Deceased
Angel Louise Hensgen
Demographics
13y, female
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2015-11-17
Finding date
2020-08-11
Cause of death
Acute paracetamol toxicity
AI-generated summary
Angel Hensgen, aged 13, died from acute paracetamol toxicity following intentional self-harm with an excessive overdose. She was exposed to intense cyberbullying, distressed by family relationships, peer conflicts, and a relationship breakdown, all while experiencing poor school engagement and self-harming. Red Cliffs Secondary College staff responded appropriately to specific incidents but failed to assess her welfare holistically or effectively engage her family. Critical missed opportunities included: no comprehensive risk assessment despite known self-harm; passive rather than assertive engagement with a refusing student; no follow-up regarding her school transfer request; and no escalation to senior management despite constellation of concerning signs. Medical intervention with N-acetylcysteine within 24 hours of overdose could have averted death. Key clinical lesson: adolescent mental health presentations require holistic assessment, active family engagement, documentation of risk assessments, and early medical intervention when overdose is suspected.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2015 5859
FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Paresa Antoniadis Spanos, Coroner Deceased: Angel Louise Hensgen Date of birth: 2 December 2001 Date of death: 17 November 2015 Cause of death: Acute paracetamol toxicity Place of death: Mildura, Victoria 3500
Angel Hensgen (Angel) was the 13-year old daughter and second eldest of the four children Rebecca Mathers and Graeme Hensgen had together.1 Angel’s parents separated when she was about nine years of age.2 Angel and her younger brother and sister lived with Ms Mathers after the separation until Christmas 2013, when Angel decided to live with her paternal grandmother, Barbara Hensgen, with whom her older brother, Marcus, also lived.3
Although Angel had ongoing and regular contact with both parents, it appears that relationships were somewhat strained. Angel told friends that she felt she had to choose between her parents when they separated.4 Mrs Hensgen noted ‘issues’ between Angel and her mother and Ms Mathers perceived Angel to be ‘distant’ after moving in with her grandmother.5 Mr Hensgen was aware that Angel ‘had a lot of issues’ with him spending time with his children from a subsequent relationship and that she believed he had ‘traded her for a new family’.6 There appears to have been limited, if any, communication between Ms Mathers and Mrs Hensgen.7 Mr Hensgen recalled talking to Ms Mathers about Angel’s wellbeing proximate to her death.8
Angel was a Year 8 student at Red Cliffs Secondary College (RCSC).9 Although her transition to high school was relatively smooth, there was some concern that Angel tended to socialise with older students and that ‘it was a bit tricky at home’.10 Her school attendance was ‘never great’ but her grandmother ‘would always know where 1 Coronial Brief, Statements of Rebecca Mathers and Barbara Hensgen.
2 Coronial Brief, Statement of Rebecca Mathers.
3 Coronial Brief, Statements of Rebecca Mathers and Barbara Hensgen.
4 XUNO Notes by Barbara O’Hara dated 29 May 2015 and Coronial Brief, Statement of KLK.
5 Coronial Brief, Statement of Rebecca Mathers.
6 Coronial Brief, Statement of Graeme Hensgen.
7 Coronial Brief, Statements of Rebecca Mathers and Barbara Hensgen.
8 Coronial Brief, Statement of Graeme Hensgen.
9 Ibid.
10 Coronial Brief, Statement of Kylie Morrish.
she was’ and would inform the school.11 Angel’s academic performance was impeded by absences from school rather than her ability to learn.12
Socially, relationships with peers were ‘very hot and cold,’ with Angel ‘attaching herself to whoever was giving her the attention she needed’.13 She was part of what teachers regarded as the ‘princess group’ in which female peers were ‘very bitchy and involved very heavily in the social media scene’.14
RCSC staff were aware that Angel was engaging in self-harming behaviours in July 2014 and May 2015.15 They knew of her relationship with a Year 11 male student, ST, four years her senior in 2015 and of rumours about her ‘engaging in sexual acts’ in July 2015, and that these were ‘causing lots of problems’ in her friendship group and across three year levels.16 RCSC’s Wellbeing Co-ordinator knew that Angel was ‘very upset and sobbing uncontrollably’ at school due to ‘legal issues with her family’ in August 2015.17 In September 2015, Mrs Hensgen informed the Year Level Coordinator that Angel was ‘struggling with depression … and hated school’.18 RCSC staff were also aware of a threat made by another student on social media – to ‘bash’ Angel because she was a ‘suicidal bitch’ – and of a verbal and physical altercation relating to this on school grounds in October 2015.19 RCSC’s responses to these events will be discussed in greater detail below.
Angel’s school attendance throughout 2015 was poor,20 with nearly 30 unexplained absences21 and no attendance at all after 22 October 2015.22 11 Coronial Brief, Statement of Kylie Morrish.
12 Ibid.
13 Ibid.
14 Ibid.
15 Coronial Brief, Statement of David Browne dated 4 November 2016 and XUNO Suite Notes (XUNO Notes) relating to Angel Hensgen.
16 Ibid.
17 Ibid.
18 Ibid.
19 Ibid.
20 Coronial Brief, Statement of Kylie Morrish: Angel attended only 68.3% of school days.
21 Ibid.
23 Coronial Brief, Statements of Graeme Hensgen, Rebecca Mathers and Barbara Hensgen.
24 Coronial Brief, Statements of Graeme Hensgen, Rebecca Mathers and Barbara Hensgen.
25 Coronial Brief, Statements of Graeme Hensgen, Rebecca Mathers and Barbara Hensgen.
26 Coronial Brief, Statement of Rebecca Mathers: Ms Mathers saw ‘new cuts on [Angel’s] arm’ when she attended Mrs Hensgen’s home on 15 November 2015.
27 Coronial Brief, Statement of ST.
28 Coronial Brief, Statement of KLK.
29 Ibid.
30 Coronial Brief, Statements of DSC Tinkler, Graeme Hensgen and Rebecca Mathers.
31 The friend with whom Angel was purportedly staying denied having seen Angel for more than a month prior to her death: Coronial Brief, Statement of Aaliyh Nugent.
32 Coronial Brief, Statement of Barbara Hensgen.
33 Coronial Brief, Statement of ST.
34 Coronial Brief, Statement of KLK.
Around 1.00am on Sunday, 15 November 2015, ST saw several Snapchat messages Angel had sent him sometime earlier.35 Among them were messages depicting Angel crying, another showing a ‘couple of packets of some pills’ with a caption, ‘before’, a short video of Angel swallowing a ‘few’ of the pills, and another message depicting empty pill packets with the caption, ‘done’.36 ST messaged Angel who responded that she had taken ‘25 pills #deadsoon’;37 his subsequent Snapchat messages remained unanswered for several hours.38
Around 7.30am on Sunday, 15 November 2015, Angel returned to her grandmother’s home.39 She took a long shower and when her grandmother asked why she had showered for so long, Angel told her she ‘felt sick’ and then went straight to bed.40 According to Mrs Hensgen, Angel did not describe specific symptoms and her grandmother did not ask her to elaborate.41
At about 8.00am, ST received a Snapchat message from Angel.42
Angel spent most of 15 November 2015 in bed. She only left her bedroom to get something to drink and to shower again around 2pm.43
At about 2.00pm, worried that he had not heard from Angel again that day, ST sent Ms K a message via Facebook asking her to contact Angel and attaching the Snapchat messages he received in the early hours of the morning.44 Ms K called Ms Mathers and told her Angel ‘may have tried to take her own life last night’ by taking pills.45 35 Coronial Brief, Statement of ST.
36 Coronial Brief, Statement of ST.
37 Coronial Brief, Statement of KLK.
38 Ibid.
39 Coronial Brief, Statement of Barbara Hensgen.
40 Ibid.
41 Ibid.
42 Coronial Brief, Statement of ST.
43 Coronial Brief, Statement of Barbara Hensgen.
44 Coronial Brief, Statements of ST and KLK.
45 Coronial Brief, Statement of KLK.
Ms Mathers and her younger daughter went to Mrs Hensgen’s home around 5.00pm.46 Both of her sons and their cousin were there, and Angel was in bed.47 Ms Mathers pulled the douvet off Angel; she saw that there were ‘new cuts on her arm’.48 Angel seemed ‘definitely intoxicated’, was drowsy and ‘mumbling and not making much sense’.49 Ms Mathers told Angel that she would take her to the doctor and that she ‘needed to see a psychiatrist’.50
While at Mrs Hensgen’s home, Ms Mathers’ younger daughter showed her a Snapchat message depicting Angel with pills in her hands and a caption, ‘bye’.51 She looked around Angel’s bedroom for pills but could not see any save for a half-empty packet of the oral contraceptive pill (OCP) Angel was prescribed. She asked Angel ‘about it but she kept saying, “Leave me alone, Mum”’.52 Ms Mathers was upset, and left with her younger daughter telling Marcus ‘not to leave [Angel] alone’.53
Angel said she was ‘still sick’ and her grandmother allowed her to remain at home.55 Angel did not complain of any pain or ask to see a doctor.56
47 Ibid.
48 Ibid.
49 Ibid.
50 Ibid.
51 Ibid.
52 Ibid.
53 Ibid.
54 Coronial Brief, Statement of ST.
55 Coronial Brief, Statement of Barbara Hensgen.
56 Ibid.
57 Ibid.
Marcus arrived home from work around 4pm. His father and grandmother were there, and Angel still in her room, asleep.58
Around 4.30pm, Mr Hensgen had a conversation with Angel to ‘see how she was going’.59 Angel told him she was ‘good’, and when he asked about a doctor’s appointment to ‘get a referral to see a psychologist’, she told him her mother had booked an appointment for the following day and would pick her up around 11.30am.60 According to Mrs Hensgen, Angel ‘would barely wake up’ to speak to her father.61
At about 5.00pm, Angel’s younger brother went into Angel’s bedroom, woke her up, and had a conversation with her.62
Mrs Hensgen asked Marcus to call his mother to arrange a doctor’s appointment for Angel because she was not feeling well.63 When Marcus called Ms Mathers, she told him that she had already made a doctor’s appointment for the following afternoon.64
Mr Hensgen left Mrs Hensgen’s home around 6.00pm and did not return that night.65 Angel’s younger brother left around 7.00pm.66
Mrs Hensgen told Marcus that Angel had been ‘dazed and confused’ that afternoon and that she ‘didn’t seem to know where she was or what was going on’.67
At around 8.30pm, Angel came out of her room, saying she was hot, had a drink of water and lay down on the couch in the lounge room with a blanket over her. Her 58 Coronial Brief, Statement of Marcus Hensgen.
59 Coronial Brief, Statement of Graeme Hensgen.
60 Ibid.
61 Coronial Brief, Statement of Barbara Hensgen.
62 Coronial Brief, Statement of Marcus Hensgen.
63 Ibid.
64 Ibid.
65 Coronial Brief, Statement of Graeme Hensgen.
66 Coronial Brief, Statement of Marcus Hensgen.
67 Ibid.
grandmother brought her a fan to keep her cool, observing that the ‘didn’t look any worse than she had for the previous days’.68
Overnight, at 1.00am, 2.00am and 3.00am on Tuesday, 17 November 2015, Mrs Hensgen checked on Angel. On the first two occasions, there were signs that Angel had been up to get herself a drink from the kitchen.69 At 3.00am, Angel asked her grandmother to bring her a drink, which she did, and pulling a blanket over her asked Angel whether she was cold with the fan on. Angel said she was not.70
When Mrs Hensgen got up to drive Marcus to work around 5.00am, she noticed Angel on the couch with the blanket over her as she had been at 3.00am.71
After returning home around 6.30am, Mrs Hensgen did not try to wake Angel. She attended to household matters until about 11.00am at which point, she tried to wake Angel so that she could get ready for her doctor’s appointment.72 Angel was unresponsive and appeared pale and cold.73 Mrs Hensgen called her son who told her to call the emergency services.74
Mrs Hensgen called Triple Zero and followed the operator’s directions to perform cardiopulmonary resuscitation until paramedics arrived.75 Ambulance Victoria paramedics arrived a short time later and confirmed that Angel was deceased.76
69 Coronial Brief, Statement of Barbara Hensgen.
70 Ibid.
71 Ibid.
72 Ibid.
73 Ibid.
74 Ibid.
75 Ibid.
76 Ibid.
Angel’s death was reported to the Coroner as it appeared to be unexpected, unnatural or to have resulted, directly or indirectly, from an accident or injury and so fell within the definition of a reportable death.79
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 but is confined to those circumstances sufficiently proximate and causally relevant to the death, and not all those circumstances which might form part of a narrative culminating in death.80
The broader purpose of any coronial investigations is to contribute to the reduction of the number of preventable deaths through the findings of the investigation and the making of recommendations by coroners, generally referred to as the prevention role.81
Coroners are empowered to report to the Attorney-General in relation to a death; 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 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 77 Section 67(1).
78 See the definition of “death” in section 3 of the Act.
79 The term is exhaustively defined in section 4 of the Coroners Act 2008 [the Act]. Apart from a jurisdictional nexus with the State of Victoria a reportable death includes deaths that appear to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury; and, deaths that occur during or following a medical procedure where the death is or may be causally related to the medical procedure and a registered medical practitioner would not, immediately before the procedure, have reasonably expected the death (section 4(2)(a) and (b) of the Act).
80 This is the effect of the authorities – see for example Harmsworth v The State Coroner [1989] VR 989; Clancy v West (Unreported 17/08/1994, Supreme Court of Victoria, Harper J.) 81 The ‘prevention’ role is now explicitly articulated in the Preamble and purposes of the Act, compared with the Coroners Act 1985 where this role was generally accepted as ‘implicit’.
justice.82 These are effectively the vehicles by which the coroner’s prevention role can be advanced.83
Victoria Police Detective Senior Constable Liam Tinkler of Mildura Criminal Investigation Unit attended Mrs Hensgen’s home and commenced an investigation of Angel’s death. He later compiled the coronial brief on which this finding is largely based. The brief contains, inter alia, photographs of the scene, content downloaded or copied from Angel’s social media accounts and statements made by attending police members, Angel’s family and friends, her general practitioner (GP), and RCSC staff.
During an examination of the scene, seven empty blister packets designed to hold 12 ‘Panadol Osteo’ tablets, one empty blister packet of ‘Panadol Cold and Flu’ designed to hold 10 tablets and one empty blister packet of ‘Nyal Sinus’ designed to hold 12 tablets were found between the bed in Angel’s room and one of the walls.85 A single white tablet and a partially-digested white tablet in a drying patch of what appeared to be vomit were located on the carpet near Angel’s bed.86 82 See sections 72(1), 67(3) and 72(2) regarding reports, comments and recommendations respectively.
83 See also sections 73(1) and 72(5) which requires publication of coronial findings, comments and recommendations and responses respectively; section 72(3) and (4) which oblige the recipient of a coronial recommendation to respond within three months, specifying a statement of action which has or will be taken in relation to the recommendation.
84 Section 69(1). However, a coroner may include a statement relating to a notification to the Director of Public Prosecutions if they believe an indictable offence may have been committed in connection with the death. See sections 69 (2) and 49(1).
85 Coronial Brief, Statements of Leading Senior Constable Nicholas Watkins and Sergeant Paul Dacey.
86 Ibid.
Angel’s body was brought to the Coronial Services Centre. Dr Yeliena Baber, forensic pathologist at the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy on Angel’s body in the mortuary and reviewed the circumstances of death as reported by police to the coroner (Form 83)87 and postmortem computed tomography scanning of the whole body undertaken at VIFM.
Among Dr Baber’s anatomical findings were multiple areas of self-harm on both upper outer thighs comprised of multiple parallel linear superficial incised wounds, some being relatively well-healed scars and others apparently inflicted more recently, a slightly swollen brain and ischaemic changes to the liver.88
Routine toxicological analysis of post-mortem samples taken from Angel detected paracetamol89 in blood (~700mg/L) and stomach contents (~106mg) but no alcohol or other commonly encountered drugs or poisons.90 According to the toxicologist’s report, blood concentrations of paracetamol in recorded fatalities attributed to paracetamol toxicity range from 160mg/L. The minimum lethal dose is 10g and hepatotoxicity and liver necrosis may occur in plasma concentrations of 120300mg/L.91 87 Form 83 prepared by Detective Senior Constable Liam Tinkler dated 17 November 2015.
88 Medical Investigation Report of Dr Yeliena Baber dated 25 February 2016.
89 Paracetamol is a potent mitochondrial toxin in massive ingestions with very high paracetamol blood concentrations. It can result in direct development of sedation and coma and disrupt lactate metabolism resulting in severe metabolic acidaemia.
90 VIFM Toxicology Report of Luke Rodda dated 29 January 2016.
91 Ibid.
February
April
93 Twenty paracetamol tablets were referenced in the Form 83.
94 Ibid.
95 Ibid.
96 XUNO Notes dated 9 February 2015 indicate that Angel had received a ‘last warning’ for ‘constant disruption, refusal to work and rudeness’.
97 Coronial Brief, Statement of Barbara O’Hara.
98 Angel’s RCSC Student Report (Years 7 and 8).
99 Coronial Brief, Qooh Me post by _angellouise (undated): ‘[ST] is now my life, I could not be happier’.
12 April 2015 including a discussion about it being ‘illegal’ to have sexual intercourse with a 13-year old.100 RCSC staff deny knowledge that the relationship was sexual101 and it is unclear whether Angel’s parents or grandmother were aware of this aspect of their relationship.102 May
On 5 May 2015, a RCSC Education Support Officer documented that ‘this [was] the second time’ she had observed ‘what looks like cutting … on Angel’s thighs … I can see the marks up very high … [and] have not said anything to her’.103 The Year Level Coordinator Martine Hendy became aware of Angel’s self-harming and referred her to the Student Wellbeing Coordinator Barbara O’Hara.104
On 11 May 2015, Ms Hendy informed Mr Hensgen that Angel had ‘self-harmed and agreed to speak to the Wellbeing Team’.105 She also advised him that Angel had failed to complete a ‘significant’ amount of schoolwork and had agreed to try to 100 Coronial Brief, Qooh Me post to _angellouise: ‘Its [sic] illegal to have sex at 13 baby girl’ 101 Coronial Brief, Statements of Kylie Morrish (‘Angel started dating a Year 11 boy … opened up her world, she started going to parties, she had access to alcohol and became sexually active …[ST] was good enough to her, despite the age difference, which worried us’) and Barbara O’Hara (Angel ‘said the same thing of her boyfriend [ST]’). I note that in a statement provided by Principal David Browne dated 4 November 2016 he advised that his enquiries revealed that neither the Junior School Coordinator nor Senior Sub-School Coordinator were aware of a sexual relationship between Angel and ST. In correspondence from Annette Wiltshire, Executive Director Legal Division at the Department of Education and Training dated 26 June 2020, I was advised that information in Ms Morrish’s statement that suggested the school was aware of a sexual relationship before Angel’s death was provided in the ‘mistaken’ belief that this was the case but that it ‘did not actually come out until after her death.’ Moreover, there was no RCSC ‘record’ of any sexual relationship between Angel and ST.
102 Coronial Brief, Statements of Graeme Hensgen (‘Angel had a boyfriend a while ago, he was a good placid bloke but was just too old … they never snuck around or anything’), Rebecca Mathers (‘she was seeing an older guy … Angel’s ex-boyfriend’) and Barbara Hensgen (‘she did have a boyfriend … who is around 16 or 17 … they were dating for around six months’).
103 XUNOS Notes by Carlie Tierny dated 5 May 2015. RCSC records record an earlier incident of self-harming behaviour by Angel in July 2014: the Year Level Coordinator discussed the behaviour with Angel (who confirmed cutting her wrist and forearm ‘once … when she was being silly with some classmates’). An unsuccessful attempt was made to contact Mrs Hensgen. Angel was referred to the school’s Wellbeing Team and met with the Nurse on 22 August 2014. Angel showed cutting marks on her wrist, which the Nurse considered ‘not consistent’ with one incident of self-harming. Angel told the Nurse that RCSC had already contacted her grandmother but that ‘her grandmother had not spoken to her about it’. The Nurse informed her of the support available to her at school and that she could return to see her if she had concerns in the future: Statement of David Browne dated 4 November 2016.
104 Statement of David Browne dated 4 November 2016.
105 XUNO Notes by Martine Hendy dated 11 May 2015.
complete one outstanding task each week.106 Mr Hensgen was ‘happy with this agreement’.107
On 11 May 2015, Ms O’Hara met with Angel ‘very briefly, maybe 2 minutes’ during which she performed a risk assessment and ‘had no concerns for her safety’.108 The Wellbeing Coordinator made an appointment for Angel to see the Nurse, Julia Lohmeyer, the following day, with a plan to see Angel herself on 13 May 2015 if Ms Lohmeyer had been unable to see her.109
Angel did not see the RCSC Nurse in May 2015110 and was not seen by the Wellbeing Coordinator as planned on 13 May 2015.111 The Wellbeing Team agreed that ‘urgent’ follow-up occur with Angel as she had failed to attend appointments.112 Angel was paged to attend the Wellbeing Coordinator ‘on several occasions’ but failed to present.113
Ms O’Hara also endeavoured to contact Angel by phone up to twice per day for the next fortnight which was not her usual practice so ‘there may have been something’ of particular concern.114 She observed that it was not uncommon for students to initially indicate a willingness to see the Wellbeing Team but then fail to engage.115 Nonetheless, on 29 May 2015, the Wellbeing Coordinator directed the duty students to collect Angel from class.116 106 XUNO Notes by Martine Hendy dated 11 May 2015.
107 Ibid.
108 Coronial Brief, Statement of Barbara O’Hara.
109 Coronial Brief, Statement of Barbara Hensgen.
110 Coronial Brief, Statement of Julia Lohmeyer.
111 Coronial Brief, Statement of Barbara O’Hara.
112 Statement of David Browne dated 4 November 2016.
113 Ibid.
114 Coronial Brief, Statement of Barbara O’Hara.
115 Ibid.
116 Ibid.
On 29 May 2015, Ms O’Hara started by asking Angel why ‘she wasn’t turning up’ when called and ‘whether she wanted to see anyone else’.117 Angel ‘got a bit teary’ and, when pressed, disclosed – what the Wellbeing Coordinator characterised as ‘nothing drastic’ – that her female friends and ‘boyfriend [ST]’ just ‘don’t understand what’s going on in my life’.118 Ms O’Hara suggested that her friends ‘weren’t mindreaders’ but Angel failed to disclose anything that would help her understand the situation.119
Ms O’Hara asked Angel about self-harming behaviours and was shown ‘some scratchy superficial stuff on her wrists under some bands’.120 She asked about selfharming on her legs but Angel declined to show Ms O’Hara any further marks.121 The Wellbeing Coordinator suggested that Angel engage in activities she enjoyed – such as drawing and writing – as well as exercising, eating and sleeping well and ‘getting off social media’ to manage negative emotions, rather than harming herself.122 A referral to the Nurse or to ‘check in with Ms Hendy’ were offered in anticipation of Ms O’Hara going on extended leave. Although Angel ‘nodded’ the Wellbeing Coordinator ‘wasn’t sure how much she would actually do since she wasn’t turning up’ for her.123
During the same meeting, Ms O’Hara learned that Angel was living with her ‘strict’ grandmother and that her mother had ‘made her choose’ between her and Mr Hensgen’s current partner which had made Angel ‘sad’ at first.124 Angel also reported being ‘worried’ about her brother who ‘sleeps for weeks’.125 The Wellbeing Coordinator perceived that Angel’s presentation had brightened in the course of their interaction and her ongoing risk assessment showed ‘no risk of suicide despite the 117 Coronial Brief, Statement of Barbara O’Hara.
118 Ibid.
119 Coronial Brief, Statement of Barbara O’Hara.
120 Ibid.
121 Ibid.
122 Ibid.
123 Ibid.
124 Ibid.
125 Ibid.
scratches’ on her arms.126 The Wellbeing Coordinator communicated her observations to the Nurse by email with an expectation that Angel would see Ms Lohmeyer the following week.
June
The Nurse ‘tried every day she was at school’ to contact Angel but was unsuccessful.127 On 16 June 2015, she sent an email to Ms O’Hara confirming this and indicating that she would ‘leave it up to Angel’ to contact her if needed.128 July
On 13 and 16 July 2015 there were verbal and physical incidents in the RCSC school yard between ST and other students, the former arising when ST was talking to Angel.129 Upon investigation, RCSC staff learned that two Year 9 male students had been spreading rumours about Angel engaging in sexual acts and ‘cheating on’ ST the previous weekend.130 Staff ‘spoke to’131 the students involved in the rumours and other incidents which spanned students across three year levels.132
Angel appeared visibly upset by the rumours133 and related conflict with her friends as while at school.134 A Year Level Coordinator asked the Nurse to speak with Angel, who presented to Ms Lohmeyer’s office ‘initially unaware’ why she had been summoned.135 Angel confirmed distress about the rumours and repercussions within her friendship group.136 Ms Lohmeyer ‘spoke to her about the … importance of 126 Ibid.
127 Coronial Brief, Statement of Julia Lohmeyer. It’s understood that Ms Lohmeyer worked at RCSC part-time.
128 Ibid.
129 XUNO Notes by Narelle Greenwood dated 17 July 2015.
130 Coronial Brief, Statement of Kylie Morrish.
131 XUNO Notes by Michael Divola dated 15 July 2015.
132 XUNO (Confidential) Notes by Kylie Morrish dated 15 July 2015. I note that management of the rumours was facilitated by staff with the hope that the reason Angel did not wish to approach relevant teachers herself was because ‘there is much more to the story than she has disclosed’ to Mr Morrish.
133 Angel’s social media posts suggest that her relationship with ST ended for a short time during July 2015.
134 XUNO (Confidential) Notes by Kylie Morrish dated 15 July 2015.
135 Coronial Brief, Statement of Julia Lohmeyer.
136 Ibid.
having someone to speak to about these matters’.137 Angel said she preferred keeping things to herself rather than confiding in a family member or anyone on the Wellbeing Team.138 The Nurse suggested anonymous online counselling and scheduled a follow-up meeting in a fortnight’s time.139
Angel did not attend any subsequent meeting with the Nurse, despite being paged.140 Given that Angel had told her that she did not want to engage with the Wellbeing Team, Ms Lohmeyer emailed the Year Level Coordinator about ‘support networks available’ to be conveyed to Angel.141
On 27 July 2015, Angel was prescribed the OCP to treat dysmenorrhea by Dr Robert Meyer of Lime Medical Clinic.142 August
In August 2015, the relationship with ST appears to have continued and Angel posted on social media her belief she had taken his virginity.143 There are several posts by ST on Qooh Me defending Angel when she received negative posts, and he had made declarations of love.
On 20 August 2015, Angel was seen crying near the lockers at the start of the school day. When a RCSC staff member asked if she was alright, Angel ‘sobbed uncontrollably’.144 At recess, Ms O’Hara spoke with Angel who was ‘flat and teary’; she ‘presumed it was about the boyfriend again’ but Angel disclosed that the cause was ‘legal issues with her family’ and said she just wanted to go home.145 The 137 Ibid.
138 Coronial Brief, Statement of Julia Lohmeyer.
139 Ibid.
140 Ibid.
141 Ibid.
142 Angel Hensgen’s Lime Medical Clinic medical records.
143 Coronial Brief, Qooh Me post by _angellouise (undated): ‘I sure did :))’ in response to question, ‘You took [ST’s] virginity though? :/’ 144 XUNO Notes by Vikki Arthur dated 20 August 2015.
145 Coronial Brief, Statement of Barbara O’Hara.
Wellbeing Coordinator offered support and made arrangements for Angel to go home.146 September
According to ST, he broke off the relationship after Angel had cheated on him.147 There was further escalation in online negative events after Angel noted she would maintain a relationship with ST as a ‘fuck buddy’148 and she was happy to be contacted by him whenever he wanted.
On 15 September 2015, the Year Level Coordinator spoke with Angel about her increased absence from school. She was noted to have refused help because it ‘doesn’t fix anything’.149 Ms Hendy contacted Mrs Hensgen about Angel’s poor attendance and was told Angel hated RCSC, had difficult periods and was depressed.150
Qooh Me records contain exchanges related to Angel’s wish to move to Irymple Technical College (ITC) which resulted in disparaging posts telling her not to come to Irymple because the school was ‘full of bullies’ and that ITC did not need ‘any more sluts’.151 October
On 21 October 2015, a threat to ‘bash’ Angel because she was a ‘suicidal bitch’ was made on Facebook.152 This resulted in an incident at school between two groups of girls during which Angel was struck by another student who was later suspended.153 146 Coronial Brief, Statement of Barbara O’Hara.
147 Coronial Brief, Statement of ST.
148 Coronial Brief, Qooh Me post by _angellouise (undated): exchange – ‘fck buddies babe ;)’, ‘already have one babe ;)’, ‘your [sic] wasting your time with [ST]’, ‘nah’ 149 XUNO Notes by Martine Hendy dated 15 September 2015.
150 Ibid.
151 Coronial Brief, Qooh Me posts.
152 Coronial Brief, Statement of Kylie Morrish, and the Statement of David Browne dated 4 November 2016.
153 Coronial Brief, Statement of Kylie Morrish.
Ms Mathers contacted RCSC the following day wanting to report the incident to police and was told to speak with Angel first, the incident having been managed in accordance with school policy.154
Angel continued to be absent from classes, with several teachers raising concerns about her poor attendance and its effect on her academic attainment via RCSC’s XUNO record-keeping software.155
ST attempted to communicate with Angel via social media but she appears to have refused to answer;156 he later asked her to remove the picture of him from her social media display.157 Angel blamed herself for the relationship breakdown and posted that ST remained a ‘close friend’.158
Social media posts reveal that several of Angel’s friends offered support, but she withdrew from them, resulting in some negative and aggressive responses.159 November
In early November 2015, Angel posted on social media that she had begged ST for three days until he allowed her to see him.
155 See for instance, XUNO Notes by Leanne Gray dated 27 October 2015.
156 Coronial Brief, Qooh Me posts (undated): [ST] posted ‘Going to reply to any of my questions?’ to which by _angellouise responded ‘nope’.
157 Coronial Brief, Qooh Me posts (undated): from ST, ‘Please change your dp [display picture] :(’ to which _angellouise responded, ‘okay :)’.
158 Coronial Brief, Qooh Me post by _angellouise (undated): ‘[ST] and I? we’re just close friends’.
159 See for instance, Coronial Brief, Qooh Me posts to _angellouise (undated): ‘You can’t do this alone Angel … You need help and support and it would be stupid for you to push that away …’ and another ‘Why do you push people away? You push the ones that are willing to help you … your [sic] so selfish’.
160 XUNO Notes dated 5 and 9 November 2015.
161 XUNO Notes by Martine Hendy dated 6 November 2015.
information about Angel’s academic progress and attendance would have been provided by the Year Level Coordinator who took the call.162
On 7 November 2015, Angel stayed with Rebecca Mathers overnight after Angel had ‘passed out’ from drinking alcohol at a party.163 According to Angel’s social media exchanges, she was stressed because ST just kept coming back and then leaving.164 Angel also said she had been so sick she had to be taken to hospital on 8 November 2015, however, this could not be substantiated.165
On 10 November 2015, Acting Assistant Principal Karen Boyce of ITC met with Angel and her grandmother.166 Angel complained of ‘bullying’ at her current school.167 This led to a discussion about ‘bulling and social media’ and that it ‘would not stop by changing schools’.168 When asked whether she had spoken to the Wellbeing Team at RCSC, Angel said she ‘had not as they wouldn’t listen and didn’t care’.169
Ms Boyce canvassed with Mrs Hensgen whether she could make an appointment for Angel to see RCSC’s Wellbeing Coordinator or with headspace if that was preferred.170 Mrs Hensgen said she would do so. Angel and Mrs Hensgen were advised that it was ‘an agreed procedure’171 among schools in the district that students 162 Statement of David Browne dated 4 November 2016. I note that the XUNO Notes do not disclose the content of any discussion between the schools.
163 Coronial Brief, Statement of Rebecca Mathers.
164 Coronial Brief, Qooh Me post by _angellouise (undated): in response to a query about the status of her relationship with ST, ‘I have no fcking idea, I can’t even seem to explain it to be honest. Just message him because I’m so confused at this point’.
165 Mildura Base Hospital had no record of contact by Angel Hensgen over the relevant period; she last contact with the hospital on 25 June 2014. There is a private hospital in Mildura and there are district health services in nearby towns, including Robinvale, however these were not contacted as part of this investigation.
166 Correspondence from ITC’s Acting Principal Robyn Blackie dated 15 September 2016.
167 Ibid.
168 Correspondence from ITC’s Acting Principal Robyn Blackie dated 15 September 2016.
169 Ibid.
170 Ibid.
171 Although requested, ITC did not provide confirmation that there existed any formal procedure along these lines.
in Angel’s situation work with their current school to resolve any issues before a transfer was undertaken.172 In the absence of resolution, ITC would consider a transfer in 2016.173
According to Mr Hensgen and his mother, Angel was ‘knocked … around … emotionally’ when she was unable to transfer to ITC.174
On the weekend before Angel’s death Ms Mathers was contacted by Angel’s friends because Angel was intoxicated, vomiting and unresponsive.175 Ms Mathers took her home and stayed in the same bed as her overnight and Angel returned to her grandmother’s next day.176
Prescription of the OCP – Management by Lime Medical Clinic
Angel was a patient of Lime Medical Clinic and consulted GPs there on four occasions between August 2003 and July 2015.
On 27 July 2015, Angel attended an appointment with Dr Robert Meyer with a peer.178 She requested the OCP.179 According to clinical notes, Angel reported that menstruation commenced 18 months earlier and that ‘lately’ her period was 172 Correspondence from ITC’s Acting Principal Robyn Blackie dated 15 September 2016.
173 Ibid.
174 Coronial Brief, Statements of Graeme Hensgen and Barbara Hensgen.
175 Coronial Brief, Statement of Rebecca Mathers.
176 Coronial Brief, Statement of Rebecca Mathers.
177 The Coroners Prevention Unit was established in 2008 to support the prevention role of coroners. The CPU is staffed by independent, highly skilled and experienced investigators, medical clinicians, and mental health and allied health professionals. The CPU provides advice to coroners during their investigations, assists formulation of prevention-focused comments and recommendations and monitors their effectiveness.
178 Coronial Brief, Statement of Dr Robert Meyer dated 11 February 2016.
179 Angel’s Lime Medical Clinic Consultation note by Dr Meyer dated 27 July 2015.
accompanied by pain (dysmenorrhea), which was sometimes severe, and that her period was occasionally irregular.180 Angel reported that she was in ‘good health’ and ‘did not bring up any issues regarding her mental health’.181 Dr Meyer checked Angel’s blood pressure, which was unremarkable, and prescribed the OCP for dysmenorrhea.182 The GP’s usual practice involved review after four months to assess the effectiveness of treatment over three menstrual cycles.183
According to Dr Meyer, although Angel did not state that her request for OCP was for contraception,184 he considered a pregnancy would not be good for her given her age.185 The GP was unable to recall and did not note what, if anything, Angel said about being sexually active.186 Dr Meyer recalled Angel saying that she had mentioned to her mother that she wanted the OCP and that he had encouraged her to speak with her mother again.187 Clinical notes show that the GP was ‘unsure’ if Ms Mathers ‘agrees fully’ but ‘apparently said to try it’.188
The OCP is the recommended first-line treatment for dysmenorrhea and should only be prescribed following comprehensive assessment. What constitutes a comprehensive assessment is unclear.189 Dr Meyer’s assessment included a 180 Angel’s Lime Medical Clinic Consultation note by Dr Meyer dated 27 July 2015.
181 Dr Meyer stated that he ‘would have asked about her mental health’: Coronial Brief, Statement of Dr Robert Meyer dated 11 February 2016.
182 Angel’s Lime Medical Clinic Consultation note by Dr Meyer dated 27 July 2015.
183 Coronial Brief, Statement of Dr Robert Meyer dated 11 February 2016.
184 Ibid. Dr Meyer stated that Angel ‘predominantly wanted the pill because of period pain’.
185 Statement of Dr Robert Meyer dated 9 February 2017.
186 Coronial Brief, Statement of Dr Robert Meyer dated 11 February 2016.
187 Ibid. Dr Meyer stated: ‘I asked if her mother was aware she was trying to get the pill. Angel and her friend looked at each other and Angel said that she had discussed it with her mother but was unsure if she agreed, she said she planned to tell her mother.’ 188 Angel’s Lime Medical Clinic Consultation note by Dr Meyer dated 27 July 2015.
189 ‘Best practice’ involves healthcare providers exploration of the patient’s psychosocial circumstances, sexual history, screen for pregnancy and sexually transmitted infections, promote safer sex practices as well as provide ‘developmentally targeted’ counselling and suitable contraceptive options; young adolescent patients should be informed of the law in relation to sexual activity and the healthcare provider should assess their competence to consent to treatment: Jess McMicking and Jilly Lloyd, ‘Contraception in Adolescents’, O&G Magazine, July
discussion with Angel about her general health and menstruation cycles and basic vital observations.
Advice to GPs about consent to medical treatment by adolescents under 16 years differs across jurisdictions and precisely what level of maturity is required in the clinical setting will ‘vary with the nature and complexity of the medical treatment’.190 Broadly, the clinician must satisfy him or herself that the adolescent has the intelligence and a ‘sufficient understanding to enable him or her to fully understand’ the nature, consequences and risks of treatment.191
Dr Meyer did not document any assessment of Angel’s capacity to consent to treatment with the OCP which is recommended when prescribing the drug to adolescents aged between ten and 14 years. Moreover, a discussion with Angel about the risks and implications of the use of the OCP, the legal age of consent to sexual activity and safer sex practices was a reasonable expectation in this setting.
Management of Stressors
Bullying/Cyberbullying
The available evidence suggests that Angel regularly used Facebook, Snapchat and Qooh Me social media sites.
Individuals must be 13 years or older to open a Qooh Me or Snapchat account. All three of these social media providers have clear disclaimers192 about inappropriate use 190 Sara Bird, ‘Consent to medical treatment: the mature minor,’ Australian Family Physician, March 2011 (Vol.40, No.30).
191 Sara Bird, ‘Consent to medical treatment: the mature minor,’ Australian Family Physician, March 2011 (Vol.40, No.30).
192 See for instance, the Qoo Me disclaimer which is in the following terms: We reserve the right at all times (but will not have an obligation) to remove or refuse to distribute any Content on the Service and to terminate users or reclaim usernames. We also reserve the right to access, read, preserve, and disclose any information we reasonably believe is necessary to (i) satisfy any applicable law, regulation, legal process or governmental request, (enforce the Terms, including investigation of potential violations hereof, (iii) detect, prevent, or otherwise address fraud security or technical issues, (iv) respond to user support requests, or (v) protect the rights, property or safety of Qooh.me its users and the public.
of their platforms to abuse, harass or bully others. How these purported safeguards are monitored and enforced is unclear save for the encouragement that users report infractions to a generic email address.
Records of Angel’s Qooh Me use for over a year prior to her death193 were available and frequency count and thematic analysis was completed. Most of the Qooh Me posts are anonymous and when Angel or others responded to a question or remark, they became public. References within the Qooh Me posts to people, places and events suggest that individuals who posted comments knew, or knew of, Angel and details of her relationships. Users appear to have avoided using the full spelling of some words, such as swear words, to reduce the likelihood that abusive content is detected.
Qooh Me posts on Angel’s account were sorted by theme into four categories of events, namely those that were accusatory/denigrating,194 taunting,195 sexual196 or commands to die.197
Frequency analysis of events showed an escalation in frequency of events over the year prior to Angel’s death, with a significant increase in frequency in the three months prior to her death. For example, in September 2015 she received negative Qooh Me posts on 20 days of the 30 days of the month and the frequency of 193 Qooh Me records contained the number of days for each post from printout date. Date subtraction calculator used to assign dates of social media posts.
/www.timeanddate.com/date/dateadded.html?d1=17&m1=11&y1=2015&type=sub&ay=&am=&aw=&ad=442 &rec= 194 Examples of content categorised as ‘accusatory/denigrating’ include the following comments: pathetic whore; you’re overgrowth is ugly; you’re nothing but a filthy slut; cunt its [sic] not about you, fuck off!; you’re not a virgin you dirty fucking dog; compulsive lying bitch fuck off; you look fat in your story; you’re a slut;
195 Examples of content categorised as ‘taunting’ include the following comments: [ST] doesn’t want you anymore; think you’re going to be alive in 2016? Hope not; you wrecked [ST], do you know that?; he doesn’t want you slut; I saw [ST] getting with a girl a few weekends back; everyone hates you; [ST] doesn’t love you anymore; if I was your dad I wouldn’t stick around either.
196 Examples of content categorised as ‘sexual’ include the following comments: like sucking dick?; really want to fu.k you; do you shave or wax you v…..?; when you’re single can we fuck? Horny; please you’d be a good root; your boobs are bigger than most your age; how about we exchange nudes; you’re t.tts are massive. Links to porn sites were also sent.
197 Examples of content categorised as ‘commands to die’ include the following comments: kill yourself; bleed out; kill yourself slut; I wish you were dead, you’re worthless; not needed and your existence is not appreciated; instead of your thighs go for your throat next time.
accusatory/denigrating198 and taunting199 posts increased prior to Angel’s death, along with a small increase in commands to die.200
Many of the posts to Angel, particularly via the Qooh Me social media platform, meet the national definition of bullying for Australian schools.201 It is now common knowledge that technology expands the opportunities for people to bully others and creates new challenges to addressing the behaviour, particularly in a virtual environment where anonymity is prevalent.
The effects of bullying on an individual may be immediate, medium and long term.
Research shows that bullying can have an adverse impact on a student’s academic performance, self-esteem and self-perception, coping skills, and may increase anxiety and unhappiness.202
The removal of the negative posts may have reduced the impact of bullying on Angel, at least to the extent that she was being bullied online.
There is no evidence that RCSC was aware Angel was subject to cyberbullying, nor is there evidence that inquiries were made to establish whether or not this was the case.203 The school was aware that she was threatened once via social media by a co198 Frequency of accusatory/denigrating events in September, October and November 2015 were 30, 10 and 16 respectively, compared to April 2015 when Angel received 10 such posts.
199 Frequency of taunting events in September, October and November 2015 were 24, 43 and 8 respectively, compared to April 2015 when Angel received 2 such posts.
200 Frequency of commands to die events in September, October and November 2015 were 4, 6 and 0 respectively, compared to all other months when Angel received 2 or fewer posts of this type (except April 2015, when 6 were received).
201 The National definitions of bullying appear at Bullying No Way, https://bullyingnoway.gov.au/WhatIsBullying/Documents/definition-of-bullying.pdf: Bullying is an ongoing and deliberate misuse of power in relationships through repeated verbal, physical and/or social behaviour that intends to cause physical, social and/or psychological harm. It can involve an individual or a group misusing their power, or perceived power, over one or more persons who feel unable to stop it from happening. Online bullying (sometimes called cyberbullying) is bullying that is carried out through information and communication technology, including the internet (e.g. on social media sites) and mobile devices. Research indicates that the majority of young people who bully online also bully others in person.
202 Australian Government: Bullying No Way - https://bullyingnoway.gov.au/WhatIsBullying/FactsAndFigures/Pages/FAQs-Identifying.aspx 203 Correspondence from Annette Wiltshire dated 26 June 2020 (incorporating comments by RCSC Principal David Browne). I note several references in XUNOs Notes and the statements made by RCSC staff disclosing knowledge of Angel’s use of social media.
student in October 2015 and, ‘staff dealt with this matter’.204 Management by RCSC appears to have consisted of asking the student responsible for the ‘suicidal bitch’ comment what was meant by it and receiving no explanation.205 According to Principal Mr Browne, the Junior School Co-ordinator checked on Angel’s wellbeing afterwards – Angel reportedly said she was unconcerned by the comment206 – though there is no material before me to corroborate that this occurred.207 Disciplinary action taken against the co-student appears related to her role in the physical altercation.208
The Department of Education and Training (DET) does not mandate specific antibullying programs but requires schools to address bullying as part of their Student Engagement Policy209 in order to discharge their duty of care to students. The DET requires that an anti-bullying policy be developed in consultation with the school community, be clearly communicated and reviewed every two to three years.210 It considers an effective anti-bullying policy to be one that clearly outlines the steps the school will take in response to bullying behaviour, the strategies to prevent bullying, and the support the school will provide to all students involved.211
In 2015, RCSC did not have a stand-alone anti-bullying policy, rather bullying was addressed in its Student Engagement Policy (SEP), drafted in February 2013.212 The SEP contains a ‘whole-school prevention statement’ indicating that RCSC aims to foster positive relationships and respectful behaviours to ensure a ‘safe and inclusive school environment for everyone’.213 204 Ibid.
205 Statement of David Browne dated 4 November 2016.
206 Statement of David Browne dated 4 November 2016.
207 There is no reference to a wellbeing check occurring sometime around 21 October 2015 within the statements provided by the Junior School Co-ordinator (Kylie Morrish) and Wellbeing Coordinator (Barbara O’Hara) or contained in Angel’s XUNO Notes.
208 Statement of David Browne dated 4 November 2016.
209 Or a stand-alone bullying policy: correspondence from Annette Wiltshire dated 26 June 2020.
210 Correspondence from Annette Wiltshire dated 26 June 2020.
211 Correspondence from Annette Wiltshire dated 26 June 2020.
212 RCSC Student Engagement and Well-Being Policy – February 2013.
213 Ibid.
Bullying, cyberbullying and harassment are defined and their potential adverse effects noted in the SEP.214 Students who experience bullying or harassment are encouraged to tell the perpetrator to stop and/or discuss the matter with a student leader or teacher/coordinator.215 Witnesses to harassment or bullying are encouraged to inform the target of the behaviour that they have witnessed it and advise them to ‘report it to an appropriate person’.216 The SEP states that concerns will be ‘taken seriously’ and ‘complaints treated confidentially’ while ‘extreme forms’ of sexual harassment ‘will lead to criminal prosecution’.217 Though the consequences of bullying and cyberbullying are not specifically articulated in the SEP, ‘inappropriate behaviours’ will ‘incur a staged [disciplinary] response’ and may include suspension where other measures are inappropriate or have been ineffective.218
In 2015, cyber safety formed part of the school curriculum at RCSC.219 In semester one of 2015, Angel participated in Multimedia Studies, a subject that canvassed issues including cyberbullying.220 RCSC conducts, and continues to conduct, annual student surveys aimed in part to identify bullying and provide support and assistance to those involved through its peer support and Wellbeing programs.221
In 2011, RCSC registered in the eSmart Schools Program, developed by the Alannah and Madeline Foundation and designed to educate, track, monitor and prevent bullying and cyberbullying in schools with schools’ participation funded by the Victorian Government.222 RCSC’s existing practices were evaluated between 2011 214 Ibid.
215 Ibid.
216 RCSC Student Engagement and Well-Being Policy – February 2013.
217 Ibid.
218 Where the Principal considers an ‘immediate response’ is warranted procedures prior to suspension may be bypassed: SEP.
219 Statement of David Browne dated 4 November 2016.
220 Angel’s Student Report Semester 1, 2015.
221 Correspondence from Annette Wiltshire dated 26 June 2020.
222 Correspondence from Linda Barry, General Manager – Programs, Alannah and Madeline Foundation dated 8 October 2019.
and 2013 to identify technological, procedural and cyber safety gaps.223 In 2016, the eSmart Framework was implemented224 at RCSC and the school achieved eSmart Status.225
RCSC presently has a ‘Bullying Prevention Policy’, last updated in August 2019 and reviewed annually, which appears to comply the DET’s requirements for an effective anti-bullying policy.226
The DET advised that throughout 2015 a range of initiatives, policies and procedures were in place to support the safety and wellbeing of students. These included227 a protocol between DET, the Department of Health and Human Services (DHHS), Licenced Children’s Services and Victorian Schools,228 a procedure for ‘Responding to Allegation of Student Sexual Assault’,229 Bully Stoppers Online Toolkit230 and the requirements of the School Policy and Advisory Guide.231
Since 2015, the DET has introduced additional policies, procedures and resources for schools to identify and respond to child abuse, bullying and problem sexual behaviour by students.232 223 Correspondence from Linda Barry, General Manager – Programs, Alannah and Madeline Foundation dated 8 October 2019.
224 The eSmart Framework, which is aligned with the Australian curriculum and endorsed by the Office of the eSafety Commissioner covers six areas: effective school organisation, school plans, policies and procedures, a respectful and caring school community, effective teacher practices, eSmart curriculum and partnerships with parents and local communities. The implementation phase includes support with access to best-practice information and resources, an online system to record, track and report the school’s progress, in person and online training and support webinars and regular newsletters: Correspondence from Linda Barry dated 8 October 2019.
225 Correspondence from Linda Barry dated 8 October 2019.
226 Red Cliffs Secondary College and FLO Connect Policy, Bullying Prevention Policy, August 2019, available at www.red-cliffs-sc.vic.edu.au.
227 Correspondence from Annette Wiltshire dated 26 June 2020.
228 The protocol’s subject matter is ‘Protecting the safety and wellbeing of children and young people’.
229 The procedure was published in July 2007 by the Student Wellbeing and Support Division of the DET.
230 The toolkit provides evidence-based resources and support students, parents, teachers and principals to work together to precent and address all forms of bullying.
231 Among the requirements are that schools develop and implement an anti-bullying policy and provide detailed information about legal obligations to protect children and report child abuse.
232 Among these resources are The Policy and Advisory Library, Mandatory Reporting and other Obligations eLearning module, and the PROTECT website: correspondence from Annette Wiltshire dated 26 June 2020.
Interpersonal Stressors and their manifestations – Management by RCSC
Mandatory reporting is the legal requirement for certain professional groups to report to the DHHS a reasonable belief that a child is in need of protection from physical or sexual abuse.233 School teachers and principals are among the professionals who have mandatory reporting obligations.234
A voluntary report may be made to DHHS by anyone who has formed a reasonable belief that a child has suffered or is likely to suffer significant harm as a result of abuse or neglect,235 and their parents have not protected or are unlikely to protect the child from harm of that type. Similarly, where someone has significant concerns for the wellbeing of a child, he or she may refer the child and its family to Child FIRST, the access point for family services in Victoria.
According to Principal David Browne, RCSC staff are meticulous in the way they manage Child Protection reporting, and in making internal notification to the Incident Management Team.236 Staff complete the DET’s online mandatory reporting and child safety modules every 12 months, Child Safe posters are displayed in every room in the school and reporting processes are clearly displayed in the school’s administration area.237 Any staff member who has formed a belief that a child may be 233 Section 184 of the Children Youth and Families Act 2005 (CYFA).
234 Section 182 subsections (c) and (d) CYFA. The mandatory reporting requirement applies to teachers registered or permitted to teach pursuant to the Education and Training Reform Act 2006 and is applicable to principals of government and non-government schools.
235 The types of harm broadly falling within these categorisations are enumerated in section 162 of the CYFA: physical abuse; sexual abuse; emotional abuse and mistreatment, neglect, poor care and inadequate supervision impacting on the child's stability and healthy development; Significant family violence or parental substance misuse, psychiatric illness or intellectual disability – where there is a likelihood of significant harm to the child, or the child's stability and development; a child's actions or behaviour may place them at risk of significant harm and the parents are unwilling, or unable to protect the child; abandonment of a child (where the child's parents are dead or incapacitated) and no other person is caring properly for the child.
236 Correspondence from Annette Wiltshire dated 26 June 2020.
237 Ibid.
at risk is supported by a Principal Class Officer and/or a Wellbeing Officer before, during and after their report to DHHS Child Protection.238
Relationship with ST
Several staff RCSC members were aware of Angel’s relationship239 with ST and the rumours about ‘sexual acts’ appear to have been managed – in a timely way – as rumours, particularly as ‘Angel could not identify a reason’ for them.240 Notwithstanding that ‘such gossip [as] might occur … from 13 and 14-year old students’ would ‘not alone form the basis for reporting to Child Protection’ as it is ‘not a reliable source of information’, according to Mr Browne, as Principal he would expect staff to ‘take steps to confirm information’.241
In particular, he would anticipate that staff would talk to students, relay any concerns to parents and assess whether parents are acting protectively, before considering whether there was a belief on reasonable grounds that a child is in need of protection such that a voluntary or mandatory report need be made to DHHS.242
The Junior School Co-ordinator Ms Morrish reportedly made inquiries of the Year Level Coordinator and Senior Sub-Coordinator upon learning of the relationship between Angel and ST.243 ST denied any sexual relationship with Angel when questioned by the Senior Sub-Coordinator, as did ST’s parents when RCSC staff 238 Ibid.
239 The Junior School Coordinator, Senior Sub-School Coordinator and Wellbeing Coordinator and several teachers were aware of the relationship (‘[student] had seen Angel crying in the locker bay, as [ST] is in my class there was great interest’): XUNO Notes dated 20 August 2015 (for example) and Statement of David Browne dated 4 November 2016.
240 Correspondence from Annette Wiltshire dated 26 June 2020.
241 Ibid.
242 Ibid.
243 Statement of David Browne dated 4 November 2016.
contacted them.244 No information was provided about the timing of these inquiries, nor is there any evidence of similar inquiries being made of Angel or her family.
Distress about peer and family relationships
Mr Browne stated that he would expect the Wellbeing staff’s response to a student presenting with stressors arising from familial relationships to ‘listen, provide strategies, ask about a trusted adult in the student’s life, offer medication/support with talking to family members … and make referrals to appropriate supports’.245 He also expected interventions by staff to be documented.246 If there were safety concerns and the threshold for reporting to DHHS was met, the Principal expected that staff would make a report and document it.247
Mr Browne asserted that Angel had told RCSC staff that living with her grandmother was an improvement in her homelife and, consequently, no protective concerns were raised that met the threshold for a report to DHHS or referral to Child FIRST.248 This assertion is somewhat at odds with Angel’s disclosures to the Wellbeing Co-ordinator in May and October 2015, and there is no evidence before me that Angel was offered support to communicate her concerns about family matters to her parents or grandmother.
In addition to the expected responses outlined above, if a student were distressed about relationships with friends, Mr Browne anticipated that staff would monitor the student and their friends to ascertain if bullying or other concerning behaviours were occurring, inform parents/carers as appropriate, or refer the student to the police in appropriate circumstances.249 He again cited the legal threshold for making a report to
DHHS.250 244 Ibid.
245 Correspondence from Annette Wiltshire dated 26 June 2020.
246 Ibid.
247 Correspondence from Annette Wiltshire dated 26 June 2020.
248 Ibid.
249 Ibid.
250 Ibid.
Although specific school yard incidents in July and October 2015 were managed swiftly and appropriately by RCSC staff, there is no evidence before me to suggest that Angel’s peer relationships were monitored, or that any inquiries were made to ascertain whether there had been any repeat of adverse social media events after October 2015. It appears that Ms Mathers contacted RCSC after Angel was struck at school.251 Self-harming
The Principal’s expectations of staff managing self-harm are that a staff member approach the student concerned to investigate, assess suicide risk, provide risk/harm minimisation strategies, inform the student’s family if it is safe to do so and offer a referral to the Wellbeing Team and/or Nurse.252 ‘In some situations’ (that are not defined), a referral to the Child and Youth Mental Health Service should be made.253 The Year Level Coordinator should be informed.254 If the student is ‘at significant risk of harm’, staff should ‘urgently triage’ the student to the Wellbeing Team to escalate a protective and supportive response and file an internal report.255
In 2015, RCSC had a policy entitled ‘Managing Deliberate Self-Harm’.256 The school’s management of Angel’s self-harm appears to have complied with the policy.
However, I note that although risk assessments were reportedly performed by the Wellbeing Coordinator (who was appropriately qualified to do so),257 they do not appear to have been formally documented, nor does the relevant policy provide any guidance about how risk should be assessed or when a student should be referred to a mental health service.
251 XUNO Notes by Martine Hendy and Helen Martin dated 21 October 2015.
252 Correspondence from Annette Wiltshire dated 26 June 2020.
253 Ibid.
254 Ibid.
255 Ibid.
256 RCSC Council Policy, Managing Deliberate Self-Harm, May 2014.
257 Statement of David Browne dated 4 November 2016.
Refusal of Help
Mr Browne stated that ‘depending on the concern’, he would expect when confronted by a student refusing assistance, that staff would try to engage the student, report back to the referrer or Year Level Coordinator, continue to offer support, build rapport with the student, ‘engage’ his or her parents/carer and make external referrals or provide the contact details for relevant services.258
While RCSC staff endeavouring to assist Angel used many of the above-mentioned strategies to address her refusal of help, their efforts were largely passive. Staff persisted with telephone calls and paging her to appointments despite these being ineffective; assertive outreach – deploying duty students to bring Angel to an appointment – proved more effective.
Similarly, rather than engaging Angel’s parents or grandmother in efforts to provide support, staff merely informed Mr Hensgen of Angel’s self-harming and incomplete schoolwork in May 2015 and Mrs Hensgen about absences from school in September
Staff failed to discuss with them that ongoing engagement between Angel and the Wellbeing Team was largely unsuccessful and that there was little, if any, improvement in her school attendance and completion of schoolwork.
Absenteeism
The Education and Training Reform Act 2006 requires children aged between six and 17 years to attend school full-time259 unless an absence is approved. RCSC also has an attendance policy.260
RCSC’s Attendance Policy requires any absences from school to be explained within five days of the absence occurring and referral of any student with an attendance rate below 85% to the Sub-School Manager for a plan to be developed to increase 258 Correspondence from Annette Wiltshire dated 26 June 2020.
259 Section 2.1.1. A student may be exempt from this requirement if he or she is receiving approved home tuition, correspondence education or is otherwise exempt.
260 RCSC Attendance Policy (ratified by Council 13 September 2016). Reasonable or excused absences are those that occur due to ill-health or medical treatment, bereavement, cultural observance, school refusal ‘if a plan is in place with the parent to address causes’ or for family holidays if advance notice is provided and there is a Student Absence Learning Plan in place.
attendance.261 Collaboration between the school and parents/carers is emphasised in managing absenteeism.262
Request to change schools
The DET’s 2015 school transfer policy required school principals to approve transfers when sought at the start of the school year or term three and in secondary schools the student can be accommodated mid-year without reorganisation of the existing school program.264 It also enabled principals to approve transfers requested (at other times) by a parent/guardian in circumstances where the principals of both schools supported the request.265 The policy stated that ‘schools must avoid practices that force students to transfer266 or withdraw from school’.267
Mr Browne stated that RCSC did not receive any communication from Angel’s family about her transferring schools; it merely fielded a call from an ICT staff member who had received an inquiry about transferring schools ‘at the end of the year’.268 The advice Angel and her grandmother received from ICT’s Ms Boyce about a regional procedure to manage mid-term transfers269 – which essentially forestalls them – likely deterred Angel’s family from pursuing a transfer of schools and likely contributed to 261 Ibid.
262 Ibid.
263 XUNO Notes by Martine Hendy dated11 May and 15 September 2015; a conversation between Ms Hendy and Angel about her poor attendance is also noted on 15 September 2015.
264 DET Transfers Policy – School Police and Advisory Guide – 20150416.
265 Ibid.
266 Except when the student is expelled.
267 Ibid.
268 Ibid.
269 Correspondence from Robyn Blackie dated 15 September 2016.
her absence from school proximate to her death. Nonetheless, the lack of any followup by RCSC with Angel’s family about the ICT transfer inquiry was a further missed opportunity to discuss and address the reasons underlying her desire to change schools.
Access to a large quantity of paracetamol
Paracetamol is the substance most frequently used in overdose,270 with modifiedrelease versions271 more prevalent in overdose due to the higher concentration of paracetamol (665mg) present than in immediate release paracetamol (500mg).272
Angel was able to consume a large amount of paracetamol readily available in her grandmother’s home. Empty blister packets found in Angel’s room suggested consumption of more than 70 modified-release paracetamol ‘Panadol Osteo’ tablets – equivalent to less than one box available at a pharmacy – and more than 20 tradebrand cold and ‘flu tablets containing paracetamol.273
In some but not all countries where measures have been adopted overseas, access limitations on paracetamol and reduction in the number of doses sold in each box 270 Morthorst BR, Erlangsen A, Nordentoft M, et al. 2018. Availability of paracetamol sold over the counter in Europe: a descriptive cross-sectional international survey of pack size restrictions. Basic Clinical Pharmacological Toxicology 2018; 122:643-649.
271 The main advantage of modified release paracetamol preparations is that it is taken three rather than four times daily.
272 Cairns R, Brown JA, Wylie CE, Dawson AH, et al. 2019. Paracetamol poisoning-related hospital admissions and deaths in Australia, 2004 – 2017. Med J Aust 2019; 211 (5): 218-223.
273 Coronial Brief, Statements of Leading Senior Constable Nicholas Watkins and Sergeant Paul Dacey.
have led to a reduction in liver unit admissions and deaths related to the drug’s hepatotoxic effects.274
In Australia, the Therapeutic Goods Administration (TGA) reduced the box size of paracetamol available at retailers other than pharmacies from 24 to 20 tablets based on the average dose leading to health problems.
On 1 June 2020, the TGA rescheduled modified release paracetamol from Schedule 2 (Pharmacy only) to Schedule 3 (Pharmacist only) so that it is only available for purchase upon request to a pharmacist. However, ‘Panadol Osteo’ remains available in 96 x 665mg tablet box sizes only.
The TGA is currently undertaking a medicine labelling project which commenced in 2016 and has a transition period of at least four years. This is aimed at improving labelling of medicines, including the active ingredients and is in line with the International Harmonisation of Ingredient Names labelling reform.275
It is unlikely a change to the availability of ‘Panadol Osteo’ would have prevented Angel’s death. The amount of paracetamol she took was less than one packet of her grandmother’s supply of ‘Panadol Osteo’ and cold and ‘flu tablets which were stored in a box on a high shelf in the pantry.
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 explications. 276
Adverse findings or comments against individuals or institutions are not to be made with the benefit of hindsight but only on the basis of what was known or should reasonably have been known or done at the time, and only where the evidence 274 Cairns R, Brown JA, Wylie CE, Dawson AH, et al. 2019. Paracetamol poisoning-related hospital admissions and deaths in Australia, 2004 – 2017. Med J Aust 2019; 211 (5): 218-223.
275 Therapeutics Goods Administration 2016, Regulation Impact Statement: General requirements for labels for medicines.
276 Briginshaw v Briginshaw (1938) 60 C.L.R. 336 esp at 362-363. “The seriousness of an allegation made, the inherent unlikelihood of an 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…”
supports a finding that they departed materially from the standards of their profession and in so doing caused or contributed to the death under investigation.
(a) The identity of the deceased is Angel Louise Hensgen, born 2 December 2001, aged 13, student, late of a Kelvin Avenue, Mildura, address.
(b) Angel died at her home in Kelvin Avenue, Mildura, on 17 November 2015.
(c) The medical cause of Angel’s death is acute paracetamol toxicity.
(d) In the period immediately preceding her death, Angel was distressed about issues involving her family; deteriorating friendships; the breakdown of a relationship with ST; and several incidents at school. She was selfharming, falling behind in her schoolwork, increasingly absent from school and wanted to transfer to another school.
(e) Angel was exposed to intense bullying online, with an escalation occurring in the three months before her death.
(f) Angel’s family, peers and school were aware to varying degrees about the stressors identified during the coronial investigation.
(g) Although RCSC staff generally responded appropriately to specific incidents adversely affecting Angel’s wellbeing, opportunities to intervene effectively were missed because her welfare was not viewed holistically, and her family were not effectively engaged. As a result, the school’s management of Angel’s overall wellbeing was suboptimal.
(h) It is likely Angel’s ingestion of a large quantity of paracetamol occurred or commenced late on the night of Saturday, 14 November 2015.
(i) Notwithstanding the content of her apparently contemporaneous Snapchat messages to ST, given her youth, the available evidence does not support a finding that Angel was sufficiently mature to appreciate that an overdose of paracetamol would cause her death; nor do I conclude that she overdosed with the intention of taking her own life.
(j) That said, the available evidence does support a finding that Angel’s ingestion of an excessive amount of paracetamol was an act of intentional self-harm.
(k) Ms Mathers became aware that Angel may have taken a medication overdose on the afternoon of Sunday, 15 November 2015 and when she checked on her at Mrs Hensgen’s home around 5.00pm, Angel was in bed and appeared intoxicated.
(l) Mrs Hensgen knew that Angel was ill and remained in bed or lying down for most of the time between the morning of Sunday, 15 November 2015 and when her death was discovered around 11.00am on Tuesday, 17 November 2015. However, it does not appear that Mrs Hensgen was aware that Angel had or may have taken a medication overdose.
(m) Mr Hensgen’s knowledge of his daughter’s condition between Sunday, 15 November and when her death was discovered is unclear, but he was aware that she was in bed around 6.00pm on Monday, 16 November 2015.
(n) A period of 34 hours elapsed between Ms Mathers awareness of the possibility of an overdose and Mrs Hensgen’s last interaction with Angel at 3.00am on 17 November 2015 during which medical advice or assessment could have been obtained.
(o) Early or earlier medical intervention with N-acetylcysteine (the antidote to paracetamol poisoning) may have averted Angel’s death and/or minimised damage to her liver.
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected to the death:
Paracetamol is an effective analgesic and antipyretic. It is well tolerated and, at the recommended dose, is generally safe for (otherwise) healthy people.
In Australia, paracetamol is a well-known and widely available over-the-counter medication with no legal restriction on the number of packets sold in a single transaction. This ubiquity likely conveys that paracetamol is harmless.
However, repeated supra-therapeutic use, and acute overdose of paracetamol can produce hepatotoxicity and death; indeed, paracetamol is the substance most frequently involved in overdoses in Australia.277
According to Safer Care Victoria and the Victorian Paediatric Clinical Network Guideline,278 most patients who present for medical attention within 24 hours of large-dose paracetamol ingestion are asymptomatic though some may complain of nausea, vomiting, pallor and diaphoresis. Right upper quadrant tenderness – a sign of liver damage – may develop around 24 hours after ingestion, and if untreated or undertreated, symptoms of hepatotoxicity and hepatic failure like hypotension and encephalopathy may take two to four days to develop.
N-acetylcysteine (NAC) is a safe and effective antidote to paracetamol poisoning.
However, delayed administration of NAC is associated with progressive increased risk of liver injury.
Given the slow rate at which overt symptoms of paracetamol toxicity develop and the likelihood of liver damage, medical advice and/or assessment should be obtained promptly in all cases of large acute ingestion, repeated supra-therapeutic ingestion and ingestion of an unknown quantity of paracetamol.
The Victorian Poisons Information Centre (telephone number 131 126) provides 24hour advice about poisons and drugs including paracetamol.
Where paracetamol overdose occurs in circumstances of deliberate self-harm, apart from the necessary medical intervention, referral should also be made to local area mental health services.
277 Cairns R, Brown JA, Wylie CE, Dawson AH, et al. 2019. Paracetamol poisoning-related hospital admissions and deaths in Australia, 2004 – 2017. Med J Aust 2019; 211 (5): 218-223.
278 Safer Care Victoria and Royal Children’s Hospital Melbourne, ‘Paracetamol Poisoning Clinical Guideline’, February 2018.
RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:
That the Department of Education and Training review the compliance and competency of teachers and staff at Red Cliffs Secondary School with the mandatory reporting online training and their obligations.
That the Department of Education and Training develop a guide to assist schools’ responses when they become aware of a possible relationship between a child who is not of the age of consent and an older student.
That the Department of Education and Training work with Red Cliffs Secondary College and Irymple Technical College to establish a process to manage requests by a student supported by family/carers to transfer between schools that will ensure the best interests of the child are prioritised.
That Red Cliffs Secondary College review any policy relating to its management of self-harm by students and, if necessary, amend it to ensure it provides guidance about how risk of suicide and/or self-harm should be assessed and in what circumstances a student should be referred to a mental health service.
That Red Cliffs Secondary College review and amend if necessary, any Wellbeing policy or procedure to ensure that each student’s wellbeing is assessed and interventions implemented holistically, rather than episodically, and provide guidance about responding to students refusing help to ensure his or her wellbeing is optimised.
That the Therapeutic Goods Administration consider mandating a reduction of the number of doses sold in each box of modified release paracetamol products to minimise the risk of overdose.
PUBLICATION OF FINDING Pursuant to section 73(1A) of the Act, I order that this finding, including the comments and recommendations made above be published on the Internet in accordance with the rules.
DISTRIBUTION OF FINDING I direct that a copy of this finding is provided to the following for their information: The family of Angel Hensgen Department of Education and Training Principal, Red Cliffs Secondary College Principal, Irymple Technical School Dr Robert Meyer, Lime Medical Clinic Alannah & Madeline Foundation Therapeutic Goods Administration DSC Liam Tinkler, Mildura CIU Signature: _____________________________________ Paresa Antoniadis Spanos Coroner Date: 11 August 2020
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