Finding into death of Justin Michael Galligan

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2008 4915

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: JUSTIN MICHAEL GALLIGAN

Delivered On: November 28, 2012

Coroners Court of Victoria

Delivered At: Level 11, 222 Exhibition Street Melbourne 3000 Hearing Dates: April 16, 17 and 18, 2012 Findings of: JUDGE JENNIFER COATE, STATE CORONER

Police Coronial Support Unit Leading Senior Constable Tania Cristiano

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I, JUDGE JENNIFER COATE, State Coroner having investigated the death of JUSTIN

GALLIGAN

AND having held an inquest in relation to this death on April 16, 17 and 18 2012 at MELBOURNE find that the identity of the deceased was JUSTIN MICHAEL GALLIGAN!

born on 3 January 1992 : and the death occurred on November 2, 2008 at the Royal Melbourne Hospital, Grattan Street, North Melbourne 3051 from: :

1 (a) HYPOXIC BRAIN INJURY’. .

in the following circumstances:

Summary background

1. Justin Galligan CT ustin”)’ was 16 years old at the time of his death. He was a full time student .

in Year 10 at Kew High School. He was a keen sportsman who excelled at football, cricket

and volleyball and basket ball. He was considered a good student with a bright future.

2, Along with a number of other teenagers, Justin attended a Halloween party at the home of

Sheridan Bowden on the evening of October 31 2008,

3. Apparently fuelled by some alcohol consumption, some fights broke out during the evening, both inside the party and amongst some of the party goers and some uninvited arrivals. During the second and more serious of these incidents, at the rear of the Bowden property, Justin became engaged in the fight. He was struck by a punch in the head after which he fell to the ground and struck his head. Justin lost consciousness for a short time and was noted to be daved and confused after regaining consciousness. Justin’s friends escorted him home during which time he complained of a headache and started vomiting. He became unable to walk and his friends got him into a taxi. One friend went home in the taxi with him and got him into his ¢

home.

‘Justin was identified by his mother by certificate dated November 2 2008 2 Ryhibit 10 : Statement of Mr Bhadu Kavar Neurosurgeon and oral evidence.

3 Permission was sought from the family to refer to Justin in this way throughout the Inquest.

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4, Justin’s father met the boys at the door. Justin’s father thought Justin looked like he had a swollen jaw and asked him if he had been in a fight. Justin denied that he had. His friend did not tell Justin’s father that he had been in a fight and struck his head as he was concerned this would get Justin, into trouble with his father. Justin’s father asked about drugs and alcohol as

Justin was saying he felt sick and wanted to go to bed.

5. Justin’s friend sat up watching over Justin for some time until he (the friend) fell asleep.

About 9.00am the following morning, Justin’s parents heard Justin and came into his room to

find him on the floor moaning and having trouble breathing.

6. An ambulance was called and arrived quickly. Justin was treated and then transported to the Royal Melbourne Hospital. On arrival he was unconscious. He underwent a CT brain scan and was found to have an undisplaced skull fracture with bleeding around the brain and

evidence of having aspirated.

7, He underwent an emergency craniotomy but sadly, the bleeding was unable to be controlled

and Justin lost his life at 17.50 on 2 November 2008.

Criminal prosecution

8. In the wake of the fight at the party and Justin’s death, the police ‘pursued a criminal investigation. What emerges from the prosecution material is that there were a range of eye witness accounts as to what happened at the scene and, as is often the case, a variation in that evidence as to what happened. During the lengthy criminal investigation, about 200 people

were questioned.

9, Ultimately, five boys were charged with a range of offences including affray, unlawful | assault, intentionally causing injury, make threats to kill and drug possession. They appeared

before the Children’s Court and were sentenced in that jurisdiction.

Coronial investigation

10. After completion of the criminal proceedings, a brief was prepared by the police and delivered to this court. It was accepted that there were some issues to be explored in the coronial jurisdiction touching upon the circumstances in which Justin’s death occurred that had: not

been touched upon in the criminal investigation.

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To this end, further material was collected and the investigation ultimately went to inquest for

the examination of some of the material collected during the coronial investigation.

It was explained to Justin’s family that the coroner would not be examining the criminal prosecution, prosecutorial decisions as to what charges should be laid or decisions of the

Children’s Court as to sentencing.

Rather, this investigation would examine what happened at the party, what precautions were taken for the safe conduct of the party and what was or was not done in the wake of Justin’s head strike. It was also explained that this would be the focus of the coronial investigation in the spirit of endeavouring to understand what happened and to consider whether or not there were any lessons to be learned which may contribute to a reduction in deaths occurring in

similar circumstances in the future.

What is set out below is a summary of what happened at the party and in the wake of the party, with comments and recommendations arising out of the circumstances in which Justin’s

death occurred.

The party

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On the evening of October 31, 2008 15 year old Sheridan Bowden hosted a Halloween party at her parents’ home at 16 Jacka Street Balwyn North. She invited a number of teenage friends who were to attend by invitation only. Sheridan's parents imposed conditions on the party as follows (a) alcohol would not be provided but was permitted (b) the party had to finish at 12.30 am (c ) surrounding neighbours had to be advised in advance (d) food and soft drink

would be provided.

In the statement Mrs Bowden (Sheridan’s mother) provided in the Inquest Brief, * she stated that she told Sheridan if there were “any incidents” the party would be shut down and “if anyone was intoxicated they would be given two options: 1) Come inside, sit and wait away from the party for their friends to leave; 2) If I felt they ‘were unwell I would be calling their parents.” Mrs Bowden also stated that once agreeing to the party, she told her daughter that it

must not go onto Facebook and she must produce a full alphabetical list with phone numbers.

4 Statement of Christine Bowden: Exhibit 3

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Months earlier in April, Sheridan had hosted a party to celebrate her 15" birthday. She had invited about 40 people and this party had been conducted without incident. The party had been registered’ with the Victoria Police Partysafe program. Sheridan’s ‘parents had decided not to register this Halloween party with the Partysafe program as they did not see a police cat patrolling at the last party and thus could not see the benefit of the registration. Mr Bowden stated that he decided not to register the patty but rather that he would call the police in the event that he thought there was a need, Mrs Bowden expressed similar sentiments indicating that if they felt a situation required police involvement, they would not hesitate to make that

call

Approximately 55 teenagers were invited to this Halloween Party via e-mail and text message or over the internet. The invited names wete to be placed on a list for marking off by

supervising adults as the invitees attended, Justin was an invitee on the list.

Although 55 teenagers were invited to the party, the Bowdens stated that at the height of the party there were about 70 teenagers inside their premises.° One of the young adult supervisors

gave evidence’ that he thought it was more like about 90 inside the party at its height.

Sergeant Tim Bell the investigating member gave evidence that in the course of the criminal investigation preceding the coronial inquest, he had interviewed 120 young people who all claim to have been inside the party at some stage during the evening. It would appear that a number of young people were allowed to join the party when they arrived unannounced if they

were identified by Sheridan as people she knew.

Supervision at the party

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Sheridan's parents recruited 10 adults to assist in the supervision of the party, along with themselves. Mrs Bowden stated that she considered having in excess of 12 adults supervising 50 young people would be more than adequate.® Some of those recruited to supervise were 20

and 21 years old at the time. The evidence is that four of the older adults took up a position at

5 Statement of Mrs Bowden Ex 3

6 Rvidence of Mr and Mrs Bowden and Sheridan and Harrison Bowden: April 16 2012 7 Rvidence of Nathan Schon: Transcript April 17 2012

§ Statement of Christine Bowden Exhibit 3

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the front of the house with the list of invited guests and screened the incoming crowd, ticking

their names off the list or getting Sheridan to identify them if they were not on the list.

Sheridan’s older brother Harrison (who was 21 at the time) with four of his male friends of similar age took up a position at the rear yard fence. The rear of the Bowden’s property backs onto a public car park. The Bowdens had considered that this area was vulnerable to “gate crashers”® and thus the young adults took up a supervising position inside the yard but at the

back fence.

.Mr Randolph Bowden (Sheridan’s father) and a male parent kept the front of the house under

supervision and stated that he maintained a roving presence. Mrs Bowden and another woman who was the best friend of Mrs Bowden, were preparing food inside the house and delivering it outside to the teenagers in the yard. Mrs Bowden stated that she was circulating outside about

every 30 minutes.

The evidence was that during the evening there were numbers of young people who attended at the front of the house, who had not been invited but were asking to be let in to the party.

The evidence of Mr Randolph Bowden was that there were about 10 to 15 uninvited people who had arrived at the front of the house between about 9 to 11.00pm who were refused entry.

He stated that he did not think there was drinking amongst this group, but agreed that he found

about three empty bottles on a neighbour’s nature strip.

Mr Bowden described some of these young people out the front of the house as loud and generally noisy. He stated that one young man was persistently belligerent about getting in.

He described a group of about five males as persistent in their efforts to get in. He also stated that he overheard reference to the ability of the teenagers to go around the back and get in that way and it was for this reason Mr Bowden spoke to his older son Miles to be on the alert for this. He stated that his son Miles told him that some people were getting over the back fence into the party in the comer hidden by bushes.!° However, neither he nor any one of the supervising adults were concerned enough about any of this to consider it appropriate to call

the police to attend.

Statement of Mrs Christine Bowden Exhibit 13

© Tpid P 3 Exhibit 2

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Mr Randolph Bowden, stated that he did not feel it was necessary to call the police for

assistance to disperse the group as they were not “unruly, causing damage or threatening”.’!

As noted, numbers of young people did attend at the back of the property during the party and

tried to make their way in over the back fence.

Mr Anthony King, one of the group of adults supervising the party based at the front entry to the house, stated in evidence he was moving from the front to the back of the house. Mr King did state in evidence that he felt “a tiny bit? concerned about the numbers of young people milling around the front of the house, but he too described them as boisterous and persistent

rather. than threatening. 2

On the other hand, Ms Kerry Carlson, who came’ to pick up her 15-year-old daughter from the party at 11.00pm, painted a different picture. She stated that she saw a large group of teenagers milling around the front of the house and in the street. She described them as yelling and “yahooing” and drinking. She stated she hcard bottles smashing maybe one or two houses along.'? She stated that she felt the atmosphere was getting tense and that she was anxious that

the situation was going to become “yaly?.M4

Mrs Carlson gave evidence that she has had three teenage children and felt quite experienced with teenage parties but stated that this scene at the front of the party house was “out of the ordinary.””° She stated that the noise level of this group and their anxiety about getting in

created a bit like a “mob mentality” about getting in. 5 She described herself as anxious to _

leave and frightened for the safety of herself and her daughter.'”

Alcohol consumption amongst the teenagers

The evidence is consistent, that the vast majority of these 15 and 16 year old guests at the

patty were visibly affected by alcohol whilst there. Whilst no alcohol was supplied inside the

1 Statement of Randolph Bowden: Exhibit 2 '2 Ryidence of Anthony King: April 17 2012 Transcript p 117

8 Transcript p 123

14 Exhibit 7: Statement of Kerry Carlson 5 Evidence of Kerry Carlson: 17.4.2012 ‘6 Transcript 125 .

"Ry 7: Statement of Kerry Carlson

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“party, it is clear that the teenagers were drinking alcohol inside the patty. Some stated they

had obtained and consumed alcohol before arriving at the party as well as consuming alcohol at the party. '® Whilst the adults who have provided evidence to the Inquest have stated they did not observe any teenager as vomiting or falling down drunk, but rather just “merry”, perhaps the most zeliable account of the condition of the young people at the party comes from Sheridan herself, who knew these young people. She stated: “During the night I was talking to everyone who was there and almost everyone was drinking alcohol and everyone in

my opinion was drunk or affected by alcohol.”"?

Fighting at the party

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The evidence is that there were two fights between groups of males that night. One occurred © in the backyard in the ‘middle of the party and the other occurred in the car park immediately behind the Bowden house. It was in this second fight that Justin was struck, hit his head as he fell to the ground and lost consciousness. The evidence is that these two fights were separated

by about 30 minutes.

The first fight

The first fight broke out inside the Bowden's back garden amongst a group of boys. Sheridan described the first fight as one in which she heard yelling and saw “about 10 guys pushing and shoving each other”. She saw that Justin was there. She stated that the scuffle lasted for about 5 minutes and whilst she did not sce any punches thrown she saw a lot of pushing and shoving.” Another witness to this fight inside the party was one of Justin’s friends, Tim Brown. He too described a scene that involved about 10 boys in which punches were thrown.

and one of the boys received a cut above the eye which was visibly bleeding. There is no

evidence that Justin was struck at this time.

As is predictable, there were some varying accounts of this first fight. Some of the accounts

came across as attempts to both minimise the nature of what took place between the boys

18 The current state of the law appears to be that the supply of alcohol to a minor in a private residence without parental consent is an offence, but the law is silent on the issue of allowing a minor to consume alcohol in a private residence.

(See Liquor Control Reform Amendment Act 2011).

19 Exhibit 1: Statement of Sheridan Bowden

20 exhibit 1 Statement of Sheridan Bowden

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involved in this first fight and ignore its significance in the context of young boys and alcohol

and what was tolerable levels of behaviour inside the party.

The second fight

There was evidence in the Inquest Brief that after this first fight occurred, that mobile phone calls were made to summon others to thé party location. The evidence is that about 20 to 30 minutes after the first fight, numbers of young males were observed congregating on the

outside of the rear fence to the property.

Sheridan describes noticing that lots of people at the party were looking over the back fence into the car park. She too looked over to see, in het words, “heaps of guys standing in the car park behind my house and they were drinking”. She stated that she saw them walk away. She

rejoined the party after that observation and saw nothing more.

Justin’s close friend Tim Diakoumakos, made a statement about his version of what happened to Justin during this second fight. He stated that he and Justin had jumped the fence into the car park in response to their perception that one of their group was being attacked. Tim stated that after they joined the fight, he looked around and could see Justin holding a boy by the Tshirt. He stated that Justin was just holding him. He then saw another boy come up behind Justin and with his right fist hit Justin to behind his right ear. Tim stated that the punch was really hard and caused Justin to drop to the ground. Tim stated... “When Justin dropped you could hear his head hit the ground. It sounded awful. He hit pretty hard. The surface was

bitumen where he hit.” 74

Sheridan’s brother Harrison, who was amongst the group supervising the back yard, stated that at about 11.00pm he looked over the back fence and saw that there were people milling around out there and he saw a fight erupt. He then observed about 10 people from the party go over the back fence and join in what he described was a “huge fight",”? His brother Miles stated that when alerted about the fight over the fence he looked and saw a “‘scuffle” in which

he saw “arms swinging everywhere and wrestling going on.” He went on to state that “it

2 Statement of Tim Diakoumakos.

» Statement of Harrison Bowden

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Al,

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looked like the usual scuffle of a group of boys, not particularly violent, but there was about 8

to 12 people involved.and hovering around.” 3

Miles stated that he saw a boy on the ground in the wake of this scuffle, but then paid attention to the boys rejoining the party and did not give any further consideration to either

calling the police or seeking to understand what may have happened to the boy on the ground.

Harrison stated that he went out to the fight and screamed at the boys to get away. Lots of young people did scatter. A group of Justin’s friends stayed to care for Justin. Harrison stated that as he reached the group he could see there was one boy lying on the ground and he

appeared to be unconscious. This was Justin.

Harrison stated that he checked Justin’s pulse and breathing. He thought that his pulse was racing and that he was breathing. There ate varying accounts of how long Justin was unconscious but it appears to have been somewhere from between 10 to 15 seconds up to 3

minutes.

Nathan Schon, one of Harrison’s friends providing adult supervision at the back of the property that night, also attended in the car park and saw Justin on the ground. He confirmed Harrison’s evidence that Harrison checked his pulse and his breathing. Nathan stated that he and Harrison took Justin over to an area where he could sit down. They helped Justin to a seat and thought he then seemed a little dazed but otherwise “pretty good.” He said one of the girls

said she would take him to hospital.

Despite this being suggested by one of the young girls” present, no ambulance was called and

Justin was not taken to hospital at that time.

Whilst standing outside the property, in the wake of the second, fight and Justin’s loss of consciousness, both Harrison and Nathan stated they had their attention drawn to a girl who had cut her foot in the car park. They took her inside to have her cut attended to by Mrs

Bowden and saw and heard nothing more of Justin and his friends.

The evidence is that Justin was dazed and confused upon regaining consciousness and

unsteady on his feet and having some blurred vision. He was asking what had happened but

Statement of Miles Bowden: Exhibit 5

% Statement of Clare Matthews: Inquest Brief 320

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stating that he was fine. From this point, the evidence is that Justin left the party on foot with

his friends.

Justin left the patty with his friends including Tim Diakoumakos and Tim Brown and Sean Thomas. These friends stated that on the way home, Justin started vomiting and complaining of a headache. He became unable to walk and his friends hailed a taxi for him and escorted

him home in a taxi. Tim Diakoumakos went to Justin’s home with him.

Tim stated that just as the taxi pulled up outside Justin’s place, Justin’s father called Justin on his mobile phone. Tim answered Justin’s phone and Justin’s father asked why Justin did not answer. Tim told Justin’s father that Justin was fecling a bit sick. Tim stated that Justin’s father then came outside and helped Justin inside. Justin’s father noticed that Justin’s jaw appeared swollen and he asked him if he had been fighting. Justin told his father that he had

not been fighting and that he would talk about it in the morning.

Justin was asking for a bucket as he felt sick. Justin was taken to his bedroom and seemed to settle and was kept sitting up in a chair for fear that if he vomited he may choke. Tim remained with Justin and stated to Justin’s father that he would keep watch over him. Tim confirmed (in evidence) that he was watching Justin so that he would not choke if he vomited.

He did not understand the perils of the head strike and Justin’s loss of consciousness.

Neither Justin nor Tim told Justin’s father of the head strike or the resulting loss of consciousness. Tim told Justin’s father that there had been a bit of a scuffle. Justin’s father asked Tim if Justin had hit his head or if there was anything else he should know to which Tim had replied that there had only been a scuffle, Justin’s father specifically asked about

drugs and alcoho! as he was concemed that Justin looked as if he‘had too much to drink,

In evidence, Tim stated that he did not tell Justin’s father about the fight because he did not

want to get Justin into trouble.

Tim stated that as he watched over Justin, every now and again he would groan and vomit. He estimated that Justin vomited about three times in the night. Tim stated he (Tim) eventually fell asleep at about 5.00am. He woke at about 9.00am and found Justin on the floor moaning

and having trouble breathing.

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52. Justin’s mother, hearing that moaning, went into Justin’s room and finding him in the condition he was in called for her husband and an ambulance was called and arrived quickly.

Justin was ventilated and intubated by the paramedics and transported to the Royal Melbourne Hospital arriving in the Emergency Department at 10.42am. He was unconscious on arrival at

the hospital with a Glascow Coma Scale score of 3 (out of 15).

wa Les)

Justin underwent a CT brain scan which found an undisplaced skull fracture with an underlying extradural haemotoma (bleeding into the space between the inner surface of the skull and the external surface of soft tissue layers around the brain).>- Justin was also found to

have changes to his lungs consistent with aspiration.”°

54, Justin was taken to the operating theatre at 11.00am for an emergency craniotomy, (a

procedure used to attempt to drain blood away from the brain) which was completed at 13.30.

55, Mr Bhadu Kavar, Neurosurgeon, performed the procedure upon Justin. He stated that despite the evacuation of the haemotoma, Justin’s intracranial pressure remained “extremely high and impossible to control.” The very slow flow of blood into the intracranial area of Justin’s skull was unable to be stemmed. Tragically, Justin passed away at 17.50 on November 2,

2009. A blood sample from Justin when he arrived at the hospital did not detect the presence of

amphetamines or camabinoids and his blood alcoho! content (BAC) was less than .01,

CONCLUSION

57, Justin died as a result of being struck by one punch to the head which knocked him to the .ground and caused his head to strike the bitumen, causing a fracture to his skull and

consequent fatal bleeding into his intracranial area.

25 statement of Dr Richard Waller: Emergency Physician Inquest Brief 132

26 Relevantly in Justin's cases, the act of accidentally inhaling a foreign body, usually food or drink. If consciousness is impaired by head injury or excess alcohol intake, aspiration of stomach contents is common.

27 Statement of Mr Kavar Ex 10

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COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:

Tecnagers and alcohol

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Teenagers right across our State on a weekly basis are going to parties in droves. Most of these parties will be enjoyable and an important part of a young person’s social development and transition into adult hood. However, our courts, our police, our ambulance services and our hospitals are constantly processing the after effects of young men and alcohol related

damage.

As Mr Kavar so simply and powerfully stated, “We can never stop the.use of alcohol, but I

think we as a community need to really revisit how we promote alcohol use. We'll never get

rid of it, but we can change how we teach our children what to do. 028

The evidence in this case was that the consumption of alcohol for 15 and 16 year old teenagers

was expected and acceptable.

In this case, the Bowdens decided not to supply alcohol but were well aware that the teenagers would arrive with it and did so, The information that was given to invilees is that alcohol

would not be supplied.

The evidence in this case was that it was acceptable to the Bowdens to have 50 to 70 fifteen to sixteen year olds on their premises affected by alcohol. That this was considered acceptable and a demonstration of teenagers having fun should at lcast cause our community to reflect on

what messages this gives young people with respect to alcohol.

Supervision at the party

There was evidence that the need for security and conditions about alcohol consumption were discussed as between Sheridan and her parents in contemplation of this patty and that sensible rules were put in place during planning to regulate attendance at the party and supervision of the teenagers attending. The proposed actions in the event of any unruly behaviour or teenagers affected by alcohol were consistent with the views of the police members who gave

evidence as to how a teenage party should be controlled and supervised.

8 “Transcript 163°

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The evidence is that, despite the level of planning and discussion entered into by the Bowdens prior to the party, and the rules explained to Sheridan about what actions would be taken if there was any unruly behaviour, this is not what happened. The unruly behaviour inside the premises, during the first fight, did not appear to result in the ejection of the boys involved in that fight. The evidence is that this fight resulted in one boy being struck to the face with

sufficient force that he had sustained a cut to his forehead which was bleeding.

Randolph Bowden, father of Sheridan stated that he did not observe either fight but other adult supervisors did.” No police were called at any stage. No people were cjected from the party.

No people were identified as uninvited inside the party.

None of the adult supervisors who were aware of this fight considered it necessary to do °

"anything more about it once it appeared to stop. Miles stated “There didn’t appear to be much

to it” although he describes seeing a boy with a graze and a little bump over his cye and stated

” that he appeared to be in a little distress and angry. The evidence is that this same boy was

involved in the second fight which erupted in the car park at the rear of the Bowden property.

Nathan Schon, ironically now involved in the security industry as a professional stated that he would now respond very differently to the first fight. He was clear that he would eject the boys involved in that fight immediately. This view was supported by both Scrgeant Tim Bell and Senior Sergeant Alan Dew. Their reasoning was that there needed to be no tolerance for that sort of behaviour inside a party. It was their combined view that such violent and unpredic able behaviour can escalate very quickly, especially in the context of on-going

alcohol consumption amongst teenage boys.

There appears to have been a comfortable tolerance amongst the supervisors of aggressive

behaviour both out the front of the property and indeed inside it.

Clearly, the Bowdens turned their minds to the need for adult supervision of the party and the need to be careful of gatecrashers at both the front and back of the house. Mrs Bowden stated

that she thought that the ratio of 10 adults to 50 teenagers was more than adequate.

However, the evidence reveals that the level of tolerance of underage teenage drinking to the

point of 15 and 16 years olds being visibly effected by alcohol in large numbers, the extra 20

Statement of Randolph Bowden

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or more young people let in despite it beg an invitation only party and the level of tolerance of the fighting inside the party, together with groups of rowdy young people drinking and milling around the front and the back of the premises make for a very volatile mix and a potent recipe for the trouble which indeed did erupt. The tragic outcome in these

circumstances must be a salutary reminder to all parents who contemplate teenage patties.

Head strike and loss of consciousness

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Mr Kavar, neurosurgeon gave evidence about the perils of a headstrike injury followed by a

loss of consciousness. He stated that in any circumstance where there has been a floss of

_ consciousness after a headstrike, that is an indication that there has been a significant insult or

injury to the brain and therefore requires a medical assessment. Mr Kavar stated that where the person is experiencing. confusion, agitation, restlessness, vomiting and headaches, unstcadiness or worsening of their gait, these are all indications of brain injury? Mr Kavar also stated that young people are more vulnerable to head injury as a result of their brain

development being incomplete until about 20.

Mr Kavar stated that the critical time period for monitoring someone in the wake of a headstrike is the fitst 6 hours after the injury. Mr Kavar stated that had Justin been taken to hospital shortly after the headstrike, the outcome would have been different.*! He stated that in his opinion, Justin would have been assesscd at the hospital and probably had a CAT scan performed if the hospital had been advised that he had lost consciousness, in particular if he was also having vision problems and increasing episodes of vomiting and headache. Mr Kavar stated that he believed that a CAT scan would have revealed the blood clot and this would

have caused either Justin’s on -going monitoring or surgery at that stage.

Mr Kavar readily conceded that it is very difficult to distinguish at the time between someone

who has had too much alcohol and someone who is suffering the effects of a head injury as

‘ the symptoms are the same. However, he stated that given the risks of missing the potential

head injury, it was always better to exercise caution and seek a medical assessment.

Jt was evident from the accounts in this case, with the exception of the evidence of one young

person who thought Justin should go to hospital, none of the other group of friends looking

© Transcript P 169

3! Transcript p 156

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after Justin that night appeared to have understood the potential Icthality of what they had just witnessed. Further, none of the supervising adults who were aware that Justin had been knocked to the ground and lost consciousness appeared to understand at that time the potential

lethality of such an injury.

Mrs Bowden stated that her son Harrison came in and initially told her about the boy being knocked to the ground in the car park, but that she was busy tending to the girl with the cut foot at that time. She stated that Harrison spoke with her again at about 1.45 that morning and told her that he and his friends had attended to a fight in the car park at the rear of the house.

She stated that Harrison told her that he saw a boy on the ground but that he had got up within seconds and he was fine and that the boy and his friends had rejoined the party. Mrs Bowden stated that when talking with Harrison at 1.45 she was made aware that a boy had been hurt with a potential head injury. She stated that she was unable to establish who it was that had been hit and so was unable to communicate that to the boy’s parents. She stated that she was acutely aware of the risk of brain injury as a result of head strikes given her voluntary work

with the James Macready- Bryan Foundation.

She stated that she asked Sheridan for the list of boys and for as many phone numbers as there.

might be, but that she did not pursue calling any parents that night because she was concerned that it would be too distressing for those parents to be told to check on their boys if they had not yet reached home. Mrs Bowden described this as a “‘sickening dilemma” for her.” Mrs Bowden stated that she decided to wake Sheridan at 8am to start trying to ring around and find

out who it was that had been hit.

In his statement Anthony King stated he was aware that a boy had been “knocked out” at the party, but in evidence he wanted that to be understood as “knocked down”. Mr Randolph Bowden stated that he had not been aware of the fight in the car park.

Drawing on the evidence from this inquest about the apparent lack of general understanding of the périls of headstrikes and loss of consciousness and the need for medical intervention when such a combination occurs, further investigation was made as to enhancements to the general

“party advice” given to adults contemplating hosting partics for their teenage children. To this

® statement of Christine Bowden

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end, enquiries were made of the Victoria Police Safer Communities programs as to what

information and advice parents are given about how to plan and run an orderly party.

Senior Sergeant Alan Dew formerly of the Victoria Police Partysafe program provided a statement and gave evidence at the Inquest. He stated that the Partysafe program was developed in the Sunbury region as a pilot, in response to a high incidence of gatecrashers in that region. The basic premise of the program at its inception was that members of the community who were planning a party could register it with their local police and upon doing so, they would get a Partysafe kit that contained a door poster to display and tips and advice for what to do. Duty sergeants would advise patrol units of registered party locations and encourage members to drive past if operational demands allowed. An example of a “Puartysafe kit’ developed as between Victoria Police and a local. government was produced to the court.

The kit had a range of useful information and advice containing a list of basic “do and don’ts”,

contact numbers, posters and even a measuring glass to assist in assessing alcohol intake,

Following the success of the pilot, the program was launched across the state in December

2001. In the year between December 2001 and December 2002, 2045 parties were registered across Victoria, By 2006, 75% of all registered parties were for parties for 21 year olds and under, The Victoria Police website contains information on the. Partysafe program but also

tips for the conduct of parties and tips for party goers.

The evidence from Senior Sergeant Dew was that Partysafe are currently working on a new Partysafe Form and process for registration of parties. He also noted that a number of Local Councils have developed their own Partysafe programs complete with kits that are given to

those that register their party with Victoria Police.

Further information has been provided by Victoria Police through Inspector Tony Langdon of the Safer Communities Unit at Victoria Police. In an email of August 31 2012 Inspector Langdon advised as follows: “Victoria Police are in the final stages of implementing on line ‘Victoria Police Party Safe’ form which will enable registrants to input party information online and then have this data automatically generated to their local police station email account, This on-line portal also offers safety and alcohol awareness messaging that is.

consistent with the good conduct of a party. The online form has been created to offer practical advice and warnings if a registrant indicates they are planning a party which may

have known risks or they provide information that may impede the good conduct of their

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party. Such warnings and advice touch on themes for emergency medical plans, legislative compliance, social media risks for party planners and parental and guardian responsibilities.

It is envisaged that a trial period for the on-line form will commence towards the end of 2012.

The ‘Victoria Police Party Safe’ web page will also be updated to ensure continuity of safety messaging and advice for registrants or any person wishing to conduct a party.” (See

Recommendations)

Dangers of “One Punch”

There is evidence in this case that some of the adults who witnessed both the first and the second fight, minimised the seriousness of these fights, even though in both cases there were hits to the face and head. Many efforts have and continue to be made by governments and non-government agencies and entities in an effort to address young male ‘violence. Some of these programs and efforts have been directed at pointing out the perils and potential lethal

consequences of even one punch,

Whilst not wishing to promote any one program over another, evidence of one such community program aimed at reducing male violence was provided during this inquest and for this reason I have noted its work. The evidence with which the court was provided was that the Step Back Think program was formed in the wake of the horrific injuries sustained by James Macredy-Bryan in 2006. James was assaulted in the CBD on his 20" birthday. A single punch knocked him to the ground where his head hit the pavement and he. now has catastrophic brain injury from which he will never recover. Justin Galligan is dead as a result

of just one punch.

The sole mission of the Step Back Think program is to educate young men in particular on the catastrophic consequences one punch can have and to endeavour to reduce the levels of

violence between young males. Justin’s family expressed whole hearted support for the

program.

The program uses its affiliation with a number of football clubs to raise awareness as well as school visits to address young people. I am advised that the program has a strong relationship with the Geelong Football Club in particular. I applaud the woul of this program and others like it and will direct a copy of this Finding be delivered to the Board of the program.

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RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:

1. I recommend that Victoria Police Safer Communities Program incorporate onto its website and into the Partysafe Kits basic information about the dangers of any form of headstrikes.

2. I recommend that Victoria Police Safer Communities Program ensure that the updated Partysafe kits make clear the need for zero tolerance of any violent behaviour in and around

the party and the perils of allowing uninvited people to linger in and around the party area.

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

Mr and Mrs Galligan

Sgt Tim Bell, investigating member Senior Sergeant Alan Dew

Mr Bhadu Kavar Neurosurgeon

Chair, Board Step Back and Think Mr and Mrs Bowden Attorney-General Robert Clark

Victoria Police Chief Commissioner Ken Lay

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Signature:

WDGE JENNIFER COATE TATE CORONER Date: November 28, 2012

Q

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