse lung and central airway opacity (likely acute pulmonary oedema). Signs of resuscitation attempts Internal examination – normal heart examination, diffuse wide spread pulmonary oedema Neuropathology expert report obtained – no significant pathological abnormalities Toxicology results Delta -9 – tetrahydrocannabinol 0.009 mg/L Delta -9 -THC Acid 0.049 mg/L Amiodarone detected Biochemistry – Vitreous humour, Glucose 4.2mmol/L, no other significant abnormalities, CRP 9 mg/L Bacteriology – right and left lung swabs – no growth of pathogens, blood culture isolated Clostridium perfringens Virology – nasopharyngeal swabs detected human rhinovirus/enterovirus RNA and Enterovirus DNA, Right and left lung swabs – no viruses detected 3 August 9:15am – AC attended Casino Police Station and gave a statement. She Statement of SC 2023 3:50pm was working at the bar on the 23 June 2023. SB and CC also Clissold, Tab 69 gave statements. [41] – [43], pp 315

5 August 7:20pm Police take a statement from MB Statement of SC 2023 Clissold, Tab 69 [45], p 315 9 August 8:50am – Police obtain statements from JK, SSM and MS Statement of SC 2023 3:30pm Clissold, Tab 69 [46] – [48] pp 315 7 September Matter in Casino Local Court – non-publication order made JusticeLink 2023 8 September Matter in Casino Local Court – non-publication order made JusticeLink 2023 5 October Matter in Casino Local Court JusticeLink 2023 21 “ZZ” pleaded guilty to: Submission of December NH, Tab 12

1. Assault occasioning actual bodily harm in company 2023 Annexure 12, [resulting in imprisonment for a term of 14 months, to be Letter from the served by way of intensive correction in the community ODPP dated 6 and with additional conditions including 200 hours of February 2024, p community service work and to undertake rehabilitation as part of community corrections treatment plan]

2. Intimidate intending to cause fear of physical or mental health [imprisonment for a term of 6 months to be served Criminal history by way of intensive correction in the community and with bail report for CD, the additional conditions including 100 hours of Tab 68, pp 292 – community service work] 294

3. Contravene prohibition or restriction in an apprehended violence order [directed to enter into a conditional release order for a term of 6 months supervised by community corrections] 7 January Autopsy report signed Autopsy report, 2024 Tab 2, p 22