Finding into death of Hilda Billman

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2017 004216

FINDING INTO DEATH WITH INQUEST

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

Inquest inte the death of HILDA BILLMAN

Delivered on:

Delivered at:

Hearing dates:

Findings of:

Assisting the Coroner:

23 February 2018

Coroners Court of Victoria at Bendigo 71 Pail Mall, Bendigo

23 February 2018

Coroner Peter Charles WHITE

Acting Sergeant Sonia Reed, Police Coronial Support Unit

J, PETER CHARLES WHITE, Coroner,

having investigated the death of HILDA BILLMAN

and having held an inquest in relation to this death on 23 February 2018

in the Coroners Court of Victoria at Bendigo

find that the identity of the deceased was HILDA BILLMAN

and that the death occurred on or after 10 September 1996

at an unknown location

from:

I(a) UNASCERTAINED

in the following circumstances:

1. On23 August 2017, Detective Senior Constable Luke Simons of Bendigo Crime Investigation Unit reported the suspected death of Hilda Billman to the coroner,!

2, Mrs Billman was a 73-year old a married woman who lived in Quarry Hill, Victoria with her husband, Sydney, when on the afternoon of 6 September 1996, she absconded from Bendigo Psychiatric Centre where she was receiving treatment as an involuntary patient. Mrs Billman has not contacted her family since that date and there have been no confirmed sightings of her after 10 September 1996.

3. Laccepted DSC Simon’s report of Mrs Billman’s suspected death as the Coroners Act 2008 [the Act] defines ‘death’ as inclusive of suspected deaths.?

4. Section 14 of the Act empowers me to investigate a death that is or may be a ‘reportable death’, even if only to determine whether a reported death is reportable within the meaning given to that term in the legislation.?

5. 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, injury or medical procedure.* However, some deaths are reportable irrespective of the nature of the death, based on the status of the person

immediately before death.

' Section 12 of the Coroners Act 2008 [the.Act] establishes a general obligation that a person who has reasonable grounds to believe that a reportable death has not been reported must be reported without delay to a coroner, Correspondence from DSC Luke Simons to the Court dated 23 August 2017,

2 See section 3 of the Act.

• Section 14(1) enables coroners to investigate a death that is or may be reportable if the death appears to have occurred within 100 years before the death was reported to the coroner and s. 14(3) is the power to investigate whether or not the death is a reportable death. Section 16 provides that if a coroner determines that a reported death is not a reportable death, the investigation of it must be discontinued.

4 See section 4 of the Act for the exhaustive definition of “reportable death”,

Mrs Billman’s suspected death was reportable as she was a person placed in custody or care?

by virtue of being an involuntary psychiatric patient as defined by the Mental Health Act 1986

[MH Act], applicable at the time of her disappearance. This is one of the ways in which the Act recognises 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.

As an additional protection, until the insertion of section 52(3A) into the Act in November 2014, all deaths of people placed in custody or care required a mandatory inquest. Now, the Coroner is no longer required to hold an inquest if satisfied that the death was due to natural causes but must publish Findings made concerning natural causes deaths of people in custody or care.© Of course, the Act preserves 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 Mrs Billman was a person placed in custody or care and the circumstances of her suspected death are such that I am unable to make any findings as to the medical cause of her death,

This finding draws on the totality of the material the product of the coronial investigation of Mts Billman’s suspected death, and in particular, the inquest brief compiled by DSC Luke Simons. The brief, together with the inquest transcript, will remain on the coronial file. In writing this finding, I do not purport to summarise all of the available evidence, but refer to it only in such detail as appears warranted by its forensic significance and the interests of

narrative clarity.

Mrs Billman’s disappearance

On 27 August 1996, Mrs Biliman was admitted to the psychiatric unit of Bendigo Health

Care Group in Eaglchawk. According to her son, she had been diagnosed with paranoid schizophrenia and had received psychiatric treatment for a number of years.®

During the admission, Mrs Billman presented with depressive symptoms, anxiety, delusions and restlessness.” Although she had not recently expressed suicidal thoughts, she had aprior —

history of suicide attempts.'°

5 See section 3 of the Act for the definition of a “person placed in custody or care”,

6 Section 73(1B). Section 52(3B) outlines the circumstances in which a coroner may consider a death to be due to natural causes,

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

8 Coronial Brief of Evidence, Statement of James Billman.

12. At about 2pm on 6 September 1996, during a mecting between Mrs Billman, her husband, her niece and treating clinicians, Mrs Bilhman was informed that she would undergo electroconvulsive therapy'! on 9 September 1996. Shortly thereafter, she sought and was granted permission to leave the room in order to make herself a drink. |

13. About ten minutes later, when Mr Billman left the consulting room to look for his wife, he was unable to find her and notified staff.

14, At the time, the psychiatric unit was not a locked ward and when Psychiatric Nurse Frederick Jansen was unable to find Mrs Billman in the unit he assumed that she had left the premises.

He initiated a search of the grounds of the facility and, when this proved fruitless, extended the search to the surrounding area using his car.!2 Mr Jansen was unable to locate Mrs Billman and so at about 4pm, as she had not returned to the unit voluntarily, he reported her to police as a missing person,"

15. Among the information Mr Jansen provided to police was a physical description of Mrs : Billman and the clothes she was wearing along with an assessment of her mental state, management issues and level of risk at the time she was last seen. Mrs Billman was described as suffering from anxiety and depression with her negative outlook, lack of motivation and inattention to nourishment reflecting her mental state.'4 She was considered to be at risk of suicide given her previous history, even in the absence of recent articulation of suicidal thoughts, '° incapable of communicating with others and unlikely to approach anyone for assistance. !®

16. Mr Jansen also completed a ‘Report of Patient Absent Without Leave’ form as required by section 87 of the MH Act,!?

° Coronial Brief of Evidence, Statement if Frederick Jansen 10 Thid,

"' Blectroconvulsive therapy [ECT] is a procedure used to treat certain psychiatric conditions. It involves passing a carefully controlled electric current through the brain, which affects the brain’s activity and aims to relieve severe depressive and psychotic symptoms.

2 Coronial Brief of Evidence, Statement of Frederick Jansen.

3 Tid,

4 Missing Client Additional Information Form relating to Mrs Billman undated but faxed on 6 September 1996.

5 Ibid.

'6 Senior Sergeant Gordon McKenzie’s Patrol Duty Return dated 6 September 1996,

7 Coronial Brief of Evidence, Report of Patient Absent Without Leave dated 6 September 1996,

The Search for Mrs Billman

17. Senior Sergeant Gordon McKenzie managed the missing person investigation. On the

evening of her disappearance, local police members were alerted to be on the look out for Mrs Billman and enquiries were made with local taxi, railway, bus and ambulance services.

Planning for a large-scale search was also commenced.'®

18. On the morning of 7 September 1996, S/Sgt McKenzie contacted the psychiatric unit to obtain further details of the circumstances of Mis Billman’s disappearance. He also contacted Mr Billman who confirmed his wife had not returned home, and Mrs Billman’s sister, but neither was able to shed light on Mrs Billman’s likely whereabouts. ‘S/Sgt McKenzie liaised with his section sergeant to arrange media coverage of Mrs Billman’s disappearance.

19. At midday, S/Sgt McKenzie co-ordinated a search of the psychiatric unit, surrounding buildings and grounds with the cooperation of the health service staff while State Emergency Service [SES] volunteers conducted a line search of bushland north-west of the facility. The searchers found no sign of Mrs Billman and the search was called off for the day at dusk,?°

20. That evening, S/Sgt McKenzie made arrangements for additional resources to expand the search for Mrs Billman the following day. He also continued to contact Mrs Billman’s friends and acquaintances for any further intelligence about her whereabouts and directed police members on the night shift to patrol the streets around Mrs Billman’s home, Lake Weeroona and the Bendigo Golf Course.”!

21. Atabout 8am on 8 September 1996, S/Sgt McKenzie briefed the more than 50 police and SES personnel and civilian volunteers assembled to search for Mrs Billman. A base of operations was established at the Ken Wust Reserve in Quarry Hill from where searchers fanned out across the Greater Bendigo area while the air wing patrolled the same area?

22. Door-to-door enquiries and searches of premises and yards occurred in Harkness Street, where the Billmans lived, and adjacent areas and also in Sternberg Street following a reported sighting of Mrs Billman during the previous afternoon. Line searches were conducted of the

Spring Creek between Mclvor to Spring Gully Reserve and Spring Gully Dam. The search

'8 Coronial Brief of Evidence, Exhibit 3.

9 Tid.

9 Ibid.

2! Ibid, 2 Ibid.

23,

included Quarry Hill and the golf course, Golden Gully, Spring Gully and the reservoir, Diamond Hill, Flora Hill, the Bendigo General Cemetery, and the One Tree Hill reserve.2° Later, the base of operations was moved to the Bendigo Psychiatric Centre, From there police and volunteers searched the psychiatric centre and grounds, California Gully, Jobs Gully, Jackass Flats, Long Gully and Cellophane Gully. Following an unconfirmed sighting of Mrs Billman at a property in Holdsworth Street, White Hills, the previous morning, that area was also searched. Mrs Billman was not located.”4

On 9 September 1996, the search for Mrs Billman contiiued. Air wing, search and rescue and local police were supported by SES, Red Cross and civilian volunteers, From a base of operations at Bendigo Psychiatric Centre, several areas already searched were searched again including the psychiatric centre, Jackass Flat, California Gully, Long Gully and Long Gully Creek. A door-to-door and year search was conducted in Holdsworth Street from Prouses Road to Finn Street in White Hills. The search was also extended to Eaglehawk, including along the railway line between there and Bendigo, Bendigo Creek, Whipstick Forest Park, Iron Bark Gully and Derwent Gully. Again, there were no sightings of Mrs Billman.25

On 11 September 1996, Kangaroo Flat resident Gina Berchree reported seeing Mrs Billman at about 10,30pm the previous night. Mrs Billman was sitting against the fence of her Wesley Street property. However, when Ms Berchree tried to persuade Mrs Billman to come inside, she refused and threw rocks at Ms Berchree. Mrs Billman left, walling down Wesley Street and turned left onto Morrison Street.

Following Ms Berchree’s report, police were immediately deployed to search a rural property and a number of sheds on Wesley Street. The search was extended to Crusoe and Carcoola Roads but Mrs Billman was nowhere to be found.?6

Despite some further (unconfirmed) sightings of Mrs Billman in September 1996, she remained missing, After October 1996, the disappearance was reviewed periodically by senior police.

In 1998, enquiries by investigators revealed that Mrs Billman had not returned to the public mental health system since her disappearance. An information flyer, with photograph, was

sent to the Missing Persons Unit.

3 Ibid and Exhibits 4 and 5.

4 Coronial brief of Evidence, Exhibit 3-5 (inclusive).

3 Ibid.

26 Coronial Brief of Evidence, Exhibit 6.

29,

31,

35,

In 2000, Mrs Billman’s disappearance was featured in the Missing Persons Week media campaign.

When the missing person investigation was reviewed in 2002 and 2004 no new leads were identified.

In 2007, a Medicare and Pharmaceutical Benefits Scheme search revealed that Mrs Billman had not accessed any health services that qualify for Medicare Benefits or obtained any government-subsidised prescriptions since her disappearance more than a decade earlier.

In 2008, the investigation of Mrs Billman’s disappearance was transferred to the ‘cold case’ taskforce as part of Operation Belier, which sought to progress investigations of long term missing individuals and the identification of unidentified human remains.

In March 2015, Detective Senior Constable Dale Hallinan contacted Mrs Billman’s son, James Billman who travelled to Bendigo to meet him. Mr Billman suggested that his mother may have walked to the vicinity of Carcoola Drive, Kangaroo Flat, where the family lived when he was young. Although it had been searched as part of the original investigation in 1996, the two men went to the location and searched bushland there, to the edge of a dry creek to the south of Carcoola Drive. There was no sign of Mrs Billman and it was Mr Billman’s belief that his rnother may have fallen down a disused mineshaft in the area.”’ Mr Billman provided a deoxyribonucleic acid [DNA] sample to be used to potentially aid identification of unidentified human remains.2*> So far DNA comparison has produced no results, As mentioned above, in August 2017, DSC Simons reported Mrs Billman’s suspected death to the Coroner, in essence seeking a finding that she was, in fact, dead. Accordingly, at my request DSC Simons prepared the coronial brief of evidence on which this finding is largely based outlining the efforts made to find Mrs Billman or otherwise establish that she remains alive, over the more than 20 years that have elapsed since her disappearance. In support of his contention that Mrs Billman was no longer living were the following considerations:

a. Mrs Billman was 73 years old when she went missing and so now would be 95

years of age if she remained alive; b. Mrs Billman’s family have not heard from her since she absconded from the psychiatric unit in 1996; c. An extensive search of the Greater Bendigo area occurred at the time of her

disappearance and failed to find any trace of her;

27 Coronial Brief of Evidence, Statement of James Billman.

28 Thid.

d. No information about Mrs Billman’s whereabouts has been forthcoming since she was scen in Wesley Street, Kangaroo Flat, on the night of 10 September 1996; and

¢. Mrs Billman has not accessed the public health system, including mental health services, since her disappearance despite her advancing age and being in need

of involuntary psychiatric treatment when she went missing.”

Conclusions

36. The standard of proof for coronial findings of fact is the civil standard of proof, on the balance of probabilities, with the Briginshaw gloss or explication.*° Having applied the applicable standard to the available evidence I am satisfied that although I am unable to determine the place, cause and manner of her death, Mrs Billman, late of Harkness Street Quarry Hill, is likely to be deceased, I find that her death occurred on an unknown date on or after 10 September 1996, the last date on which she was seen alive.

37. Tam satisfied by the available evidence that the efforts made by Victoria Police to locate Mrs

Biilman were reasonable in the circumstances.

Pursuant to section 73(1B) of the Coroners Act 2008, | order that this Finding be published on the

Internet in accordance with the rules.

Cortespondence from DSC Luke Simons to the Court dated 23 August 2017,

°° Briginshaw v Briginshaw (1938) 60 C.L.R, 336 esp at 362-363. “The seriousness of an allegation made, the inherent unlikelihood ofan occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences...” ,

I direct that a copy of this finding be provided to the following: Mr James Billman A/Prof Phillip Tune, Psychiatric Services, Bendigo Health

DSC Luke Simons, Bendigo CIU

Signature:

PETER CHARLES WHITE

CORONER ; IOVS

Date: 2 |?