Finding into death of Warren Meyer

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2011 1660

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: MR JOHN OLLE, CORONER Suspected deceased: WARREN MEYER Date of birth: 3 JUNE 1950 Date of death: _ UNIDENTIFIED Cause of death: UNASCERTAINED Place of death: UNKNOWN

HIS HONOUR:

BACKGROUND

1. On 21 March 2008, Warren Meyer (Warren) and his wife Zanette (‘Zee’) travelled to the Healesville area with a group of close family friends for the Easter holiday weekend. The group stayed at the Badger Creek Caravan Park and on 22 March 2008 the group attended the Innocent Bystander Restaurant for dinner. Information from the group who attended was that Warren was in good spirits and told everyone he was going for a bushwalk to the

Dom Dom Saddle the following morning. !

2. On the morning of 23 March 2008, Warren woke at 7:00am for the planhed bush walk. He.

informed his wife the walk would take approximately 3 to 4 hours and that he would meet

the group at the RACV Club in Healesville for lunch at 1:00pm?

3. Warten showered, ate brealcfast and left the caravan park at approximately 7:45am, He was wearing light shorts and a t-shirt, sports socks anid walking shoes. He took a back pack with

him containing a map, a hand held GPS, a mobile telephone and some snacks.

4. Warren however did not arrive for lunch and at approximately 4pm the group attended the Dom Dom saddle car park and found Warren’s station-wagon parked and locked. At this point Zee Meyer contacted police and reported him missing. A later inspection of his vehicle

confirmed it appeared untouched, and that Warren had taken his backpack with him.

5. At the time of his disappearance Warren was 57 years old and resided with Zee and their two children, Renee and Julien. Warren was a consultant civil engineer who operated his

own business ‘Meyer Consulting Group P/L’ in Elwood, At the time of his disappearance

this business was very successful and financially secure.

6. Warren has been described as a loving family man and a fit and healtliy individual who

participated in numerous bush-walking activities.

7, The immediate search into Warren’s disappearance ran for five days with an average of 150 personnel daily utilising foot searchers, air wing, mounted branch, motorcycles, sniffer dogs

and electronic tracking via the mobile phone believed to be in Warren’s possession. The

' Statements of Zanette Meyer, Margaret Hewitt, Michael and Ann Cowell, Noel and Jill May, Merryn Brown and Anne Cain ? Statement of Zanette Meyer

Page t

search involving personnel from Victoria Police Search and Rescue, State Emergency Services, the Country Fire Authority, Parks Victoria and Melbourne Water failed to locate

any sign of Warren, or any of his belongings.

The search ceased on 28 March 2008, following the advice of Dr Ian Millar from the Alfred Hospital who, after taking into consideration all of the circumstances surrounding Warren’s disappearance, concluded Warren may have become incapacitated and that the chance of

survival beyond 28 March 2008, was small to negligible.

THE PURPOSE OF A CORONIAL INVESTIGATION

13,

A death constitutes a ‘reportable death’ under the Coroners Act 2008 (Vic), if the death occurs in Victoria, was unexpected, unnatural or violent or has resulted, directly or

indirectly, from an accident or injury.?

The jurisdiction of the Coroners Court of Victoria is inquisitorial. The purpose of a coronial investigation is independently to investigate a reportable death to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which death

occurred,

It is not the role of the coroner to Jay or apportion blame, but to establish the facts.° It is not the coroner’s role to determine criminal or civil liability arising from the death under

investigation, or to determine disciplinary matters.

The “cause of death” refers to the medical cause of death, incorporating where possible, the

mode or mechanism of death.

For coronial purposes, the circumstances in which death occurred refers to the context or background and surrounding circumstances of the death. Rather than being a consideration of all circumstances which might form part of a narrative culminating in the death, it is confined to those circumstances which are sufficiently proximate and causally relevant to the death.

The broader purpose of coronial investigations is to contribute to a reduction in the number

of preventable deaths, both through the observations made in the investigation findings and

3 Section 4, definition of ‘Reportable death’, Coroners Act 2008.

4 Section 89(4) Coroners Act 2008.

5 Keown v Khan (1999) 1 VR 69,

by the making of recommendations by coroners. This is generally referred to as the

‘prevention’ role.

Coroners are also empowered:

(a) to report to the Attorney-General on a death;

(b) to comment on any matter connected with the death they have investigated, including

matters of public health or safety and the administration of justice; and

(c) to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of justice. These powers are the vehicles by which the prevention role may be

advanced,

All coronial findings must be made based on proof of relevant facts on the balance of probabilities. In determining these matters, I am guided by the principles enunciated in Briginshaw v Briginshaw® 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 that they caused or contributed to the death.

Investigation and briefs

19,

There have been a variety of briefs and reports prepared for this matter, including the otiginal missing person investigation reports, a brief of material prepared by the family and

the inquest (coronial) brief.

Detective Senior Constable Walls, previously of the Alexandra Crime Investigation Unit, was the initial police investigator when Warren was reported missing. A number of different investigators had camiage of the matter until 1 November 2010, when Detective Leading

Senior Constable Andrew Dunsford was tasked with continuing the investigation.

In May 2011 DLSC Dunsford prepared a report of suspected death for the Coroner’s Office, and subsequently prepared the original inquest brief, submitted to the Court on 20 February 2012.

When this matter was first referred to the Coroners Court as a suspected death the matter

was being handled by the Police Coronial Support Unit (PCSU). As issues were later raised

§ (1938) 60 CLR 336.

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in respect to the police handing of the investigation the matter was referred to the Court’s independent In-House Legal Service to assist. DLSC Dunsford continued as the Coroner’s

Investigator.

In February 2012 Zee Meyer made an application for an inquest into her husband’s death.

In February 2012 a copy of the brief was released -to the Meyer family and they were advised their request for an inquest had been received and that the investigation was still

ongoing.

Following my initial review of the brief I directed further inquiries be undertaken that encompassed inter alia the medical and psychiatric records of Anthony Williams, who had been sighted in the area that Warren disappeared, the alleged sighting of Warren and photograph taken by Geoffrey Ellis at the Hotel Miramar in Italy, and to obtain a list of appropriate aged males who departed Tullamarine Airport in late March 2008 from the Department of Immigration to match this with the guest list from the Hotel Miramar on the evening of the alleged sighting.

The Coroner’s Investigator submitted a supplementary statement detailing his further

investigations in November 2012.

On 20 March 2013 I conducted a mention hearing. At the time I indicated that | was unable to make a coronial finding on the material before me, and that I needed to have further investigation done.” J also indicated that J was seeking an independent review by Victoria

Police of the initial missing person investigation in 2008.

The Meyer family made formal submissions to the Court in April 2013.

At a second hearing on 2 July 2013 a representative for the Chief Commissioner of Police indicated that Detective Senior Sergeant Goddard,.as he was then, from Professional Standards Command had been selected to conduct the review, and that if he identified any

gaps in the information he could assign matters to Homicide or Missing Persons.

l indicated at that time that I did not want to put any constraint on this review, but that it was

necessary that it was objective and comprehensive.

? Transcript of mention hearing, page 1 5 Transcript of directions hearing, page 7

Pape 4

'

29. I have considered all of the extensive material gathered during the initial investigative

stages, the Review, and further inquiries in the preparation of this finding, but do not purport

I to summarise all of it.

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The Goddard Review

30. DSS Goddard conducted a full review of the initial police investigation, and any identified

breaches of the relevant Victoria Police policies and procedures.

31. DSS Goddard concluded that the initial five day search of the Mt Dom Dom atea was an

efficient and effective search response and that during the search all general missing

persons’ avenues of inquiry were conducted,

32, He noted that Detectives from Alexandra Criminal Investigation Unit commenced investigating Warren’s disappearance immediately and in the following days gathered and

assessed a significant amount of information received from the public.’

33. The missing person investigation included obtaining written statements from family and

friends of the Meyer family, enquiring into Warren’s medical history, checks of-all his bank

accounts and speaking to staff from Meyer Consulting.

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Black Saturday

34. Advice was provided to DSS Goddard by the Homicide Squad, the Missing Persons Unit and the Phoenix Task Force (Black Saturday Investigation Team) that in February 2009

areas in.and around Narbethong were engulfed in the Black Saturday bushfires.

: 35. As part of my ongoing investigation I made inquiries as to the identified deceased in the :

area, and requested relevant spatial maps and data relating to the 2009 bushfires.

36. I also reviewed publically sourced material including excerpts from the Bushfire Royal

Commission Report and media articles relating to the location and identification of

individuals who perished in the Black Saturday Bushfires,

37. No unidentified deceased persons were located in the Narbethong area,'°

° Review of the Investigation into the Disappearance of Warren Meyer, pg 5 : | '© Review of the Investigation into the Disappearance of Warren Meyer, pg 14 , |

38. In July 2009 ante mortem DNA samples were taken from Warren Meyer’s children and lodged at the property store at Alexandra Police Station. These samples were transferred to the Forensic Services Department in March 2011. In May 2013 the samples were conveyed to Victorian Institute of Forensic Medicine where they were profiled and uploaded to the

Combined DNA Index System, CODIS.

39. CODIS had been introduced in Victoria in Jate 2009 to assist in the ‘Black Saturday’ investigations, however at the time there were strict legislative requirements which

prevented ante mortem DNA profiles to be added for missing persons.!!

40. Mr Meyer’s dental records were also provided in July 2009 and are stored with the

investigation file.

41, The Victoria Police Missing Persons / Homicide Squad currently has Watren Meyer recorded as a long term missing person with direct links to DNA samples being held on CODIs.?

The Financial Review

: 42, An extensive financial review of Warren Meyer’s financial situation was completed by the Manager of the Professional Standards Command’s Financial Investigation Unit in April

2015. The financial profile generated indicated that in the years leading up to his disappearance Warren had been effectively employed by the company Meyer Consulting Group both as

Director and as Company Secretary.

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44, Warren had previously been the director of a company that was de-registered in 1998, likely after he was declared bankrupt.

45, Bank accounts controlled by Warren by himself, or with his wife Zee, had in balance in | excess of $769,000 in March 2008 when Warren disappeared.

" Review of the Investigation into the Disappearance of Warren Meyer, pg 12-13.

” Review of the Investigation into the Disappearance of Warren Meyer, p& 12-13.

Page 6 |

Warren had no credit defaults, made no credit enquiries and analysis of credit cards accounts indicated they were generally paid on time, therefore indicating it was unlikely that Warren

was under pressure from creditors at the time of his disappearance,

Tt was noted that in the 24 months prior to Warren’s disappearance the Meyer Superannuation fund received $106,812 in deposits, and a total of $209, 441 was recorded as being transferred from this account to the account ‘wmsuper’, and that the shareholding of

the Meyer Consulting Group was altered for Warren to cease holding shares.

It was suggested these two things may indicate that Warren, who would have turned 60 in

2010, was actively planning for retirement.

The analysis was unable to locate any evidence of funds being streamed out of the accounts

to allow for Warren to support himself independently.

The tracks

SL.

The walk to Dom Dom summit is a recognised walk of moderate difficulty which takes approximately two hours in either direction. For a person of Warren’s bushwalking

experience it would not have been challenging.

A search of Warren’s vehicle, parked in the Dom Dom Saddle, ‘located a number of topographical maps of the surrounding area in the car. Topographical Map T8022-4-1-3 was

missing.

In the family’s submission it is identified that it is not known which track Warren took, but indicated that the two ‘likely’ options for his hike were the Morley’s track or the Monda

track as they are the two predominant tracks, and Warren knew them.

Morley’s track is a medium grade track and is 9.3km one way (approximately 3.5 houts) and is predominantly downhill. The Monda track is classified as a hard grade track and is a

16.2km circuit.

The family indicated it was characteristic of Warren to choose a known option when he

hiked alone. There were however varying views as to whether Warren would leave a track.

Friends told of Warren’s love of trees and that he may have left a track to have a closer look,

Cobwebs on the tracks

Reference had been made in the statement of an associate who had been with the Meyers that weekend, Michael Cowell, to cobwebs that had been sighted on a track it was believed

Warren was planning to travel.

Michael Cowell and other males arrived in his four wheel drive and started to drive around the tracks looking for Warren shortly after his disappearance. Michael Cowell recalled that Police Search and Rescue had told them that when they went up the mountain track to search for Warren he could not have gone that way as there were still cobwebs across that particular track, Michael Cowell stated that ‘7 distinctly remember this comment because

that was the track Warren had said he was going to walk.’™

When the original brief had been received at the Court my assistant contacted Leading Senior Constable Ian Veitch, the Search Co-ordinator from Search and Rescue, to obtain his

comments on the spider web observations.

LSC Veitch indicated that Sergeant Tim James was the initial person tasked to that area who

had searched the Dom Dom track to the top of Mt Dom Dom, and that the comment:

“,..was that there was cobwebs across the track and that if a person had been through that particular part of the track then the webs would be broken. He did continue to search the track to the top without success.

Sgt James is an ex Special Operations Group member. He is very experienced in searching

in bush conditions and looking for clues of movement through the bush.

The area along the track was searched and the comment about the cob web was an

observation that he noted on the way.

His initial search of the track up to the top was also followed by repeated line searches of

the area by SES, police, dog squad and horses.’!*

I asked for this particular aspect to be explored further by DSS Goddard querying if it was possible Warren had taken another track on that day.

18 Statement of Michael Cowell, page 2, original coronial brief.

'4 Email dated 6 March 2012 to PCSU

As part of his review DSS Goddard established that the search that was conducted of the Dom Dom area was resourced by in excess of 150 personnel and included a search of all tracks leading from the Dom Dom saddle car-park. DSS Goddard spoke further with Jan ‘Veitch and was ultimately satisfied that Search and Rescue co-ordinated an exhaustive

search of all designated tracks in the area of Dom Dom saddle,

It was concluded that Warren is unlikely to have gone down the Dom Dom track if there

were still cobwebs present when the searchers went down there.

Anthony Williams

64,

Detective Senior Constable Walls from Alexandra Criminal Investigation Unit initially reported information that an involuntary psychiatric escapee had been sighted in the vicinity of Dom Dom Saddle between 20 and 24 March 2008, and that he had been re-captured and returned to care at Upton House Box Hill. DSC Walls was initially concerned that Warren may have met with foul play, with Anthony Williams implicated, and applied for a search warrant for Anthony Williams’ premises, with nil items of interest located. Shoes and

clothing belonging io Anthony Williams were tested for blood, again with no result.

Anthony Williams when spoken to by police had stated had been picked up by a caniper

who lived in Berwick and had a Repco utility.

A call out to witnesses and campers in the area resulted in the location of a camper who

confirmed he had picked up Anthony Williams on 23 March 2008.

Jason Smith, the identified camper, stated on 28 May 2008 that around 10:00am on 23 March 2008 Williams wandered into their camp and that he drove him in his Repco utility

van to the Shell Service Station in Warburton.

On 21 March 2008 Anthony Williams stated he had driven his de facto’s car and ran out of petrol at Narbethong outside the Black Spur Inn.! Police records show that police did a welfare check on him on 21 March 2008, when he was found sleeping in his car. The relevant patrol duty sheet indicates this welfare check was conducted outside the hotel on 21

March 2008 at 9:15pm. Williams later left the car and commenced trekking in bushland,

'5 Page 6 Goddard review

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A photo believed to be Williams, and that matched the clothing he was wearing, was-

captured on a camera for deer watching in the area.

DSC Walls constructed a timeline for Williams’ identified movements, which indicated he would have had to walk 8km through bushland in an hour period to intersect with the area

Warren was believed to be, which was not possible given the terrain,

In correspondence and submissions the family raised that there were discrepancies in the timeframes regarding the movements of Anthony Williams, and that the police had the times

wrong.

Ms Meyer’s legal representatives suggested that the information on the police brief puts Anthony Williams close to Dom Dom saddle on the evening of 22 March 2008,

The family indicated that they were of the view that Anthony Williams could not be eliminated, particularly considering his possible agitated state and doctor’s notes indicating

homicidal ideation.

On 29 March 2008 all available information relating to Williams as a person of interest in the investigation had been assessed by Detective Senior Sergeant Jeffrey Maher, an investigation manager at the Homicide Squad. He concluded that Williams could be

eliminated as being involved in Warren’s disappearance.

DSS Goddard also reviewed the investigation into ‘Williams as a person of interest in Warren’s disappearance and concluded that there is no evidence available at all to show a

nexus between Anthony Williams and Warren’s disappearance.

Shooting in the area

TA,

Another matter raised during the investigation by the family was the ‘illegal’ shooting at

Easter time during the relevant time frame of Watren’s disappearance.

Police released this information to the media in April 2008, including the theory that Warren

may have been struck by a stray bullet.

‘6 Homicide Investigation Report prepared by DSC Wilson in consultation with DSS Maher

Craig McDermoit, who had initially reported hearing out of control shooting, gave a statement to police on 29 October 2008.'7 He stated that he heard shots in direction of the Monda track at approximately 3pm on Sat 22 March 2008 that he thought were from a high calibre weapon. What caught his attention was the rapid nature of firing, which went on for about 2 hours. Craig McDermott stated that this continued on Easter Sunday morning,

commencing around 8:30am,

Significant media coverage of the shooting theory occurred however upon review DSS Goddard was not able to establish any nexus between the gun shots and Warren’s

disappearance,

If Warren fell victim to an accidental shooting it is most likely that some evidence as to this would have been discovered with the extensive searching of the area, either on one of the

walking tracks, or nearby.

Medical event

Expert medical opinion was sought prior to the suspension of the search for Warren. On 28 March 2008 Dr Ian Millar was asked his opinion of survival of someone who has been unable to respond to help or make their way to safety after 5 nights / 6 days missing in the

conditions.

Dr Millar suggested that Warren may have become incapacitated and unable to respond to searchers, presumably within the first 24 hours and that his chance of survival beyond 28 March 2008 without medical attention or shelter would be extremely small to negligible, and

that he would support the decision to suspend the search pending new information.

DSS Goddard was of the opinion that Warren may have had a catastrophic event that lead to him not being able to be located in the bush terrain. The family submitted that health records

indicate the contrary, and that they believe DSS Goddard’s opinion was incorréct.

I formed that belief that although Warren was clearly a fit and healthy individual who hiked regularly it is still an open possibility that a medical event may have occurred on the day of

his disappearance.

'7 Review Report, pages 10-11

The mobile phone

On the morning he disappeared Warren Meyer was carrying his wife’s mobile phone which was registered to the Optus network. According to the family’s submission the Nokia phone

was fally charged.

Issues around the identification and location of this phone occurred throughout the Missing

Persons investigation.

The family submission contained the following:

‘The family invested much time on the reported ‘ping’ that was meant to have signalled that Warren’s phone communicated with a phone tower approximately an hour into his walk which oddly coincided with the end of a shooting spree by illegal shooters (9.01am). Police Search and Rescue had been told about this ‘ping’ by Optus on the week that Warren went missing and much effort was undertaken by experts to pick up a signal coming from Warren's phone then. We spent several hours with Optus technicians a full year before LSC Walls examined this issue himself at the end of 2009. In the end Optus claimed theré was no ping at ail.’ Victoria Police first requested a Mobile Handset check at 6:20pm on 24 March 2008, but the phone was unable to be located via the radio network. At this point Optus set up a mobile handset check or ‘ping’ that ran every few hours between 24 March 2008 and 28 March

2008. At no stage did the handset register.!9

Optus originally reported to police that the last activity from the phone occurred in the Marysville sector; that is the last event made or received via the switching network. Optus have no record of any call on file, and the account records for this mobile also indicated no

call,

In a statement provided in the original coronial brief Optus indicated they were only able to advise that the mobile phone believed to be carried by Warren passed through the coverage area of Marysville Sector 1 at some stage prior to it being turned off, losing battery power or

moving out of range.

18 Family brief submitted in April 2013, pg 20 19 Thid, page 12

97,

There has been much consideration during the investigation as to the tracing of a possible

final phone call and a registered ‘ping’.

The Search results contained in Search Co-ordinator LSC Veitch’s statement include: ‘24/03/08 — Optus phone trace indicates phone in range of Mt Gordon tower at 9:01 hours on 23/03/08 — uil activations since. Mt Dom Dom most prominent peak in this area and has

coverage from this tower.’

The suspension of search report dated 28 March 2008 also makes reference to the phone

being in the range of Mt Gordon tower at 9.01am on 23 March 2008.

DSS Goddard indicated that the ‘ping’ in the area of the Mt Gordon tower at 9.0lam on 23 March 2008 has not been able to be substantiated and that extensive enquiries were made with Optus between November 2008 and December 2009 to establish the time and date that the phone last registered back to the network, but that Optus have not been able to clarify this point.

Further DSS Goddard indicated that the information that was provided to police at the time by Optus has also been unable to be substantiated.

Alan Spencer, a-friend of the family who often hiked with Warren, tirelessly researched this point with Optus and tried to replicate phone coverage, tower and track link-up. There are

numerous emails attached to the Review Report that outline this.

Clearly this research was based on. the notion that a ping had actually registered on the

morning Warren disappeared.

In an email to the police dated 9 November 2008 Alan Spencer gave an update on the searches he conducted regarding the ‘ping’ and that he has mapped the entire area in relation to the ‘ping’ from the Mt Gordon tower. As a result of their research he indicates that they

believe that Road 8 has been eliminated, 7°

Alan Spencer indicated that they walked the entire track watching the tower markers

appearing on their phones and that:

‘My feelings are that the ‘ping’ mapping suggests Warren walked the Monda track as

2 Email from Alan Spencer to Ian Veitch, pg 332 of Review Report Appendix

99,

Buxton tower and Mount Gordon seem close and in line, Archers Hill is about 1 hours walk

from Dom Dom saddle fitting in with Warren’s phone ‘pinging’ at about 9am.’

In an email to Alan Spencer dated 4 February 2009, LSC Ian Veitch answers some queries

from Alan Spencer regarding the phone and tower as follows:

‘From the info below it seems there is confusion about the 9.01 ping. Through our police communications we were informed that the phone had registered on the network at that time. It was described to us as a ‘handshake’ to alert the tower that the Phone was polling off it. This is done automatically when the phone is trying to locate network access. We have never been informed that a call was made at that time (9 in or out) so that information would not show up on a bill etc. From talking with the police communications and Optus

techs that attended the only evidence of the phone in the area of the Mt Gordon tower was

that single ping.’?!

LSC Veitch also made reference in this email to the last call registered on the phone was, from his memory, on the Saturday before Warren disappeared and that any record of the call

has been lost.

David Finlay from Optus in referring to customer records stated that:

Optus are only able to advise that mobile service 0402910668 passed through the coverage area of Marysville Sector I at some stage prior to the mobile service moving out of range of

the Optus mobile network, losing battery power or being turned off/broken,

According to the Opius records created by staff of the Optus Network Management, the Victoria Police first requested a Mobile Handset Location check via the NMC at 6:20 on 24 March 2008. At that time NMC staff attempted to locate the mobile but it was not turned on

or was out of range and, as such, was unable to be located via the radio network.

The staff of the NMC queried the switching network and found that the last telephone call that was made or recetved by the mobile service had been located within the coverage area of Marysville Sector 1 at the time of the call. There is no record on file at this stage of the time or date of that call.

The Optus tower with the name Marysville is located at Mt Gordon Road, Marysville.

71 Pg 322 of Review Report Appendix

Optus NMC staff set up a mobile handset location check (or ping) that was run every few hours between 6:30 on 24 March 2008 until 18:08 on 28 March 2008. At no stage afier 6:20 on 24 March 2008 did the handset register back to the Optus mobile network. ”

Both the Coroner’s Investigator and DSS Goddard have indicated that this point could not be taken any further. It is a complex point that unfortunately, due to lack of records, seems to be unable to be resolved. It cannot be concluded with any certainty whether the ‘ping’

that was registered by Optus occurred on the day that Warren disappeared, or the day before.

The Ellis photo

106,

Geoffrey Ellis gave a statement to police on 30 April 2009, saying he had sighted an individual he believed to be Warren Meyer on 4 April 2008 at the Hotel Miramar in Santa Margherita. Geoffrey Ellis stated that this man was sitting with a female, reading a book and that he did not approach or talk to him. Geoffrey Ellis spoke to hotel staff, who told him the man was speaking German” and that he took a photo of this person from approximately

10-15 metres away.

The family submitted that the evidence of Geoffrey Ellis should be discounted completely.

During his review DSS Goddard discussed Mr Ellis’ statement at length with him and Mr

Ellis clarified details in his original statement. He is certain it was Mr Meyer sitting in the .

hotel in Italy, and that he was a distance of approximately 3 metres from him when he looked directly at him, front on but that he does not know why he did not approach him on the night.

DSS Goddard reviewed the investigation of this sighting and concluded in the absence of other evidence, and without satisfactory corroboration he is not satisfied that it was a sighting of Warren and that he does not believe this avenue of enquiry requires any further

investigation. 74

I made enquires as to the enhancement of the photo, and was advised that the best

enhancement would be able to be conducted from the original phone.

Statement given 7 December 2009.

3 Warren Meyer is of Gecman descent but Zee Meyer told DSS Goddard that he does not speak German 74 Page 10 Goddard Review

The Coroner’s Investigator followed this up with Geoffrey Ellis who advised that he no longer had that phone.

Irrespective of this ] sought to have the original photograph enhanced through the Macleod Forensic Centre to ensure every avenue of inquiry had been completed. Unfortunately it was confirmed by Macleod Forensic Centre in November 2016 that digital enhancement of the

original photo taken on Geoff Ellis wife’s phone was unable to be performed.

Missing persons’ week

112,

113,

Warren’s disappearance was run again during Missing Persons Week in August 2014 and

received a substantial amount of publicity.

Following on from this Victoria Police indicated to me that they were pursuing a line of inquiry regarding a caller who identified that Warren had been killed after straying onto a

marijuana plantation, and that he ‘... would never be found.’

The Coroner’s Investigator, DLSC Dunsford followed up these inquiries, including surveillance, and conducted analysis of the phone records of the individual who made the

report,”

On 10 November 2014 DLSC Dunsford indicated that his further inquiries revealed no credible information. DLSC Andrew Dunsford also provided a copy of the relevant running

sheets and Information Reports that were generated to me for review,

Professional Standards Command also advised that other discrete inquiries that had been

generated through information reports were not fruitful.

Review of the police investigation

As a result of his review of the management of the investigation into Warren’s disappearance DSS Goddard found that the investigation was protracted due to a number of

coniplex issues along the way. This in turn ‘has unfortunately led to distress for the family.

DSS Goddard has noted that the Homicide Squad had active involvement in the initial

25 Email from DSS Goddard dated 14/08/14 26 Email from DLSC Dunsford dated'21/10/14

stages of the investigation and provided ongoing guidance throughout. However the ‘Black Saturday’ fires that occurred in February 2009 had a significant effect on police resourcing

and prioritisation.

As a result of his review DSS Goddard indicated that since Inspector Dan Trimble arrived as the Local Area Commander for Benalla in 2011 -improvement opportunities and investigation management gaps were addressed, and new procedures put in place for the

investigation of missing persons.

Missing persons investigations and policy

121,

There clearly were difficulties presented in the initial investigation due to DSC Walls’ absence following the bushfires, resulting in the initial brief not being comprehensively compiled, which compounded the family contending the long delays indicate the police

handled the investigation poorly.?”

Following the review I determined to more fulsomely address the avenues of inquiry that were undertaken, and requested DSS Goddard to address these to ensure any concerns could

be ameliorated.

During his review DSS Goddard did not identify any departures from police policy, procedures and guidelines, patticularly as the Missing Persons guidelines did not exist in 2008 and that they were created in 2010. The Missing Persons Unit was established in July 2012, which contains specialist trained investigators to monitor and investigate long term

missing persons,

During his review DSS Goddard comprehensively reviewed the. investigation file, and had extensive discussions with the police personnel who were involved in the search phase and

follow up investigation.

Following the review DSS Goddard formed the belief that Warren undertook a hike from Dom Dom saddle car park and that he more than likely suffered a medical episode, or wandered off the track in severe terrain where he has become incapacitated and unable to

respond to searchers.

27 Goddard review page 16

Page 17.

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122, DSS Goddard found no evidence to indicate Warren’s disappearance was due to foul play, and attributed it to accident or misadventure.

123. A maissing persons’ case can be reported.to a coroner at any time, and a coroner can assess and potentially form the belief of the probability that the person is deceased through the outcomes of police investigation and inquiries.”*

124, If it fails on the balance of probabilities to satisfy this belief it is open to the coroner to refer the matter back to the police at any time.

125. In respect to this matter LSC Dunsford first contacted the Court in 2011 indicating a suspected death, and a brief of evidence was requested,

126. As the coronial jurisdiction is limited in investigating circumstances surrounding suspected deaths in a situation where there is a disappearance and no body located, to confirm a death has in fact occurred, the coroner must properly be satisfied that every possible inquiry has been made in an attempt to locate the person to ensure, if possible, that they are not still alive. ?

127, Following the initial issues raised around the preparation and provision of the brief the Goddard Review was instigated to ensure all possible avenues of investigation had been explored.

128, note that the missing persons’ investigation into Warren’s disappearance is still ongoing.

Inquest

129. This was not a matter that called for a mandatory inquest. As referred to earlier in 2012 Zee Meyer submitted a request for an inquest and was advised that further inquiries were necessary to assist with my investigation.

130. In the final paragraph of Zee Meyer’s correspondence attached to the request is the

following: ‘In summary we believe that an inquest is needed to try and understand what has happened to Warren on his morning’s hike, with particular reference given to the

psychiatric patient, the shooters and the reported sighting in Italy.’

#8 AFP: Navigating the coronial process: a guide for families of missing persons 25 www.missingpersons. gov.au

131. One of the primary reasons behind the initial inquest request was the conduct of police. It was indicated to Ms Meyer’s legal representatives at the time that the appropriate vehicle for

a complaint in respect to the police’s conduct was not an inquest.

132. Ms Meyer also raised her concerns with the conduct of police involved in the initial

investigation with the Chief Commissioner of Police.

Result of further inquiries

133, Since the initial application and request for inquest Ms Meyer raised a number of further

issues that were influencing her belief as to what may have occurred to Warren,

134. Considerable resources both across the Police and within the Court have been devoted to

this matter, and significant further investigation and review has been undertaken.

135. The Homicide Squad initially investigated the suspected involvement of Anthony Williams in Warren’s disappearance, and DSS Goddard concluded that there was no cogent evidence

available to pursue this avenue of inquiry further.

136. This has been a markedly long running matter within the Court, which has moved between both the coronial and criminal jurisdictions. In August 2015 the coronial investigation was formally held in abeyance whilst further allegations that Zee Meyer raised, of Warren

‘possibly being killed in cross-fire by warring mafia factions, were investigated.

137. Ms Meyer indicated to police that she had received this information from a prisoner at Loddon Prison via friends of the family. Ms Meyer further alleged that police had been involved in the disposal of Warten’s body. As‘such a perceived conflict of interest was

managed through Victoria Police.

138. Police interviewed the prisoner, who described himself as a ‘storyteller’, and said that Ms Meyer had a strong belief her husband had been murdered, that she was very keen to keep the investigation alive and that when she met with him she presented many hypotheticals

and theories as to what had occurred to her husband, but nothing to support them. 2°

139, The investigation of these allegations found that the information provided by Zee Meyer was

unable to be substantiated, it is unlikely to be true and further investigation was not

% It was disputed by the prisoner that this conversation had ever taken place. I have examined police interview transcripts as paxt of my investigation

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145,

warranted. At the time senior Victoria Police members met with Ms Meyer to convey the

investigative results to her.

Once this allegation of possible criminal conduct was completed the investigation was referred back to me and a comprehensive file including various further inquiries was received including a review of Search and Rescue holdings, further clarification of the Optus ‘ping’, information on phone equipment searches, an examination of the Missing Persons Policy and the result of further criminal investigation by the Eastern Region Crime

Command,

Detective Superintendent Paul Sheridan indicated that all of the further allegations were

unsubstantiated.

Leading Senior Constable Helyer, an independent operative with the Search and Rescue Squad, also further reviewed the entire physical file as maintained by Search and Rescue (SAR) to review the ground search coverage, the phone equipment searches and the

cobwebs reported to be over the foot track leading to the summit of Mount Dom Dom.

LSC Helyer highlighted that much emphasis has been placed on the mobile phone activity and that information contained in the SAR file indicated a signal was registered by the

Mount Gordon Optus tower on 23 March 2008.

This information originated from the Police Online Supervisor who was asked to carry out phone triangulation at the time of Warren’s disappearance. This was discounted as a call (either personal or emergency) and was attributed to the phone registering momentarily with the tower at the time. Optus were requested to attempt to locate the phone and a location based search (or ‘ping’) was used at regular intervals that did not detect any further phone

activity.

Targeted searching with reference fo the Mt Gordon Tower coverage was conducted by

police on 25 March 2008.

Tam satisfied that this point has now been thoroughly explored, and that no further inquiry is

possible,

In November 2016 it was confirmed by Macleod Forensic that the Ellis photo enhancement

requested, the last outstanding inquiry, was unsuccessful.

149,

152,

The family’s view that Warren may have died as a result of being shot has been well publicised across television and media outlets as well as social media across the years, but

has not resulted in any further verifiable information.

As there were no identified witnesses to Warren’s suspected death and his body had not been found despite extensive public and media campaigns there is a theoretical possibility

that Watren is still alive.

lnrespective of this I am required to focus on the evidence before me and determine, on the

balance of possibilities, the likelihood that Warren is deceased.

In summary the reasons for Warren’s disappearance further considered have included:

° Misadventure (that he became lost or injured in the bush). Jt is noted that the area around the Dom Dom Saddle tracks is dense;

© That he was murdered by an escaped voluntary patient Anthony Williams, now deceased. This was fully investigated by the Homicide Squad and there was no evidence discovered to support this theory;

e That he was shot by deer hunters by accident. There is no evidence available to support this theory other than information as to rapid gun fire being heard on the day before, and the day of, Warren’s disappearance;

¢ That Warren stumbled across a cannabis crop and was shot. This was explored at length -by police and whilst there was evidence of cannabis crops in the area there

was no evidence linking it to Warten’s disappearance; and

e

That Warren disappeared of his own accord. An alleged sighting of Warren by an ex work associate was unable to be corroborated, The work associate did not approach or speak to the individual he sighted in Italy and other investigative checks conducted including travel movements and financial analysis do not support the

veracity of this sighting.

The family have also of their own accord offered a significant reward for any information, to

no avail.

In December 2016 Ms Jessica Wilby, Principal In-House Solicitor, conveyed to Zee

Meyer’s legal representatives that due to the extensive further inquiries and reviews, I was

15S.

159,

satisfied I was now in a position to be able to fulfil my statutory duties and finalise the

investigation.

Particularly considering the passage of time, together with other matters having extensively pursued, it was requested of the family’s legal representatives that they re-visit the initial application for inquest. It was noted that this was not a matter that called for a mandatory

inquest.

In May 2017 Ms Meyer indicated through her legal representatives that she was still of the belief that an inquest should be held to point out the deficiencies in the police investigation, and to enable me to make recommendations as to Missing Persons Week. I noted that it is open to me to make recommendations or comments following an investigation irrespective

of whether an inquest is conducted.

Mr John Willis said that if an inquest was held the family would seek to call witnesses to outline Warren’s personal life to ‘...discount any argument that he took his’ own life,

suffered a heart attack or staged his own disappearance,’

Mr Willis indicated that Zee Meyer, whilst still seeking an inquest, wants a finding that Warren died at the hands of the other and that recommendations are made that the

investigation continued, #4

’

Despite quite considerable long-ranging inquiries there is no cogent evidence available to indicate third party involvement in Warren’s disappearance. Importantly, the matter is also

still a Victoria Police Category 2 Long Term Missing Person Investigation.

After much consideration Ms Meyer’s legal representatives indicated that she was satisfied for the matter to be finalised by way of a chambers finding without the need for a formal

inquest.

Clearly this is difficult news for Ms Meyer to deal with and she has been publically critical

of what is represented as delays in the investigation.

Itrespective of this I note that Ms Meyer has become a considerable voice in the cominunity

as to the plight of missing persons, and ber efforts have allowed other family and

3! Correspondence to the Court, 8 May 2017

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community members linked with missing persons to gather, acknowledge and validate their

distress.

The plight when no solution is provided to a missing persons case is multi-layered for the family concerned, and I have endeavoured to comprehensively explore the varying issues as

they arose throughout this investigation.

There are no records of Warren displaying any depressive illness or mental health issues, I

have no evidence before me that Warren intentionally took his own life.

As part of my investigation I visited the area that Warren disappeared and met with Search and Rescue members who had been involved in the initial search. They showed me relevant maps and the tracks that were covered with a 4WD vehicle in difficult terrain. I particularly commend all of those in Search and Rescue who perform a difficult and often unrewarding task, The efforts that were expended across the years for Warren both through professional

and personal searches are remarkable.

Unfortunately the answers that Zee Meyer so desperately seeks are unable to be provided with any certainty, but on the material before me and particularly due to the passage of time, lam satisfied on the balance of probabilities that Warren is suspected to be dead. There is no

evidence of third party involvement in Warren’s disappearance, and suspected death.

Warren’s family have made the personal choice to again increase the reward for any information about Warren’s disappearance, but despite this and a previous significant

reward no, cogent evidence has been revealed as to the circumstances of his suspected death.

FINDINGS

Having investigated the suspected death of Warren and having considered all of the

available evidence, | am satisfied that no further investigation is required.

Although I have no direct evidence, the circumstantial evidence satisfies me that on thé balance of probabilities Warren likely died of unknown causes on or after 23 March 2008

when hiking in Narbethong, Clearly his body, or remains, have never been found.

Imake the following findings, pursuant to section 67(1) of the Coroners Act 2008:

(a) that the identity of the suspected deceased is Warren Meyer, born 3 June 1950;

(b) that the cause of death is unascertained; and

(c) that the suspected death occurred in the circumstances that are unknown.

170. I find that there is no evidence to suggest the involvement of any other person in his

suspected death.

171. I find that Warren Meyer likely died on an unidentified date on or after 23 March 2008.

COMMENTS

172. Pursuant to section 67(3) of the Coroners Act 2008, 1 make the following comments

connected with this suspected death.

173. More than 38,000 people are reported missing in Australia each year.

174, This investigation highlighted the incredibly difficult situation when a missing persons matter is reported to the coroner, but is unable to be resolved. Ms Meyer has at times been publically critical of the investigation. I acknowledge her distress, but highlight that this was a remarkable case in which many numerous issues as taised on behalf of the family

have been inquired into with significant time, and resources.

175. Notably, the extensive inquiries that have been undertaken have failed to reveal Warren’s fate following his disappearance.

176. As Warren’s exact plans for his hike that day were unknown the search was somewhat confounded, but irrespective of this an incredibly extensive search was undertaken by Victoria Police, Search and Rescue, members of Warren’s family and friends, local

citizens and bushwalking groups.

177. The disappearance and suspected death of a person in circumstances such as this leaves their loved ones with many unanswered questions in addition to their loss, and it is inevitable that

thany theories may fill the void the person has left.

178, It has been suggested by Warren’s family that he may have been the victim of foul play and Victoria Police have investigated various suggested possibilities however there is no

evidence available to me to support any of these theories.

179. I convey my sincerest sympathy to Warren’s family and friends at their loss of Warren in March 2008,

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

(a) Warren’s family, senior next of kin; (b)The Coroner’s Investigator, Victoria Police; (c)Inspector Jason Goddard, Victoria Police; and

(d)VGSO on behalf of the Chief Commissioner of Police

Date: 15 December 2017