Finding into death of Bo Zhao

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2019 001132

FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Suspected deceased: BO ZHAO Delivered On: 29 October 2020 Delivered At: Coroners Court of Victoria, 65 Kavanagh Street, Southbank 3006 Hearing Dates: 21 September 2020 Findings of: SARAH GEBERT, CORONER Counsel Assisting the Coroner Senior Constable James Kett P olice Coronial Support Unit

HER HONOUR: Background

1. Bo Zhao (also known as Nick) was born on 1 November 1987. He was 31 years of age and lived with his family in Glen Iris. Mr Zhao is survived by his wife Ms T and his young daughter, Miss P.

2. Mr Zhao was born in China and moved to Australia when he was 14 years of age. He completed a Bachelor of Banking and Finance at Monash University and became an Australian citizen in February 2017.1

3. On the morning of Sunday, 3 March 2019, Mr Zhao was found deceased by hotel staff in room 320 of the Ibis Hotel, Glen Waverley where he had been a guest since 28 February 2019.

The Coronial Investigation

4. Mr Zhao’s death was reported to the coroner as it appeared to fall within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act). A reportable death includes a death that appears to be unnatural or violent, or to have resulted, directly or indirectly, from an accident or injury.

5. A coroner independently investigates reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability. Coroners make findings on the balance of probabilities, not proof beyond reasonable doubt.2

6. Victoria Police assigned Detective Senior Constable Nicholas Jung (DSC Jung), Monash Criminal Investigation Unit to be the Coroner’s Investigator for the investigation into Mr Zhao’s death. DSC Jung conducted inquiries on my behalf,3 including taking statements from 1 Report dated 20 March 2018 of Professor Warrick Brewer.

2 This is subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

3 The carriage of the investigation was transferred from Deputy State Coroner English.

witnesses and compiling a comprehensive coronial brief of evidence. The brief contains statements from Mr Zhao’s wife, his friends and business associates, his legal representative, health professionals who treated him, employees of the Hotel Ibis, a paramedic, investigating police and the forensic pathologist who examined him, as well as other relevant documentation which included CCTV footage from the Ibis Hotel.

7. Additional material was obtained by the Court which included Mr Zhao’s medical records from the Forrest Hill Medical & Dental Centre, the Glen Iris Medical Centre and Monash Health where he had been a patient.

8. Following consideration of the evidence, I determined that all avenues of investigation were exhausted, and the investigation could be concluded. However, during the course of the investigation, I was made aware of media coverage which raised the possibility of there being some suspicious circumstances around Mr Zhao’s death. Whilst this was not my view after considering the evidence, the possibility of suspicion had been raised in the public domain, and it was appropriate in those circumstances to conduct a public hearing.

9. I was assisted by Senior Constable James Kett at the Inquest and the Coroner’s Investigator, DSC Jung gave evidence.4

10. Whilst I have reviewed all the material gathered as part of the investigation and the evidence given at Inquest, this finding includes only those matters which are directly relevant to the investigation and allow the findings to be understood.

Background

11. According to police, Mr Zhao was the owner and director of Volkswagen Werribee. He also invested in and managed Heidelberg Mitsubishi and Brighton Nissan.

12. In 2017, Mr Zhao was the subject of civil proceedings following an internal investigation conducted by Volkswagen Australian which alleged that Mr Zhao had provided fraudulent contracts to obtain a bonus. During the civil proceedings it was further alleged that Mr Zhao gave false evidence under oath and affirmed an affidavit containing false information. A police investigation followed.

13. According to police, on 11 June 2018, Mr Zhao made full admissions into creating false invoices. He told police that he created invoices to get cash from the bank to put back into 4 Via WebEx

running the business. It appears that there may have been 10 invoices and he received a total of $1,457,806.50 from the Westpac Bank.

14. Further charges arose in relation to loans entered into by Mr Zhao, where it was alleged that Mr Zhao had hired a person to impersonate an individual and where guarantors were not aware of the loans, yet their signatures appeared on the loan agreements. The loans involved the sum of $4.9 million.

15. The business associates involved were Ning Zhang, Biao (Bill) Xian and Hontao Yu. Mr Xian said that as a result of Mr Zhao forging signatures on documentation, Ning, Mr Yu and I lost a lot of money; over $15 million among us. He reported these matters to police.

16. Another of his business associates, Tanya Lee (who was also a victim in the fraud) said that they started investigating all of our finances and discovered that Bo had been transferring the money we had invested into the dealerships all over the place, making it difficult to trace where it had all gone. As a result of our dealerships not having cash flow, despite all of the money we had invested, they have all now been liquated.

17. And further she said that one investor was estimated to have lost $13M as a result of Bo’s deception.

18. Arising from all these matters, the following charges were listed at the Melbourne County Court on 7 March 2019 where Mr Zhao indicated he would enter a plea of guilty:  7 charges of Obtain Financial Advantage by Deception  2 charges of Use False Document (Crimes Act)  1 charge of Pervert the Course of Justice  2 charges of Perjury (Common Law)

19. Between 1 December 2018 and 24 February 2019, Mr Zhao also borrowed various large sums of money from Ms E, who had been his former partner, promising to return the money but never doing so. Sometimes he would show her screen shots of accounts where it appeared that the money had been transferred and on one occasion he said that the money was for wages.

As they had been in a relationship previously she agreed to his requests and eventually gave him all her divorce settlement. He continued to ask her, even when she told him that she

would not have money left to buy food. The sums amounted to over $490,000 including sums from her mother.

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

20. At about 10.02am, Thursday 28 February 2019, Mr Zhao arranged to meet Mr Xian at the Ibis Hotel in Glen Waverley later that day. They decided upon 5.00pm as Mr Zhao said he needed to pick up his medication.5 Mr Xian told Mr Yu of the meeting and they arranged to go to together.6

21. At 2.12pm, Mr Zhao attended the Glen Iris Medical Centre requesting a script for Tagamet (Cimetidine) for heartburn as he said this had been effective in the past. Dr Jean Douyere said that Mr Zhao did not appear anxious or low in mood and did not complain of any symptoms relating to a mental condition. Mr Zhao subsequently attended a pharmacy in Ashburton to fill the script for Cimetidine but it was not in stock.

22. At 2.28 pm, Mr Zhao had a conversation with Ms E. She said Bo told me that we could go to his bank the next day and he would give me an extra $500,000AUD on top of what he owed me. He asked me to keep the extra cash at my house and he would come and get it when he needs it. I refused and told him that it was not my money and that I only wanted my money back.

23. Mr Zhao made a number of calls between 2.45pm and 2.49pn, to various pharmacies and Cabrini Hospital, presumably to fill his script for Cimetidine.

24. Between 3.45 and 4.00pm, Mr Zhao’s wife drove him to nearby the Glen Shopping centre in Glen Waverley, after he told her that he wanted to spend two nights away from home before his court case. They had an argument at that time. He told her that he would be going to jail for 2 or 3 years. Mr Zhao later left a message on her phone apologising for yelling at her. He also said that he would be home on Saturday.

25. At approximately 4.30pm, Mr Zhao booked into the Ibis Hotel. He was due to check out on Saturday, 2 March 2019.

5 Translated conversation exchange on ‘WeChat’. Mr Zhao’s profile picture was of Donald Trump.

6 Translated text conversation on ‘WeChat’.

26. In preparation for his upcoming County Court hearing Mr Zhao’s legal representatives had arranged for him to consult with Patrick Newton, Forensic and Clinical Psychologist on 28 February 2019 but Mr Zhao cancelled the appointment.

27. A conversation took place with his legal adviser, Mr Anthony Hargreaves at 5.02pm7 at which time Mr Zhao said, amongst other things, that he had been threatened again by the ‘investors’ who he had been in a meeting with and they had encouraged him to do something to himself (‘kill himself’) otherwise his family would be under threat.8 He said that he had spoken to the police informant and was proposing to see him. His lawyer expressed concern but Mr Zhao assured him that he was not going to kill himself. In addition, he indicated that he had an appointment with a psychiatrist and he was likely to be admitted and in those circumstances his hearing would not proceed.

28. Call records confirm that on 28 February 2019 at approximately 5.13pm, Mr Zhao contacted Ms Tanya Lee and had an eight and half minute conversation. He told her that that if anything was to happen to him ‘Bill or Mr Zhang’ were responsible. DSC Jung said, LEE explained to me that she did not take anything ZHAO said to her seriously because he had constantly deceived her for a number of years.

29. CCTV footage obtained from the Ibis Hotel showed that Mr Zhao collected Mr Xian and Mr Yu from the lobby of the hotel at about 5.25pm. They had already left a message on his phone saying they had arrived at 5.06pm and he called them at 5.09pm saying he would be there shortly.

30. CCTV footage shows that they caught the elevator to the third floor and entered room 320.

31. Mr Xian said of the meeting which took place in Mr Zhao’s room, I have known Bo for three years almost and he was calm. He wasn’t angry and didn’t appear to be stressed.

He offered Mr Yu and I each water in a glass cup. We both drank from those glass cups.

32. They spoke about their business dealings and Mr Xian said, I changed the subject to why he lost so much money on his other dealership which was Heidelberg Mitsubishi. ….

7 A 7 minute conversation.

8 He previously told his lawyer and his wife that he had been threatened by some of his investors.

We still have about $8 million that is unaccounted for. I believed that Bo would be able to provide information on this which is why I agreed to meet with him in the first place.

He was unable to give us any information on where this $8 million had gone and said that maybe one of his staff had been stealing from him.

33. During the meeting Mr Zhao said that he wanted them to get an outside accountant to go through the matter properly. Mr Xian said that, Bo basically set up the meeting to point the finger at others for the loss of the money. I think I did raise my voice at one point when I asked him how he ‘lost’ the money. There was no violence; we didn’t even have a handshake.

34. At 6.21pm, Mr Xian text his wife saying that he was in a meeting with Mr Zhao and not to wait dinner for him.

35. Mr Yu’s account of the meeting is consistent with that given by Mr Xian.

36. Mr Xian said he thought to himself that because we had a case against him, Bo wanted to be on good terms so that we would drop the case. I believe he probably expected our meeting to end the way it did; without the outcome he was looking for.

37. Following the conclusion of the meeting, the CCTV footage captures Mr Xian and Mr Yu leave the room at 6.47pm. The ‘do not disturb’ sign is placed on the door at Mr Zhao’s request.

38. At about 7.30pm, Mr Zhao made a Facetime call to his wife’s mobile as an audio call. He spoke to his daughter at that time and asked her to be good saying that he would be home in a couple of days.

39. On Saturday, 2 March 2019, Ms T made inquiries with police reporting that she was unable to contact her husband. She indicated that he was due back some time that day and was told by police to return on Sunday if no contact had been made. After not hearing from her husband, Ms T did return the following day at which time a missing person’s report was made.

40. At approximately 4.00pm, Saturday 2 March 2019 a house keeper knocked on the door of room 320, where a do not disturb sign was in place. As the room was a checkout he entered with an access card. The house keeper saw the shoulder of a mans [sic] body lying beside the bed and presumed he was sleeping, and in those circumstances they are instructed that a patron was not to be disturbed.

41. The room was checked a second time at approximately 10.15 am, Sunday 3 March 2019, where a person was again observed to be on the floor. The bedroom light was off and the curtain was closed. Shortly after, further investigations were undertaken and the person, later identified to be Mr Zhao, appeared to be deceased.

42. Emergency services were called and paramedics subsequently arrived and confirmed that Mr Zhao was deceased.

43. Police arrived at the scene at approximately 11.39am and commenced an investigation. The ambulance officer told police that Mr Zhao was in obvious rigor mortis.

IDENTITY

44. On 6 March 2019, Ms T identified her husband Bo Zhao born 1 November 1987.

45. Identity is not in dispute and required no further investigation.

CAUSE OF DEATH

46. On 4 March 2019, Dr Heinrich Bouwer, a specialist forensic pathologist practising at the Victorian Institute of Forensic Medicine (VIFM) conducted a post mortem examination and provided a written report, dated 18 July 2019. In that report, Dr Bouwer concluded that a reasonable cause of Mr Zhao’s death was Combined Drug Toxicity.

47. Dr Bouwer concluded that the cause of death was the combined toxic effects of amitriptyline, and metoclopramide. He said, Post mortem toxicological analysis detected a markedly elevated level of amitriptyline in blood together with its metabolite nortriptyline, which was also detected in stomach contents.

In addition, oxazepam and metoclopclopramide were detected. Elevated levels of amitriptyline may cause severe sedation, coma and respiratory depression, especially if used in combination with other central nervous and respiratory system depressant such as oxazepam and metoclopramide. Alcohol was not detected.

48. Toxicological analysis of specimens obtained at post mortem has shown the following results:  Amitriptyline 1.0 mg/L in blood and 344mg in stomach contents  Nortriptyline 0.2 mg/L in blood and 0.2 mg in stomach contents

 Oxazepam 0.2 mg/L in blood  Metoclopramide 0.06 mg/L in blood.

49. Amitriptyline is predominantly indicated to treat depression but is also used clinically to treat panic disorder, neuropathic pain and enuresis. Its trade names include Endep and Entrip. The amount detected was noted to be elevated in concentration.

50. Oxazepam is a sedative/hypnotic of the benzodiazepine and can be sold as Serapax. Toxic effects of benzodiazepines include impairment of mental and psychomotor functions, ataxia and drowsiness. These effects are enhanced in the presence of other central nervous system (CNS) depressants such as alcohol and opioids.

51. Metoclopramide is an anti-emetic drug used for the treatment of nausea and vomiting.

52. There was early post mortem decomposition change.

53. Dr Bouwer commented, What appeared to be post mortem discoloration was noted extending from the forehead across the nose and around the mouth. Whether these represent ante mortem injury cannot be excluded with certainty, however there was no overt suggestion of any significant injury that may have caused or contributed to his death.

There was no post mortem evidence of violence or injury contributing to death.

Minor haemorrhage noted in the strap muscles of the neck, however the larynx and hyoid bone are intact. This is therefore considered post mortem change.

54. I accept and adopt Dr Bouwer’s opinion as to Mr Zhao’s the medical cause of death.

Police investigation

55. Police examined the scene and photographic evidence was collected and formed part of the coronial brief. They located a bottle of Grey Goose vodka and two glasses. No drugs or remnants of drugs were located at the scene.

56. Mr Zhao’s phone was later located on top of the wardrobe just under the roof line. The phone was turned off.

57. CCTV footage was obtained by police and examined. It was noted that Mr Zhao did not leave the room after his guests left at 6.47pm. In addition, no other person was seen to enter the

room apart from a hotel staff member who entered briefly at approximately 4.00pm on 2 March 2019.

58. Mr Xian and Mr Yu were interviewed by police and were fully cooperative with the investigation.

59. Mr Zhao had indicated to his lawyer that his family had been threatened and provided an email written in Chinese in support of this allegation. The email was translated by First Constable Kevin Dong, a recognised Mandarin interpreter. At the Inquest DSC Jung said of that email, there was nothing, .., that would have indicated to me or a reasonable person that anything like that was being, ….passed on by Mr Zhao…There was, …, no threats, nothing of that nature.

60. Police examined the Optus Data Records for Mr Zhao’s mobile which confirmed that his wife received a Facebook call from him on 28 February 2019 at approximately 7.22pm. It also showed that Mr Zhao’s had been utilising the internet or Wi-Fi from his mobile up until approximately 8.30pm on 28 February 2019. From that point it appears that Mr Zhao’s mobile phone had been turned off.

61. Whilst police investigators were unable to access Mr Zhao’s phone, they had Optus data call and SMS records, WeChat messages and access to the phones of other relevant persons. DSC Jung said at the Inquest that police were able to paint a pretty clear picture of what had happened in the weeks, days and hours leading up to Mr Zhao's passing.

62. Ultimately, the police found no suspicious circumstances as part of their investigation including that no other person caused or contributed to Mr Zhao’s death. When asked his opinion on what had occurred, DSC Jung said, Mr Zhao was obviously someone who was very ambitious. He, he wanted to be successful , unfortunately it looks like he went about that the wrong way, , and along that way, he, , obviously dug himself into a hole, a fairly deep hole financially, one that wasn't just going to affect him but was going to affect his, his wife and daughter, , and any future prospects of being successful. , and from speaking with his associates and family members and people that knew him, that was something from a very young age that he always strived for , and it looked very much like, at least in the immediate future, that that was going to be taken away from him.

, obviously of his own doing and I feel as though in that last day when he met with Mr Jian and Mr Yu, it was a last ditch attempt at trying to, , get some sort of positive outlook on the

pending court case. Perhaps even having some sort of effect on sentencing or even, you know, the light at the end of the tunnel would be having the case dropped , and it's not something that was able to happen for him.

, obviously with the reports that have been made by the forensic psychologists and psychiatrists and professors in 2018, , suicide and mental health was something that had been an issue for Mr Zhao months prior to him passing away, taking his own life, , and I believe that perhaps it was something that he'd been planning for some time. , again which is why it doesn't concern me that we weren't able to locate, , [drug] packaging at the hotel. , I think the circumstances leading up to this day really speak for themselves. He was a man who hadn't been in the right frame of mind for some time and he, he'd reached the peak of that.

Intent

63. Mr Zhao told Associate Professor (A/P) Warrick Brewer, Consultant Clinical Neuropsychologist on 23 November 2017 that he first thought of ending his life in October [2017] after searching for methods of suicide over the Internet: these included taking an overdose of pills, jumping off a building, and cutting his wrists in a hot bath.9

64. During a consultation with Dr Lester Walton, Consultant Psychiatrist on 21 June 2018, Mr Zhao reported a significant family history of mental disturbance. Dr Walton was satisfied at that time that he was not suffering from a psychotic illness but recommended psychiatric intervention in the form of mood stabilising medication and counselling, an initial focus of which ought to be his alcohol abuse. He noted, On a background of seeming emotional privation from his parents and anxiety which reaches right back to childhood, Mr Zhao strove successfully academically and then established himself in a flourishing business, all of which would have bolstered his flagging self-esteem.

However, the rather fragile psychological house of cards has crumbled leaving Mr Zhao with a quite intense sense of despair and regret. There seems to have been an air of desperation as he attempted to cling on to his achievements and that loss now, as well as his acute awareness of the opprobrium which now surrounds him, about to be magnified by definitive court appearance, has led to his intense sorrow.10

65. Mr Zhao experienced a prolonged period of stress leading up to the court hearing in March 2019, and he appeared to have considered a number of strategies to change the path he was on. Police noted that in September 2018, Mr Zhao and his wife went to Mt Hotham for a ski 9 Report dated 20 March 2018 prepared for his court hearings.

10 Report dated 4 July 2018 prepared for his court hearings.

trip and whilst there he got frostbite on the bottom of his left foot. Ms Tanya Lee said that he had previously advised her that he would get insurance payouts by freezing off his limbs. A/P Brewer included in his report reference to Mr Zhao’s somewhat naïve and childlike idealised fantasies of attracting significant wealth in a short space of time.

66. Closer to the court hearing, the evidence suggests that his strategies included the possibility of a psychiatric admission to adjourn the case, persuading the investors that he was not to blame for the financial losses in an effort to mitigate the case and, if that did not work, an obvious attempt to make it look like they were responsible for his death, likely for the benefit of his family.

67. Upon learning of his death Ms Tanya Lee said, I think Bo has committed suicide in the hope that the insurance money would benefit his family. I’m not sure why Bo was trying to blame his death on Mr Zhang and Bill, all I can think is that the life policies would not have covered suicide if a certain amount of time hadn’t elapsed since making the policies.

68. Whilst Mr Zhao had mental health issues in the past, there is no evidence to suggest that he was experiencing psychotic symptoms or, had diminished capacity in the time before his death.

69. Having considered the available evidence, I am satisfied that Bo Zhao by his actions, intended to end his own life and did so without the threat of violence from any other person.

FINDINGS AND CONCLUSION

70. Having investigated the death of Bo Zhao and having held an Inquest on 21 September 2020, at Melbourne, I make the following findings, pursuant to section 67(1) of the Act that: a. The identity of the Deceased is Bo Zhao born 1 November 1987; b. The cause of his death is Combined Drug Toxicity; c. The death occurred between 28 February and 3 March 2019 at the Ibis Hotel, 297 Springvale Road, Glen Waverley, Victoria; d. There is no evidence that a third party caused or contributed to his death; and e. The death occurred in the circumstances set out above.

71. I convey my sincerest sympathy to Mr Zhao's family for their loss.

72. Pursuant to section 73( I) of the Act, I order that this Finding in a redacted form be published on the Internet.

73. I direct that a copy of this finding be provided to the following: Ms T, senior next of kin Detective Senior Constable Nicholas Jung, Warrnambool Criminal Investigation Unit, Victoria Police Signature: Date: 29 October 2020 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an inquest. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.