Finding into death of Paul Christian Flegel

IN THE CORONERS COURT COR 2022 006197 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the Death of Paul Christian Flegel 18 November 2025 Delivered on: Coroners Court of Victoria Delivered at: 65 Kavanagh Street, Southbank Hearing date: 18 November 2025 Findings of: Coroner Leveasque Peterson Counsel assisting the Coroner: Ms Olivia Collings, Coroner’s Solicitor Keywords: Homicide, uncharged, gunshot injury, firearm death, shooting

INTRODUCTION

1. On 27 October 2022, Paul Flegel was 61 years old when he died from a gunshot wound to the thigh.

2. At the time, Paul lived in Beechworth with Susan Conlon (Susan).

INVESTIGATION AND SOURCES OF EVIDENCE

3. This finding draws on the totality of the coronial investigation into the death of Paul Flegel including evidence contained in the coronial brief as prepared by Coroner’s Investigator, Acting Sergeant Brendan Stack, the medical examiners’ report and toxicology report produced by the Victorian Institute of Forensic Medicine.

4. All of this material, together with the inquest transcript, will remain on the coronial file.1 In writing this finding, I do not purport to summarise all the material and evidence but will only refer to it in such detail as is warranted by its forensic significance and the interests of narrative clarity.

PURPOSE OF A CORONIAL INVESTIGATION

5. The purpose of a coronial investigation of a ‘reportable death’2 is to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which death occurred.3

6. Paul’s death falls within the definition of reportable death, specifically section 4(2)(a) of the Coroners Act 2008 (Vic) (the Act) which includes an unexpected, unnatural or 1 From the commencement of the Coroners Act 2008, that is 1 November 2009, access to documents held by the Coroners Court of Victoria is governed by section 115 of the Act. Unless otherwise stipulated, all references to legislation that follow are to provisions of the Act.

2 The term is exhaustively defined in section 4 of the Act. Apart from a jurisdictional nexus with the State of Victoria a reportable death includes deaths that appear to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury; and, deaths that occur during or following a medical procedure where the death is or may be causally related to the medical procedure and a registered medical practitioner would not, immediately before the procedure, have reasonably expected the death (section 4(2)(a) and (b) of the Act). Some deaths fall within the definition irrespective of the section 4(2)(a) characterisation of the ‘type of death’ and turn solely on the status of the deceased immediately before they died – section 4(2)(c) to (f) inclusive.

3 Section 67(1).

(relevantly) violent death. Section 52(2)(a) requires that I hold an inquest into the death where I suspect the death was due to a homicide – the act of an individual killing another individual whether that conduct was criminal (i.e. constituted the offence of murder).

7. The ‘cause’ of death refers to the ‘medical’ cause of death, incorporating where possible the mode or mechanism of death. For coronial purposes, the ‘circumstances’ in which death occurred refers to the context or background and surrounding circumstances but is confined to those circumstances sufficiently proximate and causally relevant to the death, and not all those circumstances which might form part of a narrative culminating in death.4

8. The broader purpose of any coronial investigations is to contribute to the reduction of the number of preventable deaths through the findings of the investigation and the making of recommendations by coroners, generally referred to as the ‘prevention’ role.5

9. Coroners are empowered to report to the Attorney-General in relation to a death; to comment on any matter connected with the death they have investigated, including matters of public health or safety and the administration of justice; and to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of justice.6 These are effectively the vehicles by which the coroner’s prevention role can be advanced.7

10. Coroners are not empowered to determine the civil or criminal liability arising from the investigation of a reportable death and are specifically prohibited from including in a finding or comment any statement that a person is, or may be, guilty of an offence.8

BACKGROUND 4 This is the effect of the authorities – see for example Harmsworth v The State Coroner [1989] VR 989; Clancy v West (Unreported 17/08/1994, Supreme Court of Victoria, Harper J.) 5 The ‘prevention’ role is now explicitly articulated in the Preamble and purposes of the Act, compared with the Coroners Act 1985 where this role was generally accepted as ‘implicit’.

6 See sections 72(1), 67(3) and 72(2) regarding reports, comments, and recommendations respectively.

7 See also sections 73(1) and 72(5) which requires publication of coronial findings, comments and recommendations and responses respectively; section 72(3) and (4) which oblige the recipient of a coronial recommendation to respond within three months, specifying a statement of action which has or will be taken in relation to the recommendation.

8 Section 69(1). However, a coroner may include a statement relating to a notification to the Director of Public Prosecutions if they believe an indictable offence may have been committed in connection with the death. See sections 69 (2) and 49(1).

11. Paul was born to Sam and Ruth Flegel and was raised in the Wangaratta and Beechworth areas. He left school at age 14 and pursued a carpentry apprenticeship in Melbourne.

12. In 1983, Paul married Deanne Green and with Deanne’s daughter from a previous relationship, SL, the family moved around Victoria and Queensland before settling in Upwey in 1986. Around this time, Paul suffered a back injury and was no longer able to work as a carpenter, so he became an antique-seller.

13. In 1987, Paul and Deanne welcomed a daughter, Elisabeth. According to SL, Paul and Deanne shared a volatile relationship and sometimes engaged in ‘screaming matches’, they separated in 1996. Paul lived alone in Upwey and the same year, he commenced a relationship with Eliza Richards. In 2004, Sam and Ruth moved into Ruth’s late brother’s property in Beechworth. Due to their declining age, they ‘could no longer look after themselves on their own' and so Paul and Eliza moved to Beechworth to support them.

14. In 2013, Paul and Eliza separated and the same year, Paul was diagnosed with prostate cancer, had his prostate removed and commenced chemotherapy. According to SL, he became ‘exhausted’ from the treatment, causing him to close his antique shop in 2019. SL last saw Paul in September 2022 and described that he ’looked very unwell’. At the time of his death, the cancer was graded at Stage 4 (terminal).

15. Following his separation from Eliza, Paul met Susan, and they commenced a relationship, which she described as ‘up and down’.

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

16. On 27 October 2022, Paul and Susan spent the day together. He began drinking alcohol, specifically Jack Daniels, at around 5pm, and the couple began arguing. Susan went upstairs to ‘cool down’ and at Paul’s request, she went to the local IGA supermarket to buy alcohol since his friend, Timothy Dwyer (Timothy), was coming over.

17. Paul met Timothy four years earlier at a mutual friend’s birthday party. Timothy referred to Paul as ‘Uncle’ and visited him approximately every month. On this occasion, Timothy

travelled to Paul’s house with another friend, Nigel Wong (Nigel). Timothy and Nigel were staying at a local motel while in Beechworth.

18. When Timothy arrived at Paul’s house, he noticed that he ‘quickly turning intoxicated, he was slurring his words and his sentenced were broken up’. He described Paul was being ‘aggressive’ and once Susan returned home, he began arguing with her. Paul became ‘more and more agitated’ and was expressing anger towards many Beechworth residents.

19. At 6:27pm, Paul began calling several people, including Barry Butler (Barry). According to Susan, Paul and Barry were ‘not close friends and there [was] no bad blood between them’. However, Timothy stated, ‘there was an alleged debt that [Barry] owed [Paul]’. At 6:44pm, Paul left a threatening message on Barry’s voicemail: ‘Go fuck yourself. Ring me in 10 seconds. Go fuck yourself’.

20. According to Timothy, Paul began talking about ‘taking motorcycles’. In a voicemail to a friend, which is believed to be a misdial, Paul was heard saying ‘and then we’re taking away a $30,000 Harley Davidson, [Nigel] needs one’. Another male said ‘I’m fucking ready to go right now’.

21. Shortly after 7:00pm, Paul and Susan began arguing again. Susan retreated upstairs however, Paul followed her and according to Susan, he began hitting her with a cane.

Afterwards, Susan went for a walk with the dogs to the local park.

22. Between 7 and 8pm, Paul sent several explicit and threatening voice mail messages to Barry, including to state ‘we’re coming. We’re gonna fucking destroy you’. Barry told a friend that Paul threatened ‘he was going to his place and take all his shit and either shoot him or blow him away’.

23. Susan returned home momentarily around 8pm, and following further argument with Paul, went visited her daughter for the night. At 8:08pm, Paul left a threatening voicemail message for Susan.

24. At 8:09pm, Paul and Timothy went to the IGA supermarket across the road, and an employee heard Paul say, ‘I’ve had enough of this! I’m gonna fucking shoot him’. Paul

decided to visit Barry. According to Timothy, he joined Paul with the view to ‘try and mediate a conversation’ with Barry.

25. At approximately 8:15pm, Paul and Timothy arrived at Barry’s house, and they decided that Timothy would knock on the front door and speak with Barry while Paul remained in the car. Barry answered the door and asked Timothy ‘if [he] was there to hurt him’.

Timothy responded by showing he did not have a weapon and said, ‘that sounds pretty full on, I’m just here to chat’, which seemed to make Barry ‘relax’.

26. As Barry turned and invited Timothy inside, Paul had exited the car and ‘started screaming’. Timothy turned and saw he was holding a firearm, he recalled it was difficult to see and that Barry was ‘squinting’ since Paul was standing in front of the car’s headlights.

27. Paul fired his firearm, and Timothy felt the bullet pass by his head, which struck Barry in the chest. Timothy fled the scene in the direction of a local dam and began calling Nigel, who was still at Paul’s house.

28. Barry returned fire and during the altercation, he discharged three bullets and Paul discharged five. Paul was shot in the right thigh.

29. Barry retreated from his front door and hid under his car in his shed and contacted emergency services. Paul retreated to his car and attempted to get into the drivers’ seat; he placed his firearm on the back seat.

30. Barry remained on the telephone with emergency services. Victoria Police received notification of the altercation and due to the reported circumstances (which raised the risk of armed individuals), organised a coordinated response with Ambulance Victoria paramedics and various Victoria Police units including the Critical Incident Response team, K9 squad and Air Wing.

31. At around 10:30pm, Victoria Police arrived at Barry’s house and once the premises was cleared, it was established as a crime scene. Paramedics found Paul by his car and

confirmed he was deceased. Barry was transported to the Alfred Hospital, where he eventually recovered.

IDENTITY OF THE DECEASED

32. On 8 November 2022, Paul Christian Flegel, born 8 June 1961, was identified by a positive fingerprint comparison.

33. Identity is not in dispute and requires no further investigation.

MEDICAL CAUSE OF DEATH

34. Forensic Pathologist Linda Iles of the Victorian Institute of Forensic Medicine (VIFM) conducted an autopsy on 29 October 2022.

35. Dr Iles’s post-mortem examination was assisted by the following sources: a) The Victorian Police Report of Death for the Coroner (VP Form 83), b) An application from Victoria Police requesting that an immediate autopsy be performed, c) Preliminary information provided by a member of the Victoria Police Homicide Squad; and, d) A post-mortem computed tomography (CT) scan.

36. Dr Iles provided a written report of her findings dated 21 December 2022.

37. Dr Iles made several findings at autopsy: a) Indeterminate range gunshot entry wound to the right thigh passing medially, exiting the anterior right thigh and re-entering the left thigh associated with: i. Extensive soft tissue haemorrhage

ii. Comminuted9 fracture of the left femur iii. Large calibre projectile (bullet) within the soft tissue; and iv. Transection of the left femoral artery.

b) Mild cardiomyocyte hypertrophy,10 c) The prostate was absent, d) Testicular atrophy, e) Small thyroid follicular adenoma, f) Minor coronary artery atheroma, g) Histological changes of bronchial asthma, h) Cholelithiasis (gallbladder stones), i) Hyaline pleural plaques; and, j) Rental cortical pallor.

38. Dr Iles retrieved a large calibre projectile (bullet) from the left thigh. From the path of the bullet, as indicated by the entry and exit wounds, the trajectory was ‘from right to left, marginally upwards with minimal deviation posteriorly’. She commented that the transection of the left femoral artery resulted in death due to exsanguination (blood loss).

39. Dr Iles observed a number of underlying natural disease processes however these did not materially contribute to the death.

9 A comminuted fracture occurs when the bone shatters into several pieces.

10 The heart weighed 466 grams.

40. Routine toxicological analysis of post-mortem samples detected ethanol (alcohol) at a concentration of 0.17 g/100mL of blood, and of 0.19 g/100mL of vitreous humour.11

41. Dr Iles provided an opinion that the medical cause of death was 1(a) gunshot injury to thigh.

42. I accept Dr Iles’ opinion as to cause of death.

CRIME SCENE EXAMINATION

43. Several members of the Major Crime Scene Unit of the Victoria Police Forensic Services Centre attended the Beechworth address and made observations of the scene including to capture videos and photographs of the property, document and collect swabs of bloodstains, and collect gunshot residue samples.

44. The firearm in Paul’s car was seized. It was a semi-automatic pistol, with the slide rearward in the ‘lock back’ position. A box magazine was inserted into the pistol, the chamber was empty, and the box magazine was also depleted of cartridges. Under a search warrant executed at a later date, several firearms were seized from Barry’s house.

45. On the driveway beside Paul’s car, officers located and seized five fired cartridge cases and two cartridges. At the front door of the house, three fired cartridge cases were located and seized.

46. Substantial quantities of marijuana were also seized from Paul and Barry’s houses.

ARREST AND INTERVIEW OF BARRY BUTLER

47. During the ambulance journey, a Victoria Police member accompanying Barry discussed that evening’s events. It was evident that Barry was significantly affected by medication, and likely by shock due to the altercation and he was unable to provide coherent answers – often stating that he was ‘confused’.

11 Vitreous humour is the clear gel that fills the space between the lens and the retina of the eyeball. Generally, toxicological analysis of vitreous humour provides a better indicator of perimortem levels than post-mortem blood.

48. At 3:45am on 28 October 2022, when practitioners confirmed that Barry was in a stable condition, he was placed under arrest in relation to Paul’s death.

49. On 2 November 2022 at 7:19pm, Victoria Police members interviewed Barry. He provided mostly ‘no comment’ answers to police’s questions however did make clear his belief that Paul shot him, not Timothy.

50. After the interview, Barry was charged with firearm and drug offences. He was not charged with an offence relating to causing Paul’s death. He was bailed and appeared at the Wodonga Magistrates’ Court where he pleaded guilty and was convicted and fined.

FINDINGS AND CONCLUSION

51. Having applied the applicable standard of proof to the available evidence, I find that: a) the identity of the deceased was Paul Christian Flegel, born 8 May 1961, b) the death occurred on 27 October 2022 at 440 Buckland Gap Road, Beechworth, Victoria due to a gunshot wound to the thigh; and, c) the death occurred in the circumstances described above.

ORDERS AND DIRECTIONS Pursuant to section 73(1), this finding is to be published on the Coroners Court of Victoria website in accordance with the rules.

I convey my sincere condolences to Paul’s family for their loss.

I direct that a copy of this finding be provided to the following: SL, senior next of kin Acting Sergeant Brandon Stack, Victoria Police, Coroner’s Investigator

Signature: ______________________________________ Coroner Leveasque Peterson Date: 19 November 2025 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an inquest. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.