Coronial Inquest: Lawler and Morgan

THE coronial inquest into the deaths of John Lawler and Timothy Morgan was held on Wednesday and Thursday at the Scone court house, with Magistrate Prowse acting in his capacity as coroner. Mr Lawler died on August 30, 2010 in Scone from multiple catastrophic injuries as a result of being struck by a moving train. Mr Morgan died on December 13, 2015 in Scone also from multiple catastrophic injuries as a result of being struck by a moving train. Both men had been drinking at the Scone RSL Club prior to their deaths.

The inquest explored a range of information including an expert in forensic pharmacology Dr Judith Perl, who outlined the impact of alcohol on people, including people who were heavy drinkers and more adept at masking the signs of intoxication. In the case of Mr Morgan she said while he may have been able to mask signs of intoxication with his blood alcohol level at more than 0.2 he would have been displaying many signs, would have been highly cognitively impaired and when questioned about staff and police accounts that Mr Morgan was not displaying signs of intoxication, she responded that there may have been an issue with their observations.

Mr Lawler’s signs of intoxication were described by Magistrate Prowse as “resplendent” and failure to identify and manage his intoxication he said was cause for review.

The information presented at the inquest prompted a range of considerations such as if there should be a staff to patron ratio in licenced premises, the viability of marshalls to observe signs of intoxication of patrons, if the responsible service of alcohol (RSA) qualification should include further on the job training, systems for keeping track of how much alcohol patrons have consumed and what if anything the RSL may do to reduce the chance of another similar death occurring.

Magistrate Prowse made is initial findings on Thursday, which were the known facts relating to the deaths of Mr Lawler and Mr Morgan, but adjourned the final findings and recommendations until December 22.

 

MORE DETAIL:

THE coronial into the deaths of John Lawler and Timothy Morgan began with a description of both men by Senior Constable Pete Bain.

John Lawler was 46 years of age when he died. His parents were Alan and Barbara. Alan had passed away before John died, but his mother Barbara was alive. His mother passed away a few of months ago. John had two brothers who died when they were two years old and another brother, Michael, is here today. John grew up on Fairview, attended St Mary’s Primary School and Scone High School. John excelled at school and played for the Scone Thoroughbreds. He worked for Telecom then went droving. He became renown for being “a true horseman an expert in his horsemanship.” John lived with his childhood friend Phil Eveleigh and was driving transport and livestock truck. He was described as a larrikin and a good country bloke who’d do anything for anyone. So many people attended his funeral they could not accommodate them in the church and one minutes silence was held at the Thoroughbreds game after his death.

On the day of his death he was at the Thoroughbreds game and began drinking at 11am. He had eight beers at the game. His usual pub was the Willow Tree, but there was a party at the RSL after the game so he went there. By 7:30pm he was inebriated and was still buying drinks for others. He tackled a friend at the bar, there was no malice he was just being a larrikin. John and his friend Graham had a small altercation over Graham’s girlfriend and John left and was seen staggering. One witness described him as absolutely pissed and he couldn’t speak. On closed circuit television he was seen at 1:45am staggering along the tracks, he came to the platform leans in and stands against it. It is known as the danger zone. After 10 minutes he climbs onto platform, but later stumbles bac into the danger zone and began leaning on the platform, only a few minutes later at approximately 2:13am he was hit by the train.

Timothy Morgan had three younger sisters, excelled in rugby league and long distance running, loved the Brisbane Broncos and the maroons. He was a butcher. He began dating Amy when he was 16 years old and they married when he was 21. They had two daughters Annabelle who was 3 years old and Ellie who was 16 months old when he died. In September 2015 they relocated to Aberdeen and continued his job at the abattoir and was looking to buy a house in Scone. He was loved and respected by everyone who knew him ad was described as making people smile when he walked into the room. At his funeral the church was also bursting.

Mr Morgan had been at a work Christmas function at the RSL and evidence suggests he was served 19 drinks. His wife left the party early and sent a text at approximately 11:45pm saying the door was left open. On leaving the Club he had separated from the group and there is some conjecture that he may have decided to walk home to Aberdeen. It is not known how long Tim was laying on the railway tracks before he was hit by the train.

Purpose of Coronial: The purposed of the coronial into the deaths was laid out. The objective was to ascertain what happened, why it happened and what could be done to decrease the likelihood of a similar incident occurring again. Both matters were heard because they were both killed by moving trains, both had high levels of alcohol in their blood and both had been drinking at the Scone RSL. Included in the evidence were 10 CD’s of CCTV footage of Mr Lawler’s death, photos of Mr Morgan’s death, footage of the Scone RSL before Mr Morgan’s death.

Mr Shume, solicitor for Mr Michael Hollingsworth the licensee of the Scone RSL objected to a statement provided by Mr Hollingsworth to Senior Constable Payne being used in evidence. Magistrate Prowse considered the matter and said if he thought Mr Hollingsworth was in danger of being prosecuted by civil or criminal action then that would be the time to raise it.

Dr Judith Perl, a forensic pharmacologist for New South Wales police service was an expert witness in alcohol including extensive research in the psychomotor effects, or effects on mental and physical functions following the ingestion of drugs including alcohol.

Dr Perl explained the process for gathering blood alcohol readings from deceased and the preservation of evidence. She went into great detail on the metabolisation of alcohol and the effects of drinking.

“When you commence drinking some alcohol is absorbed even in your mouth and as soon as it is in your blood stream it enters the liver within approximately two minutes. If you drink more than your liver is capable of eliminating then alcohol in the blood stream increases. The peak blood alcohol is half an hour, but if you are drinking continually at more than the liver can handle the peak is within 15 minutes. If you have eaten more than an hour, but the peak is lower because there has been more time to metabolise,” said Dr Perl.

She described a process whereby regular heavy drinkers or alcoholics have a higher rate of elimination because a second type of enzyme is involved with the beak down of alcohol, describing how when the liver is pushed as far as it can go it performs more effectively, but warned once cirrhosis of the liver beings function declines.

Dr Perl was asked what Mr Lawler’s blood alcohol level could have been following 8 beers at the football followed by 5 schooners of mid-strength beer and at least 4 schooners at the Scone RSL. She said it would have been approximately 0.185, which was fairly consistent with what was found in his liver post mortem.

Dr Perl was asked what his reading may have been after the football game and she estimated under 0.1. She was then asked what physical affects would have been apparent at that stage. “It depends on the tolerance if they are a regular drinker. I’ve seen people who are 0.15 who display no visible signs until I get them to do complex tasks, but the normal signs include slurred speech, clumsy action, unsteadiness…alcoholics can learn to mask those effects. In gaining entry it may be possible not to display signs.”

What should staff look for in people? “They should look for changes over time while they are there. They may appear unimpaired and unless you are watching closely you may not pick up the signs. I would expect it to be highly visible, leaning a lot on counters or tables or they might be starting to exhibit disinhibited behaviour, they may be louder or aggressive, or swaying walking away from a point of reference. When they look at you they have to turn their head to look you, because they can’t move their eyes – that is the one thing you can’t mask.”

She explained further, “If you are heavily intoxicated your brain can’t process it all, so what you process is what you look at you have tunnel vision, you have the blinkers on.” Magistrate Prowse made further enquiries on the matter and she explained peripheral vision becomes impaired and can’t be masked like other signs of being intoxicated.

She said that Mr Lawler’s behaviour of arm wrestling and tackling friends immediately suggests disinhibitions. She suggested that after an incident such as arm wrestling or loud behaviour staff should regularly observe the patron. Dr Perl determined Mr Lawler behaviours showed he was quite intoxicated.

Of interest to the coronial was Dr Perl’s advice that a schooner of Gold is 3.5% and is 11.75 grams, since the standard drink is 10 grams, it is more than a standard drink. However a scotch is 40% and a nip is 30ml so it is 9.5%, so is just a little bit under a full 10 gram standard drink. “You’d have to drink light beer to be the equivalent of a nip of scotch.”

Magistrate Prowse asked Ms Perl why there is a perception that mid-strength beers were a safer option than a nip of scotch and she responded “marketing.”

Magistrate Prowse said he had learnt two things already from Dr Perl, “the link between eye movement and now this. Mr Bain, you’ve done very well so far, we’ve had two gems out of Dr Perl.”

Mr Morgan’s blood alcohol was above 0.2 and Dr Perl described this level of intoxication as “they would be in a stupor, a semi-conscious state or maybe totally unconscious.”

She described how heavy drinkers can mask the signs of being intoxicated, but said they display more signs when they don’t feel they are under observation. Dr Perl noted that the saying, ‘I was ok until the fresh air hit me’ is actually more that they then realise how drunk they are.

Dr Perl said while she had not viewed the CCTV footage of Mr Morgan, at the blood alcohol level even if he was a heavy drinker, there would have been obvious signs of intoxication. Dr Perl was asked, “would you expect experienced bar staff to pick up those signs?” She responded, “yes anyone who has done an RSA (responsible service of alcohol) course would be aware and should pick up those signs.” She continued, “if someone is charged with being responsible for serving alcohol it’s not sufficient simply to look at the outward signs they need to think about what drinks they’ve consumed.”

Mr Shume, said to Dr Perl that the CCTV footage of Mr Morgan was assessed by bar staff and police who came to the conclusion that Mr Morgan was not showing signs of intoxication. Dr Perl responded, “then that person is ben less than observant.”  She further explained that review of CCTV footage is rudimentary, “the CCTV is very limited, you can’t hear speech, you don’t know the context of discussion or speech, only the crude coordination of a person.” She was asked if she had read the statements of witnesses and she said, “yes, I did and there was a variety in terms of observations.”

Senior Constable Derek Hain, licencing with Hunter Valley local area command took the stand next. He discussed the need for staff to be physically walking around and observing people in their natural environment to observe them with friends and relaxed as opposed to presenting at the bar for the service of alcohol where they may try and mask the signs of intoxication. The police risk model for assessing licenced premises was outlined. The data tracks instances such as drink driving, assaults, the number of times police attend the premises. The Scone RSL rates as low risk on the model and maintained that rating during the time of the two deaths. Officer Hain was asked if he was aware of an incident where another man was hit by a train and lost his leg following drinking at the Scone RSL. He said he wasn’t aware of the matter and it wasn’t recorded in their risk model.

Officer Hain was asked why police did not take any action against the Club following the death of Mr Morgan and he explained they did not feel there was sufficient evidence for a criminal case, which needed to be beyond a reasonable doubt. Officer Hain was asked if the Club ask someone to leave was that data recorded and he responded no. He further explained that if a licenced premises operates after midnight they are required to enter incidents into a security register. While the RSL is licenced to trade after midnight, to officer Hain’s knowledge they do not exercise that right.

Officer Bain asked officer Hain about drink promotions and the impact they can have on alcohol consumption, noting that when Mr Lawler died there was a $2 schooner promotion. Officer Bain said it fell within the liquor and promotions guidelines. Magistrate Prowse clarified that if the guidelines allowed for $2.50 schooners you could drink 10 schooners, but if they served one at $2.49 “then you’re in trouble.” Officer Hain confirmed that was the case Magistrate Prowse asked if drink promotions cause problems for police and he said they could. Officer Bain said there were parameters for drink promotions such as only being able to have the promotion for two hours and most places have their promotion early in the night.

Magistrate Prowse asked if he were to hire a room of a private function and nominate the type and amount of alcohol to be served “with a tray of chicken wings served an hour in” who is responsible for the safe consumption of alcohol, is it the convenor of the function? Officer Bain said the provider or retailer of the alcohol is still responsible.

Mr Morgan had the option of a courtesy bus the night of his death and was also offered a lift home to Aberdeen by one of the bar staff. Officer Hain was asked if he thought anything more could have been done. Officer Hain said observing patrons can be helpful and spoke about the use of RSA marshalls has been successful in reducing violence. Magistrate Prowse said on occasion he had done research at licenced premises and bar staff usually had very good memories knowing what people were drinking and when finished asking them, “would you like another one of those? Some even have extraordinary memories of what the round was.” Mr Shume proposed that it was a sign of good bar staff. Magistrate Prowse agreed, “it is undoubtedly good service and efficient, so they can serve more people and make more money, but in those circumstances it is not necessarily a good thing.”

Officer Hain was asked if marshalls may be useful for licenced premises in Scone. Officer Hain said they had been very effective at the Kings Cross and perhaps in a regional area a group of licenced premises could band together to have an RSA marshall. Magistrate Prowse said it seemed like a sensible idea, “as opposed to you and the other three police officers who are covering all of the Upper Hunter that night. How do you overcome familiarity then?” Officer Hain said it was something that could be outsourced.

Officer Hain was asked what his impression was of RSA knowledge by staff at the RSL and he replied it was at an acceptable level, but that there was always room for improvement. Richard Thomas, solicitor representing Mr Morgan said, “the RSA doesn’t seem to be focused on prevention soon enough, rather than once they are very intoxicated and then asking them to leave the premises.”

Katie Ireland was the casual bar tender who was serving at the JBS Christmas function on the night that Mr Morgan died and took the stand. Prior to working at the Scone RSL she had worked at the Denman Royal Hotel. Ms Ireland was asked if there were any formal briefing or end of shift procedures. Ms Ireland said there wasn’t, but any problems or if something was broken they would report it to the shift manager. Ms Ireland lived in Aberdeen and recounted that she offered Mr Morgan a lift back to Aberdeen and one of Mr Morgan’s friends had offered him a lift, but he had refused the offers. Ms Ireland said she could understand him clearly. She said she didn’t see him leave the Club has she was cleaning the bar at the time.

Ms Ireland was asked how she assessed if someone was intoxicated. She said she would watch them walk up to the bar, observe how they handled their money at the bar and listen to their speech when they were having conversations with other people. She was asked if that was difficult to do at a Christmas and she said yes.

Ms Ireland said there were “so many people upstairs and I was the only bar staff up there.” She was asked how many and she could not recall, but agreed it would have been more than 20 people. Ms Ireland was asked a series of questions and her replies included that she didn’t find it too busy as people would come to the bar for their drink then walk away and she didn’t believe the bar tab caused more intoxication as they were “just served beer and wine.” She was asked if she thought there was anything that could have been done that night to prevent the death and she didn’t think there was.

Ms Ireland was asked if she had ever had any cause to say someone had consumed too much and needed to be cut off or needed to be kicked out and she said that had never happened to her. She was asked again if she had ever had to stop serving someone and she said no. She also didn’t observe any changes in Mr Morgan’s behaviour over the course of the night, in fact at the Christmas party she didn’t observe any of the patron’s behaviour change while they were drinking over several hours in the upstairs bar.

Mr Morgan’s lawyer, Mr Thomas questioned what Ms Ireland termed a busy night, stating that the CCTV footage only shows 1 or 2 people at the bar at any one stage and he asked “and it’s still a busy night?” Ms Ireland responded “yeah”.  He asked her further questions about determining when someone had had too much to drink and she said “if they can’t walk, trip over, can’t handle money or their speech is slurred.” Mr Thomas asked Ms Ireland how many drinks Mr Morgan had consumed, but she said she had “no idea.” Ms Ireland confirmed she was the only bar person at the function and was relieved by another bar person when she went on a half hour break. She could remember she was serving him Toohey’s New and had also served him a beer and a water downstairs.

Ms Ireland said if she suspected someone was becoming intoxicated she would let the bar manager know who could keep a look out as well.

Al Mollov was the bar manager on duty at the Scone RSL the night that Mr Morgan died. Mr Mollov outlined his extensive experience working as a barman, club supervisor and also in restaurants serving alcohol. He had been duty supervisor at the Scone RSL for two years.

Mr Mollov said there was nothing unusual at the Scone RSL the night Mr Morgan died. He noted there was an altercation that was reported to him that night in the Club, but he was unable to locate it so assumed they had left. Mr Mollov was asked about the general culture towards RSA and he said there was a very different culture in the country compared to the city. But on questioning said his comment was not meant in relation to RSA specifically, but a more board comment. He said the country culture he observed was more in relation to behaviours of swearing, people putting their fingers up and the throwing of coasters which was the norm and he believed had to change.

Mr Mollov outlined how there were weekly meetings at the Club to go over the previous week and he was asked if the previous death of Mr Lawler had been mentioned in any of those meetings and Mr Mollov said it had not been brought up. He was asked after Mr Morgan died if it came up at the meeting and he said it hadn’t. Mr Mollov was asked how intoxicated people were managed at the Club. Mr Mollov said if a bar person reported a concern he would usually quietly speak with the person they had concerns about to assess them and if necessary stop service of alcohol or eject them from the Club. He was asked if marshalls may be of assistance and Mr Mollov said for big functions like the Scone Cup it could be helpful, butt felt for other nights there were measures already in place.

Mr Mollov confirmed he had spoken to Mr Morgan the night of the Christmas party, but he had not noted any signs of intoxication. At closing time Mr Mollov walked out the front of the Club and saw a group pf patrons waiting for the courtesy bus and noted Mr Morgan was sitting several metres away from the rest of the group and wondered if anything had happened. He approached Mr Morgan, tapped him on the shoulder and asked if he was alright and Mr Morgan turned to him and said “yep”. Mr Mollov then returned inside the Club to continue closing up. Mr Mollov was asked if tthere were any systems which may improve the safety of people leaving the premises and he said “keeping them inside until the bus arrives” which is now the practice at the RSL.

Mr Mollov was asked how the ratio of staff to patrons is worked out.  Mr Mollov said Michael Hollingsworth, the licensee, would do the roster each week and if more staff were required they would put them on. Mr Mollov asked if there was a set ratio and he said no.

Mr Mollov was asked during his time at the RSL how many people had he “kicked out” and he responded “a lot!” Mr Mollov said it usually wasn’t for showing signs of intoxication, rather just “being loud”.

Michael James Hollingsworth, the licensee of the Club took the stand. A coronial inquest does not result in any civil or criminal findings or sentencing. At the beginning of the inquest ad when Mr Hollingsworth took the stand, his solicitor Mr Shume was keen to ensure no questions could result in the initiative of a civil or criminal case and objected several time throughout Mr Hollingsworth’s time on the stand.

It was noted that police had said, in general terms, there was a correlation between casual staff and their level of RSA understanding being lower than full time staff. Mr Hollingsworth was asked, at the time of Mr Morgan’s death, how many of the staff at the RSL were employed on a casual basis and he estimated 75 percent. Mr Hollingsworth said he had seen no difference between casual and permanent bar staff in terms of their knowledge of RSA as they both undertake the same education.

Mr Hollingsworth said prior to Mr Lawler’s death there were no management meetings in place but after his death there were. Following Mr Morgan’s death there was discussion of the matter at a board level about the potential implications for the Club and Mr Hollingsworth had initial discussions with staff who were working that night, but since there was a police investigation Mr Hollingsworth felt it was best left to police to conduct inquiries. He said at a management level they kept discussing responsible service of alcohol and ensured all bar staff underwent a refresher.

Officer Bain asked if Mr Hollingsworth undertook additional on the job training regularly with staff such as identifying the subtler signs of intoxication. Mr Hollingsworth asked for further information and officer Bain said perhaps identifying people who may be intoxicated and pointing them out to junior bar staff to see what observations they might make. Mr Hollingsworth said he did not.

Mr Hollingsworth said since Mr Morgan’s death they had also incorporated into their club television safety messages about drinking. The Club had also changed its bus policy, so that the patrons would wait inside for the bus, instead of outside. Mr Hollingsworth said it may be helpful to have marshalls on busy nights, but he felt they otherwise had adequate staffing.

Mr Thomas noted Mr Morgan’s extremely high blood alcohol level and asked if it was of concern to the Cub that he was able to drink to such an excess. Mr Hollingswoth said it was. Mr Thomas asked what steps the Club had taken after they became aware of his death, to ascertain how it was that he could have consumed so much alcohol that evening. Mr Hollingsworth said he spoke to bar staff on that night, but since it was a police investigation, he had left it to them to continue enquiries. Mr Hollingsworth said thee officer in charge, Rod Lea had found the RSL had not breached any legislation. Mr Thomas asked him what steps had been take since Mr Morgan’s death to ensure other patrons in the RSL would not be able to consume exorbitantly large quantities of alcohol so that they ended up with a blood alcohol level of 0.2? Mr Hollingsworth objected to the question. Mr Hollingsworth later said it is difficult to ascertain if a particular person has had a lot to drink as there are a range of different bar staff the patrons can go to and the only thing they can rely on are the visible signs of intoxication and their speech. Mr Hollingsworth was asked how he determined staffing levels and he said he would assign the number of staff based on the expected number of patrons. He said Mr Ireland wasn’t too busy the night of Mr Morgan’s death.

Mr Hollingsworth was asked if he tells staff about the deaths of Mr Lawler and Mr Morgan to stress the importance of RSA and he responded that he didn’t recall.

Second Day of the Inquest

Officer Bain began the inquest by restating the known facts of the deaths of Mr Lawler and Mr Morgan. He then suggested there may be scope for Liquor and Gaming and the NSW Police to amend the requirements of obtaining an RSA to create a more rigorous regime with on the job experience before acquiring the qualification.

Officer Bain also highlighted the need for bar staff to detected intoxication earlier than the gross signs of intoxication such as falling over or being unable to walk before cognitive function is badly impaired. He noted Dr Perl’s testimony that cognitive function could be very impaired by the consumption of alcohol, even if the gross visual signs are not apparent. Officer Bain suggested that had the subtler signs been recognised earlier and Mr Morgan was cut off from any more drinks it may have changed the outcome of that evening. He felt the recommendation could reduce the risks of similar deaths occurring.

It was noted that officer Hain had categorically stated there were no systemic issues at the RSL, although there was anecdotal evidence from staff of some issues, it was not enough evidence to support a systemic issue.

Office Bain commended the families of Mr Lawler and Mr Morgan on how they had carried themselves during such a difficult time.

Mr Thomas, Mr Morgan’s solicitor noted from the CCTV footage at the Club that Mr Morgan had purchased a beer every 23 minutes during the Christmas party. “If you watch the CCTV footage there are clear signs that he was showing signs of intoxication throughout the evening, he lurches across the bar, grabs someone, throws his arms around someone else and is unsteady on his feet. Even if the signs were not more obvious, his brain is seriously affected by the alcohol.”

The physical location of the railway line and the main road in relation to the Club was noted and Mr Thomas noted there were actually two previous incidents to Mr Morgan’s death, including the death of Mr Lawler and another man who was struck by a train after drinking at the RSL and lost a leg. “Ironically the man who lost his leg was at the same Christmas party as Mr Morgan on the night of his death and it was at the same time, Christmas,” said Mr Thomas. He also noted that it “didn’t seem to remain in the corporate memory of the RSL – no one really remembers those events at the Club and the memory and knowledge of them should inform the way in which the Club trains staff and how they go about their duties.”

Mr Thomas also talked about the need to notice the first signs of intoxication, rather than relying on the gross signs, “when people start falling over they are intoxicated, it is far too late. There needs to be more focus more on the selling of alcohol and ensure there is a sufficient staff ratio to enable staff to take RSA seriously and not be focused on serving customers one after the other.”

Mr Thomas discussed the importance of systems which can keep track of how much patrons have consumed. He spoke of a process in Europe where patrons who are intoxicated are taken to a separate area within the venue so that they can be observed, given water and time to sober up, stressing the importance of them staying on site rather than being ejected from the venue if they are.

Magistrate Prowse and Mr Thomas also discussed staff ratios to patrons. Highlighting other precedence such as buses which have a licence to carry a set number of passengers, or licenced venues which have a cap on how many patrons can be in the venue and how those figures also related to how my toilets must be on site and how many exists the venue has. They noted the RSA did not have a similar ratio for number of patrons being served to the number of bar staff.

Mr Thomas noted that Ms Ireland had not detected other signs intoxication and Mr Shume, solicitor for the RSL said it is easy to identify that in hindsight. Magistrate Prowse said “that is the point of experience.” Magistrate Prowse outlined how as a sporting referee you could undertake the qualification on a computer, but that didn’t qualify you to run on and referee an A league game. “A mere RSA does not mean you are competent, it doesn’t mean you are capable,” said Magistrate Prowse.

It was noted that Ms Ireland had been working at the RSL for 12 months and had previous experience at a Denman hotel.

Magistrate Prowse noted there was a difference between a closed function with one bar staff compared to a heaving nightclub and suggested that should have been some calculation for a cut off period, not withstanding that Mr Morgan was “a big boy and may have said he could handle another drink”, but that the calculations are there and are available. “You could say but the eighth schooner you are around x (blood alcohol) and consequently x should occur, such as “here is a schooner of Glenbawn’s finest”.

Magistrate Prowse further noted in Mr Lawler’s care his signs of intoxication were “resplendent”, that there was a clear failure and it needed to be considered how it could be addressed.

It was proposed that the deaths of Mr Morgan and Mr Lawler should be raised with staff to drive home the gravity and adherence to RSA guidelines. Mr Shume said it was difficult to know if the deaths should be raised with staff as it could have a negative impact on staff. Magistrate Prowse said that if the staff were too “faint hearted” to consider their deaths, then perhaps they may then be too faint hearted to perform their duties.

Magistrate Prowse noted that the staff from the RSL had all shown concern, were all involved in the inquest and were interested. “They haven’t treated it flippantly or lightly,” said Magistrate Prowse.

Closing

Magistrate Prowse made his initial formal findings which included the basic facts of the deaths of Mr Lawler and Mr Morgan, but would further consider recommendations for the final findings and adjourned the matter until December 22.

Magistrate Prowse called for the registrar to be brought into the court room. Ms Veronica Antcliff entered the court room and Magistrate Prowse said, “the system only works because of the extraordinary dedication of people like Ms Antcliff and her incredible corporate memory, a memory that would be proudly owned by an elephant! Because when Mr Morgan’s matter came in she went and got Mr Lawler’s matter and another matter and she maintains the files in such a way in that there are clippings from the press included in them so that a corporate picture builds up. She is owed an considerable debt of gratitude from the community, her depth of knowledge, experience and compass she brings to each and every matter and it needs to be publicly appreciated and the court extends its appreciation to you.”

He continued, “there is a move in local courts to take these services away from country areas and an active campaign in relation to provision of services, if this was to happen in Quirindi that corporate memory wouldn’t have been in place, so we are fortunate the public service in its true sense has registrar Antcliff here and interested in the betterment of the Scone community.”

Magistrate Prowse thanked the media for reporting on the inquest including getting the message out to the community to come forward with information and ensuring the local community were informed about what had happened at the inquest as while it was an open court her appreciated many members who may have wanted to attend may not have been able to, but could learn of what happened at the inquest through the local media.

Magistrate Prowse thanked Sergeant Bain for his “enormous assistance and through him senior constable Hain, again court extends commendation for the amount of work they have put in, their professionalism and local police, local ambulance people because this is what is called the ripple effect from the people at the scene, through to the person informing the families.”

Magistrate Prowse addressed the families of Mr Lawler and Mr Morgan, thanked them for attending. He said he recognised that in grief, an inquest was like “ripping off a scab” and the way in which they had bee coping was admirable. He extended his sympathies and said he hoped what they had heard at the inquest had otherwise helped in relation to the two tragic events.