Deceased
Lisa Nicole Murphy
Demographics
52y, female
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2022-02-14
Finding date
2025-09-05
Cause of death
unascertained - likely combination of underlying natural disease (myocardial infarction, myocarditis, right middle cerebral artery infarction/stroke) and physiological stress from altercation
AI-generated summary
Lisa Murphy, a 52-year-old woman with mental illness and substance use history, died following a physical altercation at a convenience store. She became involved in a verbal and physical confrontation with two women after making racist comments. During the altercation, she was restrained on the ground and reported difficulty breathing. She suffered cardiac arrest and was resuscitated but subsequently developed a massive stroke and diffuse hypoxic brain injury. The medical cause of death remains unascertained, though underlying cardiac disease (myocardial infarction, myocarditis) combined with physiological stress from the altercation created a strong possibility of contribution to her death. The coroner found the escalation by one woman (throwing coffee, then physical restraint) was disproportionate and unreasonable. No clinical management failures were identified in hospital care.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Aboriginal and Torres Strait Islander readers are respectively advised that this content contains the name of a deceased Aboriginal person.
Readers are warned that there are words and descriptions that may be culturally distressing.
IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2022 0873
FINDING INTO DEATH WITH INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Amended pursuant to section 76 of the Coroners Act 2008 on 19 September 20251 Deceased: Lisa Nicole Murphy Delivered on: 5 September 2025 Delivered at: Coroners Court of Victoria, 65 Kavanagh Street, Southbank Hearing dates: Inquest: 14 April 2025 Findings of: Deputy State Coroner Paresa Antoniadis Spanos Counsel Assisting the Coroner: Leading Senior Constable Clinton Smith, Police Coronial Support Unit, instructed by Mr James Whyman, Coroner’s Solicitor, CCOV Ms Peek-Lasry of Counsel instructed by Victoria Legal Aid appeared on behalf of Andrea Madigan 1 This document is an amended version of the Finding into Death With Inquest regarding Lisa Nicole Murphy dated 5 September 2025. Correction to paragraphs 83(b) and 83(i) and the distribution list have been made pursuant to section 76 of the Coroners Act 2008 (Vic).
Catchwords: Physical altercation, verbal/racial provocation, selfdefence, mental illness, polysubstance use, unascertained cause of death.
TABLE OF CONTENTS INTRODUCTION Page 4 OVERVIEW OF THE ALTERCATION ON 8 FEBRUARY 2022 Page 6 INVESTIGATION & SOURCES OF EVIDENCE Page 7 PURPOSES OF A CORONIAL INVESTIGATION Page 7 IDENTITY Page 8
FOCUS OF THE CORONIAL INVESTIGATION & INQUEST The cause of death Page 9 The altercation Page 12 STANDARD OF PROOF Page 20 FINDINGS/CONCLUSIONS Page 21 PUBLICATION OF FINDING Page 22 DISTRIBUTION OF FINDING Page 22
Lisa Nicole Murphy was a 52-year-old single woman who was residing at a Home Share facility in Caulfield South at the time of her passing following a physical altercation with two other patrons at a convenience store in Caulfield South.
Lisa was born in Melbourne to parents Patrician and Ernest Murphy and was their middle child with an older brother Brett and a younger brother Tim. They also had an older half-brother through their father with whom they did not maintain a relationship.2
Lisa’s family resided in Alphington before moving to Torrumbarry, a town in Victoria’s north when Lisa was 11 years of age. Lisa finished primary school and commenced her secondary education at Echuca High School where she was doing well in her studies. In 1983, Mr Murphy withdrew the children from face-to-face learning electing to educate them via correspondence, due in part to their harassment and bullying which he attributed to their Koori heritage.
Lisa was said to be a happy child who loved animals and spent her days in Torrumbarry helping her parents who were running activities and holidays for disabled people on their houseboat.
Lisa and her brother Tim participated in a student exchange program to Japan through the Lions Club. Lisa was learning Japanese at school and this continued after her return from Japan. Lisa moved to Melbourne and finished her secondary education at Preston East High School and did well enough in her studies to be offered a place at the University of Melbourne studying Arts.
Lisa completed her first year before deferring her studies and commencing full-time employment.
Lisa worked first as a personal care assistant in the aged care sector and then as a tram conductor until her employment was terminated after she tested positive to cannabis during routine workplace drug testing. The relationship with her brother Tim began to sour as she blamed him for introducing her to cannabis. Lisa’s relationship with her father also deteriorated due to an extra-marital affair and her mother’s choice to stay in the marriage.
Within a two-year period between 2000 and 2002, both Lisa’s parents passed, and she appears to have stopped seeing her brothers around this time. Lisa had met Sam Guida in 1997 through a mutual friend, and they remained in a relationship, sometimes living together and sometimes living apart until the day she passed.
2 Statement of Tim Murphy.
Sam had been diagnosed with schizophrenia and when he noticed Lisa exhibiting the same symptoms, he encouraged her to see a doctor. According to Sam, Lisa was diagnosed with schizophrenia and a bipolar disorder and prescribed medications to treat these conditions.3 However, she was not diligent about taking her medications as prescribed and continued to smoke cannabis and synthetic cannabis. She first came to the attention of Victoria Police in December 2006 and was detained under the Mental Health Act and taken to St Vincent’s Hospital for assessment and treatment.
In 2012, Lisa and Sam moved to the Northern Territory for about six months. A short time after returning to Melbourne, the Murphy family home was sold and the proceeds split between Lisa and her siblings. Lisa inherited about $100,000.00 which she spent within the next 12 months or so, buying household items, a car for a friend and giving money away to people. After spending all her inheritance, Lisa moved into the Gatwick Hotel, St Kilda, and according to Sam, this was when everything started going downhill for Lisa who began using Methylamphetamine (“ice”) and Heroin.
In 2017, Lisa and Sam leased a flat in Prahran. According to Sam, he tried his best to keep Lisa away from methylamphetamine and heroin, but she continued to use them in combination with her prescribed risperidone.4 He noticed mood and behaviour changes in Lisa and described her as ‘ranting and raving all the time’. She would pick fights with strangers at random and ‘all manner of things would set her off’.
By July 2021, Lisa and Sam’s intimate relationship broke down with Lisa moving out of the flat. However, they continued to see each other regularly and remained close friends.
On 19 January 2022, Lisa entered into a lease with Melbourne Home Share for a rooming house in Caulfield South. Lisa reportedly caused several issues during her short stay at the rooming house including being involved in a physical altercation with a co-resident, graffitiing “SS” and “Go Hitler” on the front of the property and, on 7 February 2022, standing out front of the property and screaming profanities that did not appear to be directed to anyone in particular.
3 This was Sam’s understanding. However, Lisa’s medical records obtained for the purposes of this investigation indicate she was diagnosed with borderline personality disorder in 2000, schizoaffective disorder in 2017 and asthma in 2018.
4 Risperidone, available in Australia as “Risperdal” among other names, is an atypical antipsychotic used to treat schizophrenia, bipolar disorder and aggressive and self-injurious symptoms of some people with autism spectrum disorder.
The altercation on 8 February 2022 was the main focus of the coronial investigation and inquest and will be discussed in more detail below. Suffice for present purposes to say that on this date, Lisa was at the 7-Eleven convenience store at 355 Hawthorn Road, Caulfield (the 7-11) which is within a retail shopping strip on the east side of Hawthorn Road near the intersection with Pyne Street to the north.
While in the store, Lisa became involved in a verbal and then a physical altercation with two other women. During the physical altercation, while Lisa was on the ground and being held down, she was heard to say she could not breathe.
Neither customers nor staff came to Lisa’s assistance. However, while the altercation was in progress, one of the staff members called 000 and Victoria Police members and Ambulance Victoria paramedics responded a short time later.
Responding police found Lisa lying face down, unresponsive, pulseless and purple in colour.
They commenced cardiopulmonary resuscitation (CPR) and Lisa responded within about one minute with a return of spontaneous circulation (ROSC). About one minute later, CPR was recommenced as Lisa had again stopped breathing. This cycle was repeated at least one more time before paramedics arrived at 10.31am and took over Lisa’s care at 10.33am.5
Paramedics found Lisa in asystolic cardiac arrest. She was intubated, given adrenaline, saline and muscle relaxants and sedated so that life support measures could be continued enroute to hospital. At 10.49am, paramedics noted a ROSC.6
Lisa was taken by ambulance to The Alfred Hospital (the Alfred) where initial CT scan of the brain and cervical spine showed no intracranial abnormalities. Lisa was admitted to the Intensive Care Unit (ICU) and her sedation was weaned without any improvement in her conscious state.
Lisa’s lack of improvement was investigated by a further CT scan of the brain conducted at 12.20pm on 10 February 2022. This showed a large right middle cerebral artery infarct/stroke and diffuse hypoxic brain injury. Surgical intervention was thought to be inappropriate as it was not expected to provide any therapeutic benefit.
5 Statement of Acting Sergeant Jessica Mastroianni.
6 Statement of MICA paramedic Samuel Marshall.
This finding is based on the totality of the material the product of the coronial investigation of and inquest into Lisa’s death which includes relevant witness statements, photographs, the forensic pathologist’s report and medical records.7 This finding is also based on the evidence of those witnesses who were required to testify at inquest and any documents tendered through them; and the final submissions of Counsel for each of the parties.
All this material, together with the inquest transcript, will remain on the coronial file.8 In writing this finding, I do not purport to summarise all the material and evidence but will only refer to it in such detail as is warranted by its forensic significance and the interests of narrative clarity.
The purpose of a coronial investigation of a reportable death9 is to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which death occurred.10
Lisa’s death clearly falls within the definition of “reportable death” in section 4 of the Coroners Act 2009 (the Act), satisfying both the jurisdictional nexus with the State of Victoria required by section 4(1) of the Act, and section 4(2) which includes (relevantly) – Section 4(2)(a) a death that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury;
Due to the circumstance in which it occurred, Lisa’s death also falls within the mandatory inquest requirements in section 52(2)(a) of the Act. I formed the view that the possibility that 7 The compilation of material sometimes referred to as an inquest brief (designated Exhibit A at inquest) will be referred to as the “brief” in the rest of this finding.
8 From the commencement of the Coroners Act 2008 (the Act), that is 1 November 2009, access to documents held by the Coroners Court of Victoria is governed by section 115 of the Act. Unless otherwise stipulated, all references to legislation that follow are to provisions of the Act.
9 The term is exhaustively defined in section 4 of the Coroners Act 2008 [the Act]. Apart from a jurisdictional nexus with the State of Victoria a reportable death includes deaths that appear to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury. Some deaths fall within the definition irrespective of the section 4(2)(a) characterisation of the ‘type of death’ and turn solely on the status of the deceased immediately before they died – section 4(2)(c) to (f) inclusive.
10 Section 67(1) of the Act.
Lisa’s death was the result of a homicide (in its broadest sense) had not been excluded and warranted further investigation.
The cause of death, sometimes referred to as the medical cause of death, incorporates where possible the mode or mechanism of death. For coronial purposes, the circumstances in which death occurred refers to the context or background and surrounding circumstances but is confined to those circumstances sufficiently proximate and causally relevant to the death, and not all those circumstances which might form part of a narrative culminating in death.11
The broader purpose of any coronial investigations is to contribute to the reduction of the number of preventable deaths through the findings of the investigation and the making of recommendations by coroners, generally referred to as the prevention role.12
Coroners are empowered to report to the Attorney-General in relation to a death; to comment on any matter connected with the death they have investigated, including matters of public health or safety and the administration of justice; and to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of justice.13 These are effectively the vehicles by which the coroner’s prevention role can be advanced.14
11 This is the effect of the authorities – see for example Harmsworth v The State Coroner [1989] VR 989; Clancy v West (Unreported 17/08/1994, Supreme Court of Victoria, Harper J.). Note that coroners are not empowered to determine the civil or criminal liability arising from the investigation of a reportable death and are specifically prohibited from including in a finding or comment any statement that a person is, or may be, guilty of an offence. However, a coroner may include a statement relating to a notification to the Director of Public Prosecutions if they believe an indictable offence may have been committed in connection with the death. See sections 69 (2) and 49(1) of the Act.
12 The ‘prevention’ role is now explicitly articulated in the Preamble and purposes of the Act, compared with the Coroners Act 1985 where this role was generally accepted as ‘implicit’.
13 See sections 72(1), 67(3) and 72(2) regarding reports, comments and recommendations respectively.
14 See also sections 73(1) and 72(5) which requires publication of coronial findings, comments and recommendations and responses respectively; section 72(3) and (4) which oblige the recipient of a coronial recommendation to respond within three months, specifying a statement of action which has or will be taken in relation to the recommendation.
FOCUS OF THE CORONIAL INVESTIGATION & INQUEST – the cause of death
One of the main focuses of the coronial investigation including the inquest was the medical cause of death. This was complicated in Lisa’s case due to the presence of natural disease that was both known and unknown prior to her passing; the potential contribution by way of traumatic injury or asphyxia during the altercation; and the effects of CPR and life support and other measures adopted during Lisa’s ICU admission.
Lisa’s body was brought to the Coronial Services Centre in Southbank (CSC). Forensic pathologist Dr Gregory Ross Young, from the Victorian Institute of Forensic Medicine (VIFM) reviewed the Police Report of Death to the Coroner (VP Form 83), post-mortem CT scanning of the whole body undertaken at VIFM (PMCT), the Medical Deposition and the medical records provided by the Alfred and other sources of evidence available to him and performed an autopsy. Having done so, Dr Young provided a 16-page report of his findings and opinions that is included in the inquest brief.15
Dr Young provided a summary of his autopsy findings as follows: a. Neuropathological findings - Diffuse brain swelling associated with global ischaemic injury; Right middle cerebral artery territory infarction associated with right middle cerebral artery thrombus; Patchy atheroma within the remaining sampled cerebral arteries; Cerebellar tonsillar herniation necrosis and autolytic changes in the brainstem; Agonal non-occlusive cerebral venous sinus thrombosis; No features of traumatic cerebral artery dissection.
b. Other head &neck findings - Left parietal scalp bruising; Right sternomastoid muscle bruise; Intact hyoid bone and thyroid cartilage; No evidence of carotid artery dissection.
c. Heart findings -Subacute to remote myocardial infarction involving the posterior left ventricle; No significant coronary artery disease; Noninfective endocarditis involving the mitral valve; d. Venous thromboembolism - Pulmonary thromboembolism in the left lung; Deep vein thrombosis in both lower legs.
e. Pneumonia involving the lower lobes of the lungs.
15 Dr Young’s formal qualifications and qualifications are set out in the autopsy report at pages 40-55 of the brief.
f. Acute and chronic inflammation involving the vocal cords.
g. Anterolateral fractures of the right 3rd – 6th and left 2nd – 5th ribs, associated with haemorrhage in the intercostal muscles.
h. Thyroid isthmus fibrosis.
In the preamble to his report, Dr Young set out details of the information available to him at the time he compiled his autopsy report which included the initial report of the circumstances to the coroner (VP Form 83), the medical notes from The Alfred Hospital and CCTV footage of the altercation obtained by Victoria Police members when they responded to the scene.
Despite the numerous autopsy findings, Dr Young’s opinion was that the medical cause of Lisa’s passing remained unascertained despite a full postmortem examination and ancillary tests. He described Lisa’s case as complicated and the cause of her cardiac arrest as unclear and potentially related to any or all of the following factors – neck compression in the setting of the alleged assault, pre-existing natural disease, or the consumption of drugs which were not able to be tested for. According to Dr Young, the autopsy findings did not enable the relative contribution of these factors to be ascertained but the temporal relationship between the alleged assault and the cardiac arrest must be noted.16
Dr Young excluded some of the autopsy findings as causative of the cardiac arrest. These were the pulmonary thromboembolism, deep vein thrombosis, vocal cord inflammation, rib fractures and global cerebral ischaemic injury which he considered were likely complications of the cardiac arrest and subsequent resuscitation and hospitalisation.17
Other findings of natural disease processes with no apparent traumatic cause were the right middle cerebral artery territory infarction (often referred to as an ischaemic stroke) and the findings of subacute to remote myocardial infarct which could be explained by pre-existing noninfective endocarditis or could be a consequence of the cardiac arrest. Dr Young opined that the myocardial infarct may have pre-dated or even occurred around the time of the alleged assault, but he was not prepared to put this any higher in the causation hierarchy than as a possibility.
Toxicological analysis was also problematic. Antemortem blood samples routinely taken during hospital admissions were not available for testing due to the elapsed time between Lisa’s 16 Brief page 43, comments 1 and 2.
17 Brief page 44, comment 4. In this finding those are the findings set out in paras 33(a) (first finding) and 33(d) to (g).
Dr Young also found “patchy fibrosis about the isthmus of the thyroid” (described at page 12 of his autopsy report) indicating an incidental natural disease process apparently unrelated to the cause of death (see para 33(h)).
admission immediately following the altercation on 8 February and her passing on 14 February
Such samples are the most likely to reveal any substances implicated in Lisa’s behaviour during the altercation or as causative of the cardiac arrest.
Postmortem blood was subjected to toxicological analysis for completeness and showed the presence of THC (Delta-9-tetrahydrocannabinol, the active form of cannabis), prazosin (an antihypertensive drug), paracetamol (an analgesic), and propofol (an anaesthetic agent, also used in intensive care) but no alcohol, Novel Psychoactive Substances or other commonly encountered drugs or poisons. Analysis of postmortem hair samples showed the presence of THC, methylamphetamine and amphetamine (central nervous system stimulants) and morphine (a narcotic analgesic) representing drugs ingested approximately between 14 No 2021 and 14 Feb 2022.
Based on all the toxicological analysis, Dr Young advised that postmortem test results are noncontributory to death and, apart from THC, it cannot be established if any drug consumption or dug toxicity had contributed to the deceased’s behaviour preceding the cardiac arrest or the cardiac arrest itself.
Dr Young as asked to provide a Supplementary Report in which he sought to clarify and expand as far as possible on his findings and the issues of causation.18 He was also required to testify at inquest to the same end.19 I will focus on those aspects of Dr Young’s evidence that concern the causal relationship between the altercation, if any, and Lisa’s death.
By reference to the CCTV footage of the altercation obtained from the 7-11, Dr Young testified that the interaction between Lisa and the two other women involved running around the store and resulted in Lisa being in a semi-prone position on the floor, with limbs of one woman being wrapped around her. While the autopsy did not show any definitive signs of neck compression, these may not necessarily be present in cases of broad compression, for example, an arm lock.
Also, positional asphyxia (which is the relevant mechanism of death here) can also occur without postmortem findings. As such, the autopsy could not exclude that neck compression or positional asphyxia contributed to Lisa’s.20
19 Dr Young’s evidence is at transcript pages 39-49.
20 Transcript pages 42-43, 47. Note the finding of “right sternomastoid muscle bruise” in para 33(b) above.
arrythmia leading Lisa to go into cardiac arrest at any time. Furthermore, Lisa experiencing a state of physiological stress, with or without a toxicological contribution increased the risk of cardiac arrythmia in an already vulnerable heart.21
Dr Young was pressed about the likelihood that the altercation contributed to Lisa’s death but was not prepared to say that the altercation was a probable contributor. He noted that coincidence but would not go beyond saying that it was a strong possibility that the altercation contributed – “…based purely on a statistical point of view and timing as I mentioned before people with vulnerable hearts can die at any time…But it is a big coincidence at least that she has had this cardiac arrest in the setting of this altercation. So I think that it is a very big coincidence but I can’t say that it wouldn’t have happened at any time…it’s absolutely possible that this has happened. Probable, I couldn’t really say for sure in terms of on the balance of probabilities I guess based on the autopsy examination that I’ve done. What this would really require would be some physiology testing on the deceased’s heart at the time which we don’t have. What we can see is what’s presented in front of us and all I can say is that it has happened at this time with this woman and that would elevate my suspicion that it has contributed more than if she didn’t already have this altercation in the first place.”22
Dr Young also testified about the entity known as “excited delirium” but did not invoke that as relevant to Lisa’s cause of death.23 FOCUS OF THE CORONIAL INVESTIGATION & INQUEST - the altercation
The other focus of the inquest pertained to the circumstances in which the death occurred and was the altercation between Lisa on the one hand, and Sarah Franklin (Sarah), and to a lesser extent, Andrea Madigan (Andrea) on the other. It is uncontentious that Sarah and Andrea 21 Transcript pages 43-44. Note that antemortem blood samples were not available for toxicological analysis and postmortem samples were of limited value. Discussed at paras 38-40 above as well as transcript pages 45-46.
22 Transcript pages 48-49.
23 Transcript pages 44-45. “Excited delirium is not a universally accepted medical diagnosis, but supposedly represents a clinical syndrome characterised by acute behavioural disturbance, with uncorrectable agitation or restlessness, combativeness, a focus on glass and mirrors, unexpected strength, shouting and grunting and/or signs of hyperthermia.
It is a clinical diagnosis without specific autopsy findings. It has been described in the setting of psychotic episodes, acute natural disease and drug use. For example, neuroleptic medication and illicit drugs, mostly cocaine and methylamphetamine, often in the setting of restraint. Deaths following an excited delirium-type presentation are usually believed to be multifactorial in nature and it may not be possible to ascertain the relative contributions of all of these factors in a person’s death. It is not a cause of death that I’ve ever used, nor would I use in my current practice of forensic pathology.
were close friends who had known each other for many years and were also housemates and that Lisa was unknown to them before the altercation.
The altercation was captured on CCTV footage obtained from 7-11 as well as by Mr Tynes, a third party/customer of the 7-11, on his mobile home. The footage from both sources was unvaluable to the coronial investigation not only because it shows the altercation but also because it is time-stamped and enables us to calculate how long Lisa was lying prone/semiprone under restraint.24
On 8 February 2022, at 10.11am,25 Andrea entered the 7-11. Less than a minute later, Sarah and Lisa arrived independently of each other but entered the 7-11 simultaneously. Andrea and Sarah went to the self-serve coffee machines, as did Lisa, to wait in a queue until the machines were free. Another customer, Mr Johnston, entered the store and began making coffee before Lisa cut in front of him remonstrating that he had cut the queue. Mr Johnston stepped back and, along with one of the 7-11 staff member, heard Lisa make racist remarks about Jewish people.
While Lisa was waiting for her coffee, she stuck her middle finger up at Sarah and threw a small packet of sugar in her direction.
At first, Andrea and Sarah began walking away but Sarah soon turned, walked back towards Lisa and threw the contents of her coffee cup at Lisa who turned and began to run. Lisa reached the front counter area and began speaking to Andrea before turning around to face Sarah who was marching towards her. At the same time, both Sarah and Lisa raised their arms and began grappling with each other.
Andrea tried to separate them. During the scuffle, Lisa grabbed hold of Sarah’s hair, while Sarah three several punches at Lisa. Lisa had hold of Sarah from behind and bit her on the left bicep. As this was occurring, customers were walking in and out of the store, making purchases, apparently unperturbed.
At 10.16.21am, Lisa and Sarah fell to the ground with Lisa falling on top. Sarah manoeuvred herself into a position behind Lisa, wrapped her legs around Lisa’s body and put her in a headlock. While this was occurring, Andrew was holding Lisa’s arms to stop her hitting out.
24 Mutimedia Exhibit 8 – CCTV from 7-11 Caulfield, part of the inquest brief, Exhibit A and Multimedia Exhibit 9 – video recording taken by witness Travis Kyne, part of the inquest brief, Exhibit A.
25 What follows is a description of the altercation as captured on the footage, is uncontentious and is taken from the LSC Smith’s opening at the inquest – see transcript pages 13-15.
Lisa was head to yell, ‘Leave me alone, help, help, help me, help, I can’t breathe, help, help, help me.’
At 10.17.49am, Sarah released Lisa from her headlock who rolled onto her stomach. Sarah continued to restrain Lisa by putting her left knee into Lisa’s lower back and her left hand onto her buttocks. Sarah held this position until 10:18:36am. Sarah and Andrea then left the store in Andrea’s vehicle.
Whilst the altercation was in progress, at 10:16am, a 7-11 staff member called emergency services. She reported that Lisa was lying face down on the ground, unconscious but breathing.
The footage shows the staff member bending down near Lisa’s head, at which point Lisa raised her head slightly. No one rendered first aid to Lisa as she lay on the floor of the 7-11. Staff continued to serve customers until the arrival of the first Victoria Police responders at 10:21am.
They commenced CPR with some success and continued until relieved by Ambulance Victoria paramedics who arrived at 10:31am and took over at 10:33am.
Both Andrea and Sarah were served with summonses to testify at inquest. At the commencement of the inquest, application was made by Ms Peek-Lasry on behalf of Andrea that she be excused from giving evidence on medical grounds and, in the alternative, pursuant to section 57 of the Act. Apart from relying on relevant medical reports, Counsel relied on the account of events already given by Andrea to police in a record of interview on the afternoon of 8 February 2022. I granted the application on both bases and excused Andrea from giving evidence at the inquest.
Andrea’s account of the altercation in the record of interview can be summarised as follows.
Sarah told her that Lisa had been making racist remarks towards Sarah and had thrown coffee at her. Andrea neither heard the racist remarks herself, nor saw the coffee being thrown. Andrea saw Lisa on top of Sarah while they were on the ground. Sarah was trying to prevent Lisa from hitting her. Andrea’s only involvement in the physical altercation was to hold Lisa’s arms to prevent her from hurting Sarah.26
indicated that I would consider the applicability of section 57 of the Act after hearing her evidence.27
Prior to being cross-examined, the CCTV footage from the 7-11 and the video recording made by Mr Tyne on his mobile phone were played in court, the latter included audio.
Sarah’s evidence was that she had never seen Lisa before and that she went to the 7-11 every day for coffee after collecting the mail.28 As she moved away from the coffee machines, Lisa said, ‘I saw you roll your eyes at me’ and Sarah said nothing but looked at her. Lisa then said, ‘Don’t look at me.’ and Sarah spoke for the first time, saying, ‘I can look at whoever I want’.
According to Sarah, Lisa then said, “something about white cunts and then she called me a white racist Jew.” This made her angry as she is Jewish.29
Sarah and Andrea walked off towards the counter as Lisa was - “raving on about how all Jews should die and …I shouldn’t have, but I wanted her to stop her racist ranting and raving, so…I took the lid off my coffee. The coffee was lukewarm, I never drink hot coffee and I threw it at her and she ran around to the other side…Well, it’s – to me it’s escalating. So I guess I just want it to stop, but I didn’t do it the best way.”30
28 Transcript page 23.
29 Transcript pages 24-25.
30 Transcript pages 25-26.
and then the next minute she falls on top of me…I’ve somehow manoeuvred her off so she’s lying on her … front…”31
Sarah’s evidence was that she was terrified as Lisa was very strong and she was having trouble getting her to stop. As she managed to get Lisa off her, Lisa ended on her left side with Sarah on her left side behind her. It was from this position that Sarah said she put her right arm and leg over Lisa to stop her moving around. Sarah thought Lisa could still attack so she was “restraining her lightly”. Sarah denied that she ever had Lisa in a headlock, saying her arm was across Lisa’s shoulder. She maintained this despite the video footage showing her right leg across the middle of Lisa’s torso.32
From this position, Sarah asked Lisa if she was calm now and would stop biting. Lisa did not answer but started saying “get off me, help me, help me, I can’t breathe”. According to Sarah, at this point Andrea said, ‘Let’s go’ and Sarah released her arm and leg but got into a new position. When asked why she thought Lisa would be saying such things, Sarah said she thought it was some kind of ploy so she would get off Lisa and Lisa continue attacking her.33
Then when Sarah got up, Lisa fell onto her stomach and Sarah moved her hand onto Lisa’s rear buttocks. She denied pushing Lisa down, saying she was just lightly restraining her while Andrea looked for her (Sarah’s) glasses. When asked about Lisa’s actions at that time, Sarah’s evidence was that she was not trying to get up, but she was still moving, her arms and legs were moving. Sarah could not describe the movements but said Lisa was not lashing out. Sarah was only holding her until Andrea could find her (that is Sarah’s) glasses as she was still worried that Lisa would attack her.34
When asked if she checked Lisa’s condition before leaving, Sarah said, “As far as I was concerned she was still moving.” Sarah and Andrea then left, aware that Andrea asked someone to call the police and they were aware someone was on the phone. When asked if she called the police, Sarah said “No, because Andrea had asked – Andrea had said, ‘Call the police’, so I was aware the lady was on the phone.” When asked if she thought to wait for the police, Sarah said, “You know, when you’re in that state of mind you don’t think clearly.”35 31 Transcript pages 26-27.
32 Transcript pages 27-28.
33 Transcript pages 28-29.
34 Transcript pages 29-30.
35 Transcript page 31. In further cross-examination, Sarah maintained her account and the sequence of events she described in her evidence. Transcript pages 31, 35-39.
It was uncontentious at inquest that Sarah and Andrea left the store without waiting for the police to arrive and without leaving their names and/or contact details in case the police wanted to speak to them about the altercation with Lisa. Victoria Police members were able to access CCTV footage from premises near the 7-11 which showed them leaving in a vehicle that police were able to trace to Sarah’s name and residential address. As a result, police were able to interview both women on 8 February 2022 within a few hours of the altercation and their departure from the 7-11.
The inquest brief included statements from two 7-11 staff members wo saw the altercation or parts of it. Ms Zorricueta-Fuentes was the staff member who called 000 at 10.15am on her personal mobile and approached Lisa and approached her after the altercation where she lay on the floor and heard her laboured breathing. Ms Zorricueta-Fuentes did not see but assumed Sarah threw the coffee as ‘she was the only one who had a coffee’ and then saw Lisa grab Sarah and both of them ‘sort of grabbing each other’.36
Amirhossein Ameli was another 7-11 staff member. He was filling shelves in the cool room at the back of the store when he noticed Ms Zorricueta-Fuentes on the phone and his attention was drawn to the altercation when both Lisa and Sarah were on the floor. He described Sarah’s hold on Lisa as follows – “The woman from behind had her feet wrapped around the neck, neck, a bit like a head lock. The lady being choked was yelling out “help me” at least a few times. The lady choking her was yelling out to go to the psychiatric hospital or something like that. They wrestled for about 30 seconds…” 37
There are a number of accounts of the altercation or parts of it from 7-11 customers. Roulla Spinos was waiting in the queue to be served when she “saw three women that were fighting.
All 3 were on the floor, two were on top of the woman.” She could not describe the women and stated she became frightened by the altercation.38
Mr Kyne entered after the coffee had been thrown and saw Lisa and Sarah at the front counter area grappling, pushing each other, looking like they were trying to get each other on the ground.
36 Second statement of Alexandra Zorricueta-Fuentes dated 20 February 2022 at pages 86-87 of the brief. Her earlier account is broadly consistent and is at pages 78-79 of the brief.
37 Statement of Amirhossein Ameli dated 8 February 2022 at page 98 of the brief.
38 Statement of Roulla Spinos dated 23 February 2022 at page 104 of the brief.
Judging by her appearance, he assumed Lisa was a junkie and heard Andrea say words to the effect of “she’s crazy, she’s been making racial remarks, she’s schizophrenic, she should be in a home”.39
Mr Kyne only saw Lisa and Sarah grappling for a minute or so and thought Lisa was not putting up much of a fight. He described her as looking very out of it, meaning drug affected. According to Mr Kyne’s account, Sarah was the aggressor and was pulling on Lisa’s clothes as if she was trying to get her on the ground and threw a couple of punches and elbows two of which may have connected with Lisa’s neck area40
Mr Kyne went on to describe Sarah and Lisa in two different positions while on the ground.
First, he described Sarah with her right knee pressed into Lisa’s back while she was face down on the ground with her left hand holding Lisa’s neck down – “It looked like she had all her weight on woman 2 [Lisa] She was restraining her and not letting her up … woman 2 was yelling ‘help me’ over and over again. Her voice sounded clear and I could hear her properly, she definitely sounded like she was in fear. She had a deep voice.”41
Next, Mr Kyne described the women changing positions such that Sarah was on her side behind Lisa with her right arm around Lisa’s neck – “…it looked like she was holding her arm there and I don’t think much pressure was being applied. I say that because if someone was choking another person, you would think it would be obvious that there was pressure being applied. This didn’t look like pressure being applied, they weren’t rocking back and forth in a struggle, it just looked like she was holding her arm around woman 2’s neck area. Woman 1 had her right leg over the top of woman 2’s body. I think she was held in that position for a couple of minutes…While they were in this position, woman 2 just sort of gave up, she went limp and stopped fighting, she wasn’t saying anything either.”42
Another 7-11 customer who provided a statement was Royce Johnson. He was at the coffee station to the right when Lisa came and started making a coffee at his station and he moved to the left coffee station immediately after Sarah. He described Lisa as barging in front of him and swearing. He thought she was drug affected, very agitated and started mumbling. He heard her say “white” and “cunt” and “scream out a few racist things”. He did not look at Lisa but 39 Statement of Travis Kyne dated 23 February 2022 at pages 107-108 of the brief.
40 Ibid, at paragraphs 11-12 on page 108 of the brief.
41 Ibid.
42 Ibid at pages 108-109 of the brief. Note that two minutes is an estimate and that Mr Kyne took only 12 seconds of video footage while they were in this position that he later provided to police. The video was taken from his position at the door at the door, about 1.5 metres from the altercation and nothing was obscuring his view.
though she was yelling at Sarah. He was “pretty sure” it was Sarah who thew the coffee at Lisa – “That’s when all hell broke loose.”43
Mr Johnson saw them running around the aisles, saw things flying off the shelves, heard noises and heard what he thought were “some fist fighting noises” before approaching the counter to pay. There he saw Lisa on the floor struggling, her legs were flapping, and Sarah holding her from the back with her arm around her throat. Lisa was saying “help, help, help” and Sarah was saying “are you calm now”. Mr Johson could hear Lisa’s “muffling, like when someone’s throat squeezed”.44
Benedict Herbert was using the ATM in the 7-11 with his back largely turn to the commotion when he heard a female say something like “is that your fucking mother Jew and Jude?” According to Mr Herbert’s account, Lisa then went over to Sarah and Andrea at the front counter and two of the three of them started pushing and shoving one another before they suddenly hit the ground hard, “like a sack of potatoes”. He then described them as one behind the other and wrestling. Before he left the ATM, he heard one of the females say, “get off me, I can’t breathe”.45
Julia Cher was a 7-11 customer who went in to buy a coffee on 8 February 2022. She saw three people on the ground at the end of the counter closest to the coffee station and could not tell if they were males or females. One of the three was face down on the ground with their head wedged under the gap between the floor and the chocolate stand. This person had a bun and Ms Cher assumed she was female. The other two people were sitting on top of her. Ms Cher would not see what any of their arms were doing and did not see the woman on the ground moving or flapping about. All she heard was her saying, “‘get off me’ a few times.” According to Ms Cher, the woman on the ground stopped talking before she (that is Ms Cher) left the 7-11.46
Oleksander Demyanenko also provided a statement. He parked his car in the car park at the front of the 7-11 and while still outside heard screaming coming from inside the shop. He looked inside and saw three ladies fighting on the floor, two of them were pushing the other one down.
43 Statement of Royce Johnson dated 8 February 2022 at pages 111-112 44 Ibid at pages 112-113. On 23 February 2022, Mr Johnson provided a second statement consistent with the first, except that some two weeks down the track he could not remember exactly how Sarah was holding Lisa from behind and could not remember if Sarah was choking Lisa or whether she was pressing her face into the ground and that’s why her voice sounded muffled.
45 Statement of Bernard Herbert dated 5 March 2022 at pages 126-127 of the brief.
46 Statement of Julia Cher dated 20 February 2022 at pages 136-137 of the brief.
After the two women walked away rushing, he saw a woman lying face down near the counter.
While he could not remember details about her, she was making noises like ‘ohh ohh ohh’.47
The altercation involving Lisa, Sarah and Andrea was initially investigation by the Moorabbin Crime Investigation Unit. Once Lisa had passed, the investigation was transferred to the Homicide Squad and Detective Senior Constable Zarlasht Shahpoor became the investigator.
At inquest, DSC Shahpoor provided an overview of the steps taken in relation to criminal proceedings arising from the altercation; the rationale for the choice of charges laid; and the ramifications of Dr Young’s conclusions about the cause of death.
DSC Shahpoor advised that Sarah ultimately pleaded guilty to common assault in relation to the altercation.48 That charge does not encompass Lisa’s passing as the prosecution had no evidentiary basis for a causal connection between the altercation and Lisa’s passing. He explained that the charge of common assault against Sarah related to that part of the altercation during which they were both on the floor of the 7-11 “the entire time while they’re on the ground. When you hear Ms Murphy saying, ‘I can’t breathe, help, help, I can’t breathe’, that’s in my opinion the assault.”49
The standard of proof for coronial findings of fact is the civil standard of proof on the balance of probabilities, having regard to the ‘Briginshaw sliding scale’.50 When finding facts, a coroner has to reach a comfortable or reasonable satisfaction having regard to all of the available evidence relevant to the questions in issue in the investigation.51 It is axiomatic that findings are based on what was known or should reasonably have been known at the time strictly without the benefit of hindsight.
When considering whether that level of satisfaction has been achieved, regard must be had to the seriousness of the allegation; the inherent likelihood or unlikelihood of an occurrence of fact, and the gravity of the consequences flowing from a particular finding, such as a finding that a person caused or contributed to a death or passing.52 47 Statement of Oleksander Demyanenko dated 3 March 2022 at pages 142-144 of the brief.
48 Transcript pages 49-54. Note tha the charge of common assault against Andrea was withdrawn at the same time as Sarah’s plea was negotiated.
49 Transcript pages 54-55 50 Briginshaw v Briginshaw (1938) 60 C.L.R. 336.
51 Anderson v Blashki [1993]2 VR 89 at 96; Secretary to the Department of Health and Community Services v Gurvich [1995] 2 VR 69 at 73; 52 Briginshaw v Briginshaw, op cit, at 362.
b. Lisa passed on 14 February 2022 at The Alfred Hospital,53 55 Commercial Road, Melbourne, Victoria 3004.
c. The medical cause of Lisa’s death remains unascertained despite full postmortem examination and ancillary investigations.
d. The available evidence supports a finding that it was Lisa’s racial slurs that first brought Lisa to Sarah’s attention.
e. Apart from Lisa throwing pre-packaged individual serves of sugar towards Sarah, it was Sarah who escalated the encounter by throwing her coffee at Lisa and then engaging in a physical altercation with her.
f. This escalation by Sarah was disproportionate and unreasonable in the circumstances and involved physical restraint of Lisa while she lay prone/semi-prone on the floor such that her breathing was likely compromised.
g. There is a clear temporal connection between Lisa’s cardiac arrest and subsequent death and the altercation involving Sarah and, to a lesser extent, Andrea.
h. It remains a strong possibility that Lisa’s death resulted from a combination of underlying natural disease and the physiological stress arising from the altercation on 8 February 2022.
i. There is no suggestion that there was any want of clinical management or care on the part of the medical, nursing and allied health staff of The Alfred Hospital54 that caused or contributed to Lisa’s passing.
j. I wish to convey my sincere condolences to Lisa’s family and friends for their loss.
53 ‘Royal Melbourne Hospital’ amended to ‘The Alfred Hospital’ pursuant to section 76 of the Coroners Act 2008 (Vic).
54 ‘Royal Melbourne Hospital’ amended to ‘The Alfred Hospital’ pursuant to section 76 of the Coroners Act 2008 (Vic).
PUBLICATION OF FINDING Pursuant to section 73(1) of the Act, unless otherwise ordered by the coroner, the findings, comments and recommendations made following an inquest must be published on the internet in accordance with the rules. I make no such order.
DISTRIBUTION OF FINDING I direct that a copy of this finding be provided to: Senior Next of Kin The Alfred Hospital55 Sarah Franklin Andrea Madigan c/o Victoria Legal Aid Detective Senior Constable Zarlasht Shahpoor c/o O.I.C. Macedon Ranges C.I.U.
Signature: ____________________ Paresa Antoniadis Spanos Deputy State Coroner Date: 5 September 2025 Re-signed: 19 September 2025 ________________________________________________________________________________ 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.
________________________________________________________________________________ 55 ‘Royal Melbourne Hospital’ amended to ‘The Alfred Hospital’ pursuant to section 76 of the Coroners Act 2008 (Vic).
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