Coroner's Finding: de-identified JI

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 JI Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is JI. JI was a resident at Bethlehem House in Hobart. Bethlehem House provides supported accommodation for homeless men. JI had been a resident at Bethlehem house for two to three years, was estranged from his brothers and sisters but remained in contact with his mother. As a youth he enjoyed playing football and surfing. He worked intermittently as a labourer.

JI developed issues with his mental health from a young age and was a long term user of cannabis. He did not have any long term personal relationships, never married nor had children and largely kept to himself.

JI is a chronic schizophrenic and had been alcohol and drug dependant (he claimed abstinence from alcohol and drugs for some years prior to his death). He suffered leg ulcers and musculoskeletal pain particularly affecting his right knee and hip. His psychiatric condition caused him to exhibit bizarre behaviours and experience delusions at times and he was case managed voluntarily by community mental health services over a number of years. His treatment included antipsychotic medication via depot. Psychiatric assessment undertaken in January 2024 assessed his schizophrenia to be in remission with a small likelihood of recurrence and he was discharged from mental health services into the care of his general practitioner on 24 January 2024. The delivery of antipsychotic agents via depot injections ceased however he continued to be prescribed and take

antipsychotic medication. Immediately prior to his death JI is described as being “fragile” and his movements “dottery”,1 which I take to mean doddery.

b) On 3 March 2024 RO, a resident at Bethlehem House entered the dining room and made himself a coffee. Whilst doing so he was joined by JI who also set about making himself a coffee. RO took his mug of coffee and walked through the dining room to an adjacent outdoor patio area. The patio was furnished with a table, cane outdoor furniture, a weight bench and planter boxes. A steel grate was on the ground adjacent to the planter boxes and perimeter wall. RO sat down at the table joining LK, also a resident of Bethlehem House, who was seated there. Another resident, AM, joined RO and LK sitting at the table.

After making himself a coffee JI entered the patio area and also sat at the table joining the others. AM was seated on one side of the table against the wall, LK was seated at the end of the table to AM’s left, RO was seated on one end of a cane couch which was pulled up to the side of the table opposite where AM was seated, closest and to the left of LK. JI seated himself at the far end of the table opposite LK. LK was talking on a mobile phone.

JI was known to yell random words at times. He did so on this occasion.

RO told him to be quiet as LK was trying to talk on the phone. There is some dispute as to the events that then ensued and culminated in JI landing face first on a metal grate on the floor of the outdoor patio area.

What is not in dispute is that JI responded to RO in a combative way and he and RO both stood up from the table and started grappling with each other.

RO states that in response to him telling JI to be quiet JI threw hot coffee at him, stood up and threw his coffee mug at him or hit him to the left temple with the mug and the mug broke. In response RO also stood. Neither LK nor AM refer to the throwing of coffee or the striking of RO with a mug in the statements they gave to investigating members of Tasmania Police.

Photographs taken of RO by Forensic Services show a small fresh cut to the left side of RO’s temple consistent with his claim of having been struck by the coffee mug. A broken white coffee mug, consistent with that shown on (closed circuit television) CCTV as being used by JI at this time, was 1 Statutory declaration of Mr William Foran declared 3 March 2024.

found at the scene. Over lengthy questioning by Tasmania Police RO remained resolute in his claim of coffee having been thrown at him and a mug striking him. I found his interview credible in this respect. Despite the incident not being mentioned by either LK nor AM, I find that JI did throw coffee at RO and struck him with a mug to his temple immediately prior to, and most likely precipitating, the two commencing to grapple with each other.

As JI and RO grappled with each other they moved such that at some point JI was moved backwards toward the patio perimeter and grate. JI then fell landing face first onto the grate. The mechanism of JI’s fall is in dispute, and I consider this in greater detail later in these findings.

After falling to the ground RO checked on JI turning him over and then propping him up. JI was bleeding to his face. He was unconscious. There were no signs of grazing to his hands suggesting that he had not attempted to arrest his fall by putting out his arms and hands.

Help was summoned and Ambulance Tasmania (AT) were called at 11.08am. Paramedics from AT arrived at Bethlehem House at 11.34am.

They were unable to locate a pulse and commenced cardiopulmonary resuscitation (CPR). After sustained efforts a pulse was returned, and JI was taken to the Royal Hobart Hospital (RHH). Assessment at the RHH was that JI had suffered cervical spine and brain injuries that were not survivable and in consultation with his family he received palliative care and died.

c) As part of the investigation of JI’s death an examination was conducted by forensic pathologist, Dr Ritchey MD, MSc, American Board Pathology, FRACP, who found that JI had suffered a global hypoxic brain injury, blunt trauma of the cervical spine and cardiac arrest causing his death.2 He had significant atherosclerotic vascular disease present, which was a contributing factor to his cardiac arrest, and trauma to the head and neck including laceration to the forehead, bridge and spine of the nose, facial fractures, displaced burst fracture of the first cervical vertebrae, three odontoid fractures of the second cervical vertebrae and extensive spinal cord contusion.3 The head and neck injuries were considered consistent 2 Affidavit of Dr Ritchey MD sworn 24 April 2024 p13.

3 Affidavit of Dr Ritchey MD sworn 24 April 2024 p13.

with the mechanism of JI’s fall onto the grate and brain infarction, near total, was consistent with being caused by the interval between cardiac arrest and the return of circulation achieved upon AT paramedic intervention.4 Dr Ritchey concluded that the cause of the cardiac arrest was likely the severe high cervical spinal cord injury suffered in the fall producing a rapid neurogenic shock from a loss of blood pressure and bradycardia5 which, in light of the preexisting extent of heart disease (enlarged heart and plaque build-up causing narrowing of the arteries) caused cardiac arrest.6 Toxicology tests undertaken on a postmortem sample of JI’s blood demonstrated the presence of diazepam7, tramadol8 and sertraline9 at therapeutic levels and risperidone10 at a sub therapeutic level.11 olanzapine12 was also present in as was furosemide,13 the latter a likely artifact of JI’s post fall medical care. JI died due to a global hypoxic brain injury, cardiac arrest and blunt trauma to the cervical spine.

d) JI died on 6 March 2024 at Hobart, Tasmania.

In making these findings I have had regard to the evidence gained in the investigation into JI’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;

• Affidavit of Neil McLachlan-Troup sworn 5 April 2024;

• Medical records of the Royal Hobart Hospital and GP Super Clinic;

• Affidavit of Denise Fulton sworn 25 March 2025;

• Two statutory declarations of AM both declared 3 March 2024;

• Statutory declaration of LK declared 3 March 2024;

• Statutory declaration of Jason Miller declared 3 March 2024;

• Statutory declaration of William Foran declared 3 March 2024; 4 Affidavit of Dr Ritchey MD sworn 24 April 2024 p13.

5 The slowing of the rate at which the heart beats.

6 Affidavit of Dr Ritchey MD sworn 24 April 2024 p14.

7 A benzodiazepine indicated in the treatment of anxiety disorders.

8 A centrally acting analgesic.

9 An antidepressant.

10 An antipsychotic agent.

11 Affidavit of Neil McLachlan-Troup sworn 5 April 2024.

12 An atypical antipsychotic agent.

13 A diuretic.

• Statutory declaration of Timothy Rutherford declared 3 March 2024;

• Statutory declaration of Clive Kelleher declared 4 March 2024;

• Record of interview of RO, dated 4 March 2024; and

• Statutory declarations of attending members of Tasmania Police and Ambulance Tasmania and attached body worn camera footage and photographs.

Bethlehem House Bethlehem house provides supported accommodation to men who are homeless. It is operated by St Vincent de Paul society and funded through a combination of charitable donations and government grants. Residents at Bethlehem House are supported through the provision of accommodation, case workers and are linked to services and supports relevant to their health and circumstances.

JI and RO were both long term residents at Bethlehem House and lived at its Waratah Hotel campus following the completion of renovations to the Hotel which provided a modern amenity for its residents. Allocation to the Waratah Hotel campus was a trusted position and earned by those residents of Bethlehem House who exhibited stable and good behaviour.

RO RO had been a resident of Bethlehem House for approximately two years. He has a record of prior convictions for traffic and driving matters. He had no history of convictions for offences of violence. RO, many years previously, worked in the security industry and engaged in body building as a sport, however, he now suffers from physical issues which impede his capacity including Scheuermann’s disease of the spine and an issue with his shoulder. Whilst RO and JI did not get on there was no previous record of violence between them.

Following JI’s fall and the arrival of paramedics from Ambulance Tasmania RO left Bethlehem House briefly and walked to North Hobart to purchase tobacco. He returned shortly after the arrival of officers from Tasmania Police and cooperated fully with their investigation. RO was charged with causing grievous bodily harm in respect of JI’s death however that charge was subsequently withdrawn.

Why did JI fall?

There were three witnesses to JI’s fall. LK states that he had his head turned and was attempting to talk on the phone when the confrontation between RO and JI was

occurring and by the time he had turned back to them JI was already on the ground.14 He did not see how JI came to be on the ground. AM was smoking when he heard RO and JI arguing. He states he saw RO push JI with one arm and “threw”15 RO out of the way whereupon JI fell face first onto the grate. He did not see coffee cups or punches thrown by either JI or RO.16 He stated he had a good view of the argument.

RO has given two formal statements regarding the events leading up to JI’s death.

The first was recorded on body worn camera footage in the dining room at Bethlehem House immediately after these events. At that time RO stated that he had “pushed” JI to the ground. The second was during a record of interview given under caution on 4 March 2024 in which he states that JI went limp either due to a trip or medical episode.

Over a lengthy interview RO is repeatedly asked to recount how the fall occurred, and his account remained consistent. He claims not to have deliberately pushed JI, that JI suddenly dropped as they were grappling with each other, that he was exerting force and pushing on JI, JI was pushing back on him and his aim was to protect himself. Whilst pushing back on JI he moved him backward closer to the grate, and they also moved sideways. He was unsure if he let go when RO dropped but had a scrap wound on his knee consistent with his knee being brought to the ground as JI fell.

The impact of a sudden drop by JI as the two men grappled with each other could very well have had the appearance of a push as the resistance previously being exercised by JI against RO stopped. The failure of JI to have put out his arms to protect himself from the fall, a natural reaction of a conscious person falling, could suggest at that time his hands had become caught up with RO or that he was already in cardiac failure. The severity of the fall, demonstrated by the significant facial and cervical injuries suffered by JI is consistent with either JI simply falling, a forceful push or the sudden loss of resistance from JI against RO’s pushing. The graze to RO’s knee is consistent with RO still grappling with and having hold of JI as he fell to the ground causing his knee to impact with the ground.

Whilst many areas at Bethlehem House were covered by closed circuit cameras, including the dining room, the patio was not. LK was concentrating on listening to what was being said to him on his phone, was not concentrating on the events and movements unfolding between RO and JI and didn’t see beyond their grappling with 14 Statutory declaration of LK.

15 Statutory declaration of AM.

16 Statutory declaration of AM.

each other and JI being on the ground. AM was observing but what he saw as a push may easily be explained by the sudden drop of JI in circumstances where RO was pushing back at him for self-protection. AM also had not recalled the throw of coffee by JI or the assault with the mug.

RO has no history of violence or aggression including as a resident at Bethlehem House. He gave a credible account of the circumstances of JI’s fall over a sustained period of questioning by Tasmania Police. He was fully cooperative with the investigation into JI’s death. He freely conceded that he ought to have not engaged with JI but left the area. JI was a larger man than RO but was physically infirm and weak bringing into question the extent of force he may have been able to exert whilst pushing against RO and the movement of the two from the table, where the grappling started, to nearer the grate, behind JI, suggests RO had the physical upper hand.

JI was observed to be unresponsive immediately upon RO assisting him when on the ground. RO describes his pulse to be weak and he was unconscious consistent with him suffering a cardiac arrest at that time. The grappling between JI and RO is a relevant circumstance leading to JI’s death however the evidence does not allow me to make a finding as to the exact mechanism of JI’s fall beyond that it occurred whilst JI and RO grappled with each other. JI may have fallen or tripped whilst grappling with RO or whilst they grappled RO may have pushed JI to the ground or for some reason, be it cardiac arrest or a decision to cease grappling, JI’s resistance against RO suddenly ceased and RO’s unmet momentum caused JI to drop to the ground.

Comments and Recommendations I extend my appreciation to investigating officer Detective Constable Triin Thorpe for her investigation and report.

Whilst there is a need to observe and respect the privacy of the residents at Bethlehem House, many of the common areas at the Waratah Hotel premises are monitored by CCTV. This is understandable given the vulnerabilities of the cohort of residents at the House and the need to protect their safety and that of the staff. I am advised by Bethlehem House that the Waratah Hotel campus is owned by the Tasmanian Government (through Homes Tasmania).17 Homes Tasmania did not install a CCTV camera in the patio area as part of the surveillance system at the Waratah campus but have now done so. The provision of CCTV coverage of this area is a measure that has increased the safety of staff and residents at the site by 17 Email of Jay Chipman, Operations Manager Bethlehem House, dated 11 September 2025.

providing a mechanism through which a common area can be monitored allowing for the possibility of timely intervention should the need arise. Had the coverage extended to the patio area at the time of JI’s death a better understanding of what occurred in this instance may have been obtained and if monitored at the time and an earlier opportunity may have arisen for workers at Bethlehem House to intervene once RO and JI had commenced grappling with each other.

The circumstances of JI’s death stand as a reminder of the need for tolerance and caution in the arena of human interaction and that a fall to the ground whilst wrestling or grappling, like a “one punch hit”,18 can result in a drop to the ground and serious injury or death. I do not make any recommendations pursuant to Section 28 of the Coroners Act 1995.

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

Dated: 3 December 2025 at Hobart, in the State of Tasmania.

Leigh Mackey Coroner 18 A common cause of serious injury or death where a sudden punch to the head can cause a victim to fall to the ground.