Inquest into the Death of Tracy Margaret MARSHALL

Coroners Act, 1996 [Section 26(1)] Western Australia

RECORD OF INVESTIGATION INTO DEATH Ref No: 04/13 I, Evelyn Felicia Vicker, Deputy State Coroner, having investigated the death of Tracy Margaret MARSHALL, with an Inquest held at Perth Coroners Court, CLC Building, 501 Hay Street, Perth, on 22 January 2015 find the identity of the deceased was Tracy Margaret MARSHALL and that death occurred on 21 February 2011 at Power Line Structure 65-A, near Karratha/Tom Price Access Road, Cooya Pooya, approximately 47km’s south of Karratha, as a result of Ligature Compression of the Neck in the following circumstances: Counsel Appearing : Ms K Ellson assisted the Deputy State Coroner Mr D Anderson (instructed by State Solicitors Office) appeared on behalf of the WA Country Health Services.

Table of Contents Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 1.

INTRODUCTION On 18 May 2014, skeletal remains, later identified as belonging to Tracy Margaret Marshall (the deceased) were located at the base of a power line structure (pylon 65-A) approximately 900m from the Karratha/Tom Price Road, Cooya Pooya.

BACKGROUND The deceased had been the subject of a land search in February 2011 when she disappeared from the Nickol Bay Hospital, Karratha, after being admitted as a voluntary patient due to her deteriorating state of mind.1 A search had been initiated for the deceased on 21 February 2011 when it was understood she had left the hospital, returned home, taken possession of her vehicle, a Toyota Corolla, and disappeared.

Karratha went on Cyclone Alert during the afternoon of 21 February 2011. This hampered the search for the deceased which had focused on areas in and around Karratha, the deceased was likely to visit. The cyclone, Cyclone Carlos, passed through Karratha in the early hours of 22 February 2011 during which time the search for the deceased was suspended.

1 Ex A Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 2.

The search continued on 23 February 2011 and a witness came forward with a description of the deceased’s vehicle which he had observed on the morning of 21 February 2011 on the Karratha/Tom Price access road.

On location of the vehicle the search continued using the vehicle as the basis of the last known position of the deceased. Triangulation of the deceased’s mobile phone produced information from the nearest tower but was unsuccessful in locating a defined position for the mobile phone.

The area in which the vehicle had been abandoned was in the Millstream National Park. It had been flooded during the course of the cyclone, making access from the road into the surrounding country side very difficult, and obliterating possible tracks or movements in the vicinity of the abandoned vehicle. Nevertheless the search was continued by both land and air but failed to find any trace of the deceased.

There was serious concern for the safety of the deceased.

She had been in Nickol Bay Hospital as a result of a deteriorating state of mind and apparent suicidal ideation.

She had been a voluntary patient due to her compliance with treatment suggestions and her self-reporting she felt safe in the hospital environment.

Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 3.

The search was continued until 28 February 2011 but no trace of the deceased was found.2 As a result of the deceased not being located she was declared a missing person. Pursuant to section 23 of the Coroners Act 1996, the then State Coroner reasonably suspected the disappearance of the deceased was as a result of a reportable death and held an inquest to determine, as far as possible in the circumstances, the events surrounding her death.3 On 14 February 2013 Mr Hope stated he was satisfied beyond all reasonable doubt as to the death of the deceased, on or about 21 February 2012, at an unknown location, as a result of unascertainable causes in the circumstances he described in that finding.4 Mr Hope made an Open Finding as to how the deceased’s death arose.

Following the discovery and identification of the deceased’s remains in May 2014 and further investigations concerning the likely cause and manner of her death, the current inquest was held to finalise issues surrounding the death of the deceased.

2 Ex A 3 Inquest 04/2013 held 5-6 September 2013 Ex F tab 1 4 Inquest 04/2013 appendix 1 of this finding Ex F tab 1 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 4.

LOCATION OF THE DECEASED On 18 May 2014, shortly before noon, two Rio Tinto employees were conducting maintenance inspections of pylons in the Millstream area when they observed a rope hanging from pylon 65-A. On investigation they discovered human skeletal remains at the base of the pylon and reported the matter to police. They did not interfere with either the rope or remains.5 Inquiries indicate that although inspections are expected to be conducted annually, pylon 65-A had not been inspected for the previous five years, and consequently the remains not discovered earlier.6 Sergeant Stephen Stingemore of the West Pilbara District Forensic Office (WPDFO) provided evidence to the inquest as to the Forensic Officers’ assessment of the site of the location of the deceased’s remains on 18 May 2014.

Access to the site was not direct but via a track off the Tom Price access road approximately 6kms north of tower (pylon) 65-A, only accessible via four wheel drive access.7 The pylon was approximately 900m from the access road but not visible from the road due to a high ridge between 5 Ex F, tab 6 & 7 6 t 22.01.15, p20 7 Ex F, tab 20 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 5.

the road, where the deceased’s car had been located, and pylon. Once on the ridge the pylon was clearly visible and Sergeant Stingemore was confident the position of the deceased, while suspended, would have been visible from the ridge.8 The area around the pylon was flat with little vegetation and rocks.

The skeletal remains were located below the rope ligature in an east west orientation, mostly in their anatomically correct positions, barring the skull which was directly below the ligature and next to the feet, and a few missing bones which appear to have been subject to animal disruption.

One of the missing bones was the hyoid arch in the neck configuration.

The remains were skeletonised, bleached and cracked with no damage to the bones. Parts, such as the hands were mummified, and some fingerprint ridges could be observed along with dentition in the mandibles. There was some clothing remains on the body and shoes were still attached to the feet.

The deceased’s mobile phone was located in the pocket of the shorts, along with keys and other items which did not possess identifying features. The left ring finger still held a wedding and engagement ring, while a faded hospital admission band was present on the wrist.

8 t 22.01.15, p23 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 6.

Sergeant Stingemore described the scene, the ligature, and the remains and was quite confident the evidence was entirely consistent with a person being capable of climbing the pylon and attaching the ligature; and then being able to suspend themselves from the upper loop of the ligature, approximately 180cm from the ground. That loop was stained along 1.5m of its length and was consistent with purging from a body decomposing in that position before that process caused the remains to fall from the ligature into the described position.9 The location of the pylon was approximately 900m from the access road upon which the deceased’s vehicle had been located on 23 February 2011. It had been observed abandoned on 21 February 2011 at approximately 11:15am, before Cyclone Carlos moved through the area over night, and probably obliterated any traces of the deceased’s movements away from the vehicle before it was examined on 23 February 2011.

Sergeant Stingemore described the damage to the vehicle’s radiator which appeared to have been caused by the vehicle driving off road at some point, and then ceasing to be drivable sometime afterwards, where it was abandoned.

There was a user’s manual on the front seat of the vehicle indicating it was likely the deceased had attempted to 9 t 22.01.15, p19 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 7.

assess the damage before abandoning the car and heading off over the ridge.10 The deceased’s father informed the court the rope used as a ligature had been present in the vehicle, opportunistically, as the result of an incident a week before 21 February 2011.

The deceased had attempted to self-harm and bogged the vehicle, which others had then pulled out of the sand using rope she was then able to use as a ligature on 21 February 2011.11

IDENTIFICATION OF THE DECEASED’S REMAINS On location of the human remains and their proximity to the location of the vehicle presumed to be abandoned by the deceased on 21 February 2011, it was suspected the remains belonged to the deceased.

Items located at the site of the skeletal remains were identified by the deceased’s husband as the wedding and engagement rings he had bought for the deceased.

Mr Marshall also identified the car keys as belonging to the deceased’s Toyota vehicle which had been abandoned, approximately 900m from the skeletonised remains, as found in 2014.12 10 t 22.01.15, p24 11 t 22.01.15, p25 12 Ex F, tab 4 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 8.

In addition the skeletal remains were subjected to a post mortem examination and as part of that examination, the odontologist identified the deceased as Tracy Margaret Marshall from her dental records, and the mandibles located as part of the complete skull.13

POST MORTEM EXAMINATION The post mortem examination14 of the skeletal remains was undertaken by Dr Clive Cooke, Chief Forensic Pathologist at the PathWest Laboratory in conjunction with Dr Alana Buck the Forensic Paleontologist at PathWest.

The skeletal remains were those of a female of the deceased’s approximate age and were consistent with having been exposed to the elements for a number of years.

There was no evidence of any traumatic skeletal injury and Dr Cooke was of the view that, although he could not determine a cause of death for the deceased, everything he and Dr Buck examined, including the ligature, were consistent with a death by way of hanging.15 Any hesitation in being able to conclusively determine the deceased had died by way of ligature compression of the 13 Ex F, tabs 14 & 17 14 Ex F, tab 16 15 Ex F, tab 16 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 9.

neck was due to the lack of the presence of the hyoid bone in the neck configuration.

Dr Cooke advised the court that with hanging there may (but not necessarily) be damage to the hyoid bone in the neck, subject to the extent of force present during the compression. Had the hyoid bone been present it may have been possible to determine more about the circumstances of the death, but not necessarily. It may have confirmed ligature compression of the neck but not have been conclusive as to the method of that compression.

Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 10.

LAND SEARCH 2011 Exhibit F, Tab 4, Page 2 Google Map of road, creek, tower and the deceased’s abandoned vehicle in 2011 One of the issues of concern for the family of the deceased was that despite an extensive land search between 2128 February 2011 the deceased’s remains had not been discovered. This has caused ongoing angst for everyone who knew and loved the deceased.

Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 11.

As a result of the information obtained in 2014 it is evident the deceased abandoned her vehicle sometime before 11:15am on 21 February 2011. The location of her vehicle was not known to police at that time who, although they conducted a search during the afternoon of 21 February 2011, were looking closer to the environs of Karratha itself.

By the time the deceased’s car was reported in its location on 21 February, 2011 Cyclone Carlos had swept through the Millstream National Park and deposited a significant amount of water in the area. By the time the police were able to search the deceased’s vehicle and its surrounds any trace of the deceased’s movements around the vehicle would have been obliterated.

Nevertheless on climbing to the top of the ridge the location of the pylon is clearly visible from the top of the ridge, and Sergeant Stingemore was of the opinion the deceased hanging in the position later identified would have been obvious from the top of the ridge.16 I am satisfied from the extent of staining on the ligature and the position in which the remains were located, the deceased would still have been hanging, in position, on 23 February 2011.

Pylon 65-A, while not visible from the access road at all, was in the grid searched by Land Search and Rescue (LanSaR) 16 t 22.01.15, p23 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 12.

between 21-28 February 2011. This included an aerial search by trained spotters from an aeroplane hired by the deceased’s husband for the purposes of the search.

It is not clear how the search failed to locate the deceased, who I am satisfied was already deceased by 23 February 2011.

A report by Crime Inspector Martin Voyez17concludes with a finding “That, based on all available evidence, the body of Mrs. Marshall, ought, ordinarily, to have been found during the February 2011 land search”.

He goes on to explain that the reason the deceased may not have been located was due to the tropical cyclone passing through the Millstream area, with significant rain fall, which rendered the terrain in and around the abandoned vehicle inaccessible by searchers on foot or vehicle. The localised flooding made comprehensive search by foot or four wheel access extremely difficult. In addition aerial searches looking down on the terrain, are notoriously difficult even for trained observers.

I am satisfied there was a search for the deceased in February 2011, however it is a matter of fact the deceased’s body was not located. The search was severely hampered by the event of Cyclone Carlos and its aftermath.

17 Ex F, tab 2 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 13.

CONCLUSION AS TO THE DEATH OF THE DECEASED I am satisfied the deceased left Nickol Bay Hospital in the early hours of 21 February 2011 as outlined by Mr Hope in his findings from inquest in 2013.18 I am satisfied the deceased returned home and located her car keys which she then used to drive her Toyota vehicle along the Karratha/Tom Price access road through Millstream National Park. Her destination is unknown although I note the Karratha/Tom Price access road can be used to access the Great Northern Highway towards the south of the state where the deceased had family (Dalwallinu).

It is clear the deceased was in an unstable frame of mind during that period and it was as a result of her bizarre behaviours she had been in the Nickol Bay Hospital.

I am satisfied that at some point in her journey, without money or sustenance, the deceased damaged her motor vehicle off road, and on returning to the road, the car eventually stopped operating.19 When located by police on 23 February 2011 it started easily but was un-drivable due to the damaged radiator.

18 Appendix 1 19 t 22.01.15, p24 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 14.

I am satisfied the deceased attempted to determine what was wrong with the vehicle by use of the user’s manual but at some time, and probably in frustration, decided everything was too much for her and decided to complete her attempts of the previous week.

The deceased located the rope in her vehicle and set off up the ridge to find a suitable hanging point. There before her was pylon 65-A.

I am satisfied the deceased was fit enough physically for her to be able to both climb the pylon, tie the rope and suspend herself, sometime on 21 February 2011. At that point the search was located around Karratha and by the time there was a need to widen the search Cyclone Carlos had obliterated easy access to her chosen location.

I am satisfied the deceased climbed pylon 65-A with her rope on 21 February 2011 and suspended herself with the intention of taking her life.

I find death arose by way of Suicide.

E F Vicker Deputy State Coroner 26 February 2015 Inquest into the death of Tracy Margaret MARSHALL (F/No 584/11) page 15.

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