Finding into death of LX
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
Deceased
Veronica Norah Cheney
Demographics
43y, female
Coroner
Coroner Leveasque Peterson
Date of death
1945-03-01
Finding date
2025-11-11
Cause of death
undetermined
AI-generated summary
Veronica Cheney disappeared on 1 March 1945 at age 43 from Melbourne. She had a significant psychiatric history including hospitalisation for psychosis and auditory hallucinations at Royal Park and Mont Park asylums in 1936-1938, with a recurrence requiring admission in July 1944 and discharge in November 1944. Initial 1945 police investigations were extensive but unsuccessful. In 2022, renewed investigation including DNA analysis found no evidence of life. The coroner concluded she died on or after 1 March 1945 from an undetermined cause, noting her mental health history and prior disappearance. This case highlights gaps in historical police record management and the value of modern DNA technology in cold missing persons cases, though ultimately the cause and circumstances remain unknown.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
IN THE CORONERS COURT Court Reference: COR 2023 005756
OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITH INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the Death of Veronica Cheney Deceased: Veronica Norah Cheney Delivered on: 11 November 2025 Delivered at: Coroners Court of Victoria, 65 Kavanagh Street, Southbank Hearing date: 11 November 2025 Findings of: Coroner Leveasque Peterson Counsel assisting the coroner: Ms Olivia Collings, Coroner’s Solicitor Keywords: Missing person, undetermined cause of death
This finding draws on the totality of the coronial investigation into the disappearance of Veronica Cheney including evidence contained in the coronial brief as prepared by Coroner’s Investigator, Detective Acting Sergeant Callum Bolton.
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.
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
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 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).
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.)
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
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
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 Investigation of a Suspected Death
The coronial investigation of a suspected death differs significantly from most other coronial investigations which commence with the report of a deceased person including the body or remains. In those instances, the focus of the investigation is to determine the identity of the deceased body or remains,9 using a forensic examination (internal or external) by a forensic pathologist and the subsequent formulation of a cause of death,10 together with an account of the circumstances in which the death occurred.11
Absent a body or remains, the coronial investigation focusses on the events leading to the disappearance and last recorded/confirmed sighting of an individual; any subsequent contact with family or investigating authority (i.e. Victoria Police) and evidence (or lack thereof) of proof of life since the disappearance.
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).
9 See section 67(1)(a).
10 See section 67(1)(b) 11 See section 67(1)(c).
In such cases, the coronial investigation is effectively an exercise in proof of death through the absence of evidence that the particular individual has been alive or active via searches and a series of checks of records held by various authorities and databases.
A finding that an individual is deceased, made in the absence of a body or remains, has significant legal consequence. Such a finding is not to be made lightly and requires that the evidence permits me to reach a satisfactory level of comfortability as to facts.
In that regard, I considered it appropriate to use my discretionary power under section 52(1) told hold an inquest on 11 November 2025.
This Finding is based on the totality of the material produced by the coronial investigation into Veronica’s disappearance and suspected death. In writing this Finding, I do not purport to summarise all the material and evidence but will refer to it only in such detail as is warranted by its forensic significance and in the interests of narrative clarity. The material will remain on the coronial file, together with the inquest transcript.
At around 30 years of age, Veronica first experienced an episode of mental ill health. In 1936, she was admitted to the Royal Park Receiving House and a practitioner recorded that ‘she makes inane faces and grimaces and sings short snatches of songs to herself [. . . ] in a facile fashion she admits to having auditory hallucinations’.
Veronica remained at the Royal Park Receiving House for over a year and in April 1937 was transferred to the Mont Park Asylum in Macleod under an order of the (then) Lunacy Act 1928.12 Transfer documentation listed Veronica’s ‘Causation of Insanity’ as ‘worry’. On admission, a practitioner observed that Veronica was ‘in a condition of psychotic activity continually singing, irritable, destructive and suffering from insomnia’. They also recorded a history of ‘melancholia’.
In January 1938, approximately two years after being admitted, Veronica was determined to have ‘recovered’ and was discharged. Between 1938 and 1940, Veronica wrote several letters to her family.
12 This Finding has adopted phrasing that was used during Veronica’s life, and which have become inappropriate or outdated in today’s vernacular when describing individuals experiencing mental ill health. Much of Veronica’s treatment occurred prior to the deinstitutionalisation of mental health treatment and accordingly, this Finding discusses treatment which would not occur pursuant to current clinical standards.
In the interim, Veronica and her husband, William Cheney (William), separated as he ‘wouldn’t take her back’ following a surgical procedure. Veronica entered a de-facto relationship with a solider13.
By July 1944, Veronica experienced a re-emergence of her mental ill health and was admitted to the Royal Park Mental Hospital (previously the Royal Park Receiving House). She documented her sister, living in Albert Park, and brother, living in Umbango in New South Wales, as her relatives.
Clinicians recorded her history including her separation and that her de-facto partner was killed. Veronica described experiencing a ‘nervous breakdown’ following the birth of each of her two children and was described as being ‘mildly depressed’.
On 12 November 1944, Veronica wrote to her family that she had been hospitalised and was admitted ‘before [she] got too bad this time’. She expressed gratitude to the practitioner and stated she was ‘quite well and happy again and able to go out again’. She indicated an intention to travel to NSW to visit her family.
On 19 November 1944, Veronica was discharged from the Royal Park Mental Hospital.
Evidence indicates that this occurred at her request. It is unclear what treatment she received during her admission, what her mental state upon discharge, and what her living arrangements were following her release.
At the time he reported Veronica missing, Joseph told officers that she had previously been a patient of the Royal Park Mental Hospital and said, ‘she was not in the habit of wandering’.
On 12 March 1945, officers spoke with Veronica’s sister, Bessie Snelling (Bessie). Bessie raised the possibility that Veronica had travelled to Albury to visit a sister, whom she referred to as Ms Brooks. She also informed them of Vernoica’s separation from her husband, William, 13 Believed to be the son of Sgt Webster
who was living in Umbango with their children. Bessie suggested that Veronica may have travelled to visit them.
With the assistance of NSW police, several of Veronica’s family members including sisters, Ms Brooks, Ms Cheney, Ms Stanton and Ms Doyle, and former sister-in-law, Ms Harvey (who had custody of Veronica’s children), were located and spoken to regarding her disappearance however, none of them knew Veronica’s whereabouts. Police searched various NSW towns including Adelong, Veronica’s birthplace.
Victoria Police resumed carriage of the investigation and had further conversations with Bessie and Veronica’s landlord, who told police Joseph had since returned to South Australia.
Upon request, South Australia police spoke with Joseph who stated that Veronica had disappeared on a previous occasion without money or other belongings. Joseph told officers that he believed she remained in Melbourne and had not gone to NSW.
Victoria Police spoke with the Mental Hygiene Department and obtained records of Veronica’s most recent admission, from July to November 1944 which detailed her only listed relative was Bessie. A search of the Federal Rolls Office listed Veronica’s address as a property in South Melbourne however, enquiries had established she was not living there.
Enquires with the Repatriation Department confirmed that Veronica was not drawing a military pension (as a partner beneficiary).
On 1 June 1945, an alert regarding Veronica’s disappearance was published in The Herald newspaper and encouraged persons with any information to come forward.
On 17 July 1945, Victoria Police spoke with former Sergeant Webster (Sgt Webster), who told them his son had been killed in 1942, and Veronica was the beneficiary of his will. Sgt Webster had last seen Veronica in 1942 and paid her money in 1943 via her solicitor. He also stated Veronica’s husband, William, was a member of the Military Forces and he believed she was receiving an allotment from him. Enquiries with Veronica’s solicitor did not yield useful information.
Further enquiries with the Commonwealth Electoral Office, Manpower Office, Repatriation Department, Lunacy Department and the Letter Delivery Counter at the Sudney General Post Office yielded no useful information.
The District Records Office confirmed that William was discharged from the Military Forces in 1940 due to being ‘medically unfit’. His recorded next-of-kin was his and Veronica’s daughter, Eileen Cheney, of Tarcutta NSW. NSW police spoke with Ms Harvey and Eileen, however, this did not yield helpful information.
On 23 August 1945, a final enquiry was made with Bessie, who reiterated she did not have any helpful information. This was the final investigative step taken by police at this time.
In 2020, the Australian Federal Police established the National DNA Program for Unidentified and Missing Persons. The program, led by the National Missing Person Coordination Centre, aimed to work alongside the state and territory police as well as coronial and forensic agencies to obtain and analyse familial DNA samples from relatives of long-term missing persons, with the view to resolving cold cases.
On 14 August 2022, Veronica’s granddaughter, Sandra Graham (Sandra), lodged an online report regarding Veronica which indicated she was willing to provide a DNA sample for the purposes of a comparison against unidentified human remains.
In November 2022, the Port Phillip Crime Investigation Unit of Victoria Police received Sandra’s report, and it was reviewed by Detective Acting Sergeant Callum Bolton (DAS Bolton). Contained in Sandra’s report was a newspaper clipping of The Herald, dated 1 June
The clipping read, in part: ‘Anybody knowing the whereabouts of Mrs Veronica Norah Cheney, who has been missing since March 1, is asked to communicate with the Albert Park police station’.
DAS Bolton explained to the Court that in early 1990s, Victoria Police’s computerised Law Enforcement Assistance Program (LEAP) was established, and all active missing persons investigations were transferred to the digital system (amongst other investigations). However, Veronica’s missing person file was not transferred to LEAP. It is unclear why Veroncia’s file was not transferred, and instead, the hard copy file was archived.
He obtained a copy of the entirety of the original missing person file from the State Archives of the Public Records Office of Victoria’s permanent collection.
DAS Bolton requested assistance from the NSW Police to obtain a DNA sample from Sandra for the purposes of a familial DNA comparison. On 13 June 2023, DAS Bolton transferred
Sandra’s DNA sample from the Forensic Services Centre of Victoria Police to the Molecular Biology team of the Victorian Institute of Forensic Medicine (VIFM). On 5 September 2023, mitochondrial DNA14 analysis was undertaken on Sandra’s sample by Dr Dadna Hartman, Chief Molecular Biologist of the VIFM.
The results were cross-referenced to the Victorian Missing Persons DNA database and DAS Bolton explained there were no matches obtained.
On 16 October 2023, DAS Bolton referred Veronica’s disappearance to the Police Coronial Support Unit and requested that given the passage of time since Veronica’s and her projected age at that time (122 years), the matter be reported to the Coroner.
On 22 October 2023, DAS Bolton submitted a Police Report of Death for the Coroner (VP Form 83) and which contained the information discussed in this Finding.
Evidence of Detective Acting Sergeant Bolton at Inquest
At inquest, DAS Callum Bolton gave evidence regarding the ‘proof of life’ checks which he performed as part of the renewed investigation into Veronica’s disappearance.
He explained that usually in missing persons investigation, investigator will make enquiries with Births, Deaths and Marriages (BDM) to ascertain whether a death certificate has been issued and will make enquiries with local hospitals to determine if any unidentified persons have been admitted.
DAS Bolton stated that following enquiries with BDM in November 2022, he confirmed that no death certificate had been issues for Veronica. Due to the passage of time since her disappearance in 1945, DAS Bolton did not contact local hospitals but instead contacted the Victorian Department of Health’s records department to obtain all available relevant historical medical documents.
cause the Victoria Police investigation to be revisited, DAS Bolton confirmed that the investigation will remain open and active on LEAP and if new information is received, it will be assigned to an investigator.
To this day, Veronica has not been found and given the lack of any signs of life and that her projected age at the time of the Inquest would be 124 years, I comfortably conclude that she is deceased.
Having applied the applicable standard to the available evidence, the balance of probabilities, and having held an Inquest on 11 November 2025, I make the following findings pursuant to section 67 of the Act: a) The identity of the deceased was Veronica Norah Cheney, born 1 September 1901; b) The death occurred on or after 1 March 1945 from an undetermined cause; and c) The death occurred in the context of Veronica’s history of mental ill health and of a reported history of one prior disappearance.
I note that Sandra’s DNA profile is stored on the Victorian Missing Persons DNA Database and National Missing Persons DNA Database should future comparisons need to be conducted with the hope that one day, the circumstances of Veronica’s disappearance and death may be illuminated.
Pursuant to section 73(1) of the Act, this finding is to be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: Sandra Graham, senior next of kin Detective Acting Sergeant Callum Bolton, Victoria Police, Coroner’s Investigator Signature: ______________________________________ Coroner Leveasque Peterson Date: 13 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.
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