Clubb, Monique Irene

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the suspected death of Monique Irene Clubb TITLE OF COURT: Coroners Court

JURISDICTION: SOUTHPORT FILE NO(s): 2015/1963 DELIVERED ON: 13 January 2022 DELIVERED AT: Southport HEARING DATE(s): 14 to 17 December 2021 FINDINGS OF: Jane Bentley, Deputy State Coroner CATCHWORDS: Coroners: inquest, missing person, fentanyl, prescribing, doctor shopping, police investigation

REPRESENTATION: Counsel Assisting: Ms A Martens Ms McBride: Ms A Taylor, ATSILS Commissioner of Police: Mr I Fraser Dr A: Ms J FitzGerald Instructed by Avant Mutual Dominic Lebler: Mr P Nolan Instructed by AW Bale & Sons Solicitors Findings of the inquest into the suspected death of Monique Clubb Page 1 of 33

Contents

Introduction

1. Section 45 of the Coroners Act 2003 provides that when an inquest is held the coroner’s written findings must be given to the family of the person in relation to whom the inquest has been held, each of the persons or organisations granted leave to appear at the inquest and to officials with responsibility over any areas the subject of recommendations.

2. These are my findings in relation to the missing person, Monique Irene Clubb. They will be distributed in accordance with the requirements of the Act and posted on the web site of the Coroners Court of Queensland.

3. These findings and comments confirm the identity of the missing person, whether she is deceased, when, where and how she died and the cause of her death.

Background

4. At the time of her disappearance on 22 June 2013, Ms Clubb was 24 years old. She resided with her mother, Sheena McBride, at 17 Murphy Street, Point Vernon at Hervey Bay. Ms Clubb was extremely close to her mother and siblings and Ms McBride was always aware of Ms Clubb’s whereabouts. If Ms Clubb was not at home she contacted her mother daily and told her where she was and what she was doing.

5. Ms Clubb was loved by her many friends and much loved by her family.

As a young person she was a promising student and her family expected a bright future for her. Tragically she was involved in a serious car accident and suffered quite serious back and leg injuries. Due to the ongoing pain she suffered from these injuries she became addicted to opioid drugs. Ms Clubb had battled with drug addiction for many years which continued to the time of her disappearance.

Findings of the inquest into the suspected death of Monique Clubb Page 1 of 36

June 2013

6. Ms McBride last saw Ms Clubb on 20 June 2013 when she left Hervey Bay at about 10.30am with Tracey Lee Brown, Alan-Lee Heginbotham and Leighton Sullivan, in Ms Brown’s car. Ms Clubb told her they were going to Brisbane for the night.

7. Mr Heginbotham, Mr Sullivan and Ms Clubb planned to go to Caboolture to purchase some “patches” (fentanyl patches).

8. Ms Brown drove them to McDonalds at Deception Bay where they were to be picked up by the person who was going to supply them with drugs.

Ms Brown left them there and continued on her journey to the Gold Coast.

9. All three waited at McDonalds for about five hours for the drug supplier to meet them but that person did not arrive. Mr Heginbotham and Mr Sullivan arranged for a lift to the residence of a relative of Mr Heginbotham at Deception Bay where they stayed the night. Ms Clubb remained at McDonalds and told them that someone was coming to pick her up. She gave Mr Heginbotham $70 in case he sourced some fentanyl.

10. Dominic Lebler picked Ms Clubb up.

11. Mr Sullivan and Mr Heginbotham stayed the night at Deception Bay. Mr Heginbotham obtained a fentanyl patch and he injected a solution he extracted from it.

12. On the morning of 21 June 2013 Ms Clubb and Mr Lebler went to that address. Mr Heginbotham gave Ms Clubb his used patch. Mr Lebler and Ms Clubb gave Mr Sullivan a lift to the Caboolture train station. His arrival was recorded on CCTV at 11.23am. Mr Sullivan returned to Hervey Bay.

13. Mr Heginbotham spent the night of 21 June 2013 at Deception Bay.

14. Ms Clubb sent a text message to her friend, Sean Bailey at 12.36am on 21 June 2013 stating she was in Brisbane, she was starving and had nowhere to stay. He called her back about half an hour later and she told Findings of the inquest into the suspected death of Monique Clubb Page 2 of 33

him she was cold, hungry and stranded. He said he would pick her up if he could get a car.

15. Bryce Watt was staying at Ozcare at South Brisbane at that time. He first met Ms Clubb the night of 21 June 2013 when he saw her outside Ozcare.

He got her a blanket and some food and she said she was staying at a lodge down the road. He later went to bed.

22 June 2013

16. On the morning of 22 June 2013 Ms Clubb called her mother and told her she was at Dominic’s house with Mr Heginbotham and that Mr Lebler would drive her back to Hervey Bay if they could get money for fuel.

17. Ms McBride told police that this was the last contact she could recall having with Ms Clubb.

18. Ms Clubb called Mr Heginbotham twice on 21 June and said she was at Kangaroo Point and she was going to get some patches.

19. On the morning of 22 June 2013 Mr Lebler drove Ms Clubb to Ozcare in South Brisbane and they picked up Mr Watt. Mr Lebler dropped them off at the Buranda Railway Station.

20. At about 11am Ms Clubb and Mr Watt boarded a Doomben train at Buranda train station. They got off the train at Park Road station at 11.10am.

21. Mr Watt used the public phone box at Park Road station at 11:30am. Ms Clubb also spoke on the telephone. The identity of the recipient of that phone call is unknown.

22. Ms Clubb’s friend, Natasha Ann McCarthy, who resided in Hervey Bay, received a text message from Ms Clubb on 22 June 2013 that read, “Hey can you help me out, I’m in Brissy sick.” Findings of the inquest into the suspected death of Monique Clubb Page 3 of 33

23. Ms Clubb phoned Ms McCarthy and told her she was on her way to Beenleigh on a train with some bloke and asked about Mt Gravatt buses.

She asked Ms McCarthy where she could source some Ritalin for her friend. Ms McCarthy wasn’t able to assist her.

24. Ms Clubb and Mr Watt boarded a south bound train at 11.36am and travelled to Beenleigh arriving at the Beenleigh train station at 12.10pm.

25. Ms Clubb and Mr Watt were recorded on city safe cameras walking from the Beenleigh train station into George Street towards the Beenleigh Market Place shopping centre.

26. At 12.25pm Ms Clubb was recorded on CCTV outside MediPrac, a medical centre, at the shopping centre.

27. At 12.26pm Mr Watt entered the centre and went to a taxi phone.

28. At 12.30pm Ms Clubb entered Woolworths.

29. At 12.34pm Mr Watt and Ms Clubb left the centre.

30. At 12.38pm Ms Clubb went into MediPrac. Mr Watt was outside at a taxi rank.

31. Ms Clubb saw Dr A at MediPrac and obtained prescriptions for 50 x Diazepam (5mg), Bactrim and 5 fentanyl (75mcg) patches. Ms Clubb identified herself as Sheena McBride at the medical centre.

32. At 2.21pm Ms Clubb left MediPrac and met up with Mr Watt. They both then entered MediPrac again but went through it to the adjoining pharmacy. Ms Clubb obtained the prescribed fentanyl from the pharmacy.

Mr Watt paid $5.90 for it. Ms Clubb kept his bank card.

33. At 2.24pm Ms Clubb phoned Mr Heginbotham and told him she had obtained fentanyl.

34. That was the last time Ms Clubb used her phone although phone records revealed many unanswered phone calls and text messages to her phone Findings of the inquest into the suspected death of Monique Clubb Page 4 of 33

after that time. Persons sending text messages and making phone calls included Mr Heginbotham, Ms McBride and Mr Lebler.

35. At 2.26pm Ms Clubb and Mr Watt left the pharmacy and separated.

36. At 2.27pm Ms Clubb was seen on CCTV to enter a toilet in the complex and stay there for some time. Mr Watt said that he last saw her entering the toilet. He waited for her but she did not come out so he left the complex. He returned to Beenleigh train station (he was recorded on CCTV arriving at the station at 2.50pm) and caught a train back to South Brisbane station (he was recorded on CCTV exiting the South Brisbane station at 3.30pm).

37. At 2.35pm Mr Heginbotham tried to phone Ms Clubb but she did not answer her phone.

38. Ms Clubb was recorded on CCTV as leaving the toilet at 2.55pm. She was alone.

39. At 2.56pm Ms Clubb entered Spend Less Shoes and attracted attention due to her erratic behaviour.

40. At about 3pm staff of Spend Less Shoes sent a text message to the security officer, Red Apolo stating, “Please come to Spend Less Shoes as soon as possible to get rid of a drunk woman.”

41. At 3.04pm Mr Apolo started walking to Spend Less Shoes and on the way he received another text message stating, “Please come as soon as possible.”

42. Mr Apolo told police that when he arrived at the shop he was told by the staff member that Ms Clubb had just left and she pointed to a young woman walking away in the direction of the food court. He saw that Ms Clubb was wearing a long brown, black and white dress. She headed towards entrance three and then out of the centre.

Findings of the inquest into the suspected death of Monique Clubb Page 5 of 33

43. She went out of the eastern side of the centre. Mr Apolo spoke to the staff member who told him that Ms Clubb had not stolen anything but appeared to be drunk and was swearing at customers.

44. Mr Apolo left the shop and walked out of the entrance but he could not see Ms Clubb. He then walked around to the eastern side of the building but she was not there. He then walked to the side of the complex overlooking Hugh Muntz park. He saw a group of young people running through the park and one of them told him that a young aboriginal woman had just jumped over the concrete wall into the park and ran toward the creek.

45. Mr Apolo looked toward the creek and saw Ms Clubb in the middle of the creek walking towards the bank on the other side. She stumbled in the creek but got up and continued walking to the far side of the creek. She appeared to be uninjured at this time. She was still carrying a large hand bag. The creek was only a couple of feet deep at the point she crossed it. This was the last sighting of Ms Clubb.

46. Mr Apolo returned to Spend Less Shoes and was advised that Ms Clubb left her wallet in the shop. It contained one bank card and an identification card. He lodged it with Lost Property and it was later obtained by police officers. It contained no fentanyl. Her handbag was never found.

Police Investigation

47. Ms McBride reported to police officers at Hervey Bay police station that Ms Clubb was missing on 28 June 2013.

48. Senior Constable Shannon Gray received the report and made numerous inquiries and investigations over the next days. He then briefed the Missing Persons Unit (MPU) in relation to the information he had obtained.

Findings of the inquest into the suspected death of Monique Clubb Page 6 of 33

49. Subsequent investigations revealed that Ms Clubb was last seen by Mr Apolo at the Beenleigh shopping complex.

50. An investigation was commenced by the MPU which was code named Operation Lima Credo.

51. Proof of life checks confirmed that there was no trace of Ms Clubb after she left the complex.

52. Police viewed CCTV footage from the Beenleigh Railway station and concluded that Ms Clubb had not gone to the train station after she left the complex.

53. The investigation was transferred to the Hervey Bay Criminal Investigation Branch (CIB) and subsequent inquiries were carried out by numerous officers from a number of regions including Hervey Bay, Beenleigh, Brisbane and Dutton Park as well as the MPU.

Searches

54. Extensive searches were conducted for Ms Clubb in the park and the area surrounding it. Searches included air searches by police helicopter, two land searches, police dog searches for human remains, SES searches and water searches by the police Dive Squad. All searches failed to locate Ms Clubb.

55. On 8 July 2013 Hugh Muntz park was searched by PolAir and SES ground searchers. PolAir advised that the visibility was good in most areas, although somewhat limited by long grass and the taller trees.

56. On 16 July 2013 a further search of the park was conducted using 24 recruits from the QPS academy. Nothing of interest was located.

57. On 17 July 2013 a foot search of the park was conducted with police dogs, however, much of the terrain was difficult to search with dogs and the Findings of the inquest into the suspected death of Monique Clubb Page 7 of 33

amount of rubbish present and human interference made any detection unlikely even if Ms Clubb had been there.

58. On 19 July 2013 a further search was conducted in the bushland between Stockyard Lane and the railway line. Nothing of interest was located.

59. A review of the area was carried out on 7 November and it was decided to increase the search radius to two kilometres. Further searches were conducted of a disused shopping complex and surrounds including sections of the Albert River and banks.

60. Senior Sergeant Jim Whitehead, Officer in Charge of QPS Search and Rescue reviewed the searches that had been conducted in 2020.

61. He said that the search areas surrounding the park were heavily affected by flooding during the 2016 Tropical Cyclone Debbie inundations of South Eastern Queensland. However, it is unlikely, given the extent of flood waters in the park that human remains would have been significantly impacted.

62. Senior Sergeant Whitehead mathematically calculated Probability for Detection (POD) for the PolAir search was 80% for the open areas searched. The POD for the initial search was 72% and the recruit search 80%. There is a small chance that the searches could have missed an unresponsive person but decomposition would have produced a noticeable odour that would not have been missed.

63. The park is an open area, used to a small degree for recreation and to a greater extent by some homeless people. Senior Sergeant Whitehead said that it is reasonable to expect that if Ms Clubb had died in the park she would have been found either during the searches or some time after by users of the park.

Findings of the inquest into the suspected death of Monique Clubb Page 8 of 33

Intelligence Reports

64. Police received numerous intelligence reports and reports from informants about what may have happened to Ms Clubb. A number of sources told police that Vincent Moran organised for Ms Clubb to be killed because she and others had broken into this house and stolen his property. Police spoke to Mr Moran who denied any involvement or knowledge of Ms Clubb’s disappearance. Police searched his residence and found nothing of interest.

65. All reports regarding Ms Clubb received by police were based on hearsay and conjecture. Police investigated all reports and information received but could find no credible or reliable information or evidence which would corroborate any of the allegations.

MediPrac Beenleigh

66. Ms Clubb had visited the same practice on 20 March 2012 and again on 1 April 2012 at which time it was noted that she was not to be seen due to drug issues and hostile behaviour.

67. Ms Zocaro was the receptionist at the practice on 22 June 2013. She told police that Ms Clubb attended at about midday. She was in her mid to late thirties. Ms Clubb gave a false name. She said she was Sheena McBride (DOB 5 June 1970) i.e. 43 years old. She provided no photographic identification. Ms Zocaro told Ms Clubb that she could not process her through the system without her Medicare card or $50 in cash.

She gave Ms Clubb a form to fill out and Ms Clubb telephoned someone whilst completing it and wrote the Medicare number and the expiry date on the form.

68. Ms Clubb told Ms Zocaro that she wanted to see a doctor to get pain relief as she had slipped a disc in her back and she was away from home and couldn’t see her usual doctor.

Findings of the inquest into the suspected death of Monique Clubb Page 9 of 33

69. She waited about 45 minutes to see a doctor (Doctor A) during which time she was fidgety and restless. During the consultation Ms Clubb came out of the doctor’s room to use the toilet and Dr A told Ms Zocaro that she suspected Ms Clubb might be a doctor shopper and she needed to make a call to check she wasn’t flagged. She asked Ms Zocaro to distract Ms Clubb while she made the call.

70. A short time later Ms Clubb went back in to finish the consultation and then left the surgery and walked to the pharmacy. Ms Zocaro followed her and said again that she needed to see her Medicare card and then told a staff member at the pharmacy that she needed to see some ID before Ms Clubb left.

71. About five minutes later Ms Zocaro saw Ms Clubb walk through the medical centre to the pharmacy with a male person.

72. The pharmacist came in and said that Ms Clubb told her that she had showed Ms Zocaro ID. Ms Zocaro said that this was not true and told Dr A that the patient had possibly provided a false name.

Conclusions of Investigating Police

73. Despite the conclusions of Sergeant Nelson as to the outcome of the searches, on 27 February 2015 Detective Senior Sergeant Powell of the MPU reported to the Detective Inspector of the Homicide Investigation Unit that it was his view that Ms Clubb overdosed within the bushland or nearby or met with foul play shortly after exiting the bushland.

The inquest

74. The inquest took place at Southport Magistrates Court from 14 December 2021 to 17 December 2021.

Findings of the inquest into the suspected death of Monique Clubb Page 10 of 33

75. Nineteen witnesses were called.

76. The issues explored at the inquest were:

• Whether or not Ms Clubb is deceased;

• In the event Ms Clubb is deceased, the findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how she died and the cause of her death;

• The appropriateness of the medications prescribed and dispensed on 22 June 2013;

• The adequacy of the Queensland Police Service investigation.

Initial Report

77. Sheena McBride gave evidence. Ms McBride was very close to her daughter and reported her missing when she was unable to contact her.

Ms McBride said Ms Clubb was using only one phone at the time she disappeared although she had previously often had a couple of phones that she used at the same time.

78. Ms McBride said that Ms Clubb was on her Medicare card so they had the same Medicare number.

Beenleigh Shopping Centre and MediPrac

79. Red Apolo gave evidence.

80. Mr Apolo was the security office at the Beenleigh shopping complex on 22 June 2013. He was the last person known to have seen Ms Clubb.

81. He said that when he received the text message from the staff at Spend Less Shoes he walked to the shop. He agreed, after viewing the CCTV footage, that he was in the shop at the same time as Ms Clubb but said Findings of the inquest into the suspected death of Monique Clubb Page 11 of 33

that he didn’t speak to her. The staff pointed her out and said she had been swearing at other customers. She left the shop and walked towards the entrance. He walked after her. He said that he was making sure she left the complex.

82. He did not see her jump over the barrier into the park but said he assumed she would have jumped over where it was closest to the ground which was a height of about two metres.

83. When Mr Apolo last saw Ms Clubb she had nearly crossed the creek. She did not appear to be injured. He saw her trip over in the water. It was only about a foot deep. She got up immediately and kept going. He watched her for about two to three minutes. She did not proceed into the bush but stood beside a concrete pillar on the far side of the shallow creek. She was still standing in the water when he left. He returned to the shop and told staff that she had left the centre.

84. Mr Apolo said that Ms Clubb did not appear intoxicated to him when he saw her.

85. Natalie Zocaro was the receptionist at the MediPrac at Beenleigh. She explained the practice database. She said the medical practice required new patients to provide details and a Medicare card and photo identification if they had some. They were encouraged to obtain photo identification but if they didn’t have any they could still see a doctor and were told to bring some in on their next visit.

86. Ms Zocaro said that Ms Clubb must have provided a Health Care card as she had entered that number on the file.

87. Dr A came out during her consultation with Ms Clubb and said that she had concerns about Ms Clubb and wanted to phone the Doctor Shopper Hotline. She did so whilst Ms Clubb went to the toilet and then she finished the consultation.

Findings of the inquest into the suspected death of Monique Clubb Page 12 of 33

88. Ms Zocaro told staff at the pharmacy that they should obtain identification from Ms Clubb before dispensing drugs to her. Shortly afterwards another staff member came in to see Ms Zocaro and told her that Ms Clubb advised that she had provided identification at the medical practice. Ms Zocaro became very suspicious at that time that Ms Clubb was a doctor shopper and had obtained drugs for an illicit purpose.

89. Dr A gave evidence. At the time she gave her statement to police and at court she had no independent recollection of her consultation with Ms Clubb and could only speak to the notes she had taken at the time.

90. She conceded that providing Ms Clubb with a prescription for five patches (15 days usage) of the highest available strength of fentanyl patches was inappropriate. She also conceded that prescribing 50 diazepam tablets was inappropriate. She said that she would not prescribe fentanyl for back pain, although that was the reason Ms Clubb gave for requiring it. The doctor said that if she provided the prescriptions at all it should have been for only one fentanyl patch at a lower dose and a much lesser quantity of diazepam and she should not have prescribed further drugs until she obtained Ms Clubb’s previous medical records.

91. She said that she tested Ms Clubb for a UTI but did not record that in her records nor did she record the results from the urine test when they came back from the lab. She agreed that her note taking was inadequate.

92. She said that she has not been the subject of any previous investigation or disciplinary proceedings in relation to her prescribing practices. She said that as at June 2013 she had never worked in private practice before but only in hospitals.

93. Dr Adam Griffin, Director and Senior Forensic Physician of the Clinical Forensic Medical Unit, gave evidence that the prescription of fentanyl to Ms Clubb by Dr A was inappropriate. He said that fentanyl is not effective for back pain. Further, it was inappropriate to prescribe 75mcg patches to a first time patient. Dr A could have prescribed lower dose patches.

Findings of the inquest into the suspected death of Monique Clubb Page 13 of 33

94. Dr Griffin also considered that Dr A’s contemporaneous notes were insufficient as they did not record such observations as blood pressure and temperature and did not describe any physical examinations that had been conducted.

95. Dr Griffin gave evidence that fatality from fentanyl overdose usually occurs very soon after it is injected. It is his opinion that it is very unlikely that Ms Clubb died from an overdose of the fentanyl that she took in the toilet in the park at Beenleigh as, had she taken a fatal dose, she would most likely have died quickly. The fact that she was able to leave the shopping centre and walk into the park and did not seem to be very intoxicated at that time leads to the conclusion that she had not taken a fatal dose of fentanyl. He said that as she was still walking around some thirty minutes after she had taken the fentanyl it is unlikely she succumbed to an overdose.

96. Dr Griffin said that QScript has now been introduced in Queensland which allows real time checking of prescriptions of Schedule 8 medications to patients by doctors. However, such checks are only useful if the patient has provided their true identity to the medical practice.

Last Persons to Have Contact with Ms Clubb

97. Tracey Brown gave evidence that she knew Ms Clubb well. Ms Clubb and her mother were very close. Ms Clubb used illicit drugs.

98. In June 2013 Ms Brown was living on the Gold Coast. She had been staying at Hervey Bay and on 21 June 2013 left Hervey Bay to return to the Gold Coast. She took Mr Heginbotham, Mr Sullivan and Ms Clubb with her. She was planning to return to Hervey Bay directly but when she got to the Gold Coast she knew she couldn’t make the long trip home and stayed on the Gold Coast.

99. Ms Brown did not know that Ms Clubb was missing until Senior Constable Gray contacted her.

Findings of the inquest into the suspected death of Monique Clubb Page 14 of 33

100. Alan Heginbotham gave evidence that Ms Clubb used some kind of opioid drug every day and if she didn’t she would suffer withdrawal symptoms.

She was experienced at using fentanyl patches. He had never seen her overdose. She always injected it. She wouldn’t chew it or use it any other way.

101. They went to Deception Bay as they planned to buy a box of fentanyl patches and they were waiting for the seller at McDonalds but when that person finally got in contact they were told that the box had already been sold. Mr Heginbotham said that he was going to see his son and Mr Sullivan could stay at that house as well but he couldn’t take Ms Clubb there. She said it was ok and she would get someone to pick her up. She said she was going to be picked up by the boyfriend of someone she met in prison.

102. They kept in touch over the next couple of days and both were trying to source drugs. Ms Clubb turned up at the house where Mr Heginbotham was staying on 20 June 2013 and he gave her a part of a patch that he had been able to get. She was in a car with a person matching the description of Dominic Lebler. Mr Sullivan went with Ms Clubb and Mr Lebler to the train station.

103. The morning of 22 June 2013 Ms Clubb phoned Mr Heginbotham and said that a male would call him and he should tell the male that Ms Clubb had left her handbag in his car. Shortly after that a male person called and asked if he had Ms Clubb’s bag. He said he did (although he didn’t actually have it). The male person asked him to look inside and confirm that it contained a box of cold and flu tablets. Mr Heginbotham falsely said that he had the bag and it contained the tablets. He thought that Ms Clubb was ripping someone off i.e. lying to the male person that she had drugs so he would give her drugs or money.

104. Mr Heginbotham said that a fentanyl patch was worth $100 in 2013.

Findings of the inquest into the suspected death of Monique Clubb Page 15 of 33

105. The last time he heard from her was when she phoned him from the toilet and told him she had obtained some fentanyl patches. He tried to phone and text her after that but never heard from her again.

106. Dominic Lebler gave evidence that his ex-girlfriend gave Ms Clubb his email address while they were in prison together. She contacted him on 19 June 2013 and that was the first time he had heard from her. He picked her up from a train station. It might have been at Deception Bay.

107. He drove her around that day and she was making lots of phone calls.

She was looking for drugs.

108. Mr Lebler said that he was not then and has never been a user of opioid drugs. He said he was on the methadone programme in 2014 but that was due to shoulder pain, not illicit drug use.

109. Although Mr Lebler allegedly told police in 2013 that he and Ms Clubb spent a few days together after he picked her up he gave evidence at the inquest that he left her somewhere on 19 June 2013 and can’t recall how he came to take her to Ozcare on the morning of 22 June 2013. He said he was certain that he did not take her to his residence at any time.

110. He denied that he was injecting drugs in the car as stated by Mr Watt.

111. Mr Lebler said that he phoned Ms Clubb on the afternoon of 22 June and again on 24 June 2013 as he was checking up on her to see if she was ok. He said he never heard from her again.

112. Bryce Watt said that he only met Ms Clubb on the night of 21 June 2013 and was with her on 22 June 2013 and he never saw her again after she left him to go into the toilets at Beenleigh.

113. Mr Watt said that a person who resided at Ozcare who he knew as “Old Wade” told him that Ms Clubb had been around again on the morning of 23 June 2013. However, Mr Watt said “Old Wade” could have been joking because the residents at Ozcare were joking with him that Ms Clubb left him at Beenleigh because she had taken advantage of him.

Findings of the inquest into the suspected death of Monique Clubb Page 16 of 33

114. Mr Watt impressed as an honest witness who genuinely wished to assist the coronial investigation.

115. Steven Read gave evidence that in 2013 he was living with Natasha McCarthy and they lived next to Ms Clubb. All three were daily users of opioids. He knew Ms Clubb since 2008. She always injected fentanyl and never took it any other way.

116. They regularly “doctor shopped” outside of Hervey Bay to get prescriptions for fentanyl and oxycodone and when they were successful they would sell the drugs to each other.

117. Mr Read said that he was going to buy two of the fentanyl patches that Ms Clubb obtained at Beenleigh. They had organised that he would buy patches from her before she left Hervey Bay. He said that if she needed to get home she could have phoned him and he would have transferred her money for transport immediately because he was keen to obtain the patches and she knew that was the case.

118. Mr Read said that Ms Clubb would have headed straight home to Hervey Bay to sell the patches if she was able to do so.

119. Natasha McCarthy gave evidence that she knew Ms Clubb for three years and saw her nearly every day. They all had to use opioids every day or they would get sick and they were constantly trying to get the drugs.

120. Ms Clubb phoned Ms McCarthy on 22 June 2013 and said she was on the train with someone and he was going ballistic and he needed Ritalin and asked her where she could obtain it. Ms McCarthy told her she didn’t know anyone who could supply it.

121. Ms McCarthy did not hear from Ms Clubb again.

Findings of the inquest into the suspected death of Monique Clubb Page 17 of 33

Witnesses in regard to Intelligence Reports

122. Christina Gamble gave evidence. On 29 October 2013 she told police in a recorded conversation that she was in a car with Daniel Murphy when he took a purple suitcase and a bag containing female clothing out into the bush and she believed that Ms Clubb’s body was in the suitcase. She said she went out to that location with Ms McBride and showed her where he took the suitcase.

123. In court Ms Gamble gave a significantly different version. She said she was not in fact in the car with Daniel Murphy. He didn’t dispose of the suitcase in the bush. She saw its contents and there was only clothing in the suitcase. She said she did not go with Ms McBride to the place where she saw Mr Murphy take the suitcase.

124. Ms Gamble was a completely unreliable witness who gave a version which differed significantly from that she provided to police in a tape recording at the time of the investigation. Her evidence in court was internally inconsistent and at times non-sensical. Nothing she said in court or to police could be relied upon in any way.

125. Mr Z was Ms Clubb’s boyfriend at the time of her disappearance although he had been incarcerated the week before her disappearance due to a parole violation. They had been together for about three months and had plans to live together and cease their drug usage when he was released from prison.

126. Mr Z said that he and Ms Clubb took opioid drugs daily. He said she always injected the drugs and always had needles with her for that purpose.

127. Mr Z said that he heard many rumours whilst he was in prison about what happened to Ms Clubb but they were only rumours and he was never told any reliable information.

Findings of the inquest into the suspected death of Monique Clubb Page 18 of 33

128. He said that he, Ms Clubb and another male robbed Vincent Moran in about 2011. They stole drugs, money and jewellery from him. Mr Moran found out that they were responsible for the robbery and sent people looking for them. About a month before Ms Clubb went missing the three decided to contact Mr Moran to sort the matter out amicably. He told them to come and visit him at his residence at Glenwood which they did, however, when they arrived Mr Moran was armed with a semi-automatic rifle and took Mr Z out into the bush behind his house. Mr Z believed that Mr Moran intended to kill him there but Mr Z was also armed and was able to extricate himself from the situation. Some time after that he and Ms Clubb were told that people had come to a house armed and looking for them but he was never able to identify those persons.

129. Mr Z said that he does not know what happened to Ms Clubb but he is sure she is not alive as if she was she would have been in contact with her mother and family. He believes she was murdered or died of an overdose. He said she was definitely not suicidal at any time.

Police Investigation

130. Senior Constable Shannon Gray gave evidence. He has been a police officer since 2008 and commenced at Hervey Bay which was where he was stationed in June 2013. He took the missing person report from Ms McBride and made initial inquiries and generated a missing person report in the police database.

131. Senior Constable Gray said that he was initially responsible for the investigation but once it was established that she was last seen at Beenleigh the MPU took over the investigation so they could task regional officers to carry out investigations.

132. Sergeant Anthony Nelson is the Senior Search and Rescue Officer. He oversees searches carried out in the south east region and also manages specific searches personally. He is also a shift supervisor and officer of Findings of the inquest into the suspected death of Monique Clubb Page 19 of 33

the Water Police. He is on call 24 hours per day and responsible for all land, sea and some evidentiary searches in the region.

133. He triages all reports of missing persons as soon as they are received in the region to assess whether he can assist with such investigations.

134. He was contacted by the MPU at 10.30am on 7 July 2013 and asked to assess possible searches of the park at Beenleigh.

135. He reviewed the records and footage and discussed the matter with the MPU officers.

136. He determined that urgent action was required to search for Ms Clubb.

137. At that time MPU had already carried out the initial checks such as phone records and CCTV. He said that had he done the initial checks he would also have considered bus and taxi records and spoken to drivers etc.

138. Sergeant Nelson organised for a helicopter to search the area that day and then drove to Beenleigh and met with Mr Apolo so he could see where Ms Clubb was last sighted and do an initial reconnaissance of the area.

He saw that the area was small and well boundaried.

139. The next day the initial search by SES was carried out. Sergeant Nelson described the exhaustive searches that were conducted in the park including a wading team searching the shallow water and divers searching the deeper water.

140. One week later another search was carried out using police recruits as there was still no evidence that she had been seen elsewhere. They carried out a high probability search and searched the bushland walking shoulder to shoulder.

141. Sergeant Nelson assessed that if Ms Clubb had not left the area there was an 80% chance she was within two kilometres of the last sighting. He then looked at those areas again including searching the banks of the waterway on a jetski himself. He also searched a drain under the freeway.

Findings of the inquest into the suspected death of Monique Clubb Page 20 of 33

142. Sergeant Nelson explained that QPS have now obtained the “Rescue Locate” programme which allows police to send a text message to a missing person’s phone and if they respond to it police can locate them by their phone. He explained that a matter must be assessed as “grave and imminent” before phone triangulation will be approved and Ms Clubb’s disappearance did not meet that criteria. He said that triangulation can be extremely inaccurate but the new system is very accurate. (Triangulation and “Rescue Locate” are only effective if a phone is turned on and charged. As her phone was not utilised after the afternoon of 22 June 2013 it would not have been charged by the time she was reported missing.)

143. Sergeant Nelson said that had he known Ms Clubb had taken drugs when she went missing he may have assessed the matter as “grave and imminent” but it didn’t make any practical difference as he would have carried out the same searches with the same urgency.

144. Sergeant Nelson concluded that he was 100% satisfied that Ms Clubb was not in the park and he believes that she probably met an associate and left Beenleigh soon after she was last seen.

145. Sergeant Nelson stated that he believes that every region should have a search officer triaging their missing person reports daily as the greater delay between the commencement of the search and the person going missing the more difficult it is to find them, however, in this case the search could not commence until it was established that she had last been seen in Beenleigh and even had the search commenced then it would have been carried out in exactly the same way.

146. Sergeant Nelson said that had he been involved in the matter from the first report of Ms Clubb missing he would have conducted checks on all modes of transport, all available CCTV and he would have carried out those checks in the first 24 hours of ascertaining her last known whereabouts.

Findings of the inquest into the suspected death of Monique Clubb Page 21 of 33

147. Sergeant Nelson is a very experienced search and rescue officer and an impressive witness. I accept his conclusions.

148. Senior Sergeant Jim Whitehead is the State Search and Rescue Coordinator. He is responsible for maintaining the Qld Search and Rescue System and he provides training to officers and overviews and reviews searches carried out in Queensland. He ensures that searches are carried out effectively.

149. He was involved in the initial search for Ms Clubb and in 2020 he did a peer review of all searches carried out at Beenleigh for Ms Clubb.

150. Senior Sergeant Whitehead read the entire file relating to Ms Clubb including the entire occurrence log, he visited the area and he reviewed the details of all the searches conducted. He concluded that both lots of searches reached 80% probability that she was not there and cumulatively therefore, there was a greater than 80% probability that she was not in the park.

151. Senior Sergeant Whitehead took into account that there was no record in the occurrence log of CCTV footage being checked for after 3.30pm on 22 June 2013 or subsequent days to establish if Ms Clubb exited the park.

He said that it would not have been viable to view CCTV endlessly as there was no identified end point but he believes it would have been reasonable to view the CCTV for four or five hours after she was last seen in the park to ascertain if she had left the area by train.

152. In relation to search techniques Senior Sergeant Whitehead said that there is now new technology available which can find a person’s mobile phone even if it is turned off and for many days after it appears to be flat.

The technology relies on the residual charge that stays in the phone for a lengthy period of time. It can search large areas by use of a helicopter.

QPS conducted a trial of such a product in January 2020. He does not know why the product was not purchased by QPS.

Findings of the inquest into the suspected death of Monique Clubb Page 22 of 33

153. He acknowledged that the product is quite costly but said that searches are resource intensive and the product would pay for itself very quickly and has the real potential to save lives.

154. Senior Sergeant Whitehead concluded that Ms Clubb did not die in the park and left the area shortly after she was last seen. He said she could have flagged down a lift on the motorway but it was impossible to search that CCTV now due to the passage of time. He said that as she is not in the park it is improbable that she died of a drug overdose as he took advice as to that issue and believes that had she succumbed to the fentanyl she ingested she would have done so quite quickly.

155. Plain Clothes Senior Constable Amanda Foster gave evidence. In June 2013 she was working at Maryborough Criminal Investigation Branch.

She was tasked to follow up intelligence reports received by QPS in relation to Ms Clubb’s disappearance. On 10 July 2013 she was told by her senior officer that she would be responsible for compiling the report to the coroner.

156. MPU, Hervey Bay police and Beenleigh CIB were also involved in the investigation. The MPU was generating tasks for various police districts.

She was carrying out only those tasks relevant to her unit. She was also aware of the investigations being carried out by other units.

157. Plain Clothes Senior Constable Foster had no knowledge of whether other footage from Beenleigh and Southbank stations was viewed or the time period for which the Beenleigh footage was viewed to ascertain whether Ms Clubb left Beenleigh and/or returned to Ozcare the following morning as stated by Mr Watt.

158. Plain Clothes Senior Constable Foster had little knowledge of which phone records were obtained or analysed pursuant to the investigation.

159. Plain Clothes Senior Constable Foster stated that she was responding to taskings in relation to the investigation but she was not directing the Findings of the inquest into the suspected death of Monique Clubb Page 23 of 33

investigation in any way. She believes that MPU was the lead investigator.

160. Detective Senior Sergeant Damien Powell gave evidence that at the time of Ms Clubb’s disappearance he was a Detective Senior Sergeant of the MPU. He provided a report dated 27 February 2015 to the Inspector of the Homicide Investigation Unit.

161. There were a number of inaccuracies in that report:

• That Ms Clubb obtained prescriptions for Tramadol, Diazepam, Bactrim and Durogesic patches (she did not obtain a script for Tramadol);

• That she obtained all of those medications from the chemist (only the patches were obtained);

• She entered the female toilets (she entered the disabled toilets);

• She decamped into dense bushland (she was not seen to enter the bushland);

• She was last observed some 50 metres into this area continuing into the swamp (Mr Apolo said he last saw standing in the shallow creek at the edge of the bush and she was standing by a pillar);

• It is possible that she is deceased within the dense bushland or waterway and has not been found (according to Sergeant Nelson and Senior Sergeant Whitehead Ms Clubb there was a 100% certainty Ms Clubb was not in the park and this was known to investigators at the time of the report).

162. Detective Senior Sergeant Powell concluded that it was his view that Ms Clubb overdosed within the bushland and has not been located there or elsewhere nearby.

163. That conclusion is inconsistent with the views of Sergeant Nelson and Senior Sergeant Whitehead who are the QPS experts in relation to search and rescue.

Findings of the inquest into the suspected death of Monique Clubb Page 24 of 33

164. Detective Senior Sergeant Powell said that he did not review the investigation himself as he relied on the report of Plain Clothes Senior Constable Foster and her conclusions.

165. Detective Senior Sergeant Powell said that MPU do not typically take carriage of an investigation but overview and assist the region which is investigating the matter. MPU officers ensure the matter is being investigated appropriately and obtain specific information to which they have access but regional police may not i.e. proof of life checks such as bank accounts, Medicare records etc.

166. MPU officers do not usually carry out phone record inquiries but refer those matters back to the regions.

167. In relation to the disappearance of Ms Clubb, as there were a number of regions involved (Hervey Bay, Beenleigh and Brisbane), the role of the MPU was to ensure appropriate inquiries were being made and coordinate those inquiries. However, Detective Senior Sergeant Powell said that he discussed the matter with Detective Inspector Colfs of Hervey Bay CIB and it was agreed that Hervey Bay would have “ownership” of the investigation and take responsibility for the investigation and the report to the coroner.

168. He would have expected Detective Inspector Colfs to delegate the investigation to a lead investigator i.e. Plain Clothes Senior Constable Foster and he would expect that Plain Clothes Senior Constable Foster would be in charge of the investigation. When advised that the evidence of Plain Clothes Senior Constable Foster was that she was not making any tactical decisions or critical analysis of the investigation but only reporting the investigations that had been carried out and carrying out tasks as allocated by MPU he said that was not his understanding of the plan for the investigation.

169. Detective Senior Sergeant Powell said that MPU was not leading the investigation.

Findings of the inquest into the suspected death of Monique Clubb Page 25 of 33

170. Pursuant to the QPS Operational Procedures Manual (OPM) the reporting station has responsibility for a missing person investigation until another unit or station takes responsibility.

171. Detective Senior Sergeant Powell said that the submission of the coronial report signifies the end of the missing person investigation unless other information comes to light which requires further investigation.

172. He said the occurrence log is used by MPU as a running sheet. At the initial stage of the investigation MPU liaise with the region to ensure investigations are being carried out. He advised Detective Inspector Colfs of Ms Clubb’s disappearance and advised her that MPU would carry out the initial inquiries.

173. He said phone records would be added to the occurrence log and reviewed by either MPU or the regional officer but the region was responsible for following up further investigations arising out of the records.

174. He noted that call charge records were obtained for Mr Heginbotham’s phone but that reverse call charge records were not. He did not know the reason they were not obtained.

175. Detective Senior Sergeant Powell recalled that officers reviewed CCTV from the Beenleigh railway station but was unaware of whether it was reviewed past 3.30pm on 22 June 2013 (as recorded in the occurrence log).

176. Detective Senior Sergeant Powell said that he did not carry any critical review of the investigation or read the supporting documents to the report of Plain Clothes Senior Constable Foster as he assumed Detective Inspector Colfs would have reviewed the investigation.

177. He said he forwarded the report to the Detective Inspector of Homicide Branch as that officer is his supervising officer, however, there was no real review – he just “forwarded on”.

Findings of the inquest into the suspected death of Monique Clubb Page 26 of 33

178. Detective Senior Sergeant Powell said he believed that the only person who would have actually critically reviewed the investigation was Plain Clothes Senior Constable Foster as she was the lead investigator.

179. Detective Senior Sergeant Powell accepted that there were aspects of the investigation which were incomplete. He said it is highly unlikely that any further CCTV, phone records or transport records evidencing Ms Clubb’s departure from Beenleigh could be obtained now due to the passage of time. However, he said that there was no information such as phone or other activity to indicate that she had left Beenleigh.

180. Detective Senior Sergeant Powell conceded that there could be confusion as to which region or unit is the lead investigator in relation to missing persons and said that there had been confusion in the past when regional officers had assumed that the MPU was taking charge of the investigation.

181. Detective Senior Sergeant Powell stated that his conclusion that Ms Clubb overdosed and died in the park was based on the report of Plain Clothes Senior Constable Foster which he did not review in any way.

182. Detective Senior Constable Visentin gave evidence that he first became involved in the investigation regarding Ms Clubb in 2015 when he was at the Maryborough CIB. He investigated some of the intelligence reports that had been received.

183. In 2019 he was tasked with conducting a review of the police investigation particularly the intelligence reports. He considered the initial report compiled by Plain Clothes Senior Constable Foster but was only tasked to review the intelligence reports. He also analysed the phone records which had been obtained by police. He concluded, as per the previous reports, that the last time Ms Clubb used her phone was the phone call to Mr Heginbotham on 22 June 2013.

184. He does not know how many hours of CCTV from the Beenleigh train station was reviewed by police. He made inquiries with Sergeant Massingham of the MPU who was responsible for the entry in the Findings of the inquest into the suspected death of Monique Clubb Page 27 of 33

occurrence log stating that the footage was viewed until 3.30pm. She told him that the CCTV footage was viewed “into the evening” but could not be more precise than that. She told him that she did not review it herself – someone else did it but she does not know who that was.

185. Detective Senior Constable Visentin said that the footage was in the possession of the QPS but he cannot now locate it. He said it has not been uploaded to QPrime and MPU does not have it. He said that it was not lodged as an exhibit and it cannot be found. He could also not find the request that was sent to Queensland Rail when the footage was obtained so was unable to ascertain how many hours of footage was received by QPS. He agreed that the handling of that evidence was not in accordance with QPS procedures and was inappropriate.

186. He said that he was not tasked to critically review the investigation or identify gaps in the information and he did not do so.

187. Detective Senior Constable Visentin said that he did check police records in relation to Mr Moran which showed that at the time of Ms Clubb’s disappearance he appeared to be in the Tin Can Bay area and there was no record of him being at Beenleigh.

188. Detective Senior Constable Visentin said that inquiries are ongoing into the disappearance of Ms Clubb and the matter is still with Hervey Bay CIB (this evidence was not in accordance with that of Plain Clothes Senior Constable Foster who gave evidence that the investigation ceased when she submitted the coronial report).

189. Detective Senior Constable Visentin said that he understood that Plain Clothes Senior Constable Foster was the lead investigator (again this was inconsistent with the evidence of Plain Clothes Senior Constable Foster).

190. Detective Senior Constable Visentin said that he believed that the park could not be searched to exclude the possibility that Ms Clubb had overdosed and died in the bush there and he was unaware that Sergeant Findings of the inquest into the suspected death of Monique Clubb Page 28 of 33

Nelson and Senior Sergeant Whitehead were both certain that she was not there.

Findings and Comments The Scope of the Coroner’s Inquiry and Findings

191. An inquest is not a trial between opposing parties but an inquiry into a death. The scope of an inquest goes beyond merely establishing the cause of death.

192. The focus is on discovering what happened; not on ascribing guilt, attributing blame or apportioning liability. The purpose is to inform the family and the public of how the death occurred and, in appropriate cases, with a view to reducing the likelihood of similar deaths.

193. As a result a coroner can make preventative recommendations concerning public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in future. A coroner must not include in the findings or any comments or recommendations, statements that a person is or may be guilty of an offence or is or may be civilly liable.

194. Proceedings in a coroner’s court are not bound by the rules of evidence.

That does not mean that any and every piece of information however unreliable will be admitted into evidence and acted upon. However, it does give a coroner greater scope to receive information that may not be admissible in other proceedings and to have regard to its origin or source when determining what weight should be given to the information.

195. A coroner should apply the civil standard of proof, namely the balance of probabilities. However, the more significant the issue to be determined, the more serious an allegation of the more inherently unlikely an Findings of the inquest into the suspected death of Monique Clubb Page 29 of 33

occurrence, then the clearer and more persuasive the evidence needs to be for a coroner to be sufficiently satisfied it has been proven.

196. If, from information obtained at an inquest or during the investigation, a coroner reasonably suspects a person has committed an offence, the coroner must give the information to the Director of Public Prosecutions in the case of an indictable offence and, in the case of any other offence, the relevant department. A coroner may also refer a matter to the Criminal Misconduct Commission or a relevant disciplinary body.

Submissions

197. At the conclusion of the evidence all parties made submissions and I have taken those into account.

Findings

198. I find that Ms Clubb is deceased.

199. I am satisfied to the requisite standard that Ms Clubb is not in Hugh Muntz park at Beenleigh and left the park shortly after entering it.

200. I find that Ms Clubb died soon after leaving the park. It is possible that she travelled from Brisbane to the South Brisbane area, however, as she did not contact any family or friends it is likely that she died soon after the last sighting of her by Mr Apolo.

201. I find that the prescribing of five fentanyl patches and 50 diazepam tablets to Ms Clubb by Dr A was inappropriate.

Comments and recommendations

202. Section 46 of the Coroners Act 2003 provides that a coroner may comment on anything connected with a death that relates to public health Findings of the inquest into the suspected death of Monique Clubb Page 30 of 33

or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future.

203. Despite the search and rescue coordinators coming to the conclusion that Ms Clubb was not in the park soon after the searches commenced, the police investigation failed, at that time and when further CCTV footage and relevant transport records were available, to concentrate on ascertaining her next movements.

204. Police reports concluding that she had died in the park relied on misconceptions that she was very intoxicated, that she was running away from Mr Apolo, that she was last seen entering thick bush in the park and that the bush and waterways had not been thoroughly searched. In fact, CCTV obtained early in the investigation revealed that she was not running away and she did not appear to be very intoxicated. Unfortunately statements were not obtained from the staff of Spend Less Shoes who were the last people to speak to Ms Clubb. Mr Apolo gave evidence that she had not jumped over the barrier at the highest point, that she did not appear to be injured, that she did not appear to be intoxicated and that she did not run into the bush but stood at the edge of the creek until he left.

205. There was obvious confusion as to which police officer from which unit was the lead investigator which resulted in a lack of critical review and tactical decision making leading to gaps in the investigation eg insufficient review of CCTV footage of Beenleigh station to ascertain whether Ms Clubb had caught a train later in the day, insufficient investigation of phone records (eg no checks as to which person or persons Mr Watt and Ms Clubb had been calling from the Park Road Station, no checks of phone numbers which had been in frequent contact with Ms Clubb on 22 June 2013), no checks of other public transport, no checks of CCTV footage at Southbank station, no checks of other CCTV at Beenleigh.

206. The QPS OPM provisions in relation to dealing with evidence have not been complied with by the MPU resulting in an inability to ascertain how Findings of the inquest into the suspected death of Monique Clubb Page 31 of 33

many hours of CCTV footage was obtained from Beenleigh railway station or to examine that footage again. That CCTV footage cannot now be obtained.

207. It appears that Senior Sergeant Whitehead was the only officer who carried out a critical review of the entire investigation in relation to Ms Clubb’s disappearance. He noted the absence of review of CCTV footage after 3.30pm on 22 June 2013.

208. The conclusion of Sergeant Nelson that Ms Clubb was not in the park was disregarded by or not known to other police officers who concluded (based on some inaccurate information as stated above in regard to Detective Senior Sergeant Powell’s report) that Ms Clubb had died of an overdose in the park and her body had not been located. Due to that conclusion the investigation was effectively discontinued at a time when it may have been possible to obtain further evidence as to whether she left Beenleigh and, if so, her final whereabouts.

209. The conclusion reached by investigating police is inconsistent with the evidence.

Recommendations

210. I recommend that:

• QPS consider a further trial and/or implementation of airborne phone location systems;

• QPS consider amendment of the relevant sections of the Operational Procedures Manual to remove possible confusion as to which region or unit is responsible for allocation of a lead investigator for missing persons investigations.

Findings of the inquest into the suspected death of Monique Clubb Page 32 of 33

Findings required by s. 45 I find that Monique Irene Clubb is deceased. I am required to find, as far as is possible the medical cause of death, who the deceased person was and when, where and how she came by her death. As a result of considering all of the information I am able to make the following findings.

Identity of the deceased – Monique Irene Clubb How she died – Undetermined Place of death – I find that Ms Clubb probably died in Beenleigh or in the Brisbane area.

Date of death– Ms Clubb died on or soon after 22 June 2013 I close the inquest.

Jane Bentley Deputy State Coroner

SOUTHPORT Findings of the inquest into the suspected death of Monique Clubb Page 33 of 33