Finding into death of Li Zhen Gao

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2010/3649

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of: LI ZHEN GAO

Delivered On: 9 October 2012

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

Melbourne Hearing Dates: 14 August 2012 Findings of: HEATHER SPOONER, CORONER

Police Coronial Support Unit Leading Senior Constable Tracey Ramsey

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I, HEATHER SPOONER, Coroner having investigated the death of LI ZHEN GAO

AND having held an Inquest in relation to this death on 14 August 2012

at Melbourne

find that the identity of the deceased was LI ZHEN GAO

born on 16 August 1963

and the death occurred between 16 September 2010 and 19 September 2010 at Unit 6, 2 Raynes Street, Balwyn, Victoria 3103

from: la, HANGING

in the following circumstances:

Li Zhen Gao (also known as ‘Jane’) was aged 47 when she died. She had lived alone with her daughter Sue Wang,! at 6/2 Raynes Street in Balwyn since her husband, David Wang, left on 22 July 2010. Her son Andrew Wang had moved out of home a couple of years prior. Li Zhen Gao had a relevant past medical history that included mental health difficulties at different times in the five years preceding her demise, manifested by stress, anxiety, depression and

relationship difficulties as noted by her general practitioners.

Brief Background

A police investigation was conducted into the circumstances surrounding the discovery of both Li Zhen Gao and Sue Wang deceased in their home on 19 September 2010. As noted at

Inquest”, the background circumstances were largely provided by David and Andrew Wang,

Li Zhen Gao and David Wang were married in Shanghai, China, in 1986. David Wang migrated to Australia in 1990 to study, with Li Zhen Gao remaining in China. Shortly after her husband’s departure, the couple’s first child, Andrew, was born. Tn late 1991, Li Zhen Gao followed her husband to Australia, leaving Andrew to be cared for by his grandparents.

Li Zhen Gao and David Wang were subsequently granted permanent residency in Australia.

' Case number 2010/3650

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In 1995, the couple’s second child, Sue Wang, was born. Shortly after her birth, Andrew

joined the rest of his family in Australia.

Throughout the 1990s and up until July 2010, Li Zhen Gao and David Wang operated a series

of successful small businesses and accrued a number of financial assets.

David Wang reported that from approximately 1996, he began to argue regularly with Li Zhen Gao. He stated that these arguments were constant, and as a result, the couple often spoke of

divorce.

Events Leading to Death

David Wang’s statement indicates that he had attempted to “keep the family together” but believed “nothing was working.”* As a result, he obtained legal advice and had his lawyers write to his wife with a property settlement proposal after he left for Hong Kong on 22 July 2010, It appears that he left without informing or warning Li Zhen Gao or his children of his

intentions.

Li Zhen Gao was highly distressed at the realisation of what had occurred and sought emotional support from family via telephone (expressing some thoughts of self-harm) and assistance from a couple of friends who were aware that she was not coping. An offer of counselling from the school at which Sue Wang attended was apparently declined by Li Zhen

Gao.

In the weeks preceding her death, Li Zhen Gao had contact with two general practitioners.

On 15 September 2010, Li Zhen Gao had a will prepared in which she left her estate to her

overseas aunt.

On 16 September 2010, Li Zhen Gao sent a package to her mother containing a cheque and

photos of herself and her daughter.

3 Inquest brief page 74

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Il.

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Over the next few days her son, aunt, and others attempted to contact Li Zhen Gao without

Success,

On 18 September 2010, Andrew Wang attended the Box Hill Police Station after he was unable to contact his mother and sister. He spoke with Leading Senior Constable Dean Leaumont, who conducted a LEAP check. A missing person report was not made at this time, however, Andrew was advised to return the following Monday if unable to establish contact.

The following day, 19 September 2010, Boroondara police received a telephone call from Li Zhen Gao’s friend in America expressing concerns. This prompted a welfare check by police

and the discovery of mother and daughter.

Upon their arrival at 6/2 Raynes Street, police found the body of Sue Wang lying on her back in the hall outside her bedroom with black electrical cable around her neck. An open ceiling access point and ladder was next to her body. Sue Wang had blood around her lips and blood

stains on her top.

Li Zhen Gao was found hanging in the garage, suspended using electrical cord. She had

superficial cuts to her wrists and a kitchen knife was located on the ground next to her.

Located at the scene were four envelopes, each containing an amount of money (specifically $12,000, $7,000, and two envelopes containing $10). Also located was a brown paper bag containing four passports: two were in the name of Sue Wang (of which one was current and one was expired); and two were in the name of Li Zhen Gao, (of which one was Australian and the other Chinese), A Chinese identification document for Li Zhen Gao was also with the passports, Li Zhen’s purse was in this bag, containing just over $300. The kitchen and dining area of the house were reportedly untidy, however there were no signs of a struggle or forced

entry prior to police arrival.

A suicide note was not located.

Post Mortem Examination

An autopsy was performed by Dr Matthew Lynch, Forensic Pathologist at the Victorian Institute of Forensic Medicine. Dr Lynch formulated the cause of death and set out the

following autopsy findings and comments:

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Autopsy Findings

I, Ligature mark about neck,

2. Fractured right and left superior cornua thyroid cartilage and right and left greater horns hyoid bone.

3. Bruising anterior left shoulder, radial left wrist, anterior chest and anterior right and left lower limbs.

4. Superficial incised injuries anterior aspect both wrists.

Comments

1. The cause of death in Li Zhen Gao is neck compression subsequent upon hanging. The mechanism of death in cases of hanging involves one or a combination of airway obstruction, vascular (arterial or venous) obstruction or cardiac arrhythmia induction in the setting of carotid sinus stinndation.

2. The body of Li Zhen Gao was discovered hanging from a support beam in the garage of her home, A young female subsequently identified as Sue Wang (3650/10) was discovered deceased in the house.

3. No significant natural disease was noted at autopsy.

4. Toxicological analysis was negative for drugs and alcohol.

5. This case has been subject to the Institute's technical review process.

Evidence at Inquest

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A focus of the Inquest was to seek some clarity, if possible, about the circumstances and

events leading up to the demise of Li Zhen Gao.

A police summary was read to the Court.*

Dr Lynch told the Inquest that his findings in regard to both Li Zhen Gao and her daughter

were similar in that the ultimate cause of death in both women was compression of the neck.

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In the case of Li Zhen Gao there was evidence that compression came as a result of

suspension in the form of hanging.’ Dr Lynch went on to state:

“there is a point of contrast with Sue Wang in that, (1) she was not observed to be hanging from any particular point, and I’m unaware if there’s any evidence that there may have been a hanging point, other than what I observed at the scene, that there was an open manhole and a ladder. She had a ligature mark on the neck, which is something that falls within the spectrum of injuries that I see in the setting of hanging, but without — from my perspective, without unequivocal evidence that she was suspended from anywhere at any particular point of time, I’ve retreated from using hanging as the cause of the neck compression, allowing that to be left open. And that’s because there are other ways of applying a ligature to a neck and producing the injuries that I observed. And one of those would be application of a ligature to cause death by strangulation, at the hands of another person. But there will be significant overlap — and there’s nothing in the injuries that I observed in Sue Wang that allows me to say this is ligature strangulation. Hanging is a form of ligature strangulation, but ligature strangulation used in the more traditional sense of ligature applied by another party. There’s nothing on her neck that allows me to favour either of those two mechanisms, and in fact if there was any evidence of a point of suspension, I would be of the view that it’s entirely consistent with suspension. But similarly, it’s also consistent with

application of a ligature in a different setting. “6

Dr Lynch was asked about the level and length of application of force that might have been involved in ligature strangulation of Sue Wang. He stated in part “....sufficient force to, I guess, produce an injury to the neck, render the person unconscious and ultimately result in

their death.” 7 He was unable to shed any light on who might have died first.

Detective Senior Sergeant Ian David Snare of the Victoria Police Homicide Squad attended the scene on the evening of 19 September 2010. In his statement that he read to the court he

noted:

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® Transcript page 9 - 10

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“Dr Lynch entered the scene and examined the premises and the deceased persons Wang and Gao. Dr Lynch indicated that it was unlikely that Gao could have been placed in the position in which she had been observed, and it was likely to have been a suicide. Dr Lynch

was not able to establish the circumstances of the death of Wang at that stage.

In view of the information I had received during the investigation, and the known circumstances surrounding the location of the bodies of Wang and Gao, I formed the opinion that it appeared that Gao had committed suicide, in relation to Wang it was not

established if she had committed suicide or had been murdered by Gao. vs

Although Detective Senior Sergeant Snare indicated that he initially considered it possible that the deaths of mother and daughter were the result of a double suicide, it was apparent that by the time of the Inquest he had formed the view that: “Sue Wang was murdered by Li Zhen Gao and that Li Zhen Gao has gone to the garage area and hung herself from the rail.” He went through a large number of factors which had since influenced his change of mind including the depression through separation suffered by Li Zhen Gao; family issues; her retrieval of keys from neighbours; her superficial wrist wounds; the knife located below her; the ladder located nearby Sue Wang and the position of it in relation to the manhole; the partially removed manhole cover and the height of the roof rafters which would have been difficult for either Sue Wang or Li Zhen Gao to reach. He noted there was an absence of any cord of sufficient length to reach the rafters and that the ends of the cord were located towards the rear of the neck of Sue Wang, leading Detective Senior Sergeant Snare to conclude “...it

would be difficult to strangle yourself in that [manner].””

Detective Sergeant Eric Young of Boroondara Crime Investigation Unit read his statement to the Court. He was the lead investigating police officcr in this matter. Detective Sergeant

Young concluded from his investigation that:

“An examination of the scene and background information determined that Li Zhen Gao

had murdered her daughter Sue Wang with a length of electrical cable, by strangling her

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with same, That Li Zhen Gao took her own life by hanging herself from a garage rafter, with

an electrical extension lead."

During questioning at the Inquest, Detective Sergeant Young was taken through several possible scenarios as to how Li Zhen Gao and Sue Wang may have met their demise. One scenario itivolved Sue Wang having died by suicide and having being found by Li Zhen Gao,

who in turn took her own life. In response to this, Detective Sergeant Young replied:

“IT would — and again, only an opinion — highly unlikely. She was a gifted student, 15 years of age and the — although I didn’t attend the scene on the night, the length of cord that’s been described by Detective Senior Sergeant Snare would make it almost impossible for a single individual to have strangled themselves, given the description of the position of the cord around her neck. I don’t believe there was a hanging point for her to do so nearby, where her body was, and although the ladder was positioned above or nearby her, where her body was, and the manhole removed, if she had suicided from there ~ which again is highly unlikely because of the height difference between the manhole and where the rafters are — if someone had have cut her from there, it would be my suggestion that the ladder wouldn't have been perfectly positioned under the manhole as it was, that there would have been some movement of that ladder from that position. I believe that the mother has explored the opportunity to suicide above her daughter, removed the manhole cover and saw how the gap between the manhole and the rafter, realised that it would have been next to impossible and then sought an alternative location, which was the garage, where she

hung herself. vl

Detective Sergeant Young went on to state that the gap between the manhole cover and the

ceiling rafters was approximately six feet. Further, he stated that there was no other rope or

cord or anything else similar that was attached inside the roof cavity.

A second possible scenario pertaining to the deaths of Li Zhen Gao and her daughter was raised with Detective Sergeant Young. Specifically, that Sue Wang may have murdered her

mother, and then took her own life, To this he replied:

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" Transcript page 40-42

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“Stighly unlikely. I would say that the mother would be physically stronger than the daughter, and also on the evidence of Detective Senior Sergeant Snare that was relayed to him by Matthew Lynch that it would be almost impossible for someone to have positioned Li Zhen Gao where she was found hanging from, particularly with the car almost directly

behind her, and the garage door a short distance in front.”” ,

Detective Sergeant Young noted the physical size difference between Sue Wang and her mother which would have made this even more of a difficult task, and the lack of signs of any

struggle that might be expected to occur under such circumstances.

Detective Sergeant Young was asked to comment on any measures that he believed may prevented the tragic deaths of Sue Wang and Li Zhen Goa. He stated that he did not consider there to be any from a police perspective, but possibly in connection to contact with medical

professionals who had involvement with the family. Specifically, he commented:

“There was no domestic violence reported, there’s been no police involvement, apart from

property crime matters, with any of the individuals in this. Perhaps, maybe from the medical

point of view when the doctors have seen them, but not from a police perspective. iad

Supplementary Medical Report

Following the Inquest, further inquiries were made with Dr Lynch concerning the cause of death for Sue Wang and the circumstances in which this occurred. A supplementary report was provided to the Court.'* In connection to whether Li Zhen Gao had strangled her

daughter, Dr Lynch reported the following:

“The marks observed on the neck are consistent with the cord coming in contact with the neck of Sue Wang. This contact could have occurred as a result of the ligature being applied to her neck either in the setting of hanging (i.e. where the force provided to the ligature comes form the weight of the body of Sue Wang) or by the ligature being applied by another

party (an example of what is sometimes termed ligature strangulation). Hither of these

Thid

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“ Supplementary report for Sue Wang prepared by Dr Matthew Lynch dated 3 Scptember 2012

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scenarios in posstble. I certainly have no view as to the position of the mother relative to the

daughter if in fact she has been responsible for applying the ligature. ols

31. This report articulates the difficulties in determining the circumstances in which Sue Wang

died relative to the actions of her mother,

Coroners Prevention Unit (CPU) Review

32. The Coroner sought assistance from the CPU" and a fulsome review was undertaken as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD). The deaths of Li Zhen Gao and Sue Wang met the criteria for the VSRFVD because of the family relationship

between the parties and the context in which these deaths appear to have occurred.

33. The review identified several risk and contributory factors present in the circumstances

surrounding these deaths:

• There was evidence that long-term relationship difficulties between Li Zhen Gao and her husband existed, which had included verbal conflict and frequent arguments. There was no evidence that Li Zhen Gao had made contact with the Women’s Domestic Violence

Crisis Service.

• Itis likely that Li Zhen Gao was experiencing a far greater degree of mental distress than she revealed to her medical practitioners, The review noted that the contribution of mood disorders, particularly depression, to a range of intentional cause deaths is well

established in the research literature.

• The contribution of Li Zhen Gao’s cultural background may have exerted an important influence on the manner in which she sought assistance; disclosed details of her situation; and the extent to which she was willing or able to engage with external service

providers,

' Ibid

16 The Coroners Prevention Unit is a specialist service for coroners created to strengthen their prevention role and provide them with professional assistance on issues pertaining to public heath and safety.

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34, The review examined the mental and medical healthcare provided to Li Zhen Gao. It was apparent that she had regularly consulted with two general practitioners: Dr Bee Boey Goh at Comfort Medical Centre from January 2002 and Dr Yi Yang at Box Hill Centro Clinic from December 2008. The medical records revealed that Li Zhen Gao was reporting symptoms of stress and anxiety from 2005 and both GPs recognised her mental health difficulties including her anxiety, depression and relationship problems, and they took various steps to assist her in

this area.

35. Efforts were made to link her to a psychologist and psychiatrist for more focused support, however Li Zhen Gao did not follow through with these referrals, Medical records do not document Li Zhen Gao having revealed thoughits of intentional self-harm to either Dr Goh or Dr Yang. There is one reference to her feeling ‘unsafe’ however, it cannot be established that this was expressive of suicidal ideation or of being alone. Based on the medical records, there are no clear indicators to suggest that either Dr Goh or Dr Yang should have referred Li Zhen Gao to the Mental Health Crisis Assessment and Treatment (CAT) Service. However, there is no documented evidence that suicide screening occurred. Similarly, medical records make no reference to Li Zhen Gao having been provided with referral information for specific

assistance in connection to the problems she was having in her relationship.

36, The apparent stressors in Li Zhen Gao’s life include her perceived sense of shame regarding the dissolution of her marriage, her changed financial situation and parental responsibilities, in conjunction with her long-standing health problems. The dissolution of her marriage evidently came as a considerable shock, as supported by witness statements. Regardless of David Wange’s reported discussions with Li Zhen Gao regarding divorce in the context of the ongoing verbal arguments, it appears Li Zhen Gao had no idea it was a possibility until the time he left the family home. Li Zhen Gao’s behaviour was reflective of a woman with increasing stress and anxiety. Her need to involve the mothers of her daughter’s friends to help her in the first few weeks after David Wang left, whilst at the same time instructing

people not to tell anyone about her situation, suggests that she was highly conflicted.

Finding

37. Despite the investigations that have occurred into this tragic event, a degree of ambiguity

remains as to the circumstances in which these deaths occurred. When Detective Senior

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Sergeant Snare attended the scene and observed mother and daughter in situ, he was unable to establish if Sue Wang’s death was the result of suicide or attributable to the actions of another person, namely Li Zhen Gao. He gave evidence to the Inquest that he had since formed the view that he preferred the latter scenario and supported the conclusions of Detective Sergeant Eric Young. However, having given consideration to the facts of this case as they currently stand, and the range of evidence produced for the purpose of this investigation, I am unable to be convinced to the requisite degree of certainty that Li Zhen Gao was responsible for taking her daughter’s life. Tam satisfied however, after considering the evidence of the witnesses at Inquest and the further supplementary report of Dr Lynch, together with the material contained in the Inquest Brief, that Li Zhen Gao decided, in a grief stricken state, to end her

own life.

COMMENTS

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

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Relationship breakdown, separation and divorce are understood to be significant life events that can be deeply troubling for some individuals. Changes to accustomed living patterns, social status and concerns associated with the financial and material implications arising from this transition are among the factors requiring adjustment.'7 Whilst it is impossible to determine the extent to which Li Zhen Gao’s relationship difficulties and resultant separation directly impacted upon her decision to end. her life, I am satisfied that her stress was exacerbated by the apparent end of her matriage and the circumstances under which it

occurred.

In this regard, it is important for health care professionals to keep the significance of such an event in mind, and to be vigilant to the signs of patients having difficulty adapting to the necessary changes it demands. This is particularly so for individuals from culturally and linguistically diverse (CALD) backgrounds, who may encounter additional challenges in openly discussing personal concerns and engaging with external agencies or scrvice providers

to resolve these issues.

7 Sec for example Bogolub, F. 1991, ‘Women and Mid-life Divorce,’ Social Work, 36:5, pp. 428-433; Sakraida, T.

2008, ‘Stress and Coping of Midlife Women in Divorce Transition,’ Western Journal of Nursing Research, 30:7, pp.869-887. .

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I direct that a copy of this finding be provided to the following for their information only: The family of Li Zhen Gao Investigating Member, Victoria Police Royal Australian College of General Practitioners

The Victorian Multi-Cultural Commission

Signature:

HEATHER SPOONER CORONER Date: 9 October 2012

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