Inquest into the disappearance and suspected death of Sana Salman

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the suspected death of missing person Sana Salman Hearing dates: 23 October 2025 Date of Findings: 31 October 2025 Place of Findings: Coroners Court of New South Wales, Lidcombe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – whether missing person now deceased, date and place of death, cause and manner of death, North Head, search operation File number: 2023/42462 Representation: Mr D Welsh, Coronial Advocate Assisting the Coroner Findings: Sana Salman, who was reported to a missing person to the New South Wales Police Force on 2 September 2022, is now deceased.

Ms Salman died on, or sometime after, 1 September 2022.

The available evidence does not allow for any finding to be made as to the place of Ms Salman’s death.

The available evidence does not allow for any finding to be made as to the cause of Ms Salman’s death.

The available evidence does not allow for any finding to be made as to the manner of Ms Salman’s death.

Table of Contents

1. Introduction 1.1 On 1 September 2022, Sana Salman, a 34-year-old woman, left her home in Avalon and travelled by public transport, first to Brookvale and then to Manly Wharf. In the months prior, Sana had been engaged with community mental health services and had been admitted to hospital between 10 and 22 August 2022. Previous arrangements had been made for Sana to attend an appointment with a psychiatrist at 1:00pm on 1 September 2022.

1.2 After arriving at Manly Wharf, Sana was captured by a CCTV camera at 1:01pm to be walking east along North Head Scenic Drive towards North Head. Sana’s mobile phone had been turned off a short time earlier. Sana kept walking east and was not seen again.

1.3 After Sana did not turn up to hr scheduled appointment, a concern was raised for Sana’s welfare and the New South Wales Police Force (NSWPF) were contacted. Sana was later regarded as a missing person and from the afternoon of 1 September 2022, various enquiries and search efforts were made to locate Sana. These enquiries and efforts continued over the subsequent weeks and months but did not locate Sana or any signs that she was still alive.

2. Why was an inquest held?

2.1 After Sana could not be located, the NSWPF submitted a report to the Coroner on 2 February 2023 that it was suspected that Sana was deceased. When the case of a missing person, who is suspected to have died, is reported to a Coroner, the Coroner must determine from the available evidence whether that person has in fact died.

2.2 If a Coroner concludes that a missing person has died then the Coroner is required to make findings, if possible, to determine the identity of the person who died, when and where they died, and what the cause and the manner of their death was. The manner of a person’s death means the circumstances in which that person died. If a Coroner is unable to answer these questions then an inquest must be held.1 2.3 Despite an extensive search effort, Sana has not been found and the NSWPF investigation has not found any sign of her since 1 September 2022. It has therefore not been possible to answer all of the questions that a Coroner is required to answer. Therefore, it is mandatory for an inquest to be held.

2.4 In this context it should be recognised at the outset that the operation of the Act, and the coronial process in general, represents an intrusion by the State into what is usually one of the most traumatic events in the lives of family members who have reported a loved one as missing. At such times, it is reasonably expected that families will wish to attempt to cope with the consequences of such a traumatic event in private. The sense of loss experienced by family members does not diminish significantly over time. Therefore, it should be acknowledged that both the coronial process and an inquest by their very nature unfortunately compel a family to re-live distressing memories and to do so in a public forum.

1 Coroners Act 2009, section 27.

3. Sana’s life 3.1 Inquests and the coronial process are as much about life as they are about death. A coronial system exists because we, as a community, recognise the fragility of human life and value enormously the preciousness of it. Understanding the impact that the death of a person has had on those closest to that person only comes from knowing something of that person’s life. It is hoped that what is set out briefly below acknowledges Sana’s life in a meaningful way.

3.2 Sana was born in 1988 in the Kingdom of Saudi Arabia and was the second daughter to Lhalliata Mohammed Younis and Aliya Younis. Sana’s parents were born in Pakistan. Sana had an older sister, Mahin, and a younger sister, Ayesha.

3.3 Sana’s family lived in Saudi Arabia for a year before moving to Bahrain where they stayed for several years. The family later moved to Kuwait and then Malaysia.

3.4 At school, Sana excelled at sports and the arts. She was known as a loyal friend and someone who looked after those around her. Sana’s family affectionately called her “Snoopy” as she was fascinated with the character from childhood.

3.5 Whilst the family was living in Malaysia, Sana moved to Switzerland to study hospitality. After returning to Malaysia for a period of time, Sana travelled to Australia on a student visa to continue her studies. In March 2013, Sana completed a Bachelor of Design.

3.6 Sana’s family describe her greatest strengths as her deep compassion and empathy for others. She possessed a strong sense of right and wrong and was never afraid to stand up to anyone who tried to intimidate others. Sana was also known for her quick wit and sense of humour, often bringing laughter and light to even the most difficult situations. Sana also had a sense of adventure and loved to travel.

3.7 Sana’s family have fond memories of celebrating her birthday with her in Pakistan in April 2022.

During that visit, Sana cherished spending time with her loved ones, enjoying shopping trips, and sharing all her favourite foods together.

3.8 There is no doubt that Sana is greatly missed by her family and loved ones, and that the uncertainty that has surrounded Sana going missing has only compounded the grief and loss that they have tragically experienced.

4. Sana’s social history 4.1 In 2012, Sana met Simon Jacek. They became friends and later formed a relationship. In 2013, Sana and Mr Jacek moved to Perth where Sana studied a business course.

4.2 In 2016, Sana and Mr Jacek returned to Sydney and they lived together at a property in Avalon Beach, the home of Mr Jacek’s parents. Sana completed several certificate courses in information technology whilst working at a Woolworths in Warriewood.

4.3 In around April or May 2020, Mr Jacek asked Sana to move out and she relocated to shared accommodation in Therry Street, Avalon Beach (Therry Street Property) where she rented a bedroom.

4.4 Whilst living at the Therry Street Property, Sana became close friends with Christopher Wheeler.

They talked regularly around the house and Mr Wheeler often checked on Sana.

4.5 Sana was employed as a supervisor at Woolworths and responsible for managing staff at the front of the store. She typically worked a shift from 12:30pm until 9:00pm. Sana’s manager, Sylvia Zappia, considered Sana to be a mostly happy person who was at times very quiet. Sana was known to occasionally socialise with her colleagues after work.

4.6 In mid-2022, the Woolworths closed for several months for refurbishment. Sana took the opportunity to travel to Pakistan in April 2022 to visit her family and celebrate her birthday.

4.7 When Sana returned from her trip, her work colleagues noticed a change in her, with some describing her as withdrawn, sad and not engaging with other staff. In contrast, Mr Wheeler did not notice any change in Sana’s behaviour. To him, Sana returned to work and went about her normal routine as usual.

4.8 In the period leading up to August 2022, Mr Jacek noticed a decline in Sana’s mental health and asked her to stay with him at his parents’ home. Sana stayed with Mr Jacek for one night during which she reportedly displayed extreme paranoid and delusional behaviour, expressing a belief that Mr Jacek was involved in a conspiracy against her.

5. Sana’s medical history 5.1 Sana had previously been diagnosed with bipolar disorder (in 2013) and schizoaffective disorder (in 2016).

5.2 In 2016, Sana was admitted to a mental health facility in Manly after presenting paranoia and delusions. At around this time, Sana first had contact with the Queenscliff Mona Vale Community Mental Health Service.

5.3 Sana had a further admission to the same facility in October 2018 following an apparent self-harm attempt after overdosing on prescription medication. At the time, Sana reportedly feared being sent home from Australia following the expiry of the passport.

5.4 In June and July 2019, Sana was admitted to another mental health facility after presenting with increasing stress and anxiety. Concerns were also raised for Sana’s increasing consumption of alcohol as a means to cope with anxiety. During her admission, Sana commenced taking clozapine.

5.5 On 17 March 2020, Sana saw Dr Louis Ereve, psychiatrist. It was noted that Sana had nil delusions and no thoughts of self-harm. Sana was prescribed clozapine and venlafaxine. Dr Ereve continued to review Sana throughout 2020 and 2021.

5.6 On 22 April 2022, Dr Ereve reviewed Sana and noted that she had ongoing mild severity paranoid and referential thoughts but was still maintaining a higher level of function. Following assessment, it was noted that Sana had a stable mental state and mild symptoms and was at low risk of harm to herself and to others.

Engagement with community mental health services 5.7 On 19 May 2022, Grace McBreaty, Sana’s Care Coordinator from Brookvale Community Mental Health Service (BCMHS), called Sana to follow-up regarding her trip to Pakistan. Sana reported feeling “fine” since her return and denied psychotic symptoms. Arrangements were made for Sana to be reviewed by Dr Ereve at the beginning of July 2022 when her clozapine prescription was due.

5.8 On 20 June 2022, Dr Ereve reviewed again. She reported paranoid thoughts that someone was going to harm or kidnap her. Sana also reported that her trip had been uneventful but that it had brought back distressing memories of past trips when she had fears of being kidnapped. Sana was reminded to increase her clozapine to the prescribed dose and was also commenced on aripiprazole.

5.9 Following this review, Dr Ereve had asked Ms McBrearty to see Sana in person and provide support.

Dr Ereve also asked Sana to see her GP to formulate a mental health care plan for her to see a psychologist.

5.10 On 29 June 2022, Sana met with Ms McBrearty. Sana reported increased paranoia at her previous review with Dr Ereve but indicated that she had felt some improvement since then from being prescribed aripiprazole.

5.11 On 15 July 2022, Dr Ereve reviewed Sana and noted a significant deterioration. Sana expressed firm paranoid beliefs and Dr Ereve was concerned about self-neglect and isolation. Dr Ereve adjusted Sana’s medications and organised for out of hours contact by an Acute Care Team (ACT) to assess Sana for risk of harm to herself or others.

5.12 On 18 July 2022, Dr Ereve conducted a telehealth review of Sana. She reported that her paranoid delusions had significantly worsened and that she had been unable to leave her home for the previous three days. Sana also reported that she had not eaten for the last two days and not had a shower for the last seven days. Dr Ereve again liaised with the ACT to visit Sana at home and consider the need for transfer to hospital.

5.13 Later that day, the ACT visited Sana at home. It was noted that Sana was able to take her nighttime medications, buy food at a local shop, make food at home and eat.

5.14 On 19 July 2022, Dr Ereve reviewed Sana in person. She reported that her paranoid thoughts were present but less severe. Sana felt that the deterioration in her symptoms appeared to coincide with difficulties adjusting to new arrangements and changing shifts at her work. Dr Ereve considered that Sana had experienced an improvement in her symptoms and arranged for Ms McBrearty to see her again on 21 July 2022, and for the ACT to review her over the weekend of 23 and 24 July 2022.

5.15 On 21 July 2022, Ms McBrearty attempted to contact Sana but was unable to do so. Ms McBrearty left voicemail messages for Sana and sent her a text message asking her to contact BCMHS. Sana later returned Ms McBrearty’s call and reported feeling scared but otherwise fine, denying any suicidal ideation or thoughts of self-harm.

5.16 On 22 July 2022, Sana was discussed at a multidisciplinary team meeting and it was noted that she had increased psychotic symptomology. Later that day, Ms McBrearty attempted to contact Sana without success. Follow-up by the ACT was requested.

5.17 On 27 July 2022, Ms McBrearty called Sana who reported persistent feelings of fear and paranoia.

Sana also reported adequate fluid intake but limited food consumption, denying any suicidal thoughts. Ms McBrearty encouraged Sana to take time off work to focus on her well-being but she declined to do so.

5.18 On 3 August 2022, Sana underwent a clinical review. It was noted that she presented as suspicious and hypervigilant with paranoid and persecutory delusions. It was also noted that Sana had experienced recent relapse of psychosis probably due to variable compliance with her clozapine prescription. Sana declined an offer of involuntary admission to Northern Beaches Hospital (NBH).

Instead, she agreed to take the increased dose of clozapine with the ACT calling her each night to prompt and encourage her to take the correct dose.

5.19 On 4 August 2022, Ms McBrearty spoke to Sana on the phone following multiple attempts to contact her. Sana initially indicated that she had not been to the pharmacy yet to collect her medication but later called Ms McBrearty back confirming that she had done so.

Admission to Northern Beaches Hospital 5.20 On 10 August 2022, Sana was reviewed by the Northern Beaches Community Mental Health Team.

She was found to be presenting with thought blocking and delusions of persecution, expressing the belief that her safety was in danger and that her food had been tampered with. As a result, the team brought Sana to the emergency department at NBH.

5.21 When reviewed, Sana reported that she was suspicious of unnamed groups of people and also her housemates. Sana also reported that she had not been compliant with her medication as she was often working afternoon and night shifts which made her forget about her evening doses of medication. Sana was later admitted as an involuntary patient due to the risk posed to her from selfneglect.

5.22 On 11 August 2022, Sana was reviewed by Dr Matthew Lennon, psychiatric registrar. Sana reported some intermittent thoughts of self-harm but denied any current thoughts of self-harm at the time of review. Following this, Sana’s dose of clozapine was increased.

5.23 On 15 August 2022, Sana was reviewed by Dr Lennon and Dr Peter Jones, consultant psychiatrist.

Sana reported that she was eating and sleeping better and was less worried about her food being poisoned. Whilst Sana expressed some paranoia about her housemates it was considered that she

had generally improved. Sana’s clozapine was increased with a view to discharging her the following week.

5.24 On 18 August, Dr Lennon reviewed Sana again. It was noted that Sana remained concerned that people were still after her but was much less worried about her food being poisoned.

5.25 On 22 August 2022, Dr Lennon reviewed Sana. It was noted that she reported feeling tired on the increased dose of clozapine and that she had some underlying worrying or anxiety. However, it was considered that Sana had improved considerably compared to the week before and that she no longer had the level of anxiety or worry that she had while in the community prior to her admission.

Discharge planning was commenced with Sana to be supported by case managers in the community.

Discharge from hospital 5.26 On 22 August 2022, preparations were made for Sana to be discharged. Initially, Sana indicated some stress and so plans were made for her discharge to occur the next day. However, later in the day Sana expressed a preference to be discharged that afternoon and accordingly these arrangements were made. It was noted that during her admission, Sana had been diagnosed with a psychotic relapse of paranoid schizophrenia secondary to poor compliance with clozapine.

5.27 On the afternoon of 23 August 2022, Ms McBrearty called Sana who reported feeling a bit anxious but feeling better than before her admission to NBH. Sana also reported that she was taking her clozapine as prescribed. Arrangements were made for a medical review the next day.

5.28 On 24 August 2022, Sana did not attend the scheduled medical review. Ms McBrearty later called Sana who apologised and indicated that she had slept in. Sana was reminded to collect and take her medication but she reported feeling anxious and had not been outside since her discharge.

Arrangements were made for Sana to attend a medical review the next day.

5.29 On 25 August 2022, Sana attended the medical review and presented as unwell, mildly perplexed, mildly overwhelmed and somewhat thought blocked. Sana reported feeling uncomfortable at home with her flatmates and with leaving home. Arrangements were made to review Sana in a week and to increase her dose of aripiprazole.

5.30 On 30 August 2022, Ms McBrearty called Sana and left a message reminding her about her medical appointment the next day and asked her to return the call.

6. Events of 31 August 2022 and 1 September 2022 6.1 On 31 August 2022, Sana contacted Ms McBrearty and told her that she would not be attending the medical review that was scheduled for that day. Sana reported that she was struggling to get out of the house. Sana also reported having some interrupted sleep and feeling anxious and panicky at times. Sana also indicated that she was taking her medications as prescribed. Sana’s review was rescheduled to 1:00pm the next day.

6.2 Later that evening, Sana met up with Mr Jacek. They ordered some takeaway food and had dinner at Sana’s home. Sana appeared relaxed to Mr Jacek but he noticed that she continued to make brief references to being worried about a conspiracy and about people being “out to get her”. After dinner, Mr Jacek left and returned home.

6.3 At 3:17am on 1 September 2022, Sana’s mobile phone accessed the internet for about 2 hours and 30 minutes. At 6:19am, Sana’s mobile phone again accessed the internet for about 2 hours and 12 minutes.

6.4 At 9:28am, Sana called Ms McBrearty and asked the reschedule her appointment at 1:00pm that day.

Mobile tower records indicate that Sana made this call from her home. Sana reported feeling too tired to attend and that she was struggling to get out of the house. Following encouragement from Ms McBrearty, Sana agreed to attend the appointment at 1:00pm.

6.5 At 9:55am, Sana sent a text message to her manager indicating that she had seen her doctor who advised her to “take further time off until next week”. At 10:12am, Ms McBrearty called Sana’s phone but the call was terminated.

6.6 At 10:51am, mobile phone records indicate that Sana travelled south by bus. At 11:15am, Sana received a call from a friend but did not answer it.

6.7 At 11:30am, Sana got off the bus at Brookvale and entered Warringah Mall. She was captured on CCTV footage wearing a black hooded jumper, long black pants, a black pair of sports shoes, and to be carrying a long grey overcoat and a black handbag.

6.8 At 11:44am, Sana entered a Coles supermarket where she bought some mandarins and a bottle of water, paying for these items with her debit card at 11:52am. Sana made her way to a carpark on the first level where she remained briefly before making her way back inside the mall.

6.9 At 11:57am, Sana exited the mall and walked to a bus stop on Pittwater Road where, at 12:04pm, she caught a bus to Manly Wharf.

6.10 At 12:33pm, Sana was captured on CCTV footage walking across Manly Wharf forecourt towards Manly Wharf Bar. As Sana approached the bar she handed some money from her purse to a person in need of spare change and continued walking along East Esplanade and out of sight at 12:35pm 6.11 Sometime between 12:34pm and 12:37pm, Sana’s mobile phone last accessed a cell tower in South Manly before the phone was turned off.

6.12 At 1:01pm, Saba was captured on CCTV footage walking east past 29 North Head Scenic Drive towards North Head and out of view.

7. Events of 2 September 2022 7.1 On the morning of 2 September 2022, Ms McBrearty went to Sana’s home but could not raise her. Ms McBrearty had earlier called Sana’s mobile phone and sent her an email, without receiving any response.

7.2 After being unable to raise Sana, Ms McBrearty contacted Mona Vale police station to ask that a welfare check be performed. Ms McBrearty also asked BCMHS to contact Mr Jacek who attended Sana’s home a short time later. It was noted that whilst the front door was unlocked, Sana’s bedroom door was locked. Mr Jacek suggested that Sana may have gone for a walk to the beach which was her usual routine. Ms McBrearty contacted Sana’s employer who indicated that Sana remained on sick leave.

7.3 NSWPF officers attended Sana’s home that afternoon and gained entry to her room. It was noted that Sana’s room was in complete disarray and unkempt. Whilst Sana’s medication was found on a bedside table, the NSWPF officers were unable to locate any wallet or handbag belonging to Sana.

7.4 Sana was subsequently regarded as a missing person. That afternoon a number of preliminary inquiries were made to locate her including:

(a) a Keep a Lookout notice created on the NSWPF radio and Computer Aided Dispatch system;

(b) enquiries were made with hospitals in the Northern Beaches area to ascertain if Sana had been admitted as a patient;

(c) enquiries were made at Sana’s workplace;

(d) patrols were conducted at Avalon Beach;

(e) as Sana was known to have an interest in Buddhism and had previously visited Buddhist temples and centres in Newtown and Enmore, enquiries were made at these locations;

(f) a NSWPF Event was created and a risk assessment was performed leading to a medium risk rating given Sana’s mental health history.

7.5 None of the above steps located any sign of Sana.

8. Enquiries and search efforts to locate Sana 8.1 Over the following months, the NSWPF made extensive efforts to locate Sana or any sign of her. A summary of these efforts is set out below:

(a) various enquiries were made with Ayesha, Mr Jacek, Mr Wheeler, Sana’s manager, and Sana friends.

(b) a statewide broadcast, including a picture of Sana, was sent to NSWPF staff requesting assistance to locate Sana;

(c) the Buddhist temples and centres in Newtown and Enmore were visited multiple times to check whether Sana had attended;

(d) records of Sana’s financial accounts were obtained which identified her transactions at Warringah Mall on 1 September 2022;

(e) enquiries were made regarding CCTV cameras installed at public and private locations in the Northern Beaches area which identified Sana’s last known movement on 1 September 2022;

(f) repeat enquiries were made with hospitals in the Northern Beaches area;

(g) enquiries were made with Medicare which revealed that Sana had not made any claim since 25 August 2022 at Avalon when she obtained her prescription medication;

(h) enquiries with made the Australian Border Force which confirmed that Sana had not departed Australia using travel documents in her own name;

(i) after obtaining consent from Ayesha for a media release was issued requesting information from the public regarding Sana;

(j) multiple canvasses were conducted of Sara’s neighbours, areas she was known to frequent, and the area around Manly Wharf and North Head Scenic Drive where she was last seen;

(k) Sana’s call charge records were obtained which revealed that her mobile phone was last used to access data at 11:52am near a cell tower in Manly South;

(l) several geo-targeted SMS messages were sent by the NSWPF Media Unit;

(m) several extensive air, land and sea searches were conducted of North Head and surrounds, including the cliffs and sea areas around North Head, using personnel form the NSWPF, State Emergency Service and Rural Fire Service, cadaver dogs, and assets from the NSWPF Marine Command, Aviation Command (known as PolAir) and the Westpac rescue helicopter;

(n) multiple foot patrols were conducted in the areas along and surrounding North Head Scenic Drive;

(o) a drone was used to conduct a search of inaccessible areas withing North Head;

(p) samples were collected from Sana’s personal belongings and also from her family for the purposes of DNA comparison;

(q) reported sightings of persons believed to be Sana were followed up and investigated with no reliable evidence that any of the persons were in fact Sana; and

(r) a number of documentary and electronic searches, which are commonly known as “signs of life checks”, were made with financial institutions, government organisations, and interstate law enforcement agencies to identify whether there are any records indicating that Sana had some interaction with these organisations and institutions after 1 September 2022.

8.2 None of the extensive enquiries or search efforts described above were successful in locating Sana or any evidence as to what happened to her after she was last seen on North Head Scenic Drive on 1 September 2022.

9. Is Sana now deceased?

9.1 The first finding that a Coroner must make following an inquest into the suspected death of a missing person is whether that person is now deceased. A finding that a person is deceased is a finding of great significance and gravity, not only for the family members of that person and the emotional burden that such a finding will invariably bring, but also because such a finding carries with it important legal and administrative consequences. Such a finding is made on the balance of probabilities, but there must be clear, cogent and exact evidence that a missing person has died before it can be made.2 9.2 The available evidence establishes the following:

(a) Despite extensive and comprehensive physical, documentary and electronic searches no evidence has been identified indicating that Sana is still alive.

(b) The various signs of life checks which have been performed have not produced any evidence that Sana is still alive.

(c) Sana enjoyed a good relationship with her parents and sisters. Even though Sana lived in Sydney, and her sisters lived interstate and overseas, Sana kept in regular contact with them.

There is no plausible reason why Sana has not maintained this contact with her family since 1 September 2022 or otherwise informed her family of her whereabouts and reason for not maintaining contact.

(d) Sana’s previous mental health history, previous admissions to hospital and engagement with community mental health services meant that she was particularly vulnerable at the time that she went missing, especially in circumstances where Sana was known to not always be compliant with her prescribed medication which could lead to exacerbation of her symptoms.

9.3 Some of the evidence suggests that Sana, who was known to be a spiritual person, may have decided to pursue a monastic lifestyle and live “off grid”. However, there is no evidence that Sana took any definite steps to make such a change in her life and follow such a lifestyle.

9.4 There is also no evidence that Sana undertook any preparation for such a significant change in her life in the days and weeks leading up to 1 September 2022. Almost all of her belongings were left behind at the Therry Street Property and there is no evidence that Sana accessed any of her finances after 1 September 2022 which would likely have been required to establish an entirely new lifestyle.

Indeed, the evidence regarding Sana’s movements on that day instead suggest a degree of spontaneity or uncertainty with her travelling to Brookvale and then to Manly for no apparent reason.

2 Briginshaw v Briginshaw (1938) 60 CLR 336.

9.5 Further, although Mr Jacek gave evidence Sana had previously visited North Head up to two years, and possibly more, prior to September 2022, there is no evidence of Sana having detailed knowledge or familiarity with the area. Therefore, Sana’s motivation for travelling to this location on 1 September 2022 cannot be reliably discerned.

9.6 Finally, as part of the NSWPF investigation, CCTV footage of the two main arterial roads leading into and out of North Head was reviewed from 1 September 2022 until the following morning. Sana was not seen in any of the footage to leave North Head.

9.7 Having regard to all the matters set out above, the conclusion that must, sadly, be reached is that, on the balance of probabilities, Sana is now deceased.

10. When and where did Sana die?

10.1 Having concluded that Sana is now deceased, the questions that now arise, as part of the functions of the coronial jurisdiction, are whether the available evidence allows for any finding to be made as to where and when Sana died, and the cause and manner of her death.

10.2 As to the date of Sana’s death, the evidence establishes that she was last known to be alive at 1:01pm on 1 September 2022 when she was captured on CCTV footage on North Head Scenic Drive. Whilst there is no other evidence of Sana being alive after this point in time, there is equally also no evidence of when Sana in fact died. Therefore, the only finding that can be made is that Sana died some time on or after 1 September 2022.

10.3 As to the place of Sana’s death, as noted above there is no evidence that she left North Head via the two main exit points. The NSWPF investigation identified that it is possible for a person to take the one kilometre Shelly Beach to Barracks Precinct Walk through bushland in order to avoid being captured by CCTV cameras when leaving North Head. Further, if Sana had entered the waters around North Head, either intentionally or as a result of misadventure, it is possible that she could have died at a location not within North Head. Therefore, the available evidence does not allow for any reliable finding to be made as to the place of Sana’s death.

11. What was the cause and manner of Sana’s death?

11.1 The manner of a reportable death typically falls into a number of well-established categories: natural causes, misadventure, intentionally self-inflicted and, sometimes, homicide. From the available evidence, only limited conclusions can be reached as to the possible manner in which Sana died.

11.2 First, as at 1 September 2022, Sana was not known to be suffering from any underlying medical condition that might have suddenly and unexpectedly caused her to die from natural causes. The likelihood of this occurring is considered even more remote because if Sana had suddenly collapsed from a medical episode and been unable to seek assistance, it is likely that the extensive search efforts would have located some sign of Sana.

11.3 Second, the NSWPF investigation did not identify any evidence considered to be suspicious regarding the circumstances in which Sana went missing. Similarly, there is no evidence that any third party had any involvement in Sana going missing.

11.4 Third, Sana’s mental health history and her travel to North Head on 1 September 2022 for no apparent reason raises the possibility that Sana may have been intending to cause her own death.

As noted already, Sana previously attempted self-harm in 2018 by prescription medication overdose. However, Mr Jacek gave evidence that he considered Sana’s actions to be impulsive and out of character rather than a result of a genuine intention to end her life. Further, there is no evidence that Sana had made any other self-harm attempt since 2018.

11.5 Indeed, the evidence from the clinicians involved in Sana’s treatment and management is consistently that Sana had not expressed any thoughts of self-harm in her interactions with them.

Dr Lennon gave evidence that Sana did not express any clear thoughts of suicidal ideation to him or the nursing staff involved in her care during her presentation to hospital in August 2022. Dr Lennon also gave evidence that during her admission, Sana denied any thoughts of suicidal ideation or intent and that his assessment at the time was that Sana was at low risk of self-harm.

11.6 Similarly, Dr Ereve gave evidence that during the entire period that he was engaged with Sana, she had not expressed any suicidal thoughts or ideation, or exhibited any warning signs that she was at risk of self-harm. Finally, Ms McBrearty gave evidence that during her interactions Sana had never mentioned the possibility of self-harm. To the contrary, Ms McBrearty gave evidence that when asked, Sana consistently denied having any suicidal thoughts or ideation.

11.7 Fourth, it is possible that Sana may have died as a result of misadventure sometime after she was last seen on CCTV footage on 1 September 2022. Several factors are relevant to this possibility. Sana had a history of not always being compliant with her medication regime. There is no evidence that Sana left home on 1 September 2022 with sufficient medication. Dr Lennon gave evidence that if Sana were to suddenly stop or reduce her medication this would result in a rapid onset of her previous psychotic symptoms. Dr Ereve similarly gave evidence that if Sana ceased taking her medication she was at high risk of relapse of psychotic symptoms and paranoia. This in turn created a high risk that Sana’s self-neglect would become “dramatically worse”. In this regard, the evidence establishes that when Sana had previously not taken her medication consistently she showed signs of self-neglect. Consequently, Sana had difficulty maintaining sufficient levels of nutrition and hydration.

11.8 All the above leads to a conclusion that as at 1 September 2022, Sana was a vulnerable person at risk of being unable to care for herself. In addition, Sana was travelling to an unfamiliar location with no additional clothing, equipment, food or water to provide shelter and sustenance. Finally, North Head Sanctuary consists of areas of dense bushland and treacherous cliffs. Combined, these factors establish that the possibility that Sana died as a result of misadventure cannot be excluded.

11.9 Having regard to each of the above matters, the available evidence does not allow for any reliable conclusion to be reached as to the manner of Sana’s death. There is simply not enough known about Sana’s movements after 1:01pm on 1 September 2022 and what may have occurred to her to exclude any of the possibilities described above.

11.10 Similarly, as Sana has not been found, a post-mortem examination has obviously not been performed to determine a precise cause of her death. Whilst a sudden and unexpected natural cause of death for Sana is considered unlikely, it remains a possibility that an underlying medical condition may have manifested for the first time and caused sudden death. Equally, Sana may have sustained an injury which she was unable to treat or from which she was unable to self-rescue. Without adequate preparation and supplies, Sana may have been exposed to environmental factors which could have caused or contributed to her death. Overall, no reliable finding can be made as to the cause of Sana’s death.

12. Findings pursuant to section 81(1) of the Act 12.1 Before turning to the findings that I am required to make, I would like to acknowledge, and express my gratitude to Ms Karissa Mackay, Coronial Advocate, for her admirable assistance in preparing the matter for inquest, and to Mr Durand Welsh, Coronial Advocate, for his equally noteworthy assistance during the inquest. I also thank Ms Mackay and Mr Welsh for the sensitive manner in which they have approached this matter and engaged with Sana’s family.

12.2 I also thank Detective Senior Constable Amy-lee Austin, the NSWPF Officer-in-Charge, for conducting a comprehensive investigation of high quality which assisted the inquest greatly.

12.3 The findings I make under section 81(1) of the Act are: 12.4 Sana Salman, who was reported as a missing person to the NSWPF on 2 September 2022, is now deceased.

Identity The person who died was Sana Salman.

Date of death Ms Salman died on, or sometime after, 1 September 2022.

Place of death The available evidence does not allow for any finding to be made as to the place of Ms Salman’s death.

Cause of death The available evidence does not allow for any finding to be made as to the cause of Ms Salman’s death.

Manner of death The available evidence does not allow for any finding to be made as to the manner of Ms Salman’s death.

13. Epilogue

13.1 On behalf of the Coroners Court of New South Wales, I offer my sincere and respectful condolences, to Sana’s parents and sisters, her other family members, loved ones, and friends.

13.2 The profound uncertainty and loss experienced by a family when a loved one goes missing cannot be adequately expressed in words. It is hoped that, in due course, further information may become available to enable Sana’s family to obtain some measure of comfort and peace arising from this tragic circumstance.

13.3 I close this inquest.

Magistrate Derek Lee Deputy State Coroner 31 October 2025 Coroners Court of New South Wales