Coronial Findings

Record of Investigation into Death

Coroners Act 1995

Coroners Regulations 1996

Regulation 14

Form 4

I, Donald John Jones, Coroner, having investigated a death of

Victoria Anna Elizabeth CAFASSO

WITH AN INQUEST HELD AT St Helens Coroners Court in Tasmania on the 3rd day of March 2003.

FIND THAT :

Victoria Anna Elizabeth Cafasso died on or about the 11th day of October 1995 at Beaumaris Beach, Beaumaris.

Victoria Anna Elizabeth Cafasso was born on the 8th day of June 1975 in Surrey England and at the time of her death was aged 20 year(s).

Victoria Anna Elizabeth Cafasso was a single woman whose occupation at the time of her death was a Student.

I find that the death of the deceased was due to exsanguination due to multiple stab wounds including wounds to the right atrium.

At the time of the deceased’s person’s death she was not being treated by a medical practitioner.

CIRCUMSTANCES SURROUNDING THE DEATH : 

I commenced this Coronial Inquest with a plea for public assistance, requesting members of the public to provide information which may lead to the apprehension of the person(s) involved in the murder of Victoria Cafasso; this plea could not be compared to the plea for help that I have no doubt was screamed by Victoria immediately prior to being rendered unconscious and then brutally murdered.

In handing down my findings, I want to publicly acknowledge and express my gratitude to all of those persons who came forward with further evidence for consideration in this Inquest.

I would like to assure members of the public that I have caused a significant number of those matters received through the help line to be investigated, and have carried out many investigations by myself with the personal desire of bringing closure for the family and friends of Victoria Cafasso and all Tasmanians to the tragic circumstances which resulted in the brutal murder of a daughter, a sister, a friend and a tourist to our State.

I should add that some information received required an in depth consideration of matters, which arose outside of this investigation, but which some believed may have had relevance. To those persons they have my assurance that those matters were fully investigated by me personally and I found no evidence which satisfied me that there was any link between those matters and the Inquest before me.

Again some persons indicated that they were in possession of matters relevant to the Inquest, but as at this date they have not come forward and produced the evidence that they say exists and is available. Notwithstanding, I have still investigated the veracity of the suspicions and existence of such evidence. To those people who believe they hold evidence or are aware of its whereabouts, unless they come forward with the information or produce the evidence it is impractical to continue to investigate the allegations or suspicions. To the extent that I have been able to investigate them they have not assisted me in making findings in this Inquest.

Any investigation of this nature is always difficult. The vagaries of human nature and the imprecision of the memories of people make it more so.

The ephemeral nature of time and its effects over the past ten (10) years has, in my view affected the recollections of many persons who were spoken to at or about the time of the brutal murder. Matters that were certain at that time have become less focussed and uncertain, whereas in other instances vague recollections have become definite and beyond question, notwithstanding they may be at variance with other memories recorded in writing those many years ago.

It is my belief the reception of information through the hot line and the subsequent Inquest has crystallised the evidence with the acknowledgement to the effects of time, and some persons who were suspects at the time are now unlikely to have been involved considering the current state of the evidence.

To comprehend the depth of the investigation, I refer to the incident of the jacket purportedly located at Diana’s Basin during the Inquest. Much publicity local, national and international was given to the finding of this jacket. The jacket had in it the name of the daughter of one of the persons of interest in the initial investigation. This jacket, under my direction, has been the subject of extensive forensic analysis and several lines of enquiry have been pursued to determine the relevance or otherwise of this jacket. As a consequence of those investigations I am satisfied that the jacket does not, and has not belonged to, been owned by, or worn by the daughter of the person of interest. Forensic analysis has not detected any blood that matches the DNA profile of Victoria. The size of the jacket does not appear to match the size of the daughter, as she would have been at the date of the murder. There is absolutely no evidence linking the jacket in any way with the murder of Victoria. I am satisfied that the investigation in respect of the jacket and the surrounding area where it was purportedly found was thorough and comprehensive.

I am at a loss to understand the mentality of the person or persons who must have planted this jacket in the location where it was purportedly found. Conduct of this type wastes public resources and importantly can direct an inquiry away from issues that should be investigated. I hope that Tasmania Police continue to investigate this matter and if evidence is found which links any persons or persons to the planting of the jacket that the person or persons be charged.

I would like to express my gratitude to Tasmania Police, and in particular Commissioner McCreadie and Deputy Commissioner Johnston who placed police officers under my authority during the period I have had carriage of this Inquest. I have used their services extensively and they have carried out many enquiries and interviews pursuing information that came before me and which required further consideration. I have been granted access to a wealth of documents that have been collected over the period of 9 years, and even other documents relating to other matters that may have been relevant. These documents would total thousands of pages and whilst I have not minutely examined each and every document, to do so would take another 10-20 years, I am satisfied that I have considered all relevant material available.

I should also make mention of the thorough investigation and review carried out by Inspector Colin Little. Inspector Little had not been involved in any part of the Cafasso investigation and approached the review with total impartiality and highlighted a number of matters which until that time had not been considered or investigated. I am aware that he spent numerous days reading, compiling, researching and organising further investigations to assist me in making my findings. I publicly acknowledge and thank him for his thoroughness and his comprehensive reports.

I also wish to express my gratitude to Chris Lawrence, the State Forensic Pathologist, who has spent innumerable hours discussing forensic issues with me, and for his untiring efforts in reviewing the entire forensic evidence collected since the murder. Chris was not involved in the original investigation. The original Forensic Pathologist had left the State having gained another appointment and I should also thank Tim Lyons the former State Pathologist who has made himself available during the Inquest and assisted in the review of the evidence.

I wish to thank Terry Reaney and Trudie Lusted the Coroners Associates for the untiring assistance in preparing the Coronial file and assisting at the Inquest.

Finally, I should not overlook the Press. I thank all of those who aired my opening remarks when I appealed for public assistance in providing any further information that may lead to me making the necessary findings at the conclusion of this Inquest. I thank them for their courtesy and the professional manner in which they reported the matter. A number of reporters offered assistance in obtaining information that was not readily available, and I especially thank Rohan Wade for his assistance.

I will now proceed to make findings as to the circumstances surrounding the brutal murder of Victoria Cafasso as I am able to find on the basis of the evidence adduced at the Inquest and the documents and statement s that I have read

The deceased was a dual Italian/English citizen who spent most of her time residing in Italy but regularly visited her grandparents in England. She lived with her parents and younger sister in Italy and was described by her mother as a trusting person. The Cafasso family has been described as affluent, due to Mrs Cafasso managing a travel agency owned by the family and Mr Cafasso practicing as a solicitor until his death in November 1995.

The deceased held a British passport and spoke fluent Italian, English and French and was well travelled, having travelled several times with her mother as well as previously acting as a tour guide. She was well educated and attended University in Italy where she was studying Law. She deferred that course in July 1995, against her father’s wishes and travelled to England to stay with her grandparents which was a common event to consider her options. She enrolled in a language course at Portsmouth University due to start in August 1996 and she expressed a desire to travel to Australia and stay with her cousin, Simon Howard DeSalis. This was to be the largest journey she had undertaken alone and she had only met De Salis on two (2) previous occasions.

The deceased rang DeSalis from England and made arrangements to travel to Tasmania from England via Hong Kong and Melbourne arriving in Launceston at 1.50pm on Friday the 6th day of October 1995. She was met by De Salis and a visiting friend of his, Peter Holder of Sydney and conveyed to De Salis’s residence at “Larby’s Cottage” Charles Street, Beaumaris.

Whilst being driven to the cottage from the airport, DeSalis had decided to go surfing and for this purpose had gone to Shelleys Point, being at the southern end of Beaumaris Beach. It was at this time that the deceased had her first contact with other residents of Tasmania, being Hilda Jackson, Mark Jackson and Mario Agius. This contact occurred on the lookout constructed on Shelleys Point which provided a full view of Beaumaris Beach and what was subsequently to be the ‘‘Crime Scene’’.

Between the time of her arrival in Tasmania until the 11th of October 1995, the deceased had remained with De Salis at Beaumaris and had very limited contact with other person(s) except for a social event they attended, being a small private birthday party for a Mandy-Lou Larby on Monday the 9th of October, the owner of De Salis’s residence. There were two other occasions only where she could have had contact with other person(s) and that was two (2) short walks on Monday the 9th and Tuesday the 10th. There is evidence that on the 9th of October, the deceased visited the residence of Hilda Jackson and remained there for approximately half an hour.

The lack of evidence enables me to draw the inference that the deceased visited no other person(s) during her short time in Tasmania, and this indicates clearly that her contact with other people was extremely limited.

According to the evidence presented to the Inquest, it was at about 8.10am on Wednesday the 11th of October 1995, that the deceased informed De Salis that she was going for a walk to the beach and asked to borrow a small carry bag. From other evidence, it would appear that the deceased left the cottage at about 9am and commenced walking in the direction of the beach.

There is a lack of cogent evidence as to what the deceased was wearing on this particular occasion. Accounts given by witnesses are varied and vague. There is no evidence to suggest that the deceased was wearing a tee shirt with a wolf motif and from the evidence it would appear that the grandmother (C153) of the deceased on examining the deceased’s clothing noted the item was missing along with a pair of beige linen trousers and a large beach towel.

From this statement a conclusion was drawn that the deceased must have been wearing the missing clothing. On reviewing the evidence of Iris Smith (C15) and if her recollection was accurate, it was her belief that if the person she saw was the deceased, she was wearing ‘……a light brownish skirt or similar and a darker top …… a sleeveless singlet type.’

From the evidence I can be satisfied that immediately prior to her death, the deceased was wearing a two piece bikini, being blue and white floral. There is evidence from which I can find that white sand shoes, a watch, bangle, ring or necklace were located in an area of disturbed sand some 55 metres form the deceased’s body. There is no independent evidence that the deceased was carrying a borrowed carry bag which contained a large beach towel, a flask of water, a Sony walkman (radio), sunglasses, sun cream, scarf and a purse containing personal papers, $509.00 in Australian currency and some foreign currency, although these items were located within the area of disturbed sand.

On reviewing the evidence, some six (6) witnesses gave various conflicting accounts of the deceased’s movements from “Larby Cottage” to Beaumaris Beach on the day of her death. From that evidence, it is believed that the deceased entered Beaumaris Beach via a footway opposite the Surfside Hotel situated on the Tasman Highway at Beaumaris. The deceased was allegedly seen sunbaking by an Iris Smith some 700 metes south of where she had entered the beach. These sightings were reportedly about 9.55am and again about 10.10am.

Beaumaris is a seaside township on the east coast of Tasmania, lying between Scamander (1.5km south) and St Helens (6km north). The town consists of one (1) motel and approximately 150 homes/shacks with a population of approximately 350 persons made up of retirees, employed and unemployed persons. Due to its location, the population rises significantly over the summer and holiday periods. The beach itself is a popular attraction for local residents and visitors and on the day of the deceased’s death, it would appear from the Police evidence that in excess of fifty (50) people visited the actual beach between 8.30am and the time the deceased’s body was discovered by Margaret McIntyre (C14).

These people were performing such activities as fishing, walking, a young child bathing at the water’s edge and being supervised by his mother just to name a few.

The Tasman Highway runs north/south through the town and parallel to the beach and is the main coastal route. The town comprises five (5) separate areas with all but eight (8) houses located on the inland side of the highway. Beaumaris Beach stretches for 4 km, including the 2 km length of the town. The beach lies 75 metres to the east of the highway and is predominantly shielded from view by a coastal reserve strip of low dunes and light scrub. The northern and southern ends of Beaumaris Beach are defined by rocky points which prevent easy access further along the coast. Inland of Beaumaris exists extensive pine plantations, forested areas and a network of gravel roads that stretch to the Midland Highway.

At about 1.30pm on Wednesday the 11th of October 1995, Ms McIntyre (now deceased) was walking her dog north on Beaumaris Beach near Freshwater Creek when she discovered the deceased’s body at the waters edge and being lapped over by the tidal action of the sea. Ms McIntyre went to a nearby house where she spoke to a Russell Harwood (C37) and a Geoffrey Adams (C38) where she raised the alarm. These two men accompanied her back to the beach where Harwood and Adams approached the deceased’s body and upon identifying it as a human, Ms McIntyre and Harwood left the beach to contact Police. From this time until the arrival of Sergeant Galloway (C39), Senior Constable Pedder (C33) and Constable Ferguson (C73) at approximately 1.37pm, Mr Adams remained with the body.

On the evidence I am satisfied that Galloway, Pedder and Ferguson were the first police Officers to attend the scene. This is supported by the evidence given by Harwood and Adams. I am unable to reconcile the evidence of Constable Stingel when he stated that he was in fact the first Police Officer to attend the scene, or that at the time he did attend the scene there were no other person(s) present on the beach. To do so would mean I would have to find that Harwood, Adams, Galloway, Pedder and Ferguson were all mistaken or deliberately lying.

As to the next sequence of events, there is a considerable amount of confusion of the evidence of the three (3) officers and the accounts given by Harwood and Adams as to their movements, state of the tide and actions undertaken by Police at this time.

Firstly, Mr Adams in his evidence refers to two (2) footprints approximately 6 - 7 metres north west of the body. He described these footprints as being ‘…… bare foot prints and seemed to be of a man, the front part of the foot print appeared deeper than the back and they were pointing towards the water.’ It would seem that no Police Officer observed these footprints nor were they photographed or casts made of the impressions. Mr Adams evidence was that he had observed these footprints during the estimated twenty (20) minutes that he stood with the body of the deceased whilst waiting for the arrival of the police.

I also note in his evidence, that he stated that the water was rising and I can therefore assume that high tide had not been reached at the time he was awaiting the police. This is consistent with photographs tendered (C36) that clearly show the body of the deceased being lapped by the tide.

There is some confusion as to when these photographs were taken and by whom. I do not intend to try and reconcile the conflicting evidence save and except to say in my view it is obvious that one of the photographs in the bundle marked C36, shows the body on the water’s edge where as the remaining five (5) photographs show the body out of the water. It could be assumed that these five (5) photographs had been taken after the body had been moved by police. To which I will refer again later. The other photographs tendered and marked C34 show the body clearly out of the water with the tide receding and therefore must have been taken at a later time although I would infer taken within a short period of time of the first set of photographs.

Whilst a number of police gave evidence indicating that they were not aware that the deceased’s body had been moved from its original location, I am satisfied and I accept the evidence of Mr Harwood that the police did in fact move the body. This is supported by the evidence of Mr Adams who stated that he was present when some photographs were taken of the deceased’s body where it had been found and he had left the area at the request of Sergeant Galloway to obtain a tarpaulin to cover the body.

I can draw the inference that during the period that Adams has left to obtain the tarpaulin the deceased’s body was moved and this was observed by Mr Harwood who had a clear memory of the body being moved. I am unable to say which Police Officer(s) were involved in the moving of the body but I am satisfied that it was done for the purposes of preserving evidence and with the authorisation of the CIB, Launceston. These inferences are clearly supported by the photographic evidence tendered and marked C34 and C36.

I am satisfied that the tarpaulin was placed over the body shortly after the first set of photographs were taken and after Mr Adams had returned to the beach with the tarpaulin and prior to the attendance of other Police Officer(s).

It was at or about this time that the three (3) attending Police Officers conducted a search of the general area and an area of disturbed sand commonly referred to during the Inquest as the ‘‘Crime Scene’’ was located some fifty five (55) metres on the northern side of the body together with assorted personal items and various footprints. Again there is much confusion as to the state of and/or existence of footprints in the area.

Evidence was given by Constable Ferguson (C73-78) that he had walked in a northerly direction along the beach and in doing so came across the first set of footprints which he described as being parallel ones and angling in towards the ‘‘Crime Scene’.’ He described one of these impressions as being made by a person wearing sand shoes or similar and the others being ‘……female footprints.’ He has then travelled in a general westerly direction and walked along an overhanging sand bank where he had observed a number of footprints. He followed these footprints to a location which was immediately to the west of the ‘‘Crime Scene’’ where he noted, from his observations that it appeared a person had moved from the overhang and moved towards the location where it was presumed that the deceased had been attacked. Constable Ferguson had previously been employed as a shoe salesman and the pattern from the footprint was of such clarity he was able to give a clear description of the ripple sole of that shoe which was different to the sand shoe impression he had seen earlier.

Constable Ferguson stated that no casts were made of this footprint and at the Inquest accepted full responsibility for this oversight indicating in hindsight he should have preserved it by covering it with his jacket.

It was Constable Ferguson’s opinion that the footprint that he had observed was connected with the deceased’s death and using his own words, that he was ‘…… so convinced when I found it and I’ve never ever deviated or changed my mind since.’

Detectives and Forensic personnel from Launceston subsequently attended, as did the Forensic Pathologist and Forensic Scientists from Forensic Science Services Tasmania (FSST).

An examination of the ‘‘Crime Scene’’ revealed the presence of some items that it was assumed belonged to the deceased. These items were described as a bangle, sun glasses, a multi coloured shoulder bag, sand shoes, ring and watch. These items were spread over an area up to 8.5 metres from the ‘‘Crime Scene’’ or the area that has been commonly referred to as the ‘‘‘Disturbed Area’’’ and most of them to the north. The area which is depicted in many photographs show an area of sand measuring approximately 2.5 metres by 2.5 metres of significantly disturbed sand which has been described by some witnesses as suggestive of a violent struggle having taken place.

Located within the ‘‘Crime Scene’’ were a number of footprints which were referred to by a number of police witnesses. Of these footprints only one was cast and this has been subjected to much forensic testing and has been used to exclude a number of person(s) as potential suspects. Unfortunately the cast is not of sufficient clarity to exclude the deceased as being the person who made the impression. Of the items located neither the glasses nor the ring appeared to be damaged in any way where as the bangle showed signs of damage and the watch had a broken band.

The deceased whose body was located some fifty two (52) metres from the “‘Crime Scene’’ was naked except for a bikini top which was intact above her breasts. Her face and head had been stabbed, lacerated and bludgeoned resulting in horrific and extensive wounds. She had also been stabbed to the back and chest. Examination of the ‘‘Crime Scene’’ did not produce any teeth missing from the deceased as a result of these injuries.

Initial action at the scene on following discovery of the deceased’s body included a preliminary examination of the body by Dr T Brain (state pathologist), scene examination by Police and Forensic Scientists, the establishment of road blocks, door knocks and searches of the immediate beach area including the sand dunes.

Forensic evidence establishes the likelihood of two (2) distinct weapons being used in the attack, one of which appears to be a blunt object and the other a pointed object such as a knife. Whilst it can not be stated with any certainty it appears highly likely, according to the medical evidence, that the blunt object was used first and that the initial blows may have been to the buttocks and the right upper arm. It is highly likely that one of the subsequent blows to her face was delivered with such force that it knocked out three (3) teeth from the upper jaw, causing fractures to the alveolar bone and around the bridge of the nose.

It would seem highly likely that this particular blow would have rendered the deceased unconscious. It seems incongruous that a person receiving such blows prior to being rendered senseless would not have been screaming until that time, yet despite the presence of in excess of fifty (50) people visiting the beach on that day, and the presence of workers in the immediate vicinity, no cries were heard at all. It is also surprising that an area such as Beaumaris which has frequent visitors and person(s) walking along the highway, that none of these person(s) heard any cries of distress.

No offender(s), weapon or eye witnesses to the attack was ever located. I do not intend to give any further description of the murder weapon(s) as it may only cloud the issue and transfer my perception(s) of the weapon(s) into the minds of others and lead to persons discounting any object which may be relevant to the murder.

The time of death was unable to be easily established through body temperature as at the time of discovery the body had been subject to the tidal actions of the sea for an unknown period of time and the wind chill fact of the breeze on the wet body once removed from the water. Therefore an interpretation was made of the ‘‘Crime Scene’’ to determine the time at which the ‘‘‘Disturbed Area’’’ was created and it is a presumption that it was created very close to the time of death.

It was reasoned that the ‘‘‘Disturbed Area’’’ occurred at or about the time of high tide, as it was partially in moist sand and it was reasoned that as the lower part of the ‘‘‘Disturbed Area’’’ had been ‘washed out’ by waves, the disturbance took place when the water was at that level on the beach and receding. The Harbour Master at St Helens, Colin Andrews was consulted for his opinion as to when the tide was at the approximate level on the beach and in his opinion the relevant time would have been 11.30am to 12.35pm.

A subsequent interpretation of the scene using the same logic was undertaken by an Oceanographer employed at the Atlantic Research Centre, Dr John Hunter who determined the ‘‘Disturbed Area’’ to have been created at 12.15pm and allowed a 20 minute margin of error either side for local inconsistencies in reported tide heights/times.

Accordingly, the investigation into this death has used a relevant time as 11.30am to 12.40pm when considering alibis’ of person(s) nominated as persons of interest during this enquiry.

On the 12th of October 1995, a post mortem examination was undertaken at the Royal Hobart Hospital by the (then) State Forensic Pathologist, Dr Tim Lyons who gave the cause of death as exsanguination due to multiple stab wounds including wounds to the right atrium.

The autopsy determined the following:

• There were 21 "stab" wounds to the body, all except one (1) which was on the right side of the body in the area of the shoulder/chest/neck;
• there were a large number of injuries to the head, neck, arms, legs and torso including "slashes", "lacerations", abrasions and bruises;
• there was a bruise on the right wrist, possibly due to a bangle that was being worn;
• there were abrasions on the left wrist possibly due to a watch strap;
• there were three (3) teeth missing from the upper jaw, fracture to the alveolar bone and fractures around the bridge of the nose, attributable to blunt force injury;
• there were fractures sustained to bones in the right hand attributable to blunt force injury;
• "luminol positive" areas were detected on various parts of the body;
• an examination of the body with “magni-powder” technique did not detect fingerprints;
• no obvious signs of sexual penetration of the vagina or anus; and
• there were no signs of natural disease processes, old injury or recent medical intervention.

A number of swabs, fibres, blood and tissue samples were taken for further analysis. There was nothing significant arising from this analysis. No evidence to assist in the identification of the offender(s) was detected as a result of this analysis.

• Dr Lyons, following his examination of the deceased made the following observations:-
• a knife may have been used to inflict the stab wounds;
• a heavy straight edged object may have been the second weapon;
• the injuries to the forearm and hands are consistent with the victim having defended herself; and
• innumerable minor bruises and abrasions could have been caused through a variety of mechanisms.

In December 2002, the current State Forensic Pathologist, Dr Chris Lawrence conducted a review of the autopsy findings of Dr Lyons and as a result determined the following:-

• there are 17 separate stab wounds;
• the two (2) fatal stab wounds are in the right front of the chest and penetrated the heart;
• there are seven (7) stab wounds in the right back, two (2) of which have penetrated into the chest, damaging the lung;
• the knife used to inflict the stab wounds is likely to be as described by Dr. Lyons, and the knife appears to be thick bladed; such as a diving or hunting knife;
• it is not possible from the autopsy to determine whether the attacker was left or right handed;
• there appears to be blunt force injuries on both arms - which are consistent with defensive wounds - and these show significant bruising;
• blunt force injuries are randomly distributed on the body and show significant bruising;
• the stab wounds are concentrated on the right side of the body and are associated with only a small amount of bruising; and
• all defensive wounds were associated with blunt force rather than stabbing.

Dr Lawrence concurred with Dr Lyons as to the cause of death. He offered the most likely scenario leading up to the death of the deceased is an assault with an object causing the blunt force injuries which subdued the deceased prior to the stabbing attack.

The task of investigating the circumstances surrounding the death of the deceased was allocated to the Launceston Criminal Investigation Branch with the operational aspect of the enquiry being directed by Detective Sergeant Jim Harvey (now retired). In order to piece together the circumstances leading to the death of the deceased, members of the Tasmania Police Service used the following framework:-

• traditional/conventional investigative practices and procedures by Detectives;
• scene and body examinations by expert personnel;
• historical profiling of the deceased; and
• psychological profiling of a person likely to commit such a crime.

The activities performed within this framework were:

• the use of search patterns of the precincts (land & water) of Beaumaris Beach to locate further evidence that could be connected to the deceased or offender(s);
• interviewing persons who had recent contact with the deceased;
• door knocks in the vicinity of Beaumaris Beach to elicit information in connection with the investigation;
• the presence of a permanent police contingent at Beaumaris Beach, to speak with members of the public who may have had information in relation to the investigation;
• the use of regular media releases through the television, radio and print media, to prompt responses from the public about suspicious activities in the Beaumaris area;
• public meetings at Beaumaris to prompt responses from the public about suspicious activities in the Beaumaris area;
• the interviewing of selected persons in relation to any knowledge they may have had in relation to the investigation;
• the collection of alibi statements from selected persons for the time of the murder;
• the collection of foot samples from selected persons for the purpose of comparison with impressions detected at the scene;
• the use of forensic experts both within and external to Tasmania Police Service to manage the scenes and conduct forensic examinations;
• close liaison with the Forensic Pathologist, to provide information that may be of primary concern to him;
• extensive background checks to profile selected persons and thereby establish a motive; and
• development of an offender profile by Detective Inspector B. Killmier of the Australia Violent Crime Analysis Centre, Australian Bureau of Criminal Intelligence.

From October 1995 to March 1996, a team of personnel under the command of Detective Sergeant Harvey was stationed at the St Helens Police Station and tasked with the ongoing investigation into the deceased’s death.

On the 12th of February 1996, Tasmania Police conducted a review of the investigation and this was overseen by Detective Inspector M Wicks (now retired). In a report to the Assistant Commissioner (Crime & Operations), this review identified thirty five (35) aspects requiring further attention. As a result, Detective Inspector Wicks assumed control of a special Task Force, charged with carrying out all investigatory matters relating to the review.

From the 8th of March 1996 to March 1998, another team of personnel under the control of Detective Sergeant P Gregory were dedicated to the investigation of this death. This team continued to investigate avenues previously identified, with intense focus upon selected person(s) of interest.

In September 1998, a further review was carried out this time by Detective Inspector G Frame. Essentially this review was aimed at consolidating the evidence and information on hand and making a determination as to the future direction of the investigation.

On Monday the 3rd day of March 2003, I commenced the Coronial Inquest into the death of the deceased at St Helens and after hearing evidence for a week adjourned it to a date to be fixed. Due to the volume and complexity of the evidence tendered, I arranged for a review to be carried out before re-commencing the Inquest.

In June 2003, Detective Inspector Little was appointed by the Deputy Commissioner of Police, Mr J Johnston to assist me with the investigation into the death of Victoria Cafasso.

His initial investigations focussed on a review of the ‘Crime Scene’ material commonly referred to as the ‘‘Crime Scene’’ and all available forensic/scientific material relating to the murder of the deceased. This included the re-examination of all relevant file material, analysis of evidence already tendered to the Inquest and extended to interviews with person(s) positioned to contribute to a better understanding of the ‘Crime Scene’. Where additional information was available, formal affidavits and reports were obtained from witnesses at my direction.

As part of this process, in July 2003 a number of experiments directed at gaining a better understanding of the quantity of blood, it’s staining and the impressions and marks visible in the sand at the scene, were conducted at the scene of the murder on Beaumaris Beach by police officers from Forensic Services, Hobart. These experiments were video recorded and overseen by the State Forensic Pathologist, Dr C H Lawrence.

In November 2003, an extensive interpretive analysis, designed to assist in the interpretation and understanding of the ‘Crime Scene’, forensic examinations and other physical evidentiary material relating to the ‘Crime Scene’, was finalised with a written report being made available to me together with the video recording and affidavits/reports obtained during the review.

The review also determined that the efficacy of any forensic examination of the deceased, at the time she was located, was principally determined by the fact that she had been fully immersed in salt water, and therefore exposed to the degrading effects of the wind and ultraviolet light for a significant amount of time before it was discovered.

Also during this review, Lester Franks Survey & Geographic, a company with expertise in the area of spatial information and terrestrial photogrammetry, were commissioned to undertake a photogrammetric survey of points of interest in the police photographs of the ‘‘Crime Scene’’ with a view of fully dimensioning and modelling those points of interest.

In April 2004, the Managing Director of Lester Franks Survey & Geographic, Mr Malcolm Lester supplied a report detailing the results of this survey. I am now satisfied that the ‘‘Crime Scene’’ has now been mapped appropriately utilising all current technology. Although I do not accept that a general line of blood stains were evident on the beach as depicted in the plan submitted by him as all evidence adduced indicated that the effects of the tide had washed away any significant areas of blood, although there is evidence that traces of blood were located in and around the area identified.

Dr John Osborn, Senior Lecturer in Spatial Information Services at the University of Tasmania was also consulted during this phase of the review. Dr Osborn agreed to investigate the possibility of photogrammetric mapping of the plaster cast derived from a footprint located on Beaumaris Beach the day of the deceased’s death and tendered during the Inquest.

The mapping was undertaken using digital stereo photogrammetric techniques and a stereo model of the cast can be viewed in 3-dimensions. Whilst this technology was in existence in 1995, I have been informed that it was an emerging technology and did not form part of the ‘Crime Scene’ examination protocols used by the Tasmania Police.

I now believe that investigations conducted by Lester Franks Survey & Geographic and Dr Osborn have produced data that is likely to be of benefit in the conduct of any further oceanographical calculations relating to the timing of events on Beaumaris Beach on the day the deceased was killed.

On Monday the 19th day of April 2004, I re-commenced the Coronial Inquest at St Helens and finished hearing all the evidence relevant to Ms Cafasso’s death including the new information gathered during the last review done at my request.

During the course of the investigation and follow up reviews, some 1,200 information reports have been recorded with over 300 individuals being nominated as potential suspects. Despite numerous requests for public assistance and the offer of a reward leading to the conviction of the person(s) responsible for the deceased’s death, no information has been received regarding the whereabouts of any property of the deceased or an eye witness to the crime itself. Enquiries to identify the weapon(s) used have been undertaken, however the weapon or object used has not been located.

It is apparent to me, that the Tasmania Police Service has devoted considerable time and resources to this investigation and despite this, the offender(s) remain at large. However some aspects of the investigation are open to criticism especially in the early stages of the investigation. These include:-

• the non-attendance at the scene by the State Forensic Pathologist;
• delay in attendance of all specialist ‘Crime Scene’ examiners - Tasmania Police and Forensic Science Service Tasmania (FSST);
• establishment of inadequate cordons of the ‘Crime Scene’ - that is, non-closure of the entire beach itself;
• contamination of the scene by the introduction of foreign objects (eg. the tarpaulin used to cover the body);
• the scene not being recorded on video;
• oversight of all potential sources of evidence/exclusion of suspects (eg. foot impressions);
• only casting one (1) suspect footprint at the scene;
• lack of communication between local police and CIB officers; (eg. moving of body and photographs);
• omission to cast the foot of the deceased; and
• the co-ordination of the ‘Crime Scene’ examination to ensure that a thorough examination occurred having regard to the impending loss of the scene through natural forces (tidal and wind action).

Since this death, the Tasmania Police Service has addressed the issue of management of a ‘Crime Scene’ through the enhancement of Major ‘Crime Scene’ protocols and the establishment of the Integrated Crime Management Strategy (ICMS) which allows for training and increased forensic awareness for metropolitan based members.

Based upon the evidence, I can draw the following conclusions:-

• the deceased died at Beaumaris Beach;
• death occurred between 10.10am and 1.30pm on Wednesday 11th October 1995 - most likely between 11.30am and 12.35pm;
• prior to her death, she had been involved in a violent struggle, during which the deceased attempted to defend herself;
• it is probable that the person(s) responsible for her death were physically powerful;
• the ‘blunt object’ used in the attack was used whilst the deceased was still defending herself;
• the knife used in the attack was used after the deceased was subdued;
• death was caused by two (2) fatal stab wounds in the right front of the chest, penetrating the heart;
• following death, the body was left in the water;
• it is highly probable that the body drifted south along the beach with the prevailing current; and
• the distance from the site of the main attack and where the body was subsequently located is consistent with the body drifting on the current, rather than being moved by a person(s) along the beach.

However it is not possible for me to conclude:-

• whether the attack was carried out by a person acting alone or more than one (1) person acting in common purpose; or
• a motive for the attack.

COMMENTS & RECOMMENDATIONS:

I find that the death of the deceased was due to exsanguination due to multiple stab wounds including wounds to the right atrium.

I find that Victoria Anna Elizabeth CAFASSO died on Beaumaris Beach on the East Coast of Tasmania on the 11th day of October 1995 as the result of foul play by person(s) unknown.

Although this concludes the Coronial side of Ms Cafasso’s death, it should be remembered that her death is the subject of an ongoing Police investigation by members of the Tasmania Police.

Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded.

DATED : 23rd March 2005 at Launceston in the state of Tasmania

Donald John Jones
CORONER