Finding into death of Israel Bodean Brenssell-Rimene

IN THE CORONERS COURT OF VICTORIA

AT MELBOURNE Court Reference: COR 2015 3461

FINDING INTO DEATH WITH INQUEST

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

Inquest into the Death of ISRAEL BODEAN BRENSSELL-RIMENE Delivered On: 4 JULY 2019

Delivered At: ; THE CORONERS COURT OF VICTORIA

65 KAVANAGH STREET, SOUTHBANK

Hearing Date: 4-7 JUNE 2019 Findings of: CORONER PHILLIP BYRNE Attendees:

Counsel Assisting the Coroner MS RACHEL ELLYARD

I, PHILLIP BYRNE, Coroner, having investigated the death of Israel Bodean Brenssell-Rimene AND having held an inquest in relation to this death from 4-7 June 2019.

at The Coroners Court of Victoria

find that the identity of the deceased was Israel Bodean Brenssell-Rimene

born on 29 July 2014

and the death occurred 13 July 2015

at Hamilton Hospital

from:

(a) UNASCERTAINED

in the following circumstances:

BACKGROUND

1. Baby Israel Bodean Brenssell-Rimene, 11 months old at the time of his death, resided at 7 Strachan Street, Hamilton, Victoria with his mother Ms Tanita Brenssell, her partner Mr Quinton Thompson and his three older siblings. The domestic relationship between Ms Brenssell and Mr Thompson commenced in May 2015.

BROAD CIRCUMSTANCES SURROUNDING DEATH

2. On the evening of 12 July 2015, Baby Israel had his dinner and a bottle. It was reported he fed well and was put to bed by Mr Thompson. Shortly prior to midnight on 12 July 2015, Mr Thompson found Baby Israel awake in bed. Ms Brenssell made up a bottle which was then given to him by Mr Thompson. After giving Baby Israel the bottle, Mr Thompson went to the bungalow and smoked cannabis after which he claims to have fallen asleep prior to smoking more cannabis. At about 3am, Mr Thompson claims he went to the door of the room in which Baby Israel was asleep, smelling vomit he went to Baby Israel’s cot and observed him face down on the bed apparently unresponsive. Ms Brenssell did not observe Baby Israel after he

was fed and put to bed at about 7:30pm.

3. Having located Baby Israel unresponsive, Mr Thompson took him from the cot to the couple’s bedroom where he attempted cardiopulmonary resuscitation (CPR). A call to the 000 emergency number resulted in an ambulance being dispatched and the call taker providing instructions about CPR. When she first saw Baby Israel after he was taken to the bedroom,

Ms Brenssell noted he was blue in the face.

4. Ambulance paramedics attended in a timely manner and noted Baby Israel to be in cardiac arrest with a body temperature of 31.1°C. Baby Israel’s presentation, with very obvious physical injuries, alarmed the attending ambulance paramedics who appropriately requested police attendance. It was noted that throughout their involvement, Baby Israel was in asystole with no heart activity. A decision was taken to urgently transfer Baby Israel to hospital where more advanced resuscitation measures could be undertaken. The ambulance was driven to the Hamilton Base Hospital by a Victoria Police member while the paramedics continued to work

on Baby Israel in the back of the ambulance.

5. Upon arrival at Hamilton Hospital, Baby Israel was transferred into the care of medical practitioners who undertook full resuscitation measures. After a period of time it became clear that Baby Israel’s condition was unsalvageable and attempts to revive him were abandoned.

He was formally declared deceased by Dr Stewart Perry at 3:47am in the Emergency Department at the Hamilton Hospital.

REPORT TO THE CORONER

6. The death of Baby Israel was appropriately referred to the coroner. The coroner who had

carriage of the matter at the time directed a full autopsy and ancillary tests.

AUTOPSY REPORT AND FINDINGS

7. Acting on that coronial direction, Dr Linda les of Victorian Institute of Forensic Medicine (VIFM) undertook an exhaustive autopsy and ancillary tests, including toxicology. Following protocol, a radiographic skeletal survey and whole body CT examination was undertaken at

the Royal Children’s Hospital.

8. Dr Iles, now Head of Pathology at VIFM, provided a comprehensive Medical Examiners

Report in which she described various injuries identified at post mortem examination.

9. At page 18-19 of her autopsy report, Dr Iles enumerated the anatomical findings demonstrated

by her post mortem examination: For completeness I include the full list of findings.

ANATOMOCAL FINDING

1, Neuropathological findings:

(a) Pattern of early vascular axonal injury throughout the cerebrum (ischaemic

encephalopathy).

(b) Focal traumatic axonal injury, predominantly within the medullary

pyramids.

(c) Thin film chronic subdural membrane, left convexity dura.

(d) Focal axonal injury of the cervical spinal cord white matter (like

traumatic), associated with a microglial response.

2. Extensive organising subacute/chronic scalp haematoma.

3. No evidence of skull fracture or intracranial haemorrhage.

4. Forehead bruising associated with bilateral periorbital haematomas.

5. Parchmented excoriated abrasions about the nose and beneath the left eye.

6. Healing torn upper oral frenulum.

7. Areas of healing abrasion of the upper and lower lip mucosa.

8. Healing left tibial metaphyseal fracture (torus fracture).

9. Healing ulcerated lesions about the inner aspects of both ankles and the outer

aspect of the left thigh associated with deep organising fat necrosis.

10, Small discoid bruises on either side of the jaw.

1]. Patchy areas of healing ulceration about the ears.

12. Thymic haemorrhage.

13. Gastric contents throughout airways without evidence of associated reactive

change.

10. Tinclude in this formal finding several excerpts from Dr Iles’ report:

“Post mortem examination reveals bruising to Israel’s forehead and associated

periorbital haematomas. These appear to be recent injuries.

Post mortem examination also demonstrates an extensive subacute/chronic subgaleal haematoma (bleeding and bruising beneath the scalp). There are features that indicate that this bleeding has occurred a considerable time prior to death. There is no empirical data to accurately age this haematoma. Features suggest this was potentially sustained a number of weeks prior to death. However, I cannot exclude superimposed more recent episode(s) of haemorrhage/bruising at this site. There was

no post mortem evidence of skull fracture or acute bleeding inside the cranial cavity.

Autopsy examination also demonstrates a non-acute laceration of the upper oral Jrenulum along with healing abrasions to the upper and lower oral mucosa. These are due to blunt trauma to the face. There are no specific features that allow precise ageing of these lesions, however macroscopic features of healing indicate that these

have occurred a significant time prior to death and are not directly related to death.

There is a healing fracture of the left tibial metaphysis. The precise ageing of this Jracture is not possible, however there is evidence of well-established healing, with radiological features indicating that the injury occurred at least 10 days prior to

death, and it is quite possible that this occurred a considerable time prior to death.

Based on the information available to me at this time, there is no history to account Jor the presence of a large healing subgaleal haematoma, torn oral frenulum and

healing oral mucosal abrasions and the healing left tibial fracture. This cluster of

ll.

injuries, in the absence of a coherent account as to how they occurred, suggests

inflicted injuries. This constellation of injuries is not typical of accidental injury in

this age group. No natural disease process has been identified to account for these

injuries. The presence of the healing skin injuries further supports this assertion.

Histological sections from this case have been independently reviewed by paediatric pathologist Assoc. Prof: Duncan MacGregor. He has not identified any underlying natural disease process to account for death, or the injuries observed.”. (My emphasis) In effect Dr Iles, whilst opining the cause of Baby Israel’s death remains “unascertained”, gave evidence that her exhaustive investigation excluded any natural disease process which

could have to led to Baby Israel’s untimely death.

In viva voce evidence, Dr Iles stated that while Sudden Infant Death Syndrome (SIDS) is a diagnosis of exclusion, the injuries demonstrated at autopsy precluded the cause of death

being attributes to SIDS.

In very broad terms Dr Iles, having excluded death due to natural disease process, turned her mind to unnatural or accidental reasons why Baby Israel stopped breathing. I include a further important excerpt from the transcript of Dr Iles’ oral evidence. Ms Ellyard, counsel assisting

on behalf of Ms Brenssell, asked:

“But would it be fair to say that we are talking with — talking about either un-natural

or accidental causes rather than natural causes for the stopping of breathing? ---Yes.

And in terms of accidental or versus un-natural, it would be difficult as I understand it on autopsy, to be able to identify with precision, whether the event which led io the

reduction in breathing was an accident or was deliberate?” Dr Iles responded:

“So I guess in the sense of, for example, going down that expiratory pathway of some blunt head trauma, precipitating a decrease in conscious state, there’s nothing that I can say, so whether it was inflicted or accidental for example, a fall. There would

presumably be other evidence to speak to the likelihood of that.” Dr Les was then asked:

“And again, and I don’t want to over simplify things that are not capable of over simplification — that shouldn’t be able to simplify, but in broad terms, is it a choice or

~ the two main options are either some direct impact on capacity to breathe, whether

by suffocation, deliberate or accidental or suffocation, or a head trauma that caused

the impact on respiration. Are those the two choices?” Dr Iles responded:

“Yep. Maybe — for example, they are two options. There is also the possibility of head trauma reducing the level of conscious siale and then being in a position, face down, where he’s unable to breathe properly and then suffocating as a consequence of not being able to be in a position to breathe because of that reduced conscious state. So

it’s probably — those two things are a combination.”

14. I will return later in this finding to the critical issue of how the injuries identified by Dr Iles

may have been occasioned.

TOXICOLOGICAL ANALYSIS OF POST MORTEM SPECIMENS

15. Toxicological analysis of a post mortem hair sample demonstrates methamphetamine, MDMA (ecstasy) and cannabis. Not surprisingly, this raised a concern in my mind as to how that could have occurred in an 11 month old child. Consequently, I sought advice from Dr Dimitri Gerostamoulos, Head of Forensic Sciences and Chief Toxicologist at the VIFM. Dr Gerostamoulos advised that as the presence of these drugs were not detected in post mortem

blood samples, but the hair:

“The presence of the drugs in the hair is most likely due to environmental exposure, although consumption cannot be entirely ruled out — but it does indicate that drugs

were being used in the home where the child was living.”

I accept Dr Gerostamoulos’ advice, particularly as the evidence demonstrates Mr Thompson was using these drugs while living at the Strachan Street address with Ms Brenssell and the children. On this issue I only add that I am satisfied that during the relevant period, Ms

Brenssell was not using illicit drugs.

COURSE OF THE INVESTIGATION

16. Although Baby Israel’s death was appropriately reported to the coroner as a “reportable death” within the meaning of the Coroners Act 2008, due to the raft of injuries identified by Dr iles and Baby Israel’s presentation from the outset, the initial investigation, not surprisingly, was undertaken by Victoria Police as a suspected homicide, The lead investigator was Inspector Stuart Bailey (then a Detective Senior Sergeant in the Homicide Squad). Throughout, Inspector Bailey undertook the dual roles of head crime investigator in relation to possible criminal charges, and coroner’s investigator. At an early stage “from day

1”, Mr Thompson was identified as a potential suspect. On the other hand, Ms Brenssell was

initially treated as a witness and a statement was taken from her rather than being formally interviewed. Subsequently, when Dr Iles advised investigators that the injuries identified were likely to have been sustained over a several week period, and Ms Brenssell had access to Baby Israel during that time, she was appropriately treated as a suspect. She was then formally cautioned and interviewed. Inspector Bailey gave evidence that as part of covert investigations undertaken, investigations which it must be said were intensive; listening devices and ‘extensive telephone intercepts were authorized and utilised including communications between Mr Thompson and Ms Brenssell. Ms Ellyard put the following

question to Inspector Bailey:

“You would have been present in court and heard me tell His Honour earlier in the week that the assessment made by the investigators and the police, that was Ms Brenssell hadn’t been involved in the causing of any injuries to Israel. I take it that’s

your view?” Inspector Bailey responded: “Yes it is.” and added:

“.-- there was nothing that came to bear that would suggest in any way, shape or form

that she was involved in any injuries or to the death of Israel.”

The coronial investigation lay in abeyance until the matter was re-allocated to me in midDecember 2018. I noted that as Ms Brenssell’s three older children Kingston, Aiden and Indika remained in care under a child protection order obtained by New Zealand Child Youth and Family Services due to Ms Brenssell and Mr Thompson re-cohabiting back in New Zealand. Although the relationship was subsequently terminated by Ms Brenssell, the New Zealand authorities, probably due to an abundance of caution, were apparently not prepared to retutn the children into the care of their mother until an inquest had been conducted. In the circumstances, once re-allocated to me, I endeavoured to progress the matter as expeditiously

as I could.

On 22 March 2019, I conducted a Mention/Directions Hearing to determine the scope and parameters of a proposed inquest, settle a list of witnesses and seek to fix a hearing date for a mandatory inquest, due to Baby Israel’s death being a suspected homicide. At that preliminary hearing, Ms Brenssell participated by way of video link from New Zealand. Mr Thompson

was invited to engage but did not appear and had no input.

Having determined the scope/parameters, and settled a list of witnesses, the matter proceeded to formal inquest over 4 days, Tuesday 4 June — Friday 7 June 2019. In total I received viva voce evidence from 13 individuals. Although Mr Thompson was subpoenaed to attend to give oral evidence by way of video link from New Zealand, he did not answer the subpoena on the day he was scheduled to give evidence, although he attended the Invercargill Court on the previous day and on the morning he was scheduled to give evidence. As Mr Thompson was

out of my jurisdiction, there was nothing I could do about his non-engagement.

Quite frankly, although there was some discussion by video link with a solicitor at the Court at Invercargill who provided advice to Mr Thompson about section 57 of the Coroners Act 2008, the reality is that it was highly likely | would have excused Mr Thompson from giving

evidence had he made an application based on self-incrimination.

In any event, the inquest proceeded without input from Mr Thompson save for his two records of interview, the first one in July 2015 and the second on 18 August 2015 at which, having

taken legal advice as was his right, he gave a “no comment” record of interview.

THE EVIDENCE

Two critical issues I sought to resolve were:

e Whether the various injuries identified by Dr Iles were occasioned by accident;

if not, how and by whom they were inflicted.

¢ Whether the various injuries identified by Dr Iles were causal or contributing

factors in Baby Isracl’s death.

I consider it important at this point to state that in spite of the extensive authorised telephone intercepts over 52 days and listening devices in the house, no information was gleaned from those covert operations that could reasonably be considered compelling, cogent evidence that

the injuries to Baby Israel identified by Dr Iles were inflicted by Mr Thompson.

Due to the number of separate injuries observed, which were occasioned over the short period of time during which Mr Thompson was in residence at the home, I conclude the vast majority of injuries were not due to accident. I do not accept that some of the injuries identified, particularly the leg fracture, were due to being wrapped too tightly at bed time.

Furthermore, I am satisfied the injury to the upper oral frenulum was very likely due to blunt force trauma.

Having excluded that possibility, I have to consider the prospect of the various injuries being

inflicted by someone other than Mr Thompson. I have already noted Inspector Bailey’s

extensive investigation has exonerated Ms Brenssell from the perspective of Victoria Police,

which leaves few other possibilities. The prospect that one of the other children occasioned the serious injuries is, in my view, fanciful. Whilst others had care of Baby Israel for short periods, although he had no previous experience caring for children, Mr Thompson from the likely onset of the injuries was the principal carer of Baby Israel. An arrangement that Ms

Brenssell was gratefully accepting of.

CORE FINDINGS REQUIRED TO BE MADE (Section 67 (1) (a)(b)(c))

26. As identity is not a controversial issue in this case I tum to Section 67 (1) (c) of the Coroners

27,

Act 2008 which requires me to seek to determine the circumstances surrounding Baby Israel’s

death. In her submission, Ms Eltyard said:

“On the evidence Your Honour couldn’t but adopi Dr Mes’ formulation of unascertained, as the medical cause of death. ‘But that doesn’t mean that there's not quite a lot of evidence that Your Honour can have regard to in making your findings

about the circumstances of Baby Israel’s death.”

I accept Ms Ellyard’s submission that in considering the issue if how and by whom the injuries were inflicted I am able to conclude that Baby Israel’s home life, before Mr Thompson came on the scene, was loving and he was well cared for. While attending childcare, no injuries were observed, nor concerns raised. Baby Israel ceased attending childcare soon after Mr Thompson, for all intents and purposes, took over daily care of Baby

Israel.

A number of events and circumstances form part of what I will call the mosaic being

assembled upon which I have sought to reach conclusions. Ms Ellyard, who submitted that those various matters alone might not be sufficient to form concluded views, even on the balance of probabilities, invited me to carefully consider the evidence of the older children, Kingston and Aiden which was taken under the appropriate protocols. They claimed to have experienced harsh discipline at the hands of Mr Thompson who they claimed had also physically disciplined Baby Israel. While one has to be, as Ms Ellyard submitted, cautious in relation to that evidence, Ms Leah Brenssell, Baby Israel’s maternal grandmother, gave evidence that the children also told her of these incidents towards the children’ by Mr Thompson. Having regard to the fact Ms Leah Brenssell said she suspected Mr Thompson was implicated in Baby Israel’s death even before she arrived in Hamilton, I also have to be cautious as to what weight I attach to her evidence. In that regard I must say Ms Leah

Brenssell impressed as a credible witness of truth and reliability.

33,

I also have regard to the fact that after Ms Leah Brenssell entered the household, Mr Thompson extraordinarily literally shadowed Ms Brenssell everywhere, not giving her the

opportunity, in his absence, to speak with her mother.

Other evidence that forms part of the mosaic relates to events after Baby Israel’s death.

Several witnesses opined that Mr Thompson, even at Baby Israel’s funeral, did not exhibit

genuine grief, but appeared more concerned for his own issues.

Once again, whilst not determinative, Ms Amber Poihipi gave evidence that in the period leading to Baby Israel’s death, away from the house, Mr Thompson had been smoking methamphetamine over several days, a drug that has the potential to alter people’s behaviour.

The events of the evening of 12 July 2015 are concerning. After Baby Israel had been in the bathroom with Mr Thompson for some 20 minutes, Ms Tanita Brenssell heard a “loud bang” .

which when queried, Mr Thompson stated Baby Israel “had a tumble and was whinging”, which in evidence Ms Tanita Brenssell described as a “quiet cry”. As stated earlier in this finding, what occurred after Baby Israel was put to bed until he was located unresponsive at

about 3am, relies solely on the information provided by Mr Thompson.

Ms Ellyard posed the following question to Ms Brenssell:

“So as you sit here today, having heard all of the evidence and had a lot of time to think about it, who do you think caused those injuries to Israel that we’ve heard

about?” Ms Brenssell replied: “Quinton Thompson”

While in isolation the issue may appear insignificant I think it pertinent that after Baby Israel’s death, Mr Thompson who had not been displaying any affection towards Ms Brenssell, and was allegedly having an affair, suddenly professed his love for her and

expressed a desire to recommence their relationship.

Amongst the reasons why Ms Brenssell said that she decided to start a relationship with Mr Thompson was that she was a fitile bit lonely, and that, he was like a friend, so I gathered that T had trusted him already and I felt he generally wanted to be with me. When asked about who could possibly have caused any of the injuries to her son, she said, / didn’t think anybody would be capable of doing that. Like, who would do that. Ms Brenssell’s vulnerability and naivety has come at a heavy price to her; as I stated earlier, the other children were removed

by child welfare authorities in New Zealand and at the time of the hearing were still not in her

care. I hope that in the intervening few weeks that issue has been satisfactorily resolved, or at

least progressed.

34. At the conclusion of her questioning of Ms Brensseli, Ms Ellyard asked Ms Brenssell if there was anything else she would like to tell me about what had happened to Baby Israel. An

emotional Ms Brenssell said:

“After talking with my family over the last few days about what’s been happening and how the circumstances of him dying, I believe strongly in my head and in my heart that he suffocated Israel, or he’s done something along those lines. And something’s happened in between the time of that happening and him telling me, because when he brought him in, I knew he was passed. I knew it. So as a mum, you know these things and you can —I could just smell it. I can’t explain it. To me, you can smell death and I smelt it. I knew. That I knew. That’s what I strongly believe today, after hearing everything —”

While Ms Brenssell may well be right, having regard to Dr Iles’ evidence as to the cause of

death, that is a conclusion I am unable, on the evidence, to reach.

35. It must be said that there is no compelling DIRECT evidence that Mr Thompson inflicted any of the injuries identified, so that I am required to consider what inferences can reasonably be

drawn from the body of evidence which constitutes the mosaic.

ROLE OF CORONER — RELEVANT LAW

36. The role of the coroner is in my view, generally misunderstood in the broader community. In

Keown v Khan (1999) 1VR 69, Justice Callaway said:

“In future the function of an inquest should be simply to seek out and record as many of the facts concerning the death as public interest required, without deducting from

those facts any determination or blame.”

He added:

“In many cases, perhaps the majority, the facts themselves will demonstrate quite

clearly whether anyone bears any responsibility for the death ---"

In some cases it is difficult, without appearing to lay blame fault or responsibility, to detail the circumstances surrounding the death being investigated; this is one of those cases. The conundrum was addressed by the New Zealand Court of Appeal in Coroner’s Court v Susan Newton and Fairfax New Zealand Ltd (2006) N2TR 312, 320 where it was said:

“The implicit attribution of blame may be unavoidable in order for the coroner to

ascertain or explain how the death occurred in the wider events ---" (My emphasis)

CONCLUSIONS

CIRCUMSTANCES SURROUNDING DEATH

What conclusions can be properly reached on the body of evidence I have found to be very difficult. I am mindful of section 69 of the Coroners Act which precludes me from finding, or indeed commenting, that person is, or may be guilty of an offence. I proceed on the basis that Iam satisfied Baby Israel did NOT die due to natural causes. Furthermore, I am satisfied that at least the majority of the injuries identified were NOT the result of accident. If the injuries were not due to accident, then they were deliberately or negligently inflicted by a third party.

In relation to those injuries 1 have referred to a mosaic constituted by evidence of various

events occurring after Mr Thompson came on the scene. Mr Thompson had the primary

carriage of Baby Israel’s care over the relevant period.

While in ISOLATION the various events I am satisfied occurred do not enable a firm conclusion to be reached, when one looks at the “picture” the mosaic provides, there are

inferences open to be drawn which in COMBINATION led me to the conclusion that Mr

Thompson was in some manner involved in Baby Israel’s death and he was indeed the only

person present during the period proximate to his death.

CAUSE OF DEATH

Another core finding. I am required to make is cause of death; that is the medical cause of death. Generally, this issue is uncontroversial. After autopsy, or external examination, including full body CT scan, the forensic pathologist who performs the procedure will usually be able to advise the coroner of the medical cause of death, whether it be a natural cause or otherwise. However, from time to time, even after exhaustive autopsy and ancillary tests, the

medical cause of death is “unascertained”; unfortunately, that is the case here.

In broad terms, although Dr Iles identified various injuries on Baby Israel’s body, some external, some internal, including to the brain and the cervical spinal cord white matter, she

was unable to provide a definitive cause of death.

It was suggested, and apparently initially considered a plausible explanation for Baby Israel’s death, that he died due to choking on his own vomit. In relation to that prospect, Ms Ellyard

posed the following question to Dr Iles:

“Is choking on vomit something that would be able to be excluded or left open based

on the findings that you’ve made?”

Dr Tles responded:

“So choking on vomit, particularly infants, but even adults, in the setting of somebody who has a normal central nervous system function, so his brain is not impaired for any reason, people who don’t have a reduced state of consciousness do not die from choking on vomit. So for example, so in terms of a mechanism of death, it’s a secondary thing. The primary problem is whatever has caused the reduced conscious state. So if baby Israel was put to bed happy and well, choking on vomit without

anything else happening to him is not an explanation for his death.” Ms Ellyard then asked:

“But if he already had some reduced capacity, for example, by way of brain injury associated with reduced respiration or something of that kind, is that the kind of circumstance where the body might cease to have the capacity that it would otherwise

have to protect itself against choking on vomit?” Dr Iles replied:

“Yes.” I conclude that aspiration of stomach contents, choking on vomit, was not the primary cause of Baby Israel’s death.

42. I reiterate, in spite of exhaustive post mortem investigations the cause of Baby Israel’s death

remains “unascertained”. Unfortunately, I can take that matter no further.

FINDING

43. I formally find Baby Israel Bodean Brenssell-Rimene, who was formally declared deceased at the Hamilton Base Hospital at 3:47am on 13 July 2015 after full resuscitation measures were abandoned as futile, actually died earlier that morning prior to admission to the hospital.

However, I am unable to be precise as to the time of death. I am also satisfied Baby Israel did not die due to natural causes. Although, on the evidence I am unable to conclude the injuries identified were direct causal factors in Baby Israel’s death, [ am satisfied they were not due to

accident.

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

the Coroners Court of Victoria website.

DISTRIBUTION OF THE FINDING

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

Ms Tanita Brenssell, Senior Next of Kin;

Mr Quinton Thompson, former partner of Ms Brenssell; Mr Nicolaas Van Zyl, Western District Health Service; Leading Senior Constable Rodney Charman, Victoria Police; and

Officer in Charge, Homicide Squad, Victoria Police.

Signature:

Date: 4 July 2019

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