Finding into death of Mawuone Ngutgar

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 4450/08

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of MAWUONE NGUTGAR

Delivered On: 19 Match 2012

Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne 3000

Hearing Dates: 24 October 2011

Findings of: JOHN OLLE, CORONER

Police Coronial Support Unit: Leading Senior Constable Remo Antolini

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I, JOHN OLLE, Coroner having investigated the death of MAWUONE NGUTGAR

AND having held an inquest in relation to this death on 24 October, 2011 at Melbourne

find that the identity of the deceased was MAWUONE NGUTGAR

born on 31 December, 1986

and the death occurred on 1 October 2008

at Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168

from: la, CEREBRAL EDEMA, CEREBRAL INFARCTS AND PNEUMONIA ib, SUBDURAL HEMATOMA

in the following circumstances:

1. Mawuone Negutgar was aged 21 years at the time of his death. He lived at 1 Carcoola Court, Morwell.

2. The coronial brief has fully addressed the circumstances of death of Mr Ngutgar.

3. Following concerns raised by the family! a Directions Hearing was held. The family were

represented, The coronial investigator gave evidence. He was questioned about family concerns. At my request, he undertook further enquiries. A further report has becn provided and forwarded to the family.

4. The investigation has been comprehensive. All issues raised by the family have been thoroughly investigated. There is no evidence of foul play. The family were advised I do not consider further investigation warranted.

5. The summary of evidence and subsequent report of the coronial investigator, comprehensively and accurately, addresses the circumstances of death of Mr Ngutgar. The summary, brief of evidence and final report of the coronial investigator will remain on the Court file,

Circumstances of death

6. At about 8.00pm on 16 September 2008, Mr Ngutgar was located unconscious on the ground outside the residence of 4/32 Kelvinside Road, Noble Park ("the residence"). He had been sleeping at the residence for some days. He would regularly return of an evening in an intoxicated condition.

7. Passers by located Mr Neutgar and alerted the occupants of the residence. An ambulance was called and conveyed Mr Ngutgar to the Monash Medical Centre. He underwent emergency surgery for subdural haematoma.

1 The family expressed concerns Mr Ngutgar had met with foul play.

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8. The residents had not been alerted to any suspicious activity. Mr Ngutgar was found lying on his back, facing upwards. His arms facing outwards beside his body. It appeared he had fallen to the left of the doorway. :

The Investigation

9. Numerous witnesses have been interviewed. The family reported rumours within the Sudanese community that Mr Ngutgar may have been murdered, because he fathered a child to a Sudanese girl out of wedlock, Subsequent investigations found no evidentiary support for the alleged rumour. The individual who allegedly raised concerns ‘initially, subsequently denied knowledge of the rumour.

Further, he denied having disseminated such information.

Overview

10. The coronial investigator explained:

"Based on medical evidence obtained, witness evidence and attendance at the alleged scene, investigators have not found any evidence to support any activity of suspicious activity leading up to the location of the deceased outside 4/32 Kelvinside Road, Noble Park.

There is clear witness evidence that the deceased had a prior history of drinking alcohol to excess.

That on the 16 September 2008, he was in the company of friends drinking large amounts of ‘Sunny Vale Wine’. That at the end of the drinking session he left on his own accord stating he would be okay. It was of the opinion of witnesses that he was ‘drunk’. There is no evidence suggesting that anything out of the ordinary occurred between the deceased and his friends prior to him leaving, The deceased was last seen walking off by himself in the direction that would take him to his residence, .

No witnesses at the residence heard or saw any suspicious activity when the deceased was located.

All the deceased's property that was described by his girlfriend Nuak as being in his possession when he left Morwell, was found in his possession, negating any motive for theft or robbery.

The deceased's blood alcohol level was .32g/100ml of blood at the time it was taken as indicated on hospital records that accompanied the deceased at 9.49pm on 16/9/2008. As indicated in the toxicology report attachment 2 sect 5 Blood alcohol concentrations (BAC) in excess of 0.157% can cause: considerable depression of the central nervous system. The deceased concentration was more than double that reading.

No other injuries were detected on the deceased pre or post mortem other than small grazes on his.

right palm that would indicate he was not assaulted about the body, face or head.

It is the opinion of the investigators that the deceased had been able to walk to the premises outside the address of 4/32 Kelvinside Road, Noble Park, He has attempted to either open the front

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fiyscreen door (as described by witness (Malakal Gai (sic)) or failed. As a result and by the way he has been found lying in his body position, he has fallen backwards owing to the state of his sobriety and struck his head on the concrete footpath hard enough to have caused bleeding about his brain.

It is of the opinion of the investigator that the grazes detected on the palms of the deceased hands may have been caused in attempt to break his fall prior to any head impact on the ground.

As described by Malakal Guy (sic), the deceased was lying on his back with his feet closest to the front door and his arms outstretched to the left and right sides of his body. Owing to the state of his sobriety, he has struck his head on the concrete footpath hard enough to have caused bleeding about the brain.

This is further stated by Doctor Paul Bedford.on page 8 of 9 of his Autopsy report Comment 3 - In summary brain bleeding can occur due to simple trauma in those with high blood alcohol levels although trauma had not been excluded. . :

It is the opinion of this investigator that the alcohol consumption of the deceased recorded as twice the level excess of 0.15% can cause considerable depression of the central nervous system.

That the blood alcohol level of the deceased has been a major contributing factor that has caused the deceased somehow to loose balance when approaching or attempting to open the font door of the residence. He has fallen and most likely hit his head on the ground either with force or low impact. However, impact enough causing such trauma to his brain causing it to bleed io such extent it has led to his death.

No suspicious circumstances have been detected in this investigation." 2

11. As indicated above, further inquiries were undertaken by the coronial investigator at my request to address concerns raised by the family. At the Inquest hearing on 24 October, 2011 the surname of the person Neil, previously mentioned on 13 April 2010 was provided. Family members and friends present at the inquest maintained Neil was the last person to see Mr Negutgar alive. 1 expressed my disappointment his name had not been provided at the Direction Hearing, I asked the coronial investigator to obtain a statement from him,? together with a further statement from Mr Choul.4

12. It became increasingly clear that the family and friends of Mr Ngutgar had no reasonable basis to suspect Mr Ngutgar was assaulted on the night of his death. Rather, they had doubts Mr Ngutgar could have received a subdural bleed as a result of falling backwards on to concrete, I explained in open court their belief is incorrect. There were no injuries indicative of assault.

13. Mr Ngutgar lived at the residence with Mr Gai. He explained:

2 Summary inquest brief.

Noting there was uncertainty about his surname Tt was claimed Mr Choul told family members Nei! follawed Mr Ngutgar. A claim not previously made.

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• Mr Negutgar drank heavily,

• He was found laying on his back, feet closest to the door;

• There was no blood on his head, face or body except for a small graze on the palm of a hand;

• The door opens out and to the left,

• The position Mr Ngutgar was found was consistent with falling to his left from the door.

14. Mr Negutgar had a history of binge drinking. On the evening in question, he was extremely intoxicated. He had a blood alcohol level of 0.32g/100ml,

15. His injuries were consistent with having fallen backwards, striking his head on the concrete on janding, He sustained head injuries and underwent emergency surgery. He subsequently died in

hospital.

16. I am satisfied Mr Ngutgar returned to his residence and fell at the doorway. He was extremely intoxicated. There is no evidence of foul play and no suspicious circumstances.

17. Mr Negutgar was a young man who consumed alcohol in alarming quantities. His death is nonetheless tragic for his wife, child, family and friends.

18. ‘I take this opportunity to acknowledge the invaluable contribution to my investigation of the coronial investigator, Detective A/Sgt Dean Hedge.

Post Mortem Medical Investigation

19, On the 3 October 2008, Dr Paul Bedford, Forensic Pathologist with the Victorian Institute of Forensic Medicine, performed an autopsy on the body of Mawuone Neutgar.

20. Dr Bedford found the cause of death to be cerebral edema, cerebral infarcts and pneumonia and subdural haematoma: Blood alcohol levels were noted at 0.32g/100ml.

Finding

I find the cause of death of Mawuone Neutgar to be cerebral edema, cerebral infarcts and pneumonia and subdural haematoma.

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I direct that a copy of this finding be provided to the following:

Senior Next of Kin Investigating Member

Signature: 4 “l

JOHN OLLE [|

CORONER |

i

<—

Date: 19 March, “|

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