Finding into death of Gregory David Tory

IN THE CORONERS COURT

OF VICTORJA AT MELBOURNE Court Reference: COR 2019 001759

FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Suspected deceased: GREGORY DAVID TORY Delivered On: 31 August 2020 Delivered At: Coroners Court of Victoria, 65 Kavanagh Street, Southbank 3006 Hearing Dates: 23 Fuly 2020 Findings of: SARAH GEBERT, CORONER

Counsel Assisting the Coroner Ms Eleanor Downie, Coroner’s Solicitor

Catchwords Missing Person

HER HONOUR:

Background

1. Gregory David Tory! was born on 15 September 1969 and lived alone in a rental home

located in Mallacoota.

2. Greg grew up in Warrnambool with his parents Jean Tory and David Tory (now deceased), and younger sister Lia. Greg’s friend said that, Every time he spoke about his parents, he was

always glowing. He used to talk about them a lot.

3. Greg loved sport, surfing and was a keen fisherman. He moved to Mallacoota from

Warrnambool in September 2016 for a new start.

4. On 17 May 2018, Greg’s real estate property manager reported him missing as he had failed

to pay his rent. Greg was 48 years of age when he was reported missing.

The Coronial Investigation

5. Reportable deaths under the Coroners Act 2008 (Vic) (the Act) include deaths that appear to be unexpected, unnatural or violent, or to have resulted, directly or indirectly, from an

accident or injury. ‘Death’ is defined to include a suspected death.

6. 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.”

7. On 8 April 2019, Detective Senior Constable Matthew Garbutt (DSC Garbutt) notified the Coroners Court that Greg had been missing since 24 April 2018 and, despite extensive searches being conducted, all of which proved unsuccessful, he suspected that he was

deceased. The notification was accepted as a report of a suspected death and DSC Garbutt

' Referred to in my finding as Greg, unless further formality is required.

2 In the coronial jurisdiction facts must be established on the balance of probabilities 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,

submitted a coronial brief of evidence. The brief included statements from Greg’s mother, his general practitioner (GP) Dr Sara Renwick-Lau, persons who had contact with Greg

proximate to when he was reported missing as well as DSC Garbutt.

Additional material was obtained by the Court including, Greg’s medical records from Latrobe Regional Hospital, a statement from Dr Gurvinder Kalra, La Trobe Regional Hospital and Ambulance Victoria Patient Care Record from 27 September 2016.

Following consideration of the evidence, ] determined that all avenues of investigation were

exhausted, and an Inquest was appropriate.

Prior to the Inquest, I requested that the Victorian Institute of Forensic Medicine undertake a check of the unidentified remains stored at their facility. | was subsequently advised that following consideration of all the available ante-mortem information held for Greg, no match

was found.

At the Inquest, DSC Garbutt gave evidence and Greg’s mother and his sister were present?

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.

Circumstances leading to Greg’s disappearance

March — April 2018

Mrs Tory said that her son came to Warmambool around 13 March 2018 and stayed for two nights. She said that he had definitely changed and appeared to have gone downhill. This was

the last time she saw her son. Mrs Tory stated,

I believe that towards the end, Greg was using hard drugs and that this was having effects on his mind..I believe that when he came to visit and took us to lunch, he had gone to see

someone to organize some drugs...

On 29 March 2018 Greg was admitted to the Flynn Unit, La Trobe Regional Hospital under an Inpatient Assessment Order with paranoia and thought disorder after using methamphetamine (Ice) in the preceding 24 hours. He appeared agitated and was threatening

‘which required police presence and restraint for the admission. By 31 March, he was

3 Via WebEx

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engaging well and acknowledged using Ice prior to his admission but denied that his symptoms were in this context. Greg’s Assessment Order was revoked and he was moved to the low dependency unit until he was discharged on 4 April 2018. During the latter part of his stay he was pleasant and polite on the ward, and there were no concerns held arising from a number of mental health examinations with no reported self-harm/suicidal ideations or

perceptual disturbances.*

Greg had a previous admission in September 2016 with a similar presentation on a background of recent Ice use. The Ambulance Victoria Patient Care for 27 September 2016 document, Pt was witnessed to be acting in a strange manner & Police were called to location. upon arrival Police [including Sergeant Andrew Scott] stated that Pt was wearing only underwear and appeared agitated. AV called. Pt admitted to consuming ‘ICE’ in past 24 hrs and also discussed self harm & suicidal ideations. Pt admitted to requiring assistance. On this occasion he informed police that he had left his car at the Davis Beach carpark having

been in the water.

Following his discharge on 4 April 2018, Trevor Jennings RN, Mental Health Practitioner, Orbost Community Mental Health Service tried to contact Greg on several occasions (and also wrote to him by letter dated 9 April 2018), but was unsuccessful. He noted that substance use was the contributing factor for his episode of mental health culminating in admission to Flynn. It was strongly recommended that Greg make contact with a Drug and Alcohol support

worker to address issues related to drug use and the impact it was having on his menial health.

On 10 April 2018 Greg saw his GP, Dr Renwick-Lau at the Mallacoota Medical Centre and,

discussed his recent admission to the psychiatric ward at LRH. He reported that he had been using Ice prior to Christmas which was consistent with his presenting demeanor and weight loss. He reported that when he had ceased prescribed opiates around August 2017 that he had taken up nightly cannabis smoking and that he was continuing to smoke cannabis daily

and that he was drinking a small amount of alcohol.

Dr Renwick-Lau further said that Greg’s,

mental State examination was unremarkable apart from some pressured speech and some lack of insight in regards to the impact of his aggression towards others. His mood and affect

were normal. He did not report any suicidality on direct questioning. He was provided with

4 Statement of Dr Gurvinder Kalra, La Trobe Regional Hospital dated 6 February 2020.

5 Statement of Dr Sara Renwick-Lau dated 28 June 2019

supportive counselling and advice including ongoing education regards to the possible effects

of his current drug use on his menial state.®

19. On 17 April 2018, Greg again attended his GP and requested a medical certificate for Centrelink.

20. The evidence suggests that on 19 April 2018 Greg travelled to Warrnambool and returned to Mallacoota on 21 April 2018. Investigators suspect that he obtained drugs during this trip.

21. Greg presented at his GP’s office on 23 April 2018 requesting a letter of introduction to the local drug and alcohol counsellor. He denied any current drug and alcohol use and was not

taking any prescription medications at that time.

22. Dr Renwick-Lau said of the last contact with Greg,

Mental state examination demonstrated some mild persistent paranoia especially in regards to his neighbour and the police. He reported a new very recent symptom of fluctuating low mood and poor sleep. The patient reported that he had been carefully documenting all of his daily activities and he was observed to be carrying a notebook. He reported that he was doing this as means of proof to his carers and police that he was making good choices. He was

provided with psychoeducation, supportive advice and counselling.7

23, At 1.37pm on 23 April 2018 Greg scheduled an appointment at the Bega radiology Clinic on 1 May 2018, which he did not attend.

24, Somewhere between 1.30pm and 2.00pm on 24 April 2018, Colleen Mechan, a registered nurse had a brief chat with Greg in Maurice Street, Mallacoota. He thanked her for a ladder she had lent him to help paint his house. She said that he seemed happy at that time.

25. On17 May 2018, Greg’s real estate property manager reported him missing due to an overdue rental payment on his Mallacoota address.

Police investigation

26. Victoria police commenced an investigation following the missing persons report being made,

and attended Greg’s home in Stanley Avenue, Mallacoota. Their search revealed a well-kept

§ As above.

7 As above.

home with no signs of disturbance or any suspicious circumstances. Mrs Tory said that ke was

pedantic, he liked things a certain way and he always wanted the place nice and neat.

The house was found to be unlocked (back door) and his house keys (including his car keys), wallet (including a small amount of cash, credit cards, Medicare card), mobile phone and cigarettes were located. Greg was noted to be a heavy smoker. Mrs Tory said that these

discoveries were just so far out of character for her son.

Approximately 4 grams of methamphetamine was located in a kitchen drawer. A ‘bong’ was

located in the washing machine.

Greg’s vehicle was parked in the driveway and his pushbike, boat and fishing equipment were

located in the shed.

An AFL fixture tipping card with results marked up until round 5, 24 April 2018 was located.

A wall calendar had been marked up until 24 April 2018. A personal diary was found noting a Dawn Service on 25 April 2018, which he was expected to attend, but did not.

A review of Greg’s phone records noted data use for a 24 hour period up until 10.29am on 25

April 2020. He did not own a computer.

A small unharvested cannabis crop was located between the Mallacoota Golf Course and 90 Mile Beach which was confirmed to be Greg’s through DNA analysis. The area around. this

crop was searched to no avail.

Victoria Police media releases and subsequent news coverage did not elicit any sightings of

Greg and no information was passed on via Crime Stoppers in relation to his disappearance.

DSC Garbutt conducted the following enquiries in an effort to locate Greg;

(a) Department of Health and Human Services confirmed that no medical benefits had been claimed since 23 April 2018 and his Newstart benefit was cancelled for failing to

report;

(b) Greg had not accessed his bank account since 24 April 2018 when he last purchased items in Mallacoota. His Westpac Bank account held almost $50,000°;

8 Mrs Tory advised that her son received a payout as a result of a motor vehicle accident.

{c)

(d)

()

(g)

(h)

G)

(k)

{m)

No records were found following a canvass of Births Deaths and Marriages, Coroners Officers nationwide, the residential tenancies bond authority, mental health institutions

and utilities checks;

VicRoads confirmed that Greg had not obtained a license or permit since his licence

expired on 8 November 2018;

City Link confirmed that no account was held in Greg’s name and there was no

activity recorded in relation to his vehicle;

Telstra, Optus and Vodaphone provided information that no service had been

connected in Greg’s name since 27 January 2016;

The Immigration Department provided information that Greg did not hold a current

passport and there were no travel movements recorded in relation to him;

Enquiries with local airlines, V-Line buses and Work Solutions produced no further

information; Checks of interstate police records produced no records in relation to Greg;

Checks with local doctors/medical centres and fishing charters produced no further

information;

Inquiries with AMP where Greg had a superannuation account and insurance policy

resulted in advice that there had been no contact from Greg since 2014;

Extensive air, land and sea searches were conducted on 18 June 2018 which utilised Victoria Police Airwing, Mounted Branch, Water Police, local police and State

Emergency Service (SES); and

Following wide inquiries being made, the last confirmed sighting was between 1.30pm and 2.00pm on 24 April 2018 in Maurice Street, Mallacoota when, as noted above, Greg spoke to Colleen Meehan. There were later sightings, but they were

unconfirmed.

At Inquest, DSC Garbutt indicated that whilst there had not been any recent searches, much of

the original search area had been burnt by the bush fires in 2020 and there had been ‘a Jot of

traffic in that area with CFA, firefighting crews, and.. aerial craft as well’.

DSC Garbutt considered that in those circumstances, if Greg’s remains were in the bushland covered by the search area which comprised areas of light scrub, they would have been

discovered following the fires.

DSC Garbutt concluded that Greg was most likely deceased. Mrs Tory also holds this view.

DSC did not believe there were any suspicious circumstances surrounding there the death

including the involvement of a third party.

At Inquest, DSC Garbutt, who had given considerable thought to what was likely to have happened to Greg said,

Ido have a theory and I know this is tough for Jean and probably Lia also to hear.this,... In relation to the incident where Andrew Scott attended and found Greg in his underwear and Tshirt, Greg had detailed also to police on that occasion that he had been wading through the water in his underwear, ... as a result of feeling like his body was on fire, and this was something that I believe occurred when he had used methamphetamine. 1! believe it's quite possible that with the drugs located in his premises, that something similar may well have

occurred to Greg.

While I am unable to make findings with respect to the precise circumstances surrounding Greg’s death, a theory involving some form of misadventure at a beach near his home,

appears open on the available evidence.

FINDINGS AND CONCLUSION

Having investigated the suspected death of Gregory David Tory and having held-an Inquest on 23 July 2020, at Melbourne, I make the following findings, pursuant to section 67(1) of the Act that:

a. Gregory David Tory, born on 15 September 1969 is likely to be deceased;

b. The cause of his death is unascertained;

c. The death is likely to have occurred on or about 25 April 2018;

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.

42. Despite extensive searches having been conducted by Victoria Police, Greg’s remains have not been located. Should this change, section 77 of the Act allows any person to apply to the Court

for an order that some or all of these findings be set aside.

43. I convey my sincerest sympathy to Greg’s family for their loss and thank Mrs Tory and his

sister, Lia for their attendance and participation in the Inquest.

44. Mrs Tory said at the Inquest,

It's very hard....

...-he always tried, and he'd also tell me he'd try harder, and for a while, when he moved to Mallacoota, we thought he actually had made the grade, because we visited him and had a lovely time. But then in the next times that he rang, I just knew in my own heart that things were going downhill again. It didn't matter what I said or what we tried to do. Nothing could

45. Pursuant to section 73(1) of the Act, I order that this Finding be published on the Internct.

46. Idirect that a copy of this finding be provided to the following:

Mrs Jean Tory, senior next of kin

Detective Senior Constable Matthew Garbutt, Warrnambool Criminal Investigation Unit,

Victoria Police.

Signature:

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CORONER Date: 31 August 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.