Coroner's Finding: Lukendlay, Charlotte (OM) Findings

FINDINGS of Coroner Olivia McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of: Charlotte Lukendlay

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 Charlotte Lukendlay with an inquest held at Launceston in Tasmania make the following findings.

Hearing Dates 19, 20 and 21 February, 21 March 2019 in Launceston and 18 April, and 23 May 2019 in Hobart Representation Counsel Assisting the Coroner: R Lancaster Rongrong Lu In person Guarav Endlay In person Introduction

1. Charlotte Lukendlay died on 25 February 2016 at the Royal Hobart Hospital (RHH) after having suffered a cardiac arrest in her home in Launceston four days previously. She was an infant aged 11 weeks. She was an apparently healthy baby from birth, suffering no illnesses or medical conditions. As her death was sudden and unexpected, it was reported to the coroner and an investigation ensued.

2. When Charlotte initially presented at the Launceston General Hospital (LGH) following her cardiac arrest, multiple rib fractures were identified consistent with non-accidental injury. Charges were commenced against her father in respect of her injuries, but were subsequently discontinued. As the coroner conducting the investigation, I suspected on the basis of the medical and other evidence that Charlotte’s death was the result of homicide. That being the case, I was required to hold a public inquest pursuant to section 24(1)(a) of the Coroners Act 1995 (“the Act”).

3. The inquest was held over five days. The witnesses called to give evidence comprised treating and expert medical practitioners; paramedics; other professionals involved with Charlotte and her family; the family’s neighbour who assisted with resuscitation efforts; and Charlotte’s parents, grandparents and aunt. The documentary evidence comprised

80 exhibits including comprehensive medical records and reports, witness and police statements, photographs and court records.

4. Charlotte’s father was the last person to see her in a conscious state, having put her to bed but, later, entering the bedroom and finding her unresponsive. The focus of the inquest centered around how her death occurred, and in what circumstances, pursuant to s28(1) of the Act. In particular, her father’s possible role in her death was explored, as was the protective actions of both parents during Charlotte’s life.

Background and General Circumstances

5. Charlotte Lukendlay was born on 2 December 2015 to parents Rongrong Lu (“Ms Lu”) and Gaurav Endlay (“Mr Endlay”). The family resided at Unit 2/32 Camira Street, Newnham in Launceston. Mr Endlay and Ms Lu married in 2011 and have subsequently divorced. At the time of Charlotte’s death Mr Endlay was a university student studying Health Science; Ms Lu was a university student studying Nursing and was employed in Aged Care.

6. Ms Lu and Mr Endlay met in Launceston in 2009, shortly after her father had passed away. Mr Endlay had almost completed his Bachelor of Accounting degree at that time.

Ms Lu was also a student. Mr Endlay is of Indian heritage and Ms Lu of Chinese heritage. For both, English is their second language, although they speak it fluently. They communicated with each other in English. Both had no family connections in Tasmania and their circle of friends was limited.

Credibility of the Evidence of Ms Lu and Mr Endlay

7. From the outset, it is important to record that Ms Lu and Mr Endlay provided diametrically opposed evidence concerning their relationship and their parenting and treatment of Charlotte.

8. Ms Lu provided a most detailed, compelling and consistent account of matters relevant to the inquest, both in written statements and oral evidence under oath. She gave evidence that the relationship with Mr Endlay was one in which she was extremely vulnerable and subject to intimidation and control by Mr Endlay. She was a most articulate and thoughtful witness who left me in no doubt of the accuracy of her account on almost every aspect of her evidence. Ms Lu was entirely consistent in her account across her second and third interviews given with police as well as her subsequent written statement. She gave evidence at the inquest over an entire day, in a logical, structured and consistent manner.

9. Ms Lu described a relationship that was dysfunctional from an early stage, with Mr Endlay drinking alcohol to excess and exerting an extreme level of control over her actions such that she had no effective ability to live independently. In particular, Ms Lu described Mr Endlay embarking on a process of socially isolating her from family, friends and sources of social support. The control by Mr Endlay over Ms Lu extended to

depriving her of financial independence, even though the evidence indicates that she was the main income earner and provider of assets.

10. Ms Lu, in her evidence at inquest, provided many examples of controlling behaviour by Mr Endlay as well as verbal and physical violence. During this finding, I will make mention of the main incidents that were the subject of evidence. It is also relevant to note at this point that Ms Lu made early disclosures to Ms Heather Malerbi, a family violence worker, and also to Ms Gretchen Scott, a social worker at the Royal Hobart Hospital, concerning the nature of her relationship with Mr Endlay, including her fear for Charlotte’s life and her own. The disclosures made by Ms Lu to Ms Malerbi were made subsequent to Mr Endlay being remanded in custody. Both Ms Scott and Ms Malerbi gave evidence that the disclosures about the relationship and Mr Endlay’s treatment of Charlotte were credible and consistent and, in their view, genuine. The evidence of Ms Chan (Ms Lu’s sister-in-law), who stayed in the household at the time of Charlotte’s birth, also corroborated Ms Lu’s evidence regarding Mr Endlay’s intimidation and control as well as his inappropriate, rough treatment of Charlotte. Ms Chan provided clear, credible evidence regarding her observations and, for the reasons discussed further in this finding, I accept her evidence as correct.

11. Contrary to the evidence of Ms Lu, Mr Endlay gave evidence that their relationship was a good one and that there had never been any physical, verbal or emotional abuse on his part. He denied that he used alcohol excessively and denied that he misspent the family’s finances on material possessions solely for his own use. He stated that he treated Charlotte carefully, appropriately and always put her to sleep in accordance with correct safe sleeping practices. He gave evidence that Ms Lu did not undertake any cooking or household tasks at all and that he performed all such tasks at all stages in the relationship.

12. As will be further discussed, the evidence of Mr Endlay was, in most respects, inconsistent and implausible, particularly when compared to the objective and other credible evidence. On many occasions his answers were simply fanciful, and invented to avoid portraying himself in a poor light. His evidence was not given to assist the Court but instead to advocate for his own cause and to denigrate Ms Lu. It was most surprising that Mr Endlay, whilst giving his evidence, apparently believed that the Court would accept fabricated and, in parts, nonsensical answers as the truth.

13. His parents both gave evidence corroborating Mr Endlay’s evidence in some respects, however their evidence also was most unhelpful to the Court. Their answers were evasive and consistently in the nature of a united character reference for their son. This was despite the fact that they had stayed in the household at the time of Charlotte’s birth and could have assisted with important matters of fact, particularly relating to the parenting of Charlotte by Ms Lu and Mr Endlay. As will be further discussed, I largely discount their evidence.

14. There will be further discussion regarding conflict between Ms Lu’s evidence and Mr Endlay’s evidence. However, in finding the facts as follows, I accept Ms Lu’s evidence and reject Mr Endlay’s evidence on any matter of conflict between them, such matters

being central to the findings required to be made. Even in the absence of conflict, I cannot rely on any material part of Mr Endlay’s evidence without credible corroboration.

The Course of the Relationship

15. Ms Lu gave evidence that the relationship with Mr Endlay commenced in September 2009, being three months after her father had passed away. Her father’s death had been difficult for her and she suffered from a profound sense of loss which was compounded by the fact that she did not return to China for his funeral.

16. Ms Lu had regular employment but Mr Endlay did not work (at least in any stable employment) and he did not have a regular income. The inquest did not explore in depth the reasons for Mr Endlay’s inability to secure and sustain employment. He had successfully completed a university degree, was articulate and well presented. Having heard his evidence over the course of two days, it seemed to me that his sense of entitlement was significant and his work ethic was lacking. His propensity to fabricate evidence may also indicate a broader lack of integrity that might not militate in favour of continued employment. It may also be that his dependence upon alcohol prevented him from working effectively. In any event, Ms Lu appeared to be a reliable employee with a strong work ethic. She provided financially for both of them when they commenced living together. She did not drink alcohol or smoke but throughout the relationship spent large amounts of her income purchasing alcohol and cigarettes for Mr Endlay. Ms Lu described how, on at least two occasions, Mr Endlay visited her at her workplace in an intoxicated state demanding that she buy him more alcohol. Ms Lu also provided a deposit for a home she purchased in Launceston. The deposit was provided by her family as a loan and yet the property came to be in both her name and Mr Endlay’s name. Ms Lu was responsible for all the mortgage repayments.

17. In addition to her paid employment, Ms Lu said that she was responsible for all of the cooking for both her and Mr Endlay. She was also responsible for the up-keep of the household. Mr Endlay’s suggestion that Ms Lu did not contribute on even one occasion to cooking a meal, cleaning or partaking in general household duties was fanciful.

18. Mr Endlay was regularly verbally abusive towards Ms Lu. He would make disparaging comments about her and her family and call them “beggars”. He did not like her talking to her family and he did not like her friends. She said that he actively tried to isolate her from her friends. Ms Lu, for example, described an incident where, before their marriage, Mr Endlay pushed her causing blood to come from her nose and a female friend helped her and assisted in cleaning the blood. Subsequent to this incident, Mr Endlay informed Ms Lu that the friend was not a “real friend” to her and embarked upon a process of isolating Ms Lu from that friend.

19. It was clear from the evidence that Mr Endlay was extremely close to his own parents who lived in India. Mr Endlay’s father is a medical doctor and his mother has not had paid employment. He is their only child. He maintained almost-daily telephone contact with them in the Hindi language. His parents took a close interest in his life and it was obvious that Mr Endlay sought their advice and approval on many decisions, notwithstanding that he was married to Ms Lu. Mr and Mrs Endlay Senior made several

visits to see their son and Ms Lu in Australia. The lengthy conversations in Hindi, not understood by Ms Lu, had the effect of further isolating her, particularly as she did not believe that they were protective and kind towards her. Ms Lu’s assessment in this regard proved correct.

20. In 2012, a year after their marriage, they left Tasmania and moved to Darwin for Mr Endlay to commence a position with the Australian Defence Force. Since graduating in Accounting he had not been successful in securing permanent employment in this field.

Ms Lu stated that, before moving to Darwin, Mr Endlay’s drinking became heavier and his behaviour towards her increasingly abusive. Ms Lu worked at a private hospital in Darwin and described how Mr Endlay would telephone the hospital demanding that she come home to attend to his needs. She described how Mr Endlay would not eat with her but would demand that she prepare him dinner at late hours after he had finished drinking. Mr and Mrs Endlay Senior visited them in Darwin and Ms Lu spoke to them about Mr Endlay’s drinking. Mr Endlay Senior denied that his son had a problem with alcohol.

21. Whilst in Darwin, on 27 June 2014, Ms Lu telephoned the police for help as Mr Endlay, whilst drunk, had approached her whilst she was almost asleep in bed and choked her around the neck so that she was unable to breathe. These actions were accompanied by threats to kill her, wielding a kitchen knife, and further violence after which she left the house. Ms Lu’s report to police resulted in the imposition of a Domestic Violence Order upon Mr Endlay requiring him, amongst other things, to obey protective conditions including no contact with Ms Lu whilst he was intoxicated. This Order remained in place for 3 months after which it was dismissed with the assent of Ms Lu, who gave evidence that she was told by Mr Endlay that no one would believe her account. Further, she was subject to pressure from Mr and Mrs Endlay Senior (in India at that time), who telephoned her numerous times advising her to discontinue the order. Mr Endlay’s account of what occurred in this incident was implausible - it was that Ms Lu actually called the police because Mr Endlay refused to accede to her request to sleep in the bedroom with her, preferring to sleep in the lounge room. His version of the events conflicts starkly with the independent evidence of the police affidavits and reports and Ms Lu’s detailed, emotional and most compelling description of the incident. Her fear for her life was palpable in her evidence.

22. Ms Lu considered leaving the marriage at that time but Mr Endlay would not agree to a divorce as he was concerned about his reputation if that occurred. He also promised her he would stop drinking. She said she remained fearful of Mr Endlay, particularly when he was intoxicated. After this incident, Mr Endlay resigned from the Defence Force. I am not able to make findings as to why he made this decision, although it appears that it was not feasible for him to remain at the Darwin base due to the family violence episode.

23. In November 2014 Mr Endlay and Ms Lu returned to Tasmania to live in Westbury. I do not accept the evidence of Mr Endlay that Ms Lu initiated the move so that she could continue her study. The evidence indicates that the relationship deteriorated further with Mr Endlay unable to obtain alternative employment and expressly attributing this situation to Ms Lu’s report to the police in Darwin. Ms Lu said that, in Westbury, Mr

Endlay was drinking excessively and engaged in continued verbal abuse towards her.

She described an episode of physical violence on the part of Mr Endlay by slapping her face. Ms Lu considered that she did not have an option to separate from Mr Endlay for various reasons, ranging from an inability to obtain permanent residency in Hong Kong (where her siblings lived), the potential repercussions of reporting to police, and the pattern of control established in the relationship.

24. The couple planned to have a child whilst in Westbury. Ms Lu believed that a child might heal the relationship. There was also pressure exerted upon her to have a child by Mr Endlay and his parents, with Mr Endlay unashamedly giving evidence that his parents advised him to convince Ms Lu to have a child so that they could have a grandchild.

25. In the early months of 2015 Ms Lu became pregnant with Charlotte. Although Mr Endlay was initially happy with the pregnancy, upon learning of the baby’s gender as the result of an ultrasound scan, he expressed disappointment to Ms Lu that the baby was a girl. At this news, Mr Endlay poured cold water upon Ms Lu whilst she was in the shower and then refused to allow her to get dressed. Mr Endlay kicked her stomach and punched holes in the walls of their rented accommodation. Mr Endlay told her that she had ruined his life and career. Ms Lu was able to give a detailed account of this incident, including the arrangements that she made to obtain a tradesperson in Invermay to repair the hole in the wall. She also gave evidence that she did not call the police because, during the incident in Darwin, Mr Endlay was only kept in custody for a few hours, and there would be significant repercussions to her if she did so. The extent of her fear of Mr Endlay was obvious from her evidence. Mr Endlay denied the occurrence of the incident but I reject that denial.

26. During the period of Ms Lu’s pregnancy, Mr Endlay’s drinking to excess continued, accompanied by verbal abuse. He would also tell Ms Lu that she was responsible for his drinking as she caused him too much stress. Ms Lu gave evidence that he would apologise for his behaviour the next day when he was sober, and would promise to change his behaviour. However, no change occurred.

27. Whilst Ms Lu was still pregnant with Charlotte, Mr Endlay and Ms Lu moved to their rented accommodation in Newnham in Launceston. The unit was small and consisted of two bedrooms, one bathroom, a kitchen area and a lounge room.

28. Mr and Mrs Endlay Senior arrived in Tasmania on 18 November 2015 for a prolonged stay with their son and Ms Lu in their unit in the lead-up to Charlotte’s birth.

29. On 25 November 2015, Ms Lu’s sister-in-law, Ms Fanny Chan, arrived from Hong Kong to also stay in the unit to provide support to Ms Lu before, during and after Charlotte’s birth. Mr and Mrs Endlay Senior occupied the spare bedroom with their son, whilst Ms Chan and Ms Lu shared the main bedroom. Ms Lu was provided with little support by Mr and Mrs Endlay Senior or her husband and felt the burden of having to look after guests whilst pregnant. Mr Endlay made it clear to Ms Lu that he did not wish Ms Chan to be present in the house, although tolerated her presence for the short time she was there.

At a time close to the birth of Charlotte, he tried to prevent Ms Lu and Ms Chan taking a short trip to town to buy some gifts for Ms Chan to take home with her. In evidence, he

maintained that it was inappropriate for Ms Lu to leave the house at that time. He continued drinking heavily at home, accompanied by his father. It was Ms Lu’s evidence at inquest that he and his father consumed a bottle of strong spirits together almost daily.

I accept that this was the case.

Charlotte’s Birth, Life and Care

30. On 2 December 2015 Charlotte was born. She was a healthy baby born at full term.

There were no complications with her birth apart from the requirement for forceps which caused no trauma to Charlotte. After three days in hospital Ms Lu and Charlotte returned home. Charlotte’s allocated sleeping place was a cot in the main bedroom, located just off the living area.

31. Ms Chan gave evidence that at the birth of Charlotte, Mr Endlay seemed hesitant to be in the room and, in fact, invited Ms Chan to be in the delivery room to his exclusion. She told him that he ought to be there as the father. Mr Endlay himself said he offered Ms Chan to be present at the birth as only one family member could be in the room. Ms Lu gave evidence that, during the birth process and subsequently, Mr Endlay did not comfort her, congratulate her or show emotion.

32. Ms Chan gave evidence that the reason she came to Tasmania and stayed with Ms Lu and Mr Endlay was to teach them how to care for the baby. She herself had her own children and had cared for other infants. However, she observed Mr Endlay to lack interest in learning and he made no effort to take care of Charlotte. She said that he was loud around her and shouted at her. He did not behave in a loving manner. Ms Lu corroborated this evidence, observing that Mr Endlay would not accept advice from Ms Chan in the interests of Charlotte. She further commented that Mr Endlay did not seem happy and spent most of his time with his parents at home speaking with them in the backyard in the Hindi language.

33. Ms Chan also gave evidence about occasions where Mr Endlay tried to put Charlotte to sleep on her stomach, a dangerous sleeping practice. She said that Ms Lu tried to stop him, however he locked the door to the room and would not let Ms Lu in. Ms Chan said that she discussed with Ms Lu an escape plan to take Charlotte away from the home in the event that Mr Endlay became violent.

34. Ms Lu gave evidence at length about the way in which Mr Endlay handled and treated Charlotte all of which evidence I accept without hesitation.

35. On one occasion, Ms Lu recounted that Mr Endlay helped change Charlotte’s nappy, although he was intoxicated and was rough with her. He lifted her legs up high and caused a bruise to her stomach. He told Ms Lu “a baby is not as weak as you think”. Ms Lu gave evidence that this was the only occasion when he changed Charlotte’s nappy.

36. Ms Lu stated that Mr Endlay would pick Charlotte up by her middle and would squeeze her tightly so that she screamed “abnormally”. He did not support her head or her neck.

Charlotte would cry when he handled her. He was often intoxicated. Ms Lu stated that his face would appear angry when he handled her and he would shout at her. He would

also throw her in the air and catch her. On about two occasions she witnessed Mr Endlay shake Charlotte for about 10 seconds which caused her head to flop. At a time after Ms Chan had left, she saw him place a handkerchief over Charlotte’s face. On one occasion, Ms Lu stated that Mr Endlay had been drinking, took Charlotte in the bedroom and insisted on sleeping with her. Ms Lu had to ask Mrs Endlay for help.

37. He would take Charlotte from Ms Lu whilst she was feeding, stating that it was not time to eat. He did not want to spend money on nappies or formula. He did not allow Ms Lu to change Charlotte’s nappy unless he said she could. Ms Lu stated that he punched Charlotte in the chest on one occasion whilst she was asleep, stating that “everything is the baby’s fault”. This caused Charlotte to wake. When Ms Lu described this incident to Mr and Mrs Endlay Senior they said “what can we do?”

38. Despite a lack of interest in learning how to care properly for his infant daughter, Mr Endlay would control Charlotte’s routine and determine when she would be put to bed, even if she was not tired. He would insist on putting her to bed. He would also wake her up in the morning when he was awake. Ms Lu said that, at times when Charlotte was quiet, Mr Endlay would do something to make her cry such as blowing air into her eyes, put her over his shoulder without neck support or pushing her hands above her head with force whilst her nappy was being changed. She gave evidence that Mr Endlay would shout at Charlotte to keep her quiet and make angry faces at her. She said that he did not look at her with a soft or loving face. He would also pat her very hard on her back and rub his beard on her face regularly until she cried.

39. In a detailed and compelling affidavit sworn by Ms Lu in July 2016, made whilst Mr Endlay was in custody, she described the way in which he treated Charlotte as well as providing vivid descriptions of Mr Endlay’s treatment of her in the relationship. The content is confronting and comprehensive. Ms Lu described Mr Endlay as a man full of anger, something she could not understand given his indulged upbringing. She described a course of deliberately cruel and callous behaviour by Mr Endlay towards Charlotte and his refusal to help with any aspect of her care. Ms Lu stated that if she showed anger about his treatment of Charlotte, he would tell her that she could leave but he would keep Charlotte.

40. Ms Lu stated in that affidavit that one morning, the occupants of the house were all sitting in the living room and Mr Endlay was using a knife to open a coconut. At that time he said that he wanted to do the same thing to Charlotte’s head as her head was the same size as a coconut. He then found an ant on the coconut and placed the ant on Charlotte’s head. On another occasion, she stated that Mr Endlay said that Charlotte was like a chicken and that he wanted to cut her into pieces to make an Indian curry. Ms Lu described him as an “evil father”. On yet another occasion, he told Ms Lu that he would kill Charlotte and dig a hole in the garden to bury her because everything was her fault. He told her that after Charlotte died they could have a second baby, a better one.

She stated that at one point she offered him all of the assets of the marriage if he would allow her to leave for Hong Kong with Charlotte. He refused.

41. Relevantly, Ms Lu gave very careful and detailed evidence to police and at inquest about the way in which Mr Endlay wrapped Charlotte to put her to bed. He would draw her knees up to her chest and then wrap her with the blanket and tie it in a knot. He would also tie a knot in the blanket around her neck and place Charlotte to sleep on her stomach. As will be discussed, this wrapping method is not recognised as appropriate in any culture or for any purpose and restricts all ability of the infant to move. Ms Lu demonstrated in her interview with police the manner in which Mr Endlay wrapped Charlotte using a doll. The demonstration was confronting to view. Ms Lu said that when she saw this wrapping of Charlotte she told Mr Endlay not to wrap her in that way and showed him the “Blue Book” (Child Health Record) which contained instructions on safe sleeping. She told him not to put babies to sleep on their tummies, telling him that it is not safe because babies cannot breathe in that position. Mr Endlay replied that he would not do it again although she subsequently saw him do so. Ms Lu said that Mr Endlay commenced this wrapping method once Ms Chan had departed for Hong Kong on 14 December 2015.

42. Ms Lu gave evidence that Mr Endlay’s rough behaviour and dangerous wrapping and sleeping practices with respect to Charlotte were often witnessed by Mr and Mrs Endlay Senior. She gave evidence that Mrs Endlay told her son that he needed to spend more time with his baby and reduce his drinking, although she said that Mr Endlay did not receive that advice well. Ms Lu said that Mr and Mrs Endlay Senior expressed concern about the inappropriate behaviours of their son towards his infant daughter and she said that on one occasion Mr Endlay Senior cried at the realisation of how his son had changed. She said that Mr and Mrs Endlay Senior specifically spoke to Mr Endlay about safe sleeping practices. This had no effect.

43. In stark contrast to Mr Endlay’s treatment of Charlotte, Ms Lu’s care of her appeared to be diligent and appropriate to a newborn infant. However, she was unable to protect Charlotte from the very significant risks posed by Mr Endlay’s treatment of her. Ms Lu said in evidence that, whilst Mr Endlay treated Charlotte very cruelly, she did not consider that he was capable of killing Charlotte. She said that she thought he eventually would adjust to the changes of having an infant.

44. The evidence indicates that Charlotte’s health checks were attended to conscientiously by Ms Lu. The Child Health Nurse, Ms Rebecca Thatcher, provided an affidavit and evidence at inquest relating to these checks. Ms Thatcher conducted the 4 and 8 week checks upon Charlotte and described her as a healthy baby who met all developmental milestones, with no medical conditions or apparent injuries. Ms Thatcher observed Ms Lu handling Charlotte and described her as “an attentive, loving mum”. At the 4 week check she noted that Ms Lu was spending a lot of time alone in her room with Charlotte, possibly due to the presence of her parents-in-law staying at the house. At the 8 week check she noted that Ms Lu declined to participate in the post-natal depression question/screening and also again declined the suggestion that she may wish to join a mothers’ group. Ms Thatcher discussed safe sleeping practices with Ms Lu and had no concerns about Ms Lu’s handling of or interactions with Charlotte. She noted that Mr Endlay was not present at the 8 week check and was unable recall if he was present at the 4 week check. Overall, her impression was that Ms Lu may have been socially

isolated given her lack of support outside Mr Endlay and her parents-in-law. As part of her examinations, Charlotte was undressed and physically examined. Although the purpose of the examination was not to look for signs of trauma, Ms Thatcher gave evidence that if she had seen bruises or signs of obvious trauma she would have noted this fact as was her practice. She noted no bruises and that Charlotte appeared comfortable being handled, consistent with an infant without significant injuries. Although it is likely that Charlotte had suffered the clavicle and rib fractures at the time of Ms Thatcher’s examinations, it is not necessarily the case that there would have been outward signs of these. Further it is possible that the fractures at that time were healing.

45. Apart from the occupants of the house, the family had only limited contact with other persons or services. There was no evidence that either Ms Lu or Mr Endlay had contact with friends or acquaintances.

46. On 14 January 2016 Ms Lu took Charlotte to Dr Alice Downie for her 6 week vaccinations and a full medical check. Dr Downie performed a thorough newborn examination and concluded that Charlotte was a “healthy new baby”.

47. A week later, on 21 January, Ms Lu took Charlotte to the Emergency Department of the Launceston General Hospital concerned about the presence of some blood in her mouth.

Dr Huiling Tan examined Charlotte and was unable to sight the blood or determine the source of bleeding. Dr Tan examined Charlotte physically and concluded that she was fit and healthy and discharged her. There were no x-rays or scans performed at that time, which would have detected fractures indicating abuse.

48. Ms Dionne Pedder, the neighbour living in the next door unit, provided an affidavit in the investigation and gave evidence at inquest. Ms Pedder stated that Ms Lu and Mr Endlay did not interact with her or make an effort with conversation. She did not notice anything unusual in the household whilst she lived next door to the family.

49. Mr Endlay gave evidence about his treatment of Charlotte. He denied every particular of inappropriate treatment and ill-treatment of Charlotte described by Ms Lu in her evidence, police interviews and affidavit. He denied causing any injuries to Charlotte. He said that it was “magic” when he first held Charlotte after her birth. He said that his role was to support Ms Lu in looking after Charlotte. He said it was “wonderful” to have Charlotte at home. However, he gave evidence that Ms Lu was in control of Charlotte and he was only allowed by Ms Lu to handle her in the common or lounge area of the house, and not whilst she was having a bath or inside the bedroom with Ms Lu. He said that, generally, Ms Lu did not allow him to enter into her room whilst she was with Charlotte. He said that he was accepting of these restrictions because he had full confidence in Ms Lu’s care of Charlotte. This evidence was contrary to the evidence of Ms Lu, Ms Chan and Mr and Mrs Endlay Senior who gave detailed evidence (whether favourable or unfavourable) of Mr Endlay’s apparently unrestricted care and interactions with Charlotte. I reject Mr Endlay’s evidence that Ms Lu controlled his access and contact with Charlotte. The opposite is, in fact, the truth.

50. Mr Endlay denied drinking alcohol to excess and, after giving contradictory evidence, stated that he had only been drunk on three occasions - an occasion in 2007 resulting in

a drink driving charge, the occasion in Darwin resulting in the Domestic Violence Order against him, and upon Charlotte’s birth. I reject his evidence as false and manufactured.

He also vacillated in evidence regarding the number of days per week he would consume alcohol, initially stating that he would drink two days per week but, upon further questioning, saying that he consumed at least one alcoholic drink every day.

51. Importantly, Mr Endlay gave evidence that he was familiar with safe sleeping practices and appropriate ways to wrap an infant, such information having been provided at prenatal classes prior to Charlotte’s birth. Mr Endlay was able to recite in detail the correct wrapping technique, explaining that initially it is appropriate to wrap a newborn infant with the arms in the wrap with the legs straight and the wrap folded up from the bottom. He was aware that it is appropriate, perhaps with an older infant, to leave an infant’s arms out of the wrap. The wrap he described was a normal, safe wrapping technique and completely different to that which Ms Lu said that he often used upon Charlotte. Similarly, he was able to recite accurately the main safe sleeping practices for an infant, particularly that a baby should never be placed on its stomach or side to sleep.

He said that if a baby is placed on its side it may roll onto its stomach and would not have the limb power to turn over, in which case the baby’s breathing may be obstructed by contact with the bedding. Mr Endlay denied that he was permitted by Ms Lu to wrap Charlotte at all, but certainly his position was that, if he had wrapped Charlotte, it would have been in the manner that he was taught. He denied ever wrapping Charlotte in a strange and tight wrapping technique with her legs bent. He denied ever having placed Charlotte to sleep on her side or stomach, given the known risks of breathing obstruction associated with such a practice.

52. Towards the end of his evidence, Mr Endlay volunteered for the first time that there had been an incident where he had found Charlotte on her stomach in her cot in the lounge room whilst Ms Lu was on the phone. He observed Charlotte having difficulty breathing, had a pale face and was almost unconscious. Despite this, he did not call an ambulance or seek medical treatment for Charlotte. Further, Mr Endlay did not mention such a highly relevant incident in his police statements or put the incident to Ms Lu in crossexamination. I find that he fabricated such evidence in order to implicate Ms Lu in poor treatment of Charlotte.

53. Mr Endlay, on numerous occasions in his evidence, said that Lu was lying in giving evidence that he treated her and Charlotte abusively. He was not, however, able to provide any cogent reason why Ms Lu was telling such lies. In his evidence, he contradicted himself and changed his account on so many occasions that it was difficult to understand his narrative. This is notwithstanding that he was provided a full opportunity to give his evidence and questioned carefully and fairly by counsel assisting, Ms Lancaster.

54. As previously indicated, Mr and Mrs Endlay Senior could potentially have provided assistance to the court regarding relevant occurrences in the household. I fully accept Ms Lu’s evidence that they were aware of and witnessed cruel and tormenting behaviour by their son towards Charlotte. However, in evidence, Mr Endlay Senior described Ms Lu as a selfish and careless person. Further, he said she did not know how to handle

Charlotte and was not interested in caring for her. Mrs Endlay said that Ms Lu would “talk roughly” to Charlotte and she would tell her not to do so but Ms Lu ignored her advice. Mr Endlay Senior told police in his recorded phone call that his son was very involved in looking after Charlotte and that he would read books and watch videos on how to care for babies. Mrs Endlay said that she did not see her son handle Charlotte roughly or incorrectly.

55. Both Mr and Mrs Endlay said that did not have any concerns about Charlotte when they left Tasmania to return home. At the inquest, Mr and Mrs Endlay were unable to answer a question directly or responsively. To each question, they would frame their answer only in the form of a positive comment towards their son. Whilst at the same time, any response in relation to Ms Lu was gratuitously negative. The evidence given by both at the inquest was unhelpful, contrary to the credible evidence and is to be given very little weight. Their sole objective was only to cast their son in a favourable light, to disparage Ms Lu and to avoid answering questions regarding matters that could have assisted the court.

56. One particular incident of physical violence by Mr Endlay after Charlotte’s birth was the subject of evidence at inquest and deserves mention. Ms Lu told police in her video interview that an assault by Mr Endlay occurred after she had given birth to Charlotte and returned home. Mr Endlay’s parents were present in the house and it seems that the incident occurred in mid-January 2016. Ms Lu stated that she had confronted Mr Endlay about his treatment of Charlotte, particularly in light of the concern over unsafe sleeping practices and his wrapping of Charlotte. Ms Lu stated that Mr Endlay squeezed her throat and punched her to the eye. Her glasses broke as a result of the punch and cut the skin under her eye. She stated that Mr Endlay Senior heard the incident and came into the room. Ms Lu told him that Mr Endlay had hit her. Mrs Endlay Senior then also entered the room and, at that point Mr Endlay passed Ms Lu’s phone to his mother who then hid it. Ms Lu gave evidence that she believed this was an attempt to prevent her from calling the police after the ramifications of the incident in Darwin.

57. The evidence of Mr Endlay in respect of the incident was that, during an argument, Ms Lu punched him in the face whilst he had Charlotte in his arms. Concerned that he may trip due to the narrow space, he made contact with Ms Lu, trying to protect Charlotte. At that point Ms Lu slipped and her glasses broke causing a cut. Mr Endlay’s evidence was rehearsed, implausible and inconsistent with other versions given to police. In the context of Ms Lu’s fear of him, her lack of propensity to be violent and his control of the relationship, I do not accept that she punched him to the face. I accept Ms Lu’s evidence concerning this incident even though in her first interview to police she provided a benign and incorrect account for fear of repercussions from Mr Endlay, who was not in custody at that stage.

58. Mr and Mrs Endlay Senior returned to India on 11 February 2016.

59. On 8 February 2016 Mr Endlay received an offer of a place at a university in Wagga Wagga. The decision was made for the family to move in order that Mr Endlay could commence university there. Ms Lu and Mr Endlay therefore began packing up the

household in preparation for the move. The removalists were scheduled to arrive at midday on 22 February 2016.

Charlotte’s Death Events of 21 February 2016

60. On Sunday 21 February 2016 Charlotte woke at around 6.00-7.00am as usual. Ms Lu changed and fed her and she went back to sleep until 10.00am. Again, this was in accordance with her usual routine. Ms Lu told police, and I accept, that Mr Endlay then held her or placed her on her chair in the living room. Ms Lu then fed her by breast for 5 minutes and then formula (75 ml) which was the normal feeding routine. Charlotte was well and happy with no illness or medical problems. It seems that Charlotte spent time in her cot or in her chair awake during the afternoon whilst Ms Lu and Mr Endlay continued to pack for their move. In any event, her routine and temperament were unremarkable during the day.

61. At approximately 6.00pm Charlotte started to cry and Mr Endlay put Charlotte to bed.

She was appropriately dressed in a light cotton jumpsuit and likely a jacket. Mr Endlay maintained in evidence that he placed her on her back to sleep, covering her with a light blanket with her arms free. She was crying at that time and continued to cry for about 10 minutes before she stopped and then Mr Endlay came out of the bedroom. Ms Lu did not go into the bedroom at any time but she told police in her interview that about 20 minutes after Mr Endlay came out of the bedroom she heard Charlotte crying for 1-2 minutes before stopping. Mr Endlay does not state that she cried at this time. In any event, he then returned to Charlotte’s bedroom. He told police in his interviews that he found her to be not breathing, was unresponsive and was turning black around her mouth. He carried her into the living area and indicated to Ms Lu that she was not well. There is little discrepancy between the evidence of Ms Lu and Mr Endlay regarding the time of Mr Endlay’s entries and exits from the bedroom and it is clear on both accounts that Ms Lu did not play any part in either the act of putting Charlotte to bed or removing her from the bedroom. It is also common evidence that Ms Lu did not check on Charlotte whilst she was in the bedroom. It is common evidence that Charlotte was in an unresponsive state when she was brought out of the bedroom by Mr Endlay.

62. Mr Endlay carried Charlotte into the lounge room and laid her on the couch. Almost immediately upon Ms Lu noticing Charlotte’s condition and the blue colour of her skin, she ran outside to get mobile telephone reception and, at 7.23pm, called for an ambulance. She also spoke with her neighbour, Ms Pedder, and asked her for assistance with CPR. Ms Lu was extremely distressed.

63. Ms Pedder gave credible evidence at inquest about the events that followed. She was experienced in first aid and immediately went to Charlotte to perform CPR after overhearing Ms Lu’s distressed voice speaking to ambulance operators. Ms Pedder saw that Charlotte was on her back on the couch, supported by Mr Endlay who was kneeling with his hands on her thighs. Charlotte was cold and discoloured. Ms Pedder picked Charlotte up and placed her on the floor and commenced CPR using breaths and

compressions. Ms Pedder was also guided in her efforts by the ambulance operator who Ms Lu had on the phone.

64. At inquest, Ms Pedder described in detail the method of CPR she used, being 30 compression to 2 breaths with three fingers on Charlotte’s body and two fingers on top of those. She completed ten cycles before the ambulance arrived and was asked to continue CPR whilst paramedics placed defibrillation pads on her back. Ms Pedder noticed bloody mucous on Charlotte’s top to the right hand side of chest, and discolouration on the top of her lip but was unsure if this was a bruise or a skin marking.

When questioned about the pressure of her chest compressions Ms Pedder said that she used what she believed to be sufficient force but not too much, commenting that “I would do the same thing again”.

65. Paramedics worked on Charlotte and managed to obtain a pulse prior to transporting her the LGH for treatment.

66. The two attending paramedics, David Grant and Matthew Geoghegan, provided affidavits and gave evidence at inquest. Mr Grant, upon entering the house, observed that Ms Pedder was competently performing CPR upon Charlotte. Whilst she continued CPR, he and Mr Geoghegan prepared to carry out emergency resuscitation procedures.

They were given a history of Charlotte being found limp and unresponsive 15 minutes before their arrival and that she had previously been well and healthy. CPR was continued for 44 minutes before resuscitation occurred by return of cardiac output and independent respirations.

Charlotte’s Treatment and Hospitalisation

67. Charlotte was transported to the LGH by ambulance. Ms Lu and Mr Endlay also were taken to the LGH in another ambulance that had arrived as back up.

68. In the ambulance, Mr Grant observed a small thumbprint sized bruise to one of Charlotte’s cheeks and dried blood on her nose.

69. At 8.32pm Charlotte arrived at the Emergency Department (ED) of the LGH.

70. Dr Robert Smithers, Intensive Care Unit (ICU) registrar at the LGH, treated Charlotte upon her arrival at the ED. Dr Smithers performed further stabilisation procedures and ordered radiological examinations including a chest x-ray and intracranial and abdominal ultrasounds. The investigations revealed a fractured left clavicle and at least two rib fractures that were partially healed, raising the suspicion of non-accidental injury. After stabilisation, Dr Smithers prepared to have Charlotte transferred to the RHH by air ambulance for further investigations and treatment. At 3.00am on 22 February Charlotte was transported from the LGH bound for the RHH.

71. When Charlotte arrived at the RHH she was taken to the Neonatal and Paediatric Intensive Care Unit. She came under the care of Dr Chris Williams, Paediatric Intensive Care Consultant, and then Dr Michelle Williams, Staff Specialist Consultant Paediatrician.

72. Dr Michelle Williams provided a report for the investigation and gave evidence at inquest.

In her report Dr Williams stated that upon clinical examination and medical investigation there were brain injuries in a pattern of global hypoxic damage (being widespread damage from lack of oxygen) and extensive cerebral odema (brain swelling). Medical imaging revealed that Charlotte had suffered a number of rib fractures and a fractured left clavicle. Dr Williams also noted fluid collection in the liver, with abnormal function. Dr Williams concluded from the medical imaging that the fractures were in various stages of healing, ranging from very recent fractures to many weeks old. She immediately identified this pattern of injury as being consistent with non-accidental trauma (being deliberate abuse).

73. She stated that Charlotte required ongoing support of her respiratory and cardiac functions. Her condition was critical but continued to deteriorate despite full intensive care support.

74. It is pertinent to make comment regarding the events surrounding Charlotte’s hospitalisation at the RHH.

75. At about 7.00am Dr Chris Williams telephoned Child Protection Services (CPS) to advise that Charlotte had possibly suffered non-accidental injuries. It seems from the records that another notification was made by police to CPS at about 10.00am. As a result of the first notification Ms Alice Clifford, Child Protection Liaison Officer at the RHH, proceeded to the hospital to investigate. At the hospital Ms Clifford was briefed by Dr Michelle Williams regarding Charlotte’s medical condition and, in turn, Ms Clifford contacted the Clinical Lead Social Worker for Women’s and Children’s Service, Ms Gretchen Scott.

76. A meeting occurred between Dr Williams and Ms Lu in the company of Ms Clifford and Ms Scott. Mr Endlay was not present as Ms Lu advised that Mr Endlay had dropped her off at the hospital and was in the process of travelling back to Launceston to continue packing for their planned move to Wagga Wagga later that day. Dr Williams explained to Ms Lu the severity of Charlotte’s injuries, the fact that her survival prospects were uncertain and suggested that she attempt to contact Mr Endlay to have him return to Hobart. The evidence of Ms Clifford and Ms Scott at inquest was that Ms Lu called Mr Endlay but asked Dr Williams to speak to him and explain the situation. Ms Clifford gave evidence that she heard Mr Endlay on the telephone to Dr Williams, refusing to return and she therefore spoke to him on the telephone herself and reinforced that he needed to come back, which he did. Mr Endlay in evidence disagreed that he refused to return to Hobart, stating that he did return when he realised that Charlotte was in a critical condition.

77. The evidence of Ms Clifford and of Ms Scott was of high quality and was based upon notes and their affidavits made whilst events were fresh in their memory; they were professional persons who had no apparent motivation to give incorrect or exaggerated evidence. They both expressed concern about the attitude of Mr Endlay in refusing to return, even when Charlotte’s critical condition had been emphasised to him. I accept their evidence as credible and reject the evidence of Mr Endlay on this point. I am in no doubt that Mr Endlay did not wish to return to the hospital to be with Charlotte and Ms

Lu. It appears that he may have been intent upon completing the planned move to Wagga Wagga or avoiding the possible consequences of his own treatment of Charlotte.

His failure to return to the hospital where his critically ill infant daughter was being treated was not the action of a caring parent and provides corroboration of Ms Lu’s evidence about his character and attitude towards his daughter and herself.

78. Charlotte continued to deteriorate and died at the RHH on 25 February 2016 in the presence of Ms Lu and Ms Lu’s brother (who had arrived from Hong Kong). As discussed below, Mr Endlay was in custody at this stage.

Criminal Proceedings

79. Both Ms Lu and Mr Endlay were interviewed by members of Tasmania Police on 22 February 2016 whilst Charlotte was being treated at the RHH. As a result of some matters raised in those interviews Mr Endlay was charged with three counts of common assault pursuant to the Police Offences Act 1935. Two of those counts involved Charlotte, namely that he assaulted her between 1 February and 21 February 2016 by pinching her to the ears. The second assault was between the same dates for pinching her to the left cheek. There was a third allegation of assault involving Ms Lu, alleging that Mr Endlay assaulted her on 15 January 2016 by punching her in the left eye and holding her to the ground by the throat and strangling her. Throughout the police interviews Mr Endlay denied any mistreatment of Charlotte.

80. On 23 February 2016 a further complaint was lodged for one count of assault pursuant to the Criminal Code. Mr Endlay was charged with assaulting Charlotte by striking her to the left side of her back. Mr Endlay was remanded in custody with respect to this charge.

81. In July 2016 Mr Endlay was committed to the Supreme Court on his plea of not guilty to the assault charge. The Director of Public Prosecutions subsequently reviewed the evidence. Based upon that evidence a determination was made that Mr Endlay would be indicted with one count of ill treatment of a child – the allegation included the particulars that he caused Charlotte’s rib injuries and broken clavicle. None of the charges involving Mr Endlay injuring Charlotte alleged that he did any act that caused her death.

82. As a result of further investigation and assessment of the evidence, a determination was made by the Director of Public Prosecutions not to proceed with the ill- treatment charge and it was withdrawn on 10 August 2017. Mr Endlay was then released from custody.

83. The summary assault charge against Mr Endlay alleging assault upon Ms Lu is awaiting hearing in the Court of Petty Sessions.

84. After the indictable charges were not continued the file was returned to the Coronial Division and completed in preparation for the inquest.

85. When investigating a reportable death a coroner performs a role very different to other judicial officers. The coroner’s role is inquisitorial and is not bound by the strict rules of evidence applicable to criminal proceedings. The coroner is required to thoroughly

investigate a death and answer the questions (if possible) that are posed by section 28(1) of the Coroners Act 1995. These questions include who the deceased was, the circumstances in which he or she died, the cause of the person’s death and where and when the person died. This process requires the making of various findings, but without apportioning legal or moral blame for the death. A coroner is required to make findings of fact from which others may draw conclusions. A coroner does not punish anyone or award compensation. A coroner does not charge people with crimes or offences arising out of the death the subject of investigation. In fact, a coroner must not even state that a person is or may be guilty of a crime or offence.

86. The standard of proof in coronial inquests is the civil standard. This means that where findings of fact are to be made a coroner needs to be satisfied on the balance of probabilities as to the existence of those facts. However, if an inquiry reaches a stage where findings being made may reflect adversely upon an individual, the standard applicable is that articulated in Briginshaw v Briginshaw (1938) 60 CLR 336.That case is authority for the proposition that the task of deciding whether a serious allegation is proved should be approached with great caution.

Expert Medical Evidence Regarding Cause of Death

87. I have, above, made factual findings concerning important matters pertaining to the relationship, care of Charlotte and facts surrounding the incident that led to Charlotte’s death.

88. The primary issue to determine is how Charlotte was deprived of oxygen such that she ceased breathing and suffered severe brain injury that caused her death. It must be determined with reference to the facts I have found.

89. Dr Williams indicated that the hypoxic brain injury, such as that causing Charlotte’s death, may result from a number of different clinical scenarios, including hypoxia from airway obstruction and also inadequate respiratory effort.

90. Dr Williams stated that there was no evidence to suggest that Charlotte suffered from blunt trauma to the head. She also stated that no medical causes, such as infectious or metabolic disease, were identified in Charlotte.

91. Dr Williams stated that medical imaging revealed the following fractures:- Charlotte’s right anterior 5th rib (which had no callus formation indicating very recent origin); her right anterior 6th rib ( no callus); a possible fracture of the left 5th rib (no callus); a possible fracture of the left 6th rib ( no callus); right posterior 7th rib (which was healed); her right posterior 11th rib (no callus); her left clavicle (which had a well-defined callus indicating healing). There was also fluid collection in the liver with abnormal function.

92. Dr Williams’ opinion, in light of these findings, was that Charlotte had suffered nonaccidental trauma on a number of occasions prior to her presentation as a result of which she sustained a fractured clavicle and multiple fractured ribs.

93. On 26 February 2016 Dr Donald Ritchey, forensic pathologist, conducted an autopsy upon Charlotte. In his opinion also, the cause of death was hypoxic brain injury following cardio-pulmonary arrest. The autopsy conducted on the baby revealed a normally developed and nourished infant girl with a small bruise on her right cheek. There were healing fractures of the mid-left clavicle and healing fractures of the right fourth, fifth and sixth ribs and an almost healed fracture of the posterior seventh rib. To the extent that the rib injuries seen by Dr Ritchey vary from those apparent on the radiology, I accept Dr Ritchey’s evidence from the autopsy. However, this point is not material. Dr Ritchey stated that her heart was normal. Early pneumonia had developed, although his opinion was that this had developed during intubation in the intensive care unit.

94. In Dr Ritchey’s opinion, there were several possible causes of the cardio-pulmonary arrest. The presence of multiple rib fractures in various phases of healing strongly suggested that significant chest compressions had occurred on more than one occasion during Charlotte’s life. Like Dr Williams, he was not able to determine the exact number of occasions or time periods when Charlotte suffered trauma causing fractures.

However, Dr Ritchey was of the opinion that the healing fractures of the right ribs had occurred weeks prior to her death. The fracture of her seventh rib with almost complete bony repair was likely to be several weeks older.

95. Dr Ritchey’s opinion was that the fractures, which involved both anterior and posterior ribs, may have been inflicted by adult hands squeezing Charlotte or pushing on the chest or back whilst she was in a lying position. He further opined that inappropriate tight swaddling of the infant, especially if she was subsequently placed face down and left unattended, could cause respiratory and cardiac arrest. Deliberate smothering of the baby would leave little physical evidence and, in his opinion, this was another possibility as to the cause of Charlotte’s death.

96. Importantly, he did not accept that Sudden Infant Death Syndrome (SIDS) was a likely cause of Charlotte’s death. SIDS entails a death by uncertain natural causes. SIDS was excluded, in his opinion, due to the presence of multiple bone fractures that radiographically and histologically suggested various ages and which were an indication of sustained, deliberate abuse. Like Dr Williams, Dr Ritchey said that Charlotte was healthy and without disease or abnormality prior to her being found unresponsive by Mr Endlay.

97. Both doctors, together, gave helpful and knowledgeable evidence at the inquest which was consistent with their prior reports and consistent with each other.

98. Dr Williams, agreeing with Dr Ritchey, also gave evidence that Charlotte may have arrested due to an abusive act such as smothering or being placed face down and unable to breathe. They said that other possible mechanisms of death could have involved pressing directly on the chest (or back) to prevent breathing; or squeezing or shaking her. Neither doctor could say that one mechanism over another is more likely.

It is also possible that the recent rib fractures occurred in the same incident as Charlotte’s cessation of breathing.

99. Both doctors were questioned by counsel assisting as to the possibility that Charlotte may have arrested due to a natural medical condition, unrelated to any intentional act of abuse or obstruction of breathing, which could not be determined. Both doctors gave evidence that it was theoretically possible that an unidentified medical condition may have caused Charlotte’s death. However, in light of the pattern of her injuries, both discounted the proposition that she ceased breathing due to natural causes.

100. Although it is not possible to determine that Charlotte’s most rib fractures occurred in the same incident as she ceased breathing, I am able to discount that these rib fractures were a result of CPR and resuscitation attempts by Ms Pedder and by the treating medical professionals. Mr Geoghegan, the most experienced paramedic, gave evidence that the pressure exerted by Ms Pedder in her CPR efforts and their own CPR was appropriate and was unlikely to have resulted in rib fractures. Further, he stated that while it is expected that adult ribs may fracture during CPR, he had experience in resuscitating children and had never seen that type of trauma to a child from chest compressions. Similarly, Dr Smithers gave evidence that the fractures were unlikely to have been caused by recent CPR, also noting that rib fractures to children are uncommon due to the flexibility of their bones. Finally, Dr Williams and Dr Ritchey also gave evidence that the recent rib fractures were very unlikely to have been caused by pressure on Charlotte’s rib cage from resuscitation efforts.

Conclusion

101. For the reasons expressed in this finding, I fully accept the evidence of Ms Lu concerning the treatment of Charlotte by Mr Endlay. It is also clear from the evidence that Ms Lu did not physically harm Charlotte in any way. She adored Charlotte and tried assiduously to be a caring mother to her. The attempts by Mr Endlay to portray Ms Lu as an irresponsible parent were simply implausible. Ms Lu had only love for her child and desired to see her grow into a happy and healthy girl. However, she was not able to protect herself or Charlotte from Mr Endlay’s abusive treatment.

102. I find that Mr Endlay was physically, emotionally and financially abusive to Ms Lu from the beginning of their relationship. He controlled all aspects of their relationship and isolated Ms Lu from the friendship and supports that may have assisted her to leave.

Much of his behaviour appeared to be driven by a deep-seated anger, exacerbated by excessive consumption of alcohol.

103. Charlotte was a healthy infant with an easy temperament. Upon her birth, Mr Endlay was disappointed that his child was not a boy, as he wished. It appears that his anger was then directed at Charlotte, whom he held responsible for what he described as his “stress”.

104. There is no evidence in the investigation that Mr Endlay had ever been treated by a psychiatrist or psychologist or that he suffered from any particular mental health condition or personality disorder. However, the level of his rage towards his infant

daughter, manifesting in abusive treatment towards her, suggests a lack of ability to love, empathise and to consider the needs of any other person but himself.

105. On all of the evidence, the only conclusion available in respect of Charlotte's broken bones and bruising is that they occurred as a result of the treatment of her by Mr Endlay. I am not able to determine the occasions upon which he caused her clavicle fracture and rib fractures, except that they occurred over the course of her short life. I am in no doubt that Mr Endlay inflicted harm upon Charlotte which was not witnessed by Ms Lu. Several posterior and anterior rib fractures occurred close to or at the time of her cardiac arrest on 21 February 2016. I cannot determine exactly how and when Mr Endlay caused those fractures to Charlotte, although in some manner (possibly by squeezing her hard or pushing her forcefully into a mattress), he exerted pressure upon her rib cage.

106. The fractures did not themselves cause Charlotte's death but, together with the other episodes of Mr Endlay's maltreatment and abuse, are evidence of his regularly expressed desire to hurt Charlotte.

107. Mr Endlay was the only witness to Charlotte's cessation of breathing and subsequent cardiac arrest. He alone had put her to bed and retrieved her, unresponsive, from the bed less than an hour later. He had a propensity to place her in unsafe sleeping positions with her face into the mattress and wrapped in an unsafe manner. This was despite full knowledge of appropriate safe sleeping practices and warnings from Ms Lu and his own parents that he should not place Charlotte to sleep in a way that rendered her unable to breathe. Mr Endlay’s actions towards his daughter are in the context of a regularly expressed desire to kill her or to see her dead.

108. I conclude that, at a time between about 5.30 and 6.45pm on Sunday 21 February 2016, Mr Endlay was alone in the bedroom with Charlotte. By an act that is unknown upon the evidence, he caused Charlotte to stop breathing and proceed into cardiac arrest. Although she was resuscitated, she was not able to survive the brain injury which had been caused by the cardiac arrest.

109. Whilst Ms Lu was unable to influence the actions of Mr Endlay. Mr and Mrs Endlay Senior were, in fact, able to exert influence upon him. They had knowledge of the serious risk to Charlotte at the hands of their son and could have intervened in several ways to protect Ms Lu and, most importantly, Charlotte. If they had tried to initiate action to help remove Charlotte from the home, she may have lived.

110. As a final comment, I commend the actions of Ms Dionne Pedder who quickly went to Charlotte’s aid and performed effective resuscitation upon her until the ambulance officers arrived.

Findings required by s28(1) of the Coroners Act 1995 I find: a) The identity of the deceased is Charlotte Lukendlay; b) Charlotte died in the circumstances detailed in these findings; c) The cause of Charlotte’s death was global hypoxic brain injury caused by a prolonged period of cessation of breathing arising from an act done by her father, Guarav Endlay; and d) Charlotte died on 25 February 2016 at the Royal Hobart Hospital in Tasmania.

I am most grateful for the assistance of Ms Lancaster and coroner’s associate, Sergeant Lisa Heazlewood, in this inquest.

Dated: 26 June 2019 at Hobart in the State of Tasmania Olivia McTaggart Coroner