IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2024 001398
FINDING INTO DEATH WITH INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Deceased: Suk Ching Annie Ng1 Delivered on: 24 November 2025 Delivered at: Coroners Court of Victoria, 65 Kavanagh Street, Southbank Hearing dates: 24 November 2025 (inquest) Findings of: Coroner Sarah Gebert Counsel assisting the Coroner: Leading Senior Constable Fiona Nation Police Coronial Support Unit Keywords Homicide; Intimate Partner Homicide; gambling; no criminal or family violence history 1The names of family members have been replaced with pseudonyms.
INTRODUCTION
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Suk Ching Annie Ng1, born 5 November 1959, was 64 years old at the time of her death. She resided in Bulleen with her husband, Chai Fong Wan (Chai).
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Tragically, Annie died at The Royal Melbourne Hospital on 9 March 2024 after being located unresponsive by police at the family home during a welfare check on 27 February 2024, having apparently suffered traumatic injuries. Her husband was located deceased at the scene in circumstances which suggested that he had taken his own life.2
THE CORONIAL INVESTIGATION
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Annie’s death was reported to the Coroners Court as it fell within the definition of a reportable death in the Coroners Act 2008 (Vic) (the Act) because his death appeared to have been unexpected, unnatural or violent or to have resulted from accident or injury.
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Coroners independently investigate reportable deaths to find, if possible, identity, cause of death and the surrounding circumstances of the death. Cause of death in this context is accepted to mean the medical cause or mechanism of death. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death.
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Under the Act, coroners have an additional role to reduce the number of preventable deaths and promote public health and safety by their findings and by making comments and or recommendations about any matter connected to the death they are investigating.
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When a coroner examines the circumstances in which a person died, it is to determine causal factors and identify any systemic failures with a view to preventing, if possible, deaths from occurring in similar circumstances in the future.
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In the coronial jurisdiction, the standard of proof applicable to findings is the balance of probabilities.3 1 Referred to as ‘Annie’ unless more formality is required.
2 I also investigated Chai Fong Wan’s death (COR 2024 1157).
3 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.
“The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question
Mandatory inquest
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An inquest into Annie’s death was mandatory as the death appeared to be the result of homicide4, where homicide is given the ordinary meaning of being an act in which a person causes the death of another person.
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The Act does provide for certain exceptions including where a person has been charged with an indictable offence in respect of the death being investigated by the coroner, however in this case there was no person available to be charged in relation to the death.
Sources of evidence
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As part of the coronial investigation, Detective Acting Sergeant Michael Newgreen (DS Newgreen) as the Coroner’s Investigator prepared a comprehensive coronial brief. The brief comprises statements from witnesses including Annie and Chai’s family and friends, the forensic pathologist who examined Annie, ambulance paramedics, investigating police officers as well as other investigative material such as medical records, bank records, call records, Body Worn Camera (BWC) footage, photographs, audio recordings (Triple Zero calls) and video recordings (such as a crime scene video).
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The inquest heard evidence from DS Newgreen, and family were invited to attend at their discretion.
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This finding is based on the entirety of the investigation material comprising of the coronial brief of evidence including material obtained after the provision of the brief, the evidence at the inquest and any documents tendered at the inquest. All this material, together with the inquest transcript, will remain on the coronial file and comprises my investigation into Suk Ching Annie Ng’s death. I do not purport to summarise all the material and evidence in this finding, but will refer to it only in such detail as is relevant to comply with my statutory obligations and necessary for narrative clarity.
BACKGROUND
- Annie was born in Hong Kong and had five siblings. She immigrated to Australia in 1993 where she studied childcare. She was also working part time in a Chinese restaurant in China whether the issues had been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences …”. (pages 362-363) 4 Section 52(2)(a) of the Act.
Town where she met her future husband, Chai. Chai was working as a chef and had immigrated to Australia in 1985. In contrast to Annie, Chai spoke little to no English (and could not read English).
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The couple married on 23 October 1994. They never had children but adopted a child in Hong Kong, Miss P. She remained in Hong Kong with relatives as the Australian government did not recognise the adoption as legitimate.
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Chai had worked overseas for about 10 years before he came to Australia and was understood to be financially comfortable including the ownership of at least one property.
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Family members report that Annie was quite controlling. This included limiting the frequency of contact her husband could have with his family members. One of Chai’s family members thought Annie was very aggressive, very stubborn, very competitive, and always had to be number one.
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Annie’s brother described her as a very good sister who was a very strong person with a strong personality who never gave up. He also described her as very controlling and controlled everything. Annie’s niece described as her having a very dominant personality and was very dominant in the relationship towards her uncle.
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Chai was described as an anxious person who didn’t like to communicate with people. He was described as very timid and agreeable, he rarely argued and a ‘yes’ man. It appeared that Annie was in charge if their bills and financial matters whereas Chai did the cooking and cleaning of the house.
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Chai retired around 2012, and Annie retired approximately a year later. They were considered to be financially stable, at this time. Relatives thought they were financially stable enough not to have to work.
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The couple gambled at the Crown Casino for many years and, following their retirement their attendance increased to daily. They were black tier VIP customers at Crown Casino giving them access to the restricted high roller rooms.
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In 2017 Annie began to lose vision in one of her eyes which required brain surgery. The surgery dramatically affected her mood and behaviour including being verbally aggressive towards family members and hospital staff.
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Further examinations revealed that Annie had stage four breast cancer which required medication and regular hospital consultations. Annie’s niece described the years that followed as challenging, where Annie continued to be aggressive and was difficult to please. As she was unable to drive, Chai took Annie to all her appointments and prepared her meals, which she would often complain about. A family stated, My uncle was good to her and was looking after my aunty quite well. I would often see him making my aunty’s favourite juices and dinners and making sure she was happy.
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In 2019, Annie’s mother passed away and each of the siblings received an equal share of about $180,000 as an inheritance.
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Prior to December 2019, Annie had asked her sister for a loan following which she lent her money on multiple occasions. She later stopped when she discovered that she was a problem gambler. Annie did however repay all the loans she received.
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Annie subsequently borrowed frequently from her brother up until October 2023 (approximately $150,000), including through COVID which she said was to help with cancer treatment and expenses related to her property portfolio. It is apparent that she received additional financial support from other family members as well.
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In January 2024, Chai discovered that his bank accounts were all depleted, following which there were arguments between the couple. Chai contacted Annie’s niece via mobile phone on 12 January 2024 and was very upset and intense which was extremely out of character. He said that there had been between two and three million dollars in the account and that Annie had withdrawn all of his money.
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Chai also contacted Annie’s brother on the same day, advising him of the depleted funds. It was extremely unusual for Chai to contact him, and he appeared anxious, paranoid, and worried. Chai learnt for the first time that Annie’s brother had been lending her money. Annie later advised her brother that Chai was crazy and that he should have known about their financial situation.
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Chai was apparently informed by the bank that Annie had been transferring funds from his account and Chai confirmed with his banks that he was penniless.
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He later discovered Annie burning documents in the sink at home with the house full of smoke.
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Chai complained to his brother that Annie had also deleted his call history and erased his phone to prevent him calling anyone. He attended his brother’s house more frequently over a month, which was unusual, and stated, How can I live like this?. He also spoke to Annie’s niece advising that he had no knowledge that Annie was borrowing money from family members and thought he was financially sound. He expressed the view that that the whole family was against him and had taken his money.
31. Family members suggested that he seek help about how to recover his money.
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The family decided not to intervene given Chai’s view of the family’s involvement and Annie’s aggressive presentation.
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Annie also changed her phone number. She advised her niece that her husband was crazy but confirmed that she had deleted all his numbers in his mobile phone so he wouldn't contact anyone.
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Chai continued to ask Annie for money and they argued as she had none to give. She implied to family members that he was verbally aggressive to her but considered that he would not harm her physically.
35. Chai continued to gamble at times with money from an unknown source.
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It was apparent that Chai would no longer assist his wife to her appointments unless he gave him money, and she indicated to family that she told the hospital that she wished to stop her treatment (which is not reflected in the medical records). Annie was however being supported by family members who were seeking community supports for her.
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On 18 January 2024, Annie was scheduled to attend St Vincent’s Hospital for a chemotherapy appointment but did not attend. Multiple attempts were made to contact her and her next of kin but no contact could be made as the numbers were disconnected. Contact was made with Victoria Police to request a welfare check given that Annie had previously been very reliable with her attendance at her appointments. Police officers carried out a welfare check later in the day and reported back to advise that Annie was at home but unable to attend her appointment as her husband had left to go to the casino.
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Annie’s last attendance at St Vincent’s Hospital was on 2 February 2024 for an oncology consultation where a recent CT scan had indicated the progression of the cancer. She was aware that her anticipated survival was being shortened given the extent of her prior treatment
and that further late-line chemotherapy may not be effective but wished to pursue alternative chemotherapy and was commenced on the treatment.
- Chai consulted with general practitioners at Box Hill Centro Clinic. His medical history was limited to physical issues such as type 2 diabetes and high lipids as well as difficulty sleeping.
It was not until early 2024 that he presented with anxiety in addition to difficulty sleeping. On 16 January 2024 he complained of poor sleep (at times) and was prescribed temazepam. On 26 January, he presented as very anxious and worried, noting that his wife had late stage breast cancer and there were financial issues. He was trialled on mirtazapine as the temazepam was no longer working. However, he stopped taking the medication after four days as he found that it was not effective, and was prescribed Stilnox for severe insomnia at his last consultation on 12 February 2024.
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Annie informed her niece on 16 February that Chai had gone crazy again. She was however extremely calm on the phone and did not appear stressed or fearful.
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On 22 February 2024, Annie was scheduled to attend for an oncology consultation and chemotherapy appointment but did not attend.
CIRCUMSTANCES OF DEATH
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On 27 February 2024, a nurse from St Vincent’s Hospital contacted police via Triple Zero to conduct a welfare check on Annie as she had failed to attend a hospital appointment a week earlier.
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A Doncaster police unit attended at 1 William Street, Bulleen, at approximately 10.15am on that day. They noted that the shutters on the windows were down, the garden was well maintained and there was no build-up of mail. Annie's car was also in the driveway. It appeared that nobody was home. They spoke to the neighbour who advised that the bins had been put out and they saw the husband at the supermarket about a week before. Annie’s phone rang out and the phone of Chai and Annie’s niece were not connected. In the circumstances it was decided that the job should be revisited in the afternoon/evening.
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The afternoon shift Doncaster divisional van attended the address at 4.33pm. They entered the rear of the property after noticing an unusual smell coming from within the home. It was at this time they observed a person, later identified as Chai hanging from a curtain rail inside the house. Police entered via an unlocked rear door and discovered him with an electrical cord around his neck. It was apparent that he was deceased.
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Annie was soon located a short distance away lying face down in the hallway outside the laundry. Police noted signs of trauma including a pool of blood around her face as well as what appeared to be a stab wound on the rear of one leg. She was unresponsive but found to be breathing with a faint pulse. Ambulance Victoria was called and attended the scene.
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Police further noted that gas appeared to be coming from the stove which was later turned off by Fire Rescue Victoria to allow the scene to be safely investigated. Fire Rescue Victoria noted that the knobs on the gas cooktop were in the on position.
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Annie was placed in an induced coma and conveyed to The Royal Melbourne Hospital but died despite maximal treatment on 9 March 2024.
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Police investigators, including Major Crime Scene Officers, thoroughly examined the scene and seized various items. A CCTV canvass was conducted, and footage was obtained from the premises directly across the road from the residence.
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An examination of banking records (approximately eight accounts) revealed little credit and over $55,000 in debt including their joint home loan.
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There were no previous reports of family violence between Annie and her husband held by police. Chai had no criminal record.
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At inquest, DS Newgreen clarified that whilst Chai indicated to family members that Annie has taken two to three million dollars from him, there was no available evidence to support that this was the amount was taken.
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He further indicated that the items used to assault Annie were not identified by investigators at the scene. It was his view that Annie and Chai had likely been in the state police found them for as long as three days.
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Following the police investigation DS Newgreen could not identify any evidence that there was preplanning of in relation to the deaths. No suicide note was located and there was no indication that Chai discussed his plans with any other person. In addition, there were no signs of a disturbance at the scene and no apparent signs of forced entry even though the rear door to the property was unlocked. CCTV footage showed no evidence of a third party attending the scene in the days leading up to this incident.
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Based on all the evidence, DS Newgreen formed the view that Chai had struck Annie with an unknown object intending to end her life before taking his own life.
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Chai underwent an external examination following which forensic pathologist, Dr Hans De Boer of the Victorian Institute of Forensic Medicine formulated that the cause of death was compression of the neck caused by hanging.5 Toxicological testing of post-mortem blood detected Tamazepam, Mirtazapine, Citalopram6, Metformin and Linagliptin. No Stillnox was detected.
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Annie’s niece stated, I think this whole incident has occurred due to money and my uncle believing that my aunty had stolen money from him, and he no longer trusted her. I don't know the whole story about the incident, but it has come as a huge shock as I didn't believe my uncle could be physical with anyone.
IDENTITY OF THE DECEASED
- On 9 March 2024, Suk Ching Annie Ng born on 5 November 1959 was identified by her niece, Miss T.
58. Identity is not in issue and required no further investigation.
CAUSE OF DEATH
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On 31 January 2022, Dr Michael Duffy, registered medical practitioner practising as specialist as a forensic pathology fellow at the Victorian Institute of Forensic Medicine, conducted an autopsy examination and prepared a written report dated 24 July 2024.7
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Dr Duffy formulated the cause of death as “1(a) Blunt Force Trauma to the Head in the Setting of Prolonged Lie, 2. Metastatic Breast Carcinoma.” There were no suitable ante-mortem samples for toxicological analysis.
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Dr Duffy provided the following comments, The deceased …. aged 64 years, had a history of stage 4 metastatic breast cancer and she was located lying face down on the ground on her hallway floor. Her husband reportedly hung himself in a nearby room. She sustained head injuries and was taken to hospital where she was noted to be hypothermic. She had a CT scan which showed multifocal intracranial haemorrhage (left cerebral convexity subdural haemorrhage, right frontal haemorrhage in the area of encephalomalacia, haemorrhagic contusion right temporal lobe, small 5 Report dated 13 May 2024.
6 There is no record of Citalopram being prescribed to Chai or Annie.
7 Under the supervision of Forensic Pathologist, Dr Victoria Francis.
th subarachnoid haemorrhage within the left cerebellar hemisphere), right anterolateral 5 rib fracture and left common femoral vein thrombus. She was treated with antibiotics for positive blood cultures. Despite treatment and in view of her advanced metastatic breast carcinoma and no improvement of her conscious state, invasive treatment was withdrawn, and she passed away 11 days following admission.
At autopsy there was evidence of intracranial haemorrhage with a left sided subdural bleed and underlying cortical necrosis. There was associated midline shift to the right with mild subfalcine and uncal herniation of the left cingulate cortex and left temporal lobe respectively.
There was also a focus of organising right temporal lobe haemorrhage. These findings were a result of blunt force trauma to her head evident with diffuse scalp bruises predominantly on the left side. Blunt force trauma refers to injuries to the body caused by a flat or edged surface.
There were no obvious patterned injuries to the head to suggest a specific implement.
However, she was admitted to hospital for over a week which may have changed the appearance of these injuries, thereby hindering their interpretation.
There were bruises to her head in multiple planes which suggests more than one impact to her head. Although, some tracking extension of bruising along tissue planes, in the setting of a survival following the infliction of the injuries, cannot be excluded. She also had scattered abrasions and bruises to her limbs with linear patterned abrasions to her chest and left shoulder, which are not specific.
There were ulcers to her left face, knees and left foot which were due to pressure ulcers from a prolonged lie of uncertain duration. She was likely incapacitated from her head injuries and unable to move. Histologically these ulcers contained significant suppurative inflammation and may have been the source of her sepsis. Creatine kinase (95 U/L) and ketones (0.5 mmol/L) were not significantly elevated, and she had no renal impairment on her admission blood tests to suggest rhabdomyolysis contributed to her death. She did have elevated sodium levels due to hypovolaemia which may have contributed to further metabolic derangements affecting her neurological status in the period of her prolonged lie.
She had evidence of metastatic breast carcinoma to her bone marrow and other organs. The replacement of bone marrow by tumour can reduce red and white blood cell production making her susceptible to infections and reducing her ability to replace any blood loss from trauma. The liver was partially replaced by tumour (with evidence of treatment effect) which can also contribute to a degree of coagulopathy.
- I accept Dr Duffy’s opinion and formulation in relation to the cause of death.
OTHER INVESTIGATIONS Coroners Prevention Unit
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As part of the investigation, I requested the Coroners Prevention Unit (CPU) provide background information on intimate partner homicides and suicides in the context of gambling.
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The CPU identified 18 intimate partner homicides in a gambling context, including the present investigation. Four cases were homicide-suicides.
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The CPU collaborated with external researchers on a study that examined gambling-related suicides in Victoria between 2009 and 2016. The study results included: From 2009 to 2016 there were 4788 suicide deaths in Victoria. Of these, 184 were identified as direct GRS [gambling-related suicide] and a further 17 were GRS by ‘affected others’.
Together, these GRS comprise 4.2% of all suicides in Victoria over this eight-year period.
- The researchers noted that this number is likely an undercount for reasons such as, some deceased may have concealed their gambling from loved ones, or loved ones being unwilling to disclose it to the coroner because of shame and stigma. Further to the data above, researchers found that in 121 deaths, there was evidence of a relationship breakdown or conflict.
Link between gambling harm and family violence
- In the death of 8, the then State Coroner Judge Cain said, Although this area of research is still developing, there is an established link between gambling harm and family violence.9 Studies have shown that between 11% and 56% of people with a gambling problem perpetrate family violence10, and gambling often escalates the frequency and severity of family violence11.
The report of the Rapid Review of Prevention Approaches published in August 2024 (‘the Rapid Review’) commented on the link between gambling and family violence, noting that the gambling industry too often functions as the foundation for the escalation of abuse.12 The Rapid Review noted that “men’s gambling harms can create situations that heighten the risk of intimate partner violence (IPV), such as men experiencing anger and shame over losses and responding with violence when female partners object to gambling-behaviours”.13 8 Case number: COR 2022 00687 9 Public Accounts and Estimates Committee, Gambling and liquor regulation in Victoria: a follow up of three AuditorGeneral reports (Inquiry, November 2023) 23.
10 Our Watch, Change the story: A shared framework for the primary prevention of violence against women in Australia, 2nd edn., Our Watch, 2021; Department of Social Services (DSS), Aboriginal and Torres Strait Islander Action Plan to End Violence against Women and Children 2023-2025, DSS, Australian Government, 2023.
11 Centre for Innovative Justice, Compulsion, convergence or crime? Criminal justice system contact as a form of gambling harm, RMIT University, 2017.
12 Ms Elena Campbell et al. Unlocking the prevention potential: Accelerating action to end domestic, family and sexual violence (August 2024), 10.
13 Ms Elena Campbell et al. Unlocking the prevention potential: Accelerating action to end domestic, family and sexual violence (August 2024), 106, citing N Hing, C O'Mullan, L Mainey, N Greer and H Breen, ‘An integrative review of
The Rapid Review noted that Australians spend more money on online gambling than any other country in the world and suggested that there are “clear regulatory opportunities for governments to prevent problem gambling both online and through restrictions on electronic gaming machines”.14 Recommendations 17 c and d of the Rapid Review relate to these opportunities and are relevant in this case:
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The Commonwealth and state and territory governments to work with industries that are well positioned to prevent DFSV [Domestic, Family and Sexual Violence], including homicide, with a focus on alcohol and gambling industries in addition to media and pornography. This includes reviewing and strengthening alcohol and gambling regulatory environments to prioritise the prevention of gender-based violence. This should include: c. stronger restrictions leading to a total ban on advertising of gambling (Commonwealth and states and territories); d. examining the density of electronic gaming machines, and use of online gambling, in relation to the prevalence of DFSV across different populations and communities (Commonwealth and states and territories).15 As of June 2025, there are no publicly available responses by the Victorian Government to the Rapid Review. I therefore intend to recommend that the Victorian Government implements Recommendation 17 c and d of the Rapid Review.
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By correspondence dated 31 October 2025, Emma Cassar PSM, Secretary, Department of Justice and Community Safety provided the following response to Judge Cain’s recommendation.
An alternative to the Coroner’s recommendation will be implemented.
research on gambling and domestic and family violence: Fresh perspectives to guide future research’, Frontiers in Psychology, 2022, 13:1-16.
14 Ms Elena Campbell et al. Unlocking the prevention potential: Accelerating action to end domestic, family and sexual violence (August 2024), 106.
15 Ms Elena Campbell et al. Unlocking the prevention potential: Accelerating action to end domestic, family and sexual violence (August 2024), 24.
Banning the advertising of gambling Regarding implementing stronger restrictions leading to a total ban on advertising of gambling, the regulation of gambling advertising crosses both Victorian and Commonwealth government jurisdictions.
In 2018, Victoria introduced a ban16 on static betting advertising within 150 metres of schools, on public transport infrastructure and on public roads and road infrastructure to prevent the normalisation of gambling and limit the exposure of advertising to vulnerable people, including children and young people.
Television, radio and online advertising (including social media) are predominantly the responsibility of the Commonwealth Government. As such, the Victorian Government is unable to achieve a total ban on gambling advertising independently of the Commonwealth Government.
You may be aware that the Commonwealth House of Representatives’ Standing Committee on Social Policy and Legal Affairs held an inquiry into online gambling and its impacts on those experiencing gambling harm in late 2022. The final report, You win some, you lose more, was tabled in the Commonwealth Parliament in June 2023 and includes, among other things, a recommendation for a 3-year phased approach to implement a comprehensive ban on all forms of advertising for online gambling.
While the Commonwealth is yet to respond to this report, the Victorian Government in its third action plan to end family and sexual violence, covering 2025 to 2027, has committed to working with the Commonwealth Government and other state and territory governments to develop a national strategy to reduce harm from online gambling.
Examining the density of electronic gaming machines and the use of online gambling Victoria maintains a statewide cap on the number of electronic gaming machines, which is in place until 2042. This cap limits the overall number of machines and their distribution across local communities.
16 Amendments made to the Gambling Regulation Act 2003 by the Gambling Legislation Amendment Act 2018.
With respect to examining gambling products in relation to the prevalence of DFSV, the Victorian Government supports further research into gambling harm, including co-occurring conditions and the impact on diverse communities.
The department’s gambling harm research priorities for 2025–2028 broadly cover gambling products and environments, community impacts of gambling, gambling harm prevention, industry marketing, and recovery and support.17 Each year, the department funds a range of research projects to address these priorities.
Guided by these thematic priorities, the research program will:
• support examination of environmental factors that undermine or support attempts to avoid or reduce gambling harm
• further understanding of how gambling harm intersects with other health issues
• further understanding of the health and social costs of gambling in Victoria
• identify effective approaches to address social and commercial determinants of gambling harm.
This research program will add to the existing evidence base examining links between the availability of gambling products and determinants of gambling harm, including those in common with gender-based violence. It is important that pre-existing evidence is considered, and future research is based on gaps or needs analysis.
- In the circumstances therefore, I do not propose to make any further recommendations arising from this investigation at this time.
FINDINGS AND CONCLUSION
70. Pursuant to section 67(1) of the Act I find as follows:
(a) the identity of the deceased was Suk Ching Annie Ng born on 5 November 1959; 17 Department of Justice and Community Safety. Gambling harm prevention research priorities 2025-2028. February 2025.
(b) Suk Ching Annie Ng died on 9 March 2024 at The Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria, from 1(a) 1(a) Blunt Force Trauma to the Head in the Setting of Prolonged Lie, 2. Metastatic Breast Carcinoma.”; and
(c) the death occurred in the circumstances described above.
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Having considered all of the circumstances, I am satisfied that Chai Fong Wan contributed to the death of Suk Ching Annie Ng by inflicting injury with an unknown object following which she was rendered unconscious and suffered a prolonged lie before she was discovered. A contributing factor to her death was the metastatic breast carcinoma she suffered. The evidence suggested that Chai Fong Wan also turned on the gas stove at the family home, following which he took his own life.
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I convey my sincere condolences to Annie’s family for their loss and acknowledge the violent and traumatic circumstances in which her death occurred.
DIRECTIONS
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Pursuant to section 73(1B) of the Act, I order that this finding (in redacted form) be published on the Coroners Court of Victoria website in accordance with the rules.
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I further direct that a copy of this finding be provided to the following: Miss P, Senior Next of Kin (copy to Colin Biggers & Paisley) Mr L Royal Melbourne Hospital Detective Acting Sergeant Michael Newgreen, Coroner’s Investigator, Victoria Police Signature: ______________________________________
SARAH GEBERT Date: 24 November 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.