Coroner's Finding: de-identified CP

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased and family by the direction of the Coroner pursuant to s 57(1)(c) of the Coroners Act 1995) I, Leigh Mackey, Coroner, having investigated the death of CP.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is CP. CP was born on 16 May 2001 and was 22 years of age when she died. She experienced significant trauma and adversity over her short lifetime. She is the daughter of EU and VH and the eldest of 13 children born to her father by different partners. She had cerebral palsy due to complications suffered at birth and which confined her to a wheelchair until the age of 10.1 She suffered severe burns as an infant and consequently came to the notice and supervision of child protective services in Victoria. At times she, and her brother, YR, were removed and placed in foster care before being returned to the family home.

When CP was approximately 10 years of age her mother died leaving her father, EU, with the sole responsibility for her care. Shortly after her mother’s death she was subjected to a sexual assault by a friend of EU in the family home. Child protective services continued to remove and return her and her brother from and to the custody of EU at various times due to welfare concerns held for the children.

After the death of VH, EU entered into a relationship with QW. QW was the mother of FG, QW and EU had a child together, DO in 2014. DO was autistic with consequential care needs. QW and FG both moved to live on the northwest coast of Tasmania. EU also moved to Tasmania and resided nearby before returning to live in Victoria. FG lived independently and took 1 Record of consultation 22 April 2022 Dr Akhtar.

over the custody and care of CP in a kinship arrangement having been assessed as suitable to provide that care by Victorian child protective services. In approximately 2021 FG also took on the primary care of DO.

Health and welfare concerns regarding the care of CP by EU and to some extent her mother VH before her death, included a lack of supervision, neglect, poor hygiene and cleanliness, school absenteeism, possible sexual exploitation and the exposure of CP to substance abuse and violence.

At times concerns were also raised regarding FG’s care of CP noting her youth, own mental health issues and the potential for financial abuse.

Likely in response to her challenging life circumstances CP exhibited difficult behaviours at times. She was prone to make allegations of abuse against her carers, including FG, which were unsubstantiated. She exhibited sexualised behaviours, had an intellectual disability and post traumatic stress disorder.

In mid 2021 the Tasmanian Civil and Administrative Tribunal (TASCAT) issued an emergency order for administration and subsequently appointed the Public Trustee as administrator of CP’s estate. In this period she lived in supported accommodation in Launceston and had a carer provided through the National Disability Insurance Scheme (NDIS). She continued to engage in difficult behaviours at times seeking ambulance and hospital care for spurious claims of sickness and engaged in physically threatening behaviour toward her carers.2 CP turned 18 years of age on 16 May 2019 at which time the supervision of her by child protective services in Victoria and Tasmania ended and she was free to determine her own living arrangements. CP subsequently chose to return to live with FG. DO continued to be under the supervision of child protective services in Tasmania and continued to reside with FG.

b) CP could not swim. FG had intended to arrange formal swimming lessons for her through her NDIS worker, however, this had not eventuated by the time of her death. FG described CP as having her own “unique way of swimming” and that she had been learning to float.3 CP enjoyed frequent 2 Launceston General Hospital medical records.

3 Statutory Declaration of FG sworn 11 November 2011 p1.

trips to the beach with FG and DO 2 – 3 times a week when the weather was warm. She also regularly went to the pool.

FG describes being usually cautious when she, CP and DO swam at the beach. Her normal practice was to go no further than chest deep when in the water so she could touch the ground and walk out of the water with DO and CP if need be.4 On 11 November 2023 CP, FG and DO went to Somerset Beach toward its eastern end, near the mouth of the Cam River and proximate to the Somerset Surf Life Saving clubrooms. Their activities in the water were captured by CCTV which shows the three of them playing in the shallows, waist deep for an extended period. Other persons were also present on the beach, some swimming others walking. Water conditions appear from the footage to be slightly choppy. Charlotte Dennis who was at the beach at the time described the water conditions as varying.

Outside of the surf club it appeared calmer whilst at the Cam River mouth the water was flowing fast into the ocean.5 FG describes the three of them as enjoying playing in the water splashing each other and not going out deep.6 They headed towards the mouth of the Cam River whilst still in the water when FG noticed that CP was in deeper water and was no longer able to touch the ground. FG asked her if she needed help. The first time she responded no and the second time yes.7 FG grabbed her and the strap of her bathers. DO took hold of her hand, and they tried to drag CP in to shore. The attempt failed and all three of them could no longer touch the ground. FG got DO to grab onto her as she started swimming whilst holding CP. This also failed.8 FG was left with the unenviable choice of deciding who to save. She feared all three of them would drown. She felt the pull of the sea sending them deeper, there was panic, they were swallowing water and FG was tiring and could not support both CP and DO. She felt that CP had “already drowned. She was heavy and her eyes had rolled back in her head…”.9 FG let go of CP and focused on getting DO back to safety. As she did so she looked back frequently to check on CP and at some point, during the time 4 Statutory Declaration of FG sworn 11 November 2011 p1.

5 Affidavit of Charlotte Dennis sworn 20 December 2023 p2.

6 Statutory Declaration of FG sworn 11 November 2011 p2.

7 Statutory Declaration of FG sworn 11 November 2011 p2.

8 Statutory Declaration of FG sworn 11 November 2011 p2.

9 Affidavit of FG sworn 22 November 2023 p3.

it took for her to get back to safety, she could no longer see her head above the water.

I accept the description of these events given by FG. They are consistent with their movements seen on CCTV footage, albeit the footage does not extend to the point at which the three get into difficulty, the description she gave to Ms Pettit when she arrived to assist and the statements made by DO when interviewed by Tasmania Police on the beach that day.

After having made the safety of the beach DO and FG alerted Ms Pettit and Ms Webster, who had pulled into the carpark at the beach, of CP’s disappearance. Ms Pettit immediately ran to the beach whilst alerting others to the emergency and entered the water. Ms Pettit describes feeling a strong undertow, she was waist deep in the water, felt at risk and did not go deeper.10 Ms Artis was also on Somerset Beach painting with a friend, Charlotte Dennis. Alerted of the disappearance of CP she joined the search for her.

She walked through the river mouth of the Cam River and found the current made it a “challenge” and noted a rip approximately 50m from the point at which the mouth of the Cam River met the ocean.11 c) CP’s cause of death was not able to be determined by the examination of a forensic pathologist due to the time her body had spent in the water and on the beach before being discovered. Whilst the autopsy was significantly limited by the condition of the body, no skull fractures nor signs of trauma were identified that would point to a cause of death other than drowning.12 CP was last seen in difficulty in the water at Somerset Beach. FG observed her until her head had become submerged under the water. An extensive search for her commenced within a short time of her disappearance by members of the public, surf lifesaving club, and police, but she was unable to be located. Her body was found on 25 November 2023, 14 days after she had disappeared, on MacKenzies Beach near Wynyard. Witnesses noted a strong current in the ocean at Somerset Beach at the mouth of the Cam River on the day of her disappearance. Because of her cerebral palsy, 10 Affidavit of Karen Pettit sworn 12 November 2023 p2.

11 Affidavit of Tayla Artis sworn 20 December 2023 p2.

12 Short Final Report of Death to the Coroner by Dr Ritchey MD, forensic pathologist dated 28 November 2023.

slight build and lack of swimming experience, it was unlikely that she would have been able to survive for any length of time in the water or get herself back to shore. Because of these matters I find that CP died of accidental drowning.

d) CP died on 11 November 2023 at Somerset, Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into CP’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Affidavits confirming identity;

• Opinion of the forensic pathologist regarding cause of death;

• Medical records Merbein Family Medical, City Medical Practice, Mildura Base Hospital and Tasmanian Health Service;

• Records from the Department of Families, Fairness and Housing Victoria and Department of Education Children and Young People Tasmania;

• Records of the Tasmanian Civil and Administrative Tribunal;

• Affidavits of attending and involved members of Tasmania Police and body worn camera footage;

• Statutory Declarations and Affidavit of FG dated 11, 12 and 22 November 2023;

• Affidavit Karen Pettit sworn 12 November 2023;

• Affidavit Tayla Artis sworn 20 December 2023;

• Affidavit Caleb Khalil sworn 7 January 2024;

• Affidavit Murray Jamieson sworn 16 November 2023 and CCTV footage;

• Affidavit of Callum Munday sworn 7 January 2024;

• Affidavit QW sworn 22 January 2024; and

• Peer review of search and rescue dated 14 November 2023.

Somerset Beach and the Cam River Somerset beach is a stretch of sandy beach located at Somerset on the Northwest coast of Tasmania. It has a west to southeasterly orientation and extends a distance of approximately 1.5km. At its southern end is the mouth of the Cam River. The beach is adjacent to recreational facilities including a football oval, playground, and the Somerset Surf Life Saving Club. The beach is a popular recreational space for the local community and is patrolled by members of the surf lifesaving club on

weekends during the summer months from December to March. It was not patrolled at the time of CP’s death.

The Cam River originates in the Snowdon Plains at Oonah and near the base of Mount Leslie and flows north east for approximately 45 kms before entering Bass Strait at Somerset at the southern/eastern end of Somerset Beach.13 The beach can appear deceptively benign whilst swimmers can experience rips and challenging conditions at times. Other incidents have occurred at the beach including the drowning death of Yolande Scheffer in 2016 who had been swimming with her two daughters when caught by a wave.

CP’s physical capacity and swimming experience CP’s cerebral palsy impacted upon her mobility. Her gait was unstable, she dragged her left foot as she walked and suffered recurrent falls.14 Her general practitioner, Dr Akhtar, was of the opinion in April 2022 that she needed an assessment for a walking aid.15 CP was of a slight build weighing 52kg and a height of 159cm.16 Her slight frame, mobility deficits and lack of swimming experience would have hindered her capacity to resist a rip or strong undercurrent and limited the time in which she could have survived whilst immersed in water.

The search The search for CP commenced as soon as FG and DO made land and were able to raise the alarm with nearby members of the public. Emergency services were contacted at that time. A search of the ocean, beach and rocky outcrops was undertaken by members of the public, Tasmania Police and the Somerset surf lifesaving club. The search was comprehensive on land and on sea and involved the deployment of a drone, the marine unit catamaran, surf lifesaving vessels, datum buoys to track ocean drift, helicopter and divers. The search effort was well coordinated, methodical and evidence based in that the area of the search was informed by projections of CP’s location based on prevailing tidal, weather and current conditions. The search was conducted to 11.30pm that evening and resumed the following day but was unsuccessful in locating CP.

13 Affidavit of Senior Constable Duthoit sworn 25 November 2023 p2.

14 City Medical Practice notes of consultation Dr Akhtar 22 April 2022.

15 City Medical Practice notes of consultation Dr Akhtar 22 April 2022.

16 City Medical Practice notes of consultation Dr Omolola 1 May 2023.

CP was found by Caleb Khalil on 25 November 2023 as he walked with his daughter along Mackenzies Beach at Wynyard. Her body had washed up on the sand approximately 4.5km north west from the mouth of Cam River at Somerset Beach.

The remains were identified as being those of CP on the basis of DNA comparison.17 The bathers worn, hair length and colour on the remains matched that of CP at the time she was last seen.18 Comments I extend my appreciation to Sergeant Emilie Dellar for her investigation and report and to all who were involved in the extensive search undertaken for CP on the 11 and 12 November 2023.

The circumstances of CP’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of CP.

Dated: 21 October 2025 at Hobart, in the State of Tasmania.

Leigh Mackey Coroner 17 DNA coronial identification summary report dated 14 December 2023.

18 Affidavit of Senior Constable Duthoit sworn 25 November 2023 p2.