BROWN Samuel Timothy

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Samuel Timothy Brown TITLE OF COURT: Coroners Court

JURISDICTION: SOUTHPORT FILE NO(s): 2012/4293 DELIVERED ON: 7 March 2024 DELIVERED AT: Brisbane HEARING DATE(s): 14 July 2017; 19-21 March 2018; 21-22 May 2018 FINDINGS OF: Stephanie Gallagher, Deputy State Coroner CATCHWORDS: Coroners: inquest, cause of head injury, competing expert opinions

REPRESENTATION: Counsel Assisting: Ms RV Helsen Mr J Hartley: Mr B Reilly instructed by Jacobson Mahony Commissioner of Police: Mr IP Fraser, Queensland Police Service

Contents

History of matter

1. Samuel Timothy Brown had attended the 22nd birthday party of a friend, Josh Searles, on 24 November 2012 in Mermaid Waters. Late in the evening, Samuel and another friend, Robert Cosgrove, decided to go out to Broadbeach. They tried to catch a bus but were too intoxicated – they had a bottle of Canadian Club with them, and also a bottle of soft drink. Mr Cosgrove says they then decided to walk to Broadbeach. Initially Mr Cosgrove told Police that, at some point, he noticed that Samuel was not with him, but he couldn’t find him. Samuel’s mobile phone had apparently run out of battery. Later, Mr Cosgrove admitted that he deliberately left Samuel sitting on the side of the road because he wanted to go to Broadbeach and Samuel was too drunk. Mr Cosgrove’s phone records show that he called a taxi at 2:18am.

2. At around 2:25 am on 25 November 2012, Samuel was found lying on his back in the middle of the northbound bus and parking lane on the Gold Coast Highway, Mermaid Beach, approximately 100 m north of Heron Avenue. He died at the Gold Coast Hospital in Queensland on 26 November 2012. Samuel was 20 years old when he died.

3. The cause of death was determined to be a head injury. The head injury was a severe skull fracture to the right base of the skull. There were fractures to the right and left of the mandible, and a fracture of the left cheek bone suggesting impact to that area. There were abrasions to the back of the right shoulder and on the underside of the left arm. Internal bruising was noted in the soft tissues of the left chest wall. The pathologist concluded that the overall pattern of the injuries found was suggestive of impact with a vehicle, with the main sites of injury to the head and chest, as well as a significant impact to the under-surface of the chin. Toxicology showed that Samuel had a blood alcohol level of 0.241% shortly after his admission to hospital.

4. The Forensic Crash Unit (FCU) of Police investigated and a report of the investigation was prepared by Senior Constable Steve Cornish. SC Cornish considered whether Samuel had been hit by a vehicle; was the victim of an assault; sustained the injuries in a fall; or some combination of the three. A number of possible vehicles were examined and no relevant DNA or other forensic evidence was found which would link them to Samuel. It was considered unlikely that Samuel had been assaulted by unknown persons as he had no defensive wounds and he still had his wallet and phone on him. Mr Cosgrove was considered a possible assailant but this was considered unlikely given the extent of Samuel’s injuries. As for a fall, SC Cornish considered whether Samuel may have fallen from a nearby fence, or onto the roadway.

5. SC Cornish’s ultimate conclusion was that Samuel’s injuries were not caused as the result of contact with a motor vehicle. This conclusion appears to have been based on the lack of the usual indicia which would be seen with vehicle and person contact: no injuries to Samuel’s legs which would indicate he was hit by a car; no drag marks or abrasions on the body or clothing which would show he was propelled along the road surface; and no paint or broken glass/plastic from an impact with the vehicle itself.

6. There was a black mark on the upper left chest of Samuel’s t-shirt, described by SC Cornish as “contact markings” which, when tested was found to be “mineral oil-based lubricating oil”. SC Cornish could offer no explanation as to why oil may Findings of the inquest into the death of Samuel Timothy Brown Page 3 of 12

have been found on Samuel’s shirt, given that contact with a motor vehicle was a possibility.

Prosecution

7. In 2015 a taxi driver, Julien Hartley, was charged with a hit and run in respect of Samuel’s death. Police had obtained a statement from Mr Hartley’s ex-wife, who said that, at the time of Samuel’s death, her husband had made statements to her which implicated him in the accident.

8. After 3 days of evidence, the Prosecution offered no evidence in relation to the charge against Mr Hartley. This decision was apparently made as Ms Hartley did not come up to proof in court, another taxi driver who reported having seen Samuel’s body immediately after Mr Hartley’s taxi passed the area could not be found to give evidence, and there was no forensic evidence linking Mr Hartley’s taxi to Samuel’s injuries.

9. It was decided by Police Prosecutions that there were no reasonable prospects of securing a conviction. The prosecution had been complicated by the prosecutor’s decision not to call the FCU Investigating Officer, SC Cornish, because she had determined that he could not provide any relevant evidence, and he was unreliable as he disagreed with the view of the pathologist that Samuel’s injuries were caused by a vehicle.

Inquest

10. A pre-inquest conference was held on 14 July 2017, and the inquest was held from 19 - 21 March and 21 – 22 May 2018. The family was not represented at inquest – the parties that attended appeared for Mr Hartley and the QPS Commissioner. An expert report had been obtained for inquest from Dr John Olsen, Consultant Physician in Clinical and Trauma Biomechanics. Dr Olsen found that the most likely mechanism of Samuel’s fatal head injuries was by personal violence and assault, and not from a motor vehicle.

11. The following witnesses were called to give evidence: a) SC Steve Cornish, FCU Investigator; b) Joshua Searle, Samuel’s friend at whose 22nd birthday Samuel had been the night he died; c) Kristina Searle, mother of Joshua; d) Timothy Searle, father of Joshua; e) Caitlin Skrinis, ex-girlfriend of Samuel’s brother, also at party; f) Robert Cosgrove, Samuel’s friend; g) Kathleen Splatt, motorist who saw Samuel’s body; h) Donna Milkins, called Mr Hartley’s taxi and assisted Samuel; i) Allan Baker, in passing taxi, rendered assistance; j) Luke Pascoe, in passing taxi, rendered assistance; k) Ezabell Hanna, 1st taxi driver on scene after Samuel found on the roadway; l) Rahul Saini, taxi driver; m) Satinder Singh, taxi driver (no sworn statement); n) Julie Hanson, nearby resident; o) Allan Clarke, called Mr Hartley’s taxi and assisted Samuel; p) Jason Harris, QAS Officer - attended the scene to treat Samuel; q) Constable Michael Millar, first response; r) Dr Gregory Comadira, Intensive Care Specialist at GCH - treated Samuel; Findings of the inquest into the death of Samuel Timothy Brown Page 4 of 12

s) Sergeant Danilo Vojvodic, CIB investigator; t) Gareth Hughes, owner of GC Cabs; u) Paul Cicala, owner of Sanderson’s Body Repairs; v) Clayre Hartley, ex-wife of Julien Hartley; w) Julien Hartley, Taxi driver, defendant in criminal prosecution; x) Josie Salzman, Police Prosecutor in Hartley summary trial; y) Dr Dianne Little, Pathologist; z) Dr John Olsen, Consultant Physician in Clinical and Trauma Biomechanics

12. The evidence of the non-medical witnesses was uncontroversial, and largely consistent with their statements/reports.

13. Mr Cosgrove admitted to having deliberately left Samuel on the side of the road so that he could meet a girl he had met on a dating app. Mr Cosgrove said that he had initially lied and said that he had lost Samuel and tried to find him because he felt guilty about leaving his mate. He denied having assaulted Samuel or causing him any direct harm, and said Samuel was fine when he left him.

14. Mr Hartley denied having had anything to do with Samuel’s injuries. He said that his comments to his wife which were interpreted as him being involved somehow in the accident were simply comments saying that he was there when Samuel was discovered and he was interviewed by Police. He gave explanations for having attended three car washes to vacuum and then wash the car the day of the accident. The fact that Mr Hartley’s front bumper was repaired was explained by his employer as having to do with pre-existing damage to the bumper, and a common occurrence for taxis.

Differences in opinion of medical experts

15. During her evidence, Dr Little maintained that in her view, Samuel’s injuries could have been caused by some sort of interaction with a vehicle: Well, I – I think that that’s – it’s somehow related to a motor vehicle. It’s difficult to know exactly what – how. There’s a number of different possibilities. It’s not a pedestrian standing up and being hit by a car, because there’s no leg injuries. It’s potentially – he could’ve been sitting on the road or even lying on the road. If the vehicle had reasonable clearance and he was laying with his feet towards the oncoming vehicle, his chin may be exposed. There could be something under the car that would clip his chin and cause his neck to hyperextend, and that – if he got clipped by a car, that could throw him and cause the chest injuries on the ground. Other possibilities would be if there was a vehicle with something protruding from it and he was standing by the side of the road and it’s caught him under the chin because he’s standing near the traffic.

Another possibility would be, for example, he was, as I understand, trying to get home at the time, his judgment probably impaired by the alcohol in his body. He may have tried to jump on the back of a vehicle such as a utility or something with an open tray and lost his balance, fallen and caught his chin on the [back] of the tray. That’s another possibility, and that – that would also give the opportunity for him to have a secondary impact when hitting the ground.1

16. Dr Little was asked to comment on Dr Olsen’s findings. She disagreed with a number of these, notably:

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a. Dr Olsen’s suggestion that the injury under Samuel’s chin could have been caused by a metal or timber bar, or a kick – Dr Little’s view was that the injury would have to have been caused by something quite sharp;2 b. Dr Olsen’s conclusion that there must have been two blows to the head because of the hinge fracture and Puppe’s rule – Dr Little said that branches can occur in fractures to the base of the skull from a single blow;3 and c. Dr Olsen’s findings that Samuel’s injuries were not caused by a collision with a motor vehicle because of the absence of injuries to the legs and the absence of evidence that Samuel became airborne due to an impact – Dr Little maintained that if Samuel had been crouching or lying down rather than standing, and the collision was a glancing blow, then there is a very different pattern of injuries.4

17. In respect of Dr Olsen’s conclusion that the most likely mechanism of Samuel’s head injuries is a result of personal violence and assault, Dr Little gave the following evidence: I think the injuries are quite atypical for that scenario. I can’t say definitely what has caused his injuries, but I – from my experience in seeing hundreds and hundreds of assault victims over the years – fatally assaulted victims, I would say that this is a very unusual constellation of injuries and it’s quite atypical of what I would expect with an assault.5

18. During his evidence Dr Olsen conceded that Puppe’s rule is only an indicator, and that “…having done the autopsy, I would think that Dr Little would be in a better position to say whether there had been one or two impacts”.6 Dr Olsen said, that in his view, the severity of the injury to Samuel’s head, which he describes as a “dreadful skull fracture, very severe”, was inconsistent with a scenario in which he was hit by a slow-moving vehicle.7

19. Dr Olsen gave the following evidence in conclusion in his examination-in-chief: What really matters, I think, is that there were 18 external injuries to the head and neck with very little injury – there was a bit on the arms, a bit on the hands, a little bit, but not much and if you look at it – especially if you look at the diagrams that I drew showing where the injuries were, it’s just too – the pattern is just so – it’s – it – it – I can only see that as being in the category of – of moderate to moderately severe impacts by assault rather than, say, one massive impact by a – hit by a moving car or even run over by a car which he wouldn’t have survived. He would have been – he would have been deceased immediately from being run over by a car. But – but hit by a car, I don’t think that that could possibly explain the distribution of injuries. The – the 18 external injuries to the head and neck and – and nothing – nothing significant anywhere else, I don’t think that’s possible.8

20. In cross examination about Dr Little’s view that the injury under Samuel’s chin was caused by a sharp object rather than a blunt one, Dr Olsen maintained that the wound was a laceration, and not an incision – explaining that “…a laceration’s caused by force down on the – down on the skin causing the skin to give way

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and actually break whereas – whereas an incision slices through the skin and separates it neatly.” He said that he didn’t know what had caused the injury, except that it was a “severe impact injury” which “would indicate the use of a weapon”. He explained that, in his view: …it’s very unlikely to be an incision by a sharp object because of the shape. It’s too uneven, I think, to be an incision with a knife.9

21. Dr Olsen was also asked in cross-examination whether he expected that that number of injuries would be caused by a few blows or as the result of a fairly substantial beating. Dr Olsen said: I think it looks more like a substantial beating because of the quantity, the – the number of – there are so many – so many impacts that it wouldn’t – I wouldn’t think it would be certainly – I know there has been consideration of one person, but I don’t think it looks to me to be consistent with a – with a say one person, you know, involved in – in the assault or even two or three, but I don’t know how far we can take that. I would say – I would expect there to be more than one person involved in the – in causing these injuries.10

22. Dr Olsen also mentioned knuckle-dusters and a metal bar in his evidence, suggesting that these types of weapons could have been responsible for Samuel’s injuries. However, there does not appear to be any evidence from the FCU or CIB investigation which would suggest that there was a group of people in the area at the relevant time, with or without such weapons.

23. After the evidence, Coroner MacDougall adjourned the inquest, saying: I will adjourn, but as I said, this isn’t the end of the inquest. I propose to consider the evidence I’ve heard over the last two days and see what further investigations can be made, because I’m determined to get to the bottom of it.11 Family concerns

24. Samuel’s mother, Leanne, articulated the following concerns to coronial staff on 8 May 2018: C/O to Leanne Brown returning her call. We spoke about her submitting a letter to the Coroner in relation to the coronial inquiry, the impact it has had on her family, her concerns as to Robert Cosgrove's evidence and how let down she feels in relation to the CIB investigation. She was highly complimentary of the FCU component of the police enquiry, however, felt as though CIB never listened to her concerns and failed to consider the case properly. She also questioned the soundness of the decision to prosecute Julian Hartley, who she firmly believes had nothing to do with Sam's death. She expressed concern about the delay in finalising this matter due to the botched prosecution, and is hopeful that the Coroner will be critical of their investigation.

We discussed the evidence as it stands in relation to Robert, and that for an adverse finding to be made, that is that he was involved in Sam's death (rather than what has been established by his own admissions and the evidence obtained by police - lying etc) there would need to be a high standard of reliable evidence to support this, which is not available at present. Short of someone coming forward and attesting to something they had seen, or Robert confessing to another person, the Coroner is not able to find that he

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had a role in Sam's death, over and above his decision to ditch Sam by the side of the road without any means of getting home. She seemed disappointed by this, but I have reiterated this limitation a number of times. Leanne stated that she understood.

... She has asked that I advise the Coroner that the family feel incredibly let down by the CIB investigators.

Investigations/events since inquest Review by Prof Olumbe

25. Following the earlier part of the inquest there was some difficulty in finding an appropriate expert to review Samuel’s injuries. Professor Alex Olumbe, Eminent Specialist Senior Forensic Pathologist at the GCUH, was asked to review Dr Little’s autopsy findings as well as other investigation material. On 17 August 2021 Prof. Olumbe provided the following brief opinion: Dr Diane Little performed a detailed and comprehensive autopsy, which complimented the original findings as radiologically reported by Dr Jacques Olivier (clinical in GCUH) 25/11/12 at 05:42 hours. The findings detailed in the autopsy report are consistent with the autopsy photographs including macroscopic (gross/naked eye examination) sections of the brain.

I agree with Dr Dianne Little’s cause of death being head injury.

Although the features of the constellation of the head including injuries to the lower mandible (chin) and underlying fractures, fracture of the spinal column transverse process (T1) in the neck; and other remote injuries including abrasions on the right upper back, right lower back and on the upper extremities are not typical of those due to a motor vehicle overrun, the overall pattern of injuries are suggestive of impact by a vehicle.

From my extensive experience of conducting autopsies in similar cases, the extensive head injury i.e..Hinge fracture of the middle cranial fossa (complete fracture end to end in the middle section of the floor of the skull) associated the bruising on the back of the right ear (mastoid region) is typical of a glance impact to the right temple resulting in the hinge fracture compounded with small bone fragment as depicted in the clinical radiological report (was a fragment of bone in the right carotid canal/foreman in the floor of the middle section of the skull). In addition, the contusions on the surface of the brain in the right temporal lobe suggest a high impact primarily to the head.

The decedent had blood alcohol level of almost five times 0.241 g/100ml (0.241 %) the legal limit for a fully licenced driver, which could have contributed to the events leading to the road traffic collision.

In conclusion, there are no features in this case, which suggest blunt trauma by an object other than a road traffic/motor vehicle collision versus a pedestrian.

Opinion of neurosurgeon

26. An opinion was then sought from a neurosurgeon as to the cause of Samuel’s head injury. Dr Eric Guazzo, of North Queensland Neurosurgery and Spinal Surgery, provided a report dated 13 September 2022. He gave his opinion in response to the following questions: Having considered all the injuries Samuel sustained, on the balance of probabilities, what is the most likely mechanism by which they were inflicted?

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In my opinion, is consistent with the opinion provided by pathologist, Dr Little.

Considering the injuries sustained by [Samuel] causing his death, it is my opinion that the impact caused to Samuel’s head was initially to the chin and this caused the lacerations to his jaw and the fractures to his jaw. This injury forced his head backward, striking the ground causing the fractures and the secondary intracranial haemorrhage.

Further, please comment upon the likelihood, having considered the surrounding circumstances of Samuel Brown’s death and his injuries, of the following scenarios that: a. He sustained injuries from an impact (in any manner) with a motor vehicle.

It is my opinion that the most likely cause of the injuries to [Samuel] was from an impact with a motor vehicle. It is recognised that persons who are impacted by motor vehicle while standing and particularly when hit directly front on usually suffer long bone fractures, for example of the legs or fractures of the pelvis.

Therefore, it is my opinion that [Samuel] was not standing at the time of the impact with the motor vehicle, but was most likely crouched or kneeling or in some other way lower to the ground than in standing position. It is my opinion he was struck directly on the chin by motor vehicle and then forced backwards causing the injuries sustained.

b. He sustained his injuries as a result of an assault.

In my opinion it is very unlikely that [Samuel] sustained his injuries due to the results of an assault. The nature of the injury is most unlike those caused by an assault. Assault to the head results in many bruises and lacerations to the head and scalp caused by the assault. This did not occur to [Samuel].

c. He sustained injuries as a result from a fall from a height.

It is my opinion that [Samuel] did not sustain the injuries as a result of the fall from a height. If he were to have sustained the injuries as a result of a fall from a height, he would have needed to have fallen from a considerable height, for example three or four stories above the ground. There was no evidence to suggest such a fall was possible considering the location of [Samuel’s] body when he was found with his injury and the absence of other injuries, eg. long bone, spinal or abdominal injuries when a person falls from a height.

d. He sustained his injuries as a result of a fall and/or impact with the roadway surface.

It is my opinion that the fall or impact from the road surface did contribute to his injuries. In my opinion, it is most likely that [Samuel] was struck by a motor vehicle on the chin and fell backwards striking the hard surface of the roadway. This is consistent with the injuries that were inflicted on [Samuel’s] head and upper body.

[Samuel’s] head injuries were consistent with the type of injuries that occur when a person falls striking the head on a hard surface.

e. He sustained his injuries as a result from some other mechanism whilst near or on the roadway.

In the documentation provided, I did not find any reason to believe that there any other mechanism other than [Samuel] being directly struck by a motor vehicle on the chin and falling backwards onto the roadway.

f. There may have been separate incidents involved, which cause the injuries sustained.

I did not find any information within the documentation provided to suggest the injuries occurred at a different time frame by a separate incident.

27. In respect of Dr Olsen’s report and opinion, Dr Guazzo commented that: I refer to the report of expert Dr John Olsen whom I understand from his curriculum vitae is not involved in day-to-day management of traumatic brain injury, but provided a report Findings of the inquest into the death of Samuel Timothy Brown Page 9 of 12

based on his expertise in physical forces and other aspects of primary head injury. I do not concur that the injuries occurred to [Samuel] occurred by personal violence or assault as the nature of his injuries are inconsistent with such a cause for the reasons previously given.

Tenth Anniversary of Samuel’s death

28. 25 November 2022 was the 10th anniversary of Samuel’s accident (he died the following day). A reporter from the Gold Coast Bulletin, who has written a number of articles about Samuel’s death and the adjourned inquest, made enquiries with CCQ coming up to the anniversary. In response to these enquiries, CCQ issued the following statement on 16 November 2022: A further expert report from Neurosurgeon, Dr Eric Guazzo has been obtained as to the mechanism of Samuel’s death, which is presently being considered by the Forensic Crash Unit investigator, who responded to the incident initially.

The matter proceeded to inquest in 2018 and extensive evidence was heard during the inquiry.

As to whether further hearings will be convened, this will be dependent on the content of the reports and expert advice received, and in consultation with Samuel’s family, which will take place in due course.

Updated FCU Report

29. Dr Guazzo’s opinion was provided to Sgt Cornish, now the Officer in Charge of the Springwood FCU. Noting Dr Guazzo’s opinion as to the mechanism of the injuries, Sgt Cornish provided the following response: The chin injury is consistent with ‘blunt force trauma’. Any contact made with Mr Brown’s chin would have had to have been from a flat or protruding surface. In my view, it is highly improbable that a side sweep or lessor ‘glancing blow’ of a passing vehicle would be sufficient to cause the chin lacerations and subsequent mandible fractures seen on Mr Brown.

The three possible areas of a vehicle that could be involved in such contact would be the front bumper area, the A Pillar or the side mirror. The level of engagement of any such area to cause the injuries seen on Mr Brown would have to have been sufficient to impart a percentage of the vehicle speed (momentum) to cause the injuries, however, not sufficient enough to cause Mr Brown’s person to be projected across the road surface.

Such projection would have cause other abrasions and scuffing to his skin and clothing.

None of these markings were present on the autopsy findings nor upon examination of his clothing.

30. Sgt Cornish goes on to say that if Samuel had been hit with the front bumper he would expect some amount of forward projection, resulting in abrasions and/or scuffing. Also, had he been hit with any part of the bumper close to the headlights he would expect to see paint chips or plastic pieces from the light assembly in the wound or on the road. If Samuel had made contact with the A Pillar and/or side mirror, paint chips from the pillar and/or glass fragments from the windscreen should have been evidence in the wound or on the road. Sgt Cornish also noted any lack of abrasions to Samuel’s feet and hands, either from bracing himself after a fall or through projection on the road surface.

31. Sgt Cornish noted, in conclusion: Findings of the inquest into the death of Samuel Timothy Brown Page 10 of 12

In my view, given the lack of associated injuries and evidence at the incident location, it seems improbable that Mr Brown was struck sufficiently enough by a vehicle to cause the chin and head injuries, however, not sufficiently enough to project him post contact along a textured road surface. There is no evidence on the clothing, injuries or at the scene to suggest he has been propelled along the road surface. Insufficient propulsion suggest that there was a lower engagement between Mr Brown and a vehicle, which decreases the likelihood of contact being made with his chin by a flat or protruding part of the vehicle.

… Whilst it may be plausible for head injuries, like that sustained by Mr Brown, to have been caused by a vehicle collision, the absence of other significant factors, including associated injuries and evidence at the scene, should be considered when determining the likelihood that such a mechanism caused this incident.

Analysis

32. Given the differences of opinion by various medical experts, as well as the opinion of an experienced crash investigator, it is difficult to determine exactly what happened to Samuel after Mr Cosgrove left him on the side of the Gold Coast Highway.

33. A finding can only be made as to the most likely scenario by engaging in a process of elimination.

34. I find: a. Given the severity of the injury to Samuel’s head, which would have required significant force to inflict, it is possible to rule out a fall from a height of less than three or four stories, or an assault by a single assailant. It is therefore unlikely that Samuel fell off a nearby fence, or that Mr Cosgrove assulted his .

b. In the absence of any evidence of an armed gang in the vicinity, it is possible to rule out Dr Olsen’s theory that Samuel suffered a sustained beating by two, three or more armed assailants.

c. This leaves the possibility that Samuel’s head injuries were caused by contact between Samuel and a moving vehicle. This is the scenario accepted by three of the medical experts: Dr Little, Prof Olumbe and Dr Guazzo as the cause of Samuel’s injuries I note all three also agree that Samuel’s injuries were not typical of assault). The injuries to Samuel’s left upper body, abrasions to the underside of his left arm, impact wound to the underside of the jaw and to his left cheekbone, along with the oil mark on his left upper chest, suggest that his left side made contact with a vehicle while his left arm was in a raised position. The corresponding fractures to the right base of his skull and abrasions to his right upper back suggest that he was knocked backwards onto the road surface by that contact. Samuel’s blood alcohol level was around 4 times the legal limit shortly after the accident. In all the circumstances, it is possible that he had collapsed or passed out on the roadway and a vehicle drove over him (he was hit by the undercarriage but was not run over by the tyres), or that he was sitting on the road facing the oncoming traffic and was sideswiped by the left-hand side of a passing vehicle.

d. Despite the agreement between the medical experts (excluding Dr Olsen) the vehicle scenario is firmly rejected by SC Cornish on the basis Findings of the inquest into the death of Samuel Timothy Brown Page 11 of 12

that there is no paint or other debris from a vehicle in the wounds or on the road, and no abrasions on Samuel’s body or clothing which would indicate he was projected along the road surface. It is accepted that these features are typical of contacts between people and moving vehicles. However, the absence of these features is not proof that Samuel was not hit by a vehicle. Further, SC Cornish’s stance appears to overlook the presence of oil on Samuel’s shirt, as well as the presence of (slight) abrasions on his back, both of which are consistent with contact with a vehicle in the way described by the medical experts.

For these reasons, in my view, the opinions expressed by the medical experts (excluding Dr Olsen) should be preferred to the opinion of SC Cornish.

35. I accept the expert evidence of the medical experts (excluding Dr Olsen) and find that Samuel’s death was, on the balance of probabilities, caused by: 1(a). Head injury 1(b). Motor vehicle collision (pedestrian).

Finalisation of Inquest

36. I direct the Inquest into the death of Samuel Brown be closed.

Findings required by s. 45 Identity of the deceased – Samuel Timothy Brown How he died – Between around 2:20am around 2:25 am on 25 November 2012 Samuel was hit by a vehicle or part of a vehicle in the northbound bus and parking lane on the Gold Coast Highway, Mermaid Beach, approximately 100 m north of Heron Avenue. Samuel’s injuries suggest that his left side made contact with a vehicle while his left arm was in a raised position and that he was knocked backwards onto the road surface by that contact. Samuel’s blood alcohol level was around 4 times the legal limit shortly after the accident. It is possible that he had collapsed or passed out on the roadway and a vehicle drove over him (he was hit by the undercarriage but was not run over by the tyres), or that he was sitting on the road facing the oncoming traffic and was sideswiped by the left-hand side of a passing vehicle.

Place of death – Gold Coast Hospital SOUTHPORT QLD 4215

AUSTRALIA Date of death– 26/11/2012 Cause of death – 1(a) Head injury I close the inquest.

Stephanie Gallagher Deputy State Coroner

BRISBANE Findings of the inquest into the death of Samuel Timothy Brown Page 12 of 12