Coroner's Finding: Godley, David Geoffrey

FINDINGS, RECOMMENDATIONS and COMMENTS of Coroner Olivia McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of: David Geoffrey Godley

Contents

Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of David Geoffrey Godley with an inquest held at Hobart in Tasmania make the following findings.

Hearing Dates 21 and 22 June 2018 Appearances Assisting the Coroner: Sergeant Nigel Paul Introduction

1. David Geoffrey Godley, aged 30 years, died on 24 April 2016 as a result of multiple knife wounds in an incident occurring in the bedroom of his rented premises in Sandy Bay. Mr Godley’s wife, Ha-Na Choi (also known as ‘Windy’), was with him during at least part of the incident in which those wounds occurred before leaving the premises through a bedroom window and climbing onto the roof of the neighbouring building. She had also suffered knife wounds. Mr Godley’s housemate was at home whilst the incident took place and, upon seeing Mr Godley in the bedroom with a knife, telephoned police. When police officers arrived, they saw Ms Choi naked on the roof of the building and then saw her jump from the roof onto the roadway. She was immediately taken by ambulance to hospital. Ms Choi, a Korean national, spoke little English and was observed to be in a highly emotional, traumatised state.

2. Upon entering the premises, police and ambulance officers found Mr Godley lying deceased in the bedroom. He was covered in blood, had knife wounds to his neck and chest, and there was a kitchen knife embedded deeply into his head through his right temple. Investigating police officers initially treated the incident as a homicide by Ms Choi and investigated accordingly. Ms Choi was arrested for murder, taken into custody, and remained under police guard in hospital. Some hours later, after further police investigation and advice from the forensic pathologist, Ms Choi was discharged unconditionally from custody, as investigators formed the view that Mr Godley had inflicted the knife wounds upon himself and caused his own death.

3. A thorough coronial investigation into Mr Godley’s death took place over subsequent months. The documentary evidence, together with a detailed report from the investigating officer, was submitted to me for consideration in exercising my functions

under section 28 of the Coroners Act, principally the determination of the identity of the deceased, how death occurred, cause of death and the date and place of death.

4. The coronial investigation file comprised a report from the forensic pathologist regarding autopsy findings; results of toxicological testing of Mr Godley’s blood; Mr Godley’s medical records; a report from Ambulance Tasmania; two video records of interview by police with Ms Choi; affidavits from numerous police officers, including CIB and forensics officers involved at the scene and officers dealing with Ms Choi; footage and photographs of the scene; and key witness affidavits.

5. Upon receipt of the investigation file, it was apparent that Mr Godley had a history of mental illness and drug abuse. It appeared that Mr Godley, in a delusional episode, had inflicted the fatal knife wounds upon himself. The key evidence supporting this view came from Dr Donald Ritchey, the forensic pathologist who attended the scene; the toxicological results of testing of Mr Godley’s blood indicating an extremely high reading for methamphetamine (“ice”); the police interviews with Ms Choi who indicated that Mr Godley was responsible for his own death; and the affidavit and evidence of Mr Alexander Freeman, the housemate of Mr Godley and Ms Choi who spoke to Mr Godley in the bedroom and saw him with a knife at a time when Ms Choi was apparently outside the house.

6. Mr Godley’s parents, Anthony and Jennifer Godley, found their son’s death difficult to comprehend. They requested that I hold a public inquest to further investigate Ms Choi’s involvement in the incident and in Mr Godley’s death. I have a wide discretion to hold an inquest pursuant to section 24 of the Coroners Act whenever it is desirable to do so (see Patmore, Jason 17 November 2017). In this case, I perceived a need to further clarify the account of Ms Choi, the critical witness to the death of Mr Godley. Unfortunately, despite the best efforts of interviewing police officers, the account given through the interpreter in the video interview was difficult to follow and appeared to contain gaps in the sequence of events. Additionally, there was evidence that Ms Choi made statements to the police officer accompanying her in the ambulance from the scene implicating herself in stabbing Mr Godley.

7. Mr and Mrs Godley were understandably concerned that there was truth in those statements and that Ms Choi may have inflicted wounds upon Mr Godley that may have led to his death. The investigation file was disclosed to Mr and Mrs Godley and assistance was provided to them by Sergeant Nigel Paul, Coroner’s Associate, in explaining the evidence and answering their questions surrounding the coronial process.

Nevertheless, their concerns surrounding Ms Choi’s involvement remained.

8. In all of the circumstances, it was appropriate to hold a public inquest for the purpose of examining the immediate circumstances of Mr Godley’s death and how the fatal wounds were inflicted.

9. At inquest, the investigation file was tendered. In addition, the witnesses called to give evidence in person at the inquest were as follows: Sergeant Adrian Mollon, Dr Donald Ritchey, Constable Nikki Mackintosh, Alexander Freeman, Detective Constable Sharee Maksimovic and Ms Choi.

10. As a result of the evidence obtained in the investigation and at inquest, I make the following findings.

Background

11. Mr Godley was born in South Africa on 30 December 1985. He was the eldest of four children. The family migrated to New South Wales when he was a child.

12. Mr Godley left home when he finished his Higher School Certificate studies and commenced a university course in medical science. He finished the second year of this degree but did not complete the course. In 2012 he commenced a Bachelor of Arts degree at the University of Sydney, which he completed in June 2015. The formal graduation occurred in September 2015, which was attended by his parents. This was the last occasion that they saw their son. Mr Anthony Godley described the occasion as a “lovely, proud day”, with his son in good spirits.

13. It is evident from the account of Mr Anthony Godley and from Mr Godley’s New South Wales medical records that Mr Godley developed serious mental health issues at the age of about 14 years, taking the form of psychosis and depression. Specifically, Mr Godley experienced both auditory and visual hallucinations. Medical records indicate that he used cannabis to self-medicate for those issues, although it is possible that cannabis use may have precipitated his psychosis. Subsequently, in addition to cannabis, he used more potent substances such as synthetic cocaine, methamphetamine and heroin. It does not appear that Mr Godley disclosed these issues to his family or sought help at the time.

14. The evidence available in the investigation reveals that Mr Godley sought medical help for his mental health symptoms in October 2013 and was referred to the Continuing Care Team at St Vincent’s General Hospital in New South Wales. He continued treatment until January 2015. The medical notes indicate continued, serious psychosis manifesting in ongoing visual hallucinations, episodes of paranoia about being harmed by others, and an inability to concentrate at university. It does not appear that he expressed suicidal ideation. Mr Godley was prescribed antipsychotic and antidepressant medication on an ongoing basis and attempted unsuccessfully to reduce his cannabis intake. He also used alcohol heavily at times. It is unclear whether Mr Godley was compliant with his medication regime during this period but he appears to have tried to comply. During this time Mr Godley was also referred to St Vincent’s rehabilitation program, but elected to leave the program in February 2014.

15. In December 2014 Mr Godley began a relationship with Ms Choi. Ms Choi’s visa expired in February 2015 and she returned to Korea, but they stayed in contact through social media before she returned to Australia in May to study. In July 2015 they moved to Victoria together before moving to Tasmania in late 2015. It appears from statements made by Ms Choi after the incident to Coroner’s Associate, Senior Constable Jessica Haight, that the move to Victoria was motivated by Mr Godley’s paranoid ideation, specifically that persons such as gangsters were after him, necessitating immediate relocation. The move to Tasmania was also similarly hurried, with their rental house abandoned and bond amount lost.

16. Mr Godley’s mental health conditions did not resolve. Whilst he was in Victoria he continued to be prescribed medication for anxiety, depression and psychosis. Upon arriving in Tasmania from Victoria he saw general practitioners at the Sandy Bay Clinic on two occasions before his death. On the second occasion, 22 December 2015, he told Dr Jennifer Misson that he suffered anxiety and alluded to his history of psychosis. He told Dr Misson that he had been trying to “let his thoughts go” but they were now getting worse; he was not able to switch off, he was worried, felt negative and had compulsive behaviours. Dr Misson wrote Mr Godley a referral for the Royal Hobart Hospital psychiatrist. On 23 December 2015, in response to the referral, Dr Misson received correspondence from the Mental Health Services Helpline stating that Mr Godley reported some improvement in his anxiety since he saw her and would like to manage on his own. Nevertheless, it was recommended that Mr Godley be referred to a clinical psychologist under a mental health plan for the purpose of assessing and treating anxiety/OCD traits. Possible referral to a psychiatrist was also noted. It does not appear that Mr Godley followed up with treatment after this time.

17. Initially in Tasmania Mr Godley and Ms Choi stayed at backpackers’ accommodation.

They then responded to an advertisement on Gumtree and moved into a share house at 15 French Street in Sandy Bay with Mr Alexander Freeman. In December 2015 Mr Godley and Ms Choi were married in this house by a wedding celebrant.

18. Mr Freeman stated in one of his affidavits for the investigation, that outside of conversations regarding rent, he had few interactions with Mr Godley and Ms Choi, though they seemed “quite peaceful” and “normal to talk to”.

19. The evidence, particularly the oral evidence at inquest, helps me to discern the nature of Mr Godley and Ms Choi’s relationship. It is apparent that Mr Godley was the dominant partner in the relationship. Ms Choi gave genuine evidence that she idolised him and was prepared to do anything in an attempt to please him. To the extent that there were suggestions by Mr and Mrs Godley that she married their son for citizenship purposes, I do not accept this is the case. During her evidence she stated, on more than one occasion, that he was her ‘Captain’ and that they were the only ones who understood each other. Nevertheless, the dynamic was not that of a normal, healthy relationship. No doubt due to Mr Godley’s mental illness, he exercised the controlling position and she submitted to his control, particularly when she was fearful during his paranoid/delusional

episodes.

20. A particular indication of the level of dominance was Mr Godley’s regular “testing” of Ms Choi. This involved Ms Choi being required to prove that she loved him and to prove other various matters - that she was not unfaithful; that she was not an assassin or spy; that she was not a lesbian; or that she was not using him only for citizenship purposes.

Ms Choi told Senior Constable Haight of one particular “test” during a stressful period when enrolled in college in Sydney when she was required to travel from Melbourne to submit an assignment in person. Once they were in Sydney, Mr Godley abandoned her in the city and did not contact her for two days. When he telephoned her two days later he stated, “I was just testing you. Do you really love me or are you using me for the visa?” Mr Godley’s requirements during such “tests” were vague and unclear and therefore Ms Choi was never sure if she had passed the “test”. Despite the irrationality of these requirements, Ms Choi continued to participate in the regime of the relationship without seeking to change the power balance.

21. Mr Godley’s control extended to financial matters. Ms Choi gave consistent and credible accounts to police that Mr Godley used her money to pay for all his expenses, including his regular drug transactions amounting to around $500 on each occasion. I accept Ms Choi’s account of Mr Godley’s use of her money.

22. During her second video interview on 3 August 2016, Ms Choi stated that Mr Godley frequently used both cannabis and ice which he purchased online using funds from Ms Choi’s account. Ms Choi stated that Mr Godley had used ice while they were living together in Sydney and since arriving in Tasmania had been purchasing and using it fortnightly. Although Ms Choi states that she had used drugs with Mr Godley, it appears from her evidence that she was not a regular user. She stated that she had taken ice with him on a few occasions only. She gave evidence at inquest that she does not use drugs at all now and does not often drink alcohol. Her evidence in this regard was consistent with her presentation as a witness.

23. Despite his emotional and financial control, there is no evidence of Mr Godley having been physically violent towards Ms Choi until the episode resulting in his death.

24. In evidence at inquest Ms Choi was questioned about the extent, if any, of mental health concerns of her own. She denied any diagnosed mental health conditions or treatment, but emphasised that there had been periods of her life where she had experienced great loneliness. She was also forthcoming in recounting her background of abuse at the hands of her father as a child. She stated that Mr Godley was the only person with whom she had ever shared this information and that he was the only person who she felt understood her.

Circumstances Surrounding Death

25. The inquest focused on the immediate circumstances prior to Mr Godley’s death, in particular from the two weeks prior to his death in which he suffered increasing paranoia.

26. I make comment initially on the evidence given by Ms Choi being the primary witness to the circumstances leading to the death of Mr Godley.

27. Ms Choi’s evidence relating to the events previous to his death was consistent across her various accounts. Before giving her oral evidence at inquest, the evidence in the investigation included two police video interviews and an account to Senior Constable Haight in which she explained events of the day 24 April 2016. She participated in the first video interview whilst in hospital and injured, three days after the event. The second video interview took place on 3 August 2016 and was consistent in content with the first.

Her account to Senior Constable Haight was given from her hospital bed on 28 April 2016 and was also consistent with the initial video interview.

28. It was apparent from these accounts that she was not able to fully articulate the events of 24 April. Due to her emotion and language barriers her narrative was disjointed and possibly incomplete in some crucial aspects of her eyewitness evidence, particularly the events in the bedroom at the time when Mr Godley was allegedly harming himself as well as her.

29. In her oral evidence, given in two sessions over separate days, Ms Choi commenced by repeating matters both leading up to the death and from her time on the roof, avoiding the central incident. However, in the second session of her evidence she was able to give an account of the events directly surrounding the death of Mr Godley. She was clearly traumatised and extremely emotional when giving her evidence, necessitating regular breaks. Her oral evidence at inquest remained consistent with previous accounts given on the three previous occasions. For the most part, I accept her evidence.

30. Ms Choi had been living in Korea for some months before the inquest. Just prior to the inquest she returned to Victoria to finalise her affairs and to give her evidence in this inquest. She has now returned to Korea to reside permanently. In such circumstances it would not have been difficult for Ms Choi to avoid attending the inquest. To her credit, she agreed to attend the inquest notwithstanding her trauma and the emotional difficulty of doing so. Her actions emphasise her willingness to assist the coronial process, as well as her commitment to Mr Godley.

31. At 7.00am on 8 April 2016 Mr Godley presented at the Emergency Department of the Royal Hobart Hospital with methamphetamine toxicity after taking a large quantity of ice (2 grams). He presented as anxious and was treated with midazolam and diazepam to relieve anxiety and clonazepam to prevent seizures and panic disorder. He was discharged on the same day.

32. Although Mr Godley had a drug addiction, it is unclear on the evidence why he consumed such a large quantity. Ms Choi suggested that, during a paranoid episode, he orally consumed all of his remaining supply to destroy evidence for fear of detection.

33. Following Mr Godley’s discharge from the Royal Hobart Hospital, Ms Choi was hopeful of an improvement in his mental state, but she stated that, in fact, he remained highly paranoid. She found him difficult to interact with as his delusional episodes often were directed towards her during this time. It would appear that the degree of control exercised by Mr Godley over her, in the manner described previously, escalated considerably. She described him hearing voices in his head and asking her whether she could hear them. She described the days prior to his death as being “the worst time”.

34. Ms Choi told both police in her video interviews and subsequently Senior Constable Haight that on a Sunday or Monday a week after being released from hospital (possibly about 17 April) Mr Godley was sitting with her at a park near the University. He expressed to her that he did not trust her and pulled a knife from his pocket. He said words to the effect of: “I’m going to die you bitch, so let’s die together, let’s just end this”.

Ms Choi stated that she cried and begged him not to kill himself. Mr Godley eventually desisted his behaviour. I accept that this incident occurred and indicates his poor state of mental health and the consequent risk of harm to both of them.

35. Mr Godley sought no further assistance from health professionals after his hospitalisation on Friday 8 April. Ms Choi, in her evidence at inquest, indicated that she felt that she should have obtained medical assistance for him at this time.

36. I now turn to the events occurring on the day of Mr Godley’s death.

37. During the earlier part of the day Mr Godley and Ms Choi went out, including making a trip to the bottle shop. Upon returning home in the late afternoon Ms Choi stated that Mr Godley was quieter than usual and was “serious”. Ms Choi knew that she was not permitted to distract him while he was in such a mood as it “spoiled his thoughts”. She stated that she was afraid of him so she tried to keep out of his way by being in other areas of the house. She started to cook a stew for him and did other kitchen and laundry tasks. Generally, she tried to avoid him. During this time Mr Godley was in the bedroom alone. However, some limited conversations occurred between the two. For example, at some stage Mr Godley accused her of speaking on the telephone to a man called ‘Stefan’ who was apparently Mr Godley’s drug dealer from Sydney. As the hours passed on that evening he became fixated on Ms Choi’s alleged contact with Stefan. He also accused her of poisoning his stew, of being a prostitute and generally uttering delusional statements indicating a distrust of Ms Choi.

38. Ms Choi did not know whether Mr Godley was using drugs, specifically ice, whilst he was in the bedroom. As I will discuss, it would seem that he did ingest ice as demonstrated by the very high level of methamphetamine detected in his post mortem blood sample. I accept that Ms Choi did not witness Mr Godley taking drugs.

39. At a later time during the course of the evening, Ms Choi brought two bowls of stew into the bedroom and noticed that the bedroom appeared to be very messy, as though it had been turned over by Mr Godley. It seems that this was an unusual occurrence.

40. They lay down together and Mr Godley appeared to have calmed down. He apologised for his comments relating to the food and said he enjoyed dinner. Ms Choi then thought that the ‘test’ had finished for today. It seems at this stage that the pair fell asleep for some time.

41. At some stage Mr Godley woke up and whispered to Ms Choi that they were surrounded by police. As a result of this Ms Choi believed that she received a non-verbal signal from Mr Godley that he wanted her to dispose of the package of ice. Ms Choi therefore swallowed a small, plastic bag of a white powder that she believed to be ice. When explaining her actions in evidence, Ms Choi said that she wished to protect Mr Godley and was prepared to die for him. She had made similar statements to police previously.

42. After Ms Choi swallowed the bag, Mr Godley became agitated and demanded that she regurgitate the package of ice. She attempted to do so in the toilet but was not successful.

43. When she came back from the toilet Mr Godley said to her “everything is over”. At about this time Mr Godley also re-commenced accusing Ms Choi of speaking with ‘Stefan’. In an attempt to pacify him Ms Choi falsely told him that she had spoken with ‘Stefan’.

44. Ms Choi said that Mr Godley rose from the bed suddenly and left the room. When he reappeared he was holding a knife and had cuts to the neck that were clearly bleeding.

45. The evidence given by Ms Choi about the time of this occurrence is vague but it is likely to have occurred just before Mr Freeman and his girlfriend, Page Kew, returned home by taxi at 3.30am from an evening out in Salamanca. This time is verified by the taxi records tendered in evidence and the taxi driver’s affidavit.

46. Much of the critical eye witness evidence from this point came from the account of Mr Freeman, both in affidavits and oral evidence at inquest. In evidence, Mr Freeman presented as a credible, logical and articulate witness. His evidence was consistent with that set out in his affidavits. Although he was intoxicated to a degree at the time of his witnessing relevant events, his memory appears to have been unaffected. I note that he had ceased drinking alcohol some hours before the incident.

47. Mr Freeman stated that, on arrival, noise and screaming (predominantly by Ms Choi) could be heard coming from inside the house. It continued until Mr Freeman and Ms Kew became sufficiently alarmed to approach Mr Godley and Ms Choi’s bedroom door. Mr Freeman yelled out and asked if they were okay, to which Mr Godley yelled back “yeah, we’re okay”. The screaming continued and Mr Freeman announced that he would enter the room. Mr Godley replied “we’re okay, don’t come in”. Mr Freeman attempted to push

open the door open on two or three occasions but it was blocked by Mr Godley’s body and he could not get access to the room.

48. Mr Freeman continued to try to speak with Mr Godley from the adjoining room. Ms Choi was still screaming but Mr Freeman realised the sound of her voice was coming from outside the house. As will be discussed, I accept the accuracy of this statement. Mr Freeman gave clear evidence about approaching the window in the adjoining room and although he could not see Ms Choi he could still clearly hear that she was outside in the street area. Mr Freeman asked Ms Choi to calm down. He continued to speak with Mr Godley who calmly responded saying “don’t come in”.

49. Mr Freeman was able to partially open the bedroom door. He saw Mr Godley laying on the floor with a knife near his chest area. In his affidavit he said the knife was protruding from Mr Godley’s chest but in evidence he could not be sure of that observation. There was a large amount of blood on the floor. He retreated and armed himself with a combat knife for protection, then returned to the bedroom. He tried to speak to Mr Godley again but he had stopped responding. Ms Kew called police.

50. Mr Freeman exited the bedroom and observed Ms Choi on the roof of the neighbouring units, having exited through the bedroom window. She was naked and screaming hysterically. Mr Freeman tried to calm her down and get her to come down off the roof.

51. Police officers arrived on the scene and immediately proceeded into the house. They located Mr Godley deceased in the bedroom. He was laying on the floor with a knife embedded deeply into his head, near his right temple. Stab wounds were evident on his throat and chest. Paramedics arrived shortly after police and determined that Mr Godley was deceased.

52. Together with Mr Freeman and Ms Kew, police spoke to Ms Choi, still on the neighbouring roof, attempting to calm her down. Ms Choi moved closer to the edge of the roof. She then either fell or deliberately jumped from the roof onto the road, a height of approximately 2.5 metres. The eyewitness evidence contained some discrepancies and Ms Choi herself was not able to give a reason for falling or jumping. At this time she was obviously suffering shock and, as will be discussed, the effect of the ice that she had ingested. She was immediately treated by paramedics at the scene and conveyed to the Royal Hobart Hospital.

53. As stated earlier, police immediately established a crime scene and opened an investigation into Mr Godley’s death. Dr Ritchey attended the scene to examine Mr Godley’s body.

54. On 25 April 2016 Dr Ritchey conducted an autopsy in the Hobart mortuary. He noted multiple stab and incised wounds to the neck, stab wounds to the left side of the chest and to the right temple. Samples of blood were taken at autopsy and forensically tested.

Testing revealed methamphetamine in the reported toxic range; diazepam and THC

(cannabis) were also detected. In Dr Ritchey’s opinion, the cause of death was multiple stab and incised wounds.

55. In Dr Ritchey’s opinion Mr Godley’s injuries were self-inflicted. He stated in his affidavit: “Multiple parallel stab wounds were on the left side of the chest and superficial stab and cut injuries adjacent to these wounds appeared to reflect hesitation injuries.

There were no cut defects in the t-shirt or hoodie.

Additionally there were superficial small cuts predominantly on the palmar surfaces of both hands and a superficial stab wound was on the anterior right knee.

The pattern of the injuries of the neck, specifically the multiple gaping incised wounds which had superficial parallel and intersecting cuts strongly suggest these were ‘hesitation’ marks. Likewise it would appear the clothing was lifted from the chest before similar hesitation injuries and stab wounds were made on the left side of the chest.

These findings are interpreted by me to suggest self-inflicted injuries.”

56. In oral evidence, Dr Ritchey adhered to his opinion, indicating that the “stabbing” wounds were characteristic of self-inflicted wounds.

57. Ms Choi suffered knife wounds, which were medically treated, noted and photographed by forensics officers. These wounds essentially comprised a slice wound and small stab wound to the front of the neck; a cut to the left side of the hip; and cuts to her hands.

58. Having set out the objective and expert evidence, I now turn to the account given by Ms Choi surrounding the actual death to which she was a witness. I formed the view that Ms Choi was honest, credible and largely accurate in her account of the events immediately surrounding Mr Godley’s death. I am in no doubt that this tragic incident has caused her extreme distress and ongoing trauma as her demeanour in the witness box displayed.

59. Ms Choi told the inquest that when Mr Godley came into the bedroom he had knife wounds to his neck. She could not describe them in detail. Upon entering the bedroom, she witnessed Mr Godley inflict one very large, deep wound to his neck in front of her.

She graphically demonstrated the manner in which Mr Godley sliced through part of his neck. Ms Choi’s evidence is consistent with the photographic evidence of a total of two deep cuts to the neck. Her comment in evidence that she could “see his organs” through the neck cut is also consistent with the photographic evidence and forensic evidence of Dr Ritchey.

60. Ms Choi described screaming at Mr Godley to stop and, in a crouched position, she tried to remove the knife from his hands by grabbing the blade. The wounds shown on her fingers are consistent with such accounts. She described Mr Godley flailing the knife around. He was half-leaning half-standing. She described her overriding compulsion to

stop him hurting himself. He said to her: “it’s all over, Windy”. Ms Choi felt the knife make contact with the back of her neck, thinking that he had stabbed her. The photographs of her injuries do not show a wound to the back of her neck, but a long slice wound to the front of her neck. It is understandable that Ms Choi may not be able to recount every detail of the incident with accuracy, however, I am satisfied that the wound to her neck was inflicted by Mr Godley in this incident whilst she was trying to take the knife from him and stop him. She uttered the words to Mr Godley “you stabbed me!” in disbelief.

61. It was apparent from Ms Choi’s evidence that at this point she became extremely fearful for her life. She jumped from the open bedroom window into the garden below before crawling around the side of the house and into the neighbouring property. Again, her account of the bedroom incident and her escape was vivid and I have no hesitation in accepting her evidence. Even upon escaping she remained terrified that Mr Godley would die. Her climbing onto the roof of the neighbouring property may have been for the purpose of trying to talk to him through the bedroom window. She describes saying to Mr Godley “you’re not my Captain”, the reason being that he had stabbed her. She described him calling out the words “Windy” on two occasions. This is consistent with Mr Freeman’s evidence of hearing a verbal exchange between Mr Godley and Ms Choi whilst she was on the roof.

62. I find on the basis of Ms Choi and Mr Freeman’s evidence that Ms Choi was not in the bedroom when Mr Godley embedded the knife into the right hand side of his head. It is also possible that Mr Godley was stabbing his chest whilst alone on the floor, also in the absence of Ms Choi. However, I cannot rule out that he stabbed his chest before entering the bedroom, lifting his t-shirt to do so.

63. In assessing the veracity of Ms Choi’s evidence I am particularly mindful of the statements made to Constable Nikki Mackintosh in the ambulance. The first of these comments was “save David. I did it myself”, the second being “man in room not David” and thirdly, “I kill him. I stab him in neck”. Subsequently, she made comments to Detective Constable Sharee Maksimovic on numerous occasions from her hospital bed.

These comprised repetitive statements that Mr Godley had stabbed himself in the neck and that she, in making the earlier statements, was trying to take the blame in order to protect Mr Godley, who she thought was still alive at this stage. I find that her comments made to Constable Mackintosh incriminating herself were falsehoods. She acknowledged the same in her evidence at inquest although could not remember telling Constable Mackintosh that she killed Mr Godley.

64. She explained the comments “I did it myself” as referring to her own wounds and not Mr Godley’s, once again in an effort to protect him. She stated that the comment “man in room not David” was a reference to the fact that he was not behaving like his usual self.

65. On 24 April a blood sample was taken from Ms Choi for investigative purposes. A blood analysis of this sample revealed that methamphetamine was present in her body.

66. The blood analysis revealed 1.1mg/l of methamphetamine (ice) in her body which is reported to be a very high level. This would explain, in part, her hysterical behaviour. It is unlikely that Ms Choi had any significant tolerance to the drug. Its ingestion would have likely impaired and distorted her perception and recall of events that occurred from the time she consumed the substance. How and when the methamphetamine was taken or consumed is somewhat unclear. Either Ms Choi consumed the methamphetamine with Mr Godley or the substance leaked from the package that she deliberately swallowed.

67. In evidence Ms Choi stated that she did not consume methamphetamine before or on the day of Mr Godley’s death. I accept her evidence. I find that the methamphetamine was absorbed into her system when the package was swallowed. I note that alcohol was not detected in Ms Choi’s body.

68. Having set out the evidence relating to the circumstances of death, I am satisfied that Ms Choi did not ever get control of the knife from Mr Godley and did not inflict injuries upon him. I find that Mr Godley inflicted all injuries upon himself.

69. The evidence does not allow me to determine the exact sequence of injuries suffered by Mr Godley, although plainly his final action was to stab himself in the head with great force.

70. One plausible scenario is that Mr Godley took the knife from the kitchen and immediately inflicted some superficial cuts and possibly one deep cut to his neck before re-entering the bedroom where Ms Choi was still located. Whilst still standing, he inflicted another very deep cut likely to the right side of his neck in front of Ms Choi, clearly exposing the internal anatomy of his neck. Ms Choi, then on her knees, tried to grab the knife which Mr Godley was flailing about, including close to her face and body. She received two large (but not deep) knife slashes to her neck and hip respectively and minor cuts to her hands during this struggle. She then fled through the bedroom window and made her way to the roof of the adjacent building where she communicated with Mr Godley. As soon as Ms Choi left the bedroom, Mr Godley inflicted further wounds, in particular another severe neck wound to the left side of his neck. Finally, he embedded the knife into the right side of his head before dying of blood loss from the neck wounds.

71. Sadly, Mr Godley’s actions were not the product of a rational mind. It appears that he formed an intent to end his life but, as a result of a deluded thought process. His thought and reasons for his actions can never be known, although in the hours before his death his thoughts took on a highly paranoid and delusional character, particularly that he was the subject of persecution from various sources.

72. Unfortunately Mr Godley’s severe episodes of mental illness, exacerbated by drug use, resulted in a marked change in his personality during those times, especially in the last years of his life.

73. In court a family member read a statement on behalf of Mrs Godley describing Mr Godley as being kind, compassionate, and having a generous and caring spirit. In the same statement Mrs Godley said: “The passing of Davey has left a big void in all of our lives. He was a very special and loved young man. His love and caring for his family and friends is indeed commendable. We feel a great loss, and I will never be able to fully comprehend the enormity of our great loss. Never to have the pleasure of loving his children. His loving, caring, sensitive soul never went unnoticed. Losing him is the saddest thing I will ever know.”

74. I express my deep sympathy to Mr and Mrs Godley and their children for their loss.

Formal Findings

75. I find pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is David Geoffrey Godley; b) Mr Godley died in the circumstances described above; c) The cause of death was exsanguination due to self-inflicted multiple stab and incised wounds; and d) Mr Godley died on 24 April 2016 in Sandy Bay, Tasmania.

Comments

76. A review of Tasmania’s coronial records indicates that in a five year period between the years 2012 - 2016, there were 368 suicides in Tasmania, of which five cases (not including Mr Godley’s death) involved self-inflicted wounds with a knife or scalpel where the deceased exhibited behaviour suggestive of a psychosis/psychotic event leading up to death. The coroner’s findings in these cases refer variously to the deceased having a “profoundly delusional, agitated and irrational” state of mind, “increasing paranoia”, “strange behaviours” and “significant paranoid thoughts” leading up to death.

77. All five cases were male and between 23 and 48 years. Four of the five cases had a previous diagnosis of schizophrenia or mixed anxiety/depressive disorder with paranoid and anti-social personality traits. Only one of those cases did not have a history of mental health issues, possibly due to recent arrival in the jurisdiction. Four of the five cases involved historical and current evidence of drug use, most notably cannabis use.

All five deceased were unemployed or on a disability pension due to their mental health issues. Three of the five deceased inflicted their major injuries to their neck/throat, one to the forearm and one to the chest, often inflicting several penetrating wounds.

78. In this context, the circumstances surrounding the death of Mr Godley align significantly with those in the other five deaths described above.

79. It is particularly important to highlight the role played by cannabis and methamphetamine in Mr Godley’s death.

80. There is substantial evidence that chronic cannabis use, especially during adolescence, is associated with later development of psychotic disorders. There is also strong evidence that cannabis use exacerbates symptoms in patients with established psychotic disorders, being responsible for increased relapse, rehospitalisation, positive psychotic and a poorer level of functioning.1

81. The use of amphetamine and methamphetamine is widespread in the general population and common among patients with psychiatric disorders who are particularly vulnerable to compulsive use of drugs of abuse. Amphetamines are highly addictive drugs which act directly on the mesolimbic dopaminergic “reward system” by inducing release of dopamine and norepinephrine. Amphetamines may also induce symptoms of acute psychosis.2

82. Amphetamines may precipitate acute episodes of psychosis in individuals with no preexisting mental health disorder. With further use of amphetamines there is a further increase in the risk of chronic psychosis, such risk depending on various factors including genetic vulnerability to mental disorder and use of other drugs.3

83. Therefore, Mr Godley’s long-term use of cannabis is likely to have either caused his psychosis or exacerbated a pre-existing disposition towards that condition. His use of methamphetamine would also have had similar effects upon his mental health. His death is a stark reminder of the role played by both of these illicit drugs in causing psychosis, and the tragic consequences that may arise from such an episode.

Conclusion

84. The inquest was no doubt difficult and stressful for Mr Godley's family and Ms Choi.

85. In his article “Death investigation, the coroner and therapeutic jurisprudence”, Ian Freckleton (QC) states: "The investigation of deaths occurring in unnatural, surprising and unclear circumstances is an exceptionally difficult experience for next of kin caught up in grief and distress at unexpected bereavement. The way in which the Coronial process impacts upon relatives of the deceased, from the time the coroner becomes seized of 1 Gorelick, D.A; Saxon, A.J; Hermann, R, ‘Cannabis use and disorder: Epidemiology, comorbidity, health consequences, and medico-legal status’ (2018).

2 Bramness, J.G; Gunderson, O. H; Gutersam, J. et al, ‘Amphetamine-induced psychosis – a separate diagnostic entity or primary psychosis triggered in the vulnerable?’ (2012) BMC Psychiatry, 12, 221.

3 Ibid.

death, through the period when an autopsy is contemplated, to the contact of an open inquest can either exacerbate distress or facilitate closure”.4

86. Although the sad outcome cannot be changed, I hope the process of the inquest will help bring a measure of understanding and healing to both Mr and Mrs Godley and their family, as well as Ms Choi.

87. I extend my appreciation to investigating officer Sergeant Adrian Mollon for his most thorough investigation and report.

88. I am particularly grateful to Sergeant Nigel Paul for the work undertaken by him assisting Mr and Mrs Godley, as well as appearing at the inquest to assist me.

89. The circumstances of David Geoffrey Godley’s death are not such as to require me to make any recommendations pursuant to Section 28(2) of the Coroners Act 1995.

Dated: 6 July 2018 at Hobart in the State of Tasmania.

Olivia McTaggart Coroner

4 (2007) 15 JLM 1.