Finding into death of Karim Aarras

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2017 4490

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 63(1) Section 67 of the Coroners Act 2008

Inquest into the Death of KARIM AARRAS

Delivered On: 10 MAY 2021 Delivered At: THE CORONERS COURT OF VICTORIA

65 KAVANAGH STREET, SOUTHBANK.

Hearing Dates: 30 APRIL 2021 Findings of: CORONER PHILLIP BYRNE

Counsel Assisting the Coroner: MS RACHEL QUINN, CORONER’S SOLICITOR

Representation: MS MARIA PANCOTTI APPEARED

UNREPRESENTED AS PERSON AUTHORISED TO ACT AS SENIOR NEXT OF KIN

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2017 4490

FINDING INTO DEATH WITH INQUEST

Form 38 Rule 63(2) Section 67 of the Coroners Act 2008

I, PHILLIP BYRNE, Coroner having investigated the death of KARIM AARRAS AND having held an inquest in relation to this death on 30 April 2021

find that the identity of the deceased was KARIM AARRAS

born on 14 December 1971

and the death occurred on 7 September 2017

at Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050

from: I (a) BLOOD LOSS 1(b) MULTIPLE INCISED INJURIES

Pursuant to section 67(1) of the Coroners Act 2008 I make findings with respect to the following

circumstances:

BACKGROUND

1. Karim Aarras, 45 years of age at the time of his death, resided at 39/27 Courtney Street, North Melbourne. Although I do not in this finding propose to canvass what I will call “historical” matters — my primary focus will be on issues proximate to death — I include at

this point some significant background circumstances.

2. Shortly after Mr Aarras’ death was reported to the coroner, in discussions between the Court -and Mr Aarras’ family in Morocco, Ms Maria Pancotti, Mr Aarras” former wife, was authorised. by the family to take on the role of Senior Next of Kin. Consequently, the Court has had numerous communications with Ms Pancotti as the investigation proceeded; an investigation in which progress was slow due to various matters, including the impact of the

COVID-19 pandemic

3. In 2005 Mr Aarras suffered a serious workplace spinal injury. As a result Mr Aarras suffered chronic pain and depression which led to opioid medication abuse, incidents of self-barm and suicidal ideation. Unfortunately Mr Aarras’ drug use escalated, “graduating” to heroin

and subsequently methamphetamines (“ice”).

4. In the ensuing years Mr Aarras” mental health deteriorated resulting in several admissions to psychiatric facilities following episodes of self-harm. Mr Aarras’ relationship with his wife Ms Maria Pancotti deteriorated leading to divorce in 2009, although the couple continued to have a relationship of sorts even though an Apprehended Violence Order in favour of Ms Pancotti was in place. The point I make here is that Mr Aarras had serious longstanding

mental health issues which escalated when using illicit drugs.

BROAD CIRCUMSTANCES SURROUNDING DEATH

5. In the early hours of 7 September 2017 Mr Aarras was knocking on doors demanding money in the vicinity of his residence. A resident called the 000 emergency number. Shortly after, Mr Aarras confronted a young couple in Howard Street, North Melbourne demanding “my money.” He also accused the young male of stealing his birth certificate and his mother’s death certificate. Police attended, defused the confrontation and requested Mr Aarras return to his residence, which he did.

6. Shortly after 6am CCTV footage shows Mr Aarras in various locations in Carlton near Melbourne University behaving in an extraordinarily bizarre manner; clearly very agitated and disturbed.

7. Shortly after Mr Aarras entered the grounds of Trinity College at the university and made his way to the kitchen area where he confronted two kitchen staff in attendance to take the morning’s deliveries. The kitchen staff observed Mr Aarras enter an adjacent store room and then heard “banging and smashing noises” from the storeroom. They called university security resulting in the attendance of a security guard. Mr Aarras came out of the storeroom covered in blood and, while yelling out in a foreign language, repeatedly stabbed his body with a broken bottle. At this time Mr Aarras invited the security guard to call the police. The kitchen staff, no doubt terrified, left the kitchen and locked themselves in a nearby office.

The security guard called the police. The Trinity College site manager attended and observed Mr Aarras pushing over tables and chairs, yelling, “Why me, Allah, why me,” as he continued to stab himself with the broken bottle.

At 6:35am police members Senior Constable Gilham and Constable Wood — the same two members who had been involved with Mr Aarras in North Melboume some four hours earlier — attended outside the college. They were directed to await the arrival of a second divisional van containing Senior Constables Stephen Bruty and Richard Lang. All four police members then attended the dining hall. Mr Aarras was observed to be highly agitated, on a number of occasions inviting police to shoot him. To call it a highly volatile situation is

a significant understatement.

I will address in detail the circumstances surrounding the apprehension of Mr Aarras later in this finding, suffice at this stage to say it involved a very violent confrontation with ultimately Mr Aarras being subdued, contained and conveyed to hospital where he

subsequently passed away.

REPORT TO THE CORONER

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Mr Aarras’ death was reported to the coroner. No doubt having considered the circumstances and conferring with a forensic pathologist, the then State Coroner Judge

Hinchey directed an autopsy and ancillary tests.

. The directed autopsy was performed at the Victorian Institute of Forensic Medicine (VIFM)

by Professor Noel Woodford, the Director of the Institute. A separate neuropathology report was provided by Forensic Pathologist Dr Linda Iles, head of Forensic Pathology at the Institute. Dr Woodford’s Autopsy Report is the more significant report as it refers to the

various physical injuries demonstrated.

Professor Woodford advised Mr Aarras’ death was due to: I(a) BLOOD LOSS

1(B) MULTIPLE INCISED INJURIES

He commented:

“The cause of death of this 45 year old male most probably relates to the

consequences of significant blood loss due to multiple excised injuries.”

Significantly, for reasons I will refer to later in this finding, Professor Woodford, being advised toxicological analysis of post mortem specimens demonstrated methamphetamine,

commented:

“Methamphetamine use may be associated with agitation, violent behaviour,

elevated pulse and blood pressure, and abnormalities of cardiac rhythm.”

Dr Iles in her report advised no significant acute traumatic brain changes were identified.

FURTHER INVESTIGATION

As the death under investigation involved police contact, the then State Coroner directed a full coronial brief be prepared. Following Court protocol a member of the Homicide Squad was responsible for preparation of the coronial brief, overseen by police Professional Standards Command. A comprehensive, commendable coronial brief of evidence was

subsequently submitted.

CIRCUMSTANCES OF APPREHENSION

When confronted by police members Mr Aarras declined to drop the broken bottle when asked and continued to stab himself. A decision was made to seek to apprehend Mr Aarras under s 351 of the Mental Health Act 2014 to convey him to hospital for a mental health assessment. Usually this occurs when a person is threatening significant harm to others or themselves. That was not the situation facing these police members. The person sought to be apprehended was not threatening self-harm, but was actually continuing to self-harm by stabbing himself in the torso-and neck with the broken bottle; the situation demanded immediate action. Senior Constable Bruty approached Mr Aarras and deployed a full

cannister of capsicum foam with little effect.

What followed was a very violent struggle with police members contending they had to resort to baton use, punching and kicking Mr Aarras in an endeavour to contain, secure and

ultimately handcuff him.

The confrontation was recorded by phone by an observer from outside the area where the

incident took place. This and the earlier CCTV footage forms part of the coronial brief.

While it does not provide a full picture of the incident, particularly the resistance put up by Mr Aarras, the phone footage demonstrates baton use and punching. The formal statements provided by the police members involved in the incident provide a comprehensive picture of

the dilemma police faced in trying to apprehend Mr Aarras.

I have to consider whether the extent of force used was reasonable in the circumstances, in

other words was commensurate to the situation confronting the police members.

One of the difficulties faced by police members trying to contain and secure Mr Aarras was the amount of Mr Aarras’ blood on the floor in the area the struggle occurred; the floor was wet and slippery resulting in all involved trying to maintain balance, sometimes falling to

the floor.

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19. Earlier in this finding I indicated I would return to a comment made by Professor Woodford

in relation to toxicological analysis of post mortem specimens. He noted methamphetamine is often associated with violent behaviour. That is so and furthermore we often see examples of individuals affected by “ice” displaying superhuman strength way beyond what one

would expect; such was the case here.

CONCLUSIONS

In considering the issue of the extent of force brought to bear in apprehending Mr Aarras I

note that in his report Professor Woodford opined that whilst there was some evidence of

relatively minor injuries indicative of focal blunt force trauma, the injuries which resulted in death were those self-inflicted by Mr Aarras which resulted in the fatal loss of blood.

While the issue of the level of force applied by police members is an important issue, it is not front and centre of my focus because, as stated, Mr Aarras’ death was directly due to:

self-inflicted injuries, not physical force by those seeking to apprehend him.

I conclude the level of force applied, whilst very significant, was not excessive in the extraordinary circumstances attending police had to deal with. The cruel irony is that the incident occurred in circumstances where the police involvement was undertaken to prevent

Mr Aarras further self-harming.

Ms Pancotti raised an issue in relation to the performance of Ambulance Victoria paramedics. Having examined the body of evidence I conclude there is absolutely no basis to be critical of the performance of attending paramedics; basically the “die was cast” by the time they became involved. The numerous self-inflicted injuries to vital areas of the body,

including external jugular veins and branches of the external carotid artery in the neck,

‘meant that Mr Aarras’ condition by then was virtually unsalvageable.

Although the matter has had a tortuous path, on Friday 30 April 2021 I finally conducted a summary inquest where Ms Pancotti attended accompanied by her mother. After Ms Pancotti had viewed the CCTV footage and iPhone footage counsel assisting Ms Rachel Quinn tendered the complete brief of evidence, a copy of which had previously been provided to Ms Pancotti, including two USB sticks. Ms Pancotti made brief submissions.

FINDING

I formally find Karim Aarras died in the Royal Melbourne Hospital on 7 September 2017

due to self-inflicted incised wounds resulting in unsurviveable blood loss.

DISTRIBUTION OF FINDING

26. I direct that a copy of this finding be provided to the following: Ms Maria Pancotti, authorised by Mr Aarras’ family in France to act as Senior Next of Kin on their behalf; Detective Sergeant Glenn Grandy, Professional Standards Command; and

Detective Senior Constable Megan Adams, Coroner’s Investigator, Victoria Police.

Signature:

PHILLIP BYRN (CORONER) 10 SQ