Coronial
TAScommunity

Coroner's Finding: Woldemichael, Nazrawi

Deceased

Nazrawi Samson Woldemichael

Demographics

19y, male

Date of death

2016-10-09

Finding date

2022-10-24

Cause of death

unable to be determined

AI-generated summary

Nazrawi Woldemichael, a 19-year-old with a history of severe mental illness, traumatic brain injury, suicidal ideation, and substance abuse, disappeared on 9 October 2016 from North Hobart. The coroner determined he is deceased but could not establish cause of death. While suicide by jumping from the Tasman Bridge seems probable given his documented suicidal statements specifically about the bridge, history of suicide attempts, and severe untreated psychiatric illness, this could not be proven without a body. A homicide allegation based on uncorroborated confessions from an unreliable witness could not be substantiated forensically. This case highlights gaps in mental health follow-up: after discharge from psychiatric admission in October 2015, he was discharged from community services because he declined to provide accommodation details despite being a voluntary patient with active suicidal risk, substance abuse, and housing instability. Earlier assertive follow-up and engagement despite patient resistance might have prevented this tragedy.

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

Specialties

psychiatrytrauma surgeryneurology

Error types

communicationsystem

Drugs involved

cannabislysergic acid diethylamidealcohol

Contributing factors

  • severe untreated mental illness
  • traumatic brain injury with personality changes
  • suicidal ideation with specific plan
  • substance abuse
  • housing instability
  • psychotic episodes
  • inadequate mental health follow-up after discharge
  • patient non-engagement with community services

Coroner's recommendations

  1. Mr Woldemichael's coronial file should remain open for further investigation if additional evidence emerges
Full text

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the suspected death of Nazrawi Samson Woldemichael Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Nazrawi Samson Woldemichael; b) I am unable, on the available evidence, to determine how and in what circumstances Mr Woldemichael died; c) I am unable to determine the cause of Mr Woldemichael’s death; and d) Mr Woldemichael died on or shortly after 9 October 2016 at a location unable to be identified but in the State of Tasmania.

Coroner’s Jurisdiction

  1. The Coroners Act 1995 (the Act) governs the investigation of deaths in Tasmania.

Section 21(1) of the Act provides that ‘[a] coroner has the jurisdiction to investigate a death if it appears to the coroner that the death is or may be a reportable death.’ ‘Death’ is defined in Section 3 as including ‘suspected death’.

  1. ‘Reportable death,’ defined in the same section, includes a death which occurred in Tasmania and was unexpected or the cause of which is unknown.

  2. Therefore, if a coroner suspects, on reasonable grounds, that a person has died and the death meets the definition of a reportable death, then the coroner has the jurisdiction to investigate that person’s disappearance. In the case of Mr Woldemichael, I am satisfied on reasonable grounds that he is deceased and the cause of his death is unknown.

Mr Woldemichael’s background

  1. The evidence is that Mr Woldemichael was born in Addis Ababa, Ethiopia on 11 November 1996. His mother died in childbirth and his father apparently unable to take care of him. Accordingly, Ms Hirut Woldemichael, Mr Woldemichael’s aunt, adopted him, along with his sister Sofanit Woldemichael, on 2 January 1997.1

  2. Mr Woldemichael moved to Tasmania in March 2006 at the age of 10, to join Hirut and her biological children. During this time, he lived in Warrane and attended The Hutchins School from Grade 4 until he left during his Grade 12 year.

  3. After leaving the school Mr Woldemichael spent time at TAFE studying art. It would appear he was a talented artist.

  4. The evidence is that it was about at this time, in Grade 12, that Mr Woldemichael first began using drugs,2 mostly cannabis and Lysergic acid diethylamide. Because of his drug use, Mr Woldemichael moved out of home at the end of 2014 and moved in with Ms Hirut Woldemichael’s biological son (his cousin), Promise Tekeste, in West Hobart.

  5. On 13 September 2014, Mr Woldemichael was hit by a motor vehicle, whilst heavily affected by illicit drugs. Medical reports suggest that Mr Woldemichael threw himself in front of a car in an attempt to kill himself. He spent about eight weeks in hospital, some of the time in an induced coma. As a result of the incident he suffered a serious traumatic brain injury including a right comminuted skull fracture, a subarachnoid haemorrhage and a fracture of the mastoid air cells,3 which affected his personality, causing Mr Woldemichael to become paranoid, angry and delusional.4

  6. Following discharge from hospital, Mr Woldemichael moved back in with his mother.

He remained living with her for about 18 months. His mental health remained very poor during this time. On 4 May 2015, an application was made by his treating clinician for a treatment order pursuant to section 39 of the Mental Health Act 2013 because Mr Woldemichael was suffering an acute psychotic episode. An order was duly made by the Mental Health Tribunal under the Act, on 12 May 2015.5 Mr Woldemichael thereafter spent a number of weeks as an inpatient receiving treatment. He was 1 Ethiopian Federal Democratic Republic Federal First Level court order – 26 January 1996.

2 Statutory declaration – Hirut Weldemichael [sic], made 15 March 2019.

3 Medical records – Discharge summary, 30 October 2014, page 314.

4 Statutory declaration – Hirut Weldemichael [sic], made 15 March 2019.

5 Supra, page 45.

discharged from that order on 1 June 2015.6 Following discharge of the order, he remained under psychiatric care in the community.

  1. Mr Woldemichael’s medical records indicate incidents of suicidal ideation in August 2015.7

  2. He was admitted again to psychiatric care at the Royal Hobart Hospital on 10 September 2015 after he self-presented at the hospital’s ED expressing suicidal ideation against a background of alcohol abuse and auditory hallucinations.8 Following another period as an inpatient, he was discharged on 12 October 2015 but went immediately to the ED again stating that “he [was] suicidal and wanted to jump from the Tasman Bridge”.9

  3. Following his discharge, Mr Woldemichael was referred to the Hobart and Southern District Adult Community Mental Health Service. The service made contact with Mr Woldemichael, eventually locating him at a friend’s house in New Town. Mr Woldemichael indicated he had “stable accommodation” elsewhere but declined to provide those details to the service. Accordingly, because Mr Woldemichael was a voluntary patient (that is to say not subject of any order at that time pursuant to the Mental Health Act 2013), he was discharged by the service.10

  4. It appears very clear on the evidence, he continued to use illicit drugs until his disappearance in October 2016.11

  5. In any event, after a period of uncertain accommodation, Mr Woldemichael moved, on 27 April 2016, into Trinity Apartments, a supported youth accommodation facility in North Hobart which houses young people who are either homeless or at risk of homelessness. Upon arrival at Trinity apartments, he was assigned by a youth support worker, Ms Rebekka Gale.12

  6. Mr Woldemichael, on 13 October 2016, was formally reported missing to police as a missing persons by his brother, Mr Tekeste, at the behest of his mother.

6 Supra, page 44.

7 Supra, page 173.

8 Supra, page 135.

9 Supra, page 156.

10 Supra, file note, 2 November 2015, page 203.

11 For example see statutory declaration Hirut Seboka, made 17 October 2016.

12 Statutory declaration – Rebekka Ann Maree Gale, made 17 October 2016.

  1. The following day, on the 14 October 2016, Ms Katie Wheeler, Tenancy Administer, along with Ms Gale went to Mr Woldemichael’s unit to do a welfare check. The women upon searching the unit, found the door FOB key on the entertainment unit and the letterbox key in the fridge, nothing else was present. The FOB was last used, according to the evidence, on the 9 October 2016 at 7:42:37am.

Circumstances leading up to disappearance

  1. Mr Woldemichael was living at Trinity Hill Apartments and was offered the opportunity to vacate his tenancy on two weeks’ notice. The offer was made by Trinity Hill Apartments staff as an alternative to him being served with a Notice to Vacate as a result of his unacceptable behaviour, history of previous breaches of his tenancy agreement and damage to his unit. Mr Woldemichael accepted the invitation to give notice to vacate his apartment. The period of notice was due to expire on 21 October 2016. The evidence is that Mr Woldemichael was spoken to by staff at Trinity Hill Apartments and was offered assistance in finding new accommodation.

However he declined the offer of assistance.13

  1. Ms Kathleen Williams, Facility Supervisor, spoke with Mr Woldemichael for about 15 minutes at around 10.00am on 8 October 2016 in a computer room at Trinity Hill.

She told Ms Gale he seemed fine at the time.

  1. The last confirmed social contact Mr Woldemichael had at Trinity Hill Apartments occurred later the same day. CCTV shows Mr Woldemichael engaging in a very short conversation with Mr MB, another resident at Trinity Hill. He can then be seen walking away from him. According to Mr MB’s evidence, Mr Woldemichael asked for money to buy food, but Mr MB refused to give him any.14

  2. On the 9 October 2016, Mr Woldemichael was seen at 7.50am on CCTV throwing what appear to be his belongings into a large skip bin and walking away from Trinity Hill alone.

  3. Mr Woldemichael was last verifiably seen, again on CCTV, at Eastlands Shopping Centre in Rosny between 10.43am and 11.08am. He appeared to be alone and left via a rear exit (near the pet shop) onto a roadway next to the carpark. The CCTV shows Mr Woldemichael walking in the direction of Rosny Hill Road, before he went out of sight.

13 Statutory declaration – Katie Wheeler, made 25 October 2016.

14 Statutory declaration – MB, made 15 October 2016.

  1. Checks revealed he did not have a Metro Card in his name, so whether he caught a bus could not be verified. However, I do note that he left Eastlands near the bus mall.

And of course, it is possible Mr Woldemichael paid in cash to catch a bus.

Nonetheless, his movements after those last captured on CCTV at 11.08am on 9 October 2016 are necessarily speculative.

  1. Subsequent investigation in relation to Mr Woldemichael’s mobile telephone indicated that at about this time it was switched off or non-operative. There is no evidence that it was used again.

Possible sightings after 9 October 2016

  1. Investigators became aware of several potential or alleged sightings of Mr Woldemichael after 11.08am on 9 October 2016. First, at 10.03pm on the same day, a woman called police stating she had seen a male at the western end of the Tasman Bridge, on the upstream (or northern) side leaning over the railing. According to her account, the man was wearing all dark clothing, possibly a hoodie. She was unable to describe his skin colour, but thought he might have been Caucasian. Mr Woldemichael was of course African.

  2. The Tasman Bridge cameras were checked between the time periods of 8.00am to 11.59pm on 9 October 2016 but no verified sighting of Mr Woldemichael was made.

However, CCTV of the area did show a person walking east to west on the downstream side of the bridge, waving their arms around and behaving in what might be described as an erratic manner. The person then appeared to walk off the ramp towards the direction of the Botanical Gardens. However, it is impossible to be certain that this person was Mr Woldemichael, although of course it may have been.

  1. The next claimed sighting of Mr Woldemichael was in Elizabeth Street by Ms ER, a friend of Mr Woldemichael, at about 11.00am on 15 October 2016 (a couple of days after he had been reported missing to police). Ms ER told investigators that she saw him walking past Cyclo Vietnamese Restaurant towards the Shell Service Station/Hungry Jacks in North Hobart wearing a black canvas jacket with a hood and black shoes. Ms ER said in her evidence that Mr Woldemichael appeared as though he had indulged in a ‘big night’.15 However, enquires were made with businesses in the area to review their CCTV but none showed Mr Woldemichael in the area in which Ms ER said she saw him. I note Ms ER, who had only known Mr Woldemichael for a few months said that she saw the person who she thought was Mr Woldemichael 15 Statutory declaration – ER, made 21 October 2016.

fleetingly from a moving motor vehicle. In addition, she said to investigators that she “believed” she last saw Mr Woldemichael that day. There was a lack of certainty about her account. I do not think that her alleged sighting of Mr Woldemichael can, in the circumstances be regarded as particularly reliable.

  1. The final alleged sighting was on the corner of Liverpool and Elizabeth Street at 5.00pm on 16 October 2016 (a week after being reported missing, and the day after ER said she saw him in North Hobart). MB (who it will be remembered was approached Mr Woldemichael for money on the morning he left Trinity Hill Apartments) told investigators that he saw Mr Woldemichael outside what once was the Commonwealth Bank. MB said that he had a conversation with Mr Woldemichael, in which he told him that everyone was looking for him. MB said that Mr Woldemichael replied that he was aware and he was sick of people controlling him stating that he did not need or want anyone. According to MB, Mr Woldemichael was wearing black skinny jeans, black hoodie and black shoes. He said that Mr Woldemichael looked “paranoid” and “appeared dirty”.16 Again, CCTV in the area did not confirm this sighting.

  2. I do note that like Ms ER, Mr MB had only known Mr Woldemichael for a short period of time. I do not think that either of the witnesses who indicated they thought they had seen Mr Woldemichael after the late morning of 9 October 2013 was being dishonest, or attempting to mislead police, this Coronial investigation or indeed anyone. I think, having viewed the evidence in its entirety the most likely explanation is that they were mistaken as to the circumstances, and therefore date, when they saw Mr Woldemichael. That confusion is likely to have arisen given the apparent extensive social media discussions in relation to his disappearance. And even if I am wrong as to that, and each witness is correct, it does not change my ultimate findings.

Why I am satisfied Mr Woldemichael is dead

  1. Although Mr Woldemichael’s body has never been found, there is ample evidence to support a conclusion that he is dead. In fact, on the evidence, it is the only reasonable conclusion open.

  2. First, is the fact that after his disappearance, there has been no verified sighting of Mr Woldemichael after his last confirmed sighting on 9 October 2016 at 11.08am.

16 Statutory declaration – MB, op. cit.

  1. Second, enquires have been conducted with: a. The Tasmania Police Service; b. All significant financial Institutions in Australia (including ANZ, Commonwealth, Westpac, NAB and Bendigo Bank); c. The Australian Border Force – which confirmed there were no records of offshore movements in the name of Mr Nazrawi Samson Woldemichael; d. Centrelink – Mr Woldemichael has not accessed his Centrelink since 9 October 2016 (despite money going into his account on 12 October 2016); e. Medicare and Pharmaceutical Benefits Scheme during the period of 9 September 2016 to 15 February 2019 – which also proved negative; f. All telecommunication providers – which show Mr Woldemichael has not had a mobile telephone since October 2016; and g. All State and Territory police, coronial and birth, death and marriage records - which have also proved fruitless.

  2. Third is the fact that Mr Woldemichael was the subject of an extensive local media campaign in the immediate aftermath of his disappearance. In addition, he has been the subject of several missing person campaigns in Tasmania and around Australia since then. None of campaigns have elicited any useful information as to his whereabouts.

  3. I acknowledge, and am respectful of, Mr Woldemichael’s mother’s belief that her son fled to another State in Australia and assumed a new identity. I note that she has travelled around Australia making her own enquires to try to locate her son, but sadly without any success.

  4. As a result of those enquires, Ms Woldemichael reached the view that her son may be in Western Australia with an African youth, who is known to have committed large amounts of credit card and identity fraud across Australia. The youth was said to have moved to Western Australia around the same time Mr Woldemichael disappeared.

This I suppose might explain why Mr Woldemichael has not been accessing any money and, because he had the ability to use a false name, has not come to the attention of any of the usual agencies.

  1. However, a police operation involving a friend of the youth discretely contacted him and asked if he had seen or heard anything about Mr Woldemichael. The youth, who was living in Melbourne at the time, stated he did not know anyone called Nazrawi

Woldemichael and had not seen or heard from him. I think this evidence, given the circumstances in which was obtained, is likely to be accurate.

  1. I note also Ms ER’s apparent belief that Mr Woldemichael had gone interstate.

However, there is no evidence to support this belief, and nothing to indicate the basis for that belief, other than perhaps a hope or wish that Mr Woldemichael is alive, somewhere.

  1. However, unfortunately, there is simply no evidence at all to support the theory that Mr Woldemichael left the state and travelled to Western Australia, or anywhere else for that matter. All the available evidence satisfies me to the requisite legal standard that Mr Woldemichael is dead and has been since about 9 October 2016, when he last accessed his Centrelink account.

What happened to Mr Woldemichael?

  1. Being satisfied as I am that Mr Woldemichael is dead, it seems to me that there are three possibilities based on the evidence. That is he died as a result of either: a. Suicide; b. Misadventure (accident); or c. Homicide.

Suicide

  1. To my mind, it seems possible that Mr Woldemichael committed suicide on or shortly after 9 October 2016 by jumping from the Tasman Bridge.

  2. I have already mentioned evidence from medical records, suggesting that Mr Woldemichael was suffering from mental illness, had suicidal idealisations and at least one confirmed previous suicide attempt. Aside from his medical records, there was other evidence of a history of suicidal ideation. Ms Hirut Woldemichael told investigators of an occasion when her son apparently attempted to encourage his sister and friend to kill themselves.17 There is also yet more evidence to suggest that Mr Woldemichael again attempted suicide by jumping off the bridge in a possible suicide pact with a friend but could not go through with it. Fortunately, his friend was discovered before either could act on the apparent “pact”.

17 Statutory Declaration – Hirut Weldemichael [sic], op. cit.

  1. Given his history of severe mental illness, suicidal ideation which directly involved articulation of an intention to jump from the Tasman Bridge and at least one proven previous suicide attempt, is certainly seems possible, even probable, that Mr Woldemichael jumped off the Tasman Bridge, if not on the 9 October 2016, at some point shortly thereafter. If he did, it would explain why his body has never been recovered. In my view, having regard to the evidence as a whole, I consider that the circumstances in which Mr Woldemichael disappeared suggests that he may have died by his own hand, although in the absence of a body, and more direct evidence on the point, it is impossible to be satisfied to the requisite legal standard.

Misadventure

  1. I consider that had Mr Woldemichael died by accident (other than perhaps accidental drowning) then it is almost certain his body would have been found. This conclusion is subject I suppose to the possibility he died by accident but someone else was in some way involved, and covered up his death. I do not consider this to be a realistic possibility.

  2. There is no evidence which would support a finding the Mr Woldmichael’s death was due to misadventure.

Homicide

  1. This aspect of the evidence associated with Mr Woldemichael’s death proved the most difficult. The investigation into Mr Woldemichael was allocated to the Hobart Criminal Investigation Branch on 23 November 201618 after a witness came forward, providing information which suggested that her ex-partner may have been responsible for Mr Woldemichael’s disappearance. In summary, the allegation was that a Mr JT had confessed to a Ms SA, that he had killed a young male with an axe at a homeless campsite at the Hobart Domain, opposite the BP Service Station on the Brooker Avenue. Ms SA duly contacted police.

  2. The story seemed to be that Mr Woldemichael had walked into Mr JT’s camp whist he was away and begun eating his food and “going through” his property. Upon Mr JT arriving back at the camp, he saw Mr Woldemichael, became angry and hit Woldemichael with an axe to the head, killing him instantly. Mr JT confessed to Ms SA 18 The findings of fact which follow are based on the material obtained during that very comprehensive investigation. Numerous witnesses were interviewed. The principal suspect Mr JT on video. Extensive forensic and scientific investigations were carried out in relation to a campsite on the domain and various exhibits seized as part of the investigation.

that he had buried the body and burnt all the evidence in a fire. There was he said blood “everywhere” in the campsite.

  1. In a recorded police interview, a witness, Mr MR said Mr JT had turned up at his place covered in blood, sometime on one afternoon. Mr JT then proceeded to tell MR that he had caught someone eating his food at his campsite and that he had chopped him up. Mr MR went on to say that Mr JT threw his bloodied clothes in a bin in North Hobart. Police could not locate these items of clothing.

  2. After leaving Mr MR’s unit, Mr JT then visited Mr RF, then living at the same apartment complex. Mr JT told him that he had killed a kid at his campsite and showed him the axe and said he had used it to hit him in the head. The axe was said to have been covered in blood. According to Mr RF’s evidence, Mr JT proceeded to wash the axe in the bathroom before wrapping it in a T-shirt, placing it in a backpack and leaving it in a cupboard in Mr RF’s unit. Mr JT allegedly told Mr RF that he had burnt “everything” and “buried the kid in about a metre deep grave”.

  3. Forensic testing of the axe was recovered by police showed no signs of blood, only rust and dirt. This might be thought surprising considering that if it was washed to remove the blood, as Mr RF claimed Mr JT did, the dirt and rust would have been removed also. In any event, no trace blood, at all, was found.

  4. Mr JT allegedly told a similar story to another person, Mr MT. Again, Mr JT told Mr MT that someone had come into his tent and he hit him in the head and killed him. Mr JT also told Mr MT that he then buried him near a pine tree. Mr JT, in days following this initial conversation, apparently told Mr MT again that he had killed someone by hitting him over the head with an axe and burying him beside a big tree.

  5. Sometime around 21 October 2016, Mr JT met up with his ex-girlfriend Ms SA in Hobart and it was at this point he told the story to her, which led her to contact police. According to Ms SA, she asked Mr JT if the person he had killed was the “missing African kid”19 that had been on the news and Mr JT stated to her “it probably was.” Mr JT said when interviewed by the police that he was heavily affected by drugs at the time and could not remember the encounter with Ms SA in much detail, but denied murdering someone.

19 Contextually this can only have been Mr Woldemichael.

  1. When interviewed by police, Mr JT said that he was living in the campsite for about 10 weeks from August until about the 15 October 2016. He said that once he left the campsite, he had burnt everything as he was “sick of other homeless people taking his stuff”.

  2. Police went to the campsite identified by Mr JT to search it and check the area for possible grave sites. An area was located close to the campsite, near a fence line, in a small water course to the west of a pine tree that was soft underfoot. Police excavated the site and located a buried 3XL navy blue half zip jacket with pockets and a pair of navy blue track pants with white piping detail down the side. Peculiarly, both items of clothing were laid out as if a person were wearing them. Constable Mandy Ladson, attached to Hobart Forensics, said in her opinion it appeared that the clothing had been deliberately concealed and buried underneath soil.

  3. The clothes were relatively clean and appeared to have not been buried for a very long time. Forensic testing of them revealed that Mr JT’s DNA was located on the track pants - this despite Mr JT saying in his interview with police that he knew nothing about these items of clothing.

  4. Other items located by police from the fire included a Mambo jacket, black jeans and a black Billabong T-shirt. A burnt mobile phone was also recovered. However, nothing could be linked to Mr Woldemichael from these items or anything at all in the surrounding area.

  5. On 15 November 2016, detectives seized property left at Mr MR’s unit by Mr JT. Of interest were personal papers with writing stating things such as “To kill is easy, to live with it is impossible,”20 “don’t ever dare f**k with me or you may find yourself accidentally and brutally murdered,” “7 years jail + 16yr old daughter,” “I’m a bad, bad man.” Other writings found in these papers appeared to be Mr JT working out potential gaol terms. It is difficult to know quite what to make of this material. To my mind, it does not particularly advance the proposition that Mr JT was responsible for Mr Woldemichael’s death. It is just as consistent with the ramblings of someone as erratic as Mr JT plainly was.

  6. In a recorded interview with police on 8 February 2017, Mr JT said, under caution, that he had never seen or heard of Mr Woldemichael and does not know why anyone 20 Perhaps a reference to the broad theme of Dostoevsky's "Crime and Punishment".

would say he had killed him. The explanation of course is to be found in the fact he told four different people that he had. Mr JT further stated that the writings about killing people were just song lyrics he had made up.

  1. Nevertheless, there is nothing other than his Mr JT’s story (repeated to several people) to link him to Mr Woldemichael’s disappearance. There is no evidence that the pair even met. All items seized by police were forensically tested and nothing was located to indicate that Mr Woldemichael had ever been at the campsite. No trace of blood was found. Nor was an actual grave site. It is to my mind curious to say the least why Mr JT allegedly told the story as he had nothing to gain. I note he consistently denied ever speaking about it when interviewed by police, although I am satisfied he did. An explanation may be found Ms SA’s evidence to the effect that it was not uncommon for Mr JT to make up extreme stories and would lie to get attention.

  2. Nonetheless the fact that Mr Woldemichael may have been the victim of homicide at the hands of Mr JT, or I suppose someone else, cannot not be entirely ruled out on the available evidence.

Concluding remarks

  1. Despite an extensive and comprehensive investigation by uniform, specialist Criminal Investigation Branch detectives and forensic and scientific officers, there is insufficient evidence to enable me to reach a concluded view as to what became of Mr Woldemichael. It is difficult to see what further lines of enquiry may have been pursued by investigators to attempt to identify what has become of him.

  2. Accordingly I return what used to be known as an “open verdict”. I recommend that Mr Woldemichael’s file remain open for further investigation if and when any additional evidence is uncovered.

  3. I extend my appreciation to investigating officer Detective Sergeant Kim Norton for his investigation and report. I also acknowledge the extensive work done in relation to this finding by Ms Alice Mutton, Legal Practitioner.

  4. The circumstances of Mr Woldemichael’s death are not such as to require me to make any comments and recommendations pursuant to section 28 of the Coroners Act 1995.

  5. I convey my sincere condolences to the family and loved ones of Mr Woldemichael.

Dated 24 October 2022 at Hobart in the State of Tasmania.

Simon Cooper Coroner

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