Coroner's Finding: Dixon, Isaiah Solomon; Thomas, Bree-Anna Mary Jennifer; Courto, Thomas James

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 deaths of Isaiah Solomon Dixon, Bree-Anna Mary Jennifer Thomas and Thomas Courto; Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the first deceased is Isaiah Solomon Dixon; b) Mr Dixon died in the circumstances set out further in this finding; c) Mr Dixon’s cause of death was drowning; and d) Mr Dixon died on 18 October 2021 in the waters of Bass Strait, near Table Cape, Tasmania.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the second deceased is Bree-Anna Mary Jennifer Thomas; b) Ms Thomas died in the circumstances set out further in this finding; c) The cause of Ms Thomas’ death was drowning; and d) Ms Thomas died on 18 October 2021 in the waters of Bass Strait, near Table Cape, Tasmania.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the third deceased is Thomas James Courto; b) Mr Courto died in the circumstances set out further in this finding; c) The cause of Mr Courto’s death was drowning; and d) Mr Courto died on 18 October 2021 in the waters of Bass Strait, near Table Cape, Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into the deaths of Mr Dixon, Ms Thomas and Mr Courto’s deaths. The evidence includes:

• Police Report of Death for the Coroner – Isaiah Solomon Dixon;

• Affidavits confirming identity and life extinct – Isaiah Solomon Dixon;

• Report – Dr Andrew Reid, Forensic Pathologist – Isaiah Solomon Dixon;

• Report – Forensic Science Service Tasmania – Isaiah Solomon Dixon;

• Medical Records – Isaiah Solomon Dixon;

• Police Report of Death for the Coroner – Bree-Anna Mary Jennifer Thomas;

• Affidavits confirming identity and life extinct – Bree-Anna Mary Jennifer Thomas;

• Report – Dr Andrew Reid, Forensic Pathologist – Bree-Anna Mary Jennifer Thomas;

• Police Report of Death – Thomas James Courto;

• DNA Coronial Identification Report – Forensic Science Service Tasmania – Thomas James Courto;

• Report – Dr Andrew Reid, Forensic Pathologist – Thomas James Courto;

• Affidavit – Senior Constable Lee Taousanis, (unsworn);

• Affidavit – Sergeant Genevieve Hickman, sworn 5 May 2022;

• Affidavit – Senior Constable Amanda Phair, sworn 7 March 2022;

• Statutory Declaration – Stuart John Dixon, sworn 19 October 2021;

• Affidavit – Stuart John Dixon, sworn 18 August 2022;

• Affidavit – Michelle Margaret Thomas sworn 2 September 2022;

• Statutory Declaration – Kylie Louise Thomas, made 19 October 2021;

• Affidavit – Brett Courto, sworn 7 March 2022 (and photographs);

• Affidavit – Brett Courto, sworn 29 April 2022;

• Affidavit – Brett Courto, sworn 23 August 2022;

• Affidavit – Khyle John Frost, sworn 10 December 2021;

• Affidavit – Samantha Jane Apted, sworn 29 December 2021;

• Affidavit – Ethan Patrick Jones, sworn 31 January 2022;

• Affidavit – Sophie-Lee Leslie Jones, sworn 10 February 2022;

• Affidavit – James Richard Lowe, sworn 15 June 2022;

• Affidavit – Adam Sculthorpe, sworn 12 July 2023;

• Affidavit – Robert Leigh McNeair, sworn 20 July 2022;

• Affidavit – Robert John Boon, sworn 7 August 2022;

• Affidavit – Christopher John Boon, sworn 7 August 2022;

• Affidavit – Jack Baxter, sworn 19 July 2022;

• Affidavit – Robyn Michelle Withers, sworn 30 May 2022;

• Affidavit – Sharon Bell, sworn 20 July 2022;

• Affidavit – Wendy Page, sworn 20 July 2022;

• Affidavit – Brandon Lee Cashman, sworn 21 October 2021;

• Affidavit – Damien Charles Lavell, sworn 30 October 2021;

• Affidavit – Lachlan Charles Whitten-Lowe, sworn 21 March 2023;

• Affidavit – Jeremy Bruce Stonehouse , sworn 28 November 2023;

• Affidavit – Mark Anthony Gillon, sworn 20 July 2022 (and sketch map);

• Affidavit – Constable Jack Ansell, sworn 8 February 2023;

• Affidavit – Senior Constable Damien Godfrey, sworn 19 February 2023;

• Affidavit – First Class Constable Dean Wotherspoon, sworn 23 March 2022;

• Affidavit – First Class Constable Dean Wotherspoon, sworn 14 June 2022;

• Affidavit – First Class Constable Mark Johnson, sworn 20 June 2022;

• Affidavit – Sergeant Katrina Chivers, sworn 27 October 2021;

• Affidavit – Senior Constable Roger Pearce, sworn 16 September 2023;

• Bureau of Meteorology records; and

• Forensic, CCTV and photographic evidence.

The role of the Coroner

1. Before considering the circumstances of the deaths of Mr Dixon, Ms Thomas and Mr Courto in detail, it is necessary to say something about what a coroner does. In Tasmania, a coroner has jurisdiction to investigate any death that occurs in Tasmania and appears to “have been unexpected, unnatural or violent or to have resulted directly or indirectly from an accident or injury”.1

2. The coroner’s role is inquisitorial. When investigating a death (or deaths) a coroner is required to answer the questions (if possible) that section 28(1) of the Coroners Act 1995 asks. Those questions include who the deceased was, how they died, the cause of the person’s death, and where and when the person died. It is settled law that this process requires a coroner to make various findings, but without apportioning legal or moral blame for the death.2 The job of the coroner is to make findings of fact about the death from which others may draw conclusions. A coroner may, if she or he thinks fit, make comments about the death or, in appropriate circumstances, recommendations to prevent similar deaths in the future.

1 Section 3, Coroners Act 1995.

2 R v Tennent; Ex Parte Jager [2000] TASSC 64.

3. It is important to recognise that a coroner does not punish or award compensation to anyone. Punishment and/or compensation are for other proceedings, in other courts, if appropriate. Nor does a coroner charge people with crimes or offences arising out of a death that is the subject of investigation. In fact, a coroner must not even include in “any finding or comment [sic] any statement that a person is or may be guilty of an offence”.3

4. As was noted above, one matter that the Coroners Act 1995 requires, is a finding (if possible) as to how the death occurred.4 ‘How’ has been determined to mean ‘by what means and in what circumstances’,5 a phrase which involves the application of the ordinary concepts of legal causation.6 All coronial investigations involve a consideration of the particular circumstances surrounding the particular death so as to discharge the obligation imposed by section 28(1)(b) upon the coroner.

5. The standard of proof that applies to any coronial investigation is the civil standard.

This means that where findings of fact are made, a coroner needs to be satisfied on the balance of probabilities as to the existence of those facts. However, if an investigation reaches a stage where findings being made may reflect adversely upon an individual, it is well-settled that the standard applicable is that expressed in Briginshaw v Briginshaw, that is, that the task of deciding whether a serious allegation against anyone is proved should be approached with a good deal of caution.7 Background

6. At the time of their deaths, Mr Dixon was 23 years old, Ms Thomas 31 and Mr Courto 27. All three lived and worked on the North West Coast of Tasmania. Mr Dixon and Mr Courto had been born there and were close friends. Ms Thomas moved there in around February 2021.

7. Mr Dixon was employed at Savage River Mine and had just finished a week long night shift. Ms Thomas was employed at the Wharf Hotel in Wynyard. Mr Courto was about to start work at a mine in Western Australia.

8. Each of the three were single.

3 Section 28 (4) of the Coroners Act 1995.

4 Section 28(1)(b) of the Coroners Act 1995.

5 See Atkinson v Morrow [2005] QCA 353.

6 See March v E. & M.H. Stramare Pty. Limited and Another [1990 – 1991] 171 CLR 506.

7 (1938) 60 CLR 336 (see in particular Dixon J at page 362).

9. The evidence is that Ms Thomas worked a shift at the Wharf Hotel on Sunday 17 October 2021. Both Mr Dixon and Mr Courto were at the hotel. Both arrived around 3.00pm and spent the rest of the afternoon and evening in the bar drinking and socialising.8 When the bar closed at 9.00pm Ms Thomas joined Mr Dixon, Mr Courto and another friend Mr Ethan Jones, on the ‘other side of the bar’ for a drink.9

10. At about 10.00pm Mr Dixon, Ms Thomas, Mr Courto and Mr Jones left the hotel and went to Mr Jones’ home, where they continued to drink and listen to music in a shed.

Police officers attended at about 11.30pm, to deal with a noise complaint. During their time at Mr Jones’ home, there was discussion about going out in the boat the following day. The evidence is that Mr Dixon, Ms Thomas and Mr Courto continued to drink until at least 4.00am.10 Circumstances of Death

11. At 7.43am on Monday 18 October 2021, Mr Dixon ‘messaged’ his father and asked if he might take his father’s boat out. His father replied by text and gave approval.

Shortly after, Mr Dixon went to his father’s home in York Street, Wynyard. At the time, Mr Stuart Dixon owned a 17 foot (5.2m) fibreglass Caribbean Half Cabin Cruiser. Mr Stuart Dixon said his son appeared to have ‘had a few drinks’. 11 Mr Dixon attached the boat, which was on a trailer, to his Toyota Hilux ute and left. Mr Dixon had taken the boat which his father said was named “ED Dog”12 out before. He had a motorboat license and had previously owned a half cabin runabout. His father described him as experienced handling boats and familiar with the area of Bass Strait near Wynyard13.

12. At around the same time, Mr Dixon’s Hilux was seen by an off duty police officer parked in a supermarket car park with the engine running and no-one in the vehicle.

The same police officer also saw Mr Dixon drive over a concrete parking plinth. The officer took photographs of the Hilux. In those photographs the vehicle does not have a boat trailer attached. It must therefore be this occurred before Mr Dixon picked the boat up from his father.

13. According to Mr Dixon’s father, “ED Dog” was powered by a 115hp Mercury twostroke engine, but had no auxiliary engine. He said the boat was fitted with a two-way 8 Affidavit – Ethan Jones, sworn 31 January 2022.

9 Affidavit – Samantha Apted, sworn 29 December 2021, page 2 of 3.

10 Affidavit – Sophie-Lee Jones, sworn 10 February 2022.

11 Affidavit – Stuart Dixon, sworn 19 October 2021 page 1 of 3.

12 Supra.

13 Affidavit – Stuart Dixon, sworn 18 August 2022, page 3 of 3.

radio, navigation lights and equipped with PFDs, oars, flares, a fire extinguisher and an anchor. There was, and is, some uncertainty as to whether the boat had on board an EPIRB (certainly there is no evidence that an EPIRB was activated in the area where the runabout went missing on 18 October 2021). The boat had a white hull and yellow cabin.

14. The previous owner of the boat (who told investigators it was called “Red Dog” when he owned it) said when he sold it to Mr Dixon’s father it was fitted with a 135hp Mercury outboard (he having replaced a 115hp Yamaha outboard). He also said it was fitted with an EPIRB. I do not think anything much turns on this discrepancy. He did say that the boat was structurally sound, and I accept that it was.

15. CCTV footage showed Mr Dixon, Ms Thomas and Mr Courto buying six four packs of alcoholic vodka cruiser drinks and a 10 pack of alcoholic cider from a bottle shop in Wynyard at 9.24am.

16. At about 9.30am, Mr Dixon called into the Wynyard Auto and Fishing Supplies Shop in Inglis Street, Wynyard. The owner of the Shop, Mr James Lowe, told investigators that Mr Dixon bought a bottle of two stoke oil. During their interaction, Mr Dixon told Mr Lowe he was going out on the water ‘for a fun drinking trip’. He also asked Mr Lowe of the correct ratio of petrol to oil mix for a two stroke outboard, something that ‘shocked’ Mr Lowe, evidently because it suggested to him Mr Dixon lacked boating experience.

17. Mr Lowe also told investigators that Mr Dixon (who he recognised when he saw a story about the disappearance of the boat on the TV news later that night) appeared ‘drug or alcohol affected’.14

18. Another witness saw all three about this time and thought they were very intoxicated.15

19. The evidence is that at around 10.00am on Monday 18 October 2021, Mr Dixon, Mr Courto and Ms Thomas launched the boat from the Wynyard Yacht Club. The boat ramp at the club is on the Inglis River. The Inglis River runs east into Bass Strait and enters it a little over 4km south of Table Cape.

20. Broadly speaking the weather conditions on 18 October 2021 were good. The maximum temperature was 18°, there was no rain and little cloud. There was some 14 Affidavit – James Lowe, sworn 15 June 2022, generally.

15 Affidavit – Samantha Apted, sworn 29 December 2021, page 3 of 3.

breeze, predominantly west north west ranging from 13km an hour to 26km an hour.

The conditions were more than acceptable for boating.

21. The three were seen by several people between 12 noon and 12.30pm coming into the beach at Boat Harbour. The boat was run up onto the beach. Photographs taken by a tourist show the boat leaving the Boat Harbour Beach at 12.42pm.16

22. A witness described seeing the boat also leave the Boat Harbour region with a “huge rooster tail”, that is to say a large volume of water being caused by the angle of the outboard engine. A rooster tail is ordinarily caused by an engine being poorly trimmed. 17

23. Other witnesses described seeing what I am satisfied was the boat with Mr Dixon, Ms Thomas and Mr Courto in it circling quickly, near Boat Harbour. One witness said that the boat did ‘no more than ten laps’.18

24. A Snapchat subsequently identified by police as having been ‘posted’ (if that is the correct expression) by Mr Dixon during the fatal trip shows him not wearing a PFD while the boat was underway. Reportedly, other Snapchat videos, which I was not able to view, showed all three drinking alcohol while the boat was moving.

25. The video posted by Mr Dixon was the last contact made by any of the three.

Search and investigation

26. Tasmania Police were advised that the boat was overdue at about 5.35pm on 18 October. A search was immediately commenced. Initially, triangulation of the mobile telephones of Mr Dixon, Ms Thomas and Mr Courto was undertaken (to attempt to locate them or at least determine the area where they had last been). Police patrolled the shoreline of Bass Strait near Wynyard.

27. Around the middle of the day on 20 October, searchers found the bodies of Mr Dixon and Ms Thomas on the shore between Table Cape and the mouth of the Inglis River. Neither body was wearing a PFD. Both bodies were recovered by SAR personnel and taken by helicopter to Wynyard airport for formal identification before being taken to the Royal Hobart Hospital by Mortuary Ambulance.

16 Affidavit – Robyn Withers, sworn 30 May 2022, Affidavit Robert McNair, sworn 20 July 2022, Affidavit – Christopher Boon, sworn 7 August 2022.

17 Affidavit – Robert Boon, sworn 7 August 2022.

18 Affidavit – Adam Sculthorpe, sworn 12 July 2023.

28. Ms Thomas had a watch on her wrist when her body was recovered. The watch stopped at 1.12pm.

29. No sign was found of Mr Courto until 21 April 2022 when what proved to be his femur was recovered by a recreational diver in 4-5 metres of water below Table Cape lighthouse. The bone was handed in to the Smithton Police Station. After preliminary examination suggested it was human, an examination by a forensic pathologist confirmed that fact and DNA analysis carried out at the laboratory of Forensic Science Service Tasmania proved it was Mr Courto’s.

30. The boat was never found.

Forensic Pathology Evidence

31. The Tasmanian State Forensic Pathologist, Dr Andrew Reid, performed autopsies upon the bodies of Mr Dixon and Ms Thomas. He provided reports following those procedures in which he expressed the opinion that the cause of death in both cases was drowning. I accept Dr Reid’s opinion.

32. Toxicological analysis of samples taken from both bodies at autopsy was subsequently carried out at the laboratory of Forensic Science Service Tasmania. That analysis demonstrated that Mr Dixon had a blood alcohol level of at least 0.110g per 100mL of blood at the time of his death. In addition, the presence of methylamphetamine was detected in those samples. I observe that section 16(1) of the Marine Safety (Misuse of Alcohol) Act 2006 makes it an offence to operate a non-commercial vessel such as Mr Dixon was on the day of his, Ms Thomas and Mr Courto’s deaths, with a blood alcohol concentration in excess of 0.05g of alcohol in 100mL of blood.

33. Ms Thomas had a blood alcohol level of at least 0.063 g per 100 mL of blood at the time of her death. Like Mr Dixon, the presence of methylamphetamine was detected in samples taken from the body at autopsy.

34. Mr Courto’s femur revealed no evidence that enabled Dr Reid to express an opinion as to the likely pathological cause of death. However, viewing the evidence as a whole it seems more likely than not that he also drowned.

Conclusion

35. It is difficult to escape the conclusion that a combination of alcohol, illicit drugs and a failure to take basic safety precautions was the reason for these deaths.

36. There is no evidence that adverse weather conditions, the lack of a seaworthy boat or the actions of a third party caused or contributed to the deaths of Mr Dixon, Ms Thomas and Mr Courto. Rather, no one was wearing a PFD and all were affected by alcohol, methylamphetamine and fatigue. Having regard to the evidence as a whole it is my firm opinion that Mr Dixon, Ms Thomas and Mr Courto should not have been on the water that day.

37. There is no direct evidence which would allow a definite conclusion to be reached as to why the boat sank (as it must have). However, in all the circumstances and having regard to the evidence as a whole the most likely explanation is some type of mishap, probably as the result of poor boat handling, attributable to impairment caused by alcohol and illicit drugs.

38. The tragedy was wholly avoidable.

Comments and Recommendations

39. The circumstances of Mr Dixon, Ms Thomas and Mr Courto’s deaths are not such as to require me to make any recommendations pursuant to Section 28 of the Coroners Act 1995, although I do comment that if they had been wearing PFDs it is likely each would have survived. I note that the requirement to wear a PFD while on a recreational vessel of the size upon which Mr Dixon, Ms Thomas and Mr Courto were on 18 October 2021 is underway has been mandatory in this state for many years.

40. I convey my sincere condolences to the family and loved ones of Mr Dixon, Ms Thomas and Mr Courto.

Dated: 23 January at Hobart, in the State of Tasmania.

Simon Cooper Coroner