Deceased
Robert James Lawrence
Demographics
29y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2016-10-20
Finding date
2020-04-06
Cause of death
Shotgun wound to the head
AI-generated summary
Robert James Lawrence, a 29-year-old man with complex mental health needs including ADHD, depression, anxiety, Tourette's syndrome, and borderline personality traits, died from a self-inflicted shotgun wound. He held a Category A & B firearms licence obtained in 2014. At the time of his death, he was experiencing emotional distress from relationship breakdown, financial worries, and workplace difficulties. He had been assessed by psychiatry in January 2016 as presenting moderate chronic risk of self-harm with concerning access to firearms, but this information was not communicated to the firearms licensing authority. The coroner found no procedural faults in the licence granting process but identified systemic vulnerabilities: the licensing regime relies heavily on applicant honesty rather than proactive assessment, and health professionals' notifications to police about at-risk licence holders are inconsistent. The coroner emphasised that better communication between mental health services and firearms licensing authorities, and more proactive assessment processes, could have prevented this death.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2016 4995
FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Paresa Antoniadis Spanos, Coroner Deceased: Robert James Lawrence Date of birth: 15 October 1986 Date of death: On or about 20 October 2016 Cause of death: Shot gun wound to the head Place of death: Bambra, Victoria
Robert James Lawrence was born to Julie Lawrence and Robert Lawrence and was known to his family as ‘Robbie’. He had an older sister, Stephanie Lawrence and lived with his mother in Waurn Ponds.
Robbie had a medical history of congenital blindness in his right eye, Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depression, Tourette’s Syndrome, Obsessive Compulsive Disorder and borderline Asperger’s Syndrome.
Between 2002 and 2013, Robbie was under the care of a paediatrician and was medicated for ADHD, anxiety, depression and Tourette’s Syndrome. Ms Lawrence considered Robbie had a psycho-social disability and possessed the mind and exhibited the behaviour of a 14-year-old.
In 2005, Rob and Julie Lawrence separated, which took an emotional and psychological toll on the Lawrence children.
According to Ms Lawrence, after a period of estrangement following the separation, Robbie eventually began to spend about one night a week at his father’s. Mr Lawrence later re-partnered and according to Stephanie Lawrence, Robbie did not feel part of that family.
During Robbie’s teenage years, his behaviour improved, and he remained compliant with his medication when he stayed with his mother. However, he later chose to cease taking his medication, which affected his ability to concentrate, made him irritable, irrational and aggressive and caused him to take risks and not to heed his mother.
The day before his 20th birthday, Stephanie Lawrence drove her brother to the Waurn Ponds Hotel to have a few drinks. During the journey, Stephanie mentioned that she had seen on Facebook that Robbie’s ex-girlfriend Annaliese was in a relationship with someone. Robbie seemed shocked and was very quick to end the conversation. Robbie’s best friend, Tyson, who was at the pub, told Stephanie that Robbie had called Annaliese, but that her new boyfriend answered and abused him, which further upset him.
On 18 October 2016, Robbie woke early, and Ms Lawrence heard him making a lot of noise and arguing with his sister. Stephanie told her brother that he was inconsiderate for making so much noise so early in the morning. She observed that he didn’t seem to care
and brushed off her reprimand, which was unusual as he would usually argue back and call her names. Robbie left the house, saying he was on his way to the shooting range.
According to Ms Lawrence, Robbie called his father and asked him to go out to the Little River shooting range, but Mr Lawrence said he was busy and told Robbie where the spare key to the house and the key to the gun safe were kept.
When Ms Lawrence had not heard from her son by about 4pm (which was unusual), she assumed he was busy at the range with his father. About four hours later, Mr Lawrence is said to have sent a text message to Robbie enquiring about his whereabouts but received no response.
At 10.20pm, Mr Lawrence sent a text message to Ms Lawrence asking if she had seen Robbie, as he had not returned with the guns and was not answering his phone. Mr Lawrence went on to say in a subsequent telephone call that he had allowed Robbie to take the guns out on his own as he wanted to go to the range and had sounded happy1.
Shortly before midnight, Ms Lawrence called Victoria Police and reported her concerns about Robbie’s mental state, and he was treated as a missing person thereafter. Robbie was known to drive a red Holden Commodore, registration QQA680. Telephone triangulation indicated Robbie’s mobile phone was in the Winchelsea/Inverleigh area and a command post was set up off Deans Marsh Road in Bambra.
At about 1.45pm on 20 October 2016, police received information that a red Holden sedan was seen parked along Marks Track in Bambra. Sergeant Janet Gleeson (Sgt Gleeson) and an Acting Senior Sergeant travelled to Marks Track and found the car. The bonnet was cold, indicating that it had been parked there for some time. They found a wallet and a knife in the front passenger seat and alcohol cans in the back seat.
About 50 metres to the rear of the car was a male body lying on the ground in the bush.
The male had a gunshot wound to the face and was obviously deceased. A shotgun was lying on top of him and there was a mobile phone on the ground next to him. There was one cartridge left in the chamber and a spent cartridge on the ground. The wallet in the car contained Robbie’s driver’s licence.
1 Robbie had told his mother and sister that he usually went shooting with his father at Little River Range, however Stephanie Lawrence was informed after Robbie’s death that he had been going to the range alone for months.
Sgt Gleeson commenced an investigation of Robbie’s death on behalf of the coroner and compiled the coronial brief on which this finding is largely based. The brief includes statements from Robbie’s mother and sister, psychological assessment reports from psychologist Steven Blackburn and psychiatrist Dr Eseta Akers, Victoria Police records regarding firearms licenses and photographs of the scene.
I also obtained Robbie’s medical records from Belmont Bulk Billing Clinic and You Yangs Medical Clinic and statements from psychologist Steven Blackburn and Leading Senior Constable Natalie Balinsky from the Victoria Police Licensing and Regulation Division.
Robbie’s facial injuries were such that he was unsuitable for visual identification. His dental records were obtained and an odontologist expressed the opinion that he could be conclusively identified by reference to those records. On 26 October 2016, Coroner Carlin signed a determination as to his identity based on circumstantial evidence and the odontologist’s report.
I accordingly find that the identity of the deceased is Robert James Lawrence, born on 15 October 1996, late of a Waurn Ponds address.
Robbie’s body was brought to the Coronial Services Centre, Southbank. On 21 October 2016, Forensic Pathologist Dr Victoria Francis from the Victorian Institute of Forensic Medicine (VIFM) reviewed the circumstances of the death as reported by police to the coroner and post-mortem computed tomography scans of the whole body (PMCT) undertaken at VIFM and performed an external examination of Robbie’s body in the mortuary.
Dr Francis provided a written report of her findings in which she advised that the external examination showed evidence of severe disruption of the cranium and that PMCT showed gas in the right ventricle and significant craniofacial disruption with multiple pellets through the cranial cavity with a likely intra-oral entrance wound. Dr Francis noted that routine toxicological analysis of post-mortem samples testing did not detect alcohol or any other commonly encountered drugs or poisons.
Dr Francis advised that it would be reasonable to attribute Robbie’s cause of death to shotgun wound to the head, without the need for an autopsy.
Accordingly, I find that the medical cause of death is shotgun wound to the head.
The purpose of a coronial investigation of a reportable death2 is to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which death occurred.3 For coronial purposes, death includes suspected death.4
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.5
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.6
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 2 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).
3 Section 67(1).
4 See the definition of “death” in section 3 of the Act.
5 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.) 6 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’.
with the death, including public health or safety or the administration of justice.7 These are effectively the vehicles by which the coroner’s prevention role can be advanced.8
Robbie told his mother that it was something that he and his father could do together, and she hoped it would be an activity that they could share and bond over. Ms Lawrence held serious concerns about Robbie’s mental state, but he assured her that the gun would be stored by his father, who held the keys to the gun safe, and that he would need to seek permission to access it.
In March 2015, Robbie began an apprenticeship as a mechanic. Initially, his boss was supportive, but later Robbie complained to his mother that his boss was abusive, bullying, and would engage in behaviour such as throwing spanners at him. Robbie began to panic before work and Ms Lawrence complained to the Apprenticeship Board, VACC, saying that Robbie was talking about suicide due to his employer’s treatment.
In June 2015, Robbie began a relationship with a young woman Annaliese, who seemed to understand him.
Robbie was reviewed by psychiatrist Dr Eseta Akers on 19 January 2016. Robbie denied a history of suicide attempts, despite making a noose about 12 months earlier but admitted engaging in self-harm (cutting) at 16 years of age. Robbie reported an obsession with war, guns, lighters and bayonets and was physically destructive and often disturbed the peace at his mother’s home. A history of driving erratically was reported and a refusal 7 See sections 72(1), 67(3) and 72(2) regarding reports, comments and recommendations respectively.
8 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.
9 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).
to act responsibly or to heed safety instructions such as leaving the front door open when leaving the house and leaving appliances on for long periods of time. Dr Akers noted Robbie had unresolved issues with his father and often experienced feelings of betrayal and of being replaced. Robbie threatened to hurt himself and others when relationships became difficult and threatened to use his gun on himself. However, when Robbie felt secure, he denied having any such intent.
Dr Akers considered that Robbie presented with a chronic moderate risk of harm to himself and others in the context of emotional dysregulation and impulsivity.
Ms Lawrence expressed concerns to Dr Akers about Robbie expressing suicidal ideation in response to stressful events, and concern that he held a gun licence. She indicated that there were no guns at home and Robbie did not have access to the keys to the gun safe at his father’s house. Ms Lawrence stated that although she did not have an amicable relationship with her ex-husband, she had conveyed her concerns to him. Dr Akers wrote in her report dated 20 January 2016 that Robbie’s access to guns was concerning.
Dr Akers noted that Robbie’s emotional dysregulation, impulsivity and lack of concerns for the rights of others was consistent with Antisocial Personality and Borderline Personality Traits. This occurred on a background of mild autism spectrum disorder (Asperger’s Syndrome), childhood ADHD and a history of Major Depression. Robbie presented with significant anxiety with features of social anxiety and obsessive symptoms. Dr Akers considered that Robbie’s difficulties developed in the setting of a strong family history of depression and anxiety and childhood trauma related to witnessing domestic violence as well as bullying at school related to his difficulties with social communication. Robbie was not currently taking any medications and did not wish to consider taking medication at that stage.
Dr Akers provided Robbie and his mother with contact details for Barwon Health Triage/Access for contact in a crisis, particularly if Robbie was expressing suicidal ideation or if there were other concerns for his mental health. Given Robbie’s complex presentation and moderate risk, he was referred to Child and Youth Triage for follow up by Jigsaw including assertive follow up and possible engagement with Jigsaw’s Dialectical Behavioural Therapy program.
Ms Lawrence tried to help Robbie access Jigsaw but as the program was conducted during business hours, he would not attend because he did not want to take time off work.
After the consultation, Dr Akers discussed Robbie’s access to firearms with the Clinical Director, Associate Professor Harvey. They discussed that the risks of intervening outweighed other potential risks, and the recommendation was to not make a notification to Victoria Police at that time. However, should Robbie’s mental health deteriorate or if there were any acute risks to himself of others or any other concerns raised, this decision was to be reviewed. An updated report dated 25 January 2016 containing that decision was provided to Robbie’s GP.
Clinical psychologist Steven Blackburn saw Robbie on four occasions between 28 January 2016 (the first of which Ms Lawrence attended) and 19 February 2016. Mr Blackburn did not identify any overt symptoms of a mental disorder. Robbie was described as cooperative but ambivalent about therapy and came “because he had to”, which Mr Blackburn understood to mean that Robbie was attending at the behest of his mother.
At the first session on 28 January 2016, Ms Lawrence provided written background information that she considered useful. Mr Blackburn noted the information but did not use it in therapy as Robbie indicated it would be overly critical of him. He was also provided with the opinion of Dr Akers dated 20 January 2016 which covered similar subjects.
A Depression/Anxiety/Stress scale (DASS 21) was completed at Robbie’s second appointment on 5 February 2016. The DASS 21 indicated previously severe symptoms of depression. Robbie denied current suicidal ideation, para-suicidal behaviours or having any intent or plan to suicide. Mr Blackburn’s provisional diagnosis was one of Borderline Personality Disorder (BPD). He considered it better explained Robbie’s previous long standing and recent patterns of emotional dysregulation, anger responses, resentment towards his mother, para-suicidal behaviours, inadequate interpersonal functioning and previously diagnosed behaviours and symptoms.
Robbie reportedly related to that diagnosis and noted that most of his distress had been related to interpersonal difficulties. Mr Blackburn and Robbie agreed to commence Schema Focussed Therapy with an understanding that ten sessions funded by Medicare would be insufficient to provide significant recovery and that Mr Blackburn would provide a further ten sessions at no cost. Robbie indicated he might seek access to the public Dialectical Behaviour Therapy run by Jigsaw.
Robbie agreed to undertake three to four sessions with Mr Blackburn as a trial. The first session on 28 January 2016 was introductory, mostly focussed on Ms Lawrence’s report and no therapy was provided. Session two involved counsel and validation of Robbie’s experiences and allowed him to tell his story. The third session comprised psychosocial education and an introduction to schema therapy. Mr Blackburn also explained his provisional diagnosis of BPD. The fourth session and the final session on 19 February 2016 dealt with Robbie’s relationship with his girlfriend and his avoidance of conflict and how he addressed it. Robbie cancelled further booked sessions as he did not feel he needed further therapy.
With respect to Mr Blackburn’s assessment of suicide risk, Robbie denied any suicidal ideation, intent or plans to kill himself. He had long-standing patterns of behaviour and a propensity towards dysregulated emotional states. A risk/suicide prevention plan was completed, about which Robbie was ambivalent. Mr Blackburn agreed with Dr Akers’ psychiatric report that indicated a moderate and chronic risk of suicide. Robbie’s DASS 21 score indicated recent extremely severe symptoms of depression. During their interactions, Mr Blackburn did not identify any overt symptoms and Robbie reported handling situations at work better and being invested in continuing an intimate relationship with his girlfriend.
Later that year, Robbie resigned from job as a mechanic and commenced an apprenticeship elsewhere as a small motor technician. Initially, he appeared content but eventually began to experience interpersonal problems with his co-workers.
In August 2016, Annaliese and Robbie broke up because she was moving interstate.
After this, Robbie seemed to lose confidence and struggled with everyday life. He received a $300.00 telephone bill, which he worried about paying as well as a speeding fine of $195.00. Robbie was on a low income and was very worried about meeting his financial obligations.
Ms Lawrence submitted a Request for Inquest on 24 October 2017 and on 25 January 2018, then State Coroner Judge Sara Hinchey (the Coroner investigating Robbie’s death at that time), determined not to make a decision10 about whether or not an inquest should be held, pending further and ongoing investigation of Robbie’s death. Ms Lawrence’s main concern was about the current licensing scheme for firearms in Victoria and asked why someone with a mental illness (like Robbie) was able to obtain a firearms licence.
Having assumed carriage of the investigation in October 2018, I gave directions for statements to be obtained from the appropriate Victoria Police members about the operation of the firearms licencing scheme in Victoria. The additional statements, the correspondence from Ms Lawrence and the evidence in the coronial brief enable me to finalise the coronial investigation of Robbie’s death without the need for an inquest.
The process for obtaining a firearm in Victoria
Leading Senior Constable Balinsky explained that LRD are responsible for the regulation and administration of the Firearms Act 1996. Information pertaining to firearms registered in Victoria is recorded in the Licensing and Registration System (LARS).
Interrogation of LARS showed that Robbie was the holder of a current Category A & B Firearm Licence 856-505-70B, issued and approved on 24 September 2014, with expiry on 23 October 2019. Originally, Robbie held a Junior Firearm Licence 856-505-50J, issued and approved on 15 July 2013, which expired on 15 October 2014.
The “genuine reason” for the purpose of the Licence was Hunting and Sport/Target Shooting, which was supported by a membership to the Sporting Shooters Association of Australia (obtainable online from the association’s website).
LSC Balinsky explained that, at the time of an initial application or subsequent renewal process, all applicants for junior of full firearms licences are asked about their medical history (in Part 3 and Part 4 respectively for junior and full licences) if they have had any medical history in the past five years that might affect their suitability to obtain a 10 Pursuant to section 52(6) of the Coroners Act 2008
Victorian Firearms Licence. The applicant is required to tick ‘yes’ or ‘no’ to the following areas of concern: a) Psychiatric, depression, stress or emotional problems; b) Alcohol or drug related problems; c) Stroke or head injuries; d) Any other medical condition that could preclude a person from holding a firearm licence or possessing firearms; or e) Any physical disability that might preclude a person from obtaining a firearm licence or possessing firearms.
Robbie ticked ‘no’ to all the questions in Part 3 of his junior licence application form on 9 September 2013 and in Part 4 of his application for a full licence dated 19 September
According to LSC Balinsky, a transition from a junior to a full licence, is treated as a renewal rather than an application for a new licence. However, as background/history checks in relation to Parts 3 and 4 and mental health are conducted for every application and renewal received by the LRD, there is no practical distinction here.
Firearm registration details showed that Robbie owned three firearms during the time he held a licence. One of the firearms was sold prior to his death. One of the remaining two firearms was the firearm that Robbie used on 19 October 2016 – a Category A Liege United Arms double barrel 12-gauge shotgun, serial number 44709.
No notes were listed in the LARS diary or the Victoria Police LEAP database to indicate that there were any known concerns in relation to Robbie’s mental health that would affect any licence to be issued or to cause intervention concerning any current licence.
LEAP and LARS are linked to alert the LRD to incidents that will affect the suitability of a person to hold a firearms licence.
If the LRD is informed that a firearm licence holder is having suicidal thoughts or any other mental health issues, arrangements are made as a matter of urgency for the firearms licence to be suspended and to ensure that there is no access to firearms in accordance with sections 47(1) and 49(1) (fa) of the Firearms Act 1996.
If LRD ascertain from LEAP that an applicant has a mental health condition, an ‘intent to refuse firearm application’ is generated and the applicant must provide character
references and a certified referral from a medical practitioner or psychologist to explain why that person is a ‘fit and proper person’ to hold a firearms licence. Those documents are then reviewed by a member of the rank of Senior Sergeant who will decide the applicant’s suitability to hold a firearms licence.
Absent relevant information from LEAP or LARS, if the applicant has a mental health condition, the LRD can only rely on the honesty of the applicant to tick ‘yes’ on their application to alert them that they may have, or do have, a mental health condition.
In Robbie’s case, he was issued his firearm licence in 2014 and there was no known reason for police to refuse his application as LRD were not aware that he suffered any mental health condition, and between the grant of his licence and his death, there was no opportunity for LRD to review his suitability.
However, once Robbie was reported as a missing person by his mother on 19 October 2019, an occurrence which was recorded on LEAP, LRD were subsequently informed that he suffered from depression and had hinted to his mother that he wanted to end his own life. LSC Balinksy stated that if LRD been informed that Robbie was contemplating suicide, suffered from depression and/or had a diagnosis of BPD, they would have initiated the suspension process.
The role of health professionals in the firearm licencing process
There is provision in the Firearms Act 199611 for health professionals12 to provide certain information to the Chief Commissioner of Police in relation to a person’s suitability to hold a firearm, without attracting criminal or civil liability, provided that the information is provided in good faith.
The Victoria Police LRD ‘Quick Guide: The role of health professionals in the firearm licensing process’ (the Guide) comments that as licences are renewed every three to five years, any change in the medical condition of a firearm licence holder should be brought to the attention of Victoria Police. It is for this reason that health professionals should be continually mindful of the firearm licensing regime in Victoria. The Guide states that Victoria Police has an expectation that health professionals will notify Victoria Police if 11 At section 183.
12 Pursuant to section 183(4), a health professional is a registered medical practitioner, a registered psychologist, a nurse or midwife, a prescribed class of social worker or a prescribed class of social worker.
they feel a patient is not suited to possess firearms where they suspect the patient is a firearm licence holder or has or intended to apply for a firearm licence.
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. 13
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 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.
Applying the standard of proof to the available evidence my conclusions are that: a) I find that the circumstances surrounding his death and the lethality of means chosen support a finding that Robert James Lawrence intentionally took his own life on or about 20 October 2016 at Marks Track, off Deans Marsh and Lorne Road, Bambra.
b) In the context of the current paradigm for firearms licencing in Victoria, there was nothing amiss in how Robbie’s application was processed by Victoria Police LRD and 13 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…”
no opportunity for intervention or reassessment of his suitability to hold a firearms licence before his death.
c) That said, there were processes for suspension of Robbie’s firearms licence that could have been availed of either by Robbie’s family or treating clinicians had they formed the view that he was at risk to himself or to others.
COMMENTS Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments on a matter connected with the death, including matters relating to public health and safety or the administration of justice:
As it is reasonable to assume that an applicant for a firearms licence wants a firearms licence, the current paradigm for the granting of firearms licences relies too heavily on the applicant being entirely honest and disclosing information against their own interest when they apply for a firearms licence.
It is a fair characterisation of the current licensing regime to say that it does not proactively assess an applicant’s suitability in a positive sense, rather it assumes suitability from the absence of history indicating unsuitability, that is nothing more than the fact that Victoria Police LEAP and LARS databases disclose no contraindications.
Under the current paradigm, the LRD will only be alerted to the fact that that a licence holder is experiencing a mental health issue is if they come to the attention of Victoria Police because of an incident involving a firearm or a family violence incident and the appropriate entry is made in the LEAP system.
Reliance is also placed on health professionals notifying the Licensing and Regulation Division about firearms licence holders who are experiencing a mental health issue or who are a potential risk to themselves or others. As licences are renewed every three to five years, any change in the medical condition of a firearm licence holder in the interim should be brought to the attention of Victoria Police. Hence, health professionals need to be continually mindful of the firearm licensing regime and proactive about notifying Victoria Police as appropriate.
PARESA ANTONIADIS SPANOS Coroner Date: 6 April 2020
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