Inquest into the death of H GM

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of H G-M Hearing dates: 12 and 13 December 2022; 18 April 2023 and 11 September 2025 Date of findings: 11 September 2025 Place of findings: Lidcombe Coroners Court Findings of: Deputy State Coroner, Magistrate Hosking Catchwords: Determination of cause and manner of death; whether natural causes can be ruled out; referral of matter to the Unsolved Homicide Team.

File number: 2018/226986 Representation: Counsel Assisting the inquest: Chris Mitchell instructed by Jessica Best, NSW Crown Solicitor's Office.

Findings: Identity of deceased: H G-M Date of death: 23 July 2018 Place of death: 46 George Street, Binnaway Cause of death: Unascertained Manner of death: Unascertained unnatural: H G-M died suddenly and unnaturally following a series of head injuries sustained shortly before her death as a result of blunt force trauma.

Recommendations: To the Commissioner of Police:

That the death of H G-M be referred to the Unsolved Homicide Team of the NSW Police Homicide Squad for further investigation in accordance with the protocols and procedures of that Team.

Non-publication: A pseudonym order, H G-M, is made over the name of the deceased.

Introduction 1 Section 81(1) of the Coroners Act 2009 (NSW) (the Act) requires that when an inquest is held, the coroner must record in writing their findings as to whether the person has died and if so, the date and place of the person's death, and the cause and manner of their death.

2 In addition, the coroner may make recommendations in relation to matters which have the capacity to improve public health and safety in the future, arising out of the death in question.

3 These are the findings of an inquest into the circumstances of the death of H

G-M.

4 H G-M was born at 8.50am on 26 September 2017. She was perfect wit, ..a"f •!

head of hair, tiny ears and a button nose. She was the much loved baby daughter to both of her parents. When H G-M was 9 months old, she died suddenly and unexpectedly on the morning of 23 July 2018, at her home in a small NSW country town.

5 At the end of the inquest, those present had the privilege of hearing from H GM's mother and grandmother about the special girl she was. We were also invited to share in a photo/video collage. H G-M was a beautiful, happy, giggly girl. She loved to explore with her hands and touch others. She had an infectious laugh and her smile made those around her smile. It was evident that H G-M brought her parents, extended family (including cousins), friends and community great joy and happiness. It was also clear the pain and trauma her absence brings, exacerbated by the uncertainty surrounding the circumstances of her death.

6 At the time of her death, H G-M was alone with her mother's then partner, Mitchell Callaway.

7 An autopsy conducted by Dr Elstub shortly after HG-M's death identified that H G-M had several significant head injuries at the time of her death, detailed below.

(1) An 8cm-long fracture to the left side of her skull, with a 1cm branching fracture coming off the main 8cm fracture.

(2) Thirteen discrete bruises to the back and side of her scalp.

(3) Three areas of periosteal haemorrhage.

(4) Two areas of intradural bleeding.

(5) An injury to her frenulum.

8 Those were the circumstances in which an inquest was commenced under s 24(1)(d) and 27(1)(a) of the Act.

9 In preparing these findings I have drawn from submissions by Counsel Assisting in relation to non-contentious factual matters and issues. I am grateful for this assistance.

Procedural history 10 The inquest commenced before Her Honour, Deputy State Coroner Magistrate Kennedy, on 12 December 2022 at the NSW State Coroners Court.

11 The issues for consideration at the inquest were: (1) the findings required pursuant to section 81 of the Act: the identity of the deceased; the time, date and place of death; the cause and manner of death.

(2) whether it is necessary or desirable to make recommendations.

12 A 4-Volume brief of evidence was tendered and marked Exhibit 1.

13 The inquest received reports and oral evidence from, amongst others: (1) Detective Senior Constable Michael Morris, the officer in charge of the coronial investigation (2) Professor Michael Besser, specialist in paediatric neurosurgery, report dated 22 March 2023 (3) Associate Professor Michael Buckland, neuropathologist, report dated 22 October 2018 (4) Professor Johan Duflou, forensic pathologist, report dated 29 September 2022 (5) Dr Susan Marks, paediatrician specialising in child protection and forensic medicine, report dated 12 April 2021.

(6) Dr Hannah Elstub, forensic pathologist, autopsy report dated 10 April 2019 following her post mortem examination of H G-M which took place on 26 July 2018 and supplementary reports dated 24 June 2020 and 21 February 2023.

14 On 18 April 2023, Deputy State Coroner Kennedy adjourned the inquest to consider submissions made that the inquest ought to be suspended pursuant to s 78 of the Act. During this adjournment, charges were laid by the Director of Public Prosecution which were subsequently withdrawn.

15 On 8 June 2023, Callaway was charged with H G-M's murder. On 4 December 2024, the murder charge was withdrawn and dismissed.

16 The inquest was resumed pursuant toss 79(1)(a), (2), (2A), (3), (4(a)), and (6) of the Act.

Background Events leading up to H G-M's death 17 In early June 2018, some five weeks before H G-M died, she contracted an illness that she could not shake off. According to her mother, in early June, H G-M 'just wasn't herself. She was grizzly and she had thick, green snot.' 18 On 5 June 2018, her mother took H G-M to Coonabarabran Medical Centre where she saw a medical practitioner. On examination, H G-M was afebrile1 and 'the plan was Panadol when necessary for fever.' No vomiting was reported. Her mother was told to give H G-M Panadol and Nurofen, but nothing else was prescribed for what was then thought to be a viral infection.

19 Over the following days, H G-M did not improve. H G-M also developed a cough and would 'cough so much that she would actually vomit.' 20 On 3 July 2018, her mother took H G-M to Coonabarabran Medical Centre where she saw a different medical practitioner. The medical records note, among other things, 'very runny nose, clear...Prob viral urti [sic] but need to exclude pertussis' (whooping cough). The notes also record 'post tussive vomits past few days.' No injuries to HG-M's head were recorded.

21 A medical record dated three days later- on 6 July 2018 - notes that 'child still has lots of green snot...also coughing with some p-t vomits...should start to improve now'. No injuries to HG-M's head were observed or recorded.

22 On 14 July 2018, her mother took H G-M to Coonabarabran Hospital where she saw a third medical practitioner. During this appointment, H G-M was prescribed a narrow-spectrum antibiotic for strep throat. No vomiting was recorded in the history. No injuries to HG-M's head were observed or recorded.

23 On 18 July 2018, her mother took H G-M to Coonabarabran Hospital where she saw Dr Dean Jones. The history taken by Dr Jones records H G-M 'coughs to 1·Not feverish.

the point of vomiting.' No injuries to H G-M's head were recorded. Dr Jones ordered an X-ray and, after viewing the results, formed the view that H G-M probably had pneumonia and prescribed her antibiotics.

24 On 20 July 2018 - three days before H G-M's death - her mother returned with H G-M to Coonabarabran Hospital where she was again reviewed by Dr Jones.

He recorded that H G-M appeared 'much improved.' Dr Jones listened to HGM's chest and said it was still a bit crackly, but that the antibiotics seem to be doing their job but could take up to 14 days. No injuries to HG-M's head were recorded and no further vomiting was reported.

The day before H G-M's death 25 On the morning of Sunday 22 July 2018, H G-M's father spent approximately half an hour in the morning with H G-M on his own in the local park and his car.

26 He played with H G-M and although she seemed tired for the first couple of minutes, she otherwise seemed to be her usual bubbly self. He took a video that day which shows H G-M smiling and giggling. She was also chatting nonstop: this was the first time she ever said the word 'Dad.' The video also shows H G-M with white sudo cream on her top and bottom lip, covering small abrasions to her upper lip and chin.

27 That day, her mother observed that H G-M seemed to want to eat more food.

She ate six pouches of food and drank a few bottles. Her mother commented that she 'could not feed her fast enough' and she was getting cranky because she was having to wait.

28 On the afternoon of Sunday, 22 July 2018, H G-M's mother had a rest.

According to Callaway, while HG-M's mother was asleep, he took H G-M to Coonabarabran to purchase petrol and chocolate. Callaway says he left with H G-M at around 4pm and returned at around dark. He told the police in two separate interviews that he and H G-M first went to the Coles Shell service station, where he filled up the car with petrol, then went to Woolworths where he purchased some chocolate before returning home.

29 The police reviewed CCTV from both the Coles Shell petrol station and the Woolworths store that Callaway says he attended. The police were unable to identify Callaway on any of the CCTV footage captured at either location on the afternoon of Sunday 22 July 2018, or any footage from the previous day reviewed by police. The inconsistency between the account Callaway gave to the police of his movements, and the CCTV footage from the service station and Woolworths, remains unexplained. The inquest was unable to determine Callaway and H G-M's whereabouts in those 2 hours.

30 That night, HG-M's mother noticed changes in H G-M. She told the police: (1) I was worried because the Sunday night, she did not want to take her bottle. Like, usually she'll wake up and she'll have a bottle and she didn't want to take her bottle.

(2) H G-M went to bed at around 8.30pm. She woke a few times that night and did not want her bottle. According to Callaway, he got up to H G-M one time and she did not want the bottle with him either. She maybe had a centimetre out of the bottles, and no other fluids or food.

The day of H G-M's death 31 At around 5.00am, her mother changed H G-M's nappy and H G-M went straight back to sleep.

32 At around 7:45am, Callaway went into H G-M's room and woke her up. H G-M still did not want to take her bottle, but she wanted food. Her mother fed H G-M porridge for breakfast.

33 After breakfast, her mother sat HG-Mon the lounge and Callaway put a movie on for H G-M while her mother got ready to go to work.

34 At about 8:35am, her mother gave H G-M a kiss and a cuddle and told H G-M that she loved her. She then left home to go to work at a nearby school. That

day was a pupil free day at the school as the staff were undertaking mandatory CPR and anaphylaxis training.

The period Callaway was alone with H G-M 35 Callaway gave two interviews to the police about what occurred that morning after H G-M's mother went to work.

36 In his first interview with police2 Callaway said that after HG-M's mother left for work, he went to the garage and brought a Jolly Jumper back to the house and placed H G-M in it for five or ten minutes. Callaway said he then used a blanket, a jumper and towel to make a makeshift bed for H G-M on the lounge room .fJpor. They watched television and at around 9.30am, Callaway sent a �)tt ·rnessage to HG-M's mother asking, 'should I put her to bed'? This text was not answered and Callaway said that H G-M then fell asleep on the makeshift bed.

37 Callaway said that shortly after H G-M fell asleep, he then went to the toilet for about five minutes. Upon returning, he saw 'spew' down the side of H G-M's face. Following this, Callaway says he used a towel to remove the vomit from H G-M's mouth, then moved her a few metres and placed her in front of the heater in the loungeroom. H G-M vomited again in front of the heater. Callaway then commenced CPR and telephoned HG-M's mother.

38 In his second interview with police on 27 November 2018, Callaway said that after H G-M's mother left for work, he got a gun out to clean it. The guns were kept in a safe in the bedroom. H G-M's mother had hidden the keys from Callaway, in a tomato sauce bottle in the kitchen, so Callaway first had to go and find them. It is unclear how long this took him. Once he found the keys and opened the safe, Callaway said he brought one of the guns into the lounge room. He then lay on the floor of the lounge room with the gun barrel pointing out of the lounge room door and his feet touching H G-M. Callaway says from that position, he shot two magpies.

2 This took place approximately 2 hours after the death.

39 In this second account, Callaway again said he made HG-Ma makeshift bed on the loungeroom floor. It is unclear when Callaway allegedly made the makeshift bed in his revised sequence of events. It is not clear whether he asserted that he made the makeshift bed before searching for the gun keys, or between retrieving gun from the safe and shooting the magpies, or whether it occurred after the magpies were shot. In any event, at some point after the magpies were allegedly shot, Callaway says he went to the toilet. However, in this second account, Callaway said when he went to the toilet, H G-M was not asleep, and she was not breathing normally. He then said when he returned from the toilet, H G-M had vomited so he tipped her on her side, removed the vomit, he moved her next to the heater and then called her mother.

40 The inquest heard evidence of a third account given by Callaway to H G-M's maternal grandmother in the days after H G-M's death. In this third account, Callaway allegedly said that H G-M started coughing and it sounded like she was choking as there was a lot of milk around her mouth.

41 The police have never found the towel that Callaway allegedly used to scrape vomit from H G-M's mouth.

42 Callaway's accounts are uncorroborated by independent evidence and they contain significant inconsistencies including those detailed below.

(1) In his first account he makes no mention of a gun.

(2) In his first account H G-M is asleep when he went to the toilet and in his second, she was awake - this is significant in terms of the expert evidence as will be seen below.

(3) In his first account he makes no reference to H G-M having difficulty breathing.

(4) No vomit was found on any of the other items allegedly used to make the makeshift bed. Nor was there a makeshift bed in front of the lV when police filmed the inside of the loungeroom that afternoon.

43 Given the inconsistencies in his account, absent independent corroborative evidence, I could not accept any of Callaway's factual accounts of the circumstances leading up to HG-M's death.

Attempts to resuscitate H G-M 44 At approximately 9:57am, Callaway telephoned H G-M's mother to tell her to come home as H G-M was not breathing. He called her three times; speaking to her on the third occasion. He did not call 000. Instead, HG-M's mother asked a colleague to call 000 and then she and the CPR trainer, off-duty paramedic Kirsty England, and several other school staff went to H G-M's home. On the way, HG-M's mother obtained a defibrillator from the local shop.

45 Immediately on arriving at the home, England commenced CPR on H G-M.

England noted that H G-M's airway appeared clear. England could not see anything inside H G-M's mouth, but she was not breathing, and she had no pulse.

46 The defibrillator was attached to H G-M almost immediately. Data recovered from the defibrillator shows that it was attached at 10.02am. Over the next 25 minutes, the defibrillator made nine unsuccessful attempts to find a shockable rhythm in HG-M's heart. However, H G-M was asystole3 this whole time and there was a 'total cessation of electrical activity from [her] heart.' As a result, the defibrillator did not send any shocks to H G-M inside the house.

47 CPR was performed continuously on H G-M until the ambulances arrived.

England recalled thinking 'how flaccid and floppy the child was.' England 3 In simple terms, this means that H G-M's heart was 'flatlined'.

repeatedly checked H G-M's airway for any obstruction but saw nothing and nothing was dislodged with blows to HG-M's back.

48 The first ambulance arrived at 10:26am and H G-M was placed inside at 10:27am. As H G-M was carried to the ambulance, the defibrillator detected a shockable rhythm in H G-M's heart and delivered a shock. That was the first shock delivered to H G-M since 10.02am. Subsequent expert analysis indicates that this was unlikely to be a true shockable rhythm in HG-M's heart. Rather, it is likely that the defibrillator detected that H G-M was being moved and misdiagnosed it as a shockable rhythm.

49 H G-M was taken to Coonabarabran Hospital accompanied by her mother and arrived at approximately 11:00am.

50 On arrival at Coonabarabran Hospital, the medical team requested a blood gas analysis then worked on H G-M for a further 20 minutes. H G-M was asystole the whole time.

51 At 11:24am, CPR was ceased on the advice of the critical care consultant and H G-M was pronounced dead.

Who had contact with H G-M before her death?

52 Three people had contact with HG-Min the 48 hours before her death.

HG-M's mother 53 H G-M was with her mother most of the time in the 24-48 hours leading up to her death, other than: (1) the hour and a half before HG-M's death (2) a period of about 2 hours on the late afternoon of the day before her death, when her mother was asleep and Callaway left the house with H G-M by himself

(3) about half an hour on the morning of the day before her death, when H G-M was with her father for about half an hour.

54 There was no evidence before the Court to suggest that her mother was involved in, or had any knowledge of, the injuries to H G-M's head. On the contrary, the evidence was consistently that she was a kind and loving mother who doted on her daughter including repeatedly seeking medical treatment when she was unwell.

H G-M's father 55 H G-M was with her father for about half an hour on the day before her death.

Again, there was no evidence before the Court to suggest that her father was involved in, or had any knowledge of, the injuries to H G-M during this visit.

56 Her father's evidence was that H G-M was smiling and happy and fine when he handed her back to her mother that morning. Her mother's evidence was that H G-M was fine when she returned from spending time with her father. The video of H G-M that was taken that morning, and tendered into evidence, supports the evidence of both parents on this point.

Mitchell Callaway 57 Callaway was with H G-M for the entire 48 hour period leading up to her death, other than the half hour or so when H G-M was with Mark at the park.

58 In that 48 hour period, Callaway had two extended windows of time alone with H G-M: the hour and a half before she died, and approximately 2 hours on the late Sunday afternoon when he says he took H G-M to the petrol station and Woolworths.

59 Callaway's evidence about these two periods of time contains internal inconsistencies, inconsistencies with other evidence, and assertions that are unsupported by objective facts. These include his failure to refer to the gun and shooting birds in his first police interview, the inconsistency between his first

and second accounts of whether H G-M was asleep when he left the room, his true whereabouts in the period he claimed to be at the petrol station and Woolworths, and the alleged interactions with HG-M's mother described below.

60 In addition, there is evidence before the inquest that in the days and weeks following HG-M's death, Callaway repeatedly told HG-M's mother what to tell the police. Among other things, Callaway allegedly asked H G-M's mother to make sure she told police that H G-M had fallen off a toy and hit her head.

Callaway also allegedly asked H G-M's mother to make sure she told detectives he had taken her to Woolworths the previous day. The inquest heard evidence of another occasion in late 2018 when Callaway allegedly said to H G-M's mother: I'm so sorry bub. I didn't mean to hurt her.

61 Callaway has consistently denied hurting or killing or mistreating H G-M.

The resumption of the inquest and further evidence Further expert evidence 62 In the criminal proceedings referred to in paragraph 15, Callaway procured the following: (1) Professor Warwick Butt, paediatric intensive care specialist, report dated 22 October 2023 (2) Dr Molloy, neurosurgeon, report dated 4 March 2024.

63 These reports now form part of Exhibit 2 which was tendered on 11 September 2025.

64 This additional evidence was supplied to, and supplementary reports were obtained from: (1) A/P Buckland dated 10 May 2024

(2) Professor Duflou dated 1 July 2024 (3) Dr Marks dated 4 July 2024.

65 These reports, along with those referred to in paragraph 13, form the substantive expert evidence in the inquest.

66 The salient issues for consideration include: (1) the timing of HG-M's head injuries (2) the cause of HG-M's head injuries (3) the causal link between HG-M's head injuries and her death (4) the exclusion of natural causes of death (5) conclusions reached by the experts.

The timing of H G-M's head injuries 67 On the timing of the frenulum injury: (1) Dr Elstub's evidence was that there was no evidence of the injury trying to heal itself significantly. Dr Elstub said the presence of acute inflammatory cells mostly suggests that it is most likely to have happened within hours, potentially up to a day, prior to death. While it is inaccurate to date injuries on histology, the fact that some inflammatory cells were present is more suggestive that the injury happened before, rather than after, death.

(2) Professor Duflou thought that the injury could potentially be up to a couple of days old. An injury to that part of the mouth tends to be painful and can cause difficulty in feeding. He opined: I'd say more likely than not there would be indications of a problem.

(3) Dr Marks said for an injury of this kind, you would expect to see a lot of bleeding and crying. In addition, she said it would have affected H G-M's ability to eat, such that one would expect H G-M to have reacted that morning when eating breakfast. She said that there is no way you could tear the frenulum naturally; it is the result of forceful manipulation. She emphasised 'significant force'. In Dr Mark's opinion, she said that it was 'quite_likely' that the frenulum injury occurred sometime after H G-M had breakfast on the morning of her death. She also said the presence of the inflammatory reaction suggested it occurred prior to resuscitation efforts.

68 On the timing of the scalp bruising: (1) Dr Elstub said it wasn't possible to be sure, but it was possible that the scalp bruises occurred within an hour and a half of HG-M's death, and possibly 18-24 hours before her death.

(2) Professor Duflou agreed that other than one potential deposit of hemosiderin, the descriptions indicated a day or probably a couple of days, but he said, 'I have to agree that the description of the bruises themselves on microscopy are more in keeping with a shorter period than a longer period.' (3) Dr Marks' view was that the scalp bruises occurred within hours of death.

69 On the timing of the skull fractures: (1) Dr Elstub said it could have occurred anytime from within an hour of H G-M's death to potentially several weeks.

(2) Professor Duflou said that if a small area of older extradural blood proximate to the skull fracture was associated with the fracture, then it could be several days old. But if the fracture was not associated with the extradural blood, it could have occurred as recently as within an hour or two of H G-M's death.

70 A/P Buckland's evidence was that the microscopic area of extradural blood was insignificant.

The cause of H G-M's head injuries 71 As to the cause of the injuries: (1) Dr Elstub, Professor Duflou, Dr Marks and Professor Besser were all uniformly of the view that the injuries were caused by blunt force trauma.

(2) Professor Duflou said a fall from a toy could not explain the multiple blows to HG-M's head. He also thought that a fall several weeks earlier was inconsistent with the histology of the bruising, even taking account of the microscopic spot of older extradural bleeding.

(3) Dr Elstub and Dr Marks similarly agreed that a fall from a toy was unlikely to be the mechanism for HG-M's head injuries.

The causal link between H G-M's head injuries and her death 72 Dr Elstub adhered to the conclusion in her autopsy report that H G-M's head injuries were not the direct cause of her death. By that, she said that taken in isolation they were not fatal by themselves. However, she said they could be the indirect cause of death: Yeah, so there's a few possibilities. So, any blunt force trauma to the head can produce a decreased level of consciousness and it's not possible to identify that at autopsy. So, there's a couple of ways that that could result in death. So, it's possible that it could cause what we call apnoea - so we discussed this before ..(not transcribable)..of breathing. So, blunt force impacts to the head have been shown to potentially trigger a sudden death through apnoea without there being a definitively fatal traumatic injury to the brain. So, that can sometimes occur and there's no way of detecting that at autopsy.

And, then moving onto the other possible causes of injuries around the mouth, there is also a possibility of smothering. I think this one is are [sic] a little bit difficult because the injuries to the frenulum, the mouth is a blunt force mechanism anyway. So, it's possible that blunt force trauma alone has caused this injury. It is possible that smothering as a mechanism is there but sort of pulling those two apart is really tricky.

73 Professor Duflou thought that if a head injury was days old, it was less likely to bring about a sudden death several days later. He thought it was more likely that for head injuries to cause death, they needed to occur immediately before the death, not with significant delay.

74 Dr Marks said that a small child is likely to have a reaction to being hit in the head multiple times. She said: I think much more likely to have a clinical reaction to that number of impacts.

So again crying but then also much more likely to be lethargic and possibly even lose consciousness. And you could also - certainly the little one could also vomit. They're probably the main things that would be apparent in little children.

75 She said those reactions might be immediate, or they might develop over time.

Dr Marks also said that if H G-M suffered those head injuries immediately before death, it could affect her brain in a way that hadn't manifested itself at the time of her death and therefore wouldn't be detected at autopsy. She said, 'it depends on the force and severity of the initial injury as to how quickly those things develop and progress.' 76 Professor Besser concluded that there was a causal link between H G-M's injuries and her death but its exact nature and the sequence of occurrence of the injuries is speculative. He explained that multiple bluntfo�e1r8)1,;1m�s could cause a concussion injury, not reflected on neuropafliological 1efx€lm•ination, which could lead to reduced consciousness and vomiting which could then in turn lead to hypoxia, or an epileptic fit. He also opined that 'second impact syndrome' was a mechanism by which the head injuries could have indirectly caused HG-M's death.

The exclusion of natural causes of death 77 Dr Elstub did not observe anything that obstructed H G-M's airway, including vomit or milk. She said it was 'highly unlikely' that RSV was the cause of H GM's death and that enterovirus did not cause or contribute to HG-M's death. Dr Elstub concluded:

[l]t's impossible to completely rule out these undetectable natural causes, but in the setting of multiple injuries, which still remain unexplained, that do have a possible fatal mechanism, you cannot ascribe it to natural disease.

78 Professor Duflou agreed that RSV was highly unlikely to be the cause of death.

He couldn't completely exclude the possibility of a naturally occurring undetectably arrhythmia but said 'very unlikely cause' of death. He concluded that it would not be appropriate to say that H G-M suffered a natural cause of death.

79 Dr Marks and Dr Besser similarly excluded any reasonable possibility that H GM's death was caused by natural causes.

Conclusions 80 Dr Elstub said: [i]t's impossible to completely rule out these undetectable natural causes, but in the setting of multiple injuries, which still remain unexplained, that do have a possible fatal mechanism, you cannot ascribe it to natural disease. But I also cannot be definitive in my mechanism of death. I think it's really difficult to say with certainty whether it's more likely to be one or the other, but in the presence of significant injuries they cannot be set aside and they have to be seriously considered as a possible if not likely mechanism of death.

81 Professor Duflou was more guarded on the cause of death. He said: I really don't think I can say. There're injuries there and when injuries of this nature are present you really have to be concerned about what else potentially may have happened. But at this stage I'm not aware of any factual basis for that. In terms of natural disease, there really isn't enough here for a child to have died of natural disease unless you invoke natural disease without pathological evidence. But in the setting of the injuries I think that's a, you know, that's not really an appropriate approach as far as I'm concerned. I can't say which is more likely I'm sorry.

82 Dr Marks said: So as I said before that they are evidence of trauma to her skin and to her bone of her head, but those things wouldn't in and of themselves cause death. But they also indicate significant impact injury to her head. So it's the injury to the brain that could potentially be the cause of death. So, yes, so they are connected to it, yes.

83 In Dr Marks' view, the head injuries could have led directly to an apnoea, which would not have been detectable at autopsy. She said it was more likely that H G-M's death was caused unnaturally, and she could not think of a natural explanation.

84 Professor Besser excluded any reasonable possibility of natural causes and concluded that H G-M's injuries were a substantial or significant cause of her death.

85 Professor Butts concluded that: HG-M was a well-cared for infant who died of an acute sudden event, which may well have been a sudden unexpected infant death during sleep. She had several factors known to be associated with apnoea such as RSV infection, GORD causing laryngospasm; she may also have had an acute cardiac arrythmia or seizure or another condition associated with SUDI/SIDS.

She has clearly had multiple episodes of blunt force trauma to the head and face (either intentional or accidental or both) but no other evidence of injury to her eyes, body, and limbs.[...] These injuries do not explain her cause of death.

The mechanism of injury proposed by Dr Marks is highly unlikely; Professor Besser speculates a causal link but says the evidence does not confirm his view.

86 There are a number of issues with Professor Butts' opinion which make it implausible including: (1) For HG-M's cause of death to be classified as SUDI, H G-M must have been asleep at the time of her death. In only one version provided by Callaway is H G-M asleep when he went to the bathroom. Absent cogent evidence that she was asleep, SUDI is not a reasonable hypothesis.

(2) The risk factors for SUDI deaths as identified by Dr Marks, were not present.

(3) The apnoea component of the laryngeal chemoreflexes diminishes with maturation and would be unlikely to have caused death in a 9 month old.

87 Dr Molloy concluded that:

Three compelling alternatives are given for the death of HG-M which I would consider the far more likely explanation for her death than related to head trauma. These are the HG-M specific conditions; the RSV proven infection, laryngospasm secondary to the known GORD, and vomiting as a result of a documented large breakfast. [...] I would put at the top of the list of probable Cause of Death as Laryngospasm from the RSV infection mucous or laryngospasm from vomiting. This is a very reasonable hypothesis.

[...] The most likely explanation of the bruising and fracture is accidental injury[...] taken alone the frenulum injury has no value in adding to the forensic case for a cause of death.

[...] Professor Besser speculates a causal link but he himself says the evidence does not confirm his view. This is mere speculation assuming there was significant head injury at the time of death. There is absolutely no compelling evidence for this. In fact, the evidence points to the fracture occurring in the past and as accidental. The mere speculation is based on erroneous assumptions.

[...] Here we have an unusual situation of minor injuries which in normal practice would barely warrant a mention being postulated as a potential cause of death.

There are challenges associated with the diagnosis of an unexplained bruising.

Though non-accidental injury must always be considered in such cases, medical professionals should be aware of other explanations.

In common with many areas of medicine, there is no gold-standard diagnostic test for abusive head trauma. Cases are often complex and nuanced, eluding a reasonable medical certainty of abuse. However, I have never seen a case with so little evidence as this situation presents.

There are controversies on the diagnosis of child abuse balancing the concern for the welfare of the child against non-evidenced-based pronouncements of guilt.

I don't know why HG-M died. Her cause of death is unknown. Professor Butt gave an excellent summary of several reasonable possibilities. Some such as SIDS have not been tested, in as much as they can be.

I do not consider the head trauma was a factor in her death.

88 In relation to her analysis, Dr Molloy was an 'outlier' in that:

(1) she was the only expert that suggested a large breakfast was causative.

This appears an unlikely factor absent any evidence of vomit at the scene.

(2) she was the only expert that suggested RSV as causative � all other experts ruled it out.

(3) she was the only expert that opined that the injuries were more likely to have been accidental.

89 I did not find Dr Molloy's opinion to be persuasive in the context of the entirety of the available expert evidence.

Summary of medical evidence 90 Cause of death: the experts agreed that no cause of death could be positively identified, but they were divided on whether a natural cause of death could be excluded. The experts retained on behalf of Callaway opined that a natural cause of death could not be excluded. However, for the reasons outlined I reject the opinions of Professor Butt and Dr Molloy leaving the consensus view that the cause of death was not natural.

91 Manner of death: in the period leading up to her death, H G-M suffered a series of head injuries that were caused by blunt force trauma. The mechanism of injury is unknown. All of the experts agreed that the timing is uncertain. The experts could not agree on whether they were inflicted deliberately or accidentally. Nor could the experts agree on whether there was a link between HG-M's head injuries and her death. While Professor Besser concluded that H G-M's injuries were a substantial or significant cause of her death, the balance of the experts either disagreed (particularly Professor Butts and Dr Molloy) or were equivocal.

Statutory findings required bys 81(1) 92 I am satisfied that the person who died is H G-M. She died on 23 July 2018, at around 10.00am 93 Having carefully considered the expert evidence adduced in this inquest, I am unable to determine HG-M's cause of death.

94 H G-M had sustained a series of head injuries shortly before her death as a result of blunt force trauma. While the cause of those injuries and the circumstances in which they occurred is unknown, their close proximity to her death, the absence of a credible explanation for any of them, and the material inconsistencies on Callaway's account of his movements in the timeframe in which the injuries were inflicted, collectively support a finding, on the balance of probabilities, that the injuries were not accidental and that the death itself was not natural.

95 I therefore find in relation to manner of death, that H G-M died suddenly and unnaturally following a series of head injuries shortly before her death as a result of blunt force trauma.

Recommendations 96 While unable to make a finding on the balance of probabilities that H G-M's death was homicide, it remains a strong possibility.

97 In the circumstances I make the recommendation below.

To the Commissioner of Police: That the death of H G-M be referred to the Unsolved Homicide Team of the NSW Police Homicide Squad for further investigation in accordance with the protocols and procedures of that Team.

Concluding remarks 98 I will close by conveying to H G-M's family, their friends and the broader community, my sympathy for the tragic loss of baby H G-M.

99 I acknowledge the trauma to first responders who came to assist H G-M and her family.

100 I thank the Assisting team, Chris Mitchell, Jessica Best, Harriet Griffin and Claudia Hill for their support in the conduct of this inquest. I thank Detective Senior Constable Michael Morris for his work in conducting the investigation and compiling the brief of evidence. There is no more difficult a matter than that involving the sudden and unexpected death of a child.

I close this inquest.

r Magistrate R Hoskin� Deputy State Coroner Lidcombe **********