Coronial
VICother

Finding into death of Louis Gerard Le Boeuf

Deceased

Louis Gerard Le Boeuf

Demographics

24y, male

Coroner

State Coroner Judge Ian L Gray

Date of death

1977-11-23

Finding date

2015-05-07

Cause of death

unascertained

AI-generated summary

Louis Gerard Le Boeuf, aged 24, disappeared from the Sunbury Training Centre on 23 November 1977. He had severe epilepsy, intellectual disability, and required full support for daily living including assistance with walking. He was placed on a veranda for behavioural management and disappeared within an hour. Despite extensive police searches at the time and subsequent reviews, no trace was found. A forensic medical opinion concluded it was 'more likely than not' he was deceased given his medical vulnerabilities and inability to care for himself. The coroner found he died in unknown circumstances. This case highlights risks in institutional care settings, particularly inadequate supervision of vulnerable residents with complex medical needs and the consequences of isolation as a management strategy.

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

Specialties

psychiatryneurologyforensic medicine

Error types

communicationsystemprocedural

Contributing factors

  • disappearance from institutional care
  • severe epilepsy with physical and cognitive disabilities
  • inadequate supervision during behavioural management
  • vulnerability due to inability to walk long distances unaided or self-care
  • isolation on veranda
Full text

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 1992 003557

FINDING INTO DEATH WITH INQUEST

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

Inquest into the death of: LOUIS GERARD LE BOEUF Delivered on: 7 May 2015

Delivered at: Coroners Court of Victoria 65 Kavanagh Street, Southbank

Hearing dates: 7 May 2015

Findings of: JUDGE IAN L GRAY, STATE CORONER

Police Coronial Support Unit: Leading Senior Constable A Hibbins, assisting the Coroner.

| | | | |

I, JUDGE JAN L GRAY, State Coroner, having investigated the death of LOUIS GERARD LE

BOEUF :

AND having held an inquest in relation to this death on 7 May 2015

at Melbourne

find that the identity of the deceased was LOUIS GERARD LE BOEUF born on 5,March 1953

and the death occurred on an unknown date

at an unknown place |

from:

I(a) UNASCERTAINED

in the following circumstances: Background

1, Mr Le Boeuf was last seen alive on 23 November 1977, and was aged 24 at the time.

  1. Mr Le Boeuf had a history of epilepsy, with severe seizures. He was prescribed multiple medications in order to treat his symptoms. Mr Le Boeuf had pronounced physical and cognitive disability, intellectual impairment and behavioural issues. He experienced

difficulty walking and talking. He required assistance to walk, and wore a helmet at all

times duc to the severity of his seizures.

  1. Mr Lec Boeuf was supported with all aspects of his life, and resided at the Sunbury Training Centre (Later known as Caloola) at the time of his disappearance. The Training Centre was operated by the Mental Hygicnc Branch of the Department of Health, as it then was. Thc

Training Centre housed around 500 residents and employed around 700 staff. It consisted of

scvcral buildings sprawled across a large area, including farmland.

4, Mr Le Bouef had spent most of his life in various residential care facilities, His parents

were Teresa Le Boeuf and Philip Joseph Le Boeuf; and he had two younger sisters, Mary

Fryer and Lorctta Hounihan. Mr Le Bouef Snr is now deceased.

Circumstances of disappearance

  1. Mr Le Bocuf was last seen at the Sunbury Training Centre grounds at around 4.15pm on 23 November 1977. It was reported that he had been disturbing other residents and staff by

throwing soft drink at them. A staff member stated that they therefore placed Mr Le Boeuf out on the veranda, where they told him to stay so that he could be observed. At around 5.00pm, it was discovered that Mr Le Boeuf was no longer in the vicinity of the ward. The Training Centre grounds were searched but he could not be located. His disappearance was

then reported to police.

Police conducted a thorough search of the Sunbury township, the Selesian College, and the

wider area and surrounding bushland, but found no trace of Mr Le Boeuf.

On 29 November 1977, police investigated a report from a student of Selesian College, who thought they might have secn a body below the water at the east end of the school lake. The

lake was searched with no result.

Police investigation

Police cnquirics were made again in 1991 to ascertain Mr Le Boeuf’s whereabouts.

Financial searches were conducted with the (then) Department of Social Security, which

yielded no results.

In September 1994, then Senior Constable Karen Patten made enquiries again with the relevant government departments in order to ascertain if Mr Le Boeuf was recciving any payments, and if any addresses or bank accounts had been recorded in Australia since 1977.

Again, these searches yielded no results. A brief was prepared for the Coroner.

In 1995, Deputy State Coroner lain West reviewed the file and determined that he did not have jurisdiction under the Coroners Act 1985 (as it then was) to investigate the circumstances surrounding Mr Le Boeuf’s disappearance, as he was of the view that, at that

time, there was no conclusive evidence that Mr Le Boeuf had in fact died,

Police have not found any trace of Mr Le Boeuf, and no sightings of him were confirmed.

There were no reports to police of any suspicious circumstances, or of anything that might

indicate that Mr Le Boeuf had been the victim of foul play.

The investigation was reviewed and reopened in 2009. Extensive searches with various

agencies were conducted, and all returned no results.

On 31 July 2012, the investigation was allocated to Detective Senior Constable (DSC) Troy Gourlay, who obtained DNA samples from Ms Fryer on 2 August 2012, as she was a lineal family member. The sample was checked. against all unidentified remains and deceased

persons located since Mr Le Bocuf’s disappearance, with no result. Further DNA samples

were taken from both Ms Fryer and Ms Hounihan on 16 August 2012. They were tested in

the same way and returned no result.

  1. DSC Gourlay obtained medical records for Mr Le Boeuf, and on 10 August 2013, he sought a medical opinion from Forensic Medical Officer Dr Kristine Gilbert as to Mr Le Boeuf’s

life expectancy since the time of his disappearance.

  1. Given his medical history, mental and physical disabilities, and noting that it is difficult to give an accurate life expectancy, Dr Gilbert concluded that ‘after absconding it is likely that his life expectancy would be short’, and that in the circumstances she believed that it is

‘more likely (author’s emphasis) than not that Louis Le Boeuf is deceased’

  1. DSC Gourlay provided a brief to the Coroner and requested that an inquest be held into the disappearance of Mr Le Boeuf.

Coronial investigation and inquest

  1. Apart from a jurisdictional nexus with the State of Victoria, reportable deaths are, generally, deaths that appeared to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury. However, some deaths are reportable irrespective of the nature of the death, based on the status of the person immediately before

death.

  1. As well as Mr Le Boeuf’s death (or possible death) being due to unknown causes, it was reportable as he was a person under the control, care or custody of the Secretary to the equivalent of the Department of Human Services at the time of his disappearance.” This is one of the ways in which the Coroners Act 2008 rccognises that people in the control, care or custody of the State are vulnerable, and affords them the protection of the independent

scrutiny and accountability of a coronial investigation.

  1. Another protection is the requirement for mandatory inquests. While there is a discretionary power to hold an inquest in relation to any death a coroner is investigating,’ this was a mandatory or statutorily prescribed inquest as Mr Le Boeuf was, immediately before death,

a person placed in custody or care."

' Statement of Dr Kristine Gilbert, coronial brief page 10.

? See section 3 for the definition of a “person placed in custody or care” and section 4(2)(c) of the definition of “reportable death”.

3 Section 52(1) provides that a coroner may hold an inquest into any death that the coroner is investigating.

4 Section 52(2) and the definition of “person placed in custody or care” in section 3, in particular paragraph (d)} thercof — “a person under the control, care or custody of the Secretary to the Department of Human Services.

22,

This finding draws on the totality of the material the product of the coronial investigation of

Mr Le Boeuf’s death, contained in the coronial brief compiled by DSC Gourlay, as well as the material contained in the earlier coronial brief compiled by police. All this matcrial will remain on the coronial file. In writing this finding, I do not purport to summarise all evidence, but refer to it only in such detail as appears warranted by its forensic significance

and the interests of narrative clarity.

Victoria Police conducted a thorough search for Mr Le Bocuf both at the time of his disappearance and during periodic review of the file, and pursued all avenues of enquiry and investigation. No person has been charged with any offence in relation to Mr Le Boeuf’s disappearance, and police have been unable to find any evidence to suggest that Mr

Le Boeuf is still alive.

Further, I note the expert evidence of Dr Gilbert that, in the circumstances, it is more likely

than not that Mr Le Boeuf is deccased.

Iam unable to exclude the possibility that Mr Le Boeuf’s death was due to foul play or

misadventure. He was a very vulnerable person duc to his medical history and disabilities, and the evidence that he was unable to walk for long distances unaided or care for himself for any prolonged period is compelling.

24, There is scope to consider reopening both the police and coronial investigations in the future, should compelling new facts and circumstances become known.

Conclusion

  1. Iam satisfied that the evidence supports a determination that Mr Le Boeuf is deceased.

Accordingly, I find that: a. the identity of the deccascd is Louis Gerard Le Boeuf, born on 5 March 1953; b. the cause and date of death is unknown; and

ce. Mr Le Boeuf died in unknown circumstances, having disappeared on or about 23

November 1977 in the circumstances described above.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected

with the death:

26, The disappearance and suspected death of a person in circumstances such as these leaves their loved ones with many unanswered questions, in addition to their loss, I convey my

sincere sympathies to Mr Le Boeuf’s family for their loss.

I direct that a copy of this finding be provided to the following: Ms Teresa Le Bouef, Senior Next of Kin c/o Ms Mary Fryer Ms Mary Fryer

Ms Loretta Hounihan

DSC Troy Gourlay, Victoria Police, Coroner’s Investigator

LSC Andrea Hibbins, Police Coronial Support Unit.

Signature:

JUDGE IAN L GRAY

STATE OP Date: 7 ms / ‘s—

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