Oral submissions of Paul Warren with the State Victoria Coroner

Table of contents:-

1) Oral Submissions with Mr Cain On the 11th December 2023.

2) My notes explaining my oral submissions.

a) The AFP summary of their Incompetence and their Deception.

b) Vital factual inquest transcript comments made from the doctors at the inquest.

(Transcript) Note:- Before you commence reading this I will explain who some of the people referenced in this transcript are and their roles. Also note this is a very long coroner’s court transcript and I have notes at the end to explain further.

1) AFP Mr. Noel Scruton is the main Australian Federal Police officer ( AFP) stationed in Pretoria Australian Embassy South Africa. Note: Mr Scruton was very experienced as an AFP Superintendent therefore he was fully aware of all circumstances in 2016!!

2) Stacey Walker is the Department of Foreign Affairs and Trade (DFAT) Senior Liaison Officer (SLO) stationed at Pretoria Australian Embassy South Africa. Mr Gray is also DFAT and the first person at the crime scene on the 13th November only.

3) Note: AFP Mr Scruton was on the ground in Tofo Mozambique with Stacey Walker (Translator) in 2016, and they attended meetings with authorities and the crime scene together on the 17th November. Mr Scruton had taken a sand sample from the crime scene. Mr Scruton also spoke with the first doctor who examined Elly’s body and took notes which are entered into his action sheet.

4) The Fisherman was a local person living in Tofo who found Elly’s body at 5am and took a picture of her body on the 9th November 2016.

5) Inspector Cudzi was the Mozambique chief inspector in charge from the start attending the crime scene on the 9th November 2016.

6) Mr Cain (His Honour) The Australian Victorian Coroner.

7) Mozambique Doctors completed the Initial autopsy on the 14th of November 2016 in Maputo.

8) Dr Klepp (Pathologist) performed the second autopsy in South Africa and was completed on the 16th November 2016.

9) Doctor Lynch (Pathologist) is the Melbourne doctor and he completed the third autopsy in Melbourne on the 22nd November 2016. He is stationed at the The Victorian Institute of Forensic Medicine (VIFM) which is stationed in the same building as the Australian Victorian Coroners Court.

10) Dr. O ‘Donnell (Radiologist) was the radiologist at the Victoria institute of forensic medicine. He completed his scan/report in 2019. Also from the VIFM and is also under the same roof as the Victorian coroner’s court.

11) Jade O'Shea was Elly’s friend in Tofo at the time of her death and one of the last people to see her alive at around 11.30 on the 8th November 2016.

12) The court staff are explained below and the Lawyer for the AFP is Mr Yuile. Ms Smith, Coroner's Assistant for Mr Cain.

13) Mrs Nicole and Mr David Cafarella are Elly’s mother and step father respectively.

14) Mr. King Taylor was the Victorian Coroner’s Assistant from the start, however he retired around a year ago and another assistant, Mr. Ross Treverton, had taken over recently.

15) Note : I can’t publish the radiology images showing the 1209HU upper airways and the 947HU lower airways as they are from a medical report contained in the brief.

16) Mr. Warren is me, Elly’s father.

TRANSCRIPT OF PROCEEDINGS COR 2016 5474 CORONERS COURT INQUEST

(4th day of hearing)

MELBOURNE MONDAY 11 DECEMBER 2023 BEFORE JUDGE J. CAIN, STATE CORONER

UPON THE BODY OF: ELLY WARREN

MS A. SMITH appeared to assist The Coroner.

MR A. YUILE appeared on behalf of the Australian Federal Police.

MR P. WARREN was not represented by Counsel.

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HIS HONOUR: Good afternoon, Mr Warren.

MR WARREN: Good afternoon, Your Honour.

HIS HONOUR: I understand Mrs Cafarella is online and I've also got Mr Yuile online and Ms. Smith at the Bar table.

MS SMITH: Yes, Your Honour.

HIS HONOUR: By all means, take a seat, Mr Warren. Does that cover everybody? Okay.

I will start by acknowledging the traditional custodians of the land on which we meet, the Wurundjeri Boonwurrung people of the Kulin Nations and pay my respects to elders past and present and any First Nations people that might be either in court or viewing this proceeding remotely.

The purpose of today was to allow you, Mr Warren, to make oral submissions further to the written submissions that you've already made.

MR WARREN: Yes, Your Honour.

HIS HONOUR: It was, I think, when we concluded the last hearing we hadn't yet got to a point where we had decided whether we would have oral submissions, it was going to be a matter to be reflected upon once we'd had the written submissions but I do note that you were enthusiastic about, or keen to make – have the opportunity to make written submissions – sorry, oral submissions, so that's the purpose we've convened today.

MR WARREN: And I thank you for that opportunity, Your Honour.

HIS HONOUR: No, that's fine, happy to – before we get underway is there anything you want to say, Ms Smith? I don't I think there's much you want to add.

MS SMITH: I – – –

HIS HONOUR: But if there is, I'll give you this opportunity.

MS SMITH: Thank you, Your Honour, you've covered

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some of the Warren points that I was going to raise, however I did just want to mention that Mr Warren's request for oral submissions was received by the court on 11 October and there's been I guess a short delay in this submissions hearing occurring because additional information was sought from Mr Warren and his representatives with respect to the points that he wished to cover in his oral submissions today and I just wanted to note that a summary document outlining those points is provided for your consideration late in October.

After considering that request in some detail, the actual request for oral submissions was granted on 30 November and the parties were subsequently advised. For the sake of completeness,

I also wanted to note that this morning Mr Warren's representatives provided the court with an additional document which contained some images that Mr Warren wishes to refer to, as I understand it, during the course of his oral submissions and that document has been provided to the Commissioner's representatives as well.

Lastly, Your Honour, I won't be making any oral submissions today as there's nothing further that I wish to add to the written submissions of counsel assisting that were previously provided to the court. So subject to there being anything from Mr Yuile, I would hand over to Mr Warren.

HIS HONOUR: Thank you, Ms Smith. Mr Yuile, is there anything you want to say before we got underway?

MR YUILE: No, Your Honour, thank you. I – depending on what Mr Warren has to say I may ask to say something short at the end but at this point, no.

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HIS HONOUR: Yes, thank you, I assumed that was the position. Okay, Mr Warren, I'm in your hands.

MR WARREN: Your Honour, thank you for giving me the opportunity to present my oral submissions to the court. The evidence given at the inquest has clarified critical key events which demonstrates the circumstances of Elly's death which are highly suspicious and a finding that Elly was a victim of homicide would be appropriate in this matter.

This would be consistent with the determination of the Mozambique authorities that Elly's death is a murder and the conclusion of the investigating authorities should carry significant weight for this court.

Your Honour, the AFP earlier this year, as you are aware, went over to Mozambique and they spoke to the authorities over there and they found some information which stated that ah they now have concluded that Elly's death was a homicide. They also state that they had some suspects and they're looking at the perpetrators which was conveyed to the AFP.

There was also some update from that in June of this year I think it was, with the presiding judge in Mozambique. I'm just wondering if the court has any update on – further on that?

HIS HONOUR: I haven't – I'm not aware of anything and Ms Smith is shaking her head so that to me means that she has no other – no update. I think the last piece of information we have was the letter that was sent following the meeting. I can't remember the date of that.

MS SMITH: That's correct, I believe it was around 19 June.

HIS HONOUR: Yes.

MS SMITH: It's contained in the coronial brief.

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HIS HONOUR: Yes. Yes, I think that's – which concluded, if my recollection is correct, that none of the information that they held would be released until the investigator would move to the next phase.

MR WARREN: Yes.

HIS HONOUR: Away – out of where it's currently which is described as the investigation phase before the investigating judge.

MR WARREN: So I think that – from what I could gather the presiding judge was going to decide on whether – the next step of the investigation, is that correct?

HIS HONOUR: And he had three options as I understood it.

MR WARREN: Yeah.

HIS HONOUR: Yes, or he considered he had three options.

MR WARREN: Yes. With this in mind, there are five key points that I propose to address the court on today.

I'm going to start with the volume of densely packed sand found all the way down my daughter's airways, I will then discuss the evidence that supports the conclusion that Elly's body was moved after her death and when the AFP became aware of the possibility Elly's body had been moved.

I will conclude by addressing the AFP's decision not to submit a mutual assistance request and the circumstances in which the AFP obtained a clear photograph of Elly's body in situ.

My first point, Your Honour, is the abundance of sand found in my daughter's airways.

Turning to the volume of densely packed sand found in Elly's airways, the overwhelming evidence during the inquest demonstrates that there was a significant amount of densely packed sand present throughout Elly's airways. Um, Your Honour,

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I feel that the inquest was very informative here with um - especially with Dr Klepp's evidence about the evidence that she gave about the packed sand inside of Elly's airways.

HIS HONOUR: Yes, I agree.

MR WARREN: And concurred with the Mozambique autopsy. Ah so it's interesting that they were really on the same page and then we had Dr O'Donnell's radiology report which also has clarified the high-density volumes within the airways even after the two previous autopsies, And I feel that they ah are some very key factors there that came out from the inquest.

In my submission, it is highly unlikely that this packed sand in this manner would have occurred without the involvement of a third party.

Um, Your Honour, the other possibility that was mentioned in the inquest was that Elly had just fallen over in sand for some other reason um and inhaled the abundance of sand deep down into her airways.

Now, in my reply submissions, I have mentioned in there about the Bureau of Australian Statistics. Over the last 60 years they have recorded the cause of death since - in the 1960s, so it's been about 60 years, and um they haven't or I haven't discovered any one that has just fallen over in the sand inhaled the abundance of sand that Elly has and has caused their death. Um so I consider this to be a highly unlikely factor that this has occurred considering the evidence at the inquest where Elly did not have much to drink and drugs were not involved.

What other aspect do we have? We have a lot of or

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very suspicious evidence which I will talk about further in my submissions to suggest that um there was a third party involved. While recognising the limitations of the Mozambique autopsy, it does conclude and explain at no.4 and no.5 that the abundance of sand was detected all the way down my daughter's airways. Um this is actually

referenced in the brief, volume 1, p26, 28 and we can see here - I don't know if Your Honour looks it up.

HIS HONOUR: No, look, I might - I accept that - - -

MR WARREN: You accept? Okay.

HIS HONOUR: - - - there's large volumes of sand.

MR WARREN: All right.

HIS HONOUR: And I accept the evidence that - - -

MR WARREN: Yep, yep.

HIS HONOUR: - - - it was however it's described, packed, and I have also had the opportunity to review the evidence of Dr Klepp and also of Dr O'Donnell.

MR WARREN: Yes, okay, thank you, Your Honour. Um and in this, it also states mechanical asphyxiation um and homicide as the ah cause of death but those points in the autopsy are there and they do um describe the sand that the initial autopsy had discovered. This was supported by Dr Klepp's evidence and Dr O'Donnell's radiology report which recorded very high-density levels of sand in Elly's upper and lower airways.

For example, Dr Klepp gave evidence that she was - regularly examined bodies in South Africa who had inhaled sand by being buried alive after frequently gold mines collapsing in South Africa. Now, this was um quite an evident point that she

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did raise, Your Honour, at the ah inquest and I found that this was quite interesting because she indicates that she's had a lot of experience with people that have inhaled sand and died from this um - from this so I thought that was very interesting. Against this background of Dr Klepp's experience, she gave evidence that and I quote,

“I have seen sand but I must say I have never ever, ever in 44 years seen as much sand in the oral cavity, the trachea and the bronchiole as I did in Ms Warren”.

Um I - I - I was really surprised at the inquest of that statement. I - I just - that sort of um - I find that that's pretty compelling evidence with the sand that was in Elly's ah lungs at the - and it tells true stories, you know, that um there was um - even after previous examination, she had discovered the sand was ah - was in abundance. And that's on

transcript page, Your Honour, 181, that evidence.

In supporting the evidence by Dr Klepp, subsequently she described Elly's airways “chock-a-block”, packed with sand, and that's on Transcript 181, 182.

Dr Klepp's observations were particularly insightful in circumstances where Elly's body had already been subjected to an initial examination in Mozambique and this volume of sand was still packed chock-a-block and able to be observed still in this state, after the initial examination.

Further, the radiology scan undertaken by Dr O'Donnell recorded very high mass density levels of sand in my daughter's upper and lower airways, despite being completed after two previous autopsies examinations

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as I've previously said and this sand at the back of the nose, that's - Dr O'Donnell's found has a very high density level, would have to pass through the nostrils which is a very small opening, as we are aware, to end up at the back of the nose as it has. Dr O'Donnell's report records a density reading of 1290 HU at the back of my daughter's nose.

This measurement is taken with the reference to the method of the Hounsfield unit of measurement, which is also referred to as HU, in my submissions. Your Honour should have a copy of three charts titled 'Documents referred by Mr Warren' before you.

HIS HONOUR: I've looked at them, yes.

MR WARREN: Yes, this contains three charts which I have extracted from publicly available sources. If we compare the density reading at the back of Elly's nose to figure 1, we can see on this figure chart that we have pottery and cement, and a density level of between 1300 and 1500 and Elly's density level was recorded at 1290, which is an extremely high density level, Your Honour, and you know that's - that in itself also tells us that even though the cleaning from Dr Klepp, that that's the density level that was in the airways at the time.

This contains - ah sorry, this contains, yeah, three charts which I've - yeah, I've said that, sorry. Figure 1 and Figure 2. Figure 2 is the chart which shows the wood, and that comes up at 1250 HU. And Elly's reading was 1290 HU. So that's quite significant as well.

Keep that there. Um, I also have Your Honour, in reference in a brief, Figure 1 Figure 2 Figure 3

Note the foreign material comparisons with cement and pottery are above and the 1300HU line on the graph to 1500HU and Elly’s reading was 1290HU.

1290HU is at the back of the nose and 947HU is in trachea and lungs In fact the lungs were full with sand.

What is very interesting indeed is Mr. Cain has not entered these very high density reading in his findings.

This proves the sand was there in volume when the Melbourne Pathologist from the VIFM conducted his autopsy.

It must be noted that any washing from Dr. Klepp doesn’t reduce the amount of sand present here in this instance as this Radiology report proves this high density masses of sand were THERE still after her washing when the Melbourne pathologist completed his Autopsy!!!

Note;- The highest wood HU level here is OAK 1250HU there are probably high wood density’s but this is the highest on this chart and the only wood chart I could fine with HU values. Elly’s is 1290HU even higher.

This is at the back of the nose as the washing from Dr. Klepp did not remove or dislodge this mass of densely packed sand.

This is a very high indication of how dense the sand was at the initial autopsy in Mozambique from this mass of sand at the back of the nose not to dislodge from washing by Dr .Klepp.

Note:- This graph shows the density HU readings of various organs with in the body.

The range of cortical bone starts at 300 HU and ends at 1200HU. The Lungs start at -500HU. the interesting factor here is the variance as lungs start at -500HU Elly’s reading lower lungs 947HU variance is 1447HU. The trachea and both of Elly’s lung trees are completely full with white material (SAND) in the Radiology images.

Note;- I can’t publish the radiology Imagines on here 1290 HU and 947 HU as they are part of the Brief in Volume 1, pages 67, Image of 1290HU and Page 72, image of 947HU. the above graphs are not part of the coronial brief.

MR WARREN: (continuance) volume 1, p67, a radiology report, the image of 1290 HU and it's this image here. Um, . these clearly show with the white bright areas the masses of sand with the density readings of both 1290HU at the back of Elly’s nose and the 947HU in the lower airways trachea and both lung trees.)

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find that these images are a little bit clearer than the ones in the brief.

HIS HONOUR: Yes, Mr Yuile won't be able to see that, but we can perhaps accommodate that, but is it - I perhaps should say to you, I accept there was a significant volume of sand in Elly's lungs.

MR WARREN: Yep, yep.

HIS HONOUR: If there's a sort of point beyond that that you're leading to, it might be worth moving to that now.

MR WARREN: Yep, okay.

HIS HONOUR: Because I do accept the sand volume in the lungs was significant.

MR WARREN: Okay, if you'd just bear with me - - -

HIS HONOUR: Sure, yes.

MR WARREN: I'll pass through some of what was going to - - -

HIS HONOUR: Yes, well, I'm not trying to restrict your opportunity.

MR WARREN: Yeah.

HIS HONOUR: But I might as well give you the opportunity at least, knowing where my head is at on some of these issues.

MR WARREN: Yep, yep, okay. This probably may be significant, ah if you'd just bear with me, Your Honour. Dr Klepp gave evidence that for the sand to reach Elly's lower airways as it had, she - she would've needed to be alive, at the time the sand entered her airways. This confirms that for the sand to reach Elly's lower bronchial and her lungs, it - it has entered her airways prior to her death.

IT MUST BE NOTED:-that it is also a normal procedure at autopsy to remove all organs and place them inside plastic bags for transportation.

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In concluding the abundance of sand, it is very important Your Honour that these two very high-density readings of 1290 HU and 947 HU respectively, are placed into perspective. These levels of high density are still present in the airways, even after two autopsy examinations and the cleaning from Dr Klepp.

This is in addition of - this -sorry, this is an indication of the sheer magnitude of packed sand the Mozambique doctors were confronted with at the initial autopsy and is the key reason why they have no hesitation in concluding Elly's death was a homicide.

I really do firmly believe that that's the case in - that's in - in this - that's how they examined it and that's why they came up with that conclusion, Your Honour.

The presence of packed sand all the way down Elly's airways is the common denominator between all medical professionals and the court can be satisfied, as you are Your Honour, that the sand obstructed Elly's airways and causing her death.

That concludes the sand point that I had.

Now I'd like to move on - the next point Your Honour is referring to the movement of the body.

I now wish to take the court to the relevant key evidence which demonstrates that Elly's body was moved after her death. On 18 November, Noel Scruton of the AFP and Stacey Walker from DFAT attended a meeting with Inspector Cudzi where he informed them that the local authorities suspected my daughter's body was moved to the location she was found after her death. Further in my affidavit dated 17 January 2023, I had deposed that I travelled to Tofo in October 2018 and I had organised to

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meet with the Chief Inspector Cudzi at the Criminal Investigation Headquarters, reference brief, volume 2, p290. And this is from my affidavit and this - in my affidavit on p290. It explains a fair bit about that meeting with Inspector Cudzi.

Chief Inspector Cudzi was the chief superintendent at the time and in charge of all criminal investigations and instruction in the - in Zimbabwe district. During this matter,

Chief Inspector Cudzi informed me that in his opinion, my daughter was murdered at the main beach and her body was moved to the toilet location after her death.

He states, and I quote, 'She was murdered, killed at the beach and moved to the toilet location after she was killed. The sand was a different colour in her airways, to where the body was located'.

In addition to the opinion of the local authorities, the evidence of both myself and Jade O'Shea during the inquest also demonstrates that Elly's body was moved. I gave evidence that the sand at the toilet block where Elly was found is shallow and dark in colour. Jade O'Shea also gave evidence that the area around the toilet block is quite rocky.

The clear crime scene photo shows Elly's body laying flat on top of a firm dark sandy pathway next to the toilet block. In this photo you can see at her feet level and above her head, that the sandy path where her body is laying is firm and not very deep.

Your Honour, I do have three photographs relevant to the crime scene which I feel are extremely important under the circumstances and um if I may present these important photos to you, because - - -

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HIS HONOUR: Are they photos that are already in the brief?

MR WARREN: Yeah, but I couldn't find them in the brief, Your Honour. They must be in the tendered brief.

HIS HONOUR: Well, I've already got them, that's okay, but I'm not in a position to take photos that I haven't already seen.

MR WARREN: No, they are - they - I'm pretty sure they are in the brief, but I just - - -

HIS HONOUR: Well perhaps you could - have you got them there now?

MR WARREN: I have got them here, but they - they are extremely relevant and I probably - - -

HIS HONOUR: Could you show them to Ms Smith so we can just work out whether they're in the brief.

MR WARREN: Probably do need to talk about just a couple of the things that are in the photos, to um - that you may not be aware of, Your Honour.

HIS HONOUR: Yes certainly, I just wanted to check that they were photos from the brief.

MS SMITH: We've got them.

MR WARREN: You got them? Yes, they are.

HIS HONOUR: Yes.

MR WARREN: Do you - - -

HIS HONOUR: No, I'm happy for you to proceed to talk about them.

MR WARREN: Do you want me to - - -

HIS HONOUR: If it's helpful for me to have them while you talk about them, then - - -

MR WARREN: I think it is, Your Honour, yep.

HIS HONOUR: Will be passed up to me.

MR WARREN: This first photo was taken by Stacey Walker on 17

Note: This is not the same photo I am talking about with Mr. Cain as that photo is in the brief and I am not allow to publish the original photos. However I took photos of the same area on my trip to Tofo in 2018 this is of the same area that we are talking about in the oral submissions. I refer to a red cross with Mr. Cain well in this photo it has a blue cross where Elly’s head was. Elly was face down with her on top of the sand and her head slightly tilted to the right with her feet at this end. The surface of the pathway is firm and rocky but this is taken two years after. However there is not much difference in the area.

The second photo that Mr. Cain and I are talking about has ladies in it and one lady has a pink dress that photo was taken in November 2016. This photo above is taken in 2018 and you can just make out the same black bin to the left of picture Mr. Cain and I are talking about two years on and its the same black bin.

The fisherman put there motors in this black bin which they fill up with fresh water from the only public fresh water tap in Tofo to purge out the seawater from the motor.

In this photo you can also see the entranced to the men’s toilet so it was taken in the same area. The reason why this photo is important is this is the reason the fisherman was there at 5am that morning to clean out his motor. You can also see how firm and rocky the surface is.

This third photo shows the contrast between the two sands. This is also not the same photo with Mr Cain but it gives you a good idea how different the sand is from the main beach to the roadway.

The main beach is far left and white and the road is brown there is a major difference and the sand at the toilet block is even darker where they do all their washing.

This is a very important showing the difference between the two sands on the same photo because this is how inspector Cudzi knew Elly’s body was moved after her death when he turned up at the crime scene, as Elly had the white beach sand in her mouth not the dark brown sand from where her body was found at the toilet block.

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November, and you can see in that photo there's a red cross and that is the approximate position of my daughter's head, at the crime scene. Um, and you can also see that there's quite a lot of rocks and that the sand is soft, but it's not very deep, not deep at all in, in that area. And the sand is dirty and dark.

Um, in eh second photo it's very interesting, Your Honour. This is - you're looking at the lady in the pink dress here.

HIS HONOUR: Yes.

MR WARREN: This is the only fresh water tap in Tofo and this is where they do their washing and it's completely dirty and the sand is dark and very dirty there. And Elly's body was around the corner where the women's um entrance is. Um, and it's interesting to note where these three ladies are walking, it's very rocky. You can see how rocky and hard the surface is there around the toilet block. Now this photo was taken by Mr Gray. The other one was taken by DFAT on 17 November. This was taken by Mr Gray on 13 November, right.

Now it's interesting to also note that the fisherman that found Elly, lifts this black bin on the left hand side here. The reason why the fisherman come here early in the morning is because they perch their motors with fresh water from this bin. They put it on the side of the bin and because it corrodes their motors if they don't do that. So that's why they're there at that time in the morning. And that's how they discovered Elly's body. Um, I'm not sure whether that's relevant, but you might be interested to know that um, that's how - how come the fisherman was there at that time. Um, other

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than that, that just gives you a pretty good overview of the area and how dirty it is there, Your Honour.

HIS HONOUR: Yes, thank you.

MR WARREN: In this other photo, this is really important because when we're talking about Inspector Cudzi and how he says about the different colours of sand, this is in the same photo. You can see the different colours, there's quite a big contrast between the sand down the beach and the sand at the roadway, and then you've got the toilet block even darker. So we're talking beach sand is - you know, the contrast is - is quite severe here and um - and this is why he was saying that Elly's body was definitely moved to the toilet block location after her death.

Given the volume of sand present in Elly's lungs, there can be no doubt my daughter's body was moved to this location after she died with her head on top of the sand lying flat on this firm sandy pathway.

Dr Klepp states in evidence:-

“I could not see Elly compromising her airways With her body lying flat in this position in the photo on this firm surface”. Its a point that no sand sample was not take”

This was also confirmed by - by Chief Inspector Cudzi of the observations in the meeting we had with myself, Mr Sutton, my own observations from attending the toilet block location and Jade O'Shea's evidence during the inquest which is um transcript p.27 and 156.

The fact that Elly was moved after her death is highly suspicious circumstances as it confirms the involvement of a third party.

This is supported of the finding that Elly was murdered.

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I'd like to move on to the next point, Your Honour, and this is the AFP's knowledge of the movement of Elly's body.

With respect to the knowledge of the - of the Australian Federal Police, the material before the court clearly shows that the AFP had knowledge of the possibility that my daughter's body had been moved post-mortem. In evidence given at the inquest, the AFP and DFAT state they had visited the crime scene on 17 November 2016 and the AFP had taken a sand sample from the toilet block area where my daughter's body was found.

As previously mentioned, on 18 November, Mr Sutton and Mrs Walker attended a meeting with the Chief Inspector, Cudzi, where he informed them that the local authorities suspected my daughter's body was moved to the location she was found after her death.

It was confirmed at a later date that the AFP were fully aware of this in 2016 as it states this in her action sheet on p15. At a second meeting with Chief Inspector Cudzi on 9 August 2017, it states in the AFP action sheet and I quote,

'Mr Cudzi indicated that they were still working on the possibility that Warren had died elsewhere and been transported to the position where her body had been found'.

Now, this second meeting is 10 months after the first meeting on 18 November. So Mr Scruton is indicating here in his action sheet and they're still working on the movement of Elly's body. This confirms that the AFP and DFAT were fully aware of my daughter's body having been moved after her death in 2016 and this is suspicious circumstances they should have investigated as they had the ability of the second sand sample taken inside the body at the Melbourne

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Mortuary for comparison. The sand sample the AFP had taken at the crime scene should have been forensically examined and compared with the sand sample from my daughter's body.

As I have previously said, the radiology report prepared by Dr O'Donnell shows there was plenty of sand in Elly's body in the upper and lower airways, trachea and lungs at very high-density levels. Bearing this in mind, a second sample should have been taken from my daughter's body at the Melbourne autopsy and forensically analysed for comparison with the sand sample taken from the crime scene.

The radiology scan has - was conducted before the Melbourne autopsy clearly showing my daughter's airways and lungs full with sand as Dr O'Donnell clearly states in evidence. Your Honour, in concluding um this point, with the movement of Elly's body and sand sample, the fact that no comparison was undertaken represents a significant missed opportunity in the coroner's investigation at the time.

The family feels that this is one piece of critical evidence which has hampered the family's attempts to seek answers.

The next point, Your Honour; concerns for mutual assistance request.

Turning to the circumstances surrounding the AFP's decision not to issue a mutual assistance request, Commander Smith gave evidence that the AFP did not classify Elly's death as a crime and that is the initial reason why the mutual assistance request was not sent to the Mozambique Attorney-General.

The letter for Mr Bruce Giles dated 17 December 2021 in his report in the brief clearly states twice at

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no.16 and 17 that the requirements for the mutual assistance request is simple and I quote, 'Where there is reasonable cause to believe that an offence has taken place', reference brief volume 2 p545,

and he mentions that twice, Your Honour, here in this letter. Contrary to Commander Smith's evidence, the AFP were given sufficient information early in the investigation. Mozambique autopsy which notes that the reason the Mozambique police asked for an autopsy was because of the suspicious circumstances at the crime scene were Elly was found and, no., there was an official police report on 10 April 2017. This official Mozambique police report was given to the AFP on 10 April by Stacey Walker, as indicated on p13 of the AFP action sheet.

And that's reference brief volume 2, p344.

And it's interesting to note that in this, Mr Scruton's described this as a Mozambique document and suffocation, when in actual fact it is a - an official police report and it states homicide. The autopsy and police report state that homicide is the cause of Elly's death. This should have been reasonable cause for the AFP to review their decision not to issue a mutual assistance request on the grounds that there was sufficient information suggesting Elly's death was a crime.

Further, a mutual assistance request was always possible as the Mozambique Assistant Attorney-General has recently stated in an update from the AFP and I quote,

'That the only way the coronial enquiry in Australia could officially acquire the case file would be through a mutual assistance request once the instruction phase is completed,

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which is what we talked about earlier.

HIS HONOUR: Are we still in the instruction phase?

MR WARREN: Yeah, yeah.

HIS HONOUR: So even if a mutual assistance request had been made at the time you refer to - -

MR WARREN: Yes.

HIS HONOUR: Are you saying that something different would've occurred?

MR WARREN: Yes, and I'll probably talk about that here.

HIS HONOUR: Well, perhaps talk about it now because it might be convenient for me to understand what you're actually saying about that.

MR WARREN: Well, the mutual assistance request is - is a - is a - I'll just hold it, I'll look on - is a request that um is available to countries, so that they can communicate and - and work together.

HIS HONOUR: I agree with that.

MR WARREN: Yep.

HIS HONOUR: But my question is more around if the Deputy Attorney-General's view is correct and I assume it is, that at any time, if a mutual assistance request had been made - - -

MR WARREN: Yes.

HIS HONOUR: - - - then the documents would only be released once the instruction phase was completed and the secrecy provisions are relaxed.

MR WARREN: Yes, that's - that's true.

HIS HONOUR: We're still not in that phase yet.

MR WARREN: No, but a mutual assistance request could've been um issued earlier on in the investigation.

HIS HONOUR: It may have been, but what I'm really coming to is

HD:SB 11/12/23 Court 2 264 DISCUSSIONWarren

what difference would it have made to the outcome of any investigation if it was made I 2017, in 2021 or 23 or for that matter, 24, unless the instruction phase is complete.

MR WARREN: Well, it does allow for another country's authorities to work with that - those authorities and as um Mr Scruton did, that the Mozambique authorities were difficult to work with, right. If the mutual assistance request had of gone through the process and gone to the Attorney-General in - the Mozambique Attorney-General, then they would've looked at that.

Now it's up to them to say yes or no. If they had of said yes, the government would have told their authorities to cooperate with the Australian authorities. Now the other major point here, Your Honour, is that before forensically testing, all right um evidence, um the Mozambique authorities didn't have the capabilities of DNA testing.

HIS HONOUR: But I think - - -

MR WARREN: And we could've - we could've helped them in that area.

HIS HONOUR: But I think, and I agree with what you're saying, but we also have evidence I think from Commander, yes, Smith and from the others, that regular offers of assistance were made, but not taken up. Now, I think what you're saying to me is that had a mutual assistance request been made, then that would've given - and I guess accepted or - no, made, then that would've given some greater weight to the support and assistance that Australian authorities might've been able to offer.

MR WARREN: Correct, Your Honour, and that's what I'm making out here.

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HIS HONOUR: Well, I guess where I'm up to on that is - - -

MR WARREN: That's - that's an - - -

HIS HONOUR: That's in a land of speculation.

MR WARREN: But that's an official request.

HIS HONOUR: But it's an official request that they say they ignore, until they're out of the instruction phase.

MR WARREN: But the AFP only sent a personal letter.

HIS HONOUR: But again, on the information I've got, I don't say it would've made no difference, but getting access and full cooperation really involved the instruction phase being completed and we're not there yet.

MR WARREN: Well, I'd just like to mention this, Your Honour. However, it clearly states the MA - the mutual assistance request act, that a treaty is not required between the countries because the Mutual Assistance Act was implemented so all countries can work together on issues they have, opening the door for more efficient exchange of information and communication channels between the two countries concerned. The mutual assistance request also allows for collaboration between both authorities on the case, or issues they have between the countries concerned, because it's an official request. Now they may have said no, um but there's a chance that they could've said yes. Which means that I - I - surely Your Honour, this would've made a big difference in the coroner's investigation in 2016/17, if the official request had of been sent to Mozambique and the government there instructed their authorities to support and help the AFP. Now I think Your Honour that would make a difference, it would make a difference to - - -

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HIS HONOUR: It may or may not, I'm sure Mr Yuile will have something to say about that when he has his opportunity to speak. I understand what you're saying and I've understood and followed your logic and that is that if a request had been made earlier, then it's possible that the Mozambique authorities may have asked the AFP for some assistance and done something differently, but I'm also aware that numerous offers to assist were made, albeit without the imprimatur, an informal - of a formal mutual assistance request.

MR WARREN: But what I'm saying here, I think, is that through that request, because it's official, their government then instructs their authorities to cooperate. Now, you - you mentioned just then that there - there was problems with them cooperating but if - if they - - -

HIS HONOUR: No, I didn't say that. I said they made offers to assist - - -

MR WARREN: Offers to assist and - - -

HIS HONOUR: - - - and they weren't taken up.

MR WARREN: - - - they weren't taken up.

HIS HONOUR: I don't take it any further than that.

MR WARREN: Yep. So if that mutual assistance request had been granted and the government had responded and said, 'We want you, Mr Cudzi', to help with the AFP, allow them to help you with the investigation and also with DNA testing because they just did not have that capability, um surely that would make a difference to the coroner's investigation.

HIS HONOUR: It's speculation. I don't know but I understand what you've submitted.

MR WARREN: Okay. Well, the court has actually heard evidence

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from Stacey Walker and from her statement about the poor level of resourcing available to the Mozambique police and the standards for forensic testing in Mozambique. That's in her statement and it's

referenced on p135.

I'm quite sure that the AFP with our sophisticates levels - standards would have made a big difference in the coroner's investigation. The AFP were fully aware of the - we might have covered some of this so if you just bear with me, Your Honour - - -

HIS HONOUR: Sure.

MR WARREN: I'll just read through it. Just I don't want to repeat myself. Yeah, well, I'm just going to conclude on the mutual assistance request on how I feel about it, Your Honour, and the mutual assistance request, this should have been sent early on in the investigation through the official channels set out in the Mutual Assistance Act. The family was never informed of the AFP's review process if there was a reasonable cause to suspect a crime of an Australian citizen in a foreign country.

This represents another missed opportunity I feel, Your Honour, um the case and family feels that this deprived us of justice.

Your Honour, the next point and the final which is concerning the crime scene photo.

I wish to draw the court's attention to the circumstances in which the clear photo of Elly's body in - in - in situ was not disclosed to the court in 2016-17. The conduct of the AFP in relation to acquiring the clear version of the photo and not providing it to the honourable court but giving it to the Mozambique police.

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The non-return of Elly's possessions and the Victorian Institute of Forensic Medicine requires examination.

HIS HONOUR: Sorry, what was the reference to the Victorian Institute of Forensic Medicine?

MR WARREN: Well, they were given the clear crime scene photo. I have a little bit further down in my submission about that, Your Honour.

HIS HONOUR: All right. I'll let you continue.

MR WARREN: In the most recent correspondence from the Australian Government Solicitor to the court on 16 June 2023, the AFP has indicated they acquired the clear version of the crime scene photo which was originally from a fisherman via DFAT on 25 November 2016 and that's

referenced in the brief volume 2, p555

and that goes on to indicate that they received the blurred photo - the blurred photo first and then at a later date, they received the clear photo and they also sent the photo to the Victorian Institute of Forensic Medicine. This photo was then handed to the Mozambique police by the AFP SLO which is Mr Scruton who was the AFP representative at the Australian Embassy in Pretoria, South Africa. It is also stated in the letter from Clare McCormish, the Assistant Secretary of DFAT on 22 March 2019 that DFAT received the unblurred version of the crime scene photo and had given it to the AFP which in turn passed it onto the Mozambique police in 2016 and I quote,

'The photo was passed to the Mozambique police by the AFP SLO on 8 December 2016', and that is in Clare McCormish letter dated 22 March 2019 and that's referenced in the brief at volume 3, p59 and that's on

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the second page of her letter and it states under, 'Photos and other items', Your Honour. The handing over the clear crime scene photo to the Mozambique police on 8 December by the AFP was overlooked in this latest letter from the AFP's legal representative. As previously stated in evidence, the family's consent for the photo which explicitly shows our daughter's naked body which was disclosed to the Mozambique authorities was not sought and the family is very disappointed and hurt by this.

The AFP did not classify Elly's death as a crime yet they sent an explicit photo of my daughter to a foreign country without the permission or knowledge of the coroner or the family;

reference volume 2, p270, 274.

This is actually in my affidavit, and it explains this in quite um detail and it's all facts, Your Honour, as it's in my affidavit. Um I - I - I personally find this is unacceptable um and to the best of my knowledge, the - the coroner was ah - was not informed of the circumstances in 2016.

This photo is critical evidence entered into evidence at the inquest as it is the only crime scene photo evidence showing the crime scene and a damage to Elly's clothing. The photo tells the truth and depicts Elly's top is ripped apart completely destroying her top and strongly indicates some form of physical struggle had occurred before her death.

Jade O'Shea gave evidence that when she last saw Elly, she did not recall any damage to Elly's clothing. As a result, the struggle which ripped Elly's top must have occurred shortly before or at the time of her death.

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Now, Your Honour, it clearly states in the summary of the brief for the AFP and I quote,

The blurred photo was the only available photo of Elly's body in situ, a blurred photo of a local fisherman's mobile phone screen'. In this summary,

which is on the second page of the summary entered in the brief, reference brief volume 1, p16,

at the top of the page here, it clearly states that they didn't have a clear version of the photo in 2016. However, this is a clear contradiction to the recent letter sent to the court from the Australian lawyer dated 16 June 2023. The AFP did not carry out their duty as the policing agency as they were responsible for reporting on and informing the coroner of all critical evidence given to them in 2016 for the coroner's investigation.

Mr Sutton has overlooked in his statement even receiving the critical evidence of the clear version of the crime scene photo and handing it over to the Mozambique police.

Mr Sutton has however entered the blurred photo into evidence in his statement which was obtained from DFAT in Tofo just after Elly's death in November as stated by Stacey Walker in her statement;

reference page volume 2, p133,

and in Stacey Walker's statement, she says that the grainy image was given to Mr Sutton and um this blurred grainy photo as Stacey Walker states was given to Mr Sutton by DFAT which was some time before 18 November 2016. Mr Sutton handed this blurred grainy photo over to the Mozambique police on 18 November as stated on p555 of the brief from the AFP lawyer representative in the letter that was dated 16 June 2023. So in effect they're

HD:SB 11/12/23 Court 2 271 DISCUSSION Warren

explaining that Mr Sutton had received the blurred photo before 18 November and he had handed it over to Inspector Cudzi, he then received the clear photo in - on 25 November and he then handed it over to Mr Cudzi again, the clear version on 8 December. I find these circumstances upsetting, Your Honour, and very disappointing and um - and it - it's just - just disappointing.

HIS HONOUR: Just so that I'm clear about that, Mr Warren, your concern about this aspect is that you're disappointed or feel let down that the AFP didn't communicate with you about that?

MR WARREN: Yes, and the coroner as well.

HIS HONOUR: Yes, yes.

MR WARREN: Yep. And - and - - -

HIS HONOUR: But there's no suggestion that had they communicated with you or the court in relation to that and I can't recall - I didn't have carriage of the matter at that time but are you saying that that impacted in any way on the investigation?

MR WARREN: Yes, 'cause I think the coroner having that clear - - -

HIS HONOUR: No, leave me out. How did it impact on you?

MR WARREN: Well, they - they gave the explicit photo of Elly over to the Mozambique police on the 8th and they didn't think that this was a crime at the time.

HIS HONOUR: Yes. But in terms of the - - -

MR WARREN: And I - - -

HIS HONOUR: And I understand that's upsetting to you but in terms of - - -

MR WARREN: I think that's very - - -

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HIS HONOUR: Yes. But I can't deal - like, that may be a matter that you deal with directly with the AFP by way of complaint about their conduct. And I'm not unsympathetic to you if that's - I mean your feelings on that but I'm looking at the investigation process.

MR WARREN: Yeah.

HIS HONOUR: And I'm just trying to understand whether you're suggesting that in some way something happened that meant that the investigation didn't go down a particular path or wasn't as thorough or something.

MR WARREN: Yes. So I - I do actually um think that because I - I think this is important critical evidence.

HIS HONOUR: Sure it is but how would it had made any difference if it'd been handed to the coroner back then because - and our ability to investigate it I think is what you're suggesting.

MR WARREN: Well, we might not be sitting here today, Your Honour.

MS SMITH: Sorry to interrupt, Your Honour. I just want to clarify. The AFP did provide us with some clarification on this point earlier this year and there is a letter in the brief which confirms that that photo was actually provided to the police coronial support unit that assisted the court back on November 2016 - - -

HIS HONOUR: Yes.

MS SMITH: - - - which was then subsequently provided to the Victorian Institute of Medicine as well. So the photo has been - - -

HIS HONOUR: In play with us, yes.

MS SMITH: Yes.

HIS HONOUR: Thank you.

HD:SB 11/12/23 Court 2 273 DISCUSSION Warren

MS SMITH: On the court file since that time.

MR WARREN: - excuse me, Your Honour. My understanding is that DFAT gave that photo. Is the AFP claiming that they handed that photo over?

MS SMITH: My reference is from a letter to the court dated 16 June this year in which the AFP just provided some clarification on that point and I can just read it if that would assist.

HIS HONOUR: Yes, perhaps if you read it, that will make it clear.

MS SMITH: So the relevant paragraph is that the AFP were instructed that DFAT also directly emailed the image to the Victorian police coronial support unit on 25 November 2016. It then shared the image with the Victorian Institute of Forensic Medicine as well.

HIS HONOUR: Yes.

MS SMITH: Yes.

HIS HONOUR: Thank you. So it appears from that that it was provided to the police training a support unit, which is part of - or the police unit that assists our investigations and also provided to the Victorian Institute of Forensic Medicine.

MR WARREN: Well, I'm sort at a bit of a loss, but - with that and I will explain, but first of all I'd like to say that as previously stated, the AFP also required the clear version of the crime scene photo in 2016 from DFAT. And in their action sheet, it also states that the AFP subsequently analysed this clear version of the photograph in 2018 and this is on p21 of the AFP action sheet. There was still no um, ah mention of Elly's ripped apart top until I informed Mr Kim Taylor of that

HD:SB 11/12/23 Court 2 274 DISCUSSION Warren

in mid-2019. Now talking about Mr Kim Taylor, the coroner's assistant, informed me that the coroner was not aware of any clear photo or ripped apart top in 2016/17.

Also in a meeting I had with Dr Lynch on 7 September 2017, where three AFP officers and Mr Taylor was in attendance, there was no mention of any clear crime scene photo or ripped apart top.

Dr Lynch states at this meeting, which was recorded and consent, and I quote,

'That he only had a blurred grainy photo and could not see much from this poor quality photo'.

HIS HONOUR: But, Mr Warren, I'm just not sure where this is taking us. I'm not sure how that would've altered the outcome of the investigation or what you suggest might've been different, had - whether it did or didn't occur, I suspect there'll be different ways. I'm just trying to work out where that takes out.

MR WARREN: Well - well I think the clear photo clearly shows Elly's top ripped apart.

HIS HONOUR: Very well, but - - -

MR WARREN: And I think that that is an indication that there's- there's some sort of you know - - -

HIS HONOUR: That's not in dispute that the top was ripped.

MR WARREN: Yep, yep, but the coroner - - -

HIS HONOUR: The only question - - -

MR WARREN: - - - would've known about that in 2016.

HIS HONOUR: But it wouldn't have made - well, I'm not sure when it came to me.

MR WARREN: Yep.

HIS HONOUR: Because I'm the coroner investigating this now.

MR WARREN: Yeah.

HIS HONOUR: I'm the person that's running the inquest.

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MR WARREN: Yep.

HIS HONOUR: I knew the top was ripped.

MR WARREN: Yep.

HIS HONOUR: So are you suggesting I should draw some other conclusion from that?

MR WARREN: Well, this has gone on for seven years.

HIS HONOUR: Leave that aside. I know it's a long time.

MR WARREN: Yep.

HIS HONOUR: And I'm trying to bring this to a conclusion, so if you've got a view that I should draw some other conclusion from it, you need to be really clear about it.

MR WARREN: Okay, well can I put this to you, if you were the coroner in 2016 - - -

HIS HONOUR: I'm not speculating about things like that.

MR WARREN: - - - and you were given that clear photo - - -

HIS HONOUR: I can tell you I'm not speculating about things like that. I'm the coroner that's conducted this inquest. I picked it up last year, I've reviewed it all and in hearing it, we've heard that evidence and I'm aware that the top was ripped. I've had the benefit of seeing the grainy photo and the clear photo.

MR WARREN: Yes.

HIS HONOUR: So if you're getting to the point where you want to tell me that I ought to draw a particular conclusion from that in addition to the ones you've already stated, it'd be helpful if you did that.

MR WARREN: Okay, well if you'll just bear with me, because I don't want to repeat myself again.

HIS HONOUR: Sure.

MR WARREN: I will just read over some of this before - um, yes, the um - well I don't really have much more to say

HD:SB 11/12/23 Court 2 276 DISCUSSION Warren

about that, other than to say um that um the clear photo wasn't available.

HIS HONOUR: And look, I understand your disappointment, regret, whatever the right description is, that a photo of Elly was handed to the Mozambique authorities without you knowing, I understand that, but I'm really trying to work out what you're saying I should do - what else I should do with that.

MR WARREN: Well, I - I don't know, but there's just one thing, if I could ask you, Your Honour. Do you think the coroner should've given permission for that photo to be passed on, even - because the AFP didn't classify this as a crime at the time?

HIS HONOUR: I don't think so.

MR WARREN: No? In respect of the family?

HIS HONOUR: Look, it would've been preferable if they'd spoken to you.

MR WARREN: Yep.

HIS HONOUR: But we can't on the one hand say, 'We want the authorities to cooperate', and to be able to provide them with assistance, and then on the other hand say, 'Well, look, we've got a really good photo here that's probably going to be helpful, but we're not going to provide it to you'. Now I say - I don't say they shouldn't have spoken to you - - -

MR WARREN: Yeah, I - I um - well the family's very disappointed about that.

HIS HONOUR: I get that and that's a matter - by all means, take up directly with the AFP, but it's not within the scope of a coronial investigation.

MR WARREN: Okay.

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HIS HONOUR: Mr Warren, just so that I'm clear - well, is there other matters you wanted to deal with, because that seems to be the end of your five points or is there others?

MR WARREN: No, there's, there's - there's a little bit more, Your Honour - - -

HIS HONOUR: Very well. Well, I'll let you - - -

MR WARREN: - - - that I find - that I find relevant. Um, and just bear with me cause I - I don't want - as I said, I don't - we've sort of jumped ahead here a little bit on what I was going to say. This is um - I feel this is important.

With respect to my daughter's possessions, which included her ripped apart top and underwear at her knees, that she was wearing, these were not placed into evidence by the Mozambique police.

The only trace evidence entered into evidence is stated in an official Mozambique police report, dated 11 August 2020. And the items that were placed into evidence were one Manica brand beer bottle, one Coca Cola can and one pack of Pall Mall cigarettes, and that's

referenced in p502, 505.

In fact, the clothes my daughter was wearing were eventually incinerated by the Mozambique authorities. This evidence was obtained by Nicole and David Cafarella in their investigation.

As my daughter's clothes were not placed in the evidence, this could have enabled the AFP to retrieve the clothes, in 2016, my daughter was wearing at the time of her death. The Mozambique police did not have the facilities for any DNA testing on clothing. The Australian authorities were fully aware of these circumstances in 2016 as set out in Stacey Walker's statement, and Stacey Walker's mentioned that, you know,

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they haven't got the resources and ah – and when I was over there I had to do a statement for Mr Cudzi and, Your Honour, I had to get it photocopied and they didn't even have that so their resources are very limited.

These clothes are my daughter's possessions and the AFP in their police training would have been fully aware of how vital the clothes are from the body, especially the way the body was discovered with the suspicious circumstances of the damaged top, in the clear version of the crime scene photo, and with her underwear down around her knees. These are highly suspicious circumstances.

The Coroner had asked for all of Elly's possessions to be returned and the AFP had taken the responsibility for retrieving all of Elly's possessions.

The AFP requested the return of Elly's belongings from the Chief Inspector Cudzi during the two meetings the AFP and DFAT had with the inspector. The clothes on my daughter at the time of her death are still her possessions and it states in the action sheet, 'Arrangements were made for the AFP to collect all Warren's possessions at the meeting with Inspector Cudzi, p9 and 15 of the AFP action sheet', and that's

referenced on p340 to 346

and it's there on their action sheet. However, the clothes she was wearing at the time of her death were not returned with her possessions. It states in the Mozambique autopsy the clothes travelled with the body from Inhambane to Maputo for her autopsy on 14 November 2016.

This is also a missed opportunity for DNA testing as cold cases are solved today with the advancement of DNA testing on clothing. This possibly could have helped the Mozambique

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police with identifying the recent perpetrators they had questioned or suspected, therefore this is also extremely disappointing for the family.

and this is the part about the Victorian Institute of Medicine, Your Honour. The Victorian Institute of Forensic Medicine was also given the clear photo in 2016. This is also stated in a letter from the Australian Government Solicitor on the – to the court on 16 June 2023. The reason you sent it to the laboratory in the first instance is for it to be examined. The VIFM was given the clear photo clearly showing my daughter's ripped apart top which was critical evidence and a report was not given to the laboratory – from the laboratory to the coroner or Dr Lynch in 2016 because Dr Lynch wasn't aware of it and that's when he states that in his um – the meeting I had with him.

Elly's family is critical of the AFP's handling of out daughter's case due to the fact the AFP had key pieces of evidence in and since 2016 and yet did not make these available to the court.

This critical evidence however passed onto the Mozambique Chief Inspector Cudzi without knowledge and consent of the family. This demonstrates that the AFP were aware of the significance of the photo, and it ought to have been provided to the Coroner at an early stage with the Coroner's ongoing investigation in 2016.

Now as we have discussed and this is where I'm probably going over it a bit here again, that the – the clear photo was given to somebody – – –

HIS HONOUR: It was given to the Police Coronial Support Unit

MR WARREN: Yes, yes.

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HIS HONOUR: Clear.

MR WARREN: Yes. Your Honour, there should be greater support for Australian families when faced with the suspicious death of a loved one overseas, especially in a third world country which is under–resourced and would likely face difficulties conducting a formal criminal investigation of this magnitude. There needs to be far greater transparency between all authorities and towards the family concerned who are in desperate need to be able to trust that their own authorities are fully committed in supporting all Australians

and in concluding, Your Honour, in summary,

I am asking of the court on the solid evidence presented to the court to deliver a finding that Elly was a victim of homicide. The presence of densely packed sand in Elly's airways combined with the evidence of damage to Elly's clothing and the movement of Elly's body after her death are highly suspicious circumstances and should persuade the court that Elly was a victim of homicide.

I am also asking the court to consider the process the AFP have followed in this matter and the family's experience with them. There needs to be greater transparency for the families of Australians who die suspiciously overseas and changes should be made to ensure that in future Australian families are not left feeling that their loved one has been denied justice or that more could have been done.

Thank you, Your Honour, for giving me the opportunity today to present my submissions and that concludes my submissions.

HIS HONOUR: Thank you, Mr Warren. Just so that I'm – the

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conclusions you're suggesting that I should come to are that the circumstances of Elly's death are a homicide?

MR WARREN: Yes.

HIS HONOUR: The second one was that wherever she might have been murdered or the homicide or the death occurred, I'll say death occurred, it's not the place where she was found.

MR WARREN: Correct, Your Honour.

HIS HONOUR: So she was moved there.

MR WARREN: Yes.

HIS HONOUR: That – and that other evidence of some violence or poor treatment is the T–shirt that is ripped.

MR WARREN: Yes, Your Honour.

HIS HONOUR: That's relevant, that you think that a mutual assistance request should have been made earlier.

MR WARREN: Yes.

HIS HONOUR: But I think you accept that that may not have involved a different outcome because we're still in the instruction phase other than an offer of help which the Mozambique authorities may have taken up or may not.

MR WARREN: If I can just clarify that point, Your Honour. The - they're talking about that they're not going to hand over their case file with the instruction phase still in operation. It doesn't refer to the AFP through the mutual assistance request helping with assistance.

HIS HONOUR: Yes, but the - no, I shouldn't - you will have something to say about this but I suspect he will - or they will say, 'Well, look, we made multiple offers of assistance and they weren't taken up'. Now, I don't know whether that's - well, I'll leave it to him to say but I suspect that's what he'll say and

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that's not - that's undisputed that they did make multiple requests. They just hadn't made a mutual assistance request at that time and I'm sure there'll be some explanation for that.

MR WARREN: Do you agree that the AFP had enough information to state that this was a crime at the time?

HIS HONOUR: Probably not.

MR WARREN: Well, they had the police report.

HIS HONOUR: But they had information that came from another jurisdiction. They hadn't conducted their own criminal investigation. They don't have jurisdiction over there. The problem I've got with that - the difficulty I see is that it's not for the AFP to go into some other country and conduct their own - whether offering assistance or some other way, to run their own criminal investigation. We wouldn't allow another country to come in here and run a criminal investigation.

MR WARREN: No, no.

HIS HONOUR: And - - -

MR WARREN: But if another country sent us a mutual assistance - - -

HIS HONOUR: And Mozambique would not do so either.

MR WARREN: Yeah.

HIS HONOUR: And if another country sent us a mutual assistance request, then we would probably deal with it in a similar way where we'd finish what we were doing, we'd then get to it. So I think you've got to accept that just because where an Australian - an Australian authority goes into another country that the other country is going to - in relation to one of its citizens, the other country is going to say, 'Well, look, please help us, we need your

HD:SB 11/12/23 Court 2 283 DISCUSSION Warren

assistance'. It might happen but there's no guarantee that it will.

MR WARREN: Well - well, I - I was under the assumption that that's what the mutual assistance request was - was in place for.

HIS HONOUR: Well, I think that's not a correct assumption.

MR WARREN: It's not?

HIS HONOUR: No.

MR WARREN: Oh okay.

HIS HONOUR: But I'm sure Mr Yuile had something to say.

MR WARREN: Reading the Act though, I - I look at it that way and it actually does state that countries can help with um - some countries are not advanced in DNA testing - - -

HIS HONOUR: It's a voluntary - - -

MR WARREN: - - - and they consent um items over for to be tested.

HIS HONOUR: But it's only if the agree. Only if they agree. But look, thank you, Mr Warren. That's been helpful. I now need to give Mr Yuile an opportunity to respond to any of those matters he wishes to respond to.

MR WARREN: I'd just like to say though we say only if they agree. We never gave them the opportunity to agree.

HIS HONOUR: We'll hear from Mr Yuile.

MR WARREN: Thank you, Your Honour.

HIS HONOUR: Thank you, Mr Warren. Mr Yuile, are you ready to address some of these issues?

MR YUILE: Yes, Your Honour.

HIS HONOUR: Thank you.

MR YUILE: Thank you, Your Honour. I think I can be relatively brief in respect of most of them and if there's anything Your Honour wishes to clarify, please let me know.

HD:SB 11/12/23 Court 2 284 DISCUSSION Warren

Just running through the matters in which - in the order in which Your Honour raised, Mr Warren mentioned some entries in the action sheet which suggest that the AFP knew of the possibility of Ms Warren's body being moved. The only point I make about that is that at each point, the reference is to an understanding of possibilities, for possibilities!! not foreclosed by the investigating authorities in Mozambique and that really leads into the heart of what Your Honour has been grappling with, with Mr Warren about the state of the investigation, what was known to the AFP and what processes that the Mozambique authorities were continuing to conduct and which meant that the AFP was not in a position to understand the full scope of an investigation or to make their own conclusions about the cause of death of Ms Warren!!

So to restate, it was at all points a possibility and our submissions accepted that much that that was something that the Mozambique authorities were leaving open. As a matter of clarify, Mr Warren referred to and in the action sheet as well an official police report from 10 April 2017. I think it's from p13 of the police report which his attached to his affidavit. I simply wish to point out that that action sheet refers to an autopsy report rather than to an official police document!!

That does make a difference!! and it's a matter that was discussed by the AFP in its submissions to you that that was a factor but a document authored by a person, a doctor in Mozambique rather than any official police channel!!

HD:SB 11/12/23 Court 2 285 DISCUSSION Warren

That remains as the AFP submitted !!- it was not until the more recent visit that Commander Smith made that a formal - or between-authorities statement of homicide was made and now we're in the position of waiting for the Mozambique judge to make a decision about what that investigation will do.

Your Honour, the second point - the third point I should say and the most significant one I think is in respect of the MAR and Your Honour has captured fairly well what I would seek to say about that.

I don't need to repeat what the AFP has said in its submissions but there are really two things. The first is that on many, many occasions, the AFP offered assistance in all possible forms from the very beginning onwards. Mr Scruton made that clear in his oral evidence as well as in his evidence and so did Commander Smith. It was also offered in a more formal way although not through an MAR!! - but there was a formal offer!! or request to make a joint investigation in our submissions, my submissions at paragraph 26 talk about that when it was - sorry, apologies it's not that paragraph, but there was a formal offer made when it was mentioned by Mozambique authorities in 2021 I think and no - nothing ever came of that. So the point is, on many occasions, formally and informally!! of assistance at all times was offered and never was it taken up, except on the very limited occasion through the Interpol channels and the AFP ports complied or assisted as best it could with that request. So there's simply no evidence at all to suggest that if an MAR had been made, it would've resulted in

HD:SB 11/12/23 Court 2 286 DISCUSSION Warren

anything other than silence as had the previous offers. So it wouldn't have made no difference in my submission!!

The last point, Your Honour, that I wish to say something about is in respect of the photo. The letter from the AGF to which Mr Warren referred to, which is also the letter that counsel assisting referred to, does state fairly plainly that AGF were instructed, that DFAT had provided that letter to the Police Coronial Support Unit in November of 2016!! So whenever else - it may or may not have made its way to forensic pathologists!! or - I can't say anything about that, but certainly the photo itself, the clear version of it was made available to the coroner from the earliest possible stage, I think within a day or two of DFAT receiving it. Beyond that, Mr Warren criticised that AFP was not classifying this event as a crime but was happy to send the photo through to the investigating authorities and a point really to be made is that AFP was trying, from the very beginning of this whole affair, to assist as best it could. Now that included making the offers I've referred to already to assist with whatever means the AFP had available to it through testing and analysis!! and so on. But also, where important material was available, they were keen to make it available to the investigating authorities, and it would be - it's in some ways a strange thing to criticise by Mr Warren. I understand there's a point about consent and I don't have any information about what or wasn't said or asked of the family. So I can't speak to the consent aspect of it. But certainly, it would be curious if Mr Warren was to say that it shouldn't have been sent through, which

HD:SB 11/12/23 Court 2 287 DISCUSSION Warren

obviously can't be right and Your Honour sort of asked that question. So from the AFP's point of view, it was always part of the AFP's assistance to the investigators in Mozambique to provide them with any that they could and any evidentiary material that was collected by the AFP was shared with the investigators in Mozambique to try and assist them with their investigation.

So it's certainly consistent with the idea that the AFP wasn't sure if this was a homicide or not, to provide a photo of the crime scene which might've assisted investigators to make that finding and it's certainly also, in my submission, consistent with the AFP's role to try and assist, including by providing photos of that kind where it could, including to the coroner and to investigating authorities in Mozambique. And as I say, I'm not sure, and there's no evidence in the brief one way or the other about precisely the circumstances in which happened, that let out this - or that photo was provided. If Your Honour would be assisted by a short timeline of what was provided to who and when and what was said, I'm more than happy to go away and provide that, otherwise I've said all I really think needs to be said about that and I'm content otherwise to rely on the written submissions that we've made on the other points.

HIS HONOUR: Yes, thank you, Mr Yuile. I don't think the timeline will assist. I think there is already information about the sequence of those various steps, so I'm not sure that that will assist me. One of the points that Mr Warren makes is around (indistinct) the broader

HD:SB 11/12/23 Court 2 288 DISCUSSION Warren

communication with him and the family and perhaps misalignment of expectations about what the role of the AFP is or might have been - - -

MR YUILE: Yes.

HIS HONOUR: - - - and his expectations. Do you have any comment to make about that?

MR YUILE: Your Honour, the only point I'd make about that is that there was not placed into evidence, in any formal way, the records of the extensive interactions between the AFP and the Warrens and the Cafarellas, mostly because it was not seen by - as being relevant to Your Honour's task of determining a cause of death and the circumstances of the death, but it shouldn't be thought that the interactions were anything less than extensive!! My submission would be that from the very beginning of the information coming to light of Ms Warren's death, through to - even up until the coronial inquest itself. The family liaison officers that were assigned to this case were interacting with Mr Warren!! and the Cafarellas very regularly through email, through messages, WhatsApp, through meetings in person.

The subject lines are a simple title of any particular meeting, not going into any substance about that meeting. If a record of those was produced, it would run to many, many pages over the years. There has been constant contact, constant updates!! and for it to be suggested that there has been a lack of contact, or a lack of transparency, in my submission, it is simply not made good on any of the evidence that could be placed before the court, or that the court has!! It's been a very long period, with a very sustained contact with, I might add,

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the same two family liaison officers who, as I understand it, continue to have, at least with Mr and Mrs Cafarella, quite a good rapport. So, this was raised in submissions as an issue. It wasn't the subject of extensive evidence from the AFP, because, as I say, it wasn't seen as relevant to Your Honour's tasks, but the evidence, or the records of that contact are voluminous and there was extensive contact. So, I'd simply wish to say that in my submission, the AFP's interaction with the family has been extensive and commendable!!

HIS HONOUR: Yes, thank you, Mr Yuile. Again, it's not within the scope of this inquest for me to run a review of the interactions that might or might not have occurred between the Cafarella family, Mr Warren and the AFP. I guess what I'd say about that is, if Mr Warren, you have and you clearly have concerns about that, it's not a matter I'm going to be able to assist you with, I'm afraid.

MR WARREN: No, I understand that, Your Honour. I was just more concerned about these circumstances that may occur for other Australian families.

HIS HONOUR: I understand that and there's - - -

MR WARREN: I would like to know that the AFP would support - - -

HIS HONOUR: Sorry, I - - -

MR WARREN: And I'd like to know that the AFP would support other families.

HIS HONOUR: Yes, yes, and you've made that point.

MR WARREN: Yep.

HIS HONOUR: Mr Yuile, is there anything else you wanted to say Warren at this point?

HD:SB 11/12/23 Court 2 290 DISCUSSION Warren

MR YUILE: Your Honour, just to finalise that point, I'm instructed, if the AFP was to put on that evidence of all of the interactions with the families, it would run to thousands of pages!!

HIS HONOUR: Yes.

MR YUILE: I know that's evidence from the Bar table, but that's the instruction that I have, to make it abundantly clear.

HIS HONOUR: Yes.

MR YUILE: That's all I have to say, Your Honour.

HIS HONOUR: Yes, thank you, Mr Yuile. Now, Mr Warren, sorry.

MR WARREN: I'd just like to say that some of that evidence wasn't really supported, I'd say and there was – wasn't a lot of evidence that I obtained from the AFP and a lot of emails. I did get some, but there hasn't been a lot. I do understand that Nicole has had better recall for the AFP

- - - HIS HONOUR: Yes, I'm - - -

MR WARREN: - - - and that she's received a lot more correspondence. There's just one issue - - -

HIS HONOUR: Just on that point, before you leave it. If you are concerned about that, then I think that is a matter you need to take up directly, because it's not in the scope of this inquest.

MR WARREN: Yes. It's not in the scope.

HIS HONOUR: No - yes - no, as long as that's clear. I don't want you to - -

MR WARREN: And this is where I've got to know the system, Your Honour.

HIS HONOUR: Yes.

HD:SB 11/12/23 Court 2 291 DISCUSSION Warren

MR WARREN: And I understand where you're coming from.

HIS HONOUR: Yes, thank you.

MR WARREN: There was just one issue there that Mr Yuile mentioned, that he said this was the Mozambique document in the action sheet on p13, but actually the – the Mozambique document (AUTOPSY REPORT) the AFP received this on 2 February of 2017 and the page previous to this in no.12 in the action sheet, Your Honour, was the overdose report by the police, official overdose report from the police and then when they found out about there own autopsy report, this is on 10 April 2017, was a police report and it was the revised police report that was sent from Stacey Walker to the AFP.

So, if you look at p12, you'll see that the – a police report was sent on 6 April. Then, four days later, on 10 April, was the revised police report and that's

in the brief, Your Honour, on p492 and 493.

HIS HONOUR: And is that – and I may be confused about this and it may be described as the police report, but is that the autopsy report that is referred to? It's a separate police report.

MR WARREN: No, this is the police report. I'm – I'm – I'm saying to Your Honour that I believe that this is a police report on 10 April.

HIS HONOUR: Yes, all right, thank you.

MR WARREN: Yep.

HIS HONOUR: Yes. Ms Smith, do you want to add anything?

MS SMITH: No, Your Honour, I don't.

HIS HONOUR: No, thank you. Well, look, that concludes the submissions hearing today, and can I thank you, Mr Warren, for the efforts you have gone to, to prepare the material and assist me in coming to – or being able .

HD:SB 11/12/23 Court 2 292 DISCUSSION Warren

to understand the issues that are particularly pertinent to you and also to have your understanding, or interpretation of the evidence, so that I may consider it in my findings.

MR WARREN: Thank you, Your Honour, for – for giving me this opportunity and I hope that I have assisted you and I have given you some more insight into – into the evidence that's been submitted to the court.

HIS HONOUR: Yes, yes. No, I appreciate that and can I also thank you, Mr Yuile, for your assistance here today. I've now got, as you may appreciate, I was well down the track in the writing of this finding. I am now, based on what other information I've got today, there are some tweaks that I will make to it. My intention was to try and be in a position to deliver this finding on Friday of this week. Now, whether I make Friday or not will depend on my other commitments during the course of the week, but that's what I'll be aiming to do, so that I can deliver a finding on Friday.

MR WARREN: Oh I didn't - I haven't been informed of that and that's good news that we can

- - - HIS HONOUR: That's probably because I don't think it's been generally indicated.

MR WARREN: Yes.

HIS HONOUR: Because I wasn't sure whether the outcome of today was going to be something that I hadn't fully anticipated. There're some things there that I haven't necessarily anticipated but there's - it's certainly within the realms of possibility that I will get to complete it this week and be in a position to deliver the finding on Friday morning.

HD:SB 11/12/23 Court 2 293 DISCUSSION Warren

MR WARREN: Thank you, Your Honour. I really appreciate it.

HIS HONOUR: Ms Smith will be able to confirm that perhaps not till Thursday, but I just foreshadow that now and if it's not on Friday, then unfortunately it will roll to the new year. Now, I don't want to do that to anybody because I think - - -

MR WARREN: No, we don't want to continue on with - - -

HIS HONOUR: We're seven years on.

MR WARREN: We're seven years on and - - -

HIS HONOUR: And we need to bring this to a conclusion.

MR WARREN: And we need to bring it to a closure.

HIS HONOUR: Yes. So I will do my best in that second last week before Christmas. We've got lots of other things on but I will endeavour to try and conclude the matter this week.

MR WARREN: Thank you, Your Honour, and the family appreciates that, that you are ah bringing your finding to ah - ah to us before the um - before the ah new year.

HIS HONOUR: Yes. So I don't think there's anything else to say other than thank you for your assistance and I understand that it's been a very difficult last seven years for you, Mr Warren, and the Cafarella family and everybody else involved and that's why I think it's important that if we can bring this to a close this year, we should endeavour to do so.

MR WARREN: Well, I hope that I have been of more assistance to you today, Your Honour.

HIS HONOUR: Yes. No, thank you, Mr Warren. We'll adjourn the court.

HD:SB 11/12/23 Court 2 294 DISCUSSION Warren

My Notes explaining my oral submissions;-

1) Transcript page 282,

I asked Mr Cain if he thought the AFP had enough information to state this was a crime. Below was his answer and I was really surprised by his reply. It proves he did not understand the process requirements needed for the MAR.

MR WARREN: Your Honour do you agree that the AFP had enough information to state that this was a crime at the time?

HIS HONOUR: Probably not.

MR WARREN: Well, they had the police report.

HIS HONOUR: But they had information that came from another jurisdiction. They hadn't conducted their own criminal investigation. They don't have jurisdiction over there. The problem I've got with that - the difficulty I see is that it's not for the AFP to go into some other country and conduct their own - whether offering assistance or some other way, to run their own criminal investigation. We wouldn't allow another country to come in here and run a criminal investigation.

The requirement for the AFP to help assist with the investigation is that it needed to be establish it is a crime first from the country in question and Mr Cain did not fully understand this here. therefore sending the MAR for approvel so we can help with assisting the Mozambique police with the investigation. not run and take over the investigation!!!This is the purpose of the MAR so countries can work together on major issues if required.

This was a Mozambique revised police report sent to DFAT who passed it onto the AFP on the 10th April 2017 and it states homicide. In addition to that, there was other compelling evidence to indicate this was a crime.

The AFP not only had this police report they also had a Mozambique autopsy report which all state Homicide and you also add the fact that the AFP had the clear crime scene photo of my daughter’s naked body with her top ripped apart which was given to the AFP on the 25th November 2016 by DFAT.

If all this evidence does not indicate a crime I don't know what would be good enough for the AFP to state it reasonable cause for a MAR as stated in the Assistant Commissioner letter from the AFP Mr Giles to the coroner Mr Cain.

The facts also indicate an explicit photo of my daughter’s body was given to the AFP which they completed ghosted in November 2016. In fact there has been no mention, No report from the AFP, VIFM or Mozambique Authorities about any ripped apart top in this clear photo to this day.

I had also requested the court engage the external services of the Victorian Police Forensic Services Department; and they analyzed the clear crime scene photo of Elly’s body. This report states :-

“...the clothing on the deceased’s upper body is damaged. This is evident with a sleeve visible on the left side but not on the right side…’

Mr Cain had earlier in the transcript agreed that Elly’s top was ripped apart and this was an explicit photo which was critical evidence.

Therefore we have the state coroner say “Probably not.” enough evidence for the AFP to say a crime has been committed yet Mr Cain had all this evidence and facts before him to consider if this was reasonable cause to send the MAR by the AFP in 2016/17. However Mr. Cain had already make up his mind and in his opinion a MAR was not going to make any difference with Elly’s investigation in 2016/17.

What is interesting here and this is very important Mr Cain goes on about the fact the Mozambique police are in in their instruction phase for over seven years, therefore a MAR would not have been accepted at this time until the instruction was completed but I think Mr Cain was confused or misinformed here as this was only to hand over their case file. I did try and point this our to Mr Cain in my oral submissions above.

Clarification of this is in the AFP submissions in 2020 at N0-40 it clearly states :

“A Mozambique government official indicated that it is possible for the AFP to apply to hold a joint investigation”.

Mr. Cain had all the evidence as this is in the AFP submissions!!

In effect this rules out what Mr Cain was implying that a MAR can’t be sent if they are still in the instruction phase after seven years as this applies only to the handing over of their case file.

Therefore it was always possible to have a MAR in place in 2016 but the Mozambique attorney general never received such a request from our Australian attorney general. As I clearly stated to Mr Cain in the oral submissions above.

I think the coroner was even more confused with the MAR process here and I did try to explain its purpose to Mr Cain in my oral submissions. The Mozambique government was indicating that they would not hand over their case file until the instruction phase was completed and that it would take a MAR from Australia to officially obtain their case file. This did not mean we could not send this Official Mutual Assistance Request back in 2016. If we did send a MAR in 2016 to the Mozambique government and they agreed, they would not need to asking us now to send them a MAR because it would have already been sent and in operation if it was sent by the AFP in 2016!!

Transcript pages 282-283 not sure if Mr Cain did fully understand the MAR process here.

Therefore I am not sure where Mr Cain was really at with the MAR. I don't think Mr Cain fully understood the essence of what the purpose of the MAR was implemented for. This is why I state it is one man's opinion.

I feel that in complicated cases like my daughters the approach for cases like this should have an unbiased jury of professionals in different fields of relevancy to adjudicate the evidence because Elly’s case is so complex, to decide the findings with so many variables to consider. It should not be left to just one man's opinion because Mr Cain has clearly not understood or considered all the evidence in this case.

There are other major vital points in his findings he has left out of his findings which I do explain below. We need to look at the consequences Mr Cain's opinions have had about the MAR and the impact it will have with future Australian families who find themselves facing the same circumstances not to be critical of the AFP here under these circumstances. Because changes will not accrue now!!!

If a police report and Mozambique autopsy stating Homicide and a photo with her top ripped apart is not reasonable cause to send a Mutual assistance request I don't what is!!!

Yes, I get the fact it's not the AFP Jurisdiction to step in and run their own investigation as pointed out by Mr. Cain but this is not what the MAR is about it's about giving assistance between the two countries in many FORMS especially when the death happens in a third world country.

It’s Not to step in and run our own investigation, but to help with assisting the countries authorities in question. The coroner states if the tables were turned we would not like another country coming and running their own investigation in this country.

True we would not like this.

However, again this is not what the MAR is about, it's about offering assistance not taking over an investigation from another country. It was never put in place to take over an investigation from another country. The country in question has the right to say No thank you, we don’t require any help or they may say there are areas that you may be able to help us with and say yes.

The purpose of the MAR is to offer assistance and as I have said the country has the option to say Yes or No to the request. However most countries would be confident in the Australian homicide detectives to run a proper investigation. I am not sure many would be confident with the Mozambique Authorities.

I have stated Mr Bruce Giles AFP Assistant Commissioner letter to Mr Cain on transcript page 261-262 in my oral submissions;-

that the requirement for the AFP to send a MAR is for a reasonable cause only indicating a crime has been committed.

I did mention to Mr Cain the AFP had not informed the coroner and family about the clear photo with the ripped apart top clearly visible in this clear version of the crime scene photograph in 2016. However it was just filed away by the court at the time as this clear photo was not given to anyone in 2016/17!!

The AFP had the clear photo clearly showing the ripped apart top for 14 days before deciding to hand it over to the Mozambique police on the 8th December 2016!!

The Mutual assistance request, well any one reading this you make up your own mind. I tried very hard to bring my point across to Mr Cain.

The AFP have been very SMART HERE with flooding the coroner with information on the MAR giving him pages of affidavits and submissions as indicated in his findings making Mr. Cain overthink the MAR. When in actual fact the MAR is quite simple really.

It does not take much for our Attorney General to initiate a mutual assistance request to their Attorney General, just a letter asking for an official MAR stating can we assist and help with the suspicious death of our citizen in your country.

If they were to say yes then we work out what is acceptable to them with our assistance we are able to offer.

If they say no then at least we sent it as an option early on in the investigation and i would not be complaining about the MAR not being sent today!!

Note a treaty between all countries is not a requirement for a MAR this is very important as the AFP early on in there submissions was using this as an excuse!!

Now It's not that difficult to actually send an official MAR for approval!! The AFPs Mr Scruton was already on the ground interviewing the doctor at the crime scene, Dr Delgado 9 days after Elly’s death. It’s then up to the Mozambique government to agree or not to a MAR request.

I reiterate the MAR purpose is not used or meant for another country to take over the investigation and run their own investigation as Mr. Cain implied, but to offer our assistance only. In third world countries with limited resources this can be vital assistance that we can offer. This makes a lot of sense to me.

However when you read my Mozambique deception blog and my report on the coroner’s findings you will understand more why the AFP were not keen to send a MAR.

But as I pointed out to His Honour we never gave them the chance to say yes or no as we never sent the Mutual assistance request in the first place. tRANSCRIPT pG 283

MR WARREN: I'D JUST LIKE TO SAY THOUGH WE SAY ONLY IF THEY AGREE. WE NEVER GAVE THEM THE OPPORTUNITY TO AGREE.

2) In the coroner's finding there is no mention at all of the high density HU readings in his findings. I find this is very concerning as these readings prove just how density packed the sand was at the initial Mozambique autopsy but the facts from these high density levels goes strongly against the Melbourne doctor who only found a small amount of residue of sand.

The organs are removed at autopsy which is important so they are not compromised to some degree from any washing. However it does not matter if there was any washing or not here as the sand has been detected all the way down Elly’s airways in the radiology report from the CT scan taken just before the Melbourne Pathologist performed his Autopsy!!!

You see the Melbourne doctor’s cause of death was undetermined as he did not find any sand or very little residue as stated, but when he heard the evidence from Dr. Klepp at the inquest which contradicts his undetermined conclusion he then can’t turn around and say the volume of sand is packed/ abundant and it's impossible to breathe in this volume of sand naturally because Dr. Klepp has described the sand inside Elly airways in her examination as Chockablock.

Then the Melbourne doctor will need to explain how he has missed all this sand as the radiology report also supports Dr. Klepp’s evidence which indicates the high density levels of masses of sand and her lower airways were full with sand, so it’s best for the Melbourne pathologist not to say anything!!!

Dr. O’Donnell gave evidence and said the trees in both lungs are full with sand. This radiology report was taken from the CT Scan just before the Melbourne doctors Autopsy on the 22nd November 2016. It begs the question:-

Did the Melbourne doctor examine the right body!!

If only the Melbourne doctor had phoned Dr. Klepp about the sand in 2016 there can be no doubt this would have been all sorted out in 2016 not 2023. Dr Klepp had left her Phone number on her autopsy report for this reason and started to ring her about any queries with her autopsy report!!

My solicitor and I had to fight very hard to have the radiologist Dr. O’Donnell as a witness the court did not include Dr. O’Donnell as a witness.

I reiterate Dr. O’Donnell’s report exposes the Melbourne doctor with the sand present in his scan showing sand in Elly’s upper airways and lower airways with very high density levels in the (Trachea, Lungs) indicating and showing both lungs were full with sand just before his autopsy In Melbourne on the 22nd November 2016.

You see these high density readings are facts which cannot be disputed from the radiology report. 1290HU upper airways and 947HU in the lower airways. Dr O’Donnell did say that Elly’s lung trees were full with sand at the inquest and these HU readings are solid facts which can’t be disputed that this sand was in Elly’s airways when the autopsy was performed in Melbourne.

Note: The reason why I am saying the court is protecting the Melbourne doctor is because the court did not want Dr. O’ Donnell as a witness the one CRITICAL WITNESS which could determine the cause of death if Dr. Klepp had of refused to be a witness which was only days before the inquest that Dr. Klepp did agree to being a witness . My Lawyer and I had sent correspondence and a letter to the court REQUESTING Dr. O’Donnell as a witness AT THE INQUEST.

You see Dr. O’Donnell’s radiology report exposes the Melbourne doctor as it shows there was plenty of high density readings (SAND) in the airways with both lungs full with sand just prior the Melbourne pathologist autopsy on the 22nd November 2016 from the CT scan.

THE MELBOURNE PATHOLOGISTS STATES HE DID NOT FIND ANY SAND!!!

Also I pointed out in my oral submissions and with prior correspondence to the court that the court had very poor images of the Radiology photos in the brief. I did point this out to Mr Cain and held up a much clearer image showing the Mass of sand at the back of my daughter’s nose at the time during my oral submissions on the 11th December 2023.

THE REALLY INTERESTING FACT HERE IS MR CAIN HAS LEFT OUT OF NO 39 IN HIS FINDINGS WHEN EXPLAINING THE WITNESSES THAT THE COURT DID NOT INITIALLY HAVE OR WANT AS THE COURT DID NOT WANT DR. O’DONNELL AS A WITNESS AND THAT I HAD TO REQUEST THAT THE COURT CHANGE THeir VIEWS AND INCLUDED DR O’DONNELL AS A RELEVaNT WITNESS.

3) After the AFP were informed at a meeting on the 18th November 2016 from the Mozambique inspector Cudzi that he suspected Elly’s body had been moved after her death the AFP should have taken the second sand sample from Elly’s body in Melbourne. ( I really shake my head here, this is basic police work). The AFP were aware of the possibility of the body being moved four days before the Melbourne Autopsy. Why take a sand sample from the crime scene if not to compare with the sand in the body!!

They had taken a sand sample from the crime scene but did not take a sample from Elly’s body in Melbourne for comparison!! The radiology scan showed there was plenty of sand for a Forensic sample of sand to have been taken at the time of the Melbourne autopsy.

If the sand samples were forensically tested for comparisons this would have been enough to convince the coroner at the inquest that the body was moved for a fact after death as there was a big difference between the beach sand in Elly’s mouth compared with the dark dirty sand at the toilet block.

This second sand sample was so important under these circumstances as the coroner Mr Cain could only say the movement of the body was only a possibility without the forensic results from the samples of sand.

4) Elly’s clothes gee wiz, this is also basic police work and should have been top priority as the clothes were not placed into evidence!!

This is such a missed opportunity for DNA which may have helped with the suspects the Mozambique police have today. What's very interesting is a Mutual assistance request was not needed to obtain both the second sand sample and her clothes as the Sand for the second sample was in Elly’s body in Melbourne and her Clothes she was wearing were not placed into evidence by the Mozambique police as trace evidence.

Therefore they are her possessions still which the AFP were asked to obtain for the family by the coroner in 2016!!!

5) The coroner also did not place this critical evidence in his findings below:-

Dr Klepps stated in evidence “that the body laying flat on this firm surface would not compromise her airways and it is a point about a sand sample as this may not be the location where she died”.

THIS IS A VERY IMPORTANT POINT MADE IN EVIDENCE MY DR KLEPP!!!

This should have been enough for the coroner to say well it was impossible for her to inhale the abundances of packed chockablock sand into her airways at this location given the body position laying flat and the nature of the firm ground. However this is also not mentioned in the coroner’s findings at all!! “ she could not Compromise her airways on this firm surface and has been left out of the sentence. You see this placed emphasis on the second sand sample the AFP did not take!! And I made the coroner fully aware of this in my oral submissions.

6) I need to also explain the Mozambique document comment with the AFP Lawyer at the end of my oral submissions. Transcript page 290 91 You see the AFP wording in their action sheet states Mozambique document when in fact it was an official police report. What the AFP are trying to do here is say this Mozambique Document is a Mozambique autopsy report when clearly it is not an autopsy report.

This is because of the Mutual assistance request as this is not an autopsy report but an official Mozambique police report that states homicide which proves this to be a crime which is a clarification requirement for the MAR to be reviewed by the AFP as a crime.

In Mr Scruton’s Action sheet pg. 13, ( The action sheet is a documented chronological order of events and dates). Mr Scruton has been very sneaky with the wording in his action sheet on this page being very careful stating this is a Mozambique document. It is very clear and obvious the AFP’s attempt to deceive here as this Mozambique document they are referring to in the action sheet is actually a police report that states homicide on the 10 April 2017.

The reason for this deception by the AFP is because this holds weight officially to a crime having been committed, holding further weight for a review on the MAR and reason to send the MAR to the Mozambique Attorney General for approval.

However it's very disappointing Mr Cain did not reflect this in his findings!! As he states he was not critical of the AFP.

I thought I made this point clear in my oral submissions about what was going on here with the AFP’s deception. Maybe my approach was too diplomatic or he just ignored my comments.

7) I have spoken about the clear photo and how the AFP should of reported on the ripped apart top however on transcript pages 270-273 when talking about this clear photo with Mr Cain it’s very interesting that the coroner's assistant Ms. Smith buts in as she was obviously worried where the conversation was going with the AFP at this point in time. Ms. Smith informs Mr Cain that it is stated in the AFP’s lawyers letter that the clear photo was actually provided to the police coronial support unit that assisted the court back in November 2016”

However what people do not know is the clear photo was just filed away at the time by the PCSU which was not King Taylor at this time ( Coroner’s assistant) as he was given the case later on and states to me in 2018 that;-

'‘the coroner never got any clear photo or any report from the AFP about any ripped apart top”.

It was not sent to the Melbourne doctor or the coroner in 2016,17,18 so they were not aware of it ever existing until I gave it to the coroner’s court in October 2018 two years after Elly’s death!!!

The AFP ghosted this vital evidence at the time therefore no one was aware of the clear version of the crime photo clearly showing Elly’s ripped apart top. You would think our top policing agency would give the coroner a report on this Critical Evidence at the time that it came into their possession in 2016 as they were fully involved with the coronial investigation at this time.

It was not until I went over there to Mozambique in 2018 and got the clear photo from a fisherman and emailed it to Kate Sanderson at the coroner’s court from Mozambique in October 2018 was the coroner was made aware of this clear photo. Two years after my daughter’s death!!

Then I got home from Mozambique, I had a meeting with Mr Taylor at the request of the coroner on the case at this time Mr Bracken.

However the biggest deception by the AFP is in my oral submissions on the transcript pages 270-271. In the AFP’s summary of the colonial brief pg. 16 the AFP state;-

they only ever received the blurred version of the crime scene photo in 2016!!

This is a clear contradiction from a recent letter from the Australian lawyer dated 16 June 2023. How can the AFP say they did not receive the clear crime scene photo in 2016 in their summary to the brief!!!!

How I discovered this deception from the AFP was I had found in 2021 a letter I had received from Clare McCormish the assistant secretary of DFAT dated 22 March 2019.

Clair’s letter fully exposed the AFP and the actual letter is referenced in the brief at volume 3, p59.

The correspondence relating to it here is in my oral submissions transcript pages 268-269. The AFP had no choice in the recent letter from their lawyer to inform Mr Cain they had received the clear photo in 2016 therefore they were aware of the ripped top in 2016.

I had previously sent submissions questions for the AFP to Mr Cain which I wanted the AFP to answer and they answered these questions officially with this official letter from their lawyer recently given to Mr Cain.

The AFP have known all along that I had known about their deceptions for some time as I do have all the facts which totally support that they deceived everyone and it is also in my statement 24th September 2020 to the then coroner Mr Bracken on the matter. I had also sent letters to Mr Bracken on the this matter which Mr Cain should have been fully aware of.

The facts prove Mr Scruton had Ghosted the clear version of the crime scene photo at this time as he did not enter the clear version of the photo into his statement in 2017 and he had received it from DFAT on the 24 or 25th of November 2016 and that he handed it over to the Mozambique police on the 8th December 2016.

I did inform the coroner of this in my oral submissions transcript page 270. The coroner or family were never told by the AFP in 2016 they had this clear photo and handed over this clear crime scene photo to the Mozambique police. The AFP were also responsible for reporting to the coroner for the Coroner’s investigation at the time!!

Now people may be wondering why would the AFP go to all this trouble to ghost the critical evidence from everyone well I will explain why.

There can be no question upon receiving the clear crime scene photo on the 25th November 2016 the AFP were aware of the ripped apart top as this photo clearly exposes the damage to the top at this time in November 2016.

This indicated to the AFP the deceptive circumstances of the Mozambique police at the crime scene as there was no mention of any damage ripped apart top ever to this day or report by the Mozambique police assessment of the crime scene on the 9th November 2016.

The Mozambique official report states:-

There was no signs of a struggle at the crime scene in 2016.

How can a ripped apart completely destroyed top not show signs of a struggle at the crime on the morning of the 9th November 2016!!

As I reiterate the AFP were then fully aware of the deception from the Mozambique police after receiving the clear photo from DFAT on the 25th November 2016 and did not want to open this can of worms for diplomacy reasons as pursuing Justice for the family in their view here would not be in the best interest of all Australians.

The reason why is because the AFP can’t be seen exposing other countries authorities as they will lose trust with other countries and this may affect their communication channels of trust around the world affecting their operations.

How often do you see the AFP expose another country, not very often or never! Therefore what's one Australian's death compared to the trouble it may cause diplomatically.

However what put a spanner in the works for the AFP!!;-

Was when I went over to Mozambique in 2018 and obtained the clear crime scene photograph as the family was obviously never meant to see this clear version of the crime scene photograph.

I was still not aware of the AFP deception at this time.

It was not until I received the letter from the assistant secretary of DFAT Claire McComish consular operations branch on the 22nd March 2019 which exposed the AFP.

Therefore I did not realize the deception by the AFP until this letter from Claire McComish and that the AFP and DFAT had the clear version all along in 2016.

You see DFAT was worried that I knew about the clear photo from my trip over there in October 2018 and asked if I would like a copy of this clear version of the crime scene photo in their letter even though they were already aware I obtained the clear version on my trip to Mozambique four months earlier.

The family was never meant to see or obtain the clear version of the crime scene photo clearly showing elly’s ripped apart top!!!

a) The AFP summary of their incompetence and their Deception.

1) The AFP Ghosted the clear crime scene photo keeping vital evidence from the coroner and family in 2016-17.

2) Elly’s clothes which were not placed into evidence but are her possessions for DNA testing.

3) Not taking the second sand sample.

4) The AFP action sheet Mr Scruton uses words to hide the police report using the term Mozambique document when it really was an official police report which states it was a homicide because of the Mutual assistance request. I did my best as you can see in my oral submissions transcript with the MAR. It's very important for future families who find themselves facing the same circumstances as Elly’s family to be aware that this is an option which the AFP can review.

5) The other very interesting point here in Mr Scruton’s action sheet on page 12,13 it states DFAT’s Stacey Walker had sent by email the police reports to Mr Scruton, but Stacy Walker has left these very important facts out of her statement!!

6) Not informing the coroner and family of handing over the explicit photo of our daughter to the Mozambique police when they did not view this as a crime in 2016/17. You would think an explicit photo of this nature would indicate suspicious circumstances and be reasonable cause to suspect a crime. I do realize this photo was necessary for their investigation in Mozambique at the time and I was not aware of the Mozambique deception until later but the family and coroner should have been notified of the clear photo and that the AFP intended to give it to another country.

I am sure most families would under the circumstances want to be informed first of the AFP intentions to send an explicit photo of their child to another country and see this critical evidence before it was sent to another country.

You can see diplomatically I exposed the AFP in my oral submissions. The coroner was fully aware of the AFP deception; He had all the facts on the AFP as I also sent letters to Mr Bracken, yet in Mr Cain’s findings he clearly states he is not critical of the AFP.

You have now read the facts if you get this far into reading all this. They are all facts I can support without question. It is a lot of information but it's been seven years and there have been many twists and turns along this very long journey. The bottom line is I should have seen it coming with Mr Cain as the coroner is employed by the government.

My advice to Australian families: Be very careful dealing with the Australian government or Authorities, go on your own instincts and question everything as they do what suits them.

When it happens you are not thinking straight having just lost a loved one overseas so you are wanting support at this time however you need to take control and call the shots. Be very careful and don’t believe everything you are told by the AFP.

The AFP’s perspective is looking at the bigger picture as they believe it's for the benefit of all Australians. Especially if they suspect a cover-up at any time by the country's authorities.

Where have our morals and values of life and Justice gone!! The coroner was not critical of the AFP in his findings but you can see with the transcript above he was fully aware that the AFP did not carry out their Sworn Duty.

Below is from the transcript on day 3 of the inquest about the sand sample and the extent of sand in the airways as described by all the doctors in evidence. This is referenced in my Oral submissions transcript 250-252 above.

b) It is one thing to read about the facts but it's another to have them in front of you as they were stated below by the doctors concerned at the inquest:-

.HD:MJC 24/08/23 Court 2 186-187 LYNCH/O'DONNELL/KLEPP Warren 1

Witness Dr. Lynch and Sergeant Treverton the coroner’s assistant relevant evidence below:-

WITNESS LYNCH: I confess, I saw what I've described as a small amount of sand in the airways, but I didn't think to take it as a sample but I have specifically commented that there was a small amount of residual sand, and this would be, ah, mixed with the body fluids related to decomposition and also to the embalming process.

HD:SB 11/12/23 Court 2 Day 3 Inquest transcript Pg 181- 182.

Witness Dr. Klepp and Sergeant Treverton the coroner’s assistant relevant evidence below:-

SERGEANT TREVERTON: Thank you. Dr Klepp, I'm going to ask some questions about your observations and findings in your report. Firstly, in relation to your internal examination and the presence of sand.

WITNESS KLEPP: Yes.

SERGEANT TREVERTON: Can you take the court through your general findings in your report about the presence of sand?

WITNESS KLEPP: Yes. Um, I have some experience in deaths that are related to sand. I mean, Johannesburg is the city of goldmines, um, and gold has been mined here for many, many years legally and illegally. At the moment, we have a problem with some miners that we call zama zamas, who actually tap into our old goldmines and are processing the sand for gold as I speak right now. And unfortunately, the tunnels that they burrow do collapse, and we do see people buried alive.

Um, so I have seen sand, but I must say I have never, ever in 44 years seen as much sand in the oral cavity, the trachea and the bronchi as I did in Ms Warren.

Um, for the - the sand to get down as far as it had, I did believe that she must have been breathing at the time that it was inhaled and to such a degree that I actually formulated my cause of death as aspiration of that sand, which would have created a mechanical obstruction - and not just a mechanical obstruction. The back of her throat would have closed.

SERGEANT TREVERTON: There was evidence given to the court yesterday that a local resident who was there when Elly was found, or shortly after that, described her mouth as being packed with sand. Is that an appropriate way to describe how you found her?

WITNESS KLEPP: It is, absolute accurate description. Her mouth was absolutely chock-a-block, with sand as was her trachea.

By the time Dr Lynch got the body, obviously the first doctor had probably fiddled with the sand. I had probably fiddled with the sand. Um, I - I see, quite interestingly enough, that there's some criticism that the sand was not collected, and I take that point. Um, I've never had to do that. I don't live at the coast. Ah, but it is a good point, whether that sand came from where Elly was found outside the toilet block or whether she was killed elsewhere on a different beach, if she was killed, um, and that her body had been transferred then onto that rather hard-packed surface that we look at in the picture of the toilet block.

HD:SB 11/12/23 Court 2 Day 3 Inquest transcript Pg 197-198.

Witness Dr Klepp comments below:-

WITNESS KLEPP: one with her lying flat on the beach. Um you know, lying flat doesn't compromise your breathing although having your face down into sand - um you know positional asphyxia for me is if somebody for instance is involved in a car crash, they are moved through the car and they're hanging down between the seats and they can't breathe. So um I'm not as strongly in a - of a compromised airway from a positional point of view but her airway was compromised by mechanical obstruction by sand.

HD:MJC 24/08/23 Court 2 184 LYNCH/O'DONNELL/KLEPP Warren

Witness Dr O ‘Donnell the radiologist and my barrister Mr McGlone and Mr Treverton relevant evidence at the inquest below:-

WITNESS O'DONNELL: So with CT, I can't say specifically sand because I'm not seeing it physically, but I see hypertense, so white, material on the CT scan that has an appearance that is certainly consistent with sand, and I found that material in the - not in the mouth but in the back of the nose - so the so-called nasopharynx, which is the back of the nose. And then both lungs were not in their normal position because they had been removed at the time of the autopsy. They were in a bag, but that bag was in the left side of the chest and in those two lungs I could see this same material that was in the nose, it was in the airways of both lungs, all the way

HD:MJC 24/08/23 Court 2 185 LYNCH/O'DONNELL/KLEPP Warren

down. So not just at the start of the airways, which are called the main bronchi, but all the way down to the smaller, um, tubes, bronchi, within the lungs. So that to me, given that sand had been found by pathologists it was indicative of sand in the back of the nose, um, and within both lungs, all the way down to the bottoms of the lungs.

HD:SB 11/12/23 Court 2 Day 3 Inquest transcript Pg 234- 240.

MR McGLONE: In terms of the density here, what is the density reading?

WITNESS O'DONNELL: Twelve hundred and ninety.

HD:MJC 24/08/23 Court 2 235 LYNCH/O'DONNELL/KLEPP Warren

MR McGLONE: And can you perhaps elucidate that in laymen's terms?

WITNESS O'DONNELL: Yes, so it's - you can see other white structures around it, that's bone. And that density is greater than or equal to bone. MR McGLONE: Right, so we're talking about that very solid density (indistinct words)

WITNESS O'DONNELL: We are, we're talking about a material that is not biological other than bone.

MR McGLONE: Yes.

WITNESS O'DONNELL: So bone is the most dense thing in the body. So this is at that level of bone or beyond some other material.

MR McGLONE: And this is an obstruction of the airways? WITNESS O'DONNELL: So there is - the airway would normally be filled with air.

MR McGLONE: Yes.

WITNESS O'DONNELL: And that air is no longer there, is now filled with this white material.

MR McGLONE: So clearly, it's a blocked to the air supply?

WITNESS O'DONNELL: That's correct.

WITNESS O'DONNELL: So the white colour, the - sorry, white density that you saw in the back of the nose, is reproduced here in the lung. So the one on the top and the one at the bottom, I can't say whether it's right or left lungs.

MR McGLONE: Yes.

WITNESS O'DONNELL: They - they look the same. And you can see what looks like, I guess an upside down tree?

MR McGLONE: Yes.

WITNESS O'DONNELL: So you could see a trunk with branches.

MR McGLONE: Yes.

HD:MJC 24/08/23 Court 2 237 LYNCH/O'DONNELL/KLEPP Warren

WITNESS O'DONNELL: .That is the airways of the lungs, and those airways are filled with this material.

MR McGLONE: Filled?

WITNESS O'DONNELL: Filled, yes.

MR McGLONE: How would that happen?

WITNESS O'DONNELL: I guess there's two possibilities. The first is that it was inhaled.

MR McGLONE: Yes.

WITNESS O'DONNELL: So if we've - we've established both from the autopsy and from my imaging that there is this material in the - at least in the nasopharynx which is the back of the nose. It was described in the mouth. So it is possible if someone took a big breath in, that this sand, as well as being in the upper part of the airway, could be inhaled into the lungs. So that is certainly a possibility.

HD:MJC 24/08/23 Court 2 238 LYNCH/O'DONNELL/KLEPP Warren

WITNESS O'DONNELL: Clearly, on my images, there's no sand in the mouth and Dr Klepp has described a lot of sand in the mouth. So at some stage, that has been - - -

MR McGLONE: Removed.

WITNESS O'DONNELL: - - - de-lodge, dislodged yes.

HD:MJC 24/08/23 Court 2 240 LYNCH/O'DONNELL/KLEPP Warren

MR McGLONE: And the - did you make a notation about how much is in the lungs.

WITNESS O'DONNELL: How much?

MR McGLONE: The density sorry.

WITNESS O'DONNELL: So the density, yes. So the - I did the same calculation as I did in the back of the throat and it is not as dense, but that would be expected, because if it's compacted in the nose, it will be more solid. If it goes down into the lungs, it may be mixed with other materials like normal secretions, but also possibly diluted by water or other substances used to clean the lungs.

It must be noted;-

The organs are removed in an autopsy; This is normal procedure to remove all the organs therefore washing from Dr. Klepp would not affect the density readings of the lower airways (LUNGS) as they would not be attached to the airways for water to affect them at the time.

I still can’t see this water from washing affecting the lung trees anyway deep into both lower lungs.

I am not sure if the Mozambique doctors had removed the organs (lungs) but this is likely as this is normal producer.

I did make a note of this in my oral submissions to the coroner in my oral submissions Transcript page 254. What I find very interesting is Dr O Donnell states the sand may have been moved further down into the lower airways (Lungs) from the washing from Dr Klepp. Now a doctor with his experience you would think would know the normal producer at autopsy is to remove the organs and examine them individually, placing them into plastic bags which is the case here as he states the lungs have been separated and are laying next to each other describing the Bronchi trees are full with sand and the trees are upside down in plastic bags.

We do know the upper airways were compromised by Dr. Klepps washing removing most of the sand before the radiology scan was completed but she missed behind the back of the nose 1290 HU indicating just how densely packed the sand really was in the upper airways before her washing and at the initial Autopsy in Mozambique.

The other important aspect with the evidence given at the inquest by Dr. O’Donnell is he was fully aware of the cause of death after his Radiology report in June 2019!!

Why was Dr. O’Donnell not consulted or asked by the court about his radiology report at this time!!! He would have obviously with his evidence given at the inquest recently have told the court that sand obstruction of the airways is the cause of death in 2019!! After all it was Dr O'Donnell's report. This is nowhere near good enough by the coroner’s court!!! It’s now seven years on and we just now have the official cause of death!!

I reiterate I feel the court is protecting the Melbourne Pathologist here as he is from the VIFM and they are all connected at the coroner’s court as one team!!!!!

Below is the reference source for all three graphs in the transcript:-

Case No : COR 2016/5474 In the Coroner’s Court of Victoria IN THE MATTER OF THE CORONIAL INQUEST INTO THE DEATH OF ELLY ROSE WARREN Documents Referred to by Mr Warren.

Figure 1 Source: http://onlinelibrary.wiley.com/doi/abs/10.1111/j.1556-4029.2009.01100.x

Figure 2 Source: https://www.dentaleconomics.com/science-tech/diagnostic-imaging-andcbct/art icle/16387498/cone-beam-technology-a-brief-technical-overview

Figure 3 Source: https://www.sciencedirect.com/topics/medicine-and-dentistry/hounsfield-scale.