Cole v Wilson [2024] QDC 208

DISTRICT COURT OF QUEENSLAND CITATION: Cole v Wilson [2024] QDC 208 PARTIES: SUSANNE COLE (applicant) v CORONER NERIDA WILSON (respondent) And ATTORNEY-GENERAL FOR THE STATE OF QUEENSLAND (amicus curiae) FILE NO: BD2075/24 DIVISION: Civil PROCEEDING: Application ORIGINATING COURT: Brisbane DELIVERED ON: 13 December 2024 DELIVERED AT: Brisbane HEARING DATE: 8 November 2024 JUDGE: Jarro DCJ ORDER: 1. The application is allowed to the extent that the findings of the Coroner, which are excerpted at paragraphs [17(b)] and [17(e)] of these reasons, are set aside. 2. The inquest is to not to be reopened/reordered. CATCHWORDS: CORONERS – THE CORONER AND THE CORONER'S COURT – APPLICATION TO SET ASIDE CORONER’S FINDING – where Coroner made findings as required by s 45 of the Coroners Act 2003 (Qld) – whether Coroner’s finding could not be reasonably supported by the evidence – whether new evidence casts doubt on the finding. LEGISLATION: Coroners Act 1958 (Qld) Coroners Act 2003 (Qld), s 45, s 50 CASES: Hurley v Clements [2010] 1 Qd R 215, applied Gentner v Callaghan & Ors [2014] QDC 123, applied Isles v State of Queensland [2015] QDC 335, applied COUNSEL: S J Farnden KC and J P Wallace for the applicant (pro bono) M T Hickey OAM KC for the Attorney-General (amicus curiae) -- 1 of 15 -- 2 SOLICITORS: Caxton Legal Centre for the applicant Crown Solicitor for the Attorney-General [1] By way of brief background, the Northern Coroner on 9 November 2021 delivered findings in respect to an inquest into the death of Ms Gwen Grover who died at the age of 32 on 14 October 1983 at Cairns. Her Honour found that Ms Grover’s death was from cerebral destruction caused by a self-inflicted bullet wound to the head. Her Honour ruled that the death was due to suicide. The applicant, who is the sister of the deceased, has applied under s 50 of the Coroners Act 2003 (Qld) (“the Act”) to set aside the finding and order the State Coroner to hold a new inquest into the matter. The applicant asserts that the paucity of the evidence available to the Coroner did not enable her Honour to be able to find that the deceased committed suicide. It has been contended that the lack of positive evidence of a homicide does not lead to a conclusion that the death must have been a suicide, such that the inquest was erroneously conducted and further evidence, obtained subsequent to the inquest, supports that the findings should be set aside. His Honour Judge Smith AM ordered on 9 August 2024 that the Coroner be excused from further appearance and for the Attorney-General to appear and make submissions as amicus curiae. [2] For the reasons that follow, I am of the view that the findings as to the death being self-inflicted should be set aside. Notwithstanding, I decline to order that the State Coroner hold a new inquest. Background [3] Ms Grover, the day before her death, moved into a unit located at Lake Street, Cairns. Shortly prior, she had ceased a relationship with Mr Kenneth Soper. Ms Grover’s body was identified on 14 October 1983 by witness, Mr Craig Lock, in her green Valiant Galant Sedan on Lake Street, Cairns, approximately 125 metres south of Rutherford Street, some 2.1 kilometres away from her unit. Mr Lock said he found Ms Grover sitting upright, leaned in to ask if she was alright, and saw a rifle between her legs and realised she was deceased. He then ran and called police from his house and saw police arrive. No version was taken from him at the time. Despite what Mr Lock recalled as to how Ms Grover was positioned, the limited police photographs taken at the time show Ms Grover’s body slumped to the left. [4] According to the Form 4 ‘Report Concerning Death by a Member of the Police Force’ which was furnished under the then Coroners Act 1958 (Qld), police considered: “At some time on the morning of 14/10/83 one Gwen Lorraine GROVER was shot in her vehicle at the intersection of Lake and Rutherford St’s, Cairns. Suicide is suspected. When she was last seen by her estranged husband the evening of 13/10/83 at approximately 7.30 pm she seemed to be in good spirits but was upset over the break- up of a relationship with her boyfriend, the two were contemplating marriage. The deceased had just moved into a new residence and had decided to start a new life away from her boyfriend. Inside the vehicle in which she was found was a number of empty stubbies also there was a large amount of cigarette ash on the floor of the vehicle suggesting she may have sat in the vehicle thinking for some time prior -- 2 of 15 -- 2 to committing the act. Careful attention should be given to the angle of the entry of the bullet as it may perhaps be critical of the direction of the investigation. Police attempted to interview her boyfriend however he could not be located. Enquiries are continuing. Post- mortem to be conducted.”1 [5] The Form 4 was prepared and finalised by Officer Kinbacher on 14 October 1983, who at the time, was a second year Queensland police officer. [6] An autopsy was conducted three days later on 17 October 1983 by Dr JC Ramsay who observed, among other things, in the Form 10, a “small, circular wound, with surrounding charring of left temple, compatible with entrance wound of small calibre bullet. Exit wound in high right parietal area”. The cause of death was noted to be “cerebral destruction; due to or as a consequence of bullet wound of head”. Blood was taken and forwarded for analysis. The entrance wound was excised and sent for testing. Analysis of Ms Grover’s blood returned a reading containing 158 mg/100 ml alcohol or equivalent to 0.150 per cent in road traffic terms (three times the current legal limit for driving). A Dr AJ Ansford analysed the entrance wound and noted that a “small calibre bullet entry wound, inflicted with the muzzle in contact or near contact with the skin”. [7] On 19 October 1983, relevant crime scene exhibits were placed in the possession of scientific officer Glen Kanowski, comprising one round of Remington brand .22 calibre round ammunition and one damaged lead projectile. Officer Kanowski examined the damaged projectile and, in his statement of 26 October 1983, was of the view that the “projectile was consistent with originally being a 40 gram lead projectile from a round of .22 calibre [long range] ammunition similar to the round”. He stated “[t]he projectile bore marks which indicated that it had been fired through the barrel of a .22 calibre rifle and had been damaged as the result of high velocity impact”. [8] The Form 5 ‘Decision/Recommendation and Notification that the Holding of an Inquest is Unnecessary’ dated 31 January 1984, recorded the view of the then Coroner (BJ Scanlan) being that “no good purpose would be served by the holding of an inquest” because the “body [was] identified” and there were “no suspicious circumstances”. Less than two months later, the Under Secretary of the Department of Justice, C. Pearson, decided that the holding of an inquest was unnecessary. A coronial inquest was therefore not held. [9] Fast forward 34 years later, in 2018, the applicant applied to the Coroners Court for release of any documents held concerning the death of her sister. The applicant was alarmed by the lack of documented information and the applicant did not believe that her sister took her own life. [10] In May 2019, the applicant requested the Attorney-General to direct that a coronial inquest be held into the death of Ms Grover. The request was approved. [11] In early 2020, police were directed to investigate the matter further. Under the fresh investigation by the cold case review team, steps taken included producing a scene recreation of the death (which involved the positioning of the rifle), reconsideration 1 Exhibit A6 to the Affidavit of Klaire Cole affirmed 26 July 2024. -- 3 of 15 -- 3 of old evidence such as photographs, interviewing and taking statements from several witnesses, and providing opinions as to the likely make and model of the weapon used. [12] In 2021, a three-day inquest was conducted by the Northern Coroner where the following witnesses gave oral evidence: (a) Snr Sgt Bevan Mankelow; (b) A/Det Sgt Adam Dennien; (c) Mrs Susanne Cole; (d) DSS Edward Kinbacher (‘Officer Kinbacher’); (e) Mr Craig Lock; (f) Mrs Sharon Mackedie; (g) Mr Duncan Grover; (h) Mrs Elizabeth (Betty) Grover (nee Potter); (i) Mr Kenneth Soper. Northern Coroner’s Decision [13] On 9 November 2021, the Northern Coroner delivered findings into the death of Ms Grover. In the written decision, the Northern Coroner said that her Honour could “reasonably infer” the following matters: (a) Ms Grover and Mr Duncan Grover married when Ms Grover was 16 years old. They moved from country New South Wales to Cairns at around the end of 1974 and had two sons together. (b) Mr Grover and Ms Grover separated sometime within the two-year period prior to March 1983. (c) During the period of separation, Ms Grover returned to New South Wales with her sons and lived with the applicant. (d) It is possible that during this period in New South Wales, Ms Grover harboured (perhaps a secret) hope that her marriage to Mr Grover could be reconciled. (e) Mr Grover moved in with Ms [Elizabeth/Betty] Potter when Ms Grover moved away. Ms Potter was a close friend to Ms Grover. (f) That sometime between March 1983 and 12 October 1983 (after Ms Grover had returned to Cairns with her sons), she either became aware for the first time of a relationship between Mr Grover and her friend Ms Potter, or was confronted by the reality of their relationship, (even if she had already known) when one evening (perhaps under the influence of alcohol), Ms Grover attended Ms Potter’s house, was invited in, and saw Mr Grover in Ms Potter’s bed. (Although the dates and the details differ, the event is deposed to by Mrs Sharon Mackedie and corroborated by Ms Potter and Mr Grover). (g) [Ms Potter] recalled that she and Mr Grover were together for six months prior to marriage. [The Northern Coroner considered that around March 1983 was -- 4 of 15 -- 4 probably about the time Ms Grover learned of their relationship, or that it was confirmed.] (h) Ms Grover met Mr Soper at a party around March 1983 and they formed a relationship immediately (apparently they did not spend one night apart after meeting). (i) Ms Grover and her sons eventually moved into Mr Soper’s home in Westcourt where they lived for a short time before their separation. (j) Mr Grover and Ms Potter did not see as much of Ms Grover after that. (k) Ms Grover moved from Mr Soper’s home to a unit at 177 Lake Street on or about 12 October 1983. (l) Mr Soper did not know where Ms Grover had moved/was moving to. (m) The accommodation Ms Grover secured (presumably prior to leaving Mr Soper’s house) was described as unsuitable, almost uninhabitable and likely a reflection of her lack of financial means. (n) Ms Grover sought the assistance of Ms Potter to help her move from Mr Soper’s. Ms Potter used Mr Grover’s trailer and together they moved belongings to 177 Lake Street all day on 13 October 1983. (o) The children were taken to their father’s that night because the unit was a mess and not ready for the boys (three versions include either Ms Potter collected them from school, Mr Grover collected them from the new unit, or Ms Grover delivered them to Mr Grover’s). (p) Mrs Mackedie and her husband also assisted Ms Grover to move into her unit on 13 October 1983. Neither Mrs Mackedie nor Ms Potter were aware of the other helping Ms Grover to move that day. [Her Honour considered] it was not unreasonable to conclude given the very specific memories of both women about that day, that they in fact both assisted at different times; they knew the location of the unit; they could both describe the poor condition of the unit; certainly Mrs Mackedie assisted later in the day and into the evening after the children went home with their father. Mrs Mackedie deposed to Ms Grover wanting a drink that evening with her and her husband, but they needed to return home to put their own child to bed. (q) Although speculative perhaps the move was in fact done over two days being 12 and 13 October 1983. [14] Her Honour determined that the immediate police investigation in 1983 was “perfunctory” and considered that although the investigation “reached a threshold of adequate, the investigation was left vulnerable because not all reasonable and relevant available evidence was obtained”. [15] Further the Northern Coroner made specific observations including, but not limited to, the following: (a) At the time of her death: (i) Ms Grover was survived by her two sons, aged 15 and 12. -- 5 of 15 -- 5 (ii) Ms Grover’s official residence was a unit, which she moved into the day prior to her death. By distance, the unit was approximately 2.1 kilometres from where she was located deceased in her motor vehicle. (b) Mr Lock, then 19 years of age, located Ms Grover on 14 October 1983 in a green Valiant Galant sedan on Lake Street, approximately 125 metres south of Rutherford Street. Mr Lock’s recollection was that Ms Grover was sitting upright like you would be when driving, with a rifle between her legs. He ran to his house which was within sight of the vehicle and called police. Police did not contact him or take a version from him as part of the initial police investigation. His identity and involvement were discovered during the cold case police investigation. (c) There was no reference to any firearm at all in the Form 4 prepared in 1983. There was no mention of a firearm being found in the vehicle. (d) The quality of the scene photographs were poor. (e) None of the photographs clearly depict the gun or ammunition and require interpretation. One of the photographs depicts: (i) a handbag on a heavily bloodstained passenger seat with two NQ Lager stubby bottles visible and a box of ammunition under the handbag; and (ii) Ms Grover slumped to the left passenger seat clenching the barrel of the rifle in her right hand a centimetre or two from the muzzle. (f) From the scene photographs, a firearm was present in the vehicle. Ms Grover was found holding the firearm (at the muzzle with her right hand). That firearm was removed from the scene by police. (g) Ms Grover and her children moved into Mr Soper’s house around March 1983 (approximately 6-7 months prior to her death). Ms Grover and Mr Soper contemplated marriage. (h) Mr Soper deposed in both his 1983 and 2020 statements and in his oral evidence that his relationship with Ms Grover broke down due to an argument close in time to her moving out. Mr Soper attended [the police station] and was shown a firearm and ammunition which he positively identified as previously being in his possession. (i) Two witnesses [Ms Potter and Mrs Mackedie] both separately deposed to helping Ms Grover move her belongings into her unit the day of, and into the evening of 13 October 1983. (j) The incontrovertible evidence was that the bullet located within Ms Grover during postmortem examination and excised was identified as a .22 calibre projectile. (k) What was difficult to reconcile was how, when the physical rifle was actually in the police station and shown to Mr Soper during the course of the interview, and when the scientific section had by then completed the cartridge and projectile examination and report four days prior confirming a .22 calibre, Mr Soper’s [1983] statement was infected with such a fundamental error and not questioned or remedied [viz mention of a .325 calibre rifle]. -- 6 of 15 -- 6 (l) Mr Soper was in possession of a .22 calibre firearm and ammunition at the time of Ms Grover’s death. The firearm belonged to Mr Glen Graham [a friend of Mr Soper’s]. Ms Grover had access to the firearm and the ammunition. The firearm went missing from Mr Soper’s premises on 14 October 1983. (m) The firearm missing from Mr Soper’s residence on 14 October 1983 was the firearm located at the scene of Ms Grover’s death. It was more probable than not that the make and model of the firearm was a Sterling (Squires Bingham) Model 20. (n) The reconstruction of the scene clearly demonstrates that a female with height characteristics of Ms Grover can, in the confines of that make and model of car, position a .22 rifle so that while sitting in the driver’s seat, the muzzle would touch the left temple – the left hand can comfortably reach the trigger, the right hand can wrap around the muzzle and the requisite pressure can be applied to self-discharge the firearm. (o) It was raised on behalf of the family that without knowing Ms Grover’s exact arm length such a finding could not be made. [The Northern Coroner did not agree as there was, according to her Honour, nothing to suggest that Ms Grover had any physical characteristic or deformity that might put her outside an average range.] (p) The cold case review team concluded: (i) an absence of detail within the original coronial documents; (ii) documents of significant importance were located during the cold case review including scene photographs; toxicology analysis; postmortem examination reports; (iii) important witnesses who may have been able to elaborate on Ms Grover’s last movements have since passed away; (iv) positive identification of the weapon used was not/cannot be positively identified although the evidence is of a .22 calibre rifle; (v) no evidence or information obtained contradicted the original finding (of suicide by self-inflicted gunshot wound). (q) The applicant does not believe that the gunshot wound sustained was self- inflicted. The applicant says that in her heart Ms Grover did not take her own life and that she thinks somebody else shot her, and that it may have been Mr Soper. (r) The eternal puzzlement for Ms Grover’s siblings is that they did not know her as a person to drink alcohol; she grew up in a strict home that disavowed firearms; and her actions were entirely out of character. (s) Neither Mr Soper nor Mr Grover knew Officer Kinbacher other than from their initial and cursory interactions at the time of Ms Grover’s death some 38 years ago, and then only in a professional capacity as the investigating police officer. Notwithstanding that the officer now holds the rank of a Detective Senior Sergeant, he has not influenced the investigation into the death of Ms Grover in any way, either then or now. -- 7 of 15 -- 7 (t) Mr Soper and Mr Grover did not know each other. They knew of each other’s existence but did not socialise or interact prior to Ms Grover’s death. [16] The Northern Coroner then examined what her Honour described as “circumstances in the 24 hours prior to Ms Grover’s death” by a consideration and distillation of the evidence contained in the witness statements and those who gave evidence in the coronial proceedings. Her Honour then summarised the submissions of the relevant parties, including the applicant, before making the following relevant conclusions and findings: (a) The forensic aspects of the 1983 investigation including the postmortem examination and toxicology sampling by Dr JC Ramsay, the histology undertaken by Dr AJ Ansford and the ballistics examination of Officer Kanowski were all performed to an adequate and expected standard. (b) The summary provided within the Form 4 report of death was inadequate to piece together the circumstances without relying on or obtaining further information. It could not be established from that document a description of either the site of the wound or the gun located at the scene and [her Honour] inferred from reading the summary that the death was by way of self-inflicted gunshot. (c) The ultimate conclusion of the 1983 police investigation was sound in relation to a finding of suicide, and that although the investigation “reached a threshold of adequate, the investigation was left vulnerable because not all reasonable and relevant available evidence was obtained”. (d) At the time of her death, Ms Grover was a single mother of two children. She was overwhelmed by the circumstances of her life including the previous breakdown of her 16 year marriage and despite a separation of almost two years, Ms Grover held out some hope of a reconciliation with Mr Grover upon her return to Cairns, or that in any event the realisation that he became intimately involved with her close friend Ms Potter caused her great suffering. Her emotional state was compounded by the recent breakdown of a new and very short relationship to Mr Soper. (e) The evidence bears out that Ms Grover was bereft on the evening of her death during the period she was setting up a new unit. The court was left with the sense that the unit was small and dirty and both Ms Potter and Mrs Mackedie had a visceral reaction when describing it to the court. Ms Grover was concerned about the unsuitability of the accommodation for her boys, and had few financial means. (f) In the late afternoon of 13 October 1983, Ms Grover arranged with the children’s father Mr Grover for them to stay the night with him because their rooms were not ready. When handing over the children she said words to the effect “If something happens to me promise me you will look after them”. Mr Grover was taken aback by this request and said of course he would, and then she repeated her request even more earnestly. (g) Mr Soper woke sometime on 14 October 1983 and saw that his gun had been moved from the wardrobe. He was confused but thought nothing of it and went to work and then to a hotel afterwards to drink with a friend. -- 8 of 15 -- 8 (h) Ms Grover removed the gun and ammunition from Mr Soper’s house (to which she had access) sometime on the morning of 14 October 1983, likely after he departed for work (my emphasis). She then drove to the relevant location and from the evidence of beer bottles and cigarette ash either had been drinking, and smoking previously in the car, or from the time she arrived, setting up the firearm. (i) No other person contributed to, or caused, Ms Grover’s death. (j) Ms Grover was experiencing a significant situational crisis at the time of her death. Regrettably the potential to explore what had happened between 10:30pm the night before and her discovery is now irretrievably lost. [17] The Northern Coroner made the following findings required by s 45 of the Act: (a) The deceased is Gwen Lorraine Grover. (b) Gwen Lorraine Grover, a 32-year-old woman, died sometime prior to 12:00 noon on 14 October 1983 at Lake Street approximately 125 metres south of the Rutherford Street Intersection Cairns North from cerebral destruction caused by a self-inflicted bullet wound to the head. Her death is due to suicide. She was affected by alcohol at the time, her toxicology analysis being .15%, or three times over the current legal limit for driving. At the time of her death Ms Grover was overwhelmed by the circumstances of her life and experiencing a significant situational crisis. (c) The place of death was the intersection of Lake and Rutherford Streets, Cairns. (d) The date of death was 14 October 1983. (e) The cause of death was cerebral destruction caused by a self-inflicted bullet wound to the head. Forensic Opinion Obtained Following Coronial Findings [18] Ms Farnden KC with Mr Wallace appearing pro bono for the applicant has identified that post inquest, on 29 November 2023, Forensic Pathologist Professor Johan Duflou provided a report containing his expert opinion as to the cause of death. Prof Duflou noted, with reference to the literature and his own experience, that self-inflicted gunshot wounds are most commonly the result of insertion of the muzzle either in the mouth or under the chin, with a lessor proportion applied to the side of the head or middle of the forehead. He has stated that the “handedness” of a person is important, and that where the bullet wound entrance is on the side of a body, most likely that side is the side of the dominant hand in suicide cases. Prof Duflou noted that there did not appear to be any consideration in the repeat ballistics investigation as to whether the deceased could have been shot by another person; instead, the focus was on whether the deceased could have shot herself. Importantly Prof Duflou expressed as follows: “It is my opinion that this alternative scenario (could the deceased have been shot by another person) cannot be excluded, and that some aspects such as the location of the gunshot wound appear to raise this as a more likely possibility than self-infliction.” -- 9 of 15 -- 9 [19] Ultimately Prof Duflou is of the view that he is “unable to exclude the possibility of the gunshot wound having been sustained by actions of another person”. Prof Duflou was given the Coroner’s findings, the brief of evidence that the Coroner received and the transcript of the inquest. The only evidence that Prof Duflou received which was not before the Coroner was from Ms Darlene Jattke who spoke to a podcaster, Ms Alison Sandy. Ms Jattke said that from memory the windows of Ms Grover’s car may have been shut and that the deceased was definitely sitting upright on the driver side looking straight ahead. Together with her friend, Ms Jattke then went to her home following which she returned to the scene. When she returned to the scene, she saw the deceased lying across the passenger side. [20] There are two limbs to the present application. The first is that the finding viz suicide made by the Coroner could not be reasonably supported by the evidence as it then was. The second limb is that the new evidence, in the form of the opinion expressed by Prof Duflou, casts doubt on the finding. Before dealing with each limb, I shall address the relevant law as it applies to the present application. Coroners Act 2003 (Qld) [21] Pursuant to s 45 of the Act, the Coroner must, if possible, make findings as to: (a) Who the deceased person is; (b) How the person died; (c) When the person died; (d) Where the person died; (e) What caused the person to die. [22] Mr Hickey OAM KC for the Attorney-General as amicus curiae has identified that a person “dissatisfied with a finding at an inquest” can apply to the District Court under s 50 of the Act to set aside the finding. The court’s power to set aside a coroner’s finding are prescribed by s 50(5). The powers may only be exercised if the court is satisfied of at least one of the following matters: (a) New evidence casts doubt on the finding (proposed to be set aside): s 50(5)(a); (b) The finding (proposed to be set aside) was not properly recorded: s 50(5)(b); (c) There was no evidence to support the finding (proposed to be set aside): s 50(5)(c); (d) The finding (proposed to be set aside) could not be reasonably supported by the evidence: s 50(5)(d). [23] If the court is satisfied of one of those matters, and decides to set a finding aside, the court may then order the State Coroner (themselves, or by another coroner) to reopen the inquest to re-examine the finding or hold a new inquest: s 50(7) of the Act. In light of Hurley v Clements [2010] 1 Qd R 215, as well as the decisions in Isles v State of Queensland [2015] QDC 335 and Gentner v Callaghan [2014] QDC 123, the following principles are identified: (a) The legislature has invested coroners with the decision-making authority to find facts about the deaths they are investigating. -- 10 of 15 -- 10 (b) The District Court’s power, on applications such as this, is akin to administrative review. (c) It is not the court’s task to set aside the Coroner’s findings simply because it may have a view that the correct and preferable finding on the facts is one that is different from those the Coroner found. (d) Just because another finding may have been open on the evidence does not mean the Coroner’s finding should be set aside. (e) Just because there is new evidence does not mean the Coroner’s findings should be set aside. (f) New evidence must demonstrate the capacity to engage the prospect of a different finding, to justify setting aside a Coroner’s finding. Applicant’s First Complaint – Finding Could Not Be Reasonably Supported [24] On behalf of the applicant, it was highlighted that Ms Grover was right-handed. She was the mother of two young boys and she had experienced some recent emotional turmoil. [25] It was submitted that there was insufficient evidence before the Coroner to be able to conclude that Ms Grover died by a self-inflicted wound, due in part to the paucity of evidence available from the time. The argument was advanced that the inquest proceeded on the basis that the outcome was predetermined, or alternatively, that if there was insufficient evidence that it was a homicide, then the conclusion must be that it was a suicide. [26] In support of this argument, the Form 4 (prepared by Officer Kinbacher) made no mention of the existence of a firearm or ammunition and limited photographs were taken during the very short investigation that followed the discovery of Ms Grover’s body. Therefore, in order for the findings that the Coroner made to be correct, it was submitted that the following must have been the case: (a) Ms Grover commenced drinking at some time in the morning of her death to account for the 0.150 percent BAC (yet only one or two drink beer bottles were found in the vehicle). (b) During her drinking, she had the wherewithal to attend her ex-boyfriend’s house and obtain a heavy rifle, with conflicting evidence about her knowledge of and ability to operate guns. (c) She would have had to, whilst fairly drunk, load the heavy rifle, hold it in her non-dominant hand to her temple, and pull the trigger. (d) This was near hockey fields that were likely in use during the day. (e) Her handbag (presumably) was found on top of the blood soaked into the seat. No blood can be seen on the bag itself. It therefore was either placed thereafter, or potentially was on her left shoulder when she held the heavy rifle up on that side. (f) She left behind two young boys. -- 11 of 15 -- 11 [27] It was highlighted that no pathologist was called to give evidence in the inquest, nor was any forensic pathologist called to comment on the autopsy report findings. The autopsy report does not detail the trajectory angle of the wound in great detail or give any opinion about the likelihood of self-inflicted injury which is sometimes given by pathologists. Further, Officer Kanowski (the scientific analyst) did not compare the bullet to the ammunition recovered in the car or the rifle. His statement indicated that he performed ballistics work in his role and had approximately three and half years’ experience at the time of the examination. [28] It was also highlighted that important questions were not asked of Mr Soper regarding his movements and whereabouts at the time Ms Grover died or the circumstances under which it is said Ms Grover retrieved the rifle from his home. In addition, there were some material inconsistencies in the versions he has given as to when he last saw Ms Grover. It is to be noted that Mr Soper is now himself deceased. [29] It was contended that the Coroner’s conclusions that it was suicide appeared to have been based solely on the fact that Ms Grover was found deceased in the vehicle and a rifle was located in the car with her. However, those facts, it was said, are equally consistent with a homicide. Whilst some weight was placed on Ms Grover asking her ex-husband to look after the children if anything happened to her, that fact was equally consistent with Ms Grover being fearful of Mr Soper (as opposed to contemplating a suicide) and therefore is equivocal evidence that does not resolve the issue (suicide or homicide) either way. In this respect it was highlighted that there was no evidence before the Coroner that Ms Grover was contemplating suicide. There was no suicide note. There was no evidence of suicidal ideation expressed by any of the witnesses. There were no end of life arrangements. Further Ms Grover had no familiarity with firearms. The competing inference was that she was moving forward with her life and making plans for the future with her sons because she moved out of Mr Soper’s house into a new unit and was in the process of cleaning it in preparation for her sons to come live with her. There was evidence it was said of her love for her sons and her being invested and caring for their future. These matters therefore did not support the Coroner’s finding of suicide, more particularly the paucity of evidence available to the Coroner did not enable the Coroner to be able to find that Ms Grover committed suicide. [30] In my view, the undisputed evidence which the Coroner correctly acted upon was that Ms Grover died by way of a bullet wound to the head and Ms Grover was found seated in the car with a firearm. However, for the Coroner to conclude suicide, there must be clear evidence because according to the State Coroners Guidelines 2013 at guideline [8.9] “…a finding of suicide can only be arrived at where there is clear evidence; in its absence a finding of accident or an open verdict is the proper outcome”. On the state of the evidence before her Honour (regardless of Prof Duflou’s opinion), it is unclear to me whether the Coroner could categorically conclude, as her Honour did, that the death was due to suicide and that at the time of her death, Ms Grover was overwhelmed by the circumstances of her life and was experiencing a significant situational crisis. That is because of the following matters: (a) To do so invites speculation as opposed to relying upon clear evidence or reasonable inferences open on the evidence, viz the findings of Ms Grover being overwhelmed by the circumstances of her life and experiencing a significant situational crisis. -- 12 of 15 -- 12 (b) There was insufficient evidence to conclude that Ms Grover was experiencing a significant situational crisis or being overwhelmed by the circumstances of her life. I accept there was evidence from two witnesses being Mrs Mackedie and Ms Potter of their observations of Ms Grover the night before her death, but there was competing evidence from other witnesses such Mr Grover and the applicant, such that, in my opinion, the real state of the evidence is not as unambiguous as to warrant ruling suicide. (c) There are no witnesses who witnessed the death to safely enable the finding. Assumptions were made and inferences have been drawn given the way in which Ms Grover’s body was found, yet Mr Lock who was the witness who saw Ms Grover gave evidence that he recalled her upright (as opposed to the limited police photographs taken which depicted her slumped to the side). (d) The Coroner specifically identified the evidence of Mr Soper that on the morning of Ms Grover’s death, he noticed that his gun had been moved from the wardrobe, yet her Honour determined Ms Grover removed the gun and ammunition from Mr Soper’s house (to which she had access) sometime on the morning of 14 October 1983, likely after he departed for work. I am unable to reconcile this finding, in light of Mr Soper’s evidence that the rifle was not there at the time he left for work. (e) The matters raised on behalf of the applicant in the preceding paragraphs are persuasive and perhaps suggestive of another theory other than suicide. It is not unmistakable as to rule suicide as is required by the State Coroner Guidelines. [31] In my view, the accumulation of these matters, irrespective of the fresh evidence postulating another theory other than suicide (see below), lead me to conclude that the finding of Ms Grover’s death being suicide and that at the time of her death, Ms Grover was overwhelmed by the circumstances of her life and was experiencing a significant situational crisis, cannot be reasonably supported by the evidence, particularly in the absence of clear evidence. The paucity of the evidence did not enable the presently expressed finding under s 45 of the Act of how Ms Grover died and the cause of the death being self-inflicted. The findings, excerpted at paragraphs 17(b) and 17(e) of the reasons, should be set aside in accordance with s 50(5) of the Act. Applicant’s Second Complaint - New Evidence Casts Doubt On The Finding [32] The new evidence is in the form of opinion of Prof Duflou who commenced practice in forensic pathology in 1983, and, as Mr Hickey OAM KC has described, is an eminently qualified person to give his opinion about the matters he has been asked to consider. [33] As stated earlier Prof Duflou was given the Coroner’s findings, the brief of evidence that the Coroner received and a transcript of the evidence, as well as Ms Jattke’s interview with a podcaster. [34] Further to what I have stated earlier, Prof Duflou identified that gunshot wounds to the left temple can be seen in both self-inflicted wounds and in wounds inflicted by other persons. In his experience, self-inflicted wounds are most commonly the result of insertion of the muzzle either in the mouth, or under the chin, but that they can also -- 13 of 15 -- 13 occur to the side of the head or the middle of the forehead in a lesser proportion of cases. In his experience, the handedness of the person is important as is where the bullet wound entrance site is on a side of the body, most likely that side is the side of the dominant hand in suicide cases. Prof Duflou notes: “Based on the autopsy findings and the nature of the weapon, there are certainly unusual aspects to this case which raises the possibility of involvement by another person. Although I do not exclude suicide in this case, it appears that there has not been any consideration of the alternative scenario of homicide in relation to the physical evidence – specifically, I note that the repeat ballistics investigation appears to have focused on the question “could the deceased have shot herself?”, and did not also consider the alternative scenario “could the deceased have been shot by another person?”. It is my opinion that this alternative scenario cannot be excluded, and some aspects such as the location of the gunshot wound appear to raise this as a more likely possibility than self-infliction.” [35] It was submitted on behalf of the applicant that given his opinions, further doubt is cast upon the conclusions of the Coroner. It was said that Prof Duflou’s opinion suggests that it cannot be established whether Ms Grover’s death was a suicide or whether it was by another mechanism. Since no pathologist was called to give evidence at the inquest, nothing of what Prof Duflou has opined has been explored in a coronial setting. [36] Further, his opinion in conjunction with the evidence of a witness who gave evidence at the inquest (being Mr Lock who observed Ms Grover sitting in an upright position with a rifle or gun between her legs and appearing to be deceased at the time), gains weight to an acceptance of the submission that the finding should be set aside. Additionally, Prof Duflou’s opinion should also be considered in light of recent information by Ms Jattke who, in her interview, recollected that Ms Grover was definitely sitting upright on the driver side looking straight ahead. Together with her friend, Ms Jattke then went to her home following which she returned to the scene. When she returned to the scene, she saw the deceased lying across the passenger side. [37] Therefore, there are now two witnesses who recalled observing Ms Grover in an upright position, being Mr Lock and Ms Jattke. [38] The applicant highlights Prof Duflou’s opinion about the location of the gunshot wound, the handedness of a person and the likelihood, in that scenario, of it being a self-inflicted wound. Moreover, in order to be self-inflicted from a long armed rifle, it would have had to have been held with the right hand and the evidence was that Ms Grover was right handed, held the gun to her left side with her dominant hand somewhere around the barrel of the rifle and her non-dominant hand operated the trigger at some point. It was conceded that Prof Duflou indicated that that could not be ruled out as being suicide, but ordinarily, one would expect that if it was to be a suicide with a long rifle, it would be through the mouth. [39] It was contended that whilst as Prof Duflou has accepted it may have been physically possible, the evidence supports that that outcome is unlikely, given the location of the injuries and handedness of the person operating the firearm. The applicant submits -- 14 of 15 -- 14 that Prof Duflou’s opinion, coupled with Mr Lock and Ms Jattke’s recollections, not only cast doubt on the finding that was made, but justify a reopening of the inquest. [40] I am of the view the evidence of Prof Duflou and Ms Jattke rises to a sufficient character which casts doubt upon the nature of the specific finding, such that the finding should be set aside. The new evidence demonstrates to me the requisite sufficiency, cogency and capacity to engage the prospect of a different finding, upon reconsideration of all of the relevant evidence. I am therefore satisfied that the new evidence casts doubt on the finding and it should be set aside in accordance with s 50(5) of the Act. Should a New Inquest Be Reopened/Reordered? [41] If the court sets aside a finding, then pursuant to s 50(7) of the Act, the court may order the State Coroner (themselves or by another coroner) to reopen the inquest to re-examine the findings or hold a new one. [42] I exercise a discretion to not order that the inquest be reopened or a new inquest be held. That is because, despite how tragic Ms Grover’s death was, her death occurred 40 years ago and as has been pointed out on behalf of the Attorney-General, all of which I accept: (a) The Coroner holds a specialist jurisdiction, created by statute, to make findings of fact in cases such as these. (b) The Coroner’s resources are (as with all public bodies) not inexhaustible. (c) Such recourses as are expended must be balanced against the public interest as well as the personal interests of those who seek to have deaths investigated. (d) Ms Grover’s death has already been the subject of two coronial considerations (first in 1984, which determined that no inquest was necessary, and again in 2021, when the inquest was conducted). (e) The events in question occurred more than 30 years ago and relevant witnesses had already died at the time of the inquest. Order [43] It is for those reasons that pursuant to s 50(5) of the Act, the original findings, excerpted at paragraphs 17(b) and 17(e) of the reasons, are set aside. I decline to direct that the State Coroner (by himself or another coroner) reopen the inquest to re- examine the finding or hold a new inquest. I order accordingly. -- 15 of 15 --