Finding into death of John Raynox Jansen

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: 2013 / 160

FINDING INTO DEATH WITH INQUEST Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Deceased: JOHN RAYNOX JANSEN

Hearing Date: 1 September 2016

Findings of: CAITLIN ENGLISH, CORONER

Police Coronial Support Unit LEADING SENIOR CONSTABLE JO ALLEN

I, Caitlin English, Coroner having investigated the death of John Raynox Jansen

AND having held an inquest in relation to this death on 1 September 2016

at Melbourne

find that the identity of the deceased was John Raynox Jansen born on 26 October 1961

and the death occurred between 9 and 10 January 2013

at 77 Alamein Road, Heidelberg West, Victoria

from:

1 (a) BLUNT HEAD INJURY SUSTAINED IN THE CIRCUMSTANCES OF A SEIZURE

in the following circumstances:

Introduction

John Jansen was 51 years of age at the time of his death. He resided alone in Ministry of Housing premises at 77 Alamein Road, Heidelberg West, Victoria where he had lived for the past 18 years.

Mr Jansen was born in Colombo, Sri Lanka, to Magdal and Eric Jansen. He was the only boy of six children and his father died in Sri Lanka when he was about 3 years old. In 1985, aged 24 years old, Mr Jansen migrated to Australia to join his mother and sisters. After arriving in Melbourne, he worked in a number of jobs including the Julius Marlow factory. Mr Jansen was receiving a disability pension at the time of his death. Mr Jansen never married and did not have any children. He was estranged from his four sisters! however was in regular contact

with his elderly mother.

Mr Jansen resided alone with thirteen cats:and three dogs. The Department of Human Services obtained a VCAT order on 18 September 2012 that Mr Jansen reinstate his property

to a clean condition and reduce the quantity of his pets.

Coronial Investigation

Mr Jansen’s death was reported to the Coroner as it was unexpected and fell within the

definition of a reportable death in the Coroners Act 2008.

The role of a coroner is to independently investigate reportable deaths to establish, if possible,

identity, medical cause of death and surrounding circumstances. Surrounding circumstances

' Mr Jansen’s sister, Tyris, with Downes Syndrome, died at the age of 32.

are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine

criminal or civil liability.

A police investigation was conducted into the circumstances of his death. An extensive brief was prepared by Victoria Police for the coroner which included statements obtained from

family, friends, neighbours, persons of interest, investigating officers and treating clinicians.

Following findings of significant head injury at autopsy, the Homicide squad was called in to

investigate the circumstances of Mr Jansen’s death.

Detective Leading Senior Constable Leigh Howse provided a summary of the outcome of the investigation in the coronial brief. Detective Howse stated an examination of Mr Jansen’s

house by the Major Crime Scene Unit failed to identify any signs of a struggle.

He further stated Investigators were unable to establish if Mr Jansen was the victim of an assault that resulted in his death or he died as a result of a fall within the enclosed patio of his

residential premises.

Section 52(2)(a) of the Coroners Act 2008 states that if the coroner suspects the death was the result of homicide, a coroner must hold an inquest into the death. On this basis together with the inconclusive findings of the Homicide investigation, an Inquest was held on 1 September 2016 and the coroner’s investigator, Detective Howse was called to give evidence about the

Homicide squad’s investigation.

I have based this finding on the evidence contained in the coronial brief and the evidence of Detective Howse at Inquest. In the coronial jurisdiction, facts must be established to the

standard of proof which is the balance of probabilities.

Health History

Mr Jansen was a chronic long term alcoholic and had a forensic history including numerous

alcohol related offences. As a result of his alcoholism, he had associated liver problems.

Mr Jansen suffered from epilepsy for which he was prescribed Epilim. According to medical

notes from Austin Health, he was prone to seizures as a result of not taking his medication

cs This is subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments,

LS:

and had previously been hospitalised on a number of occasions.’ According to his mother, Mr Jansen would fall and hit his head on furniture inside his home during these episodes.* He had

recently given up riding his bike as he had a number of falls caused by seizures.

Enquiries with the Austin Hospital, Heidelberg revealed that Mr Jansen had attended the Emergency Department on 22 occasions between 17 December 2009 and 27 October 2012

predominantly following epileptic fits and seizures.

Mr Jansen was treated by health practitioners at the Banyule Community Health Centre from

2000. He would often see Dr Padmini Diwikarla who noted Mr Jansen would often attend the clinic and complain of being assaulted or having an epileptic fit. Dr Diwikarla believed Mr

Jansen’s seizures were exacerbated by his alcoholism.

Events Proximate to Death

On 7 January 2013, Mr Jansen attended the Banyule Community Health Service and saw Dr Singh primarily for right knee pain. Dr Singh noted that he had not taken his anti-epileptic medication for the past 4 days.

On 8 January 2013, Mr Jansen attended Banyule Community Health Centre for consultation with dental practitioner Dr John Banky. According to Dr Banky, Mr Jansen presented with a loose left front tooth which interfered with his ability to eat.

Mr Banky conducted an oral examination, which determined that the upper left central incisor tooth was mobile. He arranged for antibiotics and provided him with an appointment on 24 January 2013 to have the tooth extracted. Mr Banky stated that Mr Jansen did not disclose the history or cause of the tooth being mobile and that during the consultation he found no

evidence of any contusions to the lips or inside of Mr Jansen’s mouth.

On the morning of either 9 or 10 January 2013, Mr Jansen’s neighbour, Peta Hughes stated that she observed Mr Jansen standing in the front yard of his premises around 8.30am, drinking from a cup with a handle. She observed he had a dark mark on the end of his nose

which was; “like a gauze or dried blood”’, and she assumed he had fallen over again.

3 Austin Health Medical Records Coronial Brief p.657.

a Transcript of Audio recording, Detective Senior Constable Smout with Magdel Jansen P. 26 of transcript.

5 Statement Peta Hughes,

6 Statement Peta Hughes, 1-4.

22,

its

On 9 January 2013, at approximately 9.00pm, Mr Jansen left his mothers’ address at 6 Pandanas Court, Heidelberg West. He had advised her that he was walking to his home

address, which was approximately one and half kilometres away.

On 10 January 2013, neighbour Tracey Price stated she arrived home, which is opposite Mr Jansen’s house, at around 12.00pm and left again at 12.30pm. Ms Price states that as she left at 12.30pm she observed the metal security door to Mr Jansen’s house to be closed and that

she did not hear or see anything unusual at the time.

At approximately 5.00pm on 10 January 2013, Mrs Jansen attended Mr Jansen’s address to check on his welfare. She located him within the enclosed patio area of his residence,

deceased and notified neighbour, Tracey Price.

Ms Price states she was awoken by Mrs Jansen knocking on her door at around 5.00pm.

When she arrived at Mr Jansen’s house the screen door was already open and Mr Jansen was

lying in the patio area, deceased.

Senior Constable Wilkins and Constable Fawcett from Heidelberg Police Station attended the scene and observed the following; ‘/Mr Jansen was]...lying outstretched on his back within the enclosed patio area with his legs leaning up against the inside of the metal security door.

An empty wine cask bladder was located beneath [Mr Jansen’s] head and a green

environmental shopping bag was located beside his body.’

The contents of the green shopping bag included reading glasses, pasta, cigarettes and a

Banyule Community Health appointment card for 12.00pm, 15 January 2012.

Mr Jansen’s wallet was located inside his right pocket by Senior Constable Andrew Wilkins.

His door keys were located next to his head. Senior Constable Wilkins stated he did not

observe anything to heighten his suspicions about the cause of death.

Police initially concluded that Mr Jansen had fallen and sustained a significant head injury as

a result of his alcoholism and epilepsy.®

Emergency services were contacted and attended at 17.28pm.

Post Mortem Examination

A post mortem autopsy was completed by Forensic Pathologist Dr Linda Iles at the Victorian

Institute of Forensic Medicine on 14 January 2013. Dr Iles formulated the cause of death as

8 Statement Andrew Wilkins, Page 2.

blunt head injury. I accept her opinion, however as a result of the police investigations and medical evidence, I have added ‘in the circumstances of a seizure’ to her formulated cause of

death.

30. Dr Iles noted the following:

‘Post mortem examination demonstrates features of blunt head injury. There is an area of fresh bruising about the left temporal scalp associated with a fracture of the left temporal bone extending into the middle cranial fossa. This is accompanied by a small right acute subdural haematoma, right temporal burst lobe and right frontal burst lobe. The latter appear to represent contrecoup ° type injuries related to blunt trauma to the left side of the head. There is no evidence of underlying natural disease to account for these intracranial injuries; in particular no right middle cerebral artery trifurcation aneurysm identified. In addition to the above, there is evidence of blunt trauma to the front of the face. There is bruising and laceration to the upper lip mucosa. The lacerations correspond to the front of the deceased's teeth. There is also bruising to the tip of the tongue. Odontological examination by Dr Tony Hill has also identified fractures to both central incisors of the

upper jaw on radiographic examination.

The injuries to the mouth are due to blunt force trauma. Whilst the possibility that these injuries were sustained during a fall onto an object with a compact surface with direct impact to the mouth, or impact with a small object in the course of a seizure, cannot be completely excluded, the localised nature of the injuries to the perioral region is suggestive of a blow to the front of the face. The injury to the left scalp and skull is due to blunt force trauma, and whilst there is no specific patterning to this injury, it is possible that this injury was sustained in a fall. This raises the scenario of the deceased sustaining his blunt

head injury as a result of a fall, potentially precipitated by a blow to the front of the face.

Neuropathological examination demonstrates axonal injury likely ischaemic in aetiology, along with ischaemic neuronal injury to the left hippocampus, The fact that these ischaemic injuries are demonstrable histologically indicates a period of survival likely in the order of several hours following these injuries being sustained. I am not able to determine whether the deceased would have been immediately unconscious following these injuries being sustained. It is well recognised that cortical contusions and haemorrhage

can enlarge following initial injury.

° Contrecoup injuries are injuries that occur opposite the area of the body that has been subjected to force.

31,

Examination of the rest of the deceased's body demonstrates scattered bruises of varying ages. There is also mild enlargement of cardiac muscle, testicular atrophy and moderate to

severe fatty change within the liver. The latter is consistent with a history of alcohol abuse.

Post mortem toxicological studies demonstrate a blood alcohol concentration of 0.16%.

Given the deceased's documented long term high level alcohol consumption, this would not necessarily render the deceased overtly inebriated due to a high tolerance to the effects of alcohol. Toxicological studies also demonstrate the presence of valproic acid

metabolites. Valproic acid is used to control seizures.’

Dr Iles’ report indicated it was the injury to the left side of Mr Jansen’s skull and brain that

has caused his death, as opposed to the more superficial injuries to the front of his face.

Homicide squad investigation

34,

Inquiries proximate to time of death

As a result of the findings at autopsy regarding Mr Jansen’s head injuries, on 15 January 2013, the Homicide squad commenced an investigation into the circumstances of Mr Jansen’s

death.

The major crime scene unit attended Mr Jansen’s premises on 15 January 2013 to examine the scene and locate any forensic evidence of value. The scene was videotaped and the photographed. The primary purpose was to determine whether there was any foul play with

regards to Mr Jansen’s death.

In his evidence at Inquest, Detective Leigh Howse, who was with the Homicide squad at the time, indicated it was regrettable the Homicide squad was not informed until four days after

Mr Jansen’s death. This impacted on the integrity of the crime scene.!°

A video and audio recorded interview was conducted with Mr Jansen’s elderly mother, Magdel Jansen. She stated she could not confirm that the metal screen door leading to the enclosed patio area was locked at the time she discovered Mr Jansen’s body, although she specifically recalled using the key and that the key is defective and always sticks, which it did in this instance.'' She called out to her son to come and open it and received no answer. She

stated she then opened the wire door and found Mr Jansen lying on the ground in the patio

a Inquest transcript p 12.

ul Transcript of Audio recording, Detective Senior Constable Smout with Magdel Jansen P. 16 of transcript.

area deceased and the front door was closed. She opened the wire door just enough to allow her to squeeze in, She went to neighbour Tracey Price for help. She stated she was unsure whether he was in the same clothes he was in the day before he died and that three days prior to his death, he had struck his head. She stated Mr Jansen had previously had difficulty with a

person by the name of Ivan Hutton-Latham and a person by the name of Rocco Ottone.

Investigating officers confirmed that the lock on the metal security door leading into the enclosed patio area of the Mr Jansen’s residential premises was operable and in working condition. Investigators believed it was usually locked by Mr Jansen, that was ‘...reinforced by the fact that his mother had utilised the key to attempt to gain access, but just couldn’t

determine whether or not she’d actually had to disengage the lock when she came in.’ *

Detective Howse gave evidence the next step in his investigation was a residential canvas whereby police go door to door to speak with neighbours and others in an effort to determine

exactly what happened on the day of Mr Jansen’s death.

Mr Jansen’s mother was the last person to speak with Mr Jansen when he left her house at 9pm on 9 January 2013. Sergent Howse indicated police were unable to confirm the route Mr

Jansen took home that evening and there were no reported sightings of him.

*...the most logical route would have been across through the park area, and then down on to the commencement of Alamein Road off Southern Road. We extended the search in and

around the school...’

It was not able to be confirmed whether Mr Jansen’s mother had given him the items in his green shopping bag and whether the bag was with him when he left her house on the evening

of 9 January 2013. There was no receipt for the grocery items in it.

As well as making a media release seeking information with regards to Mr Jansen’s movements in the lead up to his death, on 31 January 2013 Homicide squad members set up an information caravan at The Mall, where Mr Jansen was known to frequent. The media release generated a limited number of information reports. The information caravan led to assistance from a shop keeper (who used to give Mr Jansen credit for food) who detailed ‘an

incident whereby he’d observed Mr Jansen have a fit within the Mall some time previous...’'*

a Inquest transcript p 17.

Me Inquest transcript p 14.

4 Inquest transcript p 20.

44,

45,

Investigators spoke to Peta Hughes, a neighbour of Mr Jansen, who stated that she had seen Mr Jansen fall over stumbling drunk on a number of occasions and was always hurting himself.'° She was a significant witness as she had seen Mr Jansen on either 9 or 10 January 2013 and when she saw him, he had a mug of something in one hand and seemed to be speaking on a mobile phone on the other. Detective Howse confirmed Mr Jansen did not have a mobile phone. The dark mark Ms Hughes had noticed on Mr Jansen’s nose was not

confirmed in photographs of Mr Jansen when he was discovered deceased.

Brendan Littler, who did not know Mr Jansen, provided a statement in relation to a conversation he had with his friend, Robert Waight who, according to Mr Littler, is an alcoholic. Mr Littler stated that Mr Waight told him the following whilst intoxicated; that a person visiting Mr Waight on ‘the night’ (meaning 9 January 2013), had admitted they had head butted Mr Jansen. Mr Waight mentioned the names Ivan and Rocky. Mr Waight apparently then went to the deceased’s house and saw blood on the footpath and a blood train

leading up to the house.

Crime scene investigators identified stains on the concrete footpath outside Mr Jansen’s pedestrian gate. The staining was examined by the Major Crime Scene Unit and confirmed it

was not biological material.'°

Robert Waight, provided a statement to the Police. Mr Waight stated that he had known Mr Jansen for about one and a half years and they would regularly drink together. He stated that Mr Jansen’s death had caused a lot of local gossip in the area due to the Police attention it had

received, and that he had heard and discussed lots of different versions with people.

He indicated that his friend, Tina Patterson told him that Mr Jansen was deceased. He stated that Ms Patterson told him that she ‘reckoned’ Mr Jansen was attacked outside his house and that there was blood on the footpath outside his gate. He stated he went to have a look and saw what he thought to be blood.

Mr Waight stated he would have repeated his conversation with Ms Patterson to Mr Littler.

He could not recall telling Mr Littler about a conversation with a person who hit the deceased prior to his death. He stated that conversation did not happen but he may have told Mr

Waight about past episodes of conflict between Mr Jansen and Ivan and Rocco. He also stated

'S Statement of Peta Hughes, Coronial Brief p.

18 Statement Detective Howse, 4.

48,

that in his opinion he did not think Ivan or Rocco would have had anything to do with Mr

Jansen’s death.!”

Investigators approached Tina Patterson on a number of occasions but she declined to make a

statement in relation to the deceased.

Investigators reviewed CCTV footage of the mall in Heidelberg and the Aldi Supermarket in Heidelberg West where Mr Jansen was known to frequent. Mr Jansen did not attend either of

these two locations on 10 January 2013.

Inquiries with the Commonwealth Bank revealed Mr Jansen had not accessed his account since 27 December 2012. His last Centrelink benefit was deposited in his account on 10

January 2013.

Persons investigated

Ivan Hutton-Latham

Ivan Hutton-Latham was subject to an intervention order between 27 July 2010 and 26 July 2011 which prevented him from having any contact with Mr Jansen. There is no record of the

order being breached.

On 28 June 2012, Mr Jansen attended the Heidelberg Police Station and reported that Mr Hutton-Latham had confronted him the previous day in Heidelberg West and threatened to kill him. Mr Hutton-Latham was interviewed in relation to the allegations and denied them.

There was no independent witnesses and no charges were laid.

On 13 September 2012 Mr Jansen was served an intervention order precluding him from having any contact with Mr Hutton-Latham which had been made at Heidelberg Magistrates

Court. There is no record of the order being breached.

Mr Hutton Latham provided a statement indicating that in 2012 he damaged a vehicle in the front yard of Mr Jansen’s property after being threatened and had stayed away from him since. He and Mr Jansen had orders against each other and he had not seen him for some

time prior to his death.

He stated that on 9 and 10 January 2013, he was in the company of his girlfriend Belinda Meyer and had attended Pick-a-Part market in Campbellfield. Detective Howse confirmed in

his evidence Ms Meyer had corroborated Mr Hutton Latham’s whereabouts.

'T Statement Robert Waight Coronial brief p. 102.

Investigators obtained Call Charge Records in relation to both parties’ mobile phones. The records indicate that the phones utilised cell towers in the Heidelberg West and Campbellfield

areas on 10 January 2013.'8

Rocco Ottone

Rocco Ottone was interviewed by investigating officers in relation to his dealings with Mr Jansen. Mr Ottone stated he resides in the Heidelberg West area and has known Mr Jansen for about 10 years. The two men would drink together regularly. Mr Ottone stated they had a falling out around a year prior to his death and that the last time he had seen Mr Jansen was in December 2012, when he observed him walking back from the Banyule Community Centre.

Mr Ottone stated he was in the company of his ex-wife, Maree Stapleton throughout the 10 January 2013. This was subsequently confirmed by investigating officers and confirmed in

evidence by Detective Howse.

Robert Ford

Sas

Investigators spoke to an associate of Mr Jansen’s, Robert Ford. Mr Ford refused to provide a statement however during a subsequent recorded conversation Mr Ford relayed an incident that occurred several months prior where he punched Mr Jansen in the face after he refused to leave his premises, which was the last time he had seen him. Mr Jansen’s mother also referred

to this incident occurring.

It was Detective Howse’s evidence that Mr Ford, also a chronic alcoholic, was frail and elderly and was not known to have been near Mr Jansen’s house proximate to his death.

Detective Howse’s opinion was that he was not capable of involvement with Mr Jansen’s

death. !°

Unknown Male

Janet Matthews stated she lived diagonally across the street from Mr Jansen. She recalled that on 10 or 11 January 2013, she saw a man walking from Mr Jansen’s front door along the pathway to the front gate. The person had trouble opening the gate as it was stuck. He opened the gate and walked out onto Alamein Road towards Southern Road, leaving the gate open.

He did not look very happy at the time and she remarked upon this to her sister. She stated

that the male was in his forties or fifties, of medium build, five foot six inches tall, with an

'8 Coronial Brief p140.

u Inquest transcript p 51,

olive complexion and short dark hair.*” Ms Matthews states she does not know any reason

why anyone would seek to harm Mr Jansen.

Investigators have been unable to establish the identity of the male described by Ms

Matthews.

Other witnesses interviewed regarding Mr Jansen’s general demeanour

Police interviewed Mr Jansen’s sister, Merryel Perera, who told investigators that the family rarely saw Mr Jansen as his alcohol consumption tended to make him argumentative and inappropriate, although they all still loved him very much. She stated he would often have

seizures and be admitted to hospital, not staying very long.

Department of Human Services Senior Housing Officer, Jacqueline Shereff, who had known Mr Jansen since 2006, provided a statement for the Coroner. She reported he was frequently verbally inappropriate and argumentative, and would often clash with people, was frequently getting into altercations when drunk and always had cuts and bruises on his face and

elsewhere on his body.”!

Banyule City Council Ranger, Jenney Cotterell had contact with Mr Jansen in the months leading up to his death in relation to his pets and living conditions. Ms Cotterell described Mr Jansen’s behaviour as erratic. At times he would lash out and abuse people and the next minute he would be laughing and happy. She stated she would often see him with bruises on his face and ask about them. Mr Jansen would tell her he was beaten up and would brush the

incidents off as minor.

Mr Jansen’s friend, Alan Urquhart gave a statement to investigators. Mr Urquhart stated he had known Mr Jansen for about 12 years and the two men used to drink together until around

2006. He stated Mr Jansen was always very drunk. He last saw Mr Jansen about 5 weeks before his death outside the front of his house. He described him as being under the influence

of alcohol, drinking what he believed to be alcohol from a coffee jar.

Police theory regarding Mr Jansen’s injuries

In his evidence Detective Howse confirmed Mr Jansen had no defensive type injuries. The

police theory was that if the metal security door was locked, then it is probable that Mr Jansen

20 Statement Janet Matthews, 1-2.

2! Statement of Jacquelene Sherreff Coronial Brief p. 111

70,

rae

had slipped and sustained a major skull fracture whilst alone in the closed paved area. He

could have fallen or stumbled as he went up the step into his residence.

With respect to explaining the injuries to the front of his face, Detective Howse stated Mr Jansen had complained of walking into a clothesline and striking the front of his face. I find this theory to be unlikely as his mother’s interview states Mr Jansen had complained to her about a knock to his head two or three days prior to the Wednesday, and that she did not see

any blood or injury on his face on 9 January 2013.

Detective Howse noted Mr Jansen had walked a kilometre and a half from his mother’s house to his home that evening and may have sustained some sort of blow to the front of his face.

Mr Jansen had a high blood alcohol level (from toxicology report Mr Jansen’s blood alcohol concentration was .16) and there are drips of blood on his shirt suggestive he has bled whilst he was upright. He later may have had a fit or seizure and sustained the fracture to the back of

his skull when he has fallen.

Investigators found no evidence that Mr Jansen had been assaulted in the enclosed patio area.

Blood samples taken from within the patio area were not tested as Detective Howse stated

they were presumed to belong to Mr Jansen as they were located proximate to his face. 72

Detective Howse accepted the theory Mr Jansen may have had a complicated series of seizures which resulted in the injuries to the front of his face and then to the side and back of

his skull.

With respect to the time of Mr Jansen’s death, Detective Howse was of the view it occurred during the evening of 9 January 2013: there was no CCTV footage of him attending The Mall or Aldi supermarket on 10 January and he had not accessed his bank account despite the fact

his Centrelink payment was paid on 10 January 2013.

Detective Howse confirmed the police investigation into Mr Jansen’s death was closed.

Finding

Mr Jansen had a well-documented history of falls and injuries due to uncontrolled epilepsy and his

ongoing alcoholism.

2 Inquest Transcript p 47.

Mr Jansen had not taken his Epilim for the four days preceding his death. It is highly likely that his serum Sodium Valproate level was sub-therapeutic at that time. This medication is used to treat epilepsy.

Post mortem toxicology indicates that Sodium Valproate was ‘detected’ in the blood but not in sufficient quantities to provide a measurable level. The level found would not be considered to be

therapeutic.

Coronial Investigators were unable to establish any evidence to indicate foul play occurred either in the hours preceding or at the time of his death. Mr Jansen’s wallet was in his pocket and his keys were next to his head. This suggests it is unlikely he was the victim of a robbery at the time of his

death,

In taking into consideration all the available evidence before me it is reasonable to conclude that there is a high likelihood Mr Jansen’s death occurred as a result of an epileptic seizure in the

confines of his enclosed patio.

During the seizure Mr Jansen fell in the confined space and hit his head, causing blunt force trauma, fracturing his skull, and that he sustained facial injuries during the seizure or in a separate unknown

incident prior to his death.

I find that John Jansen died from blunt head injury in circumstances where he suffered a seizure.

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

Mrs Janet Hindricus

Mts Jilska Williams

Sergent Leigh Howse

Signature: =

F a,

CAITLIN ENGLISH

CORONER

Date: 11 November 2016 ———— |