IN THE CORONERS COURT COR 2022 004478 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 COLLEEN MARY SOUTH Findings of: Coroner David Ryan Delivered on: 15 March 2024 Delivered at: Coroners Court of Victoria 65 Kavanagh Street, Southbank, Victoria Inquest hearing dates: 12 November 2023 Counsel Assisting the Coroner: Susanna Locke of counsel Chief Commissioner of Police: Amanda Dickens of counsel instructed by the Victorian Government Solicitor’s Office Keywords: Missing person – police search – transfer of interstate investigation – police dogs
TABLE OF CONTENTS
INTRODUCTION
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On 8 August 2022, Colleen Mary South was found deceased under a tree on a remote rural property in Bunguluke, Victoria. She was 58 years old and resided in South Australia. She is survived by her daughter, Veronica South, and her siblings Keith and Joe South, Heather Creed and Nicole South-McDade.
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In a Family Impact Statement delivered to the Court by Veronica, Ms South is warmly remembered as a loving and caring person who is greatly missed.
BACKGROUND
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Ms South’s medical history included epilepsy, obstructive sleep apnoea, insomnia and Type 2 diabetes. Her mental health history included depression and anxiety, bipolar disorder and schizoaffective disorder, for which she was the subject of several Inpatient and Community Treatment Orders from 2011 and which increased in regularity from
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Ms South was prescribed aripiprazole and sodium valproate but had a history of non-compliance with her medication regime.
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Ms South had been reported missing to South Australia Police on nine previous occasions.
Sometimes she would discard her phone, leave her car and wander through other people’s properties. On the last occasion, in March 2021, Ms South’s car was located on a rural property in South Australia and she was found in a dehydrated state by the owner after having walked aimlessly all night. She stated that she had “needed to escape from reality”.1 Veronica told police that her mother had previously slept on other people’s properties, sometimes near her car or she would walk around and find a tree under which to sleep.
- Heather recalled that on a previous occasion when her sister experienced a mental health episode, she travelled to a rural area and walked on foot around 20 kilometres “over fences” and through a forest during the night before being found by a farmer.
1 CB584.
CORONIAL INVESTIGATION
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Ms South’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.
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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.
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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.
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Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Ms South’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.
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A mention hearing was held in the Coroners Court on 22 May 2023 to discuss the scope and progress of the investigation. The following scope was identified at the hearing:
(a) The quality of the search conducted for Ms South;
(b) Relevant Victoria police policies and procedures;
(c) Best practice; and
(d) Opportunities for improvement identified from the search for Ms South.
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At the mention hearing, I also requested that Victoria Police provide evidence in relation to the search carried out for Ms South after she was reported missing, including whether it complied with relevant policies and procedures. Statements were subsequently provided by Victoria Police in October 2023. Correspondence was also received from Ms South’s family in which they raised various concerns about the search conducted by Victoria Police.
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The holding of an inquest into Ms South’s death was not mandatory under the Act.
However, in the circumstances I determined that it was appropriate to hold an inquest in the exercise of my discretion under section 52(1) of the Act. The inquest was held on 12 March 2024.
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At the hearing, a summary of the evidence was provided to the Court by Counsel Assisting. The individual witnesses who provided statements in the brief were not required to give evidence at the inquest as, after carefully considering all of the material in the brief, I was satisfied that there were no significant factual disputes or controversies which remained unresolved in order for me to make the findings required under section 67 of the Act. The Chief Commissioner of Police, the only interested party, was given an opportunity to make submissions.
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This finding draws on the totality of the coronial investigation into the death of Mr South including evidence contained in the coronial brief, the submissions made by Counsel Assisting and the Chief Commissioner and the correspondence received from Ms South’s family. 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.2 2 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.
CIRCUMSTANCES IN WHICH DEATH OCCURRED
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In late June 2022, Ms South was in the process of moving from her address in Renown Park to Queenstown, South Australia. Veronica noticed that her mother “was getting mentally sick before the move” and was “very stressed”.
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Veronica last saw her mother on 29 June 2022 at Veronica’s house. She recalled that her mother was “incoherent” and acting strangely which “was not normal behaviour for my mum, however she had acted like this in the past when she had gone off her medication”.
Ms South left the house at around 11.30am. Veronica spoke with her mother on the telephone the following day and they discussed her move to the new address in Queenstown.3
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On 1 July 2022, Ms South hired a truck to move her belongings to the new address in Queenstown and was assisted by three friends. She told one of them that she had lost her phone. During the course of moving her belongings into the new address at Queenstown, she had an argument with one of these friends. Later in the afternoon she drove the truck back to the address in Renown Park where she told the incoming resident that she would return later to collect the rest of her belongings.
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On 2 July 2022 at 11.20am, Ms South was recorded on CCTV driving her vehicle (a silver Hyundai sedan) out of the truck hire rental car park in Klemzig. The truck Ms South had hired was located a few days later in Eastwood with a flat tyre. She was later recorded on CCTV shopping in St Agnes at around 11.40am.4
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On Sunday 3 July 2022 at about 12.15pm, Ms South was seen in Victoria – at Sunraysia Petroleum Petrol Station in Berriwillock. She is recorded on CCTV as wearing a pink jacket.5 She was assisted by a passer-by to purchase petrol. Ms South then continued driving south on the Calder Highway.
3 CB56; CB61.
4 CB411; CB413.
5 Exhibit 7.
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At 2.00pm, Ms South was seen driving her vehicle in Towaninny. At 3.30pm, her vehicle was seen in Ninyeunook.
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At 4.00pm, Jim Coffey observed Ms South’s car abandoned at Bunguluke Wildlife Reserve, which is approximately 15 kilometres east of Wycheproof. The reserve is opposite Mr Coffey’s farm at the intersection of Charlton-Swan Hill Road and Mackies Road in Bunguluke. The following morning Mr Coffey called Victoria Police at Charlton and left a message regarding the abandoned vehicle.6
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On 4 July 2022, Veronica reported her mother missing to South Australia Police after a friend of her mother’s sent her a text message to say that they had not heard from Ms South for a while and that she was not responding to text messages. This triggered an investigation by South Australia Police and subsequent liaison with Victoria Police.
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On 5 July 2022, Mr Coffey went back out to the vehicle with a friend and observed that it had been involved in a collision with a culvert and that the airbags had been deployed.
They also noted some bags under a tree about 20 metres south of the vehicle, including a handbag containing a wallet. They returned to Wycheproof and one of their colleagues sent a text message to Senior Constable Darin Sheahan at Wycheproof Police Station about the vehicle. S/C Sheahan read the message at around 2.30pm which then triggered an investigation and search by Victoria Police. The search escalated and continued over the following weeks and involved the deployment of significant police resources, including at various times personnel from the Search and Rescue Squad (SARS), Mounted Police, the Dog Squad, the Air Wing, motorbikes and drones and also the State Emergency Service (SES).
- Information from the Bureau of Meteorology indicates that the overnight temperatures in Charlton between 3 and 6 July 2022 ranged from 3.8 degrees and -0.6 degrees.7 6 Charlton Police Station was not manned at the time; CB893.
7 CB652.
- On 8 August 2022, Ms South was located deceased by Bruce Moon under a large tree on his farming property in Bunguluke, about 1.5 kilometres south of where her vehicle had been left abandoned. Mr Moon had been operating a tractor and spraying herbicide on a crop in an open paddock which was sparsely populated by a number of large individual trees. Ms South was not wearing her pink jacket or shoes at the time her body was found.
IDENTITY OF THE DECEASED
- On 18 August 2022, Colleen Mary South was identified via DNA comparison.
27. Identity is not in dispute and requires no further investigation.
MEDICAL CAUSE OF DEATH
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On 12 August 2022, Dr Paul Bedford, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM) performed an autopsy and prepared a report of his findings dated 7 October 2022. Dr Bedford stated that findings were made difficult by the presence of decomposition.
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Dr Bedford reviewed a computed tomography (CT) scan which revealed a fracture of the 11th rib which he considered was unlikely to be a major determinant in her death. No other skeletal injuries were identified and there was no cerebral haemorrhage.
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Toxicological analysis of post-mortem samples did not detect the presence of any drugs or poisons which could have contributed to death.
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No internal pathology likely to lead to death was found at autopsy and no clear cause of death could be identified.
32. Dr Bedford formulated the cause of death as “1(a) Unascertained”.
33. I accept Dr Bedford’s opinion.
THE SEARCH CONDUCTED BY VICTORIA POLICE
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The investigation and search for Ms South which was conducted by South Australia Police and Victoria Police involved a significant deployment of resources in the weeks following the discovery of her vehicle. It involved the follow-up of many information reports from family and the community which were not ultimately relevant but nevertheless required investigation. I will only outline the steps taken in the search which were relevant to the discovery of Ms South and which are necessary in order to sufficiently describe the circumstances of her death as required by section 67 of the Act.
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Senior Sergeant Gregory Paul of SARS stated that: “The primary aim for any search and rescue operation is to save life. A key consideration for decisions about where and how to utilise search assets (search coordination) is to maximise the probability of saving life. Important yet subordinate aims for a search and rescue operation is to find remains of a deceased person/s, and to also determine the cause of death.
It is rare to be able to thoroughly search all possible and probable locations where a missing person could be located.”8
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At around 3.30pm on 5 July 2022, after being notified of the abandoned vehicle at Bunguluke Reserve, S/C Sheahan attended the scene and took photographs. He checked the vehicle registration and noted that it was registered to Ms South and she had been reported as a Missing Person in South Australia. S/C Sheahan observed three bags belonging to Ms South, including her handbag, in a neat pile approximately 20 metres to the south of her car. He also located a number of medications in one of Ms South’s bags including aripiprazole, sodium valproate and a Ventolin inhaler.
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S/C Sheahan stated that: “I was immediately concerned as the information I had obtained was that the vehicle had been at the location for the past two nights, and the overnight
8 CB915.
temperature had fallen to almost zero degrees, and the expected overnight temperature that night was expected to be minus 2 degrees. I was fearful that if [Ms] South had abandoned the vehicle there on Sunday 3rd of July, she had already spent two nights in the extremely low temperature, and that if she hadn’t already perished, she would not survive a third night out in such temperature.”9
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At around 4.00pm, S/C Sheahan contacted Sergeant Matthew Wade at the Swan Hill Police Station in order to seek approval from the Divisional Response Supervisor10 for the deployment of additional resources in the search for Ms South. He requested the services of the Dog Squad, the Air Wing and other police units.
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The Divisional Response Supervisor requested Sgt Wade to contact South Australia Police and ascertain the circumstances in which Ms South went missing before further resources were requested. In the meantime, S/C Sheahan was directed to search the immediate area and keep Sgt Wade informed of any updates.11
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S/C Sheahan was assisted by Senior Constable Deon Marks from Birchip Police Station to search dams and farm sheds in the vicinity where Ms South’s car was located. He also attempted unsuccessfully to contact Ms South on her mobile telephone.
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Sgt Wade contacted Senior Constable Robyn Ferraro from South Australia Police who provided information in relation to the circumstances in which Ms South was reported missing.
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At around 7.15pm, after gathering as much information as he could about Ms South, Sgt Wade again discussed the situation with the Divisional Response Supervisor. The search was temporarily scaled back as it was concluded that Ms South’s vehicle had been at Bunguluke Reserve for at least 48 hours, it was dark, there were no witnesses to canvass and Ms South’s previous history of wandering significantly broadened the search parameters. Further, a police unit from Swan Hill could not be deployed at that stage to
9 CB127.
10 A statement was not able to be obtained from the Divisional Response Supervisor as he is unwell.
11 CB924-CB925.
assist as it was required to provide cover in response to the management of a violent prisoner in custody.
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S/C Sheahan locked Ms South’s vehicle as directed by Sgt Wade and he and S/C Marks ceased their search efforts at around 6.45pm as darkness had fallen.
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On 6 July 2022, the Senior Sergeant Brad Bennett of Victoria Police was appointed the Forward Commander for the search but South Australia Police maintained primacy of the investigation. He attended Wycheproof Police Station which was established as the Forward Command Post. Assistance from SARS, the Dog Squad and Air Wing were requested but not provided at that stage, reportedly due to the “passage of time since the vehicle was initially located”.12 However, initial advice in relation the conduct of the search was provided by SARS over the phone.13 Grid searches of the immediate area were conducted with six members on the ground together with a drone search. South Australia Police triangulated Ms South’s phone but it had been switched off for more than six days.
The vehicle was examined and noted to have a significant amount of fuel left in the tank and it was still capable of being driven.
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The search continued on 7 July 2022 and S/Sgt Bennett maintained liaison with South Australia Police in relation to their inquiries. Further, S/Sgt Bennett contacted Ms South’s family and updated them in relation to the search.
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On 8 July 2022, members of SARS attended Wycheproof to provide oversight and tactical advice in relation to the search. Significant resources were deployed including the Dog Squad, the Air Wing, the Mounted Branch and SES volunteers.14 S/Sgt Bennett advised S/Sgt Paul that the 300-metre radius around Ms South’s vehicle had already been thoroughly searched and that police were in the process of visiting all dwellings and buildings and potential shelters within a 10-kilometre radius.
12 CB213; CB912.
13 CB910.
14 CB916-CB917.
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On 8 July 2022, Keith and Heather attended Swan Hill Police Station and received an update in relation to the search for their sister.
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Dr Paul Luckin, medical advisor to the Australian Maritime Safety Authority, provided an opinion that if Ms South had been “in the open” since 3 July 2022, noting the very low overnight temperatures, she would no longer be alive on 8 July 2022.15
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On 9 July 2022, Keith and Heather attended Wycheproof Police Station and received an update in relation to the search for their sister from Inspector Gerard De Vries.
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On 9 July 2022, the search for Ms South continued with the same resources as had been deployed the previous day apart from the Dog squad and Air Wing.16 Despite an extensive search, Victoria Police were unable to locate any evidence that indicated the direction that Ms South had travelled after leaving her vehicle. The ground search was scaled back by the end of the day.17
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On 10 July 2022, the search was continued by local units and S/C Sheahan met with Veronica at Ms South’s car.
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On 15 July 2022, the primacy of the search for Ms South was transferred from South Australia Police to Victoria Police. On 16 July 2022, Detective Sergeant Jason Frost of Victoria Police was appointed as the primary investigator and received a handover from South Australia Police.
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On 20 July 2022, Ms South’s phone was located in South Australia.
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Between 19 and 22 July 2022, SARS again attended Wycheproof Police Station and provided assistance and tactical advice in relation to the continued search for Ms South.
Resources deployed included the Dog Squad, the Air Wing, the Mounted Branch and drones. Sergeant Mark Braun from SARS coordinated the allocation of search tasks and
15 CB124.
16 It was considered that the Dog Squad was no longer required as it was believed at this point that Ms South was likely to be deceased. Further, low cloud and fog prevented the airwing from operating on 9 July 2022.
17 CB956; CB860.
included a request to members to “cross fences and walk into open paddocks to look at trees and places a person might take shelter”.18
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On 8 August 2022, Mr Moon contacted emergency services after locating Ms South’s body under a tree in a paddock on his farm. Victoria Police attended the site and it was noted that the body was “not readily visible until very close to the outer branches of the tree”.19 They examined the scene and took photographs.
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It is clear from the footage of the location contained in the coronial brief that Ms South’s body would not have been visible from the air. Further, there is no evidence that the area in the vicinity of the tree in which Ms South’s body was located was searched on foot by Victoria Police.20
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On 20 August 2022, Ms South’s pink jacket was found by Victoria Police in the hollow of a tree approximately one kilometre west of where her vehicle was located. On 25 August 2022, Ms South’s boots were found in the adjacent paddock north of where she was found.
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At the conclusion of their investigation, Victoria Police found no evidence of suspicious circumstances.
Use of the Dog Squad
- Senior Constable Cail Tuckerman from the Dog Squad was deployed to search for Ms South with Police Dog Clyde on 8 and 20-21 July 2022. He considered that the time that had elapsed from the discovery of Ms South’s vehicle to their deployment would limit their effectiveness. When Senior Constable Tuckerman and PD Clyde arrived at the scene on 8 July 2022, Ms South’s vehicle had already been removed. Tracking, as opposed to searching for Ms South, was not considered possible and SC Tuckerman deployed PD Clyde for an “off-lead, open search”.21
18 CB177.
19 CB197.
20 Ex 17.
21 CB930.
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SC Tuckerman and PD Clyde’s search included the wooded area to the south of where Ms South’s vehicle was located and the paddock to the south-eastern side of Mackie Road. They did not search the paddock on the eastern side of Charlton-Swan Hill Road as a farmer was spraying chemicals on an emerging crop. They did not detect any trace of Ms South.
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SC Tuckerman and PD Clyde returned to Wycheproof on 19 July 2022. They were advised not to enter paddocks where there were crops as they were likely to have been chemically treated. The area searched by SC Tuckerman and PD Clyde included the area up to about 1 kilometre south of where Ms South’s possessions were located. They continued their search on 20 and 21 July 2022.
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SC Tuckerman noted that when a dog tracks a person, they follow their scent, which degrades over time. He expressed the opinion that “the deployment of more canine resources at an earlier stage could have increased the chance of locating [Ms] South earlier, but the ability to respond was restricted by when the vehicle was located and the subsequent notification”.22
OTHER INVESTIGATIONS
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Section 7 of the Act requires the coroner to liaise with other investigative authorities and to not unnecessarily duplicate inquiries and investigations
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Victoria Police conducted an Operational Safety Critical Incident Review (OSCIR) and prepared a report of its findings. The report concluded that the search and missing person investigation was structurally well planned and executed, although there were avoidable delays around the initial deployment of police resources and specialist support. It also recorded that police were advised to avoid searching in areas where farmers had been spraying herbicides on crops and noted that Ms South was eventually located within such a crop site.
22 CB943.
65. The following relevant findings were contained in the OSCIR report:
(a) The closure of Charlton Police Station on 4 July 2022 delayed the initial police search until 5 July 2022;
(b) The decision on 5 July 2022 not to request deployment of a Police Air Wing and assets with Forward Looking Infrared (FLIR) capabilities was a missed opportunity to buttress the initial search efforts by local police;
(c) A formal request should have been submitted on 6 July 2022 to SARS for the deployment of specialist resources;
(d) There is no Victoria Police Manual (VPM) – Police Airwing, Specialist Support Policy which represents a significant gap in policy;
(e) The current VPM – Search and Rescue, Specialist Support Policy and Internet descriptor are adequate and meet organisational requirements around missing persons;
(f) The delayed transfer of the investigation primacy between South Australia police and Victoria Police did not adversely impact the police investigation and/or search;
(g) The ANZPAA23 Policy for Missing Person Investigation 2020 – ‘proof of life’ definition requires review to enhance understanding and application by frontline police; and
(h) Victoria Police should have accepted investigation primacy soon after search efforts commenced in and around Wycheproof.
23 Australia New Zealand Policing Advisory Agency.
66. The OSCIR Report contained the following recommendations:
(a) A state-wide audit be conducted to ensure that all non-24-hour police stations when unoccupied, have active call forwarding facilities;
(b) A Police Air Wing Policy be implemented which includes processes for the deployment of assets in respect to missing persons;
(c) VPM - Missing Persons Investigations include a hyperlink to the ANZPAA Policy for Missing Persons Investigations 2020.
COMPLIANCE WITH TRAINING, POLICIES & PROCEDURES
- Detective Senior Sergeant Anthony Combridge is a specialist missing persons investigator and subject matter expert with the Missing Persons Squad of Victoria Police.
He reviewed the coronial brief and prepared a statement dated 6 October 2023.
68. D/S/Sgt Combridge stated as follows:
(a) “While there is no prescribed allocation of resources for the purposes of conducting a missing person investigation, it appears from my review of the Coronial Brief that appropriate specialist resources were requested and utilised throughout the search for Ms South, including the SARS, Dog Squad, MTB and Air Wing, as well as State Emergency Service volunteers. The search undertaken by general duties officers and specialist response units were also supplemented by members of the public who volunteered to assist. In my view , the resourcing of the search was appropriate and capable of meeting the search objectives.24
(b) Based on my review of the documents contained in the Coronial Brief, I consider that the rational and methodology adopted for the search for Ms South conducted by Victoria Police was generally conducted in accordance with guidance provided
24 CB1061.
in the [relevant] policy documents…and to a standard expected of Victoria police members.”25
- In terms of improvement opportunities, D/S/Sgt Combridge considered that primacy of the investigation in respect of Ms South ought to have been transferred from South Australia Police to Victoria Police on 5 July 2022 when Ms South’s vehicle was located and it became clear that she was likely lost in that area. However, D/S/Sgt Combridge expressed the view that the earlier transfer of investigative primacy to Victoria Police would not have made any material difference for the investigation itself.
This is because Victoria Police had primacy of the response to the management of Ms South being reported missing, which included all operational efforts to search for, locate and rescue or recover her.
- Acting Superintendent Daniel Baynes of the Specialist Response Division (which includes the Dog Squad) reviewed the coronial brief and prepared a statement dated 6 October 2023. He stated that:
(a) The Dog Squad operates 24 hours, 7 days a week and deploys to approximately 5,000 incidents across Victoria each year;
(b) At the time of the search for Ms South, the Dog Squad consisted of general-purpose police dogs (predominately German Shepherds trained in tracking and searching, apprehending offenders and tactical deployment at high-risk incidents) and specialist detection police dogs (predominantly Labradors trained to detect narcotics, cash, firearms and ammunition);
(c) If the Dog Squad is unable to provide a canine team to respond to a particular situation because of resourcing constraints, one may be requested from an outside agency (including the Australian Federal Police and volunteer search and rescue dog groups);
25 CB1062.
(d) Depending on the location of an incident, the ability to deploy a police dog may depend on the availability of a helicopter; and
(e) Police dogs are trained to identify and track scent disseminating from living people. It is significantly more difficult for a police dog to locate a person after death as their scent changes. Victoria Police does not currently have the capability of cadaver dogs, who are specifically trained in human remains detection.
- A/Supt Baynes noted that deployment of a police dog in a missing person search is time critical and an earlier deployment may have been of utility in the search for Ms South.
Notwithstanding, he identified a number of limitations regarding the use of the Dog Squad in the search for Ms South which included the following:
(a) The time between when Ms South’s vehicle was first observed on 3 July 2022 to when police were notified on 5 July 2022, and then the subsequent request for the Dog Squad on 8 July 2022;
(b) The contamination of the scene by police and civilians and the removal of Ms South’s vehicle prior to the arrival of the Dog Squad; and
(c) The uncertainty regarding which direction Ms South may have travelled after leaving her vehicle.
- Taking into account the limitations identified above, A/Supt Baynes considered that there was no guarantee that Ms South would have been able to be located even if a police dog had been deployed at the scene on 3 July 2022. Further, he considered that it would have been “extremely challenging” to locate Ms South even if a police dog had been deployed on 5 July 2022. Finally, he stated that the ability of a police dog to track Ms South by 8 July 2022 was “more or less non-existent” and the deployment of more dogs was unlikely to have been of any utility.26
26 CB974.
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A/Supt Baynes considered that the decisions in respect of the allocation of Dog Squad resources to assist in the search for Ms South, and the rationale and methodology for the conduct of the search by SC Tuckerman, was consistent with and complied with the guidance provided by relevant police policies and procedures.
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Since the death of Ms South, Victoria Police have developed a specific search and rescue dog capability. These dogs are not required to be trained in other disciplines like general purpose dogs.27
CONCLUSION
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I consider that it is likely that Ms South had been experiencing stress and was feeling overwhelmed in the lead up to her move to new accommodation on 1 July 2022, which prompted her to drive her vehicle from South Australian to country Victoria over the following days.28
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I am satisfied that Ms South wandered into bush and farmland on 3 July 2022 after her vehicle drove off the road in Bunguluke. Noting that she was found to have a fractured rib at autopsy, it is possible that she may have sustained some minor injuries when her vehicle drove over a culvert after leaving the road which resulted in the airbags being deployed.
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Ms South was located under a tree in a paddock around 1.5 kilometres south of her abandoned vehicle. The evidence does not enable me to conclude when she arrived at that location but it may have been at some stage on 3 July 2022 or soon afterwards. It is also possible that she wandered the surrounding area for some time and may have sought to avoid detection by anybody who may have been searching for her.
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I am satisfied that it is likely that Ms South died after being exposed to the elements, perhaps over a number of days. The evidence does not enable me to find exactly how she
27 CB975.
28 A distance of around 535 kilometres.
died; however, I am satisfied that there were no suspicious circumstances or third-party involvement.
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The search for Ms South conducted by Victoria Police involved the deployment of significant resources over an extended period of time. I am satisfied that it was generally conducted in a reasonable and appropriate manner and in accordance with relevant procedures and policies. Although I consider that the primacy of the investigation ought to have been transferred from South Australia Police to Victoria Police at an earlier stage, I am not satisfied that it would have had a material impact on the conduct of the search.
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With the benefit of hindsight, the fact that Ms South was located only 1.5 kilometres from where her vehicle was abandoned may point to a conclusion that she should have been found earlier by a reasonable search. However, I consider that such a conclusion would be too simplistic and does not take into account the decision by Victoria Police to disperse its resources over a wide area, given Ms South’s history of wandering considerable distances. Further, they did not know in which direction she may have travelled.
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The initial response by Victoria Police was delayed by 24 hours due to Charlton Police Station being unmanned and having no call-forward facility. As a result, there was a missed opportunity for the search to have been commenced on 4 July 2022.
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Victoria Police has conceded that there was an opportunity to deploy their resources and specialist support earlier in the search. Specialist resources (including assets with FLIR) should have been requested on 5 July 2022 and deployed earlier.
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In particular, I consider that the assistance of the Dog Squad should have been sought directly from the Specialist Response Division on 5 July 2022 following S/C Sheahan’s request. To effectively exploit the tracking capability of a police dog, it would have been best practice for it to be deployed as soon as possible after Ms South’s vehicle was located, and before it had been removed from the scene. That said, the evidence does not enable me to conclude that earlier deployment of the Dog Squad would have led to Ms South being located alive as she may have already been deceased on 5 July 2022.
Further, there is no guarantee that a Police Dog would have successfully located her in
any event as the search parameters were also impacted by advice to avoid searching paddocks which had been recently sprayed with herbicides.
- An earlier discovery of Ms South’s body would have increased the likelihood of a forensic pathologist being able to formulate a cause of death. An unascertained cause of death deprives the family of closure and adds to their distress at the loss of their loved one. It may be that Ms South’s body would have been located earlier had Victoria Police had access to cadaver dogs.
FINDINGS
- Having held an inquest into Ms South’s death, I make the following findings, pursuant to section 67(1) of the Act:
(a) the identity of the deceased was Colleen Mary South, born on 10 January 1964;
(b) the death occurred between 3 July and 8 August 2022, in Bunguluke, Victoria;
(c) from unascertained causes; and
(d) that the death occurred in the circumstances set out above.
CADAVER DOGS
- Prior to the inquest, Victoria Police was notified that I was considering making a recommendation that it conduct an assessment to consider the practicality and viability of establishing a cadaver dog capability within the Dog Squad. At the inquest, counsel for the Chief Commissioner advised the Court that they had already commenced such an assessment.
87. Counsel for the Chief Commissioner advised as follows:
(a) Victoria Police considers that the development of Human Remains Detection Dog29 Capability is sound, achievable and appropriate; 29 Also known as cadaver dogs.
(b) Victoria Police is in the process of developing a Human Remains Detection Dog Capability to supplement its Search and Rescue Dog capability and has consulted nationally and internationally to inform its progress;
(c) There are some challenges to be negotiated in developing a Human Remains Detection Dog Capability, the most significant of which is access to appropriate training material (i.e., human remains at varying stages of decomposition) which involves working through a number of ethical and legal considerations;
(d) New South Wales Police has a Human Remains Detection Dog Capability and has developed a training facility which utilises appropriate training material, and it is working collaboratively with Victoria Police; and
(e) Victoria Police seeks to establish its own training facility and proposes to train Police Dogs with the dual capability of being deployed as either Search and Rescue or Human Remains Detection Dogs.
- It is encouraging that Victoria Police is in the process of developing its own Human Remains Detection Dog Capability. It is understandable that the process may take some time and involve prioritising resource allocation. In the meantime, I consider that the Victorian community would be served by Victoria Police continuing to strengthen its relationship with New South Wales Police so that its expertise and training facility may be utilised.
RECOMMENDATIONS
- Pursuant to section 72(2) of the Act, I make the following recommendations:
(a) Victoria Police continue its assessment to consider the practicality and viability of establishing a Human Remains Detection Dog Capability within the Dog Squad; and
(b) In the meantime, Victoria Police liaise with New South Wales Police to utilise the resources of its Human Remains Detection Dog training facility.
I convey my sincerest sympathy to Ms South’s family whose distress and grief were compounded during the extended period in which she remained missing.
Pursuant to section 73(1) 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: Veronica South, Senior Next of Kin Keith South Farah Mak Chief Commissioner of Police, c/o the Victorian Government Solicitor’s Office Senior Constable Casey Wright, Coroner’s Investigator Signature: ______________________________________ Coroner David Ryan Date: 15 March 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.