Coroner's Finding: KENNA Pamela Alice

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 2nd day of October 2008, the 10th day of December 2008 and the 4th day of September 2009, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Pamela Alice Kenna.

The said Court finds that Pamela Alice Kenna aged 65 years, late of 12 Cunningham Street, Mount Gambier, South Australia died at Sir Hubert Wilkins Road, Adelaide Airport, South Australia on the 4th day of February 2007 as a result of heatstroke.

The said Court finds that the circumstances of her death were as follows:

1. Introduction and reason for Inquest 1.1. The deceased in this matter, Ms Pamela Alice Kenna, died on Sunday 4 February

2. She was 65 years of age. She was said to be in good physical health at the time of her death.

1.2. Ms Kenna was ordinarily a resident of Mount Gambier. She resided there with her partner, Mr Michael McCarthy. On the weekend of her death she was staying with her son at premises situated at 385 Carrington Street in the city. She and Mr McCarthy had travelled to Adelaide because Mr McCarthy had to undergo an operation at the Repatriation General Hospital at Daw Park.

1.3. At about 9:17pm on Sunday 4 February 2007 Ms Kenna’s body was located lying in the car lot of the Airport Hertz car rental depot which is on the southern side of Sir Donald Bradman Drive at the Adelaide Airport. Ms Kenna had last been seen by her son at the Carrington Street premises at about 4pm that afternoon at which time she

said that she was going for a walk. This was some 5¼ hours prior to her body being found. The distance between the Carrington Street premises and the Hertz depot at Adelaide Airport is about 8 kilometres. When Ms Kenna was located, she had no possessions other than the clothing that she was dressed in. It was later established that Ms Kenna had set out for her walk with no money in her possession and no other means of conducting a monetary transaction.

1.4. Temperatures during the afternoon and early evening of 4 February 2007 were extremely hot, for the most part in the high 30ºC range.

1.5. When Ms Kenna was located the manner of her death was not clear and her death was naturally reported to the State Coroner.

1.6. There is no known sighting of Ms Kenna between 4pm when last seen by her son and 9:17pm when her body was found. I add here that after the discovery of Ms Kenna’s body, no general or specific enquiries were made of the public by investigating police as to whether Ms Kenna had been sighted along any possible route taken by her or whether any member of the public had come into contact with her between 4pm and when her body was located. In the context of an investigation into a death as unusual and as unexplained as this, to my mind this was an oversight that should not be repeated. Even if it was thought early in the piece that Ms Kenna had probably died from the heat, an attempt to establish her movements was nevertheless an essential ingredient in any investigation such as this.

1.7. In this Inquest I examined whether the anatomical cause of Ms Kenna’s death could be established and whether the precise circumstances of her death could be reconstructed. If it was the case that Ms Kenna had walked to the location where she was found, I investigated whether any person could elucidate the circumstances in which Ms Kenna had chosen to walk the considerable distance from the city to the environs of the airport on a day of extremely hot temperatures. I also examined the issue as to whether any other person was involved in Ms Kenna’s death.

1.8. When this matter came before the Court, I was concerned that little effort had been made to establish Ms Kenna’s movements in the last few hours of her life. It seemed to me that the route that Ms Kenna may have taken to travel from the city to the airport was limited to only a few options and that in all probability she would have taken major thoroughfares for the most part. Heightening my unease was the fact that

in the period since she was last seen by her son, Ms Kenna had sustained multiple bruises and abrasions, especially to her face. I adjourned the matter with a public request, that was duly published, that any citizens who believed that they may have sighted or had any contact with Ms Kenna on the afternoon or evening of Sunday 4 February 2007 should contact a member of the police force as soon as possible.

1.9. Since that adjournment two further statements have been provided. These statements related to Ms Kenna’s known propensities to walk for long periods, information that was helpful in itself. It was gratifying that two members of the public saw fit to respond to the request for information. However, no person who claimed to have seen Ms Kenna on the day in question during the relevant period contacted the authorities.

This was not really surprising due to the lapse of time since the events with which this Inquest was concerned.

1.10. Accordingly, the findings of the Court are based upon evidence that does not include any direct sightings of Ms Kenna. Nor will they include any direct explanation as to how it was that she came to be located deceased in the environs of the Adelaide Airport. However, certain inferences as to her fate are available and I will discuss them in a moment.

2. The post-mortem examination 2.1. Given the circumstances in which Ms Kenna was found, a post-mortem examination, which included a full autopsy, was conducted in respect of her remains. Dr Barbara Koszyca, a Forensic Pathologist then employed at Forensic Science SA, conducted the post-mortem examination.

2.2. The only anatomical findings of note were multiple facial and upper arm bruises and abrasions.

2.3. Toxicology testing did not reveal the presence of any alcohol or other common drugs in Ms Kenna’s bloodstream.

2.4. Dr Koszyca comments as follows: 'No underlying organic disease was identified at autopsy to explain death. Although there were multiple bruises and superficial abrasions, there was no evidence of trauma causing or contributing to death. Toxicological examination of peripheral blood was reported as not finding any alcohol or common drugs on routine screening. Biochemical

analysis of vitreous humour found no evidence of dehydration. Neuropathological examination found no intracerebral cause of death and no evidence of any underlying dementing illness on routine screening. In the absence of significant findings at autopsy, together with the environmental temperatures at the time, the findings would be consistent with death from heatstroke.' 1

2.5. Dr Koszyca expresses the cause of death as ‘undetermined presumed natural’.

2.6. I return to the cause of death after I have examined the circumstances of Ms Kenna’s death.

3. Ms Kenna’s general health prior to her death and her exercise habits 3.1. I have already alluded to the fact that Ms Kenna lived with her partner, Mr Michael McCarthy, in Mount Gambier. A statement tendered to the Inquest from Mr McCarthy2 describes Ms Kenna’s health prior to her death as being excellent. She had not seen a doctor for a number of years, simply on the basis that she had seldom been ill.

3.2. Mr McCarthy states that Ms Kenna would walk everyday such that her physical health was good.

3.3. On the other hand, Mr McCarthy states that in about 2005 he began to notice that Ms Kenna’s memory was deteriorating. Mr McCarthy had been so concerned about Ms Kenna’s memory loss that he had not wanted her to stay by herself in Mount Gambier while he was in hospital in Adelaide. So she stayed with her son who lived in Carrington Street in the city.

3.4. Before he went into hospital on the Sunday afternoon, Mr McCarthy asserts that he had to discourage Ms Kenna from walking by herself in the city. Apparently she had been annoyed at his intervention. The last he saw of Ms Kenna was when she and her son, Andrew, delivered him to the hospital that afternoon.

3.5. Mr McCarthy expresses the belief that although Ms Kenna was reasonably familiar with Adelaide, she may have become lost.

1 Exhibit C2a, page 1 2 Exhibit C1b

3.6. Ms Kenna’s son, Mr Andrew Miles, provided two statements to the police3. He refers to his mother as being physically very fit and that she would love to go for walks as her way of keeping fit. He knew that she suffered from memory difficulties and states that her partner, Mr McCarthy, had told him on the Saturday of that weekend that his mother’s memory was becoming worse.

3.7. If any corroboration was required of the evidence as to Ms Kenna’s habits as provided by the members of her immediate family, it was furnished by a Mr Carl McPhee who provided a witness statement since the adjournment of the Inquest4. Mr McPhee states that he had known Ms Kenna since the mid 1950s. He kept in touch with her from time to time over the years but more recently had only had irregular telephone contact. However, his statement reveals that Ms Kenna had told him in telephone conversations that she would regularly go on daily walks for about 2 or 3 hours.

3.8. I am satisfied from the evidence that Ms Kenna was a reasonably fit and healthy 65year-old woman who was an enthusiastic and prolific walker. However, in recent years she had been observed to be suffering from memory loss to the point where the same was of some concern to her partner, Mr McCarthy. Although she was familiar with Adelaide, the evidence about her propensity to take long walks and her memory loss might in itself suggest that on Sunday 4 February 2007 Ms Kenna walked for too long or too far, and in any case to the point of exhaustion having regard to the weather conditions.

4. The events of Sunday afternoon, 4 February 2007 4.1. As seen, Ms Kenna and Mr McCarthy were staying at the Carrington Street residence of her son, Mr Miles. Mr Miles and Ms Kenna dropped Mr McCarthy off at the hospital. They had consumed some beer at a hotel in Adelaide prior to this. Mr McCarthy’s recollection seems to be that it was after this that Ms Kenna had originally wanted to go walking, from which she had to be dissuaded. Mr Miles believes that it was on the Saturday that Mr McCarthy had to dissuade Ms Kenna from walking5, but the detail of this is not material because it is clear that at least Mr Miles was very unenthusiastic about his mother walking on the Sunday afternoon in the heat.

3 Exhibits C4a and C4b 4 Exhibit C8 5 Exhibit C4b

4.2. In any event, after Mr McCarthy was delivered to the hospital on the Sunday afternoon and Mr Miles and Ms Kenna returned to the city, Mr Miles’ statement6 reveals that at about 4pm on the Sunday afternoon his mother set off for a walk, ostensibly around the local area. He attempted to talk her out of it because it was hot and Mr Miles was concerned that she might get lost. At one stage before she set off she came back inside but then left saying that she would be back in 15 minutes.

When his mother left she did not take her handbag with her. It was left in her bedroom at her son’s premises. It is reasonably clear that she did not take any water.

4.3. After his mother set out for her walk Mr Miles went to sleep and did not wake until about 6pm. His mother had not returned. He was immediately concerned because he and his mother were meant to go out for dinner at that time.

4.4. He looked around the area trying to find his mother but was unable to locate her. He returned home and rang the Royal Adelaide Hospital to see if she was there. She was not, so he rang the police and reported her missing.

4.5. I was informed that Mr Miles reported that his mother was missing to the police call centre at about 7:48pm on the Sunday evening. A missing person report was subsequently submitted at about 8pm. A ‘keep a lookout for’ (KLOF) was broadcast by Police Communications between 7:51pm and 7:53pm to the Adelaide, Holden Hill and Sturt Local Service Areas. There is no reported sighting of Ms Kenna by police.

5. Ms Kenna is located 5.1. Ms Kenna was located in the Hertz car rental depot adjacent to the Adelaide Airport.

This location is the depot where Hertz rental vehicles were prepared prior to delivery to the Adelaide Airport terminal for use by customers. This area is not a public area.

The depot itself contains a main building and a working area which is fully secured by a fence. Next to that main area is a non-secure overflow area where additional vehicles are kept. It was in this area that Ms Kenna was located. Although access to the overflow area from the main building area was gained by way of a locked pedestrian gate, there was free access to the area from a side road off Sir Donald Bradman Drive. There were approximately 80 locked vehicles in the overflow area.

6 Exhibit C4a

5.2. Ms Kenna was located at about 9:17pm on Sunday 4 February 2007 by Mr Peter Tilbrook who was employed as a quality inspector for Hertz at the depot. At that time Mr Tilbrook was conducting a fleet count in the overflow area when he located Ms Kenna lying on the ground next to a rental vehicle. Prior to his fleet count the last time he had been in the overflow area was at about 5pm when he was with another 4 or 5 employees. They had together moved a number of vehicles from the overflow area to the main depot. During that activity they had driven by a location very close to where Ms Kenna was later to be found. Mr Tilbrook was confident that Ms Kenna had not been there at that time. To the best of Mr Tilbrook’s knowledge no other employee had been in the overflow area from that time onwards until Mr Tilbrook himself located Ms Kenna. Certainly, he saw no other person in the overflow area, and no suspicious activity within the area had been drawn to his attention.

5.3. Ms Kenna was deceased when found by Mr Tilbrook. The police were alerted and they attended the location.

5.4. By 9:17pm it had become dark and the temperature had cooled somewhat.

5.5. The body of Ms Kenna was noted by police to be lying on the ground next to a motor vehicle. She was lying in a driveway which consisted of a dirt surface. The deceased was lying mostly face down with both arms tucked underneath her chest. A scuff mark, possibly made by a hand, was located on the vehicle’s front passenger door panel adjacent to which the deceased was situated. There were also scuff marks in the dirt close to the deceased’s legs and elbows which were consistent with the deceased having kicked and moved her legs and elbows in the dirt while lying on the ground.

Rigor mortis had set in. Ms Kenna was fully clothed. It is believed to be the same clothing in which she had last been seen.

5.6. There were a number of footwear impressions located around the deceased but these were for the most part identified as having been made by footwear commonly worn by police. Ambulance officers had also already been in attendance by the time of the arrival of police. Nothing from the footwear impressions has any bearing on any aspect of this investigation.

5.7. I have already referred to the facial and other abrasions identified at the autopsy.

Police observed these features while at the scene. In his statement dated 13 February

2007, Senior Constable Richard Frost of the Sturt Criminal Investigation Branch makes the following observations: 'At the vehicle the deceased was found next to, scuff marks were found on the door, indicating that the deceased had collapsed at that location and upon falling, had attempted to support themselves on the vehicle. Further scuff marks were found in the dirt surrounding the deceased's legs and elbows and this would indicate that the deceased was kicking both their legs and their elbows. It also indicated that the deceased's arms were bent at the elbow at the time and would suggest that the deceased was clutching their chest area with their hands which is the position in which the deceased was found.

The grazing on the face of the deceased also indicates that the deceased was moving their head on the ground in the dirt. This may suggest the deceased suffered some form of seizure prior to death.

At the scene where the deceased was found, their appeared to be no sign of any struggle or fighting involving another person.' 7 In a second statement of Mr Frost dated 26 February 20088, Mr Frost states that an assumption was made that Ms Kenna suffered the abrasions possibly as a result of her body and face coming into contact with the dirt surface of the depot and not from any physical assault by another person. The post-mortem report of Dr Koszyca explains that there was no evidence of trauma causing or contributing to death. I accept that evidence. The injuries suffered by Ms Kenna are to my mind consistent with the affected parts of her person coming into contact with the ground as Mr Frost suggests.

6. Weather conditions on Sunday 4 February 2007 6.1. Documentation from the Bureau of Meteorology shows that at 5pm on 4 February 2007 the temperature recorded at Kent Town was 39ºC and at Adelaide Airport it was 34.1ºC. The temperature had cooled in Kent Town to 30.8ºC and at Adelaide Airport to 27.5ºC by 9pm.

6.2. It was an extremely hot afternoon.

7. How did Ms Kenna come to be at the Hertz depot at Adelaide Airport 7.1. The distance from Mr Miles’ residence in Carrington Street to the location where Ms Kenna was located is approximately 8 kilometres. A route that she could logically have taken if she had progressed on foot was along Carrington Street, Wright Street and West Terrace in the city and Sir Donald Bradman Drive to the west of the city. It 7 Exhibit C6, page 6 8 Exhibit C6a

is possible that Ms Kenna walked across the belt of parklands to the west of West Terrace. The roads that I have mentioned are all busy thoroughfares.

7.2. As I have alluded to earlier, no general or specific enquiries were made at the time of the discovery of Ms Kenna’s body as to whether she had been sighted along any possible route taken by her or whether any member of the public had come into contact with her at the relevant times. It is also evident that in spite of the general police broadcast to which I have referred, no sighting of Ms Kenna was made by any police patrol.

7.3. It is clear that Ms Kenna would have had sufficient time to walk from the city to Adelaide Airport between approximately 4pm and 9:17pm when she was located.

There is no evidence that she was transported by a motor vehicle or by some other means of public transport. She had no money or credit cards.

7.4. It will be noted that although Ms Kenna was used to walking for long periods, the conditions on the afternoon in question were quite unsuitable for this activity, especially without a hat and water. It is unlikely in my view that Ms Kenna consumed water at any time as she took with her neither water nor money to purchase it. In my view it is more probable than not that Ms Kenna walked the entire distance between Carrington Street and the Hertz depot at the Adelaide Airport. It is highly unlikely that Ms Kenna was transported to this location. There is no identifiable reason why she would have deliberately travelled to such a location in a motor vehicle. There is no discernible purpose in her going to the environs of the airport that afternoon. There is certainly no evidence that Ms Kenna was abducted and dumped. To my way of thinking, once Ms Kenna left the environs of her son’s premises in Carrington Street in the city, she probably continued to walk in a westerly direction until she eventually succumbed to the elements at the Hertz depot. She may well have been endeavouring to seek some shelter there from the sun, although I note that at that particular location there was nothing really apart from the shade that might have been afforded by a motor vehicle such as that might be. It may be that she saw the depot office, headed for that, but was overcome with exhaustion and collapsed before she arrived there.

7.5. It would not be at all surprising if, due to her memory deficits, Ms Kenna had become confused about her environs and had essentially become lost.

8. Cause of death 8.1. I have already referred to the post-mortem report of Dr Koszyca. Dr Koszyca opines that the cause of Ms Kenna’s death is undetermined but natural. It is consistent with death from heatstroke. Dr Koszyca provided further information as follows: 'Heat stroke refers to a situation where individuals are exposed to high environmental temperatures and develop hyperthermia (an elevated core body temperature to 40.5°C or higher) and eventual delirium and coma. Hyperthermia happens when the normal cooling mechanisms of the body cannot compensate for the increased environmental temperature. This results in an increase in core body temperature which in turn directly damages tissues. Once body temperature is > 42.4°C there is a massive dilatation of blood vessels which then leads to heart failure. The mechanisms thought to cause death in hyperthermia do not always directly involve dehydration, although it is easy to get dehydrated when you are too hot. So the absence of any biochemical evidence of dehydration does not exclude heat stroke as a cause of death. There are no specific findings at autopsy in cases of hyperthermia, so in this case I excluded other causes of death and ascribed death to heat stroke, based on reports regarding the events leading up to death. As regards the possibility of a seizure: seizures may be a complication of hyperthermia.' 9

8.2. Having regard to the circumstances in which Ms Kenna was found, and particularly in the light of her propensity to walk long for long periods, her lack of water and the heat of that day, to my mind it is obvious that she died after collapsing from the effects of the heat. There is no other sensible explanation for her death. In my view heatstroke must, on a balance of probabilities, be assigned as the cause of her death.

9. Conclusions 9.1. On Sunday 4 February 2007 Ms Kenna embarked upon a walk. I find that she walked the entire distance from Carrington Street in the city to the Adelaide Airport. It is likely that she walked the length of Sir Donald Bradman Drive from West Terrace to the Hertz car rental depot on the southern side of Sir Donald Bradman Drive.

9.2. In my view Ms Kenna’s facial and other abrasions were caused by her contact with the rough surface of the ground at the location where she was found. The movement of the variously affected body parts along the ground during the course of her terminal phase would in my view account for those injuries.

9 Exhibit C6a, page 7

9.3. In my opinion there was no other person involved in, or responsible for, Ms Kenna’s death.

9.4. I find that Ms Kenna died of heatstroke.

Key Words: Disappearance; Heatstroke In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 4th day of September, 2009.

Deputy State Coroner Inquest Number 30/2008 (0163/2007)