Finding into death of Brad Anthony Godressi

IN THE CORONERS COURT COR 2020 006110 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Judge John Cain, State Coroner Deceased: Brad Anthony Godressi Date of birth: 14 March 1980 Date of death: 9 November 2020 Cause of death: 1(a) CARDIOMYOPATHY IN THE SETTING

OF IMMERSION AND AMPHETAMINE USE Place of death: Port Phillip Bay, Swan Island, Victoria, 3225 Keywords: Boat; boat incident; marine licence; motor vehicle licence; disqualified driver; drug and alcohol use

INTRODUCTION

1. On 9 November 2020, Brad Anthony Godressi was 40 years old when he was found deceased in his boat on Port Phillip Bay in the vicinity of Swan Island.

2. At the time of his death, Mr Godressi resided with his partner, Cindy Smith at an address in Pascoe Vale. Ms Smith and Mr Godressi had been together for approximately 20 years. He is also survived by his father, Mr Antoine Godressi.

3. Mr Godressi was the only child of his parents’ marriage, and he grew up in Glenroy with a number of step siblings. He was a known user of illicit substances including methylamphetamine (ice) and marijuana.

4. In around November 2019, Mr Godressi purchased a Hydro Force Rubber Dingy. Mr Godressi had a lot of experience with boats and had been around them when he was growing up.

5. Towards the end of 2019, Mr Godressi started to experience health issues. He was subsequently diagnosed with end stage dilated cardiomyopathy and had several hospital admissions during 2019. His last admission was to the ICU at Northern Hospital on 28 October 2020 where he discharged against medical advice on 30 October 2020.

THE CORONIAL INVESTIGATION

6. Mr Godressi’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

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. Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Brad’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist and investigating officers – and submitted a coronial brief of evidence.

10. This finding draws on the totality of the coronial investigation into the death of Brad Anthony Godressi including evidence contained in the coronial brief. Whilst 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

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased, pursuant to section 67(1)(a) of the Act

11. On 12 November 2020, Brad Anthony Godressi, born 14 March 1980, was visually identified by their partner, Ms Cindy Smith.

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

Medical cause of death, pursuant to section 67(1)(b) of the Act

13. On 11 November 2020, Forensic Pathologist Dr Linda Elizabeth Iles from the Victorian Institute of Forensic Medicine, conducted an autopsy on the body of Mr Brad Godressi and provided a written report of her findings dated 12 April 2021.

14. The post-mortem examination revealed significant cardiac enlargement associated with microscopic evidence of myocyte hypertrophy and interstitial fibrosis. Dr Iles opined that this is in keeping with Mr Godressi’s known diagnosis of cardiomyopathy and associated heart failure for which he was admitted to intensive care in the weeks preceding his death.

15. There was evidence of mild pulmonary oedema and lung hyperinflation, but no significant pleural effusions were present. Sand was located throughout the large airways and sinuses.

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.

16. Dr Iles stated that the autopsy findings of drowning are non-specific and can be variably developed. It is not possible to determine with certainty whether Mr Godressi drowned or died from his underlying cardiac condition whilst being in the water.

17. Toxicological analysis of post-mortem samples identified the presence of cardiac medications bisoprolol and amiodarone. In addition, amphetamine and metabolites were present along with caffeine.

18. Dr Iles noted that the ingestion of stimulant substances in the setting of significant underlying cardiac disease and a history of cardiac failure, has significant potential to precipitate a cardiac arrhythmia in a setting of myocyte hypertrophy and interstitial fibrosis.

19. Dr Iles provided an opinion that the medical cause of death was cardiomyopathy in the setting of immersion and amphetamine use.

20. I accept Dr Iles’ opinion as to the cause of death.

Circumstances in which the death occurred, pursuant to section 67(1)(c) of the Act

21. At 12:00am on 9 November 2020, the COVID-19 25km travel restrictions were lifted in Victoria. At 12:30am that morning, Mr Godressi drove to Geelong to go fishing and see his cousin Mr Glenn Remilton.

22. At 5:00am, Ms Smith received a phone call from Mr Godressi on Mr Remilton’s phone stating that he had been assaulted by a friend, Mr Damian Rose. According to Ms Smith, Mr Godressi and Mr Rose were good friends but had a recently falling out. Most of their interactions were regarding drugs.

23. Around that time, Mr Godressi attended Mr Remilton’s house. Mr Remilton stated that Mr Godressi lump right in the middle of his forehead, and he had a split on the bridge of his nose…just like he’d fallen on concrete.

24. Mr Godressi advised Mr Remilton that he had an altercation with Mr Rose and his partner “Mikayla”. Although Mr Godressi could provide a reason for the argument, Mr Remilton believed that it was an argument over drugs. After spending some time with Mr Remilton, Mr Godressi decided to drive home and leave his boat at the back of Mr Remilton’s property.

25. At 7:23am, Mr Godressi called Ms Smith and asked her to go fishing with him. Ms Smith was unable to attend. That was the last time Ms Smith spoke to Mr Godressi.

26. At around 8:00am, Mr Godressi returned to Mr Remilton’s property and collected his boat.

27. Later that afternoon, Ms Smith tried to contact Mr Godressi on a number of occasions on his mobile phone. Although Ms Smith was concerned, it was common for Mr Godressi not to answer his phone if he was out on his boat.

28. In the early evening, Mr Lionel Waddell was cruising in his 25ft 1955 Couta Boat around Queenscliff with a friend, when he observed a boat that appeared to be washed up on the shore at Swan Island. As he approached the boat, he observed a body about 25 metres away from the boat on the shore. He rang Triple Zero and attended Queenscliff Harbour to pick Victoria Police personnel. Upon arriving at the scene, a request was made for Water Police to attend.2

29. At 6:40pm, Water Police arrived at the beach on the south/east side of Swan Island, to the right of the entrance to the Queenscliff Harbour and retrieved Mr Godressi’s body from the water. LSC Sheild’s observed Mr Godressi’s vessel to be side onto the waves, which were crashing into the port side…and it had filled with ocean water and was not moving from its position.

30. LSC Shields stated that there was a thin line running from the bow of…for a distance of 15 to 20 feet, directly out from the bow, which had half a red house brick, attached to the line and was embedded in the sand, possibly used as an anchor. There were also fishing rods and fishing equipment in the vessel. Mr Godressi’s shorts were found hanging on the fishing rod, along with some toilet paper.

31. When retrieving Mr Godressi’s body, LSC Shields recalled seeing a small wound (similar to a needle mark) on the inside of Mr Godressi’s left arm and what appeared to be a cut over his right eyebrow.

FURTHER INVESTIGATIONS

32. Following Mr Godressi’s death, Victoria Police commenced an investigation. Upon examining the scene, police located a small empty plastic bag in Mr Godressi’s shorts along 2 Statement of Lionel Waddell dated 28 January 2021 at CB, p 20.

with a syringe in his vessel. It is noted that a during a subsequent search of Mr Godressi’s motor vehicle, police located a plastic bag containing white crystals and a syringe.

33. Mr Godressi’s vessel appeared to have been deliberately pulled up on the shore of Swan Island and police concluded that Mr Godressi was not overboard at the time of his death and instead, with his vessel and able to secure it to the shore.

34. On 7 December 2020, LSC Evans-Barker attended Mr Antoine Godressi’s home address and inspected Mr Godressi’s boat and trailer. LSC Evans-Barker noted the following:  vessel appeared to be in good condition and had no obvious defects;  there was fuel in the tank and the tank did not have any obvious defects or damage;  the safety equipment, including personal flotation devices were in good condition and had not been activated;  there were no navigation lights, flares or extinguisher; and  there were no registration numbers on the vessel.

35. Upon further investigation, police determined that Mr Godressi had been disqualified from driving a motor vehicle in Victoria, due to drug related activity (licence number 54256101).

However, it was determined that at the time of the incident, Mr Godressi held a current marine licence, of the same licence number, until 4 June 2025.

36. In addition, Mr Godressi’s vessel (and motor) were not registered in Victoria and subsequently enquiries conducted with the NSW Water Police did not identify any previous owner or previous registration status. Investigating police were unable to establish any chain of ownership for the vessel.

37. LSC Evans-Barker concluded that the weather conditions, mechanical failure and vessel stability were not considered to be contributing factors in this case.

Recommendation by Victoria Police

38. During the course of the investigation into Mr Godressi’s death, LSC Evans-Barker identified two issues relating to the linking of motor vehicle and marine licences in Victoria.

39. In his statement to the Court, LSC Evans-Baker noted that the Road Safety Act 1986 (Vic) and the Marine (Drug, Alcohol and Pollution Control) Act 1988 (Vic) both provide for the cancellation of a licence in relation to offences involving drug and alcohol use. However, in Victoria a motor vehicle licence is not linked to a marine licence.

40. Further, he noted that section 24(3) of the Road Safety Act 1986 provides for the suspension of a driver licence on the grounds that it would be dangerous for the person to drive a motor vehicle because of illness or disability, medical condition or injury or because the effects of treatment for any of those things. This suspension may be applied on the basis of a report given by a registered medical practitioner and without conducting any other hearing or investigation into the matter before the suspension is imposed. This provision is not duplicated in the Marine Safety Act 2010 (Vic) or Marine Safety Regulations 2012 (Vic).

41. LSC Evans-Barker made the following comments:  the ability to suspend a marine licence when a motor vehicle licence is suspended on medical grounds would deter persons with serious conditions from legally operating a vessel for their safety and the safety of other waterway users; and  linking these licences so that suspensions and cancellations for drug and alcohol offending also effected marine licences would deter illicit drug users from operating vessels for the safety of themselves and other water way users.

42. I agree with the comments made by LSC Evans-Baker that there appears to be a gap in the legislative framework regarding the linking of maritime and motor vehicle licences in Victoria. I am of the view that if a person has been disqualified from driving a motor vehicle for offences relating to drug and alcohol use or on medical grounds, that the disqualification should also extend to their marine licence.

43. Notwithstanding this, I do accept that Mr Godressi continued to drive his motor vehicle even though his licence had been cancelled. As such, I am unable to say with any certainty if the outcome would have been different for Mr Godressi had he been disqualified from operating a marine vessel at the same time as his motor vehicle licence was cancelled.

FINDINGS AND CONCLUSION

44. Pursuant to section 67(1) of the Act, I make the following findings: a) the identity of the deceased was Brad Anthony Godressi, born 14 March 1980; b) the death occurred on 9 November 2020 at Port Phillip Bay, Swan Island, Victoria, 3225, from cardiomyopathy in the setting of immersion and amphetamine use; and c) the death occurred in the circumstances described above.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death:

45. As outlined above, in investigating the circumstances surrounding Mr Godressi’s death, Leading Senior Constable Evans-Baker identified a gap in the current legislative framework regarding the linking of motor vehicle licences and marine licences in Victoria.

46. In considering this issue, I consulted with Safe Transport Victoria who agreed that there is a gap in the current legislative framework. Safe Transport Victoria advised that they would be supportive of a proposal to work with the Department of Transport and Planning to review the current legislative framework to consider amendments to link vehicle and marine licences particularly in relation to suspension and/or cancellation for alcohol and drug us and medical grounds.

RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendation:

(i) That the Secretary for the Department of Transport and Planning consider amending the current legislative framework so that if a person has been disqualified from driving a motor vehicle for offences relating to drug and alcohol use or on medical grounds, the disqualification should also extend to their Marine Licence. Further, consideration should be given as to whether disqualification of a person’s marine licence for drug alcohol offences or medical grounds should be extend to their vehicle licence.

I convey my sincere condolences to Mr Godressi’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.

I direct that a copy of this finding be provided to the following: Cindy Smith, Senior Next of Kin Leading Senior Constable Wayne Evans-Baker, Coroner’s Investigator Secretary of the Department of Transport and Planning Safe Transport Victoria Signature: ___________________________________

JUDGE JOHN CAIN STATE CORONER Date: 5 June 2023 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 investigation. 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.