Western Australia

Coronial Inquests published by the Australian, Western Australian Coroner.

Michael Warren DYBALL

Inquest into the death of Michael Warren DYBALL

Summary : At the time of Mr Dyball’s death he was a sentenced prisoner who was serving his sentence at Casuarina Prison.\r\n\r\nPrior to Mr Dyball’s imprisonment he had been diagnosed with kidney disease and was seeing a kidney specialist. While serving his sentence he suffered chronic renal failure and was also diagnosed with an oropharyngeal tumour at the base of his tongue. Mr Dyball received medical treatment for both, but his health continued to deteriorate. The treatments for the tumour left Mr Dyball unable to swallow or talk and he had to have a PEG tube inserted to be fed. Mr Dyball was cared for in the Casuarina Prison Infirmary with input from various specialist hospital teams.\r\n\r\nOn 28 April 2016 Mr Dyball was found unresponsive in his bed in the prison Infirmary. Cardiopulmonary resuscitation was commenced by health centre staff and an ambulance attended and took Mr Dyball to Fiona Stanley Hospital where he was admitted to the Intensive Care Unit. After consultation with his family, a decision was made to palliate him and he was kept comfortable until he died in hospital on 1 May 2016.\r\n\r\nThe Coroner considered all the evidence and concluded the care provided to Mr Dyball while he was a prisoner was of a high standard and equivalent to what he would have been able to receive if he was living in the community.\r\n\r\nCatch Words : Death in Custody : Kidney Disease : Oropharyngeal Tumour : Supervision, Treatment and Care : Natural Causes

Coroner Linton on 3 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Dyball%20finding.pdf’

Anthony JOHNSTONE

Inquest into the Suspected Death of Anthony JOHNSTONE

Summary : Mr Johnstone had been seen intermittently in and around Four Mile Camp, Wyndham but would run off whenever he was approached. His family were concerned for his welfare and on 30 October 1996 he was reported missing by his family to the Wyndham Police. Mr Johnstone has never been found.\r\n\r\nMr Johnstone was reported to have a long history of being an alcoholic which had in more recent times caused him to suffer hallucinations. He had gone through a period of not drinking before returning to drinking alcohol heavily. Due to his unstable state of mind, Mr Johnstone appeared to be frightened of people, even those he knew, and when approached he would run away. It appeared he had been exhibiting this behaviour in the days leading up to 30 October 1996 and alleged sightings of him subsequently.\r\n\r\nWyndham Police were advised of Mr Johnstone behaviour and on 31 October 1996 a search with family members and Aboriginal Police Liaison Officer was conducted in the Four and Six Mile areas to see if they could located Mr Johnstone, but they were unsuccessful. A search area of the Wyndham townsite and surrounding bushland were also unsuccessful. An ultra-light plane was used on 31 October 1996 and low flying aircraft with spotters. Experienced Aboriginal trackers were involved with a large group of family members. Enquiries were made with other communities in the Wyndham area, general Kimberley and Northern Territory, but there was no sighting of Mr Johnstone.\r\n\r\nThe Coroner was satisfied beyond all reasonable doubt Mr Johnstone is deceased and died in the approximate time frame following his disappearance. The Coroner was unable to determine how the deceased died and made an Open Finding as to the manner of Mr Johnstone’s death.\r\n\r\nCatch Words : Long Term Missing Person : Land and Air Search : Open Finding

Coroner Vicker on 3 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Johnstone%20(Anthony)%20finding.pdf’

Brian Vincent ATTWELL

Inquest into the Death of Brian Vincent ATTWELL

Summary : At the time of his death Mr Attwell was a sentenced prisoner. He was initially held in Albany Prison to be close to his family. Mr Attwell was a frail, elderly man in poor health with chronic and progressive health issues and poor mobility when he was received into prison.\r\n\r\nOn 25 February 2014 Mr Attwell was noted to have significantly deteriorated in his health and a physiotherapist reported he had poor dynamic balance and had developed a fear of falling. As his health needs could no longer be appropriately managed in the general unit at Albany Prison it was decided to transfer Mr Attwell to Casuarina Prison. On 18 March 2014 he was transferred Casuarina Prison where he could receive more supervised care in the infirmary.\r\n\r\nMr Attwell’s health conditions were regularly monitored and he was provided with assistance with most of his activities of daily living. Over time his condition deteriorated, with worsening anaemia, renal failure and heart failure. He had a number of hospital admissions before his final admission to Fiona Stanley Hospital on 4 July 2017. On this admission it was apparent to the medical team that Mr Attwell had reached the end of his life and after discussions with his family, a decision was made to withdraw any life saving measures and to commence to treat him palliatively until his death on 13 July 2017.\r\n\r\nThe Coroner was satisfied Mr Attwell received a high standard of medical care while incarcerated and found he died from natural causes.\r\n\r\nCatch Words : Death in Custody : Co-morbidities : Natural Causes

Coroner Linton on 3 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Attwell%20finding.pdf’

Wilfred Arthur BARRETT

Inquest into the Suspected Death of Wilfred Arthur BARRETT

Summary : Mr Barrett was last seen alive on 30 April 1984 and over the following few days it was noticed by those resident in the area he was no longer about. A set of footprints had been observed before the fact of his disappearance was fully appreciated. No trace of Mr Barrett was ever located again.\r\n\r\nShortly before Mr Barrett’s disappearance in April 1984 it was noted by those who lived on Mount Monger Station, close to where Mr Barrett squatted in an old miner’s hut, that he was becoming more and more confused and disorientated. In late April 1984 it was reported Mr Barrett was in a very fragile and questionable state of health.\r\n\r\nThe owner of Mount Monger Station was fairly confident the date of 30 April 1984 is the day Mr Barrett was last seen alive as it was noted he had not been seen around the townsite for a few days. He explained when someone noted someone was missing there would generally be a few questions asked and people would put together what they knew about the event. Once they had worked out when Mr Barrett was last seen they returned to where tracks had been seen and searched the area with the station hands. Mr Barrett’s disappearance was not report to police until 5 May 1984.\r\n\r\nOn 7 May 1984 Kalgoorlie Police believed it was unrealistic to search the area because ground was too boggy and not safe for searchers. Mr Barrett has not been found nor has his Gloucester bag, which was important to him, ever been recovered.\r\n\r\nThe Coroner was satisfied beyond all reasonable doubt Mr Barrett is deceased. The Coroner was unable to determine how the deceased died and made an Open Finding as to the manner of Mr Barrett’s death.\r\n\r\nCatch Words : Long Term Missing Person : Open Finding

Coroner Vicker on 3 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Barrett%20(Wilfred)%20finding.pdf’

Christen Lee FOGARTY

Inquest into the Suspected Death of Christen Lee FOGARTY

Summary : On 24 July 2002 Mr Fogarty stayed at home in Newman when his mother left to travel to Meekatharra. Mr Fogarty did not appear to be at home when checked upon by his family and friends on 26, 27 and 29 July 2002.\r\n\r\nOn 24 July 2002 Mr Fogarty’s entire family left Newman for Meekatharra, intending to travel from there to Mount Magnet. Mr Fogarty had been asked repeatedly by his mother to go with the family, but he stated he wished to stay home and eventually his mother agreed. Mr Fogarty appeared to be happy at the time when they left. Mr Fogarty was standing outside the front door of the house as the family drove off and this is last time they saw Mr Fogarty alive. On 26 July 2002 Mr Fogarty’s mother made arrangements to have someone check on Mr Fogarty and was informed that after checking the house they found it was locked up and no-one was present. On 29 July 2002 Mr Fogarty’s mother asked her niece to check on Mr Fogarty and again there was no sign of Mr Fogarty and it was thought he had not been home for some time.\r\n\r\nMr Fogarty was reported to the Newman police as missing on 29 July 2002. Police and family searched for Mr Fogarty and on 31 July 2002 Newman SES commenced a search but there was no sign of Mr Fogarty. Searchers included SES volunteers, police officers, Enduro Club members on motorbikes, Qantas, with the ultra-light plane, local pilots keeping watch and local shire rangers to assist with communications, well respected Aboriginal trackers and senior members of the local Aboriginal communities, there was also extensive media coverage. A new search area was commenced on 1 August 2002 but there was no trace of Mr Fogarty.\r\n\r\nThe Coroner was satisfied beyond all reasonable doubt Mr Fogarty is deceased. The Coroner determine Mr Fogarty died of unknown causes and made an Open Finding as to how death occurred.\r\n\r\nCatch Words : Long Term Missing Person : Remote Area : Open Finding

Coroner Vicker on 2 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Fogarty%20finding.pdf’

Kate Campbell HAYTHORNTHWAITE

Inquest into the Suspected Death of Kate Campbell HAYTHORNTHWAITE

Summary : On the evening of 26 January 1968 Mrs Hathornthwaite left her friends to go home. She was last seen walking towards the direction of her home. She has not been seen since that night.\r\n\r\nMrs Haythornthwaite was a widower who was independent and settled in her routine. She worked as a cleaner at the Boulder Shire offices and was fit from walking and had no known medical issues. She cared for her animals in the home she had occupied for many years.\r\n\r\nOn the morning of 26 January 1968 Mrs Haythornthwaite went to work as usual. She went to her friend’s house at about 8.30 am where she had morning tea, until at about 11.30 am when she left with her friend to visit the small goods store to buy bread and as it was a hot day it was decided to go to the Main Reef Hotel for a drink. Mrs Haythornthwaite then went home where she found her dog had shredded a newspaper all over her kitchen floor. She would later tell a friend that she was too tired to clean up the mess and had left the paper on the floor intending to clean it up later that evening. Mrs Haythornthwaite then left her home again to collect her wages from the Council offices. After collecting her wages Mrs Haythornthwaite went shopping before meeting a friend at the Grand Hotel around 5.00 pm where they were later joined by her friend’s daughter.\r\n\r\nAll three women left the hotel at 8.30 pm with Mrs Haythornthwaite declining to share a taxi home and advising she would be safe to walk home alone. The two women watched Mrs Haythornthwaite reach the intersection where she turned left alongside the Shamrock Hotel and presumably continued on her way home. A possible brief sighting by two young men matching Mrs Hathornthwaite’s description was reported at approximately 11.15 or 11.30 pm later that night as the two men drove home from the Drive-in theatre. Neither were certain the sighting of an elderly female in the bush beyond the intersection of Vivien and Lane Streets was Mrs Haythornthwaite.\r\n\r\nWhen Mrs Haythornthwaite failed to attend work Mrs Haythornthwait’s son was contacted about her absence. At Mrs Haythornthwaite’s house it was discovered her dog was distressed on the verandah without food or water as well as the remainder of her animals. The kitchen floor was still littered with torn newspaper and Mrs Haythornthwaite was nowhere to be found.\r\n\r\nThe Boulder Police, family and the community committed to an extended search of the area including the use of Aboriginal trackers, lasting until 18 February 1968. There was media released locally and investigations in the Perth Metropolitan area. The result of the search revealed no indication of what may have happened to Mrs Haythornthwaite.\r\n\r\nThe Coroner was satisfied beyond all reasonable doubt Mrs Haythornthwaite is deceased and died on or about late evening of 26 January 1968. The Coroner was unable to determine how the deceased died and made an Open Finding as to the manner of Mrs Haythornthwaite’s death.\r\n\r\nCatch Words : Long Term Missing Person : Open Finding

Coroner Vicker on 2 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Haythornthwaite%20finding.pdf’

Barry Ray JESSEN

Inquest into the Suspected Death of Barry Ray JESSEN

Summary : On the morning of 17 August 2006 Mr Jessen was on board a fishing vessel, following breakfast at about 8.45 am as the vessel was moving to a new fishing ground on conclusion of the overnight work shift. Once at the new fishing ground sometime after 9.00 am Mr Jessen’s friend noticed Mr Jessen was missing there followed an extensive search of the vessel which then retraced its course while calling for assistance from other vessels and emergency services in the area. No sign of Mr Jessen was ever located again.\r\n\r\nMr Jessen was last seen on the back deck where he had a smoke with another crew member. The sea was rocking but not badly. Mr Jessen was then seen to climb a ladder from the back deck up to the next deck. Mr Jessen was not seen again.\r\n\r\nCrew members searched for Mr Jessen and the anchor was pulled while the engines were restarted to retrace their course to where Mr Jessen had last been known to be on board. Other vessels in the area were called to come and assist for a man overboard. Other fishing vessels responded and converged on the provided co-ordinates. Police were contacted and a search plan was implemented.\r\n\r\nWater Police were contacted and search patterns calculated for the local conditions. The local volunteer Marine Rescue were alerted and they provided their vessel to assist. The search continued into the next day but there was no trace of Mr Jessen.\r\n\r\nThe Coroner was satisfied beyond all reasonable doubt Mr Jessen is deceased and died within a very short period of falling overboard. The Coroner was satisfied Mr Jessen drowned and that his death occurred by way of misadventure.\r\n\r\nCatch Words : Long Term Missing Person : Man Overboard : Sea Search : Misadventure

Coroner Vicker on 2 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Jessen%20finding.pdf’

Wombat NGURRAKATA

Inquest into the Suspected Death of Wombat NGURRAKATA

Summary : On 17 January 1988 Mr Ngurrakata was camping in bushland in Manari when he left the camp to hunt. He was never seen again, nor were any remains ever located.\r\n\r\nMr Ngurrakata was described as a senior law man in his community. Mr Ngurrakata worked at many stations across the Kimberley and knew his way around. Medical evidence indicated that Mr Ngurrakata was an asthmatic. It was reported Mr Ngurrakata was shaking when he was last seen byfamily in Fitzroy Crossing before Christmas 1987.\r\n\r\nMr Ngurrakata’s disappearance was reported to the Broome Police on 17 January 1988 and police were advised that family and friends intended to return to Manari to look for Mr Ngurrakata. When Mr Ngurrakata could not be found and concerns were raised for his welfare, police were requested to assist on 18 January 1988.\r\n\r\nPolice arranged for a search of the Manari area with SES volunteers, local aboriginal lawmen and trackers. On 20 January 1988 a single engine wing aircraft was hired to assist in the search with four coastal watch volunteers onboard as spotters. Despite extensive air and land searching there has been no sighting of Mr Ngurrakata.\r\n\r\nThe Coroner was satisfied beyond all reasonable doubt Mr Ngurrakata is deceased and died on or about 17 January 1988 somewhere in the Manari area. The Coroner was unable to determine how the deceased died and made an Open Finding as to the manner of Mr Ngurrakata’s death.\r\n\r\nCatch Words : Long Term Missing Person : Land and Air Search : Remote Area of Kimberley : Open Finding

Coroner Vicker on 2 June 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Ngurrakata%20finding.pdf’

Michael PETA

Inquest into the Suspected Death of Michael PETA

Summary : On 15 January 1975 Mr Peta was offered a bed at the Roman Catholic Presbytery pending being able to access temporary accommodation elsewhere. Mr Peta was observed to have settled down to sleep in one of the bedrooms. Mr Peta was never seen again.\r\n\r\nOn the morning of 15 January 1975 Mr Peta was seen to be agitated and advised that he was worried for his personal safety. Mr Peta advised also he was anxious about his accommodation and so he was told he could go to the Presbytery. Mr Peta attended a house he had been living at in Broome to collect his belongings. At approximately midday Mr Peta attended at the Presbytery with his personal effects and it was believed Mr Peta was going to lie down and sleep as that was what he said he intended to do. Mr Peta made no mention of leaving Broome, although he had said he might go and sleep in the bush.\r\n\r\nThe disappearance of Mr Peta was reported to Broome Police on 31 January 1975.\r\n\r\nThe Coroner was satisfied beyond all reasonable doubt Mr Peta is deceased following his disappearance the Roman Catholic Presbytery on 15 January 1975. The Coroner determine Mr Peta died of unknown causes and made an Open Finding as to how death occurred.\r\n\r\nCatch Words : Long Term Missing Person : Remote Area : Open Finding

Coroner Vicker on 28 May 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Peta%20finding.pdf’

Simon MARBIN

Inquest into the death of Simon MARBIN

On 12 December 1992 Mr Marbin had breakfast at a friend’s house in Bayulu Community. He had taken a few days leave from Fossil Downs Station where he worked. Once he left his friend’s house he was never seen or heard from again, although it was believed he had been on his way to Muludja Community. Mr Marbin’s disappearance was reported to the Fitzroy Crossing police on 17 December 1992 by his brother. Police made enquiries at surrounding local communities which revealed no knowledge of Mr Marbin’s whereabouts. Enquiries were then extended throughout the communities by radio. A search was conducted between communities of Bayulu and Muludja by police, local SES and local trackers. No tracks for Mr Marbin were located. On 18 December 1992 a helicopter was used to search the area between the two communities and a grid search was undertaken by the helicopter. The area was searched over one and half hours before returning to its base and advising there was no indication of Mr Marbin during the helicopter search. Between 19 December 1992 and 11 January 1993 both police and locals conducted additional searches including the use of helicopters and aircraft with no result. The Coroner was satisfied beyond all reasonable doubt Mr Marbin is deceased and his death was within a time frame of 12-17 December 1992 on his way between the two communities out of Fossil Downs. The Coroner was unable to determine how the deceased died and made an Open Finding as to the manner of Mr Marbin’s death. Catch Words : Long Term Missing Person : Land and Air Search : Open Finding

CORONER on 27 May 2020

‘https://coronerscourt.wa.gov.au/_files/inquest-2020/Marbin%20finding.pdf’