Finding into death of Micky Craig Revera

IN THE CORONERS COURT Court Reference: COR 2019 0905

OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008

INQUEST INTO THE DEATH OF MICKY REVERA Findings of: Coroner David Ryan Delivered on: 3 June 2022 Delivered at: Coroners Court of Victoria, 65 Kavanagh Street, Southbank, Victoria, 3006 Inquest Hearing Dates: 31 May 2022 Counsel Assisting: Lindsay Spence Principal In-House Solicitor Coroners Court of Victoria Appearances: Ms Arms for Correct Care Ms Reynolds-Chessney for Monash Health Ms Singleton of counsel for Chief Commissioner of Police

I, Coroner David Ryan, having investigated the death of Micky Craig Revera, and having held an inquest in relation to this death on 31 May 2022 at Melbourne, find that:

• the identity of the deceased was Micky Craig Revera born on 15 April 1978;

• the death occurred on 18 February 2019 at Melbourne Assessment Prison, 317-353 Spencer Street, West Melbourne, Victoria, 3003;

• from 1(a) Unascertained causes in the following circumstances:

INTRODUCTION

1. On 18 February 2019, Micky Craig Revera was 40 years old when he was found deceased in Unit 13 of the Melbourne Assessment Prison (MAP). Micky had been arrested by Victoria Police on 12 February 2019. At the time of his arrest, Micky had no fixed residence.

BACKGROUND

2. Micky was born in the Seychelles on 15 April 1978. His father was Wilson Revera and his natural mother was not involved in his life after the age of 3 months. He was raised predominantly by his paternal grandmother, Joanes Revera and members of his extended family. In 1987, Micky immigrated to Australia with his grandmother and other members of the extended family. The same year, Joanes formally adopted Micky.

3. Upon arriving in Australia, Micky and his family lived in Murrumbeena before moving into a flat in Springvale. Micky attended Springvale Primary School and then Springvale High School, concluding his schooling in Year 10. He then worked in numerous labouring jobs including at a mechanic business, a packing factory and at a tannery.

4. Micky commenced using cannabis at around 16 years of age and his drug use escalated to include amphetamines and eventually heroin. Micky’s medical records detail years of heroin addiction including numerous overdoses. An extract of Micky’s claims under the Medicare and Pharmaceutical Benefits Scheme (PBS) indicate that he was not prescribed any medication and had not consulted a general practitioner in the 12 months prior to his death.

5. Micky’s had a significant criminal history which included convictions for assault, theft, armed robbery and drug related offences.

THE CORONIAL INVESTIGATION

6. Micky’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury. The death of a person in care or custody is a mandatory report to the Coroner, even if the death appears to have been from natural causes.

7. The role of a coroner is to independently investigate 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.

8. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

9. Section 7 of the Act provides that a coroner should liaise with other investigative authorities, official bodies or statutory officers to avoid unnecessary duplication of inquiries and investigations and to expedite the investigation of deaths.

10. Victoria Police assigned Detective Senior Constable Italia to be the Coroner’s Investigator for the investigation of Micky’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

11. This finding draws on the totality of the coronial investigation into Micky’s death including evidence contained in the coronial brief. While I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1 1 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.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred 12 February 2019 – Arrest of Micky Revera by Victoria Police

12. On Tuesday 12 February 2019 at 6.58pm, a member of the public contacted emergency services reporting that a red Kia Sportage (later confirmed being driven by Micky) was being driven erratically on Cheltenham Road, Keysborough. The member of the public followed the red Kia Sportage and relayed to emergency services that the vehicle had pulled into a driveway at premises at 27 Bloomfield Road.

13. Victoria Police conducted vehicle registration checks and confirmed that the Kia was bearing stolen registration plates.

14. The following Victoria Police units responded to the report:

(a) Constable Drew Richmond and Senior Constable Penny Russo (Springvale 201);

(b) A/Sergeant Amanda Dean (Patrol Supervisor) and Constable Scott Brooks (Springvale 251); and

(c) A/Sergeant Desmond Vis and Senior Constable David Hansen (Dandenong 751).

15. Springvale 201 acknowledged broadcasts from Police Communications about the Kia and were enroute to the location at 7.09pm, arriving at 7.17pm. On arrival, they observed the Kia in the driveway at 27 Bloomfield Road and they parked directly behind it. Springvale 251 arrived at approximately the same time and parked on the road opposite the address.

16. Constable Richmond was about to exit his police vehicle when he observed that the reverse lights on the Kia had become illuminated and the vehicle began to reverse towards Senior Constable Russo, who was on the passenger side of their police vehicle. Constable Richmond quickly placed the police vehicle into reverse and moved back approximately a metre before it was hit by the Kia, causing damage to the left quarter panel and breaking the front left headlight. The car became jammed between the police vehicle and the fence at the front of the property.

17. A/Sergeant Dean and Constable Brooks in the meantime approached the driver’s side of the Kia and were attempting to apprehend the driver. Micky continued to drive the Kia back and forward in an attempt to push past the police vehicle and onto the street. Utilising his baton, Constable Brooks smashed the driver’s side window and ordered Micky to turn off the engine and get out of the vehicle, but Micky continued to try and manoeuvre the Kia out of the property. At that time, Dandenong 751 arrived at the scene and positioned their vehicle against the rear bumper bar of the Kia but it continued to impact both police vehicles by accelerating forwards and backwards continually.

18. Both Constable Richmond and Constable Brooks then struck Micky with their batons through the smashed window approximately three times each to his forearms to try and stop him from driving the vehicle. Micky continued to ignore all directions to turn off the engine and exit the Kia, resulting in both Constable Brooks and A/Sergeant Dean deploying oleoresin capsicum (OC) spray which impacted both Micky and the female front passenger without apparent effect. Senior Constable Hansen then struck Micky with his baton once to the hand and twice to the right leg in an effort to stop him from driving and was then able to successfully remove the keys from the Kia’s ignition, turning off the engine. Constable Richmond observed at that point that “the driver was unaware that S/Cst Hansen had removed the keys and was still trying to drive the inoperable vehicle”.

19. Senior Constable Hansen and Constable Richmond then removed Micky from the vehicle onto the ground where he was placed under arrest by Senior Constable Hansen and handcuffed.

Senior Constable Russo and Constable Brooks removed the female passenger from the vehicle onto the ground where she was placed under arrest and handcuffed. Micky was subsequently placed in the recovery position, searched and provided with water from a nearby garden hose to wash his face following the OC deployment. Micky stated that his name was ‘Michael’ and was later identified by Acting Sergeant Vis.

20. Ambulance Victoria paramedics attended the location at 7.32pm and provided treatment to Micky for OC exposure. In her statement to police, paramedic Mona Massarany’s recalled that “the patient’s behaviour was abnormal and irrational, he was not answering AV questioning or engaging in any conversations but instead was irritable, crying, and occasionally muttering words to himself”.

21. Upon examining Micky, paramedics identified what appeared to be an old stab wound to his right knee that had been poorly bandaged as well as some bruising to his upper arm. They treated Micky with oxygen and he was sedated with ketamine and midazolam. At 8.38pm, Ambulance Victoria transported Micky to Dandenong Hospital for further assessment.

12-13 February 2019 – Dandenong Hospital

22. Ambulance Victoria arrived at Dandenong Hospital at 8.43pm where Micky was initially assessed by Dr Daniel Crompton. The discharge summary records that Micky was “found to have a knee laceration so transferred to ED for assessment but, in process of arrest capsicum sprayed, struck repeatedly with baton to face and right arm, restrained then sedated with ketamine and IM midazolam – failed PIV x2 in feet”. Dr Crompton observed “erythema and swelling to right cheek, bruising and swelling to right humerus and forearm, 3cm laceration to right knee – distal to patella, anterolaterally placed, superficial”. Micky’s management and treatment at the Emergency Department was recorded as “knee wound irrigated, inspected and closed with 3-0 nylon sutures – out in 7-10 days, ADT updated, x-ray of knee and right arm – nothing abnormal detected”. Micky’s discharge summary recorded within the results section “x-rays no fractures, recovered from sedation, awake, alert, oriented, mobilised out of bed, cleared for discharge”.

23. Micky remained in custody throughout the entire time at Dandenong Hospital and was cleared for discharge at 2.55am. He was then transported from Dandenong Hospital to Dandenong Police Station by Constable McKeown-Munn and Constable Dobly (Dandenong 310).

13 February 2019 – Dandenong Police Station

24. In the early hours of 13 February 2019, Sergeant Katie Johnson was the night shift Custody Sergeant at the Dandenong Police Station. Micky arrived at 3.10am and Sergeant Johnson observed him: “…exit the rear of the vehicle in a hospital gown. He was unsteady on his feet and appeared heavily sedated. He was staring and drooling. I sat Revera in the custody area and whilst sitting on the chair Revera could barely answer questions and continued to drool and stare. Revera had a laceration to his right knee which was covered up, and he had slight swelling and bruising to his face and arms”.

25. Detective Senior Constable Sally Spalding from Dandenong Criminal Investigation Unit (CIU) attended the custody area and “observed Revera to be very sluggish and non-responsive to verbal commands, he was drooling and had glazed eyes”. With the assistance of Police Custody Officers (PCOs), Micky was escorted to an interview room and DSC Spalding recalled that “as soon as Revera was seated at the table in the interview room he sat with his head on the table. Prior to commencing the interview I attempted to speak with Revera to explain the interview process however he remained with his head on the table”. DSC Spalding commenced the interview at 3.24am in the presence of Detective Senior Constable Antonio Melesia, however Micky refused to sit up and remained with his head on the table.

DSC Spalding subsequently suspended the interview and contacted a Forensic Medical Officer (FMO) for the purpose of ascertaining Micky’s fitness for interview. During this time Micky was placed in the cells.

26. At 3.41am, DSC Spalding had a telephone conversation with Dr Angela Williams, Consultant Forensic Physician at the Victorian Institute of Forensic Medicine (VIFM). DSC Spalding conveyed her observations in respect of Micky to Dr Williams who formed the opinion “that Mr Revera was unfit for police interview at that time. I did not attend the police station. I advised of the duty of care for Mr Revera, advice regarding the need for transfer to hospital and that transport should occur by ambulance. My concerns were regarding the state of the patient, the lack of ‘getting better’, the potential deterioration despite hospital care, the lack of information regarding medical investigation and the possibility of drug effects. This information was discussed at the time with DSC Spalding … … I was concerned regarding his state of consciousness, that is the potential for head injury or drug effects”. Following that telephone conversation DSC Spalding briefed Custody Sergeant Johnson.

27. At 3.50am, Sergeant Johnson contacted the Dandenong Hospital and “spoke to the nurse in charge of the ED. I confirmed that Revera had only been given medication by the ambulance and that medication consisted of 400mg ketamine and 5mg midazolam. I was informed that this dosage of medication should take 140 minutes to wear off and I discussed my concerns that it was 6 hours post dosage and that he wasn’t improving. Medical staff advised that Revera may also be coming off drugs of dependence and this could explain his sedated presentation and drooling. Medical staff stated that he had been discharged with no concerns and that he was fit to be in police custody”.

28. At 3.59am, DSC Spalding telephoned Dr Williams who maintained her previous opinion notwithstanding the most recent telephone conversation with staff at Dandenong Hospital.

29. At 4.02am, Sergeant Johnson contacted the Custodial Health Assistance Line (CHAL) and spoke with Nurse Patricia Muroyiwa. Sergeant Johnson provided to Ms Muroyiwa the discharge paperwork from Dandenong Hospital and after considering this, Ms Muroyiwa formed the opinion “Mr Revera was fit to remain in police custody … The custody sergeant told me Revera would be remanded and would be attending the custody centre where we could assess him in a few hours. I advised the custody sergeant to conduct 15-minute checks of Revera and I advised the nurse who was relieving me that Revera would need to be assessed when he arrived”.

30. At 4.20am, Sergeant Johnson attended the cells with DSC Spalding and PCOs and “Revera responded when physically moved and talked about using approximately 1g of methylamphetamine each day. Revera insisted he had not used anything else”. The Officers then left the cell and allowed Micky to sleep, with Sergeant Johnson instructing the PCOs to monitor Micky closely and to record all checks in the custody module.

31. At 9.30am, the Custodial Health Nurse who had taken over from Nurse Muroyiwa contacted Dandenong Police Station to check on Micky’s welfare. Their subsequent notation in the medical records stated “PR remains sleepy but rousable. PCOs state they have continued regular observations, encouraging eye opening and verbal responses which is still being encouraged … … He is full coherent and orientated to time and place. The PCO reports his injured leg with sutures ‘looking ok’. Advised PCOs to liaise with CHAL if they notice a drop in his conscious levels/he becomes more difficult to rouse or any other changes in his condition”.

32. At around 10.00am, Senior Constable Alison Johnson from the Dandenong CIU attended Micky’s cell with several PCOs to request an interview. The previous evening she had conducted a LEAP check on Micky and ascertained that at the time of his arrest, he was subject to four outstanding warrants. She also commenced preparing a brief in support of an application to have Micky remanded in custody.

33. Senior Constable Johnson observed that “he was awake and appeared to be alert. He didn’t answer me at first … … I grabbed his arm to help sit him up but he yelled ‘ouch’. I noticed some bruising on his arms so I avoided touching him there again …… At this point he was fully awake and coherent and was just uncooperative. I advised him that it was his opportunity to tell his side of the story. He didn’t answer me. I said ‘does this mean you are refusing to be interviewed?’, he said ‘yes’”.

34. Following Micky’s refusal to be interviewed, Senior Constable Johnson returned to the CIU Office and continued working on the remand brief in preparation for Micky’s appearance before the Magistrates Court of Victoria.

13 February 2019 – Melbourne Custody Centre

35. At 11.00am, Micky was transported to the Melbourne Custody Centre (MCC) where he was remanded to appear at the Magistrates Court at Dandenong on 12 March 2019. At 2.22pm, the following notation was made by Registered Nurse Kate Viney-Johnson in Micky’s medical records, “reviewed on arrival to MCC … … G4S requested for CNS to review PR. Reviewed at desk, PR yawning, appears tired, able to talk, standing unaided. PR states aware of location, not able to tell me about events at hospital last evening. PR states used heroin yesterday. Dressing noted on right knee. CNS informed G4S staff PR appears stable – able to be remanded in custody”.

36. Later that afternoon at around 4.00pm, Micky vomited, however he refused to attend the medical clinic and was therefore assessed in his cell by Ms Viney-Johnson and Nurse Manager Geraldine Govett with the following notations being made in his medical records “PR seen in cell as refused to come to clinic due to opiate withdrawals. PR states daily heroin user, last used yesterday. PR has been vomiting over cell floor and states hot and cold. PR unwilling to answer any more questions, however yawning and tired. PR was seen in ED last night for injury to leg and alleged assault during arrest then given some sedation. All investigations nothing abnormal detected”.

37. At 7.00pm, nightshift staff nurse Samantha Heard commenced her shift and attended Micky’s cell with Ms Viney-Johnson where a handover was conducted. Micky informed them that “he was feeling sick, he had hot and cold sweats, he was a heavy heroin user and had last used the day before. He looked tired and was yawning and he told me he was vomiting”.

38. They then contacted the on-call doctor, Dr Michael Wong, who authorised a treatment plan for Micky’s symptoms of opioid withdrawal. At 10.30pm, a dose of 10mg metoclopramide was administered via intramuscular injection in an attempt to treat Micky’s nausea. At 11.00pm, Micky was reassessed and he stated that he had not vomited since the injection. At around 11.10pm, Micky was administered an opioid starter dose to assist with his withdrawal from heroin, authorised by Dr Wong (diazepam 10mg, pantoprazole 40mg, paracetamol 1mg, codeine 16mg and hyoscine butylbromide 20mg).

14 February 2019 – Melbourne Custody Centre

39. At 8.20am on 14 February 2019, Dr Wong and Registered Nurse Megan Bowmaster conducted a welfare check to assess Micky’s opiate withdrawal symptoms. Dr Wong observed that Micky was “lying down, initially slow to wake up, once sitting up was responding verbally, making good eye contact. He was orientated to time, person and place – indicating that he was drowsy or sleepy rather than confused …there was evidence he had been vomiting …he appeared lethargic. His presentation was consistent with the provisional diagnosis of opioid withdrawal”. Micky was administered another dose for opioid withdrawal, however immediately after taking this medication, he vomited and then wanted to lie down again and was reluctant to engage in further communication.

40. Dr Wong prescribed metoclopramide 10mg via intramuscular injection again to assist with Micky’s vomiting. However, prior to administering the injection they were informed that Micky was to be transported to MAP. Dr Wong and Ms Bowmaster requested Micky to attend the clinic to receive his injection and be assessed as to whether he was well enough to be transferred to MAP. Micky attended the clinic and Dr Wong observed that “his appearance had improved. He was more alert, more awake, and was sitting up and alert and his appearance improved. He did not vomit when he attended the clinic and RN Bowmaster gave him the injection. I determined he was able to be transferred to prison custody”. Micky was transferred to MAP just after 11.00am.

14 February 2019 – Melbourne Assessment Prison

41. Micky was allocated a temporary cell at MAP. At 1.01pm, a Direct Reception Assessment was undertaken by Medical Officer Dr Carmencita Esquivel who observed that Micky “walked to the clinic unaided. He was speaking in sentences and was complaining about his injuries and that he was withdrawing from drugs. He had extensive bruising to his right upper

and lower limbs with none on his torso or face. There was no limb deformity. His observation parameters were within normal range. His temperature was 36.7C; blood pressure 134/85; heart rate 54; and respiratory rate 14. His chest was clear and there was dual heart sounds and nil murmur. He had a right knee laceration which was already dressed”.

42. Dr Esquivel prescribed an opioid withdrawal pack which included a reducing dose of diazepam 10mg twice a day for 2 days then diazepam 5mg BD for 3 days, Panadeine 2 tablets twice a day for 5 days, Nexium 20mg daily for 5 days and metoclopramide 10mg daily for 5 days. He was also prescribed analgesia for his injuries (Ibuprofen and Panadol Osteo (after his Panadeine expired). A review of his wound was booked for 15 February and a medical review in the doctor’s clinic was booked on 16 February.

43. Dr Esquivel noted the following issues at the assessment, “haematoma on right arm and thigh, right knee laceration and wound, opioid withdrawal”. The medical history taken at the time in respect of drug and alcohol history indicated that Micky used both heroin and amphetamines intravenously on a daily basis.

44. At 2.31pm, a Reception Psychiatric Assessment was conducted on Micky by Registered Psychiatric Nurse Anand Kerranchira. Mr Kerranchira noted that Micky was difficult to assess due to drowsiness, which she considered could indicate he was drug affected. Micky required extensive prompting to respond to questions and only provided very vague answers regarding his current risk of suicide or self-harm. Mr Kerranchira identified that Micky had not been in contact with the public mental health system since 2012. Ultimately, Mr Kerranchira was not able to obtain a clear picture of Micky's psychiatric state or risk of self-harm due to his drowsy and confused presentation. He assigned Micky ratings of P22 and S23 and recommended that he be placed in an observation cell for close monitoring.

45. At 3.49pm, Micky was placed within Cell 10 of Unit 13 and the observation register recorded that he was checked at both 3.50pm and 4.20pm and found to be awake.

2 P2 – where the prisoner has a significant ongoing condition requiring psychiatric treatment.

3 S2 – these prisoners are placed in an observation cell or at MAP a cell in the AAU (which are ligature proof).

Observations are required at intervals no greater than 30 minutes. A risk assessment is conducted by Forensicare on the prisoner daily and the prisoner is discussed at HRAT.

15 February 2019 – Melbourne Assessment Prison

46. The observation register for Unit 13 records that Micky was observed every half-hour on 15 February 2019 between 8.25am and 4.20pm. All observations between 8.25am and 9.20am recorded Micky as being awake while the remaining observations between 9.50am and 4.20pm recorded Micky as being asleep or apparently asleep.

47. At 8.00am, a collaborative meeting was held with Forensicare staff, Dr Mohamed Mosa from Correct Care and Psychologist Louise Williams to discuss Micky’s presentation, and current physical and mental health status. In that meeting it was recorded that Micky had refused his morning medication and that the previous day’s meal remained next to his bed, uneaten.

Micky was referred to a psychiatry registrar for review with the plan for Forensicare and Correct Care staff to continue to assess Micky’s physical and mental health.

48. At 9.52am, Psychiatric Nurse Pip Bolding made a number of notations in Micky’s medical record including “on a withdrawal pak – offered medication on x3 occasions – refused medication on 3 occasions. Established history of drug use. Hx of ice and heroin – currently not engaging with psych staff … covering himself with a doona – moving his legs when directed by CV staff. Refusing a run out. Unclear if he is eating and drinking – last night’s meal left”. A determination was made at that time for Micky to remain in Unit 13.

49. At 10.35am, Psychiatric Registrar Dr Amy Preston attended to consult with Micky, however he declined to leave his cell and it was observed that he was lying in bed with the covers over his face. Micky declined to answer any questions asked by Dr Preston including when he was offered medication (diazepam and codeine). It was noted that Micky was continuing not to engage with staff and a plan was recorded to continue to attempt engagement with him and to gather collateral information from family members when Micky’s consent was forthcoming.

50. At 2.15pm, Micky refused to attend the medical clinic for a wound review of his knee. At 3.21pm, he was observed by Registered Nurse Derek Buaya and recorded as “not engaging, not eating since dinner last night as per CV staff, booked for nurse clinic tomorrow”.

16 February 2019 – Melbourne Assessment Prison

51. The observation register for Unit 13 recorded that Micky was checked every half-hour on 16 February 2019 between 7.50am and 4.20pm. The observations recorded a mixture of Micky being both awake and apparently asleep. The overnight report made by Psychiatry Nurse Webster Mudavanhu noted that Micky accepted medication after some encouragement, had a heavily bruised right arm, was struggling to mobilise to the trap in the door, and appeared to be in pain however was not forthcoming when engaged.

52. At 8.00am, a collaborative meeting was held with Forensicare staff and Dr Mosa to discuss Micky’s presentation, and current physical and mental health status. It was noted that Micky had yet to engage with staff and he did not eat or drink the previous day, although that morning had accepted his medication and was drinking fluid. The plan formulated was for staff to continue to assess Micky’s physical and mental health. Notations made by Ms Bolding at 8.12am indicated that he was “covering himself with a doona, groaning, crawling towards the trap, needing prompting to put his hand on the trap numerous times, accepted the medication.

Bruising evident on his right arm, and thigh. Didn’t engage with psych staff, no other odd behaviour noted. Refusing a run out. Didn’t have his breakfast again – drinking water – CV staff are aware and monitoring intake”.

53. At 11.30am, a medical review was conducted by Dr Mosa. Initially Micky refused to attend the medical unit on the basis he was too sore to move. Dr Mosa attended Unit 13 and tried to examine Micky but he was difficult to assess as he was lying on his abdomen and refused to cooperate. After some time, Dr Mosa convinced Micky to attend the medical unit and he was brought there by Corrections Victoria staff in a wheelchair. Micky informed Dr Mosa that he was drinking but not eating and that he felt nauseated. He denied experiencing abdominal pain, sore throat, cough or urinary symptoms.

54. Dr Mosa examined Micky and noted a temperature of 37.9 degrees, a pulse rate of 91 and a blood pressure of 119/75. Micky's speech was normal, his chest was clear, heart sounds were noted to be normal, his abdomen was noted to be soft and non-tender and he had extensive bruises on the right upper limb and right lower limb. His left knee laceration was already dressed. Dr Mosa identified that Micky was presenting with a slight fever and his right knee wound needed review.

55. Dr Mosa stated that the plan was to continue the current medications including antibiotics, analgesia and the opioid withdrawal pack. Dr Mosa requested pathology tests and blood samples were collected that day. He also instructed staff at the clinic to send Micky to hospital if his temperature on the following day was 38 degrees or higher. He formed the preliminary diagnosis that the source of Micky's fever was the infected right knee wound rather than systemic illness. Dr Mosa instructed that arrangements be made for a review by Dr Plunkett the following Monday. Pathology results were available the following day and were within accepted limits with no indication for sepsis and with Micky's temperature having reduced down to 36.6 degrees Celsius.

56. At 12.40pm, Micky attended the nurse clinic where he was seen by Registered Nurse Genevieve Fitzpatrick. Micky’s vitals were checked and attempts were made to access his veins for urgent pathology, however due to his history of intravenous drug use, access was not possible. It was noted “prisoner peripherally shutdown, complaining he is cold, encouraged to continue hydrating”. Ms Fitzpatrick made a note for the Medical Officer to try to access his veins when Micky returned to the clinic at 3.00pm. In accordance with the plan of the Medical Officer, Ms Fitzpatrick encouraged Micky to drink two glasses of water while in the clinic, which he did. Ms Fitzpatrick also advised Micky to continue to hydrate throughout the day to improve his circulation volume and improve the chances of drawing a pathology sample.

17 February 2019 – Melbourne Assessment Prison

57. The observation register for Unit 13 records that Micky was observed every half-hour on 17 February 2019 between 7.50am and 4.15pm. The observations recorded a mixture of Micky being both awake and apparently asleep. The overnight report made by Psychiatric Nurse Webster Mudavanhu “noted improvement in mobilising to the trap, accepted nocte medication. Appeared to sleep overnight”.

58. At around 9.30am, Prison Officer Michael Dalmau entered Micky’s cell in order to escort him to the shower and noted that he “was half asleep and very groggy and struggling to move … … he was moving very slowly and I believe that was owing to the pain from his bruising … … Revera was struggling to communicate as he was slurring his words. I have no idea why he was slurring his words, though I believe it could be owing to withdrawal from illegal drugs, or from poor communication skills in general. Revera didn’t speak to me much, and it was more grunting than actual speech … … I also asked him how he was feeling, and he said that

he felt sick”. Mr Dalmau escorted Micky to the shower area and then organised for him to be taken to the medical area for assessment by Correct Care staff.

59. At 10.18am, Registered Nurse Cecilia Papdanco recorded a number of observations of Micky including his temperature (36.6 degrees) and blood pressure (118/78). Micky was brought to the clinic in a wheelchair and it was noted he was “nodding off but he was at all times rousable and responsive”. Ms Papdanco noted that although Micky was drowsy, his vital signs were normal and his conscious state had not changed as documented from previous days. The notations on Micky’s medical file included “prisoner rousable when spoken to however still in drowsy state. Brought to Nurse Clinic in wheelchair. CV report ate small amount this morning and had water with medications. Has booking MO tomorrow”.

60. At 11.32am, Ms Bolding made the following notations: “Cell – most of Micky’s food is beside his bed. Seen in the trap and courtyard. MSE wearing canvas gown/hygiene – showered sat on a plastic chair whilst in the shower.

Behaviour during the interview – closed his eyes whilst in the courtyard. Didn’t engage in conversation – looks like he is sleeping. Micky later wanted to talk wanting to know his court date and charges – March 19 – would like to talk to his grandma – put grandma number on the telephone list … … continues to drink – eating a bit of his toast and some egg”.

61. At 12.29pm, Registered Nurse Derek Buaya reviewed Micky through the trap in the door to his cell. At that time Micky advised he had no complaints of pain and the Corrections Victoria staff informed Mr Buaya that Micky had been eating and drinking.

18 February 2019 – Melbourne Assessment Prison

62. The observation register for Unit 13 records that Micky was observed on 18 February 2019 to be awake at 7.50am and 8.20am, apparently asleep at 8.50am and 9.20am with a ‘Code Black’4 called at 9.50am. The overnight report made by Psychiatric Nurse Meredith Baxter recorded that Micky “struggled over to get his meds, asked if I would be here in AM, wants to ring his grandmother, says she doesn’t know he is here, also hoping to get out of Unit 13”.

4 Used to alert staff to a medical emergency.

63. At around 7.45am, Prison Officers Dalmau and Chris Simonis conducted a ‘trap count’ and sighted Micky standing at the toilet in his cell. Micky nodded to Mr Dalmau. At 8.25am, Mr Dalmau entered the outer door of Micky’s cell to provide him breakfast and was able to see through the cell door window that he had gone back to sleep on the mattress. Mr Dalmau banged on the inner door loudly twice to wake him up and called his name twice and “could see him breathing under the blanket, as we checked for this specifically … however he didn’t wake up when I banged the door or yelled”.

64. Mr Dalmau then opened the cell door and walked over to Micky who woke and rolled over before opening his eyes. Mr Dalmau told Micky that he had to eat his breakfast and he responded “yeah, yeah”. Micky was then asked whether he wanted to shower or spend time in the yard and he nodded his head up and down. At that time, Mr Simonis was of the opinion that Micky was “coherent and stated that he wanted to come out for a shower”. Mr Dalmau then asked if he still wished to make a formal complaint against Victoria Police about being assaulted at the time of the arrest and Micky replied “yeah”. Mr Dalmau then replied “No worries, when you come out in the yard I’ll get Mr Simonis to sit in there with you and take some notes”. Prison Officers Dalmau and Simonis then departed Micky’s cell closing and securing the doors behind them.

65. Prisoner Officer Simonis was of the opinion that “Micky was fully coherent when I spoke to him last at breakfast. He didn’t complain about any pain and didn’t make any mention of feeling unwell … … He gave me no indication of feeling unwell”.

66. At around 8.30am, a collaborative meeting was held with Forensicare and Correct Care staff including Dr Plunkett, Prison Officer Dalmau, Psychologist Louise Williams, Dr Simms, Social Worker Louise Gallagher and Psychiatric Registrar Dr Walter Hipgrave. In that meeting, it was noted that while he had accepted his medications the previous evening, Micky had not accepted his morning medication but had consumed a banana. The outcome of that meeting was that both Dr Plunkett and the Psychiatric Team would review Micky later that morning and the Social Worker was to follow up and make contact with Micky’s grandmother.

67. At around 8.50am and 9.20am, Prison Officer Simonis checked on Micky who appeared to be asleep. His face on both occasions was covered with a blanket although Mr Simonis stated that this was quite normal for those sleeping due to the sunlight in the cells during the day.

68. At 9.48am, Prison Officer Dalmau entered Micky’s outer cell door to conduct the half-hourly welfare check, banging on the inner cell door twice loudly. Mr Dalmau was able to see Micky through the window who was entirely covered by a blanket except for his feet and appeared to be positioned on his back. Mr Dalmau did not get a reaction from Micky and could not see him breathing.

69. Prison Officer Dalmau then opened the inner cell door, entered Micky’s cell, removed the blanket, and observed that he could not see Micky breathing. Mr Delmau recalled that he “pressed one hand on Micky’s chest, and shook him intensely a few times. Micky did not respond in any way, but I felt that he was warm, which made me uncertain if he had died or not. I called out ‘Micky’ around three or more times and did not get a response”. Mr Dalmau immediately sought the assistance of Officers Chris Schmitt and Dennis Ebery who also failed to get a response from Micky. Mr Dalmau immediately used his radio to call a ‘Code Black’ with medical staff from Correct Care immediately responding and cardiopulmonary resuscitation (CPR) was commenced. Mr Dalmau contacted emergency services and requested an ambulance.

70. Ambulance Victoria paramedics along with a MICA Paramedic arrived on scene approximately 9.58am. Upon their arrival, Micky was found to be in cardiac arrest and despite their best efforts at resuscitation, Micky could not be revived and was pronounced deceased at 10.34am.

Identity of the deceased

71. On 21 February 2019, Micky Craig Revera, born 15 April 1978, was identified via fingerprint identification.

72. Identity is not in dispute and requires no further investigation.

Medical cause of death

73. Forensic Pathologist Dr Greg Young from VIFM conducted an autopsy on 19 February 2019 and provided a written report of his findings dated 29 October 2019.

74. The post-mortem examination revealed: (1) Extensive bruising over the right upper limb and lower limb; (2) Laceration to the skin on the back of the right forearm, with evidence of healing; (3) Laceration to the skin on the right knee, with evidence of healing; (4) Multinucleated giant cells in the lungs, associated with refractile needle-shaped crystals; no evidence of pneumonia; (5) Hepatic steatosis, fibrosis and chronic hepatitis; (6) Moderate atherosclerosis of the left anterior descending coronary artery; no significant myocardial fibrosis; no evidence of endocarditis; (7) No significant neuropathological abnormality seen in the brain; (8) No significant injuries to the face and neck; and (9) Acute fractures of the right fourth rib and sternum.

75. Dr Young made the following relevant comments in his autopsy report: (1) The cause of death remains unascertained following completion of a full post mortem examination and ancillary tests.

(2) The autopsy showed an adult male with extensive bruising over the right upper limb and right lower limb. Lacerations to the skin on the back of the right forearm and over the right knee (sutured) showed acute inflammation, in keeping with recent injuries with healing. Multinucleated giant cells were seen in the lungs associated with refractile needle-shaped crystals, consistent with the deceased’s history of injecting drug use. Pneumonia was not seen. The liver showed fatty change and fibrosis, as well as chronic hepatitis. The left anterior descending coronary artery showed moderate atherosclerosis, but there was no other significant pathology in the heart. There was no evidence of infective endocarditis. Acute fractures of the right fourth rib and sternum were seen, in keeping with the history of chest compressions administrated during cardiopulmonary resuscitation. No significant neuropathological abnormality was seen in the brain.

(3) Vitreous humour biochemistry, including glucose, was non-contributory. Of note, the deceased’s renal function was normal, and sodium was not elevated.

(4) A serum CRP (marker of inflammation) was slightly elevated consistent with minor non-specific inflammation.

(5) Post mortem specimens were taken for microbiology testing. No organisms were cultured from the blood or lungs, and no viral nucleic acids were detected in the lungs. Mixed bacterial flora were isolated from the urinary bladder, and skin flora were isolated from the skin of the right groin and left groin. The right knee wound cultured Staphylococcus aureus, which is a bacterium that is normally found on the skin.

(6) While a specific cause of death has not been determined, several important possibilities have been considered, which will each by explored in turn: a. Neuropathological examination of the brain did not show any significant head injury which may have caused or contributed to death. In particular, there was no obvious intracranial haemorrhage, skull fracture or facial injury which may be attributed to any application of force. No obvious neck injuries were seen.

It is not evident that the soft tissue injuries (bruises) to the right upper limb and right lower limb have directly caused or contributed to death.

b. Sepsis is where there is disseminated infection which may lead to multi-organ failure and death. In this case one must consider whether the deceased’s open injuries (lacerations) may have become infected leading to sepsis. Histology of these wounds, as well as post mortem microbiology testing from multiple sites around the body did not support a diagnosis of severe disseminated infection.

This was further supported by the serum CRP, which was only slightly raised.

The lungs, heart and kidneys also did not show evidence of significant infection.

c. The deceased had been diagnosed with opioid withdrawal in custody. Of significance, no opioids were present on toxicological analysis of the deceased’s blood at the time of death. Opioid withdrawal may lead to restlessness, body aches, sweating, vomiting, diarrhoea, fever, tachycardia, tachypnoea, high blood pressure and seizures. It would be expected that many

of these symptoms would have been seen by prison staff if they were present in life. Given seizures cannot be diagnosed at autopsy, it cannot be excluded that the deceased has had an opioid withdrawal-related seizure leading to death.

d. It was documented that the deceased had minimal oral intake (food and fluid) in prison. This may lead to dehydration and renal failure. However, vitreous humour biochemistry tests did not show evidence of either dehydration or renal failure.

e. Other causes of sudden unexpected death whereby no anatomical findings are revealed at post mortem examination include cardiac arrhythmias. Cardiac channelopathies such as long QT syndrome, catecholaminergic polymorphous ventricular tachycardia and Brugada syndrome have been implicated with some cardiac arrhythmias.

76. Toxicological analysis of post-mortem samples identified the presence of diazepam (and metabolite nordiazepam), 7-aminoclonazepam (metabolite of clonazepam), metoclopramide and paracetamol.

77. Dr Young provided an opinion that the medical cause of death was 1(a) Unascertained, noting that an opioid withdrawal-related seizure or a cardiac arrythmia could not be excluded.

78. Micky’s family engaged Consultant Forensic Pathologist, Dr Byron Collins to conduct an autopsy upon Micky’s body, independent of VIFM. This autopsy was performed at VIFM on 28 February 2019 in the presence of Dr Young “in order to demonstrate the various abnormalities he identified during the initial (primary) autopsy carried out on 19 February 2019”.

79. Dr Collins produced an Interim Report dated 17 April 2020 in which he made the following relevant comments: “At the completion of my autopsy, I was satisfied that Dr Young had carried out a meticulous and extensive primary autopsy, on the body of the late Micky Craig Revera and that appropriate samples of tissues and bodily fluids had been harvested for ancillary investigations such as histology, toxicology, microbiology and biochemistry.

Following detailed and diligent review of all the materials so far provided, including the ancillary investigations, I am in general agreement with Dr Young’s comments, as contained in pages 4, 5 & 6 of his autopsy report.

In the absence of an overt cause of death, the appropriate cause should presently be listed as Unascertained, although this is not necessarily “set in stone” and should not be construed as Unascertainable.”

80. I accept Dr Young’s opinion and further note the general agreement provided by Dr Collins.

SUBMISSIONS OF THE PARTIES

81. Victoria Police provided an Outline of Submissions at the inquest which was supplemented with oral submissions by Ms Singleton of counsel. In summary, Victoria Police submitted that: a) There is no evidence of any causal link or connection between the use of force by police members on 12 February 2019 and Micky’s death; b) The use of force on 12 February 2019 was necessary and justified in the circumstances; c) Police and Custodial Health Staff gave due care and attention to the deceased’s presentation at the Dandenong Police Station on 13 February 2019; and d) Custodial Health Staff at the MCC provided regular and appropriate medical assessment and care to Micky between 13 and 14 February 2019.

82. Ms Julie Lowe, Micky’s sister, acknowledged the detailed summary of evidence provided to the Court at the inquest but expressed understandable frustration and disbelief in relation to the unascertained cause of her brother’s passing. She also expressed concern that Micky’s condition while in custody had been dismissively attributed to opioid withdrawal.

REVIEW BY CORONERS PREVENTION UNIT HEALTH & MEDICAL TEAM

83. I referred this matter to the Health & Medical Investigation Team of the Coroners Prevention Unit (CPU)5 to review Micky’s medical care at Dandenong Hospital, Dandenong Police Station, MCC and MAP. Following a detailed review of the adequacy and appropriateness of Micky’s treatment, the CPU noted that: (1) Micky was assessed at the Emergency Department (ED) of the Dandenong Hospital on 12 February 2019 post his arrest. The medical records were brief with no detail of Micky’s injuries documented. Micky’s vital signs returned to normal and he was discharged into police custody when he could walk. No pathology tests were performed and there was no consideration of other causes of Micky’s altered level of consciousness apart from drug use.

(2) The staff at Dandenong Police Station were concerned about Micky’s drowsiness and contacted the FMO who recommended transfer back to hospital. Staff called the nurse in charge at ED at Dandenong Hospital and were apparently told the sedating drugs would continue to wear off and there was no need to transfer back to hospital.

(3) The assessment and care at MCC were appropriate as a diagnosis of drug withdrawal at this stage appeared most likely.

(4) Micky was placed in a secure unit at MAP with a risk of S2, meaning he had observations every 30 minutes. The individual assessments by the doctors, RNs and psychiatry team all appeared reasonable. There was no clear point when Micky deteriorated or had markedly abnormal vital signs requiring urgent medical attention and transfer to hospital. However, Micky did remain drowsy for days, with minimal oral intake, difficulty walking and failure to communicate and engage. Micky had continuing ongoing assessment and observation by both medical, nursing and psychiatry staff. It was noted he was not progressing as well as would be expected but there were no red flags to suggest any other pathology to warrant transfer to hospital.

5 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the Coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the coroner. The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.

(5) The cause of death was unascertained with there being no missed head injury, no evidence of infection, no opiates present on toxicological analysis at the time of death and no biochemical evidence of dehydration. Therefore, the CPU concluded, it is impossible to say that there was a missed or delayed diagnosis.

(6) In summary, the CPU concluded that Micky died in MAP a few days after being incarcerated. In the days prior to death, he had been drowsy, had difficulty mobilising apparently due to pain and not eating and drinking much. The provisional diagnosis for this was drug use and withdrawal and a psychiatric cause which was reasonable.

There was diagnostic uncertainty in relation to Micky’s condition as over time he did not improve as would have been hoped. The usual approach to diagnostic uncertainty is repeated assessment, looking for red flags, and time allowing signs of an evolving diagnosis to present, which was done. Unfortunately, despite the ongoing assessment a diagnosis was not able to be made in life or in death. The CPU concluded that, even with the benefit of hindsight, it is difficult to identify a way in which Micky’s death could have been prevented.

84. I accept the conclusions of the CPU.

85. Further, I am satisfied that a reasonable process was adopted in relation to resolving the difference of opinion that existed between the FMO and the staff at the ED of the Dandenong as to whether Micky should have been returned to hospital on 13 February 2019. While there is no specific Victoria Police policy in place which would guide a police member’s judgment in the circumstances, there is a policy which clearly directs members as to the circumstances when they should seek advice from an FMO (whether a person is fit for interview) or the CHAL (whether a person is fit to be held in police custody). I consider that this policy together with the application judgment by police members in Micky’s case has produced a reasonable outcome. In any event, in the following days leading to his death, Micky was assessed by numerous medical staff while he was in custody at MCC and MAP and at no stage did anybody form the opinion that his condition required him to be transferred to hospital.

REVIEW BY THE JUSTICE ASSURANCE AND REVIEW OFFICE

86. The Justice Assurance and Review Office (JARO)6 conducted a review of Micky’s death which included a review by Justice Health7 of the health care he was provided while in custody. JARO made the following findings in its report: (1) After Micky’s discovery, approximately three minutes lapsed before CPR was commenced by medical staff. In the intervening period, Emergency Response Group (ERG) officers placed Micky into the recovery position. They did not check whether his airway was clear or check his breathing.

(2) ERG officers failed to activate their Body Worn Cameras.

(3) Micky’s allegation of assault by police was not recorded on the Prisoner Information Management System (PIMS) within 24 hours, as is required by policy. However, MAP staff immediately referred the matter to senior management of Corrections Victoria. JARO was advised that the Commissioner of Corrections Victoria spoke to the Chief Commissioner of Victoria Police on 14 February 2019 in relation to Micky’s allegation, however no formal record was made in PIMS until 19 February 2019, five days after the allegation was first made.

(4) The formal debrief conducted after Micky’s death failed to examine the activity leading up to the incident or identify learnings in relation to prison policies, procedures and practices.

(5) Due to his suicide/self-harm risk rating, Micky was required to be observed every 30 minutes during the four days he was in Corrections Victoria’s custody. The observation conducted at 9.18am on the morning of 18 February 2019 lasted for approximately two seconds. Closed-circuit television (CCTV) footage revealed that during the observation Micky was covered head-to-toe by a blanket and the lights were off in his cell. The officer conducting the observation also remained in the unit hallway rather than entering the cell foyer.

6 JARO is a business unit within the Department of Justice & Community Safety (DJCS). It operates as an internal review and assurance function to advise the Secretary, DJCS on the performance of the youth justice and corrections systems.

7 Justice Health is a business unit of the Department of Justice and Community Safety with responsibility for the delivery of health and alcohol and other drug (AOD) services for prisoners across Victoria’s prison system and Youth Justice.

(6) Justice Health’s review of Micky’s health records while in custody found that although his physical observations would not have triggered any escalation of care in accordance with Correct Care Australasia’s (CCA) policy CS7.2 Vital Signs and Clinical Deterioration, the policy does not provide guidance on what health staff should do if a patient’s physical mobility deteriorates. Justice Health has made three recommendations in response to Micky’s death at the MAP on 18 February 2019, reproduced below.

87. The JARO Report also included the following recommendations: (1) That the General Manager (GM) of MAP communicates, to staff who undertake prisoner reception duties, the importance of accessing information relevant to a prisoner in line with Local Operating Procedure (LOP) 1.11-1 – Reception, Care and Control of Prisoners when a prisoner: a. presents with significant physical injuries, and b. is unable to participate in the reception process due to this, or another impairment.

(2) That the GM of MAP communicates, to all staff, the requirement to: a. record all allegations of assault by persons other than staff on PIMS within 24 hours of the allegation being made, in line with Commissioner’s Requirement (CR) 1.3.1 – Incident Reporting, and b. report all allegations of assault to Victoria Police within two hours or as soon as possible, in line with Deputy Commissioner’s Instruction (DCI) 1.19 – Incident Reporting and Monitoring.

(3) That the GM of MAP communicates, to all staff, the requirement to conduct prisoner observations in line with LOP 1.02-4 – Prisoner Observations Regimes.

(4) That the GM of MAP (or their delegate) conducts periodic audits of prisoner observations to ensure that they are in line with policy. The audit process, including its required frequency and the expected outcomes (such as remedial action) should be incorporated into the relevant LOP.

88. These recommendations have been considered by Corrections Victoria and accepted.

89. Justice Health made the following recommendations: (1) CCA to review policy CS12.1 Drug and Alcohol Assessment to ensure it meets contemporary practice guidelines.

(2) CCA to ensure all staff are fully aware of policy CS12.1 and receive appropriate training in: a. assessing prisoners for substance withdrawal symptoms, and b. prescribing medications to assist with managing withdrawal symptoms.

(3) CCA to consider mobility and functionality assessments for prisoners who have experienced significant body trauma and to update relevant policies, procedures and staff training to ensure mobility and functionality form part of a prisoner’s assessment.

90. Justice Health has stated that it will liaise with CCA in relation to the recommendations and monitor progress towards implementation.

91. In my view, the relevant findings of JARO that are sufficiently connected with Micky’s death for the purpose of the coronial investigation are: the three minute delay in commencing CPR; and the opportunity to potentially have discovered that Micky was unresponsive in his cell at the check conducted at 9.18am on 18 February 2019. However, given that the cause of Micky’s death is unascertained, I am unable to conclude that a different response would have prevented his death.

ALLEGATIONS AGAINST VICTORIA POLICE

92. Micky advised staff at the MAP that he wanted to make a complaint about the conduct of Victoria Police during his arrest. The arrest was not captured on body-worn camera but the description of the events in the police members’ statements is largely consistent. In my view, the circumstances of the arrest as described by the police members justified the use of force as detailed by them in their statements.

93. However, I do note that upon presentation to the Dandenong Hospital, Micky was observed to have some swelling to his right cheek and it was recorded by hospital staff that he was struck with a baton, including to the face. It is not clear from the police statements how any injury to the face was sustained noting that no such injury is referred to in the records from MCC or MAP.8 When the issue was raised with counsel for the Chief Commissioner at the inquest, she submitted that it was possible that any injury to Micky’s face may have been sustained when he was being restrained on the ground. Ultimately, however, I consider that resolution of this issue is not required as part of the coronial investigation as there is no evidence that any of the injuries sustained by Micky during his arrest contributed to his death.

FINDINGS AND CONCLUSION

94. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings:

(a) the identity of the deceased was Micky Craig Revera, born 15 April 1978;

(b) the death occurred on 18 February 2019 at Melbourne Assessment Prison, 317-353 Spencer Street, West Melbourne, Victoria, 3003, with the cause of death being Unascertained; and

(c) the death occurred in the circumstances described above.

I convey my sincere condolences to Micky’s family for their loss.

Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

8 There is a reference in the JARO report, p16.

I direct that a copy of this finding be provided to the following: Joanes Revera, Senior Next of Kin Forensicare Correct Care Victoria Department of Justice and Community Safety (Corrections Victoria) Chief Commissioner of Police Monash Health Detective Senior Constable Cara Italia, Coroner’s Investigator Signature: ______________________________________ Coroner David Ryan Date: 03 June 2022 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.