Coroner's Finding: Iliev, Patricia

FINDINGS of Coroner Olivia McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of: Patricia Iliev

Contents

Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Patricia Iliev, with an inquest held at Devonport and Launceston in Tasmania, make the following findings: Hearing Dates 6 May 2022, 25 March 2024, 17 April 2024, 14 June 2024, and closing submissions received by 26 September 2024.

Representation Counsel Assisting the Coroner – E Belonogoff and W Wu.

Introduction and scope

1. The deceased is Ms Patricia Iliev, born 6 December 1963 who died at her home in Sheffield on 6 March 2021 at the age of 57 years.

2. Ms Iliev died from starvation. At autopsy, she weighed 19.1 kilograms and had no subcutaneous body fat stores.

3. At the time of her death, Ms Iliev lived with her long-time partner, Mr Philip Adams, in Sheffield, a small rural town in north western Tasmania. Upon Mr Adams’ account, Ms Iliev was immobile and couch-bound in the months before her death. He gave evidence that he found Ms Iliev unexpectedly deceased on the couch after coming in from spending time in the garden. Mr Adams did not contact the ambulance or emergency services for about five hours subsequently. In that time, he said he spent time mourning her. He also took the time to wash and re-dress her body and to move her to their bed in the master bedroom. He then made contact with an online health service and attempted to obtain a medical certificate of death to certify that she died of natural causes. Mr Adams gave evidence that he did not expect Ms Iliev to die.

4. Ms Iliev’s death is one which I have jurisdiction to investigate and to hold an inquest under the Coroners Act 1995, as a death in Tasmania that appears to have been unexpected or unnatural.1 1 Sections 3, 21 and 24(2) of the Act.

5. The inquest considered the circumstances surrounding the death of Patricia Iliev to enable findings to be made, if possible, under s28(1) of the Coroners Act, including: a. Whether starvation is an appropriate medical cause of death for Ms Iliev; b. Whether Ms Iliev was reliant on Mr Adams for her basic needs, including food, water and healthcare; c. The adequacy of the care by Mr Adams in the 12 months prior to Ms Iliev’s death, including: i. What, if any, aspects of that care might have contributed to her death; ii. To what extent, if any, Mr Adams was following the decisions and directions of Ms Iliev; and iii. Whether Ms Iliev had capacity to make decisions about her medical care or treatment.

Mr Adams as a person of interest

6. In the pre-inquest processes, Mr Adams was advised that he had been identified as an interested party and that adverse findings may be made against him.

7. Mr Adams was served with a summons to give evidence at inquest and was represented by his counsel Mr Geoffrey Maguire on 4 May 2022. Mr Maguire advised the Court that Mr Adams intended to claim privilege against self-incrimination and objected to give evidence at inquest. Written submissions were filed by Mr Maguire on behalf of Mr Adams on 4 May 2022.

8. As a result, the inquest was adjourned to a further date to allow submissions to be made from Counsel Assisting and the Attorney-General’s office.

9. On 7 December 2023, I handed down my written ruling, deciding that the provisions of the Act abrogated the common law rule of privilege against self-incrimination, and therefore, Mr Adams is not entitled to invoke a claim of privilege to refuse to answer question. No application was made appealing this ruling.2

10. Mr Adams was required by summons to give evidence at inquest on 25 March 2024. A letter was sent by him on 14 March 2024 to the coroner advising that he refused to 2 Iliev, Patricia – Ruling No 1 [2023] TASCD.

https://www.magistratescourt.tas.gov.au/__data/assets/pdf_file/0006/737061/Iliev,-Patricia-Ruling.pdf

answer questions at inquest. He was advised by Counsel Assisting by a letter on 20 March 2024 that if he refuses to answer questions that seek relevant evidence and are otherwise unobjectionable, the coroner may exercise the contempt power pursuant to s17A of the Magistrates Court Act 1987. Mr Adams replied to a letter to Counsel Assisting stating that “In my letter to Coroner McTaggart dated 14th March, I acknowledged her powers and her likely use of them. However, I thank you nonetheless for confirming my expectations in this matter.”

11. On 25 March 2024, Mr Adams appeared for the inquest in the Devonport Magistrates Court. He refused to go into the witness box or answer questions from Counsel Assisting. He was subsequently charged with one count of contempt of court in contrary of s 17A(1)(b) of the Magistrates Court Act 1987.

12. After the charge being read to him and prior to him entering a plea, Mr Adams was provided with an opportunity to obtain legal advice from a duty lawyer. He did obtain legal representation. Mr Adams pleaded not guilty initially then changed his plea from not guilty to guilty. He apologised to me as presiding Coroner and indicated that he would give evidence at inquest. He proceeded to do so that day.

13. He was not sentenced upon the contempt charge until the finalisation of his evidence on 14 June 2024. In sentencing, I recorded a conviction and ordered that Mr Adams pay the court costs upon the complaint.

Documentary exhibits and witnesses at inquest

14. A number of exhibits were tendered into evidence at the inquest, including affidavits from attending police officers, Ms Iliev’s brother, her neighbour, and a police interview with Mr Adams. The documentary evidence tendered at inquest comprised 22 exhibits. The formal exhibit list is annexed to this finding.

15. At inquest, the following witnesses provided oral testimony:

• Dr Donald Ritchey, State Forensic pathologist, who conducted the autopsy on Ms Iliev;

• Ms Jennifer Sargeant, friend of Ms Iliev;

• Constable Tyrone Myers, who attended Ms Iliev’s residence on 6 March 2021; and

• Mr Philip Adams, partner of Ms Iliev.

Circumstances surrounding death

16. Ms Jennifer Sargeant was a small business owner in Sheffield. She gave evidence at inquest. When she first opened her shop 16 years ago, Ms Iliev was a regular customer of hers. Ms Iliev came to her shop once a fortnight when she did her shopping in Sheffield, sometimes longer than that.3 Ms Iliev did not always purchase goods from her shop but used to come and have a chat with her for 20 minutes. Their relationship was very superficial. Ms Iliev seemed to be a very private person. She did not respond to questions with any in-depth information, nor did she ever speak about her family.4 There was nothing indicating that Ms Iliev had issues with her intellectual capacity. She always understood what Ms Sargeant said and participated in their conversations equally.5 Ms Iliev mentioned that she had back problems which prevented her from doing a lot of physical work in the garden but did not give any details.6 She offered for Ms Iliev to see a doctor to obtain a diagnosis of her back problem but Ms Iliev was quite adamant about not doing that.7

17. Ms Sargeant described her observations of Ms Iliev over 16 years as a “tiny and birdlike” person who was “frail” and “was always stooped to her shoulders”. She did not notice that Ms Iliev was losing weight over that time.8

18. In about June 2018, Ms Sargeant talked with Ms Jo Easton, the operator of a local business and acquaintance of Ms Iliev. By that time, they had not seen Ms Iliev for well over 6 months. Ms Easton then asked police to conduct a welfare check upon Ms Iliev.9

19. Ms Sargeant confirmed that the last time she saw Ms Iliev was in October 2018.10 She had no contact at all with Ms Iliev since that time.11

20. Ms Patricia Laws lived at 30 High Street next door to Ms Iliev. Her affidavit provides that during her 14 years of living at that address, she had very little to do with Ms Iliev and Mr Adams. She did not even know their names.12 3 Transcript 6.5.22 p23.

4 Ibid p24.

5 T 6.5.22. p27 6 Ibid p26.

7 T 6.5.22 p27 8 Ibid p28.

9 T 6.5.22 p29.

10 Ibid p32.

11 T 6.5.22 p29.

12 C14 Affidavit of Patricia Rosemary Laws.

21. Ms Iliev was last seen (by someone other than Mr Adams) at 11.15am on 1 August 2019 when another police welfare check occurred.

22. Constable Tyrone Myers gave evidence at inquest that he was stationed at Sheffield Police Station and on that date he attended 32 High Street to conduct a welfare check upon Ms Iliev as Ms Easton had not seen Ms Iliev for a number of weeks as they usually saw her walking on the streets to get groceries.13

23. Constable Myers received no response after knocking on the front door. He made his way around to the rear of the house where he located Ms Iliev and a male sitting at the back door. Ms Iliev was having a cigarette, and her identity was confirmed by Constable Myers. She said that she had not been out in the last few weeks since she had been ill. Ms Iliev looked well to Constable Myers. She was a very thin lady.14 She did not describe being in any pain or having any injuries, nor did she make any requests for any further assistance from either Constable Myers or anyone else. At that time, Constable Myers had no concern in relation to Ms Iliev’s mental capacity.15

24. At 11.30pm on 6 March 2021, ambulance paramedics attended 32 High Street, Sheffield and located Ms Iliev clearly deceased. The paramedics called police and, at 12.20am, the first two police officers arrived at the scene.

25. At the scene, Mr Adams gave the account that he found Ms Iliev deceased on the couch in the lounge room at about 5.30pm, after returning inside from being in the garden for about two hours.

26. After discovering that Ms Iliev had died, Mr Adams said he spent several hours mourning her. He took time washing and redressing her, moving her body to their bed in the master bedroom. Mr Adams did not make contact with any organisation or emergency service until about 10.40pm, when he telephoned the Healthdirect Australia medical telephone service, was transferred by Healthdirect to the Ambulance Tasmania operator.

27. Ambulance officers attended the house first and had discussions with Mr Adams. They told Mr Adams that police would need to attend as a death certificate could not be issued without their attendance. Ms Iliev’s death was confirmed by attending 13 Transcript 6.5.22 p34.

14 Ibid p35.

15 Transcript 6.5.22 p36.

ambulance officers who did not make any resuscitation attempts or administer any treatment upon Ms Iliev.16

28. Police officers stationed at Sheffield Police Station attended the house at approximately 12.20am. They spoke with ambulance officers prior to entering the house and speaking with Mr Adams. Mr Adams led police officers to the bedroom where they viewed Ms Iliev fully dressed and covered with a light blanket.

29. Ms Iliev had a severely emaciated and pallid appearance. The attending police officers requested the attendance of Criminal Investigation Branch (CIB) officers. The attendance of CIB officers led to a decision to involve forensic officers.

30. Upon arrival, Senior Constable Michelle Rybarczyk of Western Forensic Services, observed Ms Iliev was lying on her back on the left side of the master bed.17 Her head was resting on a pillow and her long dark hair tied in two loose ponytails. Ms Iliev was fully dressed in a black jumper, blue jeans, dark socks and slippers. She had a pale, almost white appearance, was gaunt and obviously emaciated. Ms Iliev had an injury to the bridge of her nose, which was deep red in colour. Ms Iliev was cold and rigor mortis was present.

31. Upon removal of her clothing, police officers observed her to have very little muscle mass or body fat. Underneath the blue jeans and black jumper, she was wearing a second long black top, white singlet and thermal pants.

32. Senior Constable Rybarczyk observed red discoloration to Ms Iliev’s abdominal area in a prominent crease. Small areas of skin within that discolouration appeared to be broken, though appeared dry. Ms Iliev had a small red mark on her left middle first knuckle and smaller red marks on the second knuckles of her left little and ring fingers.

33. Senior Constable Rybarczyk also found Ms Iliev had areas of red and purple discolouration on both buttocks, which appeared to be pressure sores. The discoloured area on her left buttock was more prominent than right, however both appeared to have broken areas of skin.

34. Senior Constable Rybarczyk observed the lounge room as having a two-seater couch with folded blankets on it. The couch was on the wall facing the street. Mr Adams indicated that the couch was where Ms Iliev spent the majority of time in her last few 16 C1 Police Report of Death.

17 C10 Affidavit of Senior Constable Michelle Rybarcyzk.

weeks. A coffee table was in front of the couch, which had a large amount of property on it including speakers, a cigarette lighter and ash tray and a remote control. A large column heater was behind the coffee table and a second, small electric heater was on the floor at the right side of the two-seater couch. A black walking stick was in front of the small electric heater. A second, smaller coffee table was positioned next to the larger coffee table, to make an L shape. Three single armchairs were positioned around the lounge room and a desk and chair were on the left side of the couch. A number of other furniture items were positioned around the room and a seated walking frame was positioned near the doorway to the rest of the house. Detective Senior Constable Bartush found an empty urine bottle on the floor next to the couch.

35. The toilet was accessed through the laundry and was relatively clean and free of clutter. The toilet itself had a safety frame position on it.

36. Fruit was observed by Senior Constable Rybarczyk in the kitchen and nearby storage room, being pears, mango, rockmelon and bananas. Bottles of fruit juice and shopping bags containing grocery items were observed sitting on top of the fridge. A large amount of bottled water was underneath a small table opposite to the fridge. Further walking frames were found in the storage room beside the fridge. Constable Timothy Ford was asked by Detective Senior Constable Bartush to check the fridge and found further food stored in there.

Medical cause of death

37. Dr Ritchey, the very experienced forensic pathologist performing the autopsy, determined the primary cause of Ms Iliev’s death to be starvation. He opined that the secondary cause was gastrointestinal stromal tumour of stomach (stage 1A) and advanced lung disease caused by smoking, namely centriacinar emphysema and active respiratory bronchiolitis.

38. In his report, Dr Ritchey concluded that: “The autopsy revealed an emaciated woman with body mass index 9.9kg/m² (normal BMI > 18) who weighed only 19.1kg and had no subcutaneous body fat stores.

Toxicology testing of samples obtained at autopsy confirmed the presence of acetone at an elevated concentration. The most likely source of acetone was endogenous production due to starvation ketosis.”

39. Dr Ritchey found Ms Iliev’s stomach contained 100 millilitres of dark opaque thin bilestained liquid without solid material, and that there were approximately 200 millilitres clear yellow urine.

40. The pathologist report also states that it is likely that the gastrointestinal stromal tumour caused the depressed appetite that may have contributed to Ms Iliev’s starvation despite the low grade and stage of that tumour. In addition, individuals with advanced emphysema are also at risk of wasting syndrome in which there may be severe weight loss.

41. Dr Ritchey gave evidence at inquest. He stated that it was more likely that Ms Iliev reduced her body weight to the stage of her final appearance over a period of a year although it might occur as rapidly as in a few months.18 The gastrointestinal stromal tumour of the type found in Ms Iliev’s stomach is known to decrease the appetite and that can cause pain in that area.19

42. Dr Ritchey gave evidence that Ms Iliev did not die because of dehydration because there was some liquid in her stomach and urine in her urinary bladder. He categorically disagreed that dehydration played a part in Ms Iliev’s death. He agreed that, with appropriate medical treatment, the starvation process can be reversed, even up until a point reasonably close to death.20

43. The toxicology results provide that there were 94 milligrams per litre acetone detected from the post-mortem blood sample of Ms Iliev.21 Dr Ritchey gave evidence that in the case of starvation, sometimes a metabolic state called ketoacidosis occurs whereby acetone is produced by the body. Therefore, the presence of acetone is a good indicator within the right context of starvation ketosis.22

44. In relation to Ms Iliev’s mental status, Dr Ritchey stated that the prominent scar/gliosis of the hippocampus seen at autopsy did not necessarily affect Ms Iliev’s rational decision making.23 However, he commented that features of the evidence concerning Ms Iliev and her circumstances suggested the possibility of a psychiatric disorder. 24 Appropriately, he could not speculate further on the nature of any such disorder and 18 Transcript 6.5.2022 p14.

19 Ibid p16 -17.

20 Transcript 6.5.2022 p21.

21 C6 Toxicology Report.

22 Transcript 6.5.2022 p17.

23 Ibid p16.

24 Transcript 6.5.2022 p19.

noted that, due to her unwillingness to see doctors, no mental health condition had ever been clinically diagnosed.

45. In relation to the early non-ulcerated pressure sores found over Ms Iliev’s coccyx and buttocks, Dr Ritchey stated that they can occur over a period of days to weeks. Those pressure sores can be prevented by having basic nursing care to make sure that the person does not just stay in the same position all the time.25

46. Dr Anthony Bell, Coronial Medical Consultant, provided a report relating to the bodily reactions involved in the process of starvation. Dr Bell reported that: “Within days, faced with nothing to eat, the body begins feeding on itself. The body starts to consume energy stores… When the body uses its reserves to provide basic energy needs, it can no longer supply necessary nutrients to vital organs and tissues… People can become irritable, and it becomes difficult to concentrate… The body attempts to protect the brain by shutting down the most metabolically intense functions first, like digestion, resulting in diarrhea. The brain is relatively protected, but eventually neuronal death and brain matter loss occur… People who are in the throes of starvation look apathetic, lethargic – almost mechanical in their slow-motion reactions…”

47. I fully accept the well-reasoned, expert conclusions of Dr Ritchey and find that Ms Iliev died as a result of starvation because of insufficient food intake. I find that dehydration played no part in her cause of death.

Objective evidence of Ms Iliev’s health, capacity and personal circumstances

48. Before analysing the evidence of Mr Adams, I set out the credible evidence regarding Ms Iliev’s background and circumstances which I can accept without question. This is not to say that I do not accept much of the evidence of Mr Adams regarding Ms Iliev’s background circumstances. His general evidence concerning the period leading up to her death is largely consistent with the objective and credible evidence. However, his evidence about the circumstances surrounding her death requires careful scrutiny.

25 Transcript 6.5.2022 p14-15.

49. The evidence as a whole painted a picture of Ms Iliev having an unusual and somewhat idiosyncratic personality and lifestyle. It is quite clear from the witness evidence, that she and Mr Adams had little contact with others.

50. Their home of many years26 at 32 High Street was a small weatherboard home in poor condition, with the lawn and gardens overgrown.27 As described above, the interior of the home was cluttered in the main living area but electric heating, food and other necessary living items for Ms Iliev were present.

51. I fully accept the evidence of Mrs Sargeant that relates to her consistent observations of Ms Iliev over many years - that she was frail and stooped, refused to see doctors, was not forthcoming about her personal circumstances and had no difficulty in conversing normally.

52. I also received credible evidence corroborating Ms Iliev’s background, character and personal circumstances from her brother, Kim Iliev, who resides in Hobart. Mr Iliev presented as a calm, thoughtful and softly spoken person. At inquest, it was clear that he bore no ill feeling towards Mr Adams in respect of the circumstances of his sister’s death. It was also apparent that he did not harbour any grievance against Ms Iliev following their estrangement many years previously.

53. I am to rely on Mr Iliev’s evidence concerning his sister and I summarise that evidence below.

Evidence of Kim Iliev

54. Mr Iliev is Ms Iliev’s eldest brother. In his affidavit, he stated that he moved down to Hobart to attend university at the end of 1975. In the late 1970s, he assisted Ms Iliev in moving to Launceston and after that he only had contacted her sporadically. Ms Iliev was close to her elder brother Carlo who died by suicide in July 1990.

55. He said that, after their mother passed away, Ms Iliev and Mr Adams moved into her home at 32 High Street, Sheffield. He would sporadically visit them when his work took him to the northwest area. In 1995 or 1996, Ms Iliev and Mr Adams mentioned that they wanted to purchase Mr Iliev’s half share of the house and he agreed. After selling the house to the couple, Mr Iliev received a letter from Ms Iliev in an upset and angry tone stating that he failed to clean up the house.

26 Ms Iliev’s mother died in 1994, and the evidence indicates that Ms Iliev and Mr Adams moved into the house shortly after that time.

27 C9 Affidavit of Detective Senior Constable Allira Bartush.

56. To his knowledge, Ms Iliev had no major health issues but thought Ms Iliev was a “bit on the thin side”.28 However, he never questioned her slight build and put it down to her vegan diet which was her own business. He had no knowledge of Ms Iliev’s mental health status but knew she was a smoker.

57. At the end of inquest, Mr Iliev said that his sister and Mr Adams were not mainstream people.29 They shared the same ideas on food, nutrition and health.30 Ms Iliev had ideas about health and fasting. There was no dominant party in Ms Iliev and Mr Adams’ relationship.31

58. Mr Iliev was aware that Ms Iliev had a sore back but never heard anything more than that.32 Ms Iliev was always thin.33 She never trusted doctors.34 He did not know how the death of Carlo affected Ms Iliev.35 When he visited the couple, he would see large quantities of vegetables and food in the house.36

59. Mr Iliev said that he and Ms Iliev had been estranged for 25 or 26 years.37 The letter Ms Iliev wrote to him formed a part of the estrangement.38 The last time he met Ms Iliev in person was in the 1980s.39 The sale of house was conducted by correspondence or via phone calls.40

60. Mr Iliev said that following the estrangement, Ms Iliev changed her phone number and he had no way of contacting her. He stated that he had the impression she did not want to have anything to do with him.

61. Mr Iliev formed the view that Mr Adams was an intelligent man but a “closed book.” He said in his affidavit that, on the occasions of their interactions, they had good conversations but he did not get “anything of content” from him.

62. Mr Iliev said in his affidavit that Ms Iliev and Mr Adams had always been alternative in their lifestyle, a fact which did not concern him.

28 Transcript 14.6.2024 p49.

29 Ibid p38.

30 Transcript 14.6.2024 p43.8-9.

31 Ibid p42 - 43 32 Transcript 14.6.2024.36-37.

33 Ibid p49.2-3.

34Transcript 14.6.2024 p38.

35 Ibid p40.

36 Transcript 14.6.2024 p41.

37 Ibid p45.19.

38 Transcript 14.6.2024 p48.

39 Ibid p45.

40 Transcript 14.6.2024 p46.

Evidence of Philip Adams Interview with police on 7 March 2021

63. Mr Adams participated in a recorded interview with police voluntarily on 7 March

64. The duration of this interview is 64 minutes. The recording of this police interview was played in court on 25 March 2024.

65. In the interview, Mr Adams stated that he met Ms Iliev in 1981 in Launceston and they had lived together since 1982. They first lived in Launceston and moved to 32 High Street, Sheffield around 1998 after Ms Iliev’s mother passed away. No one else lived in the house. He said Ms Iliev did not have a medical history because since he had known her, she had never consulted a doctor. She did not like doctors due to some unsatisfactory personal experiences. He thought she might have been vaccinated at school or might have had a health check as a school procedure.

66. Mr Adams went further, saying that Ms Iliev was always a very private person and very independent, and that she “never really bothered anyone with her own needs, even me, she’d never entirely divulged everything to me um, about her own health or you know, um her own family history or details”.

67. Mr Adams outlined what he believed to be the history of Ms Iliev’s serious back injuries. In about 1988, Ms Iliev suffered a back injury, which had continued to cause her pain and suffering throughout her life. This injury was exacerbated by other incidents over the years, including one about six months before her death where she fell walking to the toilet through the laundry in their house.

68. Mr Adams recalled that the last time Ms Iliev went out into the garden was early spring which was at least six months before her death. Since that time, Ms Iliev was “pretty much confined to the couch” which he said made her stoop worse. She was unable to sleep in bed as lying flat had caused her to have difficulties in breathing. Mr Adams said that the pain caused Ms Iliev to become confined to the lounge room where she found it easier to use a bedpan and bottle, rather than moving to the toilet.

There was a sign on the lounge room door saying “please knock” so that he would not enter the room when she was toileting, and a whistle so that he would know she needed assistance afterwards.

68. Mr Adams began to prepare meals for Ms Iliev once she became confined to the couch. Mr Adams described Ms Iliev being a very light eater and a vegan. Over this sixmonth period, Ms Iliev gradually decreased her food intake to one meal per day so

that she did not experience the back pain associated with toileting on the couch by using the water bottle and bedpan. She would often have a piece of fruit early on and her typical meal was having two or three avocados with other salad ingredients, then steamed vegetables. She would have some chocolate or soft dates in the evening as a dessert.

69. About a week before her death, Ms Iliev decided not to eat anything at all, again because of the pain associated with toileting. She only had juice and water. Mr Adams said he did not make any objection to Ms Iliev’s decision, nor was he concerned about her decision. They were both familiar with fasting and Ms Iliev had done quite a bit of fasting previously. Ms Iliev had completed periods of fasting before she met Mr Adams.

70. In the last two to three days before her death, Ms Iliev slipped into a very deep sleep and was not responsive. Mr Adams noticed that she was not talking properly and had become confused about the time of day. Mr Adams believed Ms Iliev could hear him speaking but he said that she was but having trouble expressing herself in reply. For most of this time, Ms Iliev seemed to be nodding off. She could talk occasionally but not for very long.

71. Mr Adams said that he used to work as a psychiatric nurse and Ms Iliev’s conditions reminded him of how dementia patients appeared to be. Over this period of time, she was only asking for water. Mr Adams later said that in the last four to five days, Ms Iliev did not respond in the same way that she had responded in the previous weeks and months. He said that “it was almost impossible to have a conversation with her.”

72. Mr Adams noticed Ms Iliev getting thinner by seeing her arms, wrists and legs when he gave her a massage but had no idea about her body condition underneath her clothes.

He worried about this situation but had not talked to Ms Iliev about it as at that stage, “it wasn’t possible to have a normal conversation”.

73. Mr Adams slept on the couch with Ms Iliev for the three or four nights before her death as he was worried that she might slip off the couch again and he “wanted to be around twenty-four seven basically”. Previously, Ms Iliev slipped off the couch a couple of times. For example, Mr Adams found one morning that Ms Iliev was in front of the couch in between the coffee table and the couch with her knees on the floor.

74. In the morning of 6 March 2021, Mr Adams got up around 4.00am, made coffee and tried to get some more sleep. Ms Iliev asked for water and drank it through a straw.

Mr Adams spent some time working on the computer and the two watched television together.

75. In the afternoon of that day Mr Adams went outside to do some gardening. He told Ms Iliev of his intentions but she did not speak back. There was only a noise made by her. He left Ms Iliev sitting on the couch and set up cushions underneath her to prevent her from slipping over. Mr Adams estimated that he returned inside the house around 5.30pm and had been outside for approximately one to two hours.

76. After returning inside Mr Adams said that he sat on the couch next to Ms Iliev and went to speak to her about what he had been doing. He noticed that she was not breathing and realised that she had passed away.

77. They both had thought that Ms Iliev’s death was a possibility. They had a conversation about it and both assumed that with some rest and with Mr Adams taking care of Ms Iliev, she would recover in the same way that she had previously recovered. In the last two to three days, Mr Adams said that it crossed his mind that it was not going to be the case.

78. Mr Adams said that he did consider seeking medical treatment for Ms Iliev but did not do so because he was aware that Ms Iliev did not want any medical intervention, he took no action out of respect for her wishes.

79. Later in the police interview, Mr Adams said that he thought he could have done something to prevent the death of Ms Iliev, for example, calling a doctor. However, he could not force her to do anything against her wishes. Ms Iliev wanted to live but according to Mr Adams, she understood that death was a possibility.

80. After finding Ms Iliev passed away, Mr Adams decided to change Ms Iliev’s clothes, wash her body and put fresh clothes on her because he knew that she would not like to be seen like that. She had not been able to wash herself or change her clothes for at least a couple of months. Mr Adams moved Ms Iliev’s body from the couch into the bedroom and placed her on the bed where he removed her clothes. He got a basin of hot water and a soap bar to give her a sponge bath before re-dressing her in clean clothes. He noticed some dirt around her genitals. He also combed her long hair.

81. Mr Adams said that Ms Iliev had never had any prescribed medication, nor did she ever drink alcohol or use illicit drugs. However, in the six months before her death, Ms Iliev started to take aspirin. She took two tablets every two or three nights. She found that the aspirin affected her mind adversely and did not give her much relief of pain. In the last few weeks, she stopped taking aspirin.

82. Mr Adams then talked to Ms Iliev before he contacted the medical health line following which he was put through to Ambulance Tasmania. He said that he called the health line because he was searching online for a local general practitioner to issue a death certificate for Ms Iliev. He had done so as he was not sure what procedures he should follow. He also searched online for a funeral home to assist in the procedure following a death.

83. Mr Adams said that Ms Iliev had been a smoker since he met her, smoking about 10 thin cigarettes a day. A packet of tobacco would last about a fortnight, but he smoked more than her. Ms Iliev had her last puff around four or five days prior to her death.

She did not smoke a whole cigarette at that time, only a puff.

Correspondence dated 4 June 2021

84. Mr Adams sent a letter to the coroner on the abovementioned date.41 In the letter, he said that the statements he gave to the police officers on the day of Ms Iliev’s death and the following morning might seem to be incoherent and lacking in details. He said that his statements made in the police interview should be considered in the context that he was disturbed by feeling the of loss of Ms Iliev and, in addition, in dealing with the CIB investigation the whole night.

85. In this letter, Mr Adams confirmed that Ms Iliev had a serious fall around 12 months prior to her death and again about six months later when she fell whilst trying to go to the toilet. Ms Iliev ate and slept on the couch in her last months. Two weeks or so before her death, she decided to stop eating due to the unbearable pain associated with toileting on the couch. One or two days into her fasting, Mr Adams said that Ms Iliev felt a remarkable loss of pain and was able to sleep longer and more soundly than she had for months.

86. Mr Adams stated that it was not Ms Iliev’s intention to die. She only wanted to get a temporary relief from pain. Ms Iliev once completed 15 days fasting on water alone.

This helped her recover from her first back injury.

87. Mr Adams stated that during their natural discussion, Mr Adams gave his opinion but Ms Iliev always decided for herself what she thought best to do. Mr Adams respected her right absolutely. He did everything she asked him to do for her and never considered forcing her to do anything against her wishes.

41 C7B Mr Adams Submissions to the Coroner.

88. Mr Adams raised the possibility that Ms Iliev died because of dehydration. He was also wondering if diseases related to smoking were to be considered as co-factors contributing to her death.

89. In the last paragraph of this letter, Mr Adams stated that Ms Iliev decided to restrict her diet 12 months prior to her death and in the last few weeks, it was her decision to stop eating completely. Mr Adams questioned whether using the term starvation as the cause of death was appropriate because he thought it would be considered extremely rare for starvation to be the cause of death in just a few weeks of abstinence from food. In his opinion, he believed Ms Iliev’s death was due to complications of fasting and more specifically, due to accidental or unintentional dehydration.

Correspondence dated 16 February 2022

90. Mr Adams sent another letter to Coroner’s Associate on the abovementioned date. 42 He reinforced, again, that he was not in control of Ms Iliev’s care, rather, that Ms Iliev was responsible for her own care. His assistance to Ms Iliev was limited to what she asked him to do for her.

91. When Mr Adams met Ms Iliev, her artwork indicated that she was on the verge of taking her own life at 18 years old. Mr Adams stated that Ms Iliev felt being abandoned from a very early stage in her life. As a result, she developed a strong conviction that she could only trust and rely upon herself. He said that “she was a very independent minded person and sceptical of everything, preferring her own judgement in all matters of her life, including her health.”

92. In this letter, Mr Adams asked the coroner to consider that “at least qualifying the finding by making reference to the voluntary fasting that precipitated Trish’s death.” Evidence at inquest

93. At inquest, Mr Adams was questioned at length by Counsel Assisting, Ms Wu. He gave evidence that Ms Iliev was a confirmed Catholic43 who had orthodox Catholic beliefs about suffering. She accepted suffering of any kind as she believed it was ordained in some way or another. This influenced her in relation to how she managed her own health. Throughout her life, Ms Iliev successfully used fasting and restriction of diet to 42 C7C Letter to the Coroner.

43 Transcript of 25.3.2024 p21.

achieve her desired health outcomes.44 Ms Iliev had some experience with fasting before she met Mr Adams. After they met and over time, she became more and more experienced but her idea about fasting did not change.45 Ms Iliev introduced fasting to Mr Adams.46 Ms Iliev was a vegan and did not have animal products in her diet.47

94. Mr Adams gave evidence that, as a child, Ms Iliev was neglected by her mother whose mental health condition was poor. He said that she often went without food and went to school without lunch.48

95. For most of her life, Ms Iliev was unemployed. She had received Centrelink benefits (Newstart allowance), since the mid-1980s when she met Mr Adams.49 After Mr Adams retired, they were living off Mr Adams’ age pension (couples rate).

96. Mr Adams testified that Ms Iliev did receive a small amount of money from her uncle.

After Ms Iliev’s mother passed away50 she inherited the house at 32 High Street with her brother in equal shares. Later on, Mr Adams and Ms Iliev purchased Mr Iliev’s share. At that time, both of them were receiving the Newstart benefits but nevertheless managed to obtain a mortgage.51 Mr Adams gave evidence that they both had the same amount of income, owned their assets equally and did not have any separate assets.52

97. In 1975, Mr Adams said he worked as a trainee psychiatric nurse in a mental hospital known as Glenside in Adelaide for 6 weeks. The experience and knowledge he obtained from this job was therefore limited.53 During those six weeks, he observed patients deemed to have dementia.54

98. Mr Adams said that he and Ms Iliev had very limited social life and had very little contact with others.55 They had visitors occasionally and had their last visitor around three or four years ago, or longer before that, being a friend from Launceston. They were happy in their own company and did not have friends or family members to check on them.56 44 Transcript of 25.3.2024 p22.

45 Ibid p23.

46 Transcript of 25.3.2024 p22.

47 Ibid p23.

48 Transcript of 25.3.2024 p22-23.

49 Ibid p23.

50 Transcript of 25.3.2024. p24 51 Ibid 25.3.2024 p24.

52 Transcript of 25.3.2024 p27.

53 Ibid 25.3.2024 p27.

54 Transcript of 25.3.2024 p28.

55 Ibid 25.3.2024 p29.

56Transcript of 25.3.2024 p30.

99. Since Mr Adams met Ms Iliev, he only knew of two occasions where Ms Iliev was willing to consult a doctor.57 He said that she found the whole experience on each occasion to be upsetting.58

100. In his evidence at inquest, Mr Adams gave more details in relation to the injuries suffered by Ms Iliev.

101. The first back injury occurred in 1988. Ms Iliev was immobilised but could get up with extreme pain to go to the toilet.59 It took her six months to recover.60 She did not seek any professional treatment, including physiotherapy, but decided to undertake fasting for seven or eight days just with water which produced a great improvement in her condition. Mr Adams said that there had been discussions between them both in relation to how she could manage the pain. He said that Ms Iliev made up her mind about what she wanted to do. Mr Adams undertook the household chores including shopping and preparing meals. Ms Iliev did not fully recover from this first injury which caused her to have a weakness in her back that eventually developed into a stoop.61

102. The second incident occurred in Launceston when Ms Iliev tried to help Mr Adams move one of the pieces of a second-hand pizza oven. This had aggravated the injury she suffered previously since she was not fully recovered. She was in pain, but her condition improved.

103. Mr Adams described a third injury sustained by Ms Iliev in Sheffield, seemingly a long time prior to her death. She was washing quilts by hand and injured her back when lifting a quilt out of the washing trough. Mr Adams did not know whether the injury was on the same area of Ms Iliev’s back as the previous injuries.62 He said that this injury slowed Ms Iliev down in doing gardening work but did not incapacitate her. Her condition improved but she did not fully recover. She experienced pain in her back, periodically. She started to take aspirin and disprin and other over-the-counter pain medications. Those medications did relieve the pain but had side effect on Ms Iliev causing her to feel dizzy and somewhat stupefied.

104. Around 12 months prior to her death, walking to the letterbox, Ms Iliev was tripped by a stray cat going under her feet and fell backwards on her back in the driveway. As a result, she had to stay on the couch for prolonged periods but was able to sleep in 57Ibid p33.

58 Transcript of 25.3.2024 p34 59 Ibid p35.

60 Transcript of 25.3.2024 p36.

61 Ibid p36.

62 Transcript of 25.3.2024 p37.

the bed. She was able to go to the bathroom to wash herself. She could go to the toilet and prepare her meals. However, her activities in the garden slowed down dramatically.63 At this time, they purchased a walking aid online by using money from Mr Adams’ pension. Mr Adams said that he agreed with Ms Iliev’s decision not to see a doctor because she did not feel it to be necessary to go outside the house and seek assistance from a stranger.64 They discussed medical treatment but Mr Adams respected Ms Iliev making her own decisions in this regard.65

105. Mr Adams stated that there was a notable decline in Ms Iliev’s mobility after she suffered the injury 12 months prior to her death. He gave evidence that Ms Iliev applied her experience and knowledge in fasting and restricted diet to recover from her injuries. Mr Adams stated that both were aware that Ms Iliev might be entitled to get care and support from the government. However, again, Ms Iliev did not want to seek help from strangers.66

106. Ms Iliev had another fall when trying to walk to the toilet six months prior to her death. The bedpan and urine bottle were purchased after this incident.67 Ms Iliev’s condition became progressively worse. Initially, she could manage to go to the kitchen and prepare her meals. However, two to three months prior to her death, she was bound to the couch and started to use the bedpan and urine bottle for toileting in the lounge room.68 Ms Iliev refused to use the bedpan and used a plastic bag. Mr Adams was responsible for emptying the urine bottle and taking the plastic bag away.

107. Mr Adams would bring a basin of water and soap to the lounge room for Ms Iliev to wash herself.69 Ms Iliev was able to take her clothes off and wash some parts of her body. Mr Adams washed other parts of Ms Iliev’s body.70 The last time she had washed herself thoroughly was two months prior to her death. She still washed her face and hands until she stopped eating.71 Mr Adams did not see her washing herself thoroughly but offered assistance to her. Ms Iliev told him that she preferred to wash on her own.72 She never mentioned the pressure sores to Mr Adams.73 63 Transcript of 25.3.2024 p38.

64 Ibid p39.

65 Transcript of 25.3.2024 p40.18-19.

66 Ibid of 25.3.2024 p43.

67 Transcript of 25.3.2024 p44.

68 Ibid 2024 p45.

69 Transcript of 25.3.2024 p46.

70 Ibid p47.

71 Transcript of 25.3.2024 p60.

72 Transcript of 25.3.2024 p61.

73 Ibid p49.35-37.

108. Mr Adams stated that Ms Iliev restricted her diet partly as an effort to get some relief from her injury, but also for the purpose of not needing to attend to toileting as frequently as it caused her to suffer extreme pain in lifting herself up. Mr Adams agreed that Ms Iliev did lose her strength as she did not have the same level of exercise she used to have in the garden.74

109. Ms Iliev had a very set pattern about when she ate which did not change after her becoming couch-bound, only that she ate a lot less.75 She had her first meal around 3.00pm-4.00pm, and dinner around 7.00pm-8.00pm.76 She restricted herself to raw vegetable and fruits, depending on what Mr Adams could obtain at the supermarket.

She did not eat bread due to the high concentration of salt but had low salt crackers and nuts sometimes. She loved avocados, dairy-free ice cream and chocolate.77 Mr Adams trusted Ms Iliev’s judgement and did not interfere with Ms Iliev’s decision to eat less food.

110. In the last three months, Ms Iliev had lost weight. Mr Adams claimed it was not as obvious to him as he had not seen her naked for six months. He only saw her arms.78 He said that Ms Iliev did not weigh herself. She had never weighed over 35 kilograms during the entire time Mr Adams had known her.

111. Mr Adams agreed that in the last month before her death, her weight loss must have been rapid but stated that it was not obvious to him that Ms Iliev had lost a very significant amount of weight as some weight loss was expected during fasting.

112. Mr Adams also agreed that although during their relationship Ms Iliev had never weighed 19 kilograms (as she did at her death) and explained that he only appreciated how much weight she had lost after her death.79 He stated that “she understood the risks of what she was doing, we both did, but she was determined to try it in any case.”80

113. Mr Adams denied the possibility that Ms Iliev might have effected suicide by intentionally starving herself due to being in extreme pain.81 He said that, later, he speculated whether she had reached the point where the pain was too much for her 74 Transcript of 25.3.2024 p48.

75 Ibid p50.

76 Transcript of 25.3.2024 p52.

77 Ibid p51.

78 Transcript of 25.3.2024 p51.p52.

79 Ibid 2024 p53.

80 Transcript of 25.3.2024 p51. p57.

81 Transcript of 25.3.2024 p55.

and had deliberately taken steps to die. However, he did not consider this to be a possibility at that time.82

114. He stated that Ms Iliev stopped eating completely in her last week, primarily to have relief from doing toileting.83 By his account, she said “Philip, I’ve decided to stop eating.”84 She told Mr Adams that she was hoping to get relief from pain for a few days and to have some sleep.85 They did not specify a time when Ms Iliev would resume eating86 but she said to him “I’ll let you know.”87

115. Mr Adams did not challenge Ms Iliev’s decision to stop eating because he trusted her judgement as she had fasted previously and knew what she was doing.88 He said in his evidence “And immediately, the next day after she stopped eating, she did get relief from having to go to the toilet and she started to get some sleep.” Mr Adams claimed that up until a week before Ms Iliev died, she was completely lucid.89

116. Ms Iliev experienced difficulty in breathing more than 12 months prior to her death as she was a smoker.90 She did not have the full expanse of her lungs. Mr Adams mentioned that smoking is an appetite suppressant and that both of them probably used smoking to help avoid eating too much.91 Ms Iliev cut down on smoking to improve her breathing.92 She smoked Indian cigarettes called bidis which she stopped smoking three or four days before her death. Ms Iliev would ask Mr Adams for a drink, and he would pass it to her.93 Ms Iliev would have sips of water but had difficulty in swallowing it.94

117. Mr Adams denied that he abandoned Ms Iliev and stated that he relied on her to express a change (to resume eating).95 Neither Ms Iliev nor he expected her death.96 Evidence given at inquest on 14 June 2024

118. Mr Adams stated that Ms Iliev was lucid at times before she died but the conversations between them had become brief. He showed her one of the videos he 82 Ibid p58.

83 Transcript of 25.3.2024 p55.

84 Ibid p57.

85 Transcript of 25.3.2024 p55.

86 Ibid p56.

87 Transcript of 25.3.2024 p58.

88 Ibid p56.

89 Transcript of 25.3.2024 p57.

90 Ibid p61.

91 Transcript of 25.3.2024 p62.

92 Ibid p63.

93 Transcript of 25.3.2024 94 Ibid p68.

95 Transcript of 25.3.2024 p71.

96 Ibid p73.

took from the garden where Ms Iliev was concerned about some weeds around her bulbs. She asked if Mr Adams could do something about it.97 They had a brief conversation in relation to Mr Adams going down to the garden on the day that she passed away. Ms Iliev was asleep generally which was not unusual for a person who was in a fasting state. Mr Adams agreed that at least in the last three, four and five days, the complexity and length of the conversations stopped and that Ms Iliev was only intermittently responsive.98 No more than 48 hours after Ms Iliev stopped eating, she began to sleep almost immediately and for long periods.99 When she woke up, she was able to make meaningful communication with Mr Adams.

119. Mr Adams disagreed that maybe at some point, Ms Iliev was not able to make her own decisions.100 He did not accept that in her last few days, Ms Iliev had no mental capacity to make her own decision.101 When Ms Iliev increased her time of sleep, he did not think that he should seek medical attention for her.102 He never thought she was dying in her last few days.103

120. Prior to Ms Iliev making her decision to stop eating, they had long conversations to discuss the options she had. Ms Iliev understood that she was not in an ideal condition to undertake a fast. They discussed the option of going to a fasting clinic in New South Wales.104 However, Ms Iliev decided not to take the trip due to a lack of physical capacity and probably because of financial considerations.105

121. The couple did not discuss how they would manage the situation if Ms Iliev got worse during fasting.106 Mr Adams disagreed that when making the decision of not eating, Ms Iliev’s thinking was distorted, stating that “she obviously miscalculated the extent that she could ah well the le – the length that she could fast given that she’d already been restricting herself”.107

122. The last solid food Ms Iliev ate was a salad with avocados and some steamed vegetable afterwards.108 97 Transcript of 25.3.2024 p8.

98 Ibid p9.

99 Transcript of 25.3.2024 p10.

100 Ibid p11.

101 Ibid p28.

102Transcript of 25.3.2024 p11.

103 Ibid p13.

104 Transcript of 25.3.2024 p14.

105 Ibid p15.28 106 Transcript of 25.3.2024 p16.

107 Ibid p16.

108 Ibid p19.

123. On the day that Ms Iliev died, she had some water in the morning.109 Mr Adams stated that when he watched TV, Ms Iliev was sleeping.110 He told her that he was going to take care of the bulbs and that Ms Iliev nodded.111 Mr Adams later stated that Ms Iliev nodded and said “okay” to him.112 He did not come back inside or to check if Ms Iliev needed anything until 5.30pm.113 He said he washed her body after finding her deceased to give her as much respect as he could before her body going out of his control.114

124. Mr Adams said that he did not think there was anything he could do differently to prevent Ms Iliev from dying.115 He accepted that in her last few days Ms Iliev was entirely dependent on him to provide her with drink but insisted that she was not dependent on him to make her own decision.116 He did not believe Ms Iliev had a sharp cognitive decline to the extent that she was not able to tell him what she wanted.117 Ms Iliev told him expressly that under no circumstance did she want any medical intervention.118

125. After Ms Iliev died, Mr Adams inherited the house they owned jointly.119 Ms Iliev left a will to leave the house to him.120 He sold the house.121

126. Mr Adams suggested that probably, the gastric tumour impaired Ms Iliev’s ability to assess her appetite which was important when she was fasting as she was not aware that she had that tumour.122

127. After the commencement of fasting, Ms Iliev was breathing a bit more heavily which was not unexpected for people who was doing a fast.123 Conclusion

128. I have gone to some length to set out the accounts given by Mr Adams on various occasions since the death of Ms Iliev. His evidence of her character and background was generally consistent between his accounts and, for the most part, credible.

109 Ibid p19.5.

110 Ibid p19.32.

111 Ibid p20.28-32.

112 Ibid p21.11-12.

113 Ibid p21.20-22.

114 Ibid p25.19-20.

115 Ibid p28.1-2.

116 Ibid p28.8-10.

117 Ibid p28.13-16.

118 Ibid p28.24-25.

119 Ibid p28.36.

120 Ibid p28.39.

121 Ibid p29.1.

122 Ibid p30.23-27.

123 Ibid p33.35-36.

However, for the reasons that follow, I have significant doubts about much of his evidence concerning Ms Iliev’s acute decline and death. As discussed further on, I do not accept to the requisite standard his evidence that, in her last days, Ms Iliev was able to express herself coherently or had decision-making capacity. I also do not accept his evidence that he was unaware of her dangerously low body weight, that her death was unintended, and that he did not expect Ms Iliev to die.

129. I find, in accordance with the evidence, the following facts.

130. Ms Iliev had always been a very slight woman. She shunned conventional medical treatment and chose not see doctors or health professionals. Although she was a vegan, she was a daily cigarette smoker. She had advanced lung disease caused by smoking, and this was a factor that contributed to her death.

131. Over the years, she voluntarily engaged in periods of fasting. The purpose of this practice may have been to improve her health, as Mr Adams asserted, although there was no objective evidence that her fasting from food actually resulted in health benefits. It is also possible that mental illness played a part in her fasting.

132. Mr Iliev and Mr Adams were unconventional in their lifestyle. They did not engage in social activities, preferring to keep to themselves. They did not have regular contact with family members. There is no evidence that after 1 August 2019 Ms Iliev had had any contact with or had been seen by anyone apart from Mr Adams.

133. Ms Iliev experienced back pain throughout her life since she first injured her back in

134. She did not fully recover from this injury and her pain and suffering was exacerbated by other incidents over the years.

135. I find that, about 12 months prior to her death, Ms Iliev fell in her driveway and, again, injured her back. Subsequently, she was still able to mobilise and attend to activities of daily living. Walking aids were purchased for Ms Iliev. It is possible that, from this time (or even beforehand), her physical and/or mental decline prevented her from leaving the house. This may explain why she had not been seen for 18 months before her death.

136. I have given consideration to the question of whether Mr Adams exerted control over Ms Iliev in the relationship generally and, specifically, in the period leading up to her death. Nothing in the objective evidence suggests that this is the case. Upon all the evidence, including the detailed evidence from Mr Adams, they were equal partners in the relationship. Mr Adams, in fact, appeared to be devoted to Ms Iliev in many ways

and intent upon respecting her independent wishes. His insistence that he was following Ms Iliev’s own instructions and wishes concerning what should be done for her health and well-being was plausible.

136. Six months before her death, she had another fall causing her condition to further deteriorate with an escalation of pain and loss of independence. She became immobile and couch-bound, relying upon Mr Adams to prepare her meals, bring her food and water, assist her in washing herself and clean up after she had completed toileting in the lounge room (using a urine bottle and plastic bags). The house was adequately heated.

137. I accept the evidence of Mr Adams that, until approximately 10 days before her death, he provided Ms Iliev with food and fluid in accordance with her specific requests. I accept the evidence of Mr Adams that Ms Iliev deliberately reduced her intake to one meal per day about six months before her death. Her drop in body weight is consistent with a significant decrease in intake some months before her death.

138. I find that Mr Adams played no part in coercing her to reduce her food intake. Equally, he did not try and persuade her to increase her intake to a proper level but supported her in her health decisions. On any rational view, Ms Iliev had embarked upon a course that, if it continued, would inevitably lead to death as a result of inadequate nutrition.

139. I do not accept that Mr Adams genuinely believed (as he claimed) that Ms Iliev knew how best to heal herself. He is a person of intelligence, as exemplified by his articulate answers in evidence and in his written correspondence. Even with his obvious support for Ms Iliev’s unconventional methods of caring for herself, it must have been apparent to him several months before her death that she was very ill and on a deteriorating trajectory. She was immobile and confined to the couch, unable to care for herself and showing no signs of increasing her food intake or seeking medical attention.

140. He was aware at least two months before her death that she was unable to wash her body thoroughly or change her clothes. His awareness of the unacceptable state of her personal hygiene was disclosed by his actions in washing her and dressing her in clean clothes after she had died.

141. I find, accepting Ms Adams’ evidence, that seven to ten days prior to her death, Ms Iliev stopped eating solid food completely. During that period, she only took water or fruit juice. I do not accept that he did not realise her body was thinner. He could not have failed to notice her losing almost half of her body weight.

142. It is possible, as stated by Mr Adams, that part of the reason for Ms Iliev stopping eating was the pain associated with toileting. However, as will be discussed, other explanations exist.

143. I agree with the submission of counsel assisting that Mr Adams was a witness whose evidence regarding Ms Iliev’s death should be viewed with caution. Because of the isolated nature of their lifestyle, there is scant corroborative evidence supporting his account. Mr Adams’ evidence at inquest was artfully given. His answers to questions which may have led to criticism of his actions were often carefully considered as he attempted to present himself in a more favourable light. His tendency to answer questions very carefully was particularly pronounced where the questions dealt with the circumstances surrounding Ms Iliev’s death. In particular, he was at pains to convey that she was, at least at times, responsive and lucid until she died. However, his accounts about this issue varied in the particulars.

144. I do not criticise Mr Adams for his argument regarding the applicability of the privilege against self-incrimination as it may apply to the Coroners Act. However, once I had ruled that the provisions of the Act abrogated the privilege, his refusal to answer questions was not only disrespectful of the coronial process but caused me to question whether, as a critical witness in the investigation, he ever intended to provide truthful evidence concerning the circumstances around his partner’s death.

145. Other concerns regarding his evidence related to his tendency to embellish the facts and to divert attention from areas whereby he may be criticised. For example, he was not a former psychiatric nurse, as he stated in his police record of interview, but had completed a total of only six weeks training experience in a facility. Further, his letter on 4 June 2021 questioned starvation as a cause of death without any expert basis and emphasised on multiple occasions that Ms Iliev was independent in her decisionmaking at all stages of her life.

146. I do not accept, on the balance of probabilities, Mr Adams’ assertion that Ms Iliev died unintentionally in a fasting period designed to relieve her of pain and possibly assist her recover from her back injury. Mr Adams said in evidence that, prior to her decision to stop eating, they had had “long conversations” about her options, including ruling out the option of attending an interstate fasting clinic because her back was too painful for travel.

147. Mr Adam’s claim that Ms Iliev was supposed to let him know when she would resume eating is not credible and bordered on fanciful. She had become unable to properly

communicate at least a week before her death and still Mr Adams did not intervene to offer her food or get her help.

148. One obvious explanation for the failure of Mr Adams to intervene when Ms Iliev was clearly close to death is that there had been communications between them at an earlier point in time to the effect that Ms Iliev wished to die and that her reduced food intake was in line with her intention to end her life. Mr Adams, of course, did not give this evidence but it is a more realistic explanation of the circumstances of death.

Although I cannot make a positive finding, it is quite plausible that Mr Adams was expressly supporting her wish to die.

149. Following the same reasoning, I cannot discount the proposition that Ms Iliev expressly told Mr Adams that she wished for no medical treatment even in the event that she was near death. This would be consistent with how she lived her life.

Unfortunately, there was no Advance Care Directive or document evidencing her wishes. As it stood, the only evidence available was that from Mr Adams, and his evidence that her death was unexpected and unintentional is not credible.

150. As to Ms Iliev’s decision-making capacity and mental state, the evidence indicates that prior to Ms Iliev being house bound, she had the mental capacity to make her own decisions about her medical care and treatment. The evidence of her interactions with others demonstrates that, whilst idiosyncratic by nature, she had the cognitive and mental capacity to make decisions.

151. However, I have doubts about whether or not she did have such mental capacity during the period of about 18 months before her death when she was not seen by other persons. I cannot determine whether her mental state deteriorated at an early or later point in this time frame. There is simply no evidence regarding this issue, apart from that of Mr Adams, which I cannot accept at face value. Questions also arise as to whether she had provided Mr Adams with her clear wishes before any onset of incapacity for decision-making. Again, I am unable to make factual findings on this point.

152. As mentioned, Mr Adams gave varying evidence concerning the state of Ms Iliev’s consciousness responsiveness and in the last two to three days of her life. Ultimately, his evidence was that Ms Iliev was in a state of greatly reduced consciousness during this period and largely uncommunicative. It is safe to conclude that in this period Ms Iliev was unresponsive, unable to communicate to any degree and likely did not have capacity to make decisions about her care and treatment.

153. Again, I find that I cannot accept to the requisite standard the evidence of Mr Adams concerning the events on the day of her death. Specifically, I do not accept his evidence that Ms Iliev made any communicative noise to him, watched television with him actively, asked for a sip of water or interacted in any meaningful way. His evidence that she did so was exaggerated. I find that she was unresponsive and unable to interact with him by the day of her death. It is quite possible that she died earlier that morning, but I cannot make that finding. The medical evidence is not able to assist in determining time of death.

154. The evidence of Mr Adams was, I find, designed to portray that Ms Iliev was interactive and not near death. I find that he gave this evidence in order to maintain the consistent account that he did not think she was approaching the end of her life.

He conceded only once in evidence that it “crossed his mind” that she might not be okay.

155. I also doubt his evidence that he stayed in the garden for two hours on the day of her death. Apart from the scene photographs showing a very unkempt garden, it seems unlikely that he would not have entered into the house for any purpose during this time. It appears that he may have given this evidence to reinforce his account that he did not expect her death.

156. The actions of Mr Adams following Ms Iliev’s death were highly unusual, even taking into account his reluctance to engage with conventional forms of assistance. He had, on his own evidence, unexpectedly found his partner deceased. Instead of immediately calling emergency services, and he engaged in calculated actions obviously intended to avoid scrutiny. These actions included: (a) delayed reporting of Ms Iliev’s death to anyone for at least five hours; (b) during the delay, washing Ms Iliev’s dirty and emaciated body, and dressing her in clothes covering her body (many sizes too large); and (c) calling a health line unrelated to the situation and not emergency services; and

(d) attempting to obtain a death certificate when Ms Iliev’s death was unnatural or unexpected. I find that Mr Adams wished to avoid scrutiny because of the very confronting state of Ms Iliev’s body.

157. To summarise, it is a plausible hypothesis that Ms Iliev formed her own view that she wanted to die due to her pain and reduced her food intake for this purpose. Her gastrointestinal stromal tumour may have played a part in reducing her appetite.

However, reduced food intake was a practice known to her and she was aware of the consequences of fasting. I can also not discount that, at a point before her death during her physical decline, she had decision-making capacity and clearly told Mr

Adams that she did not wish to have medical treatment and that she wished to die. Mr Adams then, with a full understanding of her condition, allowed her to do so. This version sits with the manner in which he gave evidence and his actions after Ms Iliev’s death. It remains the most reasonable hypothesis.

158. An alternative and plausible hypothesis is that Ms Iliev lost rationality and decisionmaking capacity without expressing her wishes regarding treatment or resuscitation.

In such scenario, Mr Adams allowed her to pass away knowing that she would not wish to have medical treatment under any circumstances.

159. For the reasons expressed, I do not accept the implausible explanation of Mr Adams that he was largely unaware of Ms Iliev’s grave condition and that her death was imminent.

160. Despite the difficulty in determining the facts surrounding Ms Iliev’s death, I am satisfied that Mr Adams did not do any act to maliciously cause her death. He clearly had affection for her, respected her wishes (or what he believed to be her wishes), and provided her food, water and assistance on the occasions she made requests.

161. I note that Mr Adams did gain financially by her death by obtaining her share in the house. However, there is no evidence at all that he deliberately allowed her to die for financial gain. His evidence did not convey such motivation.

162. I comment that no adult person with decision-making capacity can be compelled to have medical treatment against their wishes. Further, any adult with capacity may prepare an Advance Care Directive document clearly stating their decisions in respect of future medical treatment.

163. It is clear upon the evidence in this sad and confronting case that Ms Iliev’s back pain and other medical conditions could have been well treated with conventional medical methods. In such a case, she would have seen significant alleviation of her pain and incapacity, and improvement in her quality of life. This would have obviated the need for her to resort to a method of healing unsupported by medical evidence and which, in fact, resulted in her death. Even whilst Ms Iliev was in the final days of dying from starvation, medical treatment could still have saved her life.

164. It would have been prudent for Ms Iliev and Mr Adams to have considered a consultation for Ms Iliev, before her death, with a medical practitioner capable of assessing her decision-making capacity and assisting her prepare an Advance Care Directive. In that way, there would have been documentary evidence corroborating

her capacity and her wish not to undergo medical treatment. This evidence would have assisted considerably regarding the circumstances surrounding her death and may have avoided the need for a public inquest.

Formal findings required by section 28(1) of the Coroners Act 1995: a) The identity of the deceased is Patricia Iliev; b) Ms Iliev died in the circumstances set out in this finding; c) The cause of Ms Iliev’s death was starvation; and d) Ms Iliev died on 6 March 2021 at Sheffield in Tasmania.

Concluding comments and acknowledgements

165. I do not consider it appropriate to make any recommendations pursuant to section 28 of the Act.

166. I appreciate the assistance given by both Counsel Assisting, Ms Belonogoff and Ms Wu.

167. I convey my sincere condolences to the family and loved ones of Ms Iliev.

Dated: 5 August 2025 at in the State of Tasmania Olivia McTaggart Coroner

Annexure A No. TYPE OF EXHIBIT NAME OF WITNESS C1 Police Report of Death Constable Timothy Ford C2 Life Extinct Dr Alannah Gall C3 Affidavit of Identification Constable Timothy Ford C4 Affidavit of Identification Collin O’Connor C5 Autopsy Report Dr Donald Ritchey C6 Toxicology Report Mr Neil McLachlan-Troup C7 Video of Police Interview with Philip Tasmania Police George Adams C7A Transcript of Police Interview with Philip Tasmania Police George Adams C7B Submissions to the Coroner (4/06/21) Geoff Maguire on behalf of Adams C7C Letter to the Coroner (16/02/22) Philip George Adams C8 Affidavit 1/C Cst Tyrone Myers C9 Affidavit Det Snr Cst Allira Bartush C10 Affidavit and photographs Snr Cst Michelle Rybarcyzk C11 Affidavit Jennifer Sargeant C12 Coronial Medical Report Dr A J Bell C13 Affidavit Kim Iliev C14 Affidavit Patricia Rosemary Laws C15 VACIS Electronic Patient Care Record for Ambulance Tasmania incident #317-06032021 C16 000 audio recording for incident #317- Ambulance Tasmania 06032022 C17 Body Worn Camera Footage Cst Ford C18A Nurse Triage Audio Recording 06.03.2021 Healthdirect Australia C18B Patient Health Record 06.03.2021 Healthdirect Australia