Coronial
NSWother

Inquest into the deaths of Lilie James and Paul Thijssen

Deceased

Lilie Anne James; Paul Thomas Stephan Thijssen

Demographics

21; 23y, female; male

Coroner

Decision ofState Coroner O'Sullivan

Date of death

2023-10-25

Finding date

2025-11-27

Cause of death

Lilie: multiple blunt force injuries to the head and neck. Paul: multiple blunt force injuries sustained from jumping/intentionally falling from cliff.

AI-generated summary

Lilie James, aged 21, was killed by Paul Thijssen, aged 23, a colleague at St Andrew's Cathedral School, using a hammer in a bathroom on 25 October 2023. Paul killed himself by jumping from a cliff at Diamond Bay Reserve hours later. The pair had a brief casual relationship lasting about 2 months, which Lilie ended on 20 October 2023. After rejection, Paul exhibited concerning behaviour including: technology-facilitated abuse (location tracking via Snapchat, creating a fake account), physical stalking on 7 occasions, and deliberate planning of the attack. The coroner found this was premeditated homicide in the context of domestic violence and gendered violence. No prior warning signs were evident to colleagues or friends. Critical lessons include: recognizing technology-facilitated abuse as coercive control; educating young people about healthy relationships; developing support services for young men; ensuring domestic violence screening tools incorporate stalking and technology abuse; and media responsibility in reporting intimate partner homicides.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Contributing factors

  • Rejection of Paul by Lilie when she ended the relationship
  • Paul's vulnerable and fragile sense of self and need for external validation
  • Paul's pattern of coercive control and possessive behaviour from prior relationship
  • Technology-facilitated abuse including location tracking and fake social media account
  • Physical stalking of victim on 7 occasions in days preceding attack
  • Access to hammer and victim in isolated location at school
  • Premeditation and planning including practice runs on day of attack
  • Normalization of controlling technology use in community perception

Coroner's recommendations

  1. Expand education and awareness programmes to help the community identify and respond to coercive controlling behaviours, with particular focus on emerging forms of technology-facilitated abuse
  2. Encourage individuals to critically review their technology use, including whether it is necessary or safe to share their location with others
  3. Develop targeted initiatives for 16 to 24-year-olds, delivered through further and higher education settings as well as workplaces, recognising this group's heightened vulnerability to technology-based abuse
  4. Develop respectful relationship information and advice services specifically for young men, alongside further research into effective strategies for engaging this group and promoting healthy relationship behaviours
  5. Media entities that report on intimate partner homicides should recognise that describing violence as being 'out of character', before the full facts are known, may reinforce unhelpful community stereotypes and fail to place such homicides in the context of prior coercive control
  6. Ensure domestic violence screening tools reflect the correlation between coercive control, including technology facilitated abuse and physical stalking, and the risk of intimate partner homicide
  7. Further education and information programs to raise community awareness about interpersonal relationship violence, gendered violence, intimate partner violence, coercive control, and technology facilitated abuse
Full text

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the deaths of Lilie Anne James; and Paul Thomas Stephan Thijssen Hearing dates: 18 – 20 March 2025 Date of findings: 27 November 2025 Place of findings: Coroners Court of New South Wales Findings of: State Coroner, Magistrate Teresa O’Sullivan Catchwords: CORONIAL LAW – manner of deaths – homicide by a known person – self-inflicted death – gendered violence – intimate partner violence – coercive control – domestic violence – technology facilitated abuse File numbers: 2023/00341183 and 2023/00343846 Representation: Counsel Assisting the Coroner: Ms Jennifer Single SC and Mr Jake Harris, instructed by Ms Clara Potocki (Crown Solicitor’s Office) Orders: Orders and notations made on 18 March 2025 and 21 March 2025 prohibit the publication and/or restrict release of evidence tendered in the coronial proceedings.

The orders and notations can be obtained on application to the Coroners Court registry.

Findings: Findings in relation to the death of Lilie James: Identity of deceased: The person who died was Lilie Anne James.

Date of death: Lilie died on 25 October 2023.

Place of death: Lilie died at the St Andrew’s Cathedral School at 474 Kent Street, Sydney NSW 2000.

Cause of death: Lilie died from multiple blunt force injuries to the head and neck.

Manner of death: Lilie died as a result of homicide in the context of domestic violence and gendered violence.

Findings in relation to the death of Paul Thijssen: Identity of deceased: The person who died was Paul Thomas Stephan Thijssen.

Date of death: Paul died on 25 or 26 October 2023.

Place of death: Paul died at Diamond Bay Reserve, Vaucluse NSW 2030.

Cause of death: Paul died from multiple blunt force injuries.

Manner of death: Paul died as a result of injuries he sustained having jumped or intentionally fallen from the cliff at Diamond Bay Reserve in Vaucluse with the intention of ending his life.

Table of Contents Whether a known person can be named and associated with having caused or Expert Evidence and Evidence from the Secretariat of the Domestic Violence Death

When did Lilie and Paul commence a relationship? What was the nature of their relationship, and what was the status of their relationship at the time of Lilie’s When and how did Paul commence planning the events of 25 October 2023? .... 72 With the benefit of hindsight, were there any indications that Paul could become How do the circumstances of Lilie’s death compare with other interpersonal What relevant information and education exists to assist a person in the position of Lilie, or her or Paul’s friends, family or colleagues, identify and respond to a risk of violence in similar circumstances? Is it sufficient? Are there areas for The significance of technology facilitated abuse and stalking in domestic

Section 81(1) of the Coroners Act 2009 (NSW) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death.

These are the findings of an inquest into the deaths of Lilie Anne James and Paul Thomas Stephan Thijssen.

Introduction

  1. Lilie Anne James (whom I will refer to from now on as Lilie) died on 25 October 2023 at the St Andrew’s Cathedral School (St Andrew’s) in Sydney of multiple blunt force injuries to the head and neck.

  2. The evidence that was tendered in the inquest establishes that Paul Thomas Stephan Thijssen (whom I will refer to from now on as Paul) killed Lilie in a bathroom at St Andrew’s using a hammer. Lilie had been in a brief relationship with Paul which she ended just days before her death.

  3. In the days after Lilie ended the relationship the evidence indicates that Paul physically stalked Lilie on seven (7) occasions, he carefully planned his attack and in the hours before the attack, he rehearsed the attack.

The preparation was calculated and was not a momentary loss of control. It was a premeditated killing.

  1. After killing Lilie, Paul drove to Chris Bang Crescent in Vaucluse, where he called triple zero. Shortly after making that call, and just prior to the arrival of Police, he jumped or intentionally fell from a cliff at Diamond Bay Reserve, resulting in his death. When Police conducted a search of Diamond Bay Reserve in the early hours of 26 October 2023, they found items belonging to Paul which included a backpack, some clothing, and about 10 meters away from the backpack a booklet of written mementos from an ex-partner. Paul’s body was located on 27 October 2023.

Jurisdiction

  1. Jurisdiction arises for me to hold an inquest into each death, because they are violent or unnatural deaths, and are therefore reportable deaths, pursuant to ss. 6(1)(a) and 21(1)(a) of the Coroners Act 2009 (the Act).

  2. An inquest is required to be held into Lilie’s death, pursuant to s. 27 of the Act, because it appears she died as a result of homicide.

  3. The circumstances of the two deaths are so intricately linked that the inquests into both deaths were held concurrently. The evidence that was tendered in one inquest was available in the other.

The role of the Coroner and nature of an inquest

  1. The primary role and function of a Coroner is to identify the circumstances of a person’s death.

  2. At the conclusion of an inquest the Coroner is required by s. 81(1) of the Act, to record findings with regard to the following: a) the deceased person’s identity; b) the date and place of the person’s death; c) the manner and cause of the person’s death.

  3. The Act does not define the phrase “manner and cause of death”. It is generally accepted that it is a composite phrase involving inter-related, but distinct, concepts. The manner of death relates to the circumstances in which a death took place whereas the cause of death is the direct and proximate physiological cause of the death.

  4. Pursuant to s. 82 of the Act, the Coroner may make recommendations in relation to any matter connected with the death, suspected death, fire, or explosion with which an inquest or inquiry is concerned. That involves identifying any lessons that can be learned from the death, in particular, to avoid future deaths, although not limited to that purpose. The matters that can be the subject of a recommendation are those that have the capacity to improve public health and safety in the future, and/or be investigated or reviewed by a specified person or body. A recommendation can be made if it arises from the evidence adduced and tendered at the inquest or inquiry.

  5. An inquest is a public examination of the circumstances of a reportable death. It is not the role of the Coroner or the purpose of an inquest to attribute blame or punish anyone for the death. It is not the role of the Coroner to make findings about negligence or civil liability and there is no power to award compensation. The holding of any inquest does not of itself suggest that any party is guilty of wrongdoing, the purpose is to identify the circumstances in which the death occurred.

Coronial findings cannot determine criminal liability

  1. Section 81(3) of the Act provides that when I deliver my findings, I must not indicate or in any way suggest that an offence has been committed by any person in my formal findings under ss. 81(1) and 81(2).

Consequently, if a Coroner forms a view during an inquest that a known person may be found to be guilty of homicide in a criminal proceeding, they are obliged to suspend the inquest and refer the matter to the Office of the Director of Public Prosecutions.

  1. In the findings from the Inquest into the disappearance and suspected death of Leisl Alexandra Smith delivered on 29 September 2025, Deputy State Coroner Grahame addressed this issue in detail and referenced the established body of case law, which supports “the proposition that the mere recitation of facts about how a death occurred and the cause

of death, does not contravene the s. 81(3) prohibition.” I agree and adopt what her Honour has set out in paragraphs 18 to 30 of her findings1.

Whether a known person can be named and associated with having caused or contributed to the death in coronial findings

  1. Whether a known person can be named as having caused the death was also dealt with in detail in the Inquest into the disappearance and suspected death of Leisl Alexandra Smith. I agree with what her Honour, Deputy State Coroner Grahame has set out in paragraph 31.

  2. The leading authority on the construction of s. 81(3) of the Act derives from Perre v Chivell,2 a decision of the Supreme Court of South Australia. The decision of Nyland J is clear authority for the proposition that it is permissible to identify a person as having caused or contributed to a death by some act or omission but a coroner cannot draw a legal conclusion about the person’s actions, for example, classifying the conduct as constituting the offence of “murder”, or attribute legal liability.

Procedural background

  1. The inquest into the deaths of Lilie and Paul was held from 18 – 20 March 2025.

  2. The Court received extensive documentary material as well as audio visual material into evidence including fourteen volumes of material in the form of the brief of evidence which included statements provided by lay witnesses and police officers; video and audio footage; documentary material obtained from St Andrew’s, banks, the Department of Home Affairs, and other entities; medical and scientific evidence; opinions from experts; a review from the Secretariat of the Domestic Violence Death 1https://coroners.nsw.gov.au/documents/findings/2025/Inquest_into_the_disappearance_and_suspect ed_death_of_Leisl_Smith.pdf .

2 (2000) 77 SASR 282.

Review Team; and material provided by the NSW Department of Education, the NSW Education Standards Authority, the National Association for Prevention of Child Abuse and Neglect, and the eSafety Commissioner.

  1. I should acknowledge that my understanding of the events, and in particular the relationship between Lilie and Paul, is primarily based on information provided by others which has not been tested, together with records of communication between Lilie and Paul including some phone records and Snapchat messages. These records are incomplete. In part, this is because it appears that Paul disposed of his usual phone (iPhone
  1. and Lilie’s phone, possibly taking them with him over the cliff at Diamond Bay. As a result, only a limited number of messages remain.

Further, it seems that Paul and Lilie, and their friends, often communicated by Snapchat. Given the disappearing nature of Snapchat messages, the only material available consists of photos and messages Paul saved in his account.

  1. A mobile phone was found in Paul’s backpack at Diamond Bay Reserve and was tendered at the inquest. This device was unlocked and was not the handset associated with Paul’s Australian phone number. It would appear that Paul had two mobile phones: an iPhone 8 and an iPhone 14.

The iPhone 8 was the phone found in the backpack at Diamond Bay Reserve, while the iPhone 14 has not been located.

  1. Despite the limitations in the evidence, the thorough investigation conducted by the NSW Police Force has allowed me to gain insight into the nature of the relationship between Lilie and Paul and what occurred between them, particularly in the days leading up to 25 October 2023.

  2. The Court also heard from witnesses, including the officer in charge of the coronial investigation; experts in the fields of forensic psychiatry, clinical and forensic psychology, and gendered violence; the Manager of

the Domestic Violence Death Review Team; and the eSafety Commissioner.

Background Lilie James

23. Lilie was born on 21 May 2002 and was aged 21 at the time of her death.

She lived with her father, Jamie; mother, Peta; and younger brother, Max. Lilie enjoyed a close and loving relationship with her family.

  1. Lilie attended Danebank Anglican School for Girls from Kindergarten to Year 12 where she danced, played netball and water polo and in her later years worked as a swimming coach. Lilie had a close group of friends and remained close to her school friends beyond school. In 2023, Lilie was studying a Bachelor of Sports Management at the University of Technology Sydney.

  2. Lilie was employed as a Sports Assistant at St Andrew’s and commenced her employment in Term 1 on 24 January 2023. She worked full time around her university commitments, five days a week, plus after school and Saturday morning games. She provided support with staffing and equipment, before and after school sports and with the subject, Personal Development, Health and Physical Education (PDHPE). ln addition, outside of her contract she coached and was paid casually for water polo and netball coaching. She had no association with St Andrew’s prior to her employment. Lilie was highly regarded within the school community and described as an excellent employee who was well-liked by staff and students alike.

  3. Lilie was highly social and formed close and lasting friendships with ease. Her circle included friends from school, university and colleagues from St Andrew’s. Lilie was widely described as gregarious, outgoing

and surrounded by many friends. Those who knew her spoke of her as a confident, enthusiastic, and dedicated individual – someone who worked well in a team and was engaging, calm and caring.

Paul Thijssen

  1. Paul was born on 13 November 1999 and was aged 23 at the time of his death. Paul was the only child to his parents Esther and Stefan. He was born in the Netherlands where he spent the first 15 years of his life.

  2. In July 2015, the Thijssen family relocated to Sydney for Stefan’s work, and Paul enrolled at St Andrew’s in Term 3 of Year 10. Paul played cricket and hockey and was elected the Sports Captain. While still a student he coached younger hockey teams. In February 2018, after completing school, Paul accepted a full-time position at St Andrew’s as a sports assistant in the year after school, known as “Year 13”. During “Year 13” he lived in Australia at a group residence in Balmain with other young people. Paul’s parents had, by this time, returned to live in the Netherlands.

  3. In September 2018, he returned to the Netherlands to start a Bachelor’s Degree in Business Economics at Utrecht University. He came back to Sydney in January 2020 and was again employed as a sports assistant at St Andrew’s. He continued his studies remotely.

  4. When the Covid-19 pandemic hit in 2020, Paul moved to the St Andrew’s Kirrikee Outdoor Education Centre where he lived and worked for a period before returning to Sydney. In September 2022 he moved in with friends, initially living in Zetland before moving to Kensington on 10 September 2023. Paul played and coached hockey at the UNSW Hockey Club.

The Issues

  1. The Court heard evidence in these proceedings in relation to the following issues relating to Lilie’s death:
  1. When did Lilie and Paul commence a relationship? What was the nature of their relationship? What was the status of their relationship at the time of Lilie’s death?

  2. What were the circumstances of Lilie’s death?

  3. With the benefit of hindsight, were there any indications that Paul could become violent towards Lilie?

  4. How do the circumstances of Lilie’s death compare with other interpersonal homicides?

  5. What relevant information and education exists to assist a person in the position of Lilie, or her or Paul’s friends, family or colleagues, identify and respond to a risk of violence in similar circumstances? Is it sufficient? Are there areas for improvement?

  6. What statutory findings can be made pursuant to s. 81 of the Act?

  7. Is it necessary or desirable to make any recommendations in relation to any matter connected with the death, pursuant to s. 82 of the Act?

  1. The Court heard evidence in these proceedings in relation to the following issues relating to Paul’s death:
  1. When did Lilie and Paul commence a relationship? What was the nature of their relationship? What was the status of their relationship at the time of Lilie’s death?

  2. What was the nature of Paul’s psychological state in October 2023?

  3. When and how did Paul commence planning the events of 25 October 2023?

  4. Was Paul’s death intentionally self-inflicted?

  5. What statutory findings can be made pursuant to s. 81 of the Act?

  6. Is it necessary or desirable to make any recommendations in relation to any matter connected with the death, pursuant to s. 82 of the Act?

Evaluation of Evidence

  1. I have considered all of the documentary and audio-visual material that has been tendered, and the oral evidence provided by the witnesses. I have set out the evidence that has assisted me to not only determine the formal findings that I am required to make and findings on the issues that were examined at inquest, but also the evidence that assists to promote public awareness and understanding of gendered violence, intimate partner violence, coercive control, domestic violence, and technology facilitated abuse.

  2. In reviewing the evidence and addressing the issues examined at inquest, I have been greatly assisted by the comprehensive and detailed opening address and submissions of Counsel Assisting, which effectively summarised the tendered material and oral evidence. As there were no interested parties in the inquest other than the families of Lilie and Paul - who were not legally represented - there was no party to challenge or question the evidence which has been gathered and tendered, or the submissions of Counsel Assisting.

  3. Counsel Assisting’s opening address provided an exceptionally detailed account of the evidence tendered, outlining the background and the events leading to both deaths. It also included submissions on the inferences that could be drawn from the evidence and the factual findings that may be made about the circumstances of each death.

  4. I have not reproduced Counsel Assisting’s opening address and submissions in full as they are already on the court record and occupied a day and a half of the inquest. However, I have relied on them in determining the findings I am required to make. The opening address included an extremely detailed chronology of the events which led to both deaths. I have adopted that chronology, although I will only refer to portions of it in these findings noting that the evidence is distressing and graphic. I accept the factual findings that Counsel Assisting submitted that I could make about the circumstances of each death and make those findings.

  5. I note that details of the personal and private lives of Lilie, Paul and some of their friends and families were outlined in Counsel Assisting’s opening addressing. I am grateful to the witnesses who assisted the coronial investigation and shared private and personal accounts of their lives.

Their contributions have been invaluable in helping me understand the circumstances leading up to both deaths. I do not propose to repeat those private and personal details in these findings, as they are already contained in Counsel Assisting’s opening address and submissions which, as I have indicated, I have adopted and rely on.

  1. I am acutely aware that both deaths have had a profound and lasting impact on all involved, causing immense shock and heartbreak. Despite every effort to conduct this inquest with sensitivity and to minimise further trauma, the weight of these circumstances cannot be overstated.

  2. Many of the events considered occurred inside St Andrew’s, including Lilie’s death – at her workplace, where she had worked alongside Paul since the beginning of 2023. It was a place where Lilie was entitled to feel safe. It is also a place where staff and children were present, and continue to be present today, including primary school students. I am deeply conscious of the potential for vicarious trauma among staff and students, past and present, and I acknowledge the grief, shock and

distress caused by the discovery of these tragic and horrific events within their school community.

  1. In these findings, I have included a summary of the facts and evidence presented in Counsel Assisting’s opening address where necessary to support the findings I am required make. I have also highlighted specific evidence to raise awareness of critical public health and safety issues concerning gendered violence, intimate partner violence, coercive control, domestic violence, and technology facilitated abuse.

  2. I acknowledge that some of the facts and evidence set out in these findings are confronting and may cause distress. I have sought to limit the level of detail wherever possible, while ensuring that the information necessary to explain the circumstances and support the findings is included.

Two background matters regarding Paul

  1. Before I turn to the events leading to Lilie and Paul’s deaths and my findings on those circumstances, there are two matters concerning Paul that I consider relevant to a better understanding of the context in the lead up to Lilie’s death.

University

  1. When Paul returned to Sydney in 2023, his parents believed he intended to study a Master of Teaching at the University of Sydney. They agreed to fund his degree and provided Paul with money to enrol in the course.

  2. Paul told numerous people - including his flatmates, his boss, hockey friends and his colleagues at St Andrew’s - that he was undertaking a Master of Teaching. Paul was observed at times to be doing “uni work” and was “tight” with money, blaming his financial constraints on the need to pay substantial university fees.

  3. The officer in charge of the coronial investigation, Detective Sergeant Daniel Poole made enquiries as to whether Paul was enrolled in a master’s degree in Sydney. Those enquiries came back with the following:

• there was no record of Paul making any application at the University Admissions Centre;

• the University of Sydney was unable to locate any record of Paul attending; and

• there was no record that he had enrolled at the University of Technology Sydney, the University of Technology Sydney College, or the University of New South Wales.

  1. On the evidence available to me, I find that Paul was not studying at any Australian university.

  2. It is unclear why Paul lied in the first place and continued this deception throughout 2023. It did provide a rationale for him being in Australia, both for his parents and others. It was, however, a lie that would inevitably have been exposed – either upon his failure to graduate or through further scrutiny – requiring him to fabricate yet another explanation. I find that his ongoing deception would have been a stressor in Paul’s life, although it was a stressor present from early 2023, well before he started his relationship with Lilie.

  3. I also find that lying about studying at Sydney University may have provided an explanation to others about how Paul was able to stay in Australia as a Dutch citizen.

  4. I further find that Paul told people he was present in Australia on an education visa and that this too was a lie.

Visas

  1. The investigation has revealed that Paul was present in Australia on a Working Holiday TZ 417 Visa. Paul was granted his first working holiday visa on 29 November 2019. He arrived in Australia on 25 January 2020 and remained until 12 August 2021. There is no reason to doubt the basis on which that visa was granted, and Paul appears to have complied with its conditions.

  2. Paul subsequently applied for and was granted second and third Working Holiday Visas. On the evidence before me, an individual is only eligible for three Working Holiday Visas.

  3. In order to get a second Working Holiday Visa, a holder of a first Working Holiday Visa must have completed 3 months of specified work in a designated area of Australia. In order to get a third Working Holiday Visa, a holder of a second Working Holiday Visa must have completed 6 months of specified work in an eligible area of Australia. Specified work includes work in plant and animal cultivation, and tree farming and felling, among other things.

  4. In March 2020, due to the Covid-19 pandemic restrictions, there was no work for Paul to do at St Andrew’s. Accordingly, Paul was offered work at Kirrikee. Kirrikee is a property owned by St Andrew’s in Penrose in the Southern Highlands which operates outdoor education activities. It also has pastoral land where, in 2020, cattle were agisted. Paul lived and worked at Kirrikee between 30 March 2020 and 3 July 2020.

Second visa

  1. On 8 August 2020 Paul approached Ric van Wachem, the director of Sport and Co-Curricular Education at St Andrew’s and asked for a reference to assist in his application to extend his visa. Mr van Wachem provided him with a reference dated 8 August 2020. Copies of this and other references have been provided by Mr van Wachem and were

included in the brief of evidence that was tendered at the inquest. Paul applied for a second Working Holiday Visa that day, although he subsequently withdrew this application.

  1. Paul asked Mr van Wachem for a further reference to provide more information that Paul said was required for the visa. Mr van Wachem provided this. The information provided by Mr van Wachem in the two references was correct.

  2. The Department of Home Affairs, in answer to a subpoena, provided a copy of the documents Paul submitted in support of his application for his second Working Holiday Visa which was included in the brief of evidence that was tendered at the inquest. Paul submitted a reference dated 8 August 2020.

  3. Despite having the same date and purporting to be from Mr van Wachem, Mr van Wachem confirmed that he did not write the reference which was submitted to the Department of Home Affairs. The reference submitted to the Department of Home Affairs was false in the following ways: a) The submitted reference stated Paul had been employed at Kirrikee for a four-month period (from 9 March to 20 July 2020). Paul had in fact been employed for a three-month period (from 30 March to 3 July 2020).

b) The submitted reference included a wider range of duties, including “tree felling … to ensure a safe and clean grazing surface for the herd” and “feeding and herding of cattle”.

  1. In addition to the submitted reference, Paul lodged a position description on St Andrew’s letterhead for the position “Kirrikee Farm Hand and Sports Assistant” and provided a separate position description document.

  2. St Andrew’s has confirmed that the documents submitted by Paul are not St Andrew’s documents and Mr van Wachem has confirmed he did not write the position description documents, and that these documents do not describe a role at St Andrew’s.

  3. St Andrew’s provided evidence that from 28 January 2020 to 31 July 2020 Paul was employed as a “Sports Assistant and casual Sports Coach.” Paul was redeployed to work at the Kirrikee campus from 30 March to 3 July 2020 where he performed farm hand and general duties, however, his job description was not changed as this was a temporary redeployment.

  4. I find that this evidence demonstrates that the documents provided by Paul to the Department of Home Affairs in support of his second Working Holiday Visa Application were false and were forgeries in which he embellished his role in order to satisfy the visa work requirement.

  5. On the basis of the false information Paul provided, the visa was granted on 13 December 2021.

  6. Paul entered Australia on 18 December 2021, remaining until 6 May

  7. He did not in fact work at St Andrew’s during that time. The Commonwealth Bank account records that are included in the evidence before me show no income from any source during this period.

  8. Paul entered Australia again on 9 July 2022 and took up a role at St Andrew’s on 18 July 2022, where he worked until the end of the school year. He left Australia on 11 December 2022.

Third visa

  1. On 26 January 2023, Paul applied for his third Working Holiday Visa. In support of that visa application Paul submitted the following documents:

a) Payslips from St Andrew’s for the period 1 to 14 February 2022 and the period 10 to 24 July 2022. These stated again that his position was “Kirrikee Farm Hand”.

b) A reference purportedly from Mr van Wachem dated 15 December 2022.

  1. Paul was in the Netherlands on the date the reference was apparently created having departed Australia on 11 December 2022. St Andrew’s confirmed that the documents submitted by Paul were not St Andrew’s documents. Mr van Wachem confirmed that the reference was not written by him, and the email address included in the reference as a contact detail is not one that he has ever used or was aware of.

  2. In his third Working Holiday Visa application, Paul declared that he had undertaken at least six months of specified work. He stated he had worked in tree farming and felling for St Andrew’s from 1 February to 1 May 2022 for a total of 90 days and from 10 July to 10 October 2022 for a total of 93 days. He stated that his usual occupation was “Outdoor Education” and that the industry he intended to seek employment in was “Education and Training”.

  3. St Andrew’s confirmed that Paul was not employed at the school between 1 February 2022 and 1 May 2022. From 18 July 2022 to 25 October 2023, he was employed as a “casual in Sports Administration and the After Hours team and as a casual Sports Assistant.”

  4. Consistent with this, as noted above, Paul’s bank statements show no payments from St Andrew’s between 1 January and 30 June 2022, with the first salary payment recorded on 4 August 2022.

  5. I find that the evidence establishes that the documents Paul provided to the Department of Home Affairs in support of his third Working Holiday

Visa were false and forged, deliberately embellishing his employment and role in order to satisfy the visa work requirement.

  1. As this false information satisfied the necessary criteria, the visa was granted on 6 February 2023. Paul entered Australia on 9 February 2023 and subsequently commenced work at St Andrew’s.

St Andrew’s visa process

  1. It is important to highlight and acknowledge that St Andrew’s has a process for checking its employee’s visas. The school provided the following information, which was included in the brief of evidence that was tendered at the inquest:

• At all times during the period St Andrew’s would, during recruitment, inquire as to an applicant’s right to work in Australia and obtain permission to check an applicant’s right to work status with the Department of Home Affairs.

• During 2022 and up to June 2023 St Andrew’s would request a copy of an employee’s visa and retain a record of the staff member’s visa.

  1. Currently, St Andrew’s checks a staff member’s visa status on the Department of Home Affairs’ Visa Entitlement Verification Online portal and retains a copy of the VEVO check on the staff member’s file.

Findings concerning the visas

  1. I find that the documents Paul provided to the Department of Home Affairs were not obvious forgeries, and the Department had no reason to question their authenticity. At the time, Kirrikee did have some pastoral land with cattle agisted on the property. As a result, Paul was granted visas by the Department of Home Affairs. St Andrew’s made inquiries and reasonably believed that Paul held a valid visa permitting him to work. Employers are under no obligation to verify whether a visa issued by the Department is legitimate.

  2. I further find that St Andrew’s was unaware of the existence of the false documents.

  3. This evidence is relevant to Paul’s psychological state. Paul represented to others that he was in Australia on an education visa. Mr van Wachem believed that Paul was studying for a Master of Teaching at the University of Sydney under such visa.

77. Paul’s third Working Holiday Visa would have expired on 9 February

2024. Paul could not have applied for a fourth Working Holiday Visa.

Unless he applied for and was granted another type of visa, Paul would have had to leave Australia.

  1. I find that knowing his visas were obtained through forged documents would have been a significant stressor for Paul, however, this pressure existed from 8 August 2020, well before his relationship with Lilie began.

I acknowledge that the impending expiry of his visa on 9 February 2024, requiring him to leave Australia, would have added further strain.

However, while this date was approaching, it had not yet become an immediate issue in October 2023.

Employment at St Andrew’s in 2023

  1. Lilie commenced her role as a sports assistant at St Andrew’s on 24 January 2023. Paul took up the same role on a casual basis in February 2023. Paul also worked casually as an afterhours concierge.

This position involved managing fundraisers and social activities, assisting with events and exam setups, and provided Paul with access to the school in terms of passes and keys. It also meant that his presence on campus after hours would not have raised concern, as it was consistent with his duties.

80. Lilie and Paul were both based in the Sports Faculty Unit of St Andrew’s.

The PDHPE and Outdoor Education staffroom was, in 2023, located

near the sports centre and weights room. These were accessed through sliding glass doors near the school foyer.

Events in the lead up to 25 October 2023

  1. I now turn to the chronology of events leading up to both deaths. I have drawn heavily upon the detailed account provided by Counsel Assisting in their opening address and have tried to limit distressing and graphic evidence.

1 September 2023 – 15 October 2023

  1. On 1 September 2023 the St Andrew’s Winter Sports Dinner was held at Doltone House. Paul helped organise the dinner. The sports staff, including Lilie, attended. When the dinner ended Paul, Lilie and a group of the staff members went to Bungalow 8 and then Cargo Bar. Lilie and Paul spent time together at the dinner and at the bars afterwards. Lilie spent the night at Paul’s house in Zetland.

  2. On 4 September 2023, Paul sent his parents a photo from the dinner showing himself, Lilie and another work colleague.

84. Lilie and Paul’s relationship started to evolve after the Sports Dinner.

Those work colleagues closest to Lilie and Paul became aware that they had commenced a relationship.

  1. On 10 September 2023, Paul and his flatmates moved to Kensington.

  2. During the school holidays, which took place from 23 September to 8 October 2023, Lilie and Paul called and messaged each other and spent time together.

  3. On the weekend of 29 September to 2 October 2023, Paul went away to the South Coast with some friends which included colleagues from

St Andrew’s. Throughout the weekend Paul spoke about his relationship with Lilie.

  1. On 3 October 2023, Paul and Lilie went to Diamond Bay Reserve in Vaucluse. While there, Paul FaceTimed his parents and during the call they briefly saw Lilie. The pair also met up with one of Lilie’s friends who lived nearby in Chris Bang Crescent.

  2. Paul and Lilie’s friends expressed mixed views about the nature of their relationship, and whether either of them regarded it as more than casual.

The evidence established that when not together in person, they often engaged in lengthy conversations, and Paul frequently checked Lilie’s location, ostensibly as to whether she had arrived home safely. The evidence seems to indicate that both told their friends that the relationship was not serious.

  1. On 4 October 2023, Paul travelled to Bali, returning to Sydney on 15 October 2023. While there he spent time with a childhood friend from the Netherlands who was living temporarily in Bali. He also met up with some other friends and attended a wedding. While in Bali, Lilie and Paul maintained frequent contact through FaceTime and Snapchat. Lilie ‘Snapped’ Paul photos of herself, which he saved in their Chat. Paul told his childhood friend that he and Lilie were not in a relationship and were just dating. However, his friend observed that Paul spoke about Lilie as though she was his girlfriend and noted that he FaceTimed her almost every day.

  2. On Saturday, 14 October 2023, Lilie went out to celebrate a friend’s birthday. She later recounted the events of that night to two friends. It appears that during the evening, Lilie met someone at a bar and spent time at his house. Later, after discovering she had lost her mobile phone on a bus, she travelled to a bus depot in Castle Hill to retrieve it. In the early hours of 15 October, upon recovering her phone, Lilie saw she had received a message from her ex-boyfriend. Lilie and her ex-boyfriend

met up at Balmoral Beach where they spent time together before he drove her home.

  1. On the evening of 15 October 2023, Paul returned to Australia, and Lilie picked him up from the airport. They went to Paul’s house in Kensington.

That night, Lilie told Paul that she had been intimate with someone while he was away. Paul reportedly responded that he had also been intimate with someone while he was in Bali. They then discussed the nature of their relationship.

16 October 2023

  1. On Monday, 16 October 2023, Lilie confided in a close work colleague about the events of the weekend, saying that Paul was “upset about Lilie [being intimate] with another person” but that they had “talked it out and it was fine.” Lilie also sent a Snapchat to a close school friend outlining what had happened on the weekend.

  2. Following their discussion on 15 October 2023, both Paul and Lilie told friends that they were not “exclusive”, that they were going to continue as they were until the end of term and the relationship was “casual”.

  3. On 16 October 2023, Paul was given a task by one of his supervisors at St Andrew’s to look at the statistics on sport.

  4. Since the beginning of 2023, Paul had been playing and coaching hockey at the UNSW Hockey Club where he became friendly with a female player he coached. Throughout the year they spent time together travelling to and from games and attending social activities, often with other members of the hockey team.

  5. On 16 October 2023, Paul and the female hockey player messaged each other about playing in a summer hockey competition. She offered him a

lift to training and Paul replied, among other things, “Can’t wait to see you tomorrow, it’s been way too long.” 17 – 18 October 2023

  1. On 17 October 2023, the female hockey player drove Paul to their hockey game and they spoke about his trip to Bali.

  2. After the hockey game, Paul went to a pub with two friends - both of whom he had gone away with on the long weekend - and later the three of them returned to Paul’s house. While there, they spoke about Lilie.

Paul told them that both he and Lilie had been with other people and neither had any issue with it. Paul stated that while they were together, they were not exclusive, and their relationship was very casual.

  1. While at his house, Paul showed his friends a photo of Lilie that appears to have been saved from Snapchat. The context of the photo is not known, however, it appears that when Paul showed his friends the photo, he did so to imply that it had been taken in the context of physical intimacy between Lilie and Paul. There was no evidence that Lilie was aware Paul had shared this photograph with friends, or that she consented to it.

  2. On Wednesday 18 October 2023, Lilie stayed the night at Paul’s house.

19 October 2023

  1. On Thursday, 19 October 2023, Paul and Lilie were working a shift at St Andrew’s. The available evidence indicates that Lilie was frustrated with Paul’s work performance that day. Messages were exchanged between them, and Paul appeared agitated.

  2. At around 5:30 pm, Lilie returned to the staffroom following her afternoon shift. Staff observed Lilie to be angry, saying she did not want to talk to

Paul and wanted to leave. Lilie left the staffroom, followed by Paul, and the pair had a discussion with raised voices in the area by the sliding doors close to the staffroom. This interaction, which lasted for approximately nine (9) minutes, was captured by closed-circuit television (CCTV) and appeared to be an argument. The footage shows staff and students in the vicinity, and this is consistent with statements provided by witnesses. Following this interaction, Paul returned to the staffroom to collect a food delivery and went home with Lilie. A staff member recalled seeing them having a heated discussion near the Druitt Street exit.

  1. Banking records indicate that while Lilie and Paul left work together Lilie did not spend the night at Paul’s house.

20 October 2023

  1. On the night of Friday, 20 October 2023, Lilie and her friend went to a friend’s 21st birthday party. Lilie’s ex-boyfriend was at the party, and she ended up spending some time with him. Paul was aware that Lilie’s exboyfriend was going to be at the party and asked Lilie’s friend to “make sure nothing happened” between Lilie and her ex-boyfriend.

  2. Earlier that afternoon, during farewell drinks in the staffroom, Paul remarked to a colleague about Lilie, saying “We’re not boyfriend [and] girlfriend” and that they were in a casual relationship.

  3. Paul drove Lilie’s car, taking Lilie and her friend to the party before meeting a group of friends for dinner in Camperdown. A number of Paul’s friends observed that Paul appeared stressed about Lilie being at the party with her ex-boyfriend, repeatedly commenting on it, checking her location on Snapchat, and sending her messages. One friend remarked to Paul, “you like her more than what you say if you are worried and checking on her.”

  4. After dinner the group went to Haymarket and then separated around 11 – 11:30 pm. Paul then drove to collect Lilie and her friend from the party.

  5. At the party Lilie spent time with her ex-boyfriend and told him that she felt a bit “weirded out” by Paul, that she wanted to cut things off with Paul and make it a complete break.

  6. Paul waited outside the party for Lilie for about an hour, making several calls to Lilie and her friend to tell them he was waiting. During this time, Paul was told that Lilie was spending time with her ex-boyfriend.

  7. Paul drove Lilie and her friend home. According to the friend, Paul appeared “annoyed, sour and very quiet” during the trip. Lilie spent the night at Paul’s house and told her friend the next day that she had slept on the couch.

  8. At some point – either during the day on 20 October 2023 or the party – Lilie told Paul that she wanted to end the relationship but asked for the weekend to think about it.

  9. Lilie also told her ex-boyfriend that she informed Paul of her decision to break up, but that Paul didn’t seem to understand and suggested they be “friends with benefits”. She tried to explain to Paul that she didn’t want any form of ongoing relationship with him. According to the ex-boyfriend, Lilie said there seemed to be “some sort of barrier to Paul understanding what she had been trying to tell him”.

21 October 2023

  1. On 21 October 2023, Lilie dropped Paul off at the Sydney University Sports Centre before attending the girls’ water polo games.

  2. Following the apparent argument between Lilie and Paul on 19 October 2023 - captured on CCTV - and Paul learning that Lilie had spent time with her ex-boyfriend at the party on 20 October 2023, the evidence indicates that Paul began exhibiting extremely concerning behaviour.

  3. Lilie’s friend, who had been with her at the 21st party, recalled a conversation with Paul the morning after the party. Paul said he wanted to give “his side of the story.” He was described as very upset, down and very quiet. Paul said that Lilie no longer wanted a relationship, that he didn’t want it to end with Lilie and that he felt like Lilie was choosing her ex-boyfriend over him.

  4. After the school games on 21 October 2023, Paul remained at home for the rest of the day. Paul’s flatmate recalled that they talked for a while.

During the conversation, Paul talked about the party and said that he was upset because he found out that Lilie was with her ex-boyfriend and she had told him he had to wait until Monday for her decision about their relationship and he was “angry about that”. Paul told his flatmate that he “felt like he was in limbo all weekend.”

  1. At 2:24 pm Paul sent a WhatsApp message to the woman from hockey asking her if she would like to spend time with him the following day and they arranged to meet up. It is apparent from the evidence before me that she did not know about Lilie and was unaware that Lilie and Paul had been in a relationship.

  2. Analysis of the iPhone 8 recovered from Paul’s backpack shows that between 4:32 pm and 4:33 pm, Paul had both the iPhone 8 and the iPhone 14 in his possession and used the iPhone 8 to photograph the screen of the iPhone 14. These images were Snapchat photographs of Lilie. While Lilie would have received a notification had Paul taken a screenshot of her direct message photographs on his iPhone 14, she would have been unaware that the images had been retained by Paul taking a photograph of the iPhone 14 with the iPhone 8.

  3. At 5:16 pm the evidence establishes that Paul created a fake Snapchat account using the name of the woman he had met through hockey.

Records obtained from Snapchat confirm that the Snapchat account was linked to Paul’s mobile number and used an IP address which was linked to Paul’s home address. The woman denied creating this account and stated she had no knowledge of it. The evidence further shows she could not have created it, as she was not at Paul’s house when the account was set up. The only available inference is that Paul created this Snapchat account. The purpose of Paul’s actions remains unclear; however, it may have been to try and make Lilie jealous or to monitor Lilie without her knowledge.

  1. Paul attempted to connect with Lilie via the false Snapchat account, however she observed that while the name was unknown to her, the account was connected to Paul’s mobile phone number.

  2. At about 5:35 pm a friend recalled having a conversation with Lilie where she said she was going to take a break from boys and break up with Paul.

  3. The evidence establishes that while Paul had a driver’s licence, he did not own a car and regularly hired GoGet vehicles. GoGet records each activation and deactivation of its vehicles and, while in use, logs GPS locations every minute. Police obtained the GoGet data for the vehicles Paul hired during October 2023 and, by mapping the GPS locations, were able to trace Paul’s movements. This analysis revealed significant information about Paul’s movements and activities in the days leading up to his attack on Lilie. Based on this evidence, I find that Paul was stalking Lilie in the days before her death. The available evidence indicates seven (7) known incidents of physical stalking by Paul in the lead up to his attack on Lilie on 25 October 2023, the first of which occurred on the evening of 21 October 2023.

  4. Returning to the chronology of events, GoGet records show that Paul hired a vehicle on 21 October 2023. That evening, Paul had dinner with two friends, telling them he did not want to stay out long and returned home early. Data from the hired vehicle was cross-checked against location data recovered from Paul’s mobile phone. These records reveal that between about 9:55 pm and 10:55 pm, Paul drove to the vicinity of Lilie’s home before returning to his house. It is understood that Lilie was home at the time. The evidence indicates that there was no mobile communication between them and that they did not spend time together.

  5. The iPhone 8 recovered from Paul’s backpack at Diamond Bay Reserve contained several photographs of cars parked in Lilie’s street. Police analysis of the metadata shows that these images were taken between 10:28 pm and 10:33 pm on an iPhone 14 near Lilie’s house. Each photo was found in the “Hidden” folder. The “Hidden” folder can only be accessed with Face ID, preventing others who had the phone from viewing them. Notes were added to the photos, although it is uncertain when the notes were added to the images. The notes appear to reflect Paul’s thoughts about who the cars belonged to and observations of their movements.

  6. It appears that this is the first known instance of Paul physically stalking Lilie. It is apparent that Paul took the photos and made the notes to monitor who was present at, or visiting, Lilie’s house.

22 October 2023

  1. On Sunday, 22 October 2023, Paul went out for coffee with his female flatmate. He told her that the “ball was in Lilie’s court and she was going to think” about their relationship. The flatmate was of the opinion that Paul didn’t seem upset about it, however he did ask whether she knew of any service offering relationship advice. She replied that she didn’t but suggested he could look up a hotline.

  2. The evidence shows that Paul then hired another GoGet vehicle. Data obtained from GoGet, cross-referenced with Paul’s mobile phone records, confirms that he again drove to the vicinity of Lilie’s house, leaving home at 10:54 am and returning at about 11:59 am.

  3. Again, there is no evidence that Paul contacted Lilie by call or message while near her home or otherwise alerted her to his presence. This was the second known instance of Paul physically stalking Lilie.

  4. That afternoon, Paul caught up with the woman he met at hockey. Paul left her house at about 6:00 pm, telling her that he needed to console a friend who had broken up with his girlfriend.

  5. Paul had dinner at a close friend’s house. That friend formed the opinion that Paul “seemed a little bit upset.” Paul and his friend then met up with other friends at a nearby hotel for a couple of hours. The friend dropped Paul home sometime after 10:00 pm.

  6. Shortly after returning home, Paul hired another GoGet vehicle. GoGet data, cross-referenced with Paul’s mobile phone records indicate that Paul left home at about 10:29 pm, and again drove to the vicinity of Lilie’s house, returning home at about 11:36 pm. Again, there is no evidence that Paul called or messaged Lilie while near her home. This was the third known instance that Paul physically stalked Lilie.

23 October 2023

  1. The evidence indicates that during the school recess break on Monday, 23 October 2023, Lillie told a friend that she had made up her mind and wanted no further relationship with Paul, and that she intended to speak to him about it.

  2. At 2:08 pm on 23 October 2023, the evidence establishes that Paul attended the Mitre 10 hardware store in York Street, Sydney. CCTV

footage shows Paul purchasing a roll of Heavy Duty duct tape, and trying out a few hammers by making hitting motions, before selecting a Fiberglass Claw Handle hammer.

  1. After making the purchases, Paul attended a storeroom at St Andrew’s with a Mitre 10 plastic bag in his hand. The roll of duct tape has not been located, and its intended or actual uses are unknown. The hammer Paul purchased at Mitre 10 is not the hammer he used in the attack on Lilie.

This hammer was later recovered by Police during a search of the storeroom at St Andrew’s. I find that Paul placed the hammer in the storeroom after he purchased it on 23 October.

  1. Lilie later told her friend that she and Paul had spoken, during which Paul had said some hurtful things but then backtracked and apologised.

  2. At about 3:30 pm or 3:40 pm, a student recalled seeing Lilie and Paul in St Andrew’s Square and that they were arguing and that Lilie looked upset.

  3. Later that afternoon, Lilie told her friend that she had questioned Paul about the fake Snapchat account in the name of the woman from hockey.

The evidence indicates that Paul attempted to shift blame onto the woman, claiming he had a stalker. When Lilie and her friend confronted him, Paul deleted the account. Records tendered in the inquest establish the account was deleted at 4:06 pm on 23 October 2023 using an IP address which has a host name of the school, St Andrew’s. It is clear that Paul deleted the account after being confronted and exposed.

  1. Following this confrontation, Paul spent time going in and out of the gym.

He told a friend that he had spoken to the woman from hockey, claiming she was crying, had apologised, and admitted creating the account to see what Lilie looked like. There is no evidence to support that Paul spoke to the woman. Paul also told the friend that he really needed to

speak to Lilie, that he was really upset, confused, and feeling left in the dark.

  1. I find that Paul lied about speaking to the woman from hockey and that she was not involved in the creation or use of the fake Snapchat account and knew nothing about it. I further find that Paul’s reaction to being found out about the fake Snapchat account was to fabricate a story and attempt to portray himself as a victim of stalking.

  2. Paul started his afterhours shift at about 5:00 pm on 23 October. Two colleagues observed that he was visibly not himself and appeared sad.

Paul told them that he and Lilie had broken up on the previous Friday, claiming the breakup occurred because “she wanted more than casual and he didn’t.” On the evidence before me, this statement was untruthful.

I find that Lilie broke up with Paul because she wanted the relationship to end.

  1. Paul finished his shift at 9:00 pm and went home. The evidence indicates that Paul then hired another GoGet vehicle. GoGet data records obtained by Police, cross-referenced to Paul’s mobile phone records, indicate that Paul left home at about 9:58 pm and again drove to the vicinity of Lilie’s residence, returning home at about 11:16 pm. Again, there is no evidence that Paul called Lilie or messaged her while near her home.

  2. While outside Lilie’s home, Paul again took photos of cars parked in the street. These images were found on the iPhone 8 and metadata analysis by Police showed that the photos were taken on the iPhone 14 at 10:36 pm. This is the fourth instance that Paul physically stalked Lilie.

24 October 2023

  1. On Tuesday afternoon, 24 October 2023, Paul sent an email containing the sport statistics that had been requested of him on 16 October.

  2. At 4:00 pm, the records indicate that Paul booked out a GoGet vehicle for a 3-day period, ending at 4:00 pm on 27 October 2023. The reason for this extended booking is unclear.

  3. The records indicate that Paul accessed the GoGet vehicle from his home at 4:31 pm. Paul then drove to Allawah train station where he remained between 5:25 pm and 6:25 pm. Allawah train station is the closest station to Lilie’s home. CCTV footage from Allawah train station captured Paul driving past the entrance to the station. CCTV footage also captured Lilie exiting Allawah train station at about 6:18 pm. CCTV footage obtained from a house in Lilie’s Street captured Paul’s GoGet vehicle parked in the street at about 6:28 pm. The GoGet data shows that the car was turned off at 6:33 pm. CCTV footage captured Paul getting out of the car with his phone to his ear, walking out of sight and returning to his car about 20 minutes later.

  4. The GoGet data shows that the car was activated between 6:49 pm and 6:53 pm. Consistent with this, CCTV footage captured Paul sitting in the car looking at his phone. Phone records indicate that Paul made a phone call to Lilie at 7:06 pm, with the call lasting about 16 minutes. The GoGet vehicle was then activated and left the street at 7:24 pm. This was the fifth time that Paul physically stalked Lilie. While Paul did speak to Lilie on the phone, there is no evidence that he saw her in person.

  5. The GPS data shows that Paul drove from Lilie’s house to Diamond Bay Reserve in Vaucluse, arriving there at about 8:05 pm. CCTV footage obtained from a house in Chris Bang Crescent shows Paul parking the car, exiting the car, and then crossing the road and into the reserve.

What Paul did while in the reserve remains unknown, as the area is not covered by CCTV and there are no relevant records from his phone. It is unknown if Paul was contemplating ending his life at that time or surveying the location because he already had in mind what he planned to do the following day. This issue will be revisited when I address the expert evidence later in these findings.

  1. The CCTV footage, corroborated by the GoGet data, shows Paul reentering the vehicle and leaving Chris Bang Crescent at 8:18 pm, approximately 13 minutes after he arrived. Call records show that Paul called Lilie at 8:35 pm, with the call lasting 16 minutes 48 seconds. While on the call to Lilie, Paul arrived back at his house, and the GoGet vehicle was deactivated at 8:39 pm.

  2. At 9:03 pm the records indicate that Paul’s GoGet vehicle was activated, and that he again drove to Lilie’s house, arriving at 9:21 pm. Paul’s car remained there for 17 minutes before being reactivated and later stopped near Paul’s home at 9:56 pm. There is no evidence that Lilie and Paul had any contact during this time. On the iPhone 8, police located a photo of a car. An analysis of the metadata by Police shows that the photo was taken on the iPhone 14 at 9:29 pm. The metadata indicates that this photo was taken near Lilie’s house. This was the sixth time that Paul physically stalked Lilie.

  3. At 10:32 pm Mr van Wachem sent a text to Paul asking him whether he had received a request for statistics for sport.

  4. The GoGet data shows that at 10:36 pm Paul’s GoGet vehicle was activated again near his house. The data indicates that the vehicle stopped at Lilie’s house at 11:08 pm and remained there for 18 minutes, leaving at 11:26 pm. The data indicates that Paul returned to his home at 11:54 pm. There is no evidence that Lilie and Paul had any contact during this time. This was the seventh time that Paul physically stalked Lilie.

What occurred on 25 October 2023

  1. Before outlining what occurred on Wednesday, 25 October 2023, it is important to note that the evidence shows that the iPhone 8, later found in Paul’s backpack, began syncing and downloading old photos at 11:57 pm on 24 October 2023, and this process continued overnight. It

is likely that Paul was planning to start using the iPhone 8 in place of the iPhone 14 he had been using, indicating a possible motivation to destroy or conceal at least some of the contents of the iPhone 14. It is not known what the contents were, other than messages exchanged between Paul and Lilie.

  1. Lilie left for work at about 7:10 am on 25 October 2023. When she got to work, she told a friend that Paul had called the previous night to apologise for what he had said to her and that it was all good now. This evidence is consistent with the phone call Paul made to Lilie at 7:06 pm on 24 October 2023.

  2. As Paul’s flatmate was having breakfast, he saw Paul walk from his room to the bathroom. He observed that Paul’s eyes were watery, and that he was sniffling, forming the opinion that Paul had been crying. Paul’s flatmate left for the day without speaking to him.

  3. At 8:54 am on 25 October 2023, the evidence establishes that Mr van Wachem received a response from Paul regarding the question raised the previous night about whether Paul had received a request to provide sports statistics. At about 9:00 am Mr van Wachem called Paul. Mr van Wachem recalled that he told Paul he had become aware of a request for Paul to provide sport statistics. Mr van Wachem says that he told Paul the request was unacceptable, it should have come from him, and he should not provide any information without his notice.

  4. Following his initial phone call with Paul, Mr van Wachem spoke with another staff member and then phoned Paul again and reprimanded him for sharing sports statistics without his consent. Paul appeared apologetic, and Mr van Wachem thought Paul would have felt especially guilty, concerned he had let him down, and depressed over the conversation. This was the last contact Mr van Wachem had with Paul.

  5. It is possible the reprimand regarding his conduct at work may have impacted Paul, however, it is clear that regardless of Paul’s reaction to these events, his intentions in relation to Lilie were already formed and he was already preparing to harm her.

  6. At about 9:30 am, Paul tried to call his parents, however it was 12:30 am in the Netherlands, and they did not hear the call. Both of Paul’s parents later observed that this was an unusual time for Paul to call. Esther tried calling back when she saw the missed call, but Paul did not answer. Paul later responded with a text message that it was an accidental pocket dial.

  7. At 9:39 am Paul made an electronic funds payment of $100 to his flatmate with the description “Electric”.

161. At 11:00 am Paul left his home and arrived at St Andrew’s at 12:10 pm.

Prior to leaving home he communicated with a colleague, stating that although he could not do the night shift, he might still come into work as he had some sports reports to complete and would be available if colleagues needed him to drive the manual Ute. It is apparent that Paul chose not to work that evening but still ensured that there was a justifiable reason for him being at St Andrew’s later that day. This would prevent suspicion if anyone saw him in the staffroom or on school grounds. This evidence is consistent with Paul having already decided he was going to attack Lilie that night at St Andrew’s.

  1. Paul was captured on CCTV arriving at St Andrew’s for the first time at 12:10 pm and throughout the course of the day, he spent time with Lilie.

At 12:13 pm Paul and Lilie were seen leaving the staff room together and then exiting St Andrew’s. CCTV captured that they, together with another colleague, went to the Sydney Party Warehouse store located on Liverpool Street, Sydney. CCTV footage from the store shows Paul and Lilie purchasing costumes for a Halloween party that they were intending to go to on 26 October 2023. In the footage Lilie looks relaxed in Paul’s presence and is seen smiling and talking to him. After

purchasing the costumes, they returned to St Andrew’s. Their friend noted that they were communicating normally and there was no hostility or anger.

  1. I pause here to note that Paul is captured throughout the day on CCTV interacting with Lilie in a manner that appears friendly, calm and relaxed not unlike the footage that I have referred to during their attendance at the Sydney Party Warehouse store.

  2. However, Paul is also captured on St Andrew’s CCTV undertaking what, in my view, can be described as “practice runs” for the attack on Lilie he would perpetrate later that evening. This footage is deeply disturbing as not only does it capture every step of Paul’s preparation and the moments before the attack, it also shows his interactions with Lilie during the day, which reveal that she was entirely unaware of what was to come. On my review of the footage, it appears that Paul managed to go about his day with such composure that no one, including Lilie, had any indication of what he was planning to do that evening.

  3. The first known practice run captured on CCTV occurred at 1:29 pm on 25 October 2023.

  4. While I will refer to them, I will not repeat the details of each practice run as the footage was shown in Court and it is highly distressing. Counsel Assisting addressed what the footage depicts in detail during opening submissions, and I adopt what they have submitted the footage reveals.

  5. At 1:33 pm, the CCTV captured Paul entering the storeroom at St Andrew’s. This storeroom is where the hammer that Paul purchased from Mitre 10 on 23 October 2023 was later located by Police.

  6. At 3:20 pm, CCTV captured Lilie, Paul and another colleague going to Priceline, where Lilie made some purchases. The footage shows Lilie

smiling and appearing relaxed in Paul’s presence. Lilie and Paul then walked back to school together.

  1. At 3:30 pm, Lilie left St Andrew’s on the bus with the students for water polo training at Auburn. She was planning to return to St Andrew’s later that evening so that she could change and attend her own water polo game.

  2. At around 4:00 pm, Paul left St Andrew’s carrying a backpack and went home for a brief period. He told a colleague that he had forgotten his afterhours shirt and was returning home to retrieve it before coming back. This was untrue, as Paul had already arranged for someone else to cover his afterhours shift.

  3. In late November or early December 2023, Paul’s flatmate discovered that the hammer which was part of their Supatool toolkit was missing.

The flatmate gave evidence that Paul had used the hammer on about 10 September 2023 when they had moved into the house at Kensington.

Police purchased an identical toolkit, and the hammer in it is consistent with the type of hammer Paul used to attack Lilie on 25 October 2023.

CCTV shows that after Paul returned to St Andrew’s; he did not go to the storeroom where he had placed the hammer he purchased from Mitre 10. When Police searched St Andrew’s, they located a hammer in the storeroom, identical to the one purchased from Mitre 10.

  1. I find that while at home, Paul removed the hammer from the Supatool 105-piece toolkit, put it in his backpack, and took it back to St Andrew’s.

I also find that this is very likely to be the hammer which he used to attack Lilie. I note, however, that the hammer used in the attack has not been located.

  1. The records indicate that the GoGet vehicle that Paul had hired was then accessed at 4:10 pm as he left his home and drove to St Andrew’s, with the GoGet vehicle recorded as stopping at 4:32 pm. By chance, Paul

arrived at St Andrew’s at the same time as a friend. The friend asked why he had a car and Paul said that he was going to meet the woman from hockey and needed a car to get to her place. This was untrue and likely a lie Paul fabricated to explain why he had a car that day.

  1. When Paul arrived back at St Andrew’s, CCTV captured him conducting several more practice runs. In between these practice runs Paul is seen interacting normally with colleagues and friends.

  2. At 6:42 pm Paul left the school and then returned. Paul is seen on CCTV footage obtaining a key from his colleagues who were working the afterhours shift. Paul’s colleagues recalled that he told them he needed the key as the security guard had asked him to lock the door. This was a lie to justify why he needed the keys and to justify locking the sliding doors.

  3. At this stage, the glass sliding door no longer opened automatically and could only be opened by using a swipe pass.

  4. Meanwhile, Lilie was on the bus returning from water polo with a number of students. Those on the bus recalled talking with Lilie about their favourite music and her plans to play a water polo game later that evening.

  5. At 7:11 pm, Lilie’s mobile phone made a 2-second call to Paul’s mobile.

By this time, the water polo bus had returned, and Lilie had finished waiting for all the students to be collected. Paul immediately walked to the main foyer area. A staff member let Lilie in, and she walked to the gym area. Paul met her at the sliding doors, and they walked in together towards the staffroom.

  1. Lilie exited the staffroom 17 seconds later and walked towards the bathroom. Paul exited the staffroom with the backpack over his right arm and said something to Lilie. Paul had placed a cleaning sign outside one of the bathrooms, and Lilie entered the unobstructed bathroom.

  2. At 7:14 pm, CCTV captured Paul, holding a hammer, entering the bathroom where Lilie was. The only inference to be drawn from the available evidence, is that after entering the bathroom, Paul attacked and killed Lilie with the hammer.

  3. The evidence establishes that Paul stayed in the bathroom for 1 hour and 12 minutes. The CCTV footage confirms that no other person entered or exited the bathroom during that time, and that no other person entered the bathroom prior to the arrival of Police. There is only one entrance to the bathroom, which is visible on the CCTV.

  4. Based on the forensic evidence before me, I find that it is more likely than not that the assault commenced soon after Paul entered the bathroom, that Lilie was incapacitated quickly, and that the attack was not protracted.

183. It is unknown why Paul remained in the bathroom for so long.

  1. The CCTV footage shows that about 36 minutes after Paul entered the bathroom, cleaners entered the sports area and remained there for about 10 minutes. Given their location and cleaning actions, it is likely Paul would have heard some noise. This is one possible explanation as to why he stayed as long as he did in the bathroom. It does not, however, explain why he stayed in the bathroom prior to the cleaners arriving.

  2. I pause here to make some comments and observations of the events I have just set out. While Paul was going about his actions on 25 October 2023, he did so in the presence of other staff members and students.

These were predominately primary school students. From reviewing the CCTV footage, it is clear that Paul took no steps at any time to conceal himself and must have been aware of the presence of the CCTV cameras, which are in plain sight. At times Paul appeared to look directly at the cameras. The footage not only captured Paul preparing to attack Lilie but also practicing how he was going to carry out the attack.

  1. Returning to the events of 25 October 2023, at 8:23 pm, while Paul was still in the bathroom, a message was sent from Lilie’s phone to her father asking him to come to the school and pick her up.

  2. At 8:26:51 pm, CCTV captured Paul exiting the bathroom.

  3. At 8:27 pm, Lilie’s father received another message from Lilie’s phone and again tried calling her with no answer. It is clear that the only person who could have sent the messages to Lilie’s father was Paul. It is unknown why Paul chose to send these messages. I acknowledge the distress this would have caused Lilie’s father and her family.

  4. CCTV captured Paul exiting the gym and leaving the school via the St Andrew’s house service lifts to the carpark and entered the GoGet vehicle he had rented. The vehicle was activated at 8:35 pm and can then be seen on CCTV leaving the car park.

  5. The GoGet data shows that Paul drove from St Andrew’s to Diamond Bay Reserve and that along the way he did not stop for any determinable length of time or at any place. At 8:47 pm, the evidence indicates that Paul stopped and parked the GoGet vehicle at Chris Bang Crescent in Vaucluse, the same spot where he had parked the night before.

  6. At 9:04 pm, CCTV captured Paul exiting the GoGet vehicle and walking west along the footpath and out of view. It appears that Paul was headed in the direction of a council bin which was later searched by Police. At 9:12 pm Paul is again captured by the CCTV re-entering the driver’s seat of the GoGet vehicle, still carrying his backpack. The records indicate that the vehicle was activated at 9:22 pm. The footage showed Paul sitting in the car until 9:49 pm. The flashing light inside the vehicle is consistent with Paul using a phone, or phones being operated.

  7. Banking records show that at 9:52 pm and 9:53 pm, Paul made two electronic transfers from his bank account. He made a transfer of $9,100 to each of his flatmates, with the notation “6 months rent”.

  8. At 11:15 pm, CCTV captured Paul exiting the car and walking into the reserve. He appeared to have the backpack over his right shoulder. He later returned to the car.

  9. At around 11:45 pm, Paul made a call to triple zero which lasted approximately 3 minutes. Paul informed the triple zero operator that there was a body of a female in the bathroom on the right hand side of the sports area at St Andrew’s, and that he thought that someone should go in there before people arrive in the morning. He then terminated the call. Paul did not identify himself to the triple zero operator.

  10. At 11:59 pm, CCTV captured Paul getting out of the car, crossing the road and then heading into the reserve. This was the last moment that Paul was seen alive.

Police response to 000 call and subsequent investigations

  1. While the call was made to triple zero, a triangulation commenced which showed the call had been made in the vicinity of Diamond Bay Reserve.

At 11:53 pm, Car Crew ES35 acknowledged a message directing Police to attend the vicinity of Diamond Bay Reserve and Chris Bang Crescent in Vaucluse and speak with an informant who had knowledge of a female body in a bathroom. They approached code red urgent duty. Police attempted to call Paul’s mobile, the number that had dialled triple zero, at 11:54 pm, 11:56 pm and 11:59 pm.

  1. At 11:52 pm a job was created on the NSW Police Force CAD system for Police to attend St Andrew’s. Police arrived at St Andrew’s one (1) minute later at 11:53 pm. Police entered the sports area at 11:58 pm and

located a body at 11:59 pm in one of the bathrooms. Police declared the area a crime scene.

  1. On 26 October 2023 at 12:02 am, the CCTV showed Police arriving at Chris Bang Crescent with lights flashing, only three (3) minutes after Paul was last seen on CCTV. At 12:06 am, Police parked their vehicle near the GoGet vehicle and commenced searching the area. They searched Diamond Bay Reserve, walked the fence line with torches, moved further into the bushland, and checked the cars parked in the street.

  2. I find that the NSW Police Force could not have acted in a timelier manner. Within eleven (11) minutes they had identified the location where the triple zero call was made and had arrived at Diamond Bay Reserve. They missed Paul by three (3) minutes. Further, within one (1) minute of a job being created in the CAD system following the termination of the call Paul made to triple zero, Police had arrived at St Andrew’s and commenced their investigation.

  3. Police then patrolled Diamond Bay Reserve and the Gap, Christison Park, the streets of Watson Bay and Military Road from Vaucluse to Bondi. Water Police patrolled the coastline, however, this ceased at 1:47 am as conditions had deteriorated.

  4. At 1:50 am, Police returned to Diamond Bay Reserve to conduct a further canvass. Following a search of the bushy area near the cliff edge at Diamond Bay Reserve opposite Chris Bang Crescent, Police located a backpack. Inside were, amongst other items, Paul’s driver’s licence and the iPhone 8. The backpack was seized and forensically examined, as was the iPhone 8.

  5. Nearby, in the vicinity of the backpack, Police located a black Scotch and Soda brand T-shirt and a pair of black Kimmy brand pants on the ground close to the cliff edge. I note that these were not the clothes Paul was

seen wearing on 25 October 2023 in the CCTV footage, and in particular the footage that captured Paul entering and exiting the bathroom where he attacked Lilie. As a result of the forensic examination, I find that these clothes belonged to Paul but were not the clothes he was wearing on 25 October 2023.

  1. About 10 metres from the backpack on a grass patch, Police also located a homemade booklet of personal notes (vouchers). These paper vouchers were seized. An ex-partner of Paul’s later confirmed with Police that these were the vouchers she had given to Paul in July 2021 when they were in a relationship.

  2. At about 2:45 am on 26 October 2023, after reviewing the CCTV at St Andrew’s, Lilie was identified as the body that Police had located in the bathroom in the sports area.

  3. At about 7:40 am on 27 October 2023, Police were alerted to the sighting of a body at the bottom of the cliffs at Diamond Bay Reserve. There were delays in recovering the body due to the weather. At 1:15 pm, the body was identified as Paul by comparing fingerprints to those held in connection with his passport.

  4. I note that the clothing Paul wore at the time of the attack on Lilie was never located, nor were Paul’s and Lilie’s phones, or the hammer that was used in the attack. The Police Diving Unit conducted a search of the rocks both above and below the tide mark, as well as the sea floor in the area beneath Diamond Bay Reserve. The sea floor and rocks contain an infinite number of cracks and crevices into which smaller items may drop.

A triangulation of Paul’s iPhone 14 and Lilie’s iPhone placed them in the vicinity of Diamond Bay Reserve after Paul left St Andrew’s. The CCTV at Diamond Bay Reserve showed that Paul was wearing the same pants, top and sneakers he was wearing when he exited the bathroom. As already noted, the GoGet data records confirm that Paul did not stop for

any determinable length of time between St Andrew’s and Diamond Bay Reserve.

  1. I find that Paul took his iPhone 14, Lilie’s iPhone and the hammer with him to Diamond Bay Reserve. These items have not been located.

Post-Mortem examinations Lilie James

  1. A post-mortem examination of Lilie was performed by Dr Rianie Van Vuuren on 30 and 31 October 2023. In her report, Dr Van Vuuren opined that the cause of Lilie’s death was “multiple blunt force injuries on the head and neck”. While the order in which Lilie’s injuries were obtained cannot be known, Dr Van Vuuren considered that it is likely that Lilie died soon after the assault began. I accept Dr Van Vuuren’s opinion and find that the evidence establishes that Lilie’s cause of death was multiple blunt force injuries to the head and neck.

Forensic Evidence

  1. Forensic Project Officer Ellen Konza provided two reports which were included in the brief of evidence that was tendered at the inquest.

Ms Konza has been employed by the NSW Police Force since October 2002 and has, since that time, been attached to the Forensic Evidence and Technical Services Command. I have had regard to Ms Konza’s curriculum vitae, and I accept her as an expert in this area.

  1. Ms Konza was requested by me to review the crime scene and provide an opinion to assist me to try to gain an understanding of what occurred in the bathroom where the assault upon Lilie transpired. I will not reproduce the contents of the reports as it is highly distressing and graphic. Counsel Assisting provided a detailed summary of the reports

in their opening address and submissions which as I have earlier indicated I have adopted and rely upon.

  1. I accept the opinions set out in Ms Konza’s reports that the assault upon Lilie was not protracted and that there was no evidence of a clean-up and find that the nature and extent of Paul’s assault on Lilie was violent.

  2. In light of the evidence gathered, and considering what is set out in Ms Konza’s reports, the question that arises is why Paul remained in the bathroom for the length of time he did. Unfortunately, the evidence before me is insufficient to provide an explanation, and that question remains unanswered.

Paul Thijssen

  1. A post-mortem examination was conducted on Paul on 1 November 2023 by Dr Jennifer Pokorny. In her report, Dr Pokorny opined that the cause of Paul’s death was “multiple blunt force injuries”. His toxicology analysis revealed that alcohol was detected in the blood at 0.04g/100mL, although it is not known whether that represents post-mortem production. I accept Dr Pokorny’s opinion and find that the evidence establishes that Paul’s cause of death was multiple blunt force injuries.

Expert Evidence and Evidence from the Secretariat of the Domestic Violence Death Review Team Limitations on expert evidence and secretariat review

  1. Associate Professor Danny Sullivan and Dr Katie Seidler were engaged at my request to undertake an assessment and provide an opinion on Lilie and Paul’s relationship, as well as any possible mental health diagnoses or presentations of Paul. Their assessment was based on the materials contained within the brief of evidence tendered at the inquest and the events that are known to have taken place on 25 October 2023.

They were also asked to consider whether there was evidence of intimate partner violence, coercive control and domestic violence, and if so, whether there were any potential points of intervention and/or improvements that could be made to raise public awareness and understanding of coercive control in the context within relationships, and how to identify and recognise unacceptable behaviour/s within relationships.

  1. Associate Professor Sullivan and Dr Seidler both acknowledged the limitations of such an assessment, noting that they were unable to assess either Lilie or Paul in person and that there was an absence of clinical information available to consider, such as medical, psychological or psychiatric evaluations, or any formal evidence of Paul having prior contact with mental health clinicians.

  2. Consequently, Associate Professor Sullivan and Dr Seidler relied on information drawn from various witness statements provided by family members, friends, work colleagues and ex-partners. From these statements, they inferred aspects of Paul’s character, personality, temperament and behaviour across different periods of Paul’s life, both socially and in a work environment, as well as the possible presence or absence of any diagnosable mental health condition. It was also acknowledged, and I wish to highlight and caveat, that these witness statements have not been tested.

  3. Professor Kate Fitz-Gibbon and Anna Butler were also engaged at my request to undertake an assessment based on the materials contained within the brief of evidence that was tendered at the inquest and the events that are known to have taken place on 25 October 2023. They were asked to provide an opinion on Lilie and Paul’s relationship and whether there was evidence of intimate partner violence, coercive control and domestic violence, and if so, whether there were any potential points of interventions and/or improvements that could be made to raise public awareness and understanding of coercive control

in the context within relationships, and how to identify and recognise unacceptable behaviour/s within relationships.

  1. The limitations acknowledged by Associate Professor Sullivan and Dr Seidler were similarly noted by Professor Fitz-Gibbon and Ms Butler in relation to their assessments. Ms Butler further highlighted that, given the brevity of Lilie and Paul’s relationship, there was only limited material to consider.

Expert Psychiatrist

  1. Associate Professor Danny Sullivan is a Consultant Forensic Psychiatrist who is registered as a specialist in psychiatry with the Australian Health Practitioner Regulation Authority, is a Fellow of the Royal Australian and New Zealand College of Psychiatrists, and an Accredited Member of the Faculties of Forensic Psychiatry and Adult Psychiatry of the Royal Australian New Zealand College of Psychiatrists.

Associate Professor Sullivan is currently a consultant psychiatrist and was formerly the executive director of Forensicare, which is the Victorian Institute of Forensic Mental Health, a public mental health service that provides services to people who have offended or are at risk of offending. Associate Professor Sullivan’s experience as outlined in his curriculum vitae is extensive and I have had regard to it.

  1. In his report, Associate Professor Sullivan considered whether Paul had any mental health diagnoses. In his opinion, there were no grounds to consider that Paul’s actions were the result of a mental disorder. In his view: a) There was no evidence of psychosis (characterised by symptoms such as delusions and hallucinations) or delusions of jealousy (a fixed false belief that the other party in a relationship is being unfaithful).

b) There was no evidence of bipolar disorder, or any observations suggesting a significant alteration in activity, behaviour or speech.

c) The available information did not support a diagnosis of a significant mood disorder. Paul may have been depressed at times, but there is no evidence of disturbed appetite, sleep, or energy, or that he voiced thoughts suggesting depressive cognitions, or that his performance in work or study was adversely affected.

d) There was no evidence of cognitive impairment or acquired brain injury.

e) There were no grounds to determine features of an adjustment disorder.

f) There was no evidence of clinically significant substance use or gambling.

g) No adverse inferences could be drawn with regard to pornography use given the only information available was regarding expenditures.

h) There was no evidence that Paul had a personality disorder. A personality disorder reflects inflexible and maladaptive traits, present in a range of domains in a person’s life, and evident from late adolescence or early adult years. No formal diagnosis of personality disorder was made during Paul’s life. There was no indication of behavioural disturbance at school, antisocial attitudes or behaviours, offending, significant psychopathic traits, or past actual or threatened self-harm or suicidal ideation. There was little evidence of poor emotional regulation, and indeed, the preponderance of opinion was that he was of generally calm and stable temperament. There may have been some shortcomings but not sufficient to meet a personality disorder diagnosis.

i) Similarly, there was no evidence that Paul had the traits of narcissistic personality disorder. It could be inferred that Paul had

mild forms of some of the traits, but these did not reach a pervasive and significant level. What could be seen is that in his relationships, some of those fragilities were amplified and became problematic for Paul.

j) There was little doubt from the events that Paul was experiencing a significant degree of emotional turmoil.

  1. Associate Professor Sullivan opined that Paul showed a significant pattern of possessive and controlling behaviour, emotional manipulation, anger and tears, and stalking. There was coercive control present in Paul’s previous relationship, and in the relationship with Lilie, despite it being short in duration. It can be surmised that in the relationship with Lilie, Paul had sought something similar to what he had with his expartner.

  2. However, Associate Professor Sullivan opined that Lilie appeared more socially adroit than Paul, and consequently she was setting the narrative and was in control. Lilie breaking up with Paul was a blow to his ego.

Paul constructed a narrative that he was nonchalant and in control, but deep inside he was very wounded, potentially humiliated that he was not attractive enough to her. There were threats to that narrative, of being exposed as someone who was not the person he purported to be.

However, as Associate Professor Sullivan noted, it is somewhat speculative to consider what is going on in a person’s mind, without the opportunity to ask that person questions or observe their behaviour.

  1. Associate Professor Sullivan was of the view that Paul’s forgery of documents for his visa was an aspect of his constructed narrative, although it is not known whether this has relevance to the events, or whether Paul was imminently fearful of being discovered. Equally, the reprimand that Paul received from Mr van Wachem did not have significance to the events of 25 October 2023, in Associate Professor Sullivan’s view, because Paul had already put his plans in motion.

  2. Associate Professor Sullivan considered Paul’s behaviour against risk assessment tools, including the Stalking Risk Profile (SRP), an evidenced-based structured professional judgement tool which enables assessment of the risk of stalking, the likelihood of violence and the recurrence of stalking. Paul would have constituted a rejected or resentful stalker. His initial behaviour was grounded in rejection, where the motive may have been to restore the relationship; but, in preparing to kill Lilie, Paul was clearly resentful and seeking revenge. From 20 October 2023, Paul undertook covert stalking of Lilie, both physically and electronically, in a manner which suggested he was collating data.

However, there were no expressed threats or overt behaviours which would foreshadow violence, and his jealousy would not have appeared abnormal. Assessment according to the SRP would have provided little concern of an imminent risk of violence.

  1. With regard to the creation of the fake Snapchat account, Associate Professor Sullivan agreed with Dr Seidler’s views, which are set out below. He noted that it was to create an alternate narrative of how in demand he was and opined in addition that it could be that Paul was using this not just to have a “stalker”, but also perhaps as a way of surveilling Lilie or seeing through a nom de plume that he could keep tabs on her appearance and see if she was communicating with other people through Snapchat.

  2. In retrospect, Associate Professor Sullivan was of the view that it was clear that Paul had developed both homicidal and suicidal ideation in the days before he attacked Lilie. There was definite evidence of preparation to assault and kill Lilie from 23 October 2023 and plans to kill himself from 24 October 2023, when Paul went to Diamond Bay Reserve. This is evidence of “last resort thinking”, where a person’s thinking becomes absolute, and they can no longer see a range of flexible solutions to a problem. However, there was no outward evidence or leakage, and Paul’s intended actions were not communicated to others.

  3. In Associate Professor Sullivan’s opinion, given Paul kept his thoughts and actions private, there were limited potential points of intervention.

Had the surveillance of Lilie been identified, this may have led to police notification or efforts by Lilie to avoid him, but there was limited evidence that Lilie felt threatened by Paul.

  1. Associate Professor Sullivan noted that there was no significant evidence of loss of behavioural control in the days leading up to 25 October 2023. In the CCTV footage obtained before and after the attack, Paul appeared in control, planned, methodical and calm. The circumstances of Lilie’s death are suggestive of “overkill”, a phenomenon in which grossly excessive, unnecessary and repeated force is considered to represent rage or uncontrolled anger, but the amount of violence Paul inflicted may also have been intended to disable Lilie as quickly as possible.

  2. Associate Professor Sullivan was of the view that Paul’s intention to kill Lilie arose before his intention to kill himself, judged by the behavioural evidence of his preparations in particular the purchase of the hammer on 23 October which had no other ostensible purpose, however, could say nothing more apart from that. He opined that Paul had done enough planning to perhaps have some fallback options or contingencies if things had not come to pass.

  3. Associate Professor Sullivan was of the view that the attack on Lilie was gender-based violence because Paul used physical force and violence against a woman who spurned his advances.

  4. Regarding areas for improvement, Associate Professor Sullivan noted that services for perpetrators do not meet demand, and the evidence base for those interventions remains impoverished.

  5. Associate Professor Sullivan could not offer an opinion as to why Paul killed Lilie, although he agreed with Dr Seidler’s opinion, below. He also proffered the following: “Working forwards from the fact that we don’t see clear signs of mental disorder here, it can only be taken that [Paul] had formed a hatred of [Lilie] based upon the fact she had rejected him and he punished her by killing her.”

233. I accept the opinions and views expressed by Associate Professor Sullivan.

Expert Psychologist

  1. Dr Katie Seidler is a Clinical and Forensic Psychologist with a PhD in Psychology in the area of interpersonal violence and cultural experience, and also has a master’s degree in Clinical Psychology. Dr Seidler is currently the Director of LSC Psychology, a private practice in Sydney that provides high level expert clinical and forensic services in various jurisdictions. Prior to this role, Dr Seidler worked in Corrective Services in the Barwon offender and sex offender treatment programs, and at Juvenile Justice. Dr Seidler’s experience as outlined in her curriculum vitae is extensive and I have had regard to it.

  2. In her reports, Dr Seidler also considered possible mental health diagnoses and opined as follows:

• There was no available evidence that Paul met the criteria for any diagnosable mental health condition.

• There were transitory symptoms of anxiety and depression and possibly at “a stretch” Paul could have been considered to have an adjustment disorder (a “normal” psychological response to a significant or abnormal personal stressor).

• Paul was a deeply insecure individual with poor self-esteem who did not believe he was ‘good enough’ and who needed external validation. He had a history of emotional instability, of difficulties in close relationships, struggled interpersonally and was prone to reactive, destructive and self-defeating patterns of behaviour that pushed boundaries and made others uncomfortable. This in addition to his fragile sense of self is more characteristic of a Personality Disorder. However, he does not neatly conform to any specific disorder.

• Paul’s relationships with others were generally positive, and he was generally well-liked, well-regarded and functioning in connection with others.

  1. Dr Seidler opined that Paul had a vulnerable and fragile sense of self and was probably feeling pervasively inadequate and potentially unworthy and covered that up by projecting an image of perfection, of having it all together, through all aspects of his life and maintained this façade with compulsive lying. Dr Seidler was of the view that Paul projected this image that he had carefully constructed and would have found it very difficult to cope when people did not see him in that light.

  2. Dr Seidler was of the view that the lies Paul told people about the end of the relationship with Lilie served to perpetuate his positive self-image.

Lilie’s rejection of Paul is something he would have really struggled to cope with; it would have been a stain on his perfectly constructed reputation. Dr Seidler was of the view that Paul was driven by the desire to control the public narrative and was afraid of what people would think of him if a different narrative came out.

  1. In Dr Seidler’s view the forgery of documents submitted in support of the visas speaks to how prepared Paul was to lie to construct a public narrative to suit his purpose. However, there was no evidence of Paul experiencing stress about the risk of his lies being discovered, for

example by turning up late for work, being irritable with others, being fidgety, restless, or making mistakes at work.

  1. Dr Seidler was of the view that there is no doubt that Paul would have been ruminating about the reprimand from Mr van Wachem. She hypothesised that it was strategic for Paul to be aligned with someone in that position in the school and questioned whether he truly considered him like family or not. Rather than being distressed by the reprimand Dr Seidler speculated whether Paul was angry and resentful about being put in a position by somebody else’s actions that led to him being seen in a poor light. In terms of whether the reprimand had any significance to the events of 25 October, Dr Seidler agreed with Associate Professor Sullivan that Paul’s plan to kill Lilie and then kill himself had already been put in train.

  2. Dr Seidler noted that violence is easier for people to understand if there’s a perceived loss of control but was not sure whether loss of control is a significant issue in this case. In her view, Paul was someone who preferred to maintain control rather than feeling like he was losing control, and that a sense of control was much more about Paul and how he saw himself in his world as opposed to losing control of Lilie.

  3. Dr Seidler considered that Paul’s actions were “a cold, calculated, premeditated and controlled action with evidence of ‘overkill’”. She hypothesised that Paul could not cope with the “stain” on his reputation created by Lilie ending their relationship and did not want to deal with the awkward and uncomfortable social situations that would follow, which, in his mind, would inevitably result in some judgement of him. In that context, Lilie’s ongoing presence in his life became ostensibly intolerable and he needed to neutralise this in order to cope with what he was feeling about himself.

  4. Dr Seidler hypothesised that anger was absent and not the driving force in Paul’s actions and that he was more driven by fear than anger and

retaliation when he attacked Lilie. In her view, Paul was more driven by insecurity and vulnerability. His actions were better described as “cold” and “detached from an emotional perspective” with Paul being in control and not emotionally dysregulated by anger. The fact that Paul took and used Lilie’s mobile phone after the assault supported the suggestion that he was in control cognitively and not overwhelmed emotionally.

  1. Dr Seidler was of the view that there was evidence of similar patterns of behaviour by Paul towards Lilie in the relationship Paul had with his expartner; and that there was evidence of coercive control in the relationship between Paul and Lilie despite the relationship being of a short duration.

  2. Dr Seidler perceived that the creation of a fake Snapchat account was driven by a desire to appear desirable and was designed to make Lilie jealous. Like Associate Professor Sullivan, she considered the stalking to be driven by a desire to see who was with Lilie, and whether there was another male involved.

  3. Dr Seidler agreed with Associate Professor Sullivan that the attack on Lilie was gender-based violence because it was violence perpetrated by a man upon a woman with whom he had an intimate relationship.

  4. With regard to whether there were any potential points of intervention, Dr Seidler was of the view that unfortunately there weren’t any given the brevity of the relationship and because it is likely that Lilie did not understand or see Paul’s behaviour the way we see it with the information that is now available.

  5. Dr Seidler considered opportunities for improvement. She considered it would have been helpful if there had been forensic intervention in this case. It would be useful to have a single reference point, where people can be referred for information and support, and education for friends and families to better identify the warning signs for coercive control.

Dr Seidler emphasised that men need education to better understand masculinity, femininity, relationships and gender, to start to make some different choices about how they engage with women in their relationships.

  1. As to whether Dr Seidler could explain why Lilie’s death occurred, she proffered the following hypothesis: “that at its foundational level, this is a man who couldn’t cope with how he was feeling and he neutralised a threat to that by [killing] another person in a way that is just utterly unacceptable.”

249. I accept the opinions and views expressed by Dr Seidler.

Gendered Violence and Violence Against Women Academic Expert

  1. Professor Kate Fitz-Gibbon is a Professor within the Faculty of Business and Economics at Monash University and is recognised as an international leading scholar in the prevention of violence against women and children, femicide and perpetrator interventions. Professor Fitz Gibbon has a PhD in Criminology, a Master’s Degree in Human Rights Law and holds an honorary professional role at the Melbourne Law School.

  2. Professor Fitz-Gibbon provided an expert report which was included in the brief of evidence that was tendered at the inquest and attended the inquest to give oral evidence concurrently with Ms Butler.

  3. Professor Fitz-Gibbon described this case as an example of gendered violence within the context of an intimate partner violence homicide due to there being a male perpetrator and female victim and the violence having occurred following a relationship separation.

  4. Professor Fitz-Gibbon explained that, while there is no single definition of coercive control, it can be described as a pattern of abusive behaviours used over time with the intent to control, coerce, and attack the autonomy and the liberty of the victim. These behaviours may involve physical violence, threats, intimidation, harassment, stalking, isolation from family and friends, and control over other activities such as education, employment, social activities. These behaviours are used to instil fear and control and can be used in different intensities over time.

In Professor Fitz-Gibbon’s view, there was evidence of Paul behaving in a way that was coercive and controlling towards Lilie.

  1. Professor Fitz-Gibbon noted the shock that family and friends may feel in the aftermath of a horrific event like this, which they may describe as being “out of character” for the perpetrator. However, in her view, cases of intimate partner homicide are often planned and premeditated, and that this was the case in the present matter.

  2. Professor Fitz-Gibbon explained that perpetrators can use technology to enact control over an individual and how this can be a challenge for young people to navigate when they are increasingly living and sharing their lives online. This is something that requires increased awareness and education. She provided the example of sharing your location with someone; it is important to understand relationships as dynamic and that decisions made at one point are not necessarily reflective of consent or safe decisions at another point in time of the relationship.

  3. Professor Fitz-Gibbon referred to Jane Monckton Smith’s (MoncktonSmith) eight-step timeline in intimate partner femicide as follows:

  1. Pre-relationship

  2. Early relationship

  3. Relationship

  4. Trigger event

  5. Escalation

  6. Change in thinking

  7. Planning

  8. Homicide

  1. Professor Fitz-Gibbon explained that relationship separation (or the attempt to separate) emerges as the critical trigger event in MoncktonSmith’s eight-stage model. Monckton-Smith found that in virtually all cases that progressed to homicide, the victim’s attempt to end the relationship was met with significant resistance from the abuser.

  2. Paul engaged in stalking, both in his relationship with Lilie and in his prior relationship. Stalking is a pervasive behaviour that can occur before, during, and after an abusive relationship. Professor Fitz-Gibbon viewed it as a matter of significance, as it represents an escalation, in particular when perpetrated in the post-relationship phase. Stalking is common in partner abusers who go on to commit intimate partner homicide. It represents a red flag for risk of serious harm and lethality, and, in her view, it is important to ensure that the justice and service systems use risk assessment tools which reflect the importance of stalking.

  3. Professor Fitz-Gibbon noted the evidence of a friend who observed Paul continually monitoring Lilie during a party, believing it was indicative of how much he must like her. This underlines the need for education and awareness amongst young people about behaviours that may indicate risk. She opined that young people need to be given the tools to know how to “nudge” each other to let each other know when they are seeing behaviours that are not healthy.

  4. Professor Fitz-Gibbon also referred to the evidence that Paul had asked his housemates about where to obtain relationship advice. It is important to work with young boys and men, to model acceptable behaviours and to provide safe spaces for them to seek advice.

261. I accept the opinions and views expressed by Professor Fitz-Gibbon.

Domestic Violence Death Review Team Secretariat Review

  1. Anna Butler is the Manager of the NSW Domestic Violence Death Review Team (DVDRT) and chairs the Australian Domestic and Family Violence Death Review Network. Ms Butler has formal qualifications in science and law.

  2. The DVDRT was established in 2010 under the Act to review deaths occurring in the context of domestic violence in New South Wales. It is a multi-agency committee that sits within the Coroners Court and reports biennially to the NSW Parliament. The DVDRT conducts comprehensive reviews of each death, incorporating both qualitative and quantitative elements. The examination of domestic violence deaths provides a window, or lens through which to evaluate systems, services and communities, identifying opportunities for intervention or prevention, or where the story may have been changed.

  3. Ms Butler explained the DVDRT’s understanding of Intimate Partner Violence (IPV), as the intentional use of violence and abuse to assert and maintain control over a current or former intimate partner. Ms Butler noted that approximately one-fifth of IPV homicides involve homicidesuicide, and that it is a gendered crime, almost exclusively perpetrated by a male against a current or former female partner.

  4. Ms Butler shared Professor Fitz-Gibbon’s view regarding the reference to Paul’s behaviour being “out of character”. She emphasised that it takes time to understand the background to a homicide, and so reporting IPV homicides as being out of character for a perpetrator is profoundly unhelpful in shaping the broader community understanding.

  5. Ms Butler observed that there was evidence of coercive control in the relationship between Paul and Lilie. When Lilie sought to end the

relationship, Paul employed a range of emotionally abusive and manipulative tactics to have the relationship continue. This included the use of technology to monitor Lilie, and also sharing an intimate photo of her with friends, in an attempt to demonstrate his dominance over her.

Ms Butler noted that there was an opportunity for people to intervene and to call him out on that behaviour. However, this type of behaviour has been normalised, presenting a challenge in educating people to conceptualise these behaviours as coercive control.

  1. Ms Butler viewed Paul’s physical stalking as an escalation, and that this, and the creation of a fake Snapchat account, could be viewed as attempts by him to regain control over Lilie.

  2. Ms Butler identified a gap in services and supports for young men who seek advice about relationships. In her view, there is also work to be done to educate and upskill the peer cohort, to enable proactive bystander interventions.

  3. Ms Butler also provided a comparison between the circumstances of Lilie’s death, and other deaths reviewed by the DVDRT. The DVDRT dataset now comprises 550 homicides linked to domestic violence occurring between 2000 and 2022 (representing almost one-third of all 1,832 homicides recorded during that period).

  4. Ms Butler identified that there were some differences between Lilie and Paul’s case and other cases in the dataset as follows: a) Lilie and Paul are the youngest case of IPV homicide-suicide in the dataset.

b) Their relationship was shorter than average, although emphasised that fatal violence can occur at any point in a relationship.

c) The location of the death was unusual, where most IPV homicidesuicides occur within the home. It likely represented a location where Paul could exert control.

  1. In other respects, Ms Butler noted that the case shares similarities with most other cases in the dataset. The death occurred in the context of separation, a well understood risk indicator. There was no prior physical abuse, which is the case for more than half of the cases in the dataset, where the first act of violence was the fatal act of violence. Lilie and Paul were well-educated, well-employed and had no known drug or alcohol issues.

  2. Regarding potential areas for reform, Ms Butler highlighted the important role of the broader community in identifying, calling out and interrupting problematic behaviours, as well as providing support for people experiencing violence. Ms Butler stressed the need for education and awareness about what domestic violence looks like and the wide spectrum of behaviour it can encompass.

  3. Ms Butler also referred to men’s behaviour change programs, noting a significant gap in research on how to best work with young men and boys. Ms Butler referred to research that is currently underway by ANROWS (Australian National Research Organisation for Women’s Safety) on this topic.

274. I accept the opinions and views expressed by Ms Butler and the DVDRT Team.

eSafety Commissioner

  1. Julie Inman-Grant is the eSafety Commissioner (the Commissioner) and was appointed to that role in 2017 and reappointed for a further 5-year term in January 2022.

  2. The Office of the eSafety Commissioner (eSafety) was established in 2015 as the Office of the Children’s eSafety Commissioner. The focus was on protecting young Australians from serious cyberbullying on social media sites and disrupting the online distribution of child abuse material.

In June 2017, Parliament expanded the Children’s eSafety Commissioner name and remit to the eSafety Commissioner.

  1. The eSafety mandate is to ensure Australians of all ages have safer and more positive experiences online. eSafety leads and coordinates online safety efforts across Australian Government departments, authorities and agencies, and engage with key online safety stakeholders internationally to amplify its impact across borders.

  2. The evidence in the inquest revealed that Paul used technology to track Lilie’s movements, and also in other coercive ways, such as the use of the fake Snapchat account and sharing intimate images of Lilie. He had behaved in a similar way in his previous relationship.

  3. The Commissioner referred to this type of behaviour as “technologyfacilitated abuse” (TFA), being the use of any kind of technology to harass, surveil and control another person, including in an intimate relationship. As technology is inextricably tied into every aspect of our lives, particularly for younger people, TFA is becoming prevalent in the community. One in two Australians has experienced technologyfacilitated abuse.

  4. The normalisation of TFA in the community has been demonstrated in research, including research conducted by eSafety in conjunction with the Social Research Centre. This revealed that one in four Australians think it is reasonable to expect to have a partner’s codes and passwords on their personal devices; more than one in eight agree that constantly texting a partner to check who they are with or what they are doing is usually a sign of care in a relationship; and more than one in ten think it is reasonable to expect to track a partner using location sharing apps.

  5. The Commissioner and eSafety provided a wealth of material to the inquest, in relation to TFA and initiatives that are underway to address it. Set out below is a summary of the key initiatives that were highlighted in the evidence: a) In 2018, eSafety developed an initiative called “safety by design”.

This is aimed at prompting technology companies to assess risks, understand harms, and to engineer out the misuse of technology at the design stage.

b) There is a range of resources on the eSafety website on the topic of TFA, including the eSafety Guide, which educates parents about the use and risks associated with common technology services.

c) The “Love is” campaign, which is aimed at helping Australians identify red flags or warning signs that a partner might be using technology as part of a broader pattern of control.

d) eSafety plans to put out further advisory material around TFA, in particular for the 18-24 age group. That age group has the highest prevalence of all forms of online abuse. eSafety plans to publish free webinars, diagnostic tools for young people to help identify coercive controlling behaviours, and advice on what to do and where to get help.

e) eSafety has a youth advisory council, and an advisory group of young people with lived experience of TFA, to assist in development of relevant advice and resources. The Commissioner observed that young people will not respond to something that is not authentic and does not resonate with them.

f) eSaftey has worked with Deakin University on research into “Being a young man online”, and works with different men’s groups such as R4Respect, The Man Cave, Movember and The Men’s Project to develop primary resources for men.

g) eSafety is also assisting in the development of artificial intelligence (AI) tools to detect harmful online search activity and “nudge” the user towards support and resources (as is currently the case for searches in relation to self-harm).

h) A toolkit has been developed for schools, which includes resources and professional development about online safety. Training on TFA is also available for the workplace, in conjunction with SafeWork Australia.

i) eSafety has launched the Technology-Facilitated Abuse Support Service (TFA Support Service), a referral service for family violence organisations which provides resources and advice about TFA. This includes a telephone-based advice service.

  1. I am very grateful to the Commissioner and eSafety for the material provided and evidence given at the inquest. It has been of great assistance and has cast a critical spotlight on how technology can be used in interpersonal relationships as a method of stalking and/or coercive control and abuse, as well as on where further improvement, public awareness and education is required. It has also assisted to raise awareness and potentially help young people identify and protect themselves and protect others from technology-facilitated abuse. It is encouraging to see how much work has been done to promote awareness of these significant issues and what is planned to be implemented in the future to continue raising awareness and to educate.

NSW Education Standards Authority (NESA)

  1. Dr Paul Cahill, the Executive Director of the Curriculum Division at the NSW Education Standards Authority (NESA) provided material in response to a request from me for information on what programs, guidance and support are provided by the Department of Education (the Department) on the topics of coercive control in relationships, use of

technology in relationships, and domestic violence and violence in relationships.

  1. Set out below is a summary of how the curriculum aims to educate and raise awareness at schools with regard to coercive control and TFA.

  2. All schools in NSW must have an educational program based on the NESA Personal Development, Health and Physical Education (PDHPE) syllabus, which includes mandatory content that addresses coercive control in relationships and safe use of technology.

286. The current syllabus includes the following aspects:

• How students can develop strategies to protect themselves and others from unsafe, abusive or violent situations in relationships.

• How students can address coercion, abuse, violence and harassment including an opportunity for students to practice these skills.

• Protective strategies that help keep students and others safe online.

  1. In addition to the mandatory content, NESA also provides optional teaching advice to assist teachers to deliver content related to victims, perpetrators, bystanders, respectful relationships and consent.

  2. There is a new NSW PDHPE syllabus to be implemented by 2027. This will include mandatory education on respectful relationships, at each stage of learning from Kindergarten to Year 10. The content comprises mandatory content for primary (Kindergarten to Year 6) and high school (Year 7 to 10 PDHPE) students. It has been developed in consultation with NSW Health, the eSafety Commissioner and NSW education sectors. The primary school content includes education on preventing and managing imbalances of power, coercive control in online and offline

environments, rights and responsibilities in respectful relationships, and effective ways to resolve conflict, bullying, discrimination and coercion.

  1. The high school content has been strengthened to include content on how gender equality and challenging assumptions about gender can prevent violence and abuse in relationships and respect and power in relationships. Students will also learn about how to recognise early warning signs that may lead to coercive control, assertive and upstander behaviour, and how to access support networks.

  2. I find it encouraging that proactive steps have been and are being taken to strengthen the NSW school curriculum in relation to education about respectful relationships, coercive control, the use of technology in relationships and domestic violence.

NSW Department of Education

  1. Martin Graham, Deputy Secretary of Teaching Learning and Student Wellbeing, provided information and material on behalf of the Department in response to a request from me. Mr Graham advised that the Department delivers the NESA curriculum which I have outlined above. The evidence received relates to education that is provided to NSW public schools and not the independent or Catholic school sector.

  2. From 2024 the Department has been party to Commonwealth funding pursuant to the Consent and Respectful Relationships Education Measure and will continue to receive funding until 2028. The purpose of the funding is to support consent and respectful relationships education, and the Department is required to submit progress reports annually to the Commonwealth to acquit the funding.

  3. The Department’s Curriculum and Reform Team have been part of the National Respectful Relationships Education Working Group since 2023, applying expert advice to support NSW schools. This working group is

available to all schools, not just government schools. A national framework is being developed, and the Department’s representative contributed to and advised the working group. One of the primary initiatives of this working group, is the Respectful Relationship Education framework developed by Monash University, helping to develop a national respectful relationships framework.

  1. The Department is also working closely with NSW Government agencies as part of the Pathways to Prevention: NSW Strategy for the Prevention of Domestic, Family and Sexual Violence 2024-2028 with funding from the Department of Communities and Justice.

  2. Students in NSW Government schools are taught about Respectful Relationships Education (RRE) and child protection education in an ageappropriate way through the mandatory Kindergarten to Year 10 syllabus. Individual schools have the responsibility for designing educational experiences for students in line with the curriculum requirements, best practice and student needs.

  3. RRE, which is within the syllabus, involves developing students’ attitudes and understanding of ethical, equal and non-violent relationships and skills to protect themselves and others as they challenge the abuse of power and advocate for a commitment to equity, inclusion, respect and responsibility.

  4. Life Ready is an additional mandatory 25-hour course undertaken by students in Years 11 and 12 at all NSW Government schools. The course encompasses respectful relationships and extends upon the learning implemented in earlier schooling years.

  5. In addition to the mandatory curriculum, schools have the discretion to incorporate additional programs from external providers, such as Cybermarvel, an online safety awareness initiative.

  6. The Department is also working with the Department of Communities and Justice to update materials specifically related to domestic, family and sexual violence, consent and coercive control to align with legislative changes in NSW as well as the upcoming syllabus changes. Resources and professional learning regarding this are in development and will be available to all schools in 2026.

  7. I acknowledge the broad range of supporting resources, which is reassuring, that the Department has or is in the process of developing to assist with the implementation of the NESA curriculum regarding education about coercive control in relationships, use of technology in relationships and domestic violence and violence in relationships.

National Association for Prevention of Child Abuse and Neglect (NAPCAN)

  1. To assist my understanding of what programs are available to young people about relationships and the use of technology, I sought information and material from the National Association for Prevention of Child Abuse and Neglect (NAPCAN), who are the providers of the Love Bites Respectful Relationships Program (Love Bites). Leesa Waters, the Chief Executive Officer of NAPCAN, provided me with very helpful information about the Love Bites program which was included in the brief of evidence that was tendered at the inquest.

  2. Set out below is a summary of what the program entails. Further information about the program can be found on their website: https://www.napcan.org.au/programs/love-bites/

  3. Love Bites is a primary prevention program relating to respectful relationships delivered in regional and remote schools and community settings across Australia with a focus on supporting children and young people aged 11 to 18 (Years 7 to 12). It is one program contained within the Student Wellbeing and External programs catalogue overseen by the

Department. There are currently 3213 people in NSW trained as Love Bites facilitators (excluding 1272 who have not listed a state).

  1. As a result of funding through the Department of Communities and Justice Sexual Violence Project Fund, NAPCAN has also partnered with the Institute of Child Protection Studies, Australian Catholic University, to develop a Trauma Responsive Love Bites Facilitator Program for young people aged 16 to 19 years, which was scheduled to be rolled out to facilitators across NSW, primarily in rural and remote locations, from March to June 2025.

  2. Following funding received from the Ministry of Health in 2022, NAPCAN has completed work in support of their Safer Communities for Children and Love Bites prevention initiatives. This has included the implementation of a Safer Communities for Children program, the Love Bites Online Onboarding Platform, and a program for Respectful Relationship Education for Complex Needs.

  3. I wish to acknowledge and endorse programs such as Love Bites which can equip young people with the tools to engage in respectful relationship practices.

Findings on the issues When did Lilie and Paul commence a relationship? What was the nature of their relationship, and what was the status of their relationship at the time of Lilie’s death?

  1. I find that the available evidence establishes that Lilie and Paul commenced a relationship in mid to late August 2023 when they were spending a few nights a week together and were communicating almost daily.

  2. I observe that there are differing views expressed in the available evidence on the nature of the relationship between Lilie and Paul amongst their friends and colleagues. However, the overall view appeared to be that the relationship was casual in nature. I find on the available evidence that although some of Paul’s friends held the opinion that Paul was more serious about Lilie than he was saying, this was not something that Lilie was aware of. On balance, I find that the nature of the relationship from mid August 2023 to when it concluded in October 2023 was casual.

  3. I find on the available evidence that Lilie ended the relationship with Paul on 20 October 2023. I find that it appears that Paul asked Lilie to think about them remaining in some kind of relationship, however, on 23 October 2023 Lilie confirmed that she did not want any form of relationship with Paul other than that of a friend and colleague.

  4. I find on the available evidence that Lilie and Paul were no longer in a romantic or sexual relationship at the time of Lilie’s death and that the nature of their relationship as of 25 October 2023 was that of a friend and colleague.

What was the nature of Paul’s psychological state in October 2023?

  1. I find that there is evidence which may indicate that there were some stressors in Paul’s life in October 2023. Those stressors appear to be as follows:

• It was likely that at some stage it would have been discovered that Paul was not in fact undertaking a Master of Teaching at the University of Sydney, or in fact any postgraduate degree, and that he had lied to family, friends and colleagues about this;

• That Paul would have had to leave Australia when his temporary visa expired on 9 February 2024, and it may have been discovered that

he had lied to family, friends and colleagues about his visa status; and

• That Paul had been reprimanded in relation to workplace issues at the school.

  1. However, I find on the available evidence that none of the above had become a crisis or had in any way gained particular significance prior to 23 October 2023, when Paul went to the Mitre 10 store and purchased the hammer and duct tape.

  2. Associate Professor Sullivan and Dr Seidler both agreed that there is no evidence to suggest that Paul suffered from any significant mental health condition. They both also agreed that Paul did not meet the diagnostic criteria for a personality disorder. Both agreed that while Paul may have had stressors in his life and may have experienced sadness and emotional turmoil, especially following the end of the relationship with Lilie, it did not rise to the level of any diagnosable condition. I accept their evidence.

  3. I also accept the evidence given by Dr Seidler at the inquest that at a foundational level Paul could not cope with how he was feeling about the end of the relationship with Lilie and neutralised the threat to his image and sense of self by killing her.

  4. I find on the available evidence that the event which triggered an escalation in Paul’s behaviour was Lilie’s decision to end the relationship, following which Paul started to stalk Lilie and plan his attack.

  5. As set out above, I accept the evidence of both Associate Professor Sullivan and Dr Seidler and find that Paul was not suffering from any significant mental health condition or had a diagnosable personality disorder at the time of the preparations for the attack on Lilie and at the time of the attack. I make this finding with the caveat that it is informed

by the evidence that was available to me and tendered at the inquest. It is possible that there may be evidence in existence which may indicate otherwise, however, that information is not before me and was not sought to be tendered in the proceedings.

  1. I also find that although Paul may have had stressors in his life, they did not rise to the level of any diagnosable condition.

What were the circumstances of Lilie’s and Paul’s death?

  1. I find that the evidence establishes that on 20 October 2023 Paul commenced a course of conduct which culminated in his attack on Lilie in the bathroom at St Andrew’s on 25 October 2023 and his own death.

  2. I find on the available evidence that this initially comprised of technologyfacilitated abuse such as checking Lilie’s location, surveillance, and setting up the fake Snapchat account; and from 21 October 2023 encompassed covert physical stalking of Lilie; attendance at Diamond Bay reserve in the days/nights before 25 October 2023; and numerous acts of preparation including attendance at the Mitre 10 store to purchase a hammer and practice runs at St Andrew’s of the attack that was ultimately perpetrated upon on Lilie.

  3. The circumstances of both deaths have otherwise been outlined in the comprehensive opening address and submissions that Counsel Assisting set out at the inquest which I have adopted, and are addressed in the findings that I have made above at [82]-[207] on the events that took place in the lead up to 25 October 2023 and what occurred on 25/26 October 2023.

When and how did Paul commence planning the events of 25 October 2023?

  1. I accept Associate Professor Sullivan’s opinion which he provided in oral evidence at the inquest, that by the time Paul bought the hammer at about 2:00 pm on 23 October 2023 at Mitre 10, or at the latest on the evening of 24 October 2023 when Paul visited Diamond Bay Reserve, that he had commenced planning to attack Lilie and make that finding. I also accept Associate Professor Sullivan’s opinion that at that time Paul had also resolved to take his own life.

  2. How Paul commenced the planning of the events of 25 October 2023 have otherwise been outlined in the comprehensive opening address and submissions that Counsel Assisting set out at the inquest which I have adopted, and are addressed in the findings that I have made above at [82]-[207] on the events that took place in the lead up to 25 October 2023 and what occurred on 25-26 October 2023.

Was Paul’s death intentionally self-inflicted?

  1. The evidence must be sufficiently clear and cogent to allow for a conclusion to be reached in relation to intention. The evidentiary standard to be applied to a coronial finding of intentional taking of one’s own life is the Briginshaw standard.3

  2. I am satisfied to the required standard that Paul died from intentional self-harm having jumped or intentionally fallen from the cliff at Diamond Bay Reserve at Vaucluse. I reach this conclusion based on all the circumstances and available evidence. I note that Paul had previously attended Diamond Bay, he made no attempt to disguise himself at the time he killed Lilie (and would have appreciated the legal consequences of killing her) and he left belongings near to the cliff edge.

3 Briginshaw v Briginshaw 60 GLR 336.

  1. I accept Associate Professor Sullivan’s opinion that Paul had developed both homicidal and suicidal ideation in the days before he attacked Lilie, however there was no outward evidence where he sought to communicate explicitly or implicitly to others what his intended actions were, further there was no evidence that Paul had a history of self-harm or of threatening suicide or of engaging in parasuicidal or risk-taking behaviours.

  2. I also accept Associate Professor Sullivan’s opinion that from at least 24 October 2023 when Paul went to Diamond Bay Reserve, that he was already planning to end his life and it appears that that followed sequentially from the plans to kill Lilie. I have relied upon this opinion and the evidence outlined above in forming the view that Paul died as result of self-harm and that it was a self-inflicted death.

With the benefit of hindsight, were there any indications that Paul could become violent towards Lilie?

  1. I find that the evidence establishes that there was no indication that Paul was going to attack Lilie and then end his life. There was no evidence of leakage, no comments to friends, no note left behind. His actions, even on the day, appeared normal; although at times he seemed a little upset or angry about being reprimanded at work, there was otherwise nothing to suggest he would become violent towards Lilie.

  2. Apart from the observation of one staff member on 19 October 2023 who recalled seeing Paul and Lilie having a heated discussion outside of the school near the Druitt Street exit, there was no indication Paul was in any way angry or upset with Lilie on 25 October 2023. As can be seen in the CCTV footage that was tendered and shown at the inquest, Paul appeared to be joking with Lilie throughout the day, and their interactions appeared relaxed and in no way threatening. There was no indication of violence or what was to unfold later that day.

  3. The paragraphs below address how the circumstances of Lilie’s death compare with other interpersonal homicides and what risks of violence may be evident in hindsight.

How do the circumstances of Lilie’s death compare with other interpersonal homicides?

  1. The evidence establishes that the circumstances of Lilie’s death share many characteristics with other interpersonal or intimate partner violence homicides. In particular, the fact that Lilie’s death occurred in the context of her separation from Paul, which, as the expert evidence and evidence from the Secretariat of the DVDRT confirmed, is when a significant number of interpersonal or intimate partner violence homicides occur.

  2. The evidence including the expert evidence and evidence from the Secretariat of the DVDRT establishes that the lack of any prior physical violence, the presence of previous non-violent abuse, including technology-facilitated abuse and stalking, and the lack of any prior involvement of police or notification report to the police and no known criminal history, are unfortunately seen as characteristics in many intimate partner homicides.

  3. Furthermore, while I find that some features of Lilie’s tragic death are unusual, including the short duration of the relationship and the young age of both Lilie and Paul, it otherwise fits an all too familiar pattern of intimate partner homicide.

  4. In my view, the totality of the evidence allows me to make a finding that Lilie’s death occurred in the context of domestic violence perpetrated by Paul. Lilie’s decision to end the relationship acted as a catalyst for a marked escalation in his controlling, abusive and coercive behaviours, culminating in the fatal violence.

  5. I accept all the expert evidence and evidence from the Secretariat of the DVDRT, who all agreed, that Lilie’s death can be considered gendered violence, and I find that Lilie’s death was as a result of gendered violence.

What relevant information and education exists to assist a person in the position of Lilie, or her or Paul’s friends, family or colleagues, identify and respond to a risk of violence in similar circumstances?

Is it sufficient? Are there areas for improvement? What lessons can be learnt?

  1. The relevant information and education that exists and/or is in development has already been set out in these findings along with suggested areas for improvement. Having considered this information along with the expert evidence, evidence from the Secretariat of the DVDRT and submissions of Counsel Assisting, I am of the view that there are areas where additional education is required and future action arises and/or is required which are set out below.

  2. Again, I have been greatly assisted by the submissions of Counsel Assisting.

Areas for future action Increasing community awareness about technology facilitated abuse

  1. As I have already outlined, the inquest received a large volume of material on the topic of education regarding coercive control particularly the education of young people, from the eSafety Commissioner, the NSW Education Standards Authority, NSW Department of Education, and NAPCAN.

  2. I agree with Counsel Assisting’s submission that the facts of this case highlight the critical need to address technology-facilitated abuse as an area of current and future focus. Based on the available evidence, I find

that Paul used technology in an abusive way, to monitor and control Lilie, including through the use of Snap Map and location sharing, and by showing an apparently intimate image of Lilie on his phone to friends without her knowledge or consent. I also find, on the available evidence, that Paul had engaged in similar technology facilitated abuse in a prior relationship.

  1. The evidence gathered as a result of this inquest has highlighted to me the urgent need for greater community awareness about the misuse of technology and the importance of individuals regularly reviewing their own technology practices, including their location sharing.

  2. Further, the response to Paul’s behaviour also reveals a need for greater community awareness about technology facilitated abuse. When Paul repeatedly checked Lilie’s location while she was at the party, others perceived this as an expression of care or affection. Similarly, when Paul showed his friends an image of Lilie without her consent, the behaviour was not recognised as harmful. This may reflect the way such behaviour has become normalised, pointing to the pressing need for education and awareness that these actions, in certain contexts, can be coercive, sinister and indicative of unhealthy behaviours or risk within a relationship.

  3. The evidence and information sought by the Counsel Assisting team was focused on the education of young people. It is noted that within the limitations of this inquest, evidence was only obtained from the NSW Department of Education covering public schools in NSW. A potential area of future research and inquiry could be how these issues are being addressed in religious and independent schools in NSW.

  4. I note that positive steps are being taken to educate children aged 5 to 15, particularly through the compulsory syllabus. However, young people aged 16-24 appear to fall between service gaps. This group experiences the highest levels of technology facilitated abuse, yet they

are beyond the age for mandatory respectful relationship education in schools. I am of the view that targeted education initiatives for this group would be highly beneficial. Such initiatives should recognise that some young people will be in further or higher education, while others may or may not be in the workplace. Programmes tailored to each of these settings would, therefore, be valuable.

  1. Accordingly, I am of the view that the evidence before me highlights a need for the following future action: Expand education and awareness programmes to help the community identify and respond to coercive controlling behaviours, with a particular focus on emerging forms of technology-facilitated abuse.

Encourage individuals to critically review their technology use, including whether it is necessary or safe to share their location with others.

Develop targeted initiatives for 16 to 24-year-olds, delivered through further and higher education settings as well as workplaces, recognising this group’s heightened vulnerability to technology-based abuse.

Relationship advice services that are targeted to young men

  1. There is evidence before me that Paul asked his flatmates about relationship advice services on the weekend prior to the deaths. This was identified by the experts as a possible opportunity for intervention.

  2. The experts were asked about the availability of relationship services, and I accept their evidence that there are gaps in:

  1. Services aimed at perpetrators, to help young men identify problematic behaviours in themselves, so that they may access support and make better choices; and

  2. Services aimed at the peer cohort, to educate other young men on how to be “upstanders”, how to recognise problematic behaviour in

others, to interrupt it, and to respond by guiding the person towards appropriate support.

  1. I note that there appears to be a lack of evidence, currently, on the best ways to engage young men to provide education and information on healthy relationships.

  2. Accordingly, I am of the view that the evidence before me highlights a need for the following future action: There is a pressing need to develop respectful relationship information and advice services specifically for young men, alongside further research into effective strategies for engaging this group and promoting healthy relationship behaviours.

Media reporting on intimate partner homicides

  1. Professor Fitz-Gibbon in her evidence noted that Paul’s behaviour was described as “out of character” by his friends and acquaintances. She explained that this is a common observation made in the aftermath of intimate partner homicides. However, in Paul’s case, as with most intimate partner homicides, there was a history of Paul using coercive control, both in the relationship with Lilie, and in a prior relationship.

  2. The media commentary immediately after Lilie’s death and other cases, serves to inform community understanding about intimate partner violence. Describing such a homicide as “out of character” may reinforce stereotypes and fail to provide appropriate context, where most intimate partner homicides occur following a pattern of coercive control. As Professor Fitz-Gibbon noted “this is often a tactic utilised by people who use coercive control and intimate partner violence, where the behaviours within the relationship are tacitly unknown to those outside of the relationship” and “the out of character, shock narrative suggests a different understanding of the event than what we understand occurs in the significant number of intimate partner homicides.”

  3. Ms Butler similarly referred to what she described as “unhelpful” comments about the case reported in the media. While it was understandable that individuals would make comments about Paul’s behaviour being “out of character”, as a form of “sense-making” in the aftermath of a tragic event, the approach by the media is different. In her view, it should be acknowledged that it takes time to understand the full facts, and that, in the majority of cases, this will reveal a pattern of prior coercive control.

  4. Accordingly, I am of the view that the evidence before me highlights a need for the following future action: Media entities that report on intimate partner homicides should recognise that describing violence as being “out of character”, before the full facts are known, may reinforce unhelpful community stereotypes and fail to place such homicides in the context of prior coercive control.

The significance of technology facilitated abuse and stalking in domestic violence screening

  1. In the evidence before me, Paul did not come to the attention of the criminal justice system or any support service and accordingly, the institutional response was not a focus of the inquest. Nonetheless, it is significant to note that he engaged in forms of technology facilitated abuse (TFA) with Lilie. When he commenced physically stalking Lilie from the weekend of 21-22 October 2023, this marked a significant escalation in his behaviour.

  2. As Paul was never screened for a risk of domestic violence, the adequacy of such screening was not considered in the evidence.

Nonetheless, Professor Fitz-Gibbon referred in her evidence to the fact that some existing screening tools do not refer to a history of technology facilitated abuse or to physical stalking when assessing the risk of future violence. As research demonstrates, including data from the DVDRT, there is a strong correlation between all forms of coercive control,

including technology facilitated abuse and stalking, and intimate partner homicide.

  1. Accordingly, I am of the view that the evidence before me highlights a need for the following future action: There is a need to ensure domestic violence screening tools reflect the correlation between coercive control, including technology facilitated abuse and physical stalking, and the risk of intimate partner homicide.

Findings required by section 81(1)

  1. As a result of having carefully considered all the documentary evidence, the oral evidence given at the inquest, and the submissions of Counsel Assisting, I make the following findings pursuant to s. 81(1) of the Act, in relation to the death of Lilie James: Identity of deceased The person who died was Lilie Anne James.

Date of death Lilie died on 25 October 2023.

Place of death Lilie died at the St Andrew’s Cathedral School at 474 Kent Street, Sydney NSW 2000.

Cause of death Lilie died from multiple blunt force injuries to the head and neck.

Manner of death Lilie died as a result of homicide in the context of domestic violence and gendered violence.

  1. As a result of having carefully considered all the documentary evidence, the oral evidence given at the inquest, and submissions of Counsel Assisting pursuant to s. 81(1) of the Act, I make the following findings in relation to the death of Paul Thijssen: Identity of deceased The person who died was Paul Thomas Stephan Thijssen.

Date of death Paul died on 25 or 26 October 2023.

Place of death Paul died at Diamond Bay Reserve, Vaucluse NSW 2030.

Cause of death Paul died from multiple blunt force injuries.

Manner of death Paul died as a result of injuries he sustained having jumped or intentionally fallen from the cliff at Diamond Bay Reserve in Vaucluse with the intention of ending his life.

Recommendations/Action

  1. Section 82 of the Act confers on a Coroner the power to make recommendations that he or she may consider necessary or desirable in relation to any matter connected with the death with which the inquest is concerned.

  2. The only parties that were identified as having sufficient interest in the inquest were Lilie’s and Paul’s families. No government agency or other institution was an interested party.

  3. Counsel Assisting did not propose that any recommendation(s) ought to be made to a specific agency.

  4. Accordingly, there are no recommendations arising from this inquest directed to any specific agency.

  5. However, as part of my death prevention role I have focused on the lessons that may be learnt from this tragic case. With that in mind, and acknowledging the limitations of the evidence before me, I am of the view, that action is required in the following areas:

  1. There is a need for further education and information programs to raise community awareness about how to identify and respond to coercive controlling behaviours, in particular emerging forms of technology-facilitated abuse.

  2. Individuals should be encouraged to actively consider their use of technology, and the need to share their location with others.

  3. There is a particular need to target 16 to 24-year-olds, including through programs in further or higher education and workplaces.

  4. There is a need to develop respectful relationship information and advice services for young men, and for further research in how best to engage young men and to promote healthy relationship behaviour.

  5. Media entities that report on intimate partner homicides should recognise that describing violence as being “out of character”, before the full facts are known, may reinforce unhelpful community stereotypes and fail to place such homicides in the context of prior coercive control.

  6. There is a need to ensure domestic violence screening tools reflect the correlation between coercive control, including technology facilitated abuse and physical stalking, and the risk of intimate partner homicide.

  7. There is a need for further information and education to raise awareness about interpersonal relationship violence, gendered violence, intimate partner violence, coercive control, and technology facilitated abuse.

Provision and circulation of findings

  1. I am of the view that there are lessons to learn from these tragic circumstances and areas for improvement and future action.

  2. In order to raise awareness about interpersonal relationship violence, gendered violence, intimate partner violence, coercive control, domestic violence and technology facilitated abuse; and to assist with consideration of the areas for additional education and future action that I have identified, a copy of these findings will be provided to the following:

• The NSW Premier’s Department;

• The NSW Minister for Education and Early Learning;

• The NSW Minister for the Prevention of Domestic Violence and Sexual Assault;

• The Commonwealth Minister for Education;

• The Commonwealth Minister for Social Services;

• The Commissioner and Assistant Commissioner of the Domestic, Family and Sexual Violence Commission;

• The Commissioner of Police;

• The eSafety Commissioner;

• SafeWork NSW;

• The Secretary of the NSW Department of Education;

• The Deputy Secretary of Teaching Learning and Student Wellbeing of the NSW Department of Education;

• The Executive Director of the Curriculum Division at the NSW Education Standards Authority;

• The CEO of NAPCAN;

• The Board of the Association of Independent Schools of NSW;

• The Board of the Independent Schools of Australia;

• Australian Press Council;

• Our Watch; and

• ANROWS.

Acknowledgements and concluding remarks

  1. I wish to acknowledge the public intrusion that an inquest imposes during a time of immense grief, sorrow and pain. I have endeavoured to conduct this inquest with sensitivity and care, mindful of the need to avoid further trauma for those affected by these tragic circumstances.

  2. I express my deepest sympathy and condolences to Peta, Jamie and Max, and to Lilie’s friends and loved ones. I acknowledge the heartbreak and anguish they endure as a result of Lilie’s senseless and violent death.

  3. I commend their courage and strength in participating in this inquest and sitting through evidence that described Lilie’s final moments. As I said at the conclusion of the evidence, Lilie’s parents, Peta and Jamie, were a

powerful presence in this Court – their love and grief palpable. I thank them for sharing such beautiful anecdotes about Lilie.

  1. I also express my sympathy and condolences to Esther and Stefan Thijssen for their loss and acknowledge their grief. I thank them for their family statement where they expressed their love and sadness.

  2. I wish to acknowledge and thank Detective Sergeant Daniel Poole and his team for their compassion and professionalism throughout the investigation and in preparation for the inquest. I also acknowledge the harrowing nature of this work, particularly for first responders, and I thank them for their efforts.

  3. I am grateful to Dr Seidler, Associate Professor Sullivan, Professor Fitz- Gibbon, Ms Butler, the eSafety Commissioner, the Department of Education, NESA, and NAPCAN for their invaluable assistance. The material and evidence they provided has been critical in understanding the tools, support, and guidance available to address respectful relationships, coercive control, gendered violence, domestic violence, technology facilitated abuse – and in identifying where further public awareness and education is required. It is encouraging to see the work already underway and the commitment to future initiatives. I am also grateful to Dr Van Vuuren, Dr Pokorny and Ms Konza for their helpful reports.

  4. I acknowledge and thank my counsel assisting team, Jennifer Single SC, Jake Harris of counsel and Clara Potocki from the Crown Solicitor’s Office for the professionalism and care they put into the preparation of this matter to ensure that the inquest was conducted in a sensitive manner with a focus on prevention. I also acknowledge Bronwyn Lorenc, Francesca Lilly and Catherine Pinnell of the Crown Solicitor’s Office who provided great assistance to the counsel assisting team in preparation for the inquest.

  5. I conclude by acknowledging the alarming and persistent scourge of gendered violence and domestic violence in Australia. Lilie’s death is not an isolated tragedy; it is part of a devastating pattern of violence against women that demands urgent and sustained action. I commend those who work tirelessly to support victim survivors, and families affected by homicide, and I urge that more be done – through education, prevention, and cultural change – to challenge attitudes that drive this violence and to protect women’s lives.

  6. During her Family Statement, Lilie’s mother, Peta spoke powerfully about raising her daughter to be brave and strong. Peta’s words – that we must teach boys to respect and value women’s opinions and choices, and to accept rejection – resonate deeply. It is my hope that Peta’s message, and the lessons learnt from this tragedy, echo beyond this courtroom and contribute to meaningful change.

373. I close this inquest.

Magistrate Teresa O’Sullivan NSW State Coroner 27 November 2025

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