Finding into death of Suzanne Norah Evans

IN THE CORONERS COURT COR 2020 000139 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 Suzanne Norah Evans Delivered on: 7 October 2024 Delivered at: Southbank, Victoria Hearing Dates: 4 and 5 March 2024 Findings of: Coroner Paul Lawrie Representation: Ms A. Dickens of Counsel for the Chief Commissioner of Police instructed by the Victorian Government Solicitor’s Office Counsel Assisting: Ms S. Locke of Counsel with Ms L. Bedggood Keywords: Baclofen toxicity

I, Coroner Paul Lawrie, having investigated the death of Suzanne Norah Evans, and having held an inquest in relation to the death on 4 and 5 March 2024 at Southbank, Victoria find that the identity of the deceased was Suzanne Norah Evans born on 7 August 1969 and the death occurred on 8 January 2020 at 2 Baw Baw Street, Moe, Victoria 3825 from:

COMBINED DRUG TOXICITY IN A WOMAN WITH TENSION PHEUMOTHORAX INTRODUCTION

1. Suzanne Evans was 50 years of age when she was found deceased on the evening of 8 January 2020 at 2 Baw Baw Street, Moe, Victoria. The property was the residence of her neighbour, David Wicklander, and Ms Evans had been staying there temporarily since the previous evening.

2. Ms Evans had been residing next door at 4 Baw Baw Street with her partner of two months, Mark Sgarbossa. On the evening of 7 January 2020, Ms Evans and Mr Sgarbossa became embroiled in a loud argument and police were called by Ms Evans. When police members arrived at 8.18pm, Ms Evans appeared drunk and alleged she had been assaulted by Mr Sgarbossa. The allegation she made was that he had kicked her to the stomach as she lay on a bed – however Ms Evans bore no injury or sign of the alleged assault and declined to explain or demonstrate how it had taken place. The police members concluded it was likely Ms Evans had made a false allegation prompted by Mr Sgarbossa’s insistence that she leave the property.

3. After discussions between the police members and Ms Evans concerning where she might stay that night, it was settled that she would stay next door (at 2 Baw Baw Street) with Mr Wicklander.

4. Ms Evans slept that night at Mr Wicklander’s home and was awake by 6.30am the next day. She moved about the house and spoke with Mr Wicklander at various stages during the morning until 10.30am, at which time Mr Wicklander left the house for a short while and Ms Evans went back to bed. During the afternoon, until approximately 4.00pm, Mr Wicklander could hear Ms Evans snoring loudly from the bedroom.

5. At approximately 7.30pm, Mr Wicklander checked on Ms Evans and found her on the bed and unresponsive. He called 000 Emergency and commenced cardiopulmonary resuscitation (CPR) under instruction. CFA firefighters and Ambulance Victoria paramedics arrived at 7.46pm and they attempted to resuscitate Ms Evans without success until 8.40pm, at which time she was declared deceased.

6. An autopsy conducted on 14 January 2020 revealed, inter alia, that Ms Evans had lateral right side fractures to her 3rd, 4th and 5th ribs, a right-sided tension pneumothorax and a small laceration to the right medial lobe of the lung. Toxicology revealed a blood alcohol concentration of 0.17g/100mL and a blood concentration of baclofen1 at 15mg/L.

Sertraline2 was also detected at 0.1mg/L.

7. Mr Sgarbossa was interviewed by detectives on 15 and 16 January 2020 and gave substantial answers on both occasions. No charges were laid in connection with Ms Evans’ death.

CORONIAL INVESTIGATION AND INQUEST

8. Detective Senior Constable Vin Schalken of the Victoria Police Homicide Squad acted as the Coroner’s Investigator for the investigation of Ms Evans’ death and compiled a brief of evidence. The coronial brief included statements and materials from:

(a) Mark Sgarbossa and David Wicklander; 1 Baclofen is a muscle relaxant but is used as an off-label treatment for alcohol use disorder.

2 An anti-depressant.

(b) Senior Constable Craig Backman3 and Constable Bryce Collings – the police members attending on 7 January 2020;

(c) Paramedics, firefighters and police members attending on 8 January 2020;

(d) Detectives involved in the subsequent investigation;

(e) Ms Evans’ sister, Amanda Bass, and daughter, Kelsey Dunn;

(f) Mr Sgarbossa’s former wife;

(g) Dr Heinrich Bouwer – Forensic Pathologist;

(h) Dr Linda Iles – Forensic Pathologist / Neuropathologist; and

(i) Dr Grace Wang – Toxicologist.

9. Also included4 in the coronial brief were:

(a) Transcripts of calls to 000 Emergency on 7 and 8 January 2020;

(b) CCTV recordings from a retail liquor outlet in Moe showing Ms Evans shortly after 9.00pm on 7 January 2020;

(c) A series of text messages between Ms Evans and Mr Sgarbossa on 8 January 2020;

(d) Transcripts of records of interview conducted with Mr Sgarbossa on 15 and 16 January 2020;

(e) Medical records pertaining to Ms Evans;

(f) Victoria Police policies and procedures relating to response to family violence incidents and use of Body Worn Cameras (BWC); and

(g) Victoria Police Professional Standards Command interim oversight report.

10. I took over carriage of this investigation in October 2022 and, after a directions hearing on 9 November 2023, the scope of the inquest was set as follows:

1. The cause(s) of the rib fractures sustained by Suzanne Evans.

3 Now resigned from Victoria Police. Ranks of police members are referred to as they were at the time of the events and may be omitted from time to time for ease of narrative.

4 Not an exhaustive index to the coronial brief.

2. The conduct of Victoria Police in responding to the report of a family violence incident between Mark Sgarbossa and Suzanne Evans on 7 January 2020, including: a. The risk assessment conducted in relation to Suzanne Evans’ report of family violence b. The assessment of Suzanne Evans’ mental and physical health, including assessment of her self-reported injuries c. Suzanne Evans’ relocation to David Wicklander’s residence d. The non-activation of Constable Collings’ body worn camera during police attendance at Mark Sgarbossa’s residence e. Applicable Victoria Police policies, procedures and practices and any relevant changes since January 2020.

3. The circumstances of Suzanne Evans’ ingestion of drugs on 7 and/or 8 January 2020.

4. The inquest was conducted over two days on 4 and 5 March 2024. The following witnesses were called:

(a) Dr Heinrich Bouwer – Forensic Pathologist, Victorian Institute of Forensic Medicine;

(b) Mark Sgarbossa;

(c) David Wicklander;

(d) Senior Constable (SC) Craig Backman;

(e) Constable Bryce Collings; and

(f) Detective Senior Constable (DSC) Vin Schalken.

FINDINGS I find, under section 67(1) (c) of the Coroners Act 2008 (‘the Act’) that the death occurred in the following circumstances: Background Ms Evans’ personal background, medical and mental health history

12. Ms Evans was the second of three siblings, having an older sister and a younger brother.

She grew up in the Gippsland region of Victoria and her father was a firefighter with the RAAF. Her parents divorced when she was approximately 10 years old (1979).

13. In 1991, Ms Evans had a daughter, Kelsy Dunn, and she moved to Albury, NSW.

14. In the late 1990s, Ms Evans married her new partner and had twin boys in 1998. She divorced in or about 2002 and returned to the Gippsland region. She then worked for multiple employers in various reception and office administration roles.

15. Ms Evans had a history of depression, self-harming behaviour and alcohol abuse.

16. In October 2019, Ms Evans was treated at the Emergency Department of the Royal Adelaide Hospital after she became agitated and expressed suicidal ideations while trying to board a commercial flight to Victoria. She was admitted to the short stay ward and underwent a mental health assessment.5 During this episode, Ms Evans reported that she had been sexually assaulted by a truck driver while accompanying him on a trip from Perth to Adelaide.

17. The alleged sexual assault was reported to police in South Australia, but Ms Evans is recorded as not wishing to pursue the matter any further at that time. She cited reasons that 5 Exhibit 19; CB341 to 344

her mental health was more important, and she wanted to return to Victoria. There was no other evidence available to police investigators and no suspect was ever identified.

18. On her return to Victoria in October 2019, Ms Evans was assessed at a medical centre in Traralgon and it was concluded she was suffering severe depression, anxiety and stress.6

19. On 7 October 2019, Ms Evans was arrested pursuant to s.351 of the Mental Health Act 2014 after contacting the Melton Police Station and stating that she wanted to end her own life. She was assessed at Sunshine Hospital as undergoing an acute situational crisis but also diagnosed as suffering borderline personality disorder and alcohol dependence syndrome.

20. On 9 October 2019, Ms Evans was again arrested pursuant to s.351 of the Mental Health Act 2014 after taking an intentional overdose of prescription medication.

21. In addition to these two episodes, there were a further eight instances between 2014 and 2019 when police took Ms Evans into custody for assessment under the Mental Health Act

22. Characteristically, these episodes involved excessive alcohol consumption and threats or acts of self-harm.

23. Ms Evans’ daughter, Kelsey Dunn, described her mother’s alcoholism and her behaviour when intoxicated: It all got slowly worse. Until about 2017 or 2018, she was never physical, just verbal. She was mean, she was aggressive, she would get in your face and yell and scream … When it started to get physical, she would throw things, bang things, she threw knives at me. Once she was laying on the floor kicking the wall, a large portion of the wall had to be replaced. …7 6 DASS 21 (Depression Anxiety and Stress Scale 21) test conducted 20/10/2019 – Exhibit 19;

CB449 7 Statement of Kelsey Dunn – Exhibit 19; CB158

When mum got drunk, physically she could walk fine, walk straight, but she was slow. Mentally she would lag. When she got up drunk, if she was still half asleep, she would stumble a little bit, holding onto the wall. She did fall over a few times, you would always know though because she bruised easily … For those last few years we lived together, it was daily that she was drunk. There was an occasional sober day, but most days she was drinking. I would get up to make a coffee, she would get up at the same time and pour a wine. …8

23. Ms Evans’ sister, Amanda Bass, described these characteristics as follows: She’s always drunk dry white wine as her drink of choice. She also enjoyed vodka lime and soda. When she drank vodka, her personality was very different. She was always seemed [sic] to be fine and handle it better. When she drunk wine, there was something that would make her personality change. She knew it too, but she just enjoyed the wine more.

When Suze drunk wine, she became argumentative, violent, as in throwing things, I don’t think she ever hit anyone. She was nasty. She lost a lot of friends because of it. She was paranoid, there was no way you could reason with her. You didn’t know what she was going to do. She would drink until she passes out.9

24. At the time of her death, Ms Evans was prescribed Baclofen10, Campral EC11, Prazosin12, Propranolol Hydrochloride13 and Sertraline14 by her general practitioner.15 8 Statement of Kelsey Dunn – Exhibit 19; CB159 9 Statement of Amanda Bass – Exhibit 19; CB166 10 For alcohol dependence – 1 x 25mg tablet twice daily.

11 For alcohol dependence – 3 x 333mg tablets twice daily.

12 For post-traumatic stress disorder – 2 x 1mg tablets at night.

13 Anti-anxiety (as an “off label” use) – 1 x 10mg tablet three times daily.

14 Anti-depressant – 1 x 100mg tablet daily (morning).

15 High Street Medical Centre, Bunyip – Exhibit 19; CB461

The relationship between Ms Evans and Mr Sgarbossa

25. Suzanne Evans met Mark Sgarbossa on 5 November 2019 after they made contact through an online dating application.16 In early December 2019 she moved in with Mr Sgarbossa at his home in Moe.17 Amanda Bass provided some insight into their relationship: Suze never said anything negative about Mark. She always said he was lovely to her. She said she was happy with him and he was a really nice man. When I was with Suze and Mark, they always seemed good. The only thing she said was that she got frustrated because Mark was on work cover and spent a lot of time sleeping and wouldn’t do much. Mark said to me though that he was always tired because Suze was up all night. He was sleeping on the couch because of her drinking and getting up during the night.

Mark was an ex-alcoholic and had got Suze in touch with a Doctor in Bunyip…18

26. Mr Sgarbossa stated that Ms Evans continued to drink heavily between Christmas 2019 and 7 January 2020. On the night of 5 to 6 January 2020, he slept on the couch because of arguments between him and Ms Evans over her drinking.19 He also stated that he had been sleeping on the couch for most of the time in the two weeks preceding 7 January 2020.20 7 January 2020 Confrontation between Ms Evans and Mr Sgarbossa

27. Mr Sgarbossa detailed the confrontation between himself and Ms Evans in his first written statement made on 8 January 2020. He stated that at approximately 7.00pm or 8.00pm that evening she was drunk and he had a “dummy spit” at her and said he was going to bed. He denied any assault.21 16 Second statement of Mark Sgarbosa – Exhibit 8; CB131 17 Second statement of Mark Sgarbosa – Exhibit 8; CB132 18 Statement of Amanda Bass – CB174 19 Second statement of Mark Sgarbossa – Exhibit 8; CB134 20 First statement of Mark Sgarbossa – Exhibit 7; CB119 21 First statement of Mark Sgarbossa – Exhibit 7; CB119

28. In evidence, Mr Sgarbossa recalled that the argument started at 5.00pm or 6.00pm that afternoon.22

29. At 8.06pm, Ms Evans called 000 Emergency.23 When asked what was happening by the call taker, Ms Evans stated: He’s pushing me around, he’s thrown my handbag, he’s yelling … in my face.

He’s trying to kick me out. …and he’s being physically abusive.

30. The call taker then put the proposition, So he’s pushing, punching and kicking you is he? – to which Ms Evans replied, Yes.

31. Ms Evans stated that she did not need an ambulance and just wanted the police. She also provided further detail concerning the alleged assault, saying: Yeah, he wouldn’t give me my handbag back with my car keys … He threw them at my head … He threw them at my fucking head.

32. At 8.15pm, Mr Sgarbossa and Amanda Bass exchanged text messages: Amanda Bass – She told me she had been having a few more drinks again, but also said that she still wanted to get better. Is she off the rails again tonight?

Mark Sgarbossa – Yep called the cops and I’m waiting for them. She just turns nasty wtf24

33. Mr Sgarbossa stated that “nasty” included Ms Evans physically pushing him around.25 He admitted physical contact during their argument that afternoon and evening:

22 T037 23 Exhibits 10 and 10a 24 Exhibit 9

25 T038

I threw her handbag at her at one point, and just gave her a shove out of the way as I was trying to leave the house at one point … I gave her a push to get past her to get out the door to leave the house at one point in the afternoon.26

34. He also recalled throwing Ms Evans’ handbag in her direction whilst in the kitchen and, while not remembering whether the handbag had hit Ms Evans, he conceded the possibility that this may have occurred.27

35. Mr Wicklander recalled in his second statement that Ms Evans told him (during a conversation in his kitchen in the early hours of 8 January) that Mr Sgarbossa had got her on the ground and choked her.28 Mr Sgarbossa denied this.29 Attendance by police and response to Ms Evans’ allegations

36. At 8.09pm Senior Constable (SC) Craig Backman and Constable Bryce Collings (comprising the Moe divisional van crew – “Moe 303”) received the call to attend 4 Baw Baw Street, Moe and they arrived at 8.18pm.30

37. Ms Evans alleged to Backman that Mr Sgarbossa had kicked her and, when Backman asked where she had been kicked, Ms Evans did not reply verbally but “put both hands on her belly button and sort of scrapped [sic] outwards”. Ms Evans alleged that this kick had been inflicted while she was lying on her bed, but she could not describe how this had happened.31

38. Backman formed the view that Ms Evans was intoxicated, but not grossly. He went on to examine the inside of the house, including the bedroom, but could see no signs of disturbance. He then asked Ms Evans if she was claiming to have been assaulted because

26 T039 27 T040 28 Second statement of David Wicklander – Exhibit 13; CB145

29 T040 30 First statement of SC Backman – Exhibit 15; CB042 31 Second statement of SC Backman – Exhibit 16; CB048

Mr Sgarbossa had asked her to leave, and she had nowhere to go. At that, Ms Evans put her head down and said “yeah”.32 Backman interpreted this response as an admission that the allegation of having been kicked was false.33 I am satisfied that this was a reasonable interpretation.

39. Constable Collings was present for the conversation between Backman and Ms Evans, and he formed similar views. He also remained with Ms Evans while Backman examined the inside of the house.34 Backman recalled that Mr Sgarbossa was “fairly calm”, “very softly spoken” and “very cooperative” when spoken to.35

40. Ms Evans did not say anything to Backman or Collings to indicate that she had been choked by Mr Sgarbossa during the argument36 and I am satisfied that the only person to whom she voiced this allegation was Mr Wicklander, several hours later. Moreover, Backman did not see any marks or signs of injury to Ms Evans’ neck and she did not complain of pain or show any sign that she was in any pain.37 I note Dr Bouwer’s evidence that Ms Evans had some submucosal bruising to the pharyngeal soft tissue which was seen at autopsy, and this may indicate a choking injury. Dr Bouwer also explained that the submucosal bruising was not contributory to death and the strap muscles at the front of the throat showed no sign of injury.38

41. I am satisfied that Ms Evans had an opportunity to tell either Backman or Collings about the alleged choking but did not do so. I make no finding in respect of the allegation itself.

32 Second statement of SC Backman – Exhibit 16; CB048

33 T098 34 Statement of C/ Collings – Exhibit 17; CB052-053

35 T090 36 T097 37 T098 38 T026

Presence of any injury to Ms Evans

42. A key question is whether Ms Evans was suffering from any injury following the argument with Mr Sgarbossa and before she entered Mr Wicklander’s house prior to 9.00pm.

Particularly, whether the fractures to her right lateral ribs39, seen at autopsy, may have been present at that time. I note and accept that neither Backman nor Collings observed any sign of injury or any behaviour by Ms Evans that might indicate she was suffering pain or injury.

43. Mr Wicklander stated that he gave Ms Evans a hug shortly after she came into his house.40 He recalled during his oral evidence that she had put her arms around his chest, and he had responded by placing his arms over the top of her arms and around her shoulders.41 There was no indication from Ms Evans of any pain or discomfort during this interaction.42

44. Constable Collings accompanied Ms Evans to Mr Wicklander’s house and saw the pair hug each other. He estimated that they were approximately 5 metres away from him at that moment and he also did not see anything to indicate that Ms Evans was experiencing pain or discomfort during the interaction.43

45. Shortly after 9.00pm Ms Evans is recorded on CCTV entering and then leaving a retail liquor outlet in Moe. She can be seen entering the store carrying her handbag on her right shoulder and exiting with two bottles of wine under her right arm.44 Ms Evans does not appear to be suffering from any pain or restriction of movement at either time.

39 The fractures were to the 3rd, 4th and 5th right lateral ribs.

40 Second statement of David Wicklander – Exhibit 13; CB 144

41 T082 42 T075 43 T135 44 Exhibit 6

46. Lastly, Mr Wicklander stated that he sat up talking with Ms Evans until 2.30am on 8 January.45 He did not observe her to be suffering from any shortness of breath or abdominal or chest pain.46

47. I accept the evidence of Mr Wicklander and Constable Collings. Furthermore, I consider that the CCTV recording of Ms Evans is very significant and negatives any suggestion that she may have had broken ribs at that time. The evidence of Dr Bouwer is also significant in this regard – he explained that rib fractures of this type are inherently very painful.47

48. I find that Ms Evans was not suffering any significant injury before she went to bed at Mr Wicklander’s house at approximately 2.30am on 8 January, and certainly not the three right-sided lateral rib fractures seen at autopsy.

Use of BWC

49. The evidence of events on the evening of 7 January was constrained by the absence of police body worn camera recordings of the police interactions with Ms Evans and Mr Sgarbossa.

50. SC Backman explained that he had not yet been issued with a BWC.48 Constable Collings gave evidence that he had first been issued with a BWC approximately one month prior to these events. He understood that it should have been activated for an interaction such as this, but he had not yet achieved a level of familiarity with the equipment, and he had simply forgotten to activate it.49

51. I accept the evidence of Collings and Backman and I make no criticism of Collings for failing to activate his device. I am satisfied that the deployment of BWCs to operational 45 First statement of David Wicklander – Exhibit 12; CB 136 & T067

46 T069 47 T022 48 T101 49 T138-139

police members was in its early stages and Collings was not yet habituated to the use of the equipment.

52. It is difficult to overstate the value of BWC recordings. In many coronial investigations and inquests since their introduction, these recordings have facilitated a level of understanding of events that was frequently unachievable beforehand. Witnesses (and particularly police witnesses) who are assisted by BWC recordings do not need to paint physical scenes and movement for the first time in the witness box, all the while encumbered by the limitations of expression and fallible memory. Instead, a greater focus may be brought upon subjective aspects of a case, such as a witness describing their thinking or perceptions at a particular moment.

Arrangement for temporary accommodation

53. Following Ms Evans’ death Victoria Police conducted a Family Violence-Related Death Assessment which resulted in a report dated 9 October 2020.50 This report was critical of Collings and Backman for the decision to use Mr Wicklander’s neighbouring premises as alternative accommodation, which was said to be insufficient when resolving the conflict.

I do not share this criticism.

54. The only interaction between Mr Sgarbossa and Ms Evans after the police attended on 7 January was the text message from Ms Evans at 6.54am on 8 January wherein she asked him to leave her medication in the mailbox. Mr Sgarbossa replied that he had left it in the driveway.51 There is no evidence of any other interaction.

55. I accept the evidence of Collings and Backman that Ms Evans appeared to resile from her allegations of assault, and she bore no signs of injury or pain. Also, there was nothing at the scene to suggest a disturbance or assault.

50 Exhibit 19; CB 513 (finding at CB544) 51 Exhibit 11

56. Mr Wicklander was an obliging neighbour who was willing to take Ms Evans in as a guest and she elected to accept this offer. The police members had no power to compel Ms Evans to accept another accommodation option and their decision to permit this arrangement was reasonable. At Mr Wicklander’s house, Ms Evans was in an environment where she was made comfortable and offered support. Moreover, the fact that Ms Evans was at Mr Wicklander’s house the next day does not lie at the root of her actions during the day or the fatal events.

8 January 2020

57. Ms Evans stayed at Mr Wicklander’s house overnight from 7 to 8 January. The pair stayed up talking until approximately 2.30am, during which time Ms Evans consumed a bottle of wine and Mr Wicklander described her as crying and emotional.52

58. Ms Evans went to bed in Mr Wicklander’s bedroom while he slept in the in the loungeroom.53 Mr Wicklander woke at 6.30am and went to the kitchen where he was met by Ms Evans, and they drank coffee together. Ms Evans moved about the house and spoke with Mr Wicklander at various stages during the morning and was drinking a glass of wine at 7.30 or 8.30am.54

59. At 10.30am, Mr Wicklander left the house for a short while and Ms Evans went back to bed. During the afternoon, until approximately 4.00pm, Mr Wicklander could hear Ms Evans snoring loudly from the bedroom and, from outside the open bedroom door, he could see her laying with her head on the pillow and her face towards the door.55

60. At approximately 4.00pm, Mr Wicklander went to a local supermarket in Moe to buy ingredients for dinner. On his return he did some housework and watched television. At

52 T068 53 Second statement of David Wicklander – Exhibit 13; CB 145 54 Second statement of David Wicklander – Exhibit 13; CB 146 55 Second statement of David Wicklander – Exhibit 13; CB 147

6.00pm, he took some rubbish to his recycling bin, which included two empty bottles from the wine that had been purchased by Ms Evans the previous evening.

61. At 7.30pm, Mr Wicklander was preparing dinner, and the meal was almost ready. He went to check on Ms Evans and walked into the bedroom. He saw a glass on the floor containing what appeared to be white tablet residue. He tried to wake her, but she was unresponsive, and he quickly realised it was an emergency. He called 000 and received instructions over the telephone to perform CPR.

62. Ms Evans was initially lying face down on the bed and Mr Wicklander lifted her to the floor as instructed. He did so with one arm behind Ms Evans’ knees and the other arm under her back but, in doing so, Ms Evans’ head hit the floor. Mr Wicklander described this as “her head bumped onto the carpet”. He also stated, “I was trying to move Suzanne quickly off the bed but there wasn’t any loud bang when Suzanne’s head hit the floor.”56

63. I accept the evidence of Mr Wicklander who impressed as a conscientious witness. I am satisfied that Ms Evans’ activities about the house that day, so far as they may be known, are as described by Mr Wicklander.

64. I am also satisfied that the impact of Ms Evans’ head with the bedroom floor is not significant and is not associated with any of the injuries found at autopsy.

Medical cause of death

65. On 14 January 2020, Dr Heinrich Bouwer forensic pathologist at the Victorian Institute of Forensic Medicine conducted an autopsy on the body of Ms Evans. Dr Bouwer produced a report of his findings dated 19 June 2020.57 56 Second statement of David Wicklander – Exhibit 13; CB 148 57 Exhibit 1

66. The post-mortem CT58 scan and autopsy revealed a right-sided tension pneumothorax and acute fractures to the right lateral third to fifth ribs. There was no evidence of callus formation, which indicated that the fractures were recent. There was a small laceration to the right medial lobe (right lung) which was the likely cause of the tension pneumothorax.

67. Post-mortem toxicological analysis detected a blood and vitreous alcohol concentration at 0.17% and 0.21% respectively, together with an elevated level of baclofen, and a small amount of sertraline. The level of baclofen detected was consistent with excessive and potentially fatal use and, in combination with alcohol, may cause significant central nervous system and respiratory system depression that could lead to death even in the absence of other contributing factors.

68. Dr Bouwer explained that the tension pneumothorax would make breathing more difficult and, in combination with elevated levels of baclofen and alcohol, may further potentiate the respiratory depressant effects. The compromised respiratory system could lead to death.

69. Neuropathological examination did not reveal any evidence to suggest that a significant head injury may have caused or contributed to the death.59

70. There was no evidence of trauma to the strap muscles with intact larynx and hyoid bone, however there was some submucosal bruising to the pharyngeal soft tissue. Some blood was noted in the trachea and bronchi which appeared to have come from the right bronchus due to the collapsed right lung and a small amount of blood-stained fluid was noted in the stomach.

71. There was no significant natural disease that may have caused or contributed to Ms Evans’ death.

58 Computed Tomography 59 Exhibit 2 – Neuropathology Report by Dr Linda Iles, dated 19/05/2020

72. In oral evidence, Dr Bouwer explained that the tension pneumothorax was caused by the lateral rib fracture(s) lacerating the lung, and that the condition was a medical emergency which, without treatment, is almost always fatal unless urgent care is provided.60 Cause of the rib fractures and pneumothorax

73. In addition to the fractures of the right lateral third to fifth ribs, the post-mortem CT scan and autopsy revealed multiple bilateral anterior rib fractures. Dr Bouwer explained that fractures of this type are often seen in the setting of chest compressions performed during CPR, and it was his opinion that the fractures were caused in that setting.61 I accept Dr Bouwer’s opinion.

74. The precise mechanical cause of the fractures of the right lateral third to fifth ribs is unknown save to say that the fractures were caused by blunt force trauma. There is no evidence that any other person was involved in the infliction of these injuries, and I am satisfied that Ms Evans suffered the lateral rib fractures at some moment on 8 January, in the absence of Mr Wicklander.

75. The most likely mechanism for the blunt force trauma is that Ms Evans fell onto a hard object (for example, a piece of furniture) and struck the right side of her chest. In this regard I note that Mr Sgarbossa had previously found Ms Evans unconscious on the floor and that she was prone to falls when intoxicated.62 I also note the evidence of Kelsey Dunn concerning her mother’s physical behaviour when intoxicated, including her risk of falls.63

60 T021 61 T022 62 T057 63 Paragraph 22 herein

Baclofen overdose

76. At some stage during the morning of 8 January, Ms Evans collected various belongings which had been left for her in Mr Sgarbossa’s driveway.64 These items included her medication and, notably, her baclofen.

77. The Coroner’s Investigator, Detective SC Schalken explained that an examination of Ms Evans’ mobile phone revealed internet searches at 10.12am, 10.33am and 10.34am on 8 January with the following search terms: “Baclofen toxicity”, “Baclofen overdose”, and “An unusual presentation of Baclofen overdose.”65 I am satisfied that Ms Evans conducted these searches.

78. Detectives attending the scene at Mr Wicklander’s house found (among other medications) a glass with tablet residue on a bedside table and a baclofen tablet bottle containing two tablets.66

79. Having regard to the high blood concentration of baclofen found during post-mortem toxicology and the internet searches conducted by Ms Evans during the morning, I am satisfied that she intentionally took an overdose of the drug.

Conclusion

80. There is no presumption for or against a finding that a person acted with the intention of taking their own life. However, a finding of suicide should only be made when there is clear and cogent evidence to conclude that fatal acts were carried out with such an intention.

81. Although I am satisfied that Ms Evans intended to take an overdose of baclofen, there is insufficient evidence upon which to conclude that her intention was to end her own life.

64 T049 65 T146; Exhibit 19; CB 486 66 Statement of Detective SC MacInnes – Exhibit 19; CB064

82. Over the course of 8 January 2020 at Mr Wicklander’s premises, Ms Evans was significantly intoxicated by alcohol. In combination with the alcohol, Ms Evans consumed baclofen in excess. It is most likely that she suffered impaired coordination because of her state of intoxication. I am satisfied that Ms Evans most likely fell and struck the right side of her chest, causing the lateral rib fractures and the consequent pneumothorax. I am further satisfied that the event leading to this injury most likely occurred in the absence of Mr Wicklander, at 2 Baw Baw Street, Moe.

I express my sincere condolences to Ms Evans’ family for their loss.

I thank the Coroner’s Investigator and those assisting for their work in the investigation.

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

I direct that a copy of this finding be provided to the following: Kelsey Dunn, Senior Next of Kin Chief Commissioner of Police Signature: ______________________________________ Coroner Paul Lawrie

Date: 07 October 2024 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.