Deceased
Bella Jayde Lawrence
Demographics
3y, female
Coroner
Deputy State Coroner Iain West
Date of death
2015-09-17
Finding date
2019-01-24
Cause of death
Complications of blunt force trauma to the abdomen
AI-generated summary
A 3-year-old child died from catastrophic abdominal trauma caused by her mother's partner deliberately stepping on her abdomen with his full body weight (~100kg), causing liver rupture and massive intra-abdominal haemorrhage. The perpetrator deliberately concealed the injury from the child's mother, who remained unaware of the trauma until the child presented hours later with signs of hypovolaemic shock. While clinicians appropriately provided emergency care, the coroner found no identifiable missed diagnostic or clinical opportunities that could have prevented death once the child presented to hospital with fatal injuries already sustained. The case highlights risks associated with step-parental family violence and the importance of recognising family violence contexts in emergency presentations.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
IN THE CORONERS COURT Court Reference: COR 2015 4738
OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: IAIN WEST, ACTING STATE CORONER Deceased: BELLA JAYDE LAWRENCE Date of birth: 25 March 2012 Date of death: 17 September 2015 Cause of death: l(a) Complications of blunt force trauma to the abdomen Place of death: Wimmera Base Hospital, 83 Baillie St, Horsham, VIC
3400
Background
The purpose of a coronial investigation
Matters in relation to which a finding must, if possible, be made
Identity of the deceased, pursuant to section 67(1)(a) of the Act
Medical cause of death, pursuant to section 67(1)(b) of the Act
Circumstances in which the death occurred, pursuant to section 67(1)(c)
of the Act
Comments pursuant to section 67(3) of the Act
Findings and conclusion
Bella Jayde Lawrence (Bella) was three years old at the time of her death. Bella was the second of three children bor to Angie Roberts (Ms Roberts). Her biological father was Jonathan Lawrence who also fathered Bella’s older brother. Bella’s younger, half-brother was
born to Ms Roberts and Harley Woodford (Mr Woodford) in January 2015.
Mr Woodford was born in Geelong on 21 November 1994. Mr Woodford grew up in western
Victoria having completed Year Nine and working in semi-skilled roles.
Ms Roberts and Mr Woodford had met through social media in approximately August 2013 and formed a relationship. A few months later, Mr Woodford moved in with Ms Roberts and
her two children, Bella and Bella’s older brother at their residence in Ararat.
In approximately 2014, Ms Roberts and Mr Woodford moved to Horsham and Mr Woodford
was employed with a disability aid equipment repair company in the Horsham area.
Mr Woodford was reported to be “old fashioned” in his thoughts about child rearing and believed that “kids should be seen and not heard”.? He responded aggressively if he perceived others to disobey his rules in the household and was a regular cannabis user, smoking cannabis during evenings in a shed behind the residence. Ms Roberts noted that Mr Woodford
had a short temper if he had not used cannabis to relax.?
In the months prior to her death, Ms Roberts noticed that Bella had several bruises across her
body and that family members noticed that her behaviour had changed.*
In July 2015, Mr Woodford had a car accident while Bella and her younger brother were in the car. Following this incident, Ms Roberts observed Bella complaining of a sore stomach and acting “a bit different”. Ms Roberts also noted that Bella’s appetite had significantly
declined in the two weeks prior to the fatal incident.
In a further incident a fortnight before Bella’s death, Bella allegedly had an accident and landed on a coffee table in the family home. Ms Roberts reported that she had a large bruise
1 Coronial Brief, Statement of Ms Angie Roberts dated 22 September 2015, 50
? Coronial Brief, Statement of Ms Angie Roberts dated 5 April 2016, 59
3 Coronial Brief, Statement of Ms Angie Roberts dated 5 April 2016, 59
4 Coronial Brief, Statement of Ms Angie Roberts dated 22 September 2015, 52; Coronial Brief, Statement of Linda Pilgrim dated 29 September 2015, 97
on her back as a result of this injury and she wanted to take Bella to see a doctor but Mr Woodford advised against this.°
On approximately 6 September 2015, Bella was reported to have fallen from a chair and hit the back of her head and “tt formed an egg” in the affected area. Ms Roberts noticed the injury on her head when brushing Bella’s hair.®
Bella’s death constituted a ‘reportable death’ under the Coroners Act 2008 (Vic) (the Act), as
the death occurred in Victoria and was violent, unexpected and not from natural causes.’
The jurisdiction of the Coroners Court of Victoria is inquisitorial.* The Act provides for a system whereby reportable deaths are independently investigated to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which the death
occurred.”
It is not the role of the coroner to lay 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 expression “cause of death” refers to the medical cause of death, incorporating where
possible, the mode or mechanism of death.
For coronial purposes, the phrase “circumstances in which death occurred,’" refers to the context or background and surrounding circumstances of the death. Rather than being a consideration ofall 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 by
5 Coronial Brief, Statement of Ms Angie Roberts dated 22 September 2015, 53 6 Coronial Brief, Statement of Ms Angie Roberts dated 22 September 2015, 52 7 Section 4 Coroners Act 2008
8 Section 89(4) Coroners Act 2008
° See Preamble and s 67, Coroners Act 2008
10 Keown v Khan (1999) 1 VR 69
'l Section 69 (1)
2 Section 67(1)(c)
the making of recommendations by coroners. This is generally referred to as the Court’s
“prevention” role.
(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;'4 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.'’ Thése powers are the vehicles by which the prevention role may be advanced.
provides a comfortable level of satisfaction that they caused or contributed to the death.
brief.
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the Deceased, pursuant to section 67(1)(a) of the Act
On 17 September 2015, Ms Roberts visually identified the deceased to be her daughter, Bella Lawrence, born 25 March 2012.
Identity is not in dispute in this matter and requires no further investigation.
Medical cause of death, pursuant to section 67(1)(b) of the Act
21, On 21 September 2015, Dr Matthew Lynch (Dr Lynch), a Forensic Pathologist practising at
the Victorian Institute of Forensic Medicine, conducted an autopsy upon Bella’s body. Dr
3 Section 72(1)
14 Section 67(3)
5 Section 72(2)
18 Re State Coroner; ex parte Minister for Health (2009) 261 ALR 152
24,
Lynch provided a written report, dated 9 March 2016, which concluded that Bella died from
complications of blunt force trauma to the abdomen.
Dr Lynch commented that he observed multiple bruises on Bella’s body involving the head (left front, right parietal, both occipital regions and both cheeks), chest, abdomen, back and both upper and lower limbs. Dr Lynch noted that the bruises confirmed the presence of haemorrhage but no evidence of any inflammatory reaction which is suggestive of recent injury.
Dr Lynch also noted significant abdominal trauma, particularly evidence of rupture of the liver and 600ml of blood present within the abdominal cavity. The significant volume of blood within the abdomen represented approximately 60% of Bella’s total blood volumc.!®
Toxicological analysis of post mortem specimens taken from Bella were negative for common
drugs or poisons.
J accept the cause of death proposed by Dr Lynch.
Circumstances in which the death occurred, pursuant to section 67(1)(c) of the Act
On the evening of the 16 September 2015, Ms Roberts had gone out for a drive with her two sons, in order to settle the younger one after dinner. Mr Woodford remained at home, looking after Bella. He was cleaning up after dinner and as he took some dishes from the lounge to the kitchen, he somehow tripped over Bella, as she was playing on the floor. She was
knocked on to her back.!°
Mr Woodford then deliberately stepped on her abdomen with one foot and lifted the other off the ground. He thereby placed the entire weight of his body, approximately 100 kilograms,
on to her stomach.”°
Bella immediately displayed signs of distress from Mr Woodford’s actions. Shortly afterwards, he told her not to tell her mother what he had done, other than to inform her if she had a belly ache. Mr Woodford observed Bella to be upset and he put her to bed, with a bottle
of water,!
'® This is based on estimated blood volume of 1000 ml for a 14-kilogram child.
Coronial Brief, Appendix D, transcript of interview of Harley Woodford on 1 April 2016, 180 2° Coranial Brief, Appendix D, transcript of interview of Harley Woodford on 1 April 2016, 181 21 Coronial Brief, Appendix D, transcript of interview of Harley Woodford on | April 2016, 182
29,
33,
When Ms Roberts returned home, Mr Woodford made no mention of what had taken place.
He said nothing about Bella having been hurt and told Ms Roberts that he had put Bella to bed
as she was not feeling well.??
The next morning on 17 September 2015, Mr Woodford left early for work. Later that same morning, Bella complained to her mother that she felt sick. She said that she had a sore stomach.* As Ms Roberts knew nothing of what had occurred the previous evening, she did
not seek medical attention for her.
Ms Roberts took Bella with her to drop off her eldest son at kindergarten. Upon arriving at the kindergarten, Bella told her mother that she was going to be sick. Ms Roberts then drove home with Bella. Ms Roberts sat Bella down in front of the television and after a while, Bella
appeared to be seriously'ill and started to become unresponsive.”*
At approximately 12.00pm, Ms Roberts telephoned Mr Woodford and told him that Bella was very sick.’ He returned home quickly and attempted to get Bella off the couch, but she was
unable to stand on her own, and simply collapsed.
Ms Roberts and Mr Woodford then drove Bella to Wimmera Hospital and arrived at approximately 12.35pm. Upon arrival at the hospital, Bella was unconscious and unresponsive. Treating emergency physicians were unable to resuscitate Bella and she was
pronounced deceased at 1.14pm.*6
The unexpected, unnatural and violent death of a young child is a devastating event. Violence perpetrated by a family member is particularly shocking, given the family unit is expected to be a place of trust, safety and protection.
For the purposes of the Family Violence Protection Act 2008, the relationship between Bella and Mr Woodford was one that fell within the definition of family member’ under that Act.
22 Coronial Brief, Statement of Ms Angie Roberts dated 22 September 2015, 59
23 Coronial Brief, Statement of Ms Angie Roberts dated 22 September 2015, 54
*4 Coronial Brief, Statement of Ms Angic Roberts dated 22 September 2015, 54
35 Coronial Brief, Statement of Ms Angie Roberts dated 22 September 2015, 55
6 Coronial Brief, Statement of Dr John Williams dated 28 September 2015, 68; Coronial Brief, Statement of Dr Garry Matthews dated 20 October 2015, 70
27 Family Violence Protection Act 2008, section 8.
Moreover the actions of Mr Woodford stepping forcibly on Bella and causing her death
constitutes family, violence."
the Victorian Community.
led to increased anxiety and agitation” >
contact with service providers leading up to the fatal incident.
female and male children equally**, whilst younger children were found to be at greater risk
°8 Family Violence Protection Act 2008, section 5(1)(a)(i)
°° The Coroners Prevention Unit is a specialist service for Coroners established to strengthen their prevention role and provide them with professional assistance on issues pertaining to public health and safety
30 The CPU utilised the Family Violence Risk Assessment and Risk Management Framework, also known as the
Common Risk Assessment Framework (CRAF) to assess risk factors which have been found to impact on the likelihood
of family violence occurring and the severity of family violence that is likcly to occur. CRAF was designed to assist
service providers from a wide range of fields understand and identify risk factors associated with family violence and
respond consistently.
22 Psychological report prepared Patrick Newton for Harley Woodford dated 10 February 2017, 3
33 Dominique Bourget, Jennifer Grace and Laurie Whitehurst, ‘A review of maternal and paternal filicide.’ (2007) 35(1)
Journal-American Academy of Psychiatry and the Law 74.
34 A. S.C. Ciani and L. Fontanesi, ‘Mothers who kill their offspring: testing evolutionary hypothesis in a 110-case
Italian sample.’ (2012) 36 (6) Child abuse & neglect, 519-527
of fatal harm from their mothers and older children at greater fatal risk from their fathers.*> In
addition to this, the majority of victims of filicide are below six years of age.?
children at a higher rate than genetic parents who kill their children 37
“more likely to Kill afier maltreating the child’?
the increase in filicide deaths involving a step-parent.*!
43, On 17 February 2017, in the Supreme Court of Victoria, Mr Woodford pleaded guilty to child homicide in relation to Bella’s death. On 24 February 2017, he was sentenced to nine years
and six months’ imprisonment with a non-parole period of six years and six months.*?
that could have prevented Bella’s death.
963° 4. Debowska, D. Boduszek and K. Dhingra, ‘Victim, perpetrator, and offense characteristics in filicide and filicide-suicide’ (2015) 21 Aggression and violent behavior, 113-124
37 G. T. Harris, N. Z. Hilton, M. E. Rice and A, W. Eke, ‘Children killed by genetic parents versus stepparents’ (2007) 28 Evolution and Human Behavior, 85-95
*M. Liem and F. Koenraadt, F., ‘Filicide: A comparative study of maternal versus paternal child homicide’ (2008) 18 Criminal Behaviour and Mental Health, 166-176 in Agata Debowska, Daniel Boduszek, and Katie Dhingra, ‘Victim, perpetrator, and offense characteristics in filicide and filicide-suicide’ (2015) 21 Aggression and violent behaviour, 118.
40M. Dawson, ‘Canadian trends in filicide by gender of the accused, 1961-2011’ in Thea Brown, Danielle Tyson and Paula F. Arias (eds), When Parents Kill Children: Understanding Filicide (Springer International Publishing AG, 2018), 18.
4! M, Dawson, ‘Canadian trends in filicide by gender of the accused, 1961-2011’ in Thea Brown, Danielle Tyson and Paula F. Arias (eds), When Parents Kill Children: Understanding Filicide (Springer International Publishing AG, 2018), 18-19.
® DPP v Woodford [2017] VSCA 312, 20,
investigation is required.
(a) _ the identity of the deceased was Bella Jayde Lawrence, born 25 March 2012;
(b) the death occurred on 17 September 2015 at Wimmera Base Hospital, 83 Baillie St,
Horsham, VIC 3400, from complications of blunt force trauma to the abdomen; and
(c) the death occurred in the circumstances described above.
Coroners Court website.
(a) Jonathan Lawrence and Angie Louana Roberts, senior next of kin; and
(b) Detective Acting Inspector Stuart Bailey, Victoria Police, Coroner’s Investigator.
Signature:
IAIN WEST ACTING STATE CORONER Date: 24 January 2019
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