Record Of Investigation Into Death

Coroners Act 1995
Coroners Rules 2006
Rule 11


I, Christopher Webster, having investigated the death of:

Zack Wayne Taylor

WITH AN INQUEST held in Hobart on 26, 28 and 30 November 2012 and 18 December 2012

Find That :

(a) Zack Wayne Taylor was born 19 January 2005.

(b) Zack Taylor died on 11 October 2005 at 81 Main Road, Sorell in Tasmania.

(c) The cause of death was suffocation due to inhlation of talcum powder.

(d) That the talcum powder was put on Zack Taylor to treat or hide bruising, and scratches and burns inflicted upon him.

(e) I am unable to determine the identity of the person who inflicted the bruising, scratches or burns to Zack Taylor or the identity of the person who used the talcum powder to hide and/or treat those injuries.

Preliminary :

1.                  An inquest was held into the death of Zack Wayne Taylor, born 19 January 2005, who was found dead at the age of 8 months at approximately 2.10pm on 11 October 2005 at 81 Main Road, Sorell.

2.                  The inquest was conducted in Hobart on 26, 28 and 30 November 2012 and 18 December 2012.

3.                  The Coroner, Christopher Webster, was assisted by Counsel Ms Kate Cuthbertson.

4.                  Mr G Barns and Ms J White appeared for Mr Ian Pennicott, the former partner of Zack’s mother Samantha Taylor.

5.                  Ms C Graves appeared for Ms Beverley Lawler, the owner of 81 Main Road, Sorell, and the mother of Mr Pennicott.

6.                  The following persons gave oral evidence at the inquest:

  • Dr Christopher Lawrence – the State Forensic Pathologist
  •  Dr Michelle Williams – Staff Specialist Consultant, Pediatrician in General Paediatrics at the Royal Hobart Hospital
  • A neighbour
  •  A tradesman who was working at the house next door
  •  Samantha Sybeena Taylor – mother of Zack
  •  Beverley Anne Lawler – owner of the house at which Samantha Taylor and Zack were residing at the time of Zack’s death
  • Ian Graham Pennicott – partner of Samantha Taylor who was residing at the premises with Ms Taylor

7.                  In addition, a large quantity of exhibits – medical reports, affidavits and photographs were tendered into evidence.

The Role of the Coroner

8.                  The role of the Coroner is set out in s28 of the Coroners Act 1995.

9.                  That section states:

(1)        A coroner investigating a death must find, if possible –

(a)        the identity of the deceased; and

(b)        how the death occurred: and

(c)        the cause of death; and

(d)        when and where death occurred; and

(e)        the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999; and

(f)         the identity of any person who contributed to the cause of death.

(2)        A coroner must, whenever appropriate, make recommendations with respect to ways of preventing further deaths and on any other matter that the coroner considers appropriate.

(3)        A coroner may comment on any matter connected with the death including public health or safety or the administration of justice.

(4)        A coroner must not include in a finding or comment any statement that a person is or may be guilty of an offence. 

10.              Unlike other States, Coroners in Tasmania have no power to refer a coronial matter to the Director of Public Prosecutions to consider prosecution of any person.

Medical Examinations

11.              Dr Lawrence, the State Pathologist, examined the body of Zack on 12 October 2005.

12.              He states under the heading “Opinion” in his report the following:

This 8 month old baby, Zacharie TAYLOR, died of suffocation due to inhalation of talcum powder.

The child is reported to have been unwell.  He was allegedly found dead by his mother at around 1.30pm on 11 October 2005.  At this time she noticed some injuries on the baby.  Apart from 2 bruises beneath the chin, there was no other explanation for injuries given.

Autopsy reveals extensive bruising of the scalp.  The bruises are of different ages, some are at least 18 hours old and others 2-18 hours old.  There is mild swelling of the brain with a little subarachnoid haemorrhage but no evidence of subdural haemorrhage.  There is no convincing spinal or eye damage on neuro-pathological examination.

There are a series of 6 scratches on the right side of the face and on the palm of the right hand which appear to have been inflicted by some sharp object (possibly the nail file found near the body) and talcum powder appears to have been put in the wounds, possibly to conceal them.

There is some crusting and excoriation around the eyes and mouth which may represent some form of bacterial infection.  The child is obviously teething.

There are bruises beneath the chin.  These appear to be greater than 24 hours old due to their yellow discolouration.  There is no direct evidence of acute neck compression.

There are blisters on the right hand and on the right and left feet.  These also appear to be possibly due to thermal damage.  The child is reported to be crawling, however, the blisters are in odd locations to be due to friction.  Crawling may account for some if not all of the bruises seen on the lower limbs.

The pattern of the bruising and other injuries is suggestive of physical abuse.  There are a large number of bruises and injuries on the body which are unexplained.  Some of these like the scratches are intentionally inflicted.  The bruising on the scalp is quite extensive.  The cerebral oedema may be a consequence of head injury or hypoxia.  The head injury does not appear to be sufficient to cause death.

There is evidence of inhalation of talcum powder in the bronchi and alveoli and talcum powder also appears to have been used to conceal some of the scratches on the face.  Based on all of my observations I think that the most likely cause of death is suffocation due to inhalation of talcum powder.

In my opinion this infant appears to have been physically abused.  From the autopsy it is not clear who inflicted the injuries but there appears to be a worrying failure to supervise and protect the infant from harm.

13.              Dr Michelle Williams provided a report based on her examination of post mortem photographs of Zach Taylor, and the post mortem examination.

14.              Her summary was:

The post mortem photographs and post mortem examination report of Zack Taylor demonstrate extensive bruises, abrasions and burns involving the head, face, neck, trunk, genitals and extremities.  Zack’s face demonstrates extensive, probably untreated infections of the face and eyes.  Blood cultures taken post mortem show the presence of staphylococcus and streptococcus in the bloodstream.

The exact cause of Zack’s death is an issue for the forensic pathologists and coroner.  However, Zack sustained many injuries, at differing times prior to his death.  The vast majority of these injuries are most likely to be inflicted injuries, and most probably inflicted by a person of adult strength.

15.              Dr Williams raised the question of whether the injuries to Zack may have been self-inflicted or inflicted by Zack’s 4 year old sister who was apparently sharing a room with him.

16.              She states:

Non mobile children may scratch their skin or eyes with long untrimmed fingernails, more significant injuries are exceedingly rare.  When infants begin to roll, crawl and pull to stand they are at risk of different injuries if in an inappropriate environment or if left unsupervised.  These injuries tend to be incurred when infants roll off raised surfaces, crawl into objects or down steps, fall when pulling to stand or pull objects down onto themselves and so on.  If Zack was indeed pulling to stand, he may have inflicted the bruises around his knees and on his forehead and nose.  Accidental injury would not account for the majority of injuries seen on Zack’s body.

A four year old child may cause some minor injuries to a sibling.  The degree of injury caused would depend on the mechanism involved, the strength and developmental stage of the child, the relative sizes of the children and so on.  Injuries commonly inflicted by siblings are bruises and scratches.  And [sic] fall sustained by an infant being carried by a young sibling would usually be a “short fall”.  This would generally be from the chest height of the older child to the floor, and not result in major intracranial injury.  Similarly, abrasion injuries inflicted with an object other than a fingernail require a reasonable strength of grasp.  Most four year olds would not have the strength to inflict deep cuts on the skin except with a sharp object.

17.              Dr Lawrence gave oral evidence at the inquest.

18.              His estimate of time of death was between 9.00am to 11.00am on 11 October 2005.

19.              He also gave evidence that talcum powder was imbedded in the scratches on Zack and found to be covering other injuries.

20.              Dr Lawrence gave evidence that Zack had conjunctivitis around the eyes he described as the worst he had seen in 20 years. He stated that as a parent he would be absolutely horrified by Zack’s illnesses and infections.

21.              Dr Lawrence confirmed in his oral evidence that he did not believe that Zack had died as a result of his conjunctivitis (or other illness) or as a result of his bruising or scratches.  In his opinion the cause of death was blockage of the airways by talcum powder.

22.              Dr Michelle Williams also gave oral evidence to expand and explain her written report.

23.              She confirmed that Zack had severe conjunctivitis of the eyes and sores around the mouth, which would have been readily visible to any person observing Zack and was simply cured.  This condition would have existed for days before Zack’s death.

24.              She detailed the reasons she believed that the bruising, scratches and burns on Zack were inflicted upon him by an adult.  She also detailed how such injuries would cause a child to react by crying and screaming.

25.              The evidence of these medical experts is not challenged by competing views of other medical experts nor any inroads into the opinion of these doctors by their cross-examination.

Summary and Findings

26.              Based on these medical opinions I reach the following conclusions:

(1)        Zack was suffering conjunctivitis and mouth sores at the time of his death which had existed for days prior to his death.

(2)        Zack had extensive bruising, scratches and a burn which were inflicted by an adult upon Zack prior to the time of his death.

(3)        The combination of illnesses/diseases and injuries which Zack was suffering prior to, and on, 11 October 2005, did not cause his death.

(4)        That someone had put talcum powder on Zack’s bruises and scratches.

(5)        That Zack had inhaled the talcum powder and had died as a result of his airways being blocked by talcum powder.

27.              I must now consider the question of who contributed to the cause of Zack’s death.

28.              There are three principal witnesses as to what occurred at 81 Main Road, Sorell in the period leading up to Zack’s death.

29.              I have no confidence in the veracity of any of the witnesses.

30.              Mr Pennicott and Ms Taylor were both self-confessed drug addicts using drugs extensively as at 11 October 2005.

31.              At the inquest Mr Pennicott purported to have lost his memory and could not confirm details contained in his statutory declaration made only a few days after Zack’s death.  He was a most unimpressive and unbelievable witness.  Mr Pennicott on his own admitted actions was a violent man.  He admitted to grabbing Ms Taylor and dragging her by the hair.  Evidence of his mother and Ms Taylor (which I accept) confirms his violent tendencies.

32.              Ms Samantha Taylor gave credible sounding evidence but her evidence has to be considered in the light that she is now apparently a reformed drug addict, but when the events occurred on 11 October 2005 she was a drug addict and even on her own version of events had neglected Zack.

33.              Ms Lawler was an evasive witness who gave every appearance of not wishing to give any evidence which might incriminate her son Mr Pennicott.

34.              There appears to be sufficient evidence upon which I can make the following findings of fact, namely:

 (a) Ms Lawler lived with her partner at 81 Main Road, Sorell.

 (b) Some weeks before 10 October 2005 Mr Pennicott, who occupied one of the bedrooms in the three bedroom house, began cohabiting with Ms Samantha Taylor in his bedroom.  Zack and another child of Ms Taylor’s, a 4 year old, would share that bedroom.

(c)  The other room was normally occupied by an elderly relative of Ms Lawler, but as the room had been vacant for some days Samantha Taylor and Mr Pennicott had taken to putting Zack and the other child in that bedroom to sleep.

 (d) During the days leading up to 10 October 2005 Zack was suffering gastro, with all the associated symptoms, and conjunctivitis.  Ms Taylor was aware of these problems and made an appointment for Zack to be seen by a doctor for a date approximately one week after telephoning the doctor.  She did not see the need to take Zack to seek alternative medical treatment.  Her reaction to the illnesses suffered by Zack was sub-standard.

(e) No one observed any bruising, cuts or abrasions (except for minor bruising, the cause of which was explained) prior to 10 October 2005.

(f)  Mr Pennicott and Ms Taylor were frequent abusers of drugs and around that time each was using a variety of drugs, including speed and cannabis.

(g)      On Sunday 9 October 2005 Mr Pennicott and Ms Taylor and the children had gone for a drive to Montagu Bay.  They returned to Sorell about 4.00pm and Zack was put to bed.

(h)        On Monday 10 October 2005 Zack was not well.  He had a runny nose and had been sick and vomiting for 3-4 days.

(i)        About 6.00pm that evening Mr Pennicott and Ms Taylor went to a friend’s home (to collect drugs).  They injected themselves with speed and went to bed about 9.00pm.  At that time Zack was asleep at the end of their bed.

(j)         Both Ms Taylor and Mr Pennicott state that at some time during the evening Mr Pennicott took Zack to the other room to where the 4 year old had been sleeping.  There is some contradictory evidence in their statements concerning the number of times Mr Pennicott took Zack from their bedroom to the other room.

(k)         Ms Lawler heard Zack “winging” in the spare room when she went to the toilet about 2.30am.

(l)        At 4.55am Ms Lawler was taken to her work by her husband.  Neither she nor her husband returned to their home until after 2.00pm that day, after the ambulance arrived.

(m)         Ms Taylor states that at about 9.30am she woke up.  She looked at Zack from the doorway of his room.  She then made breakfast for herself and the 4 year old and watched DVDs for a couple of hours.

(n)       After watching the movies she checked Zack again by touching him.  There was nothing untoward.  At about 1.20pm she checked Zack and commenced to his change his nappy.  At that time she noticed he was cold and realised he was dead.

(o)        She noticed injuries to Zack’s face and bruises and scratches to the body.

(p)        She alerted Mr Pennicott and the ambulance was called at 2.02pm. 

A transcript of the telephone calls to the ambulance records Mr Pennicott abusing Ms Taylor and Ms Taylor saying to Mr Pennicott “look at him” “look what you’ve done”.


35.              Zack was a neglected child.  His mother Samantha Taylor did not seek medical treatment for the illnesses and diseases from which he was suffering in a timely manner.

36.              She left Zack for long periods without checking on his condition.

37.              She left Zack in his bed for nearly 12 hours without adequately checking on him.

38.              The evidence establishes that Zack died from suffocation due to talcum powder sometime between 9.00am – 11.00am on 11 October 2005.

39.              It is difficult to accept that Zack died without giving any indication of his distress such as laboured breathing and/or coughing.

40.              These symptoms may have been observed by Ms Taylor if she had paid closer attention to Zack.  However as Zack could have died as early as 9.00am, I am unable to conclude that her lack of attention towards Zack after she arose from bed at 9.30am contributed to his death.

41.              Zack was an abused child.

42.              Some adult inflicted the injuries upon him.  Those injuries were inflicted on the evening of 10 October 2005 or early morning of 11 October 2005 (unless the three principal witnesses are all lying) by an adult.

43.              It is unlikely that Ms Lawler or her husband would have inflicted those injuries as the opportunity to do so would have been limited and the noise made by Zack’s responses to the injuries would have likely to have been heard by all the others in the house.

44.              It is likely that the injuries were inflicted upon Zack after Mr and Mrs Lawler had left the premises by an adult.

45.              This adult could only have been Samantha Taylor or Ian Pennicott acting alone or in concert.

46.              The injuries inflicted, though not causing Zack’s death directly, led to someone putting talcum powder on the bruises or cuts to either hide the wounds or to aid in their treatment.

47.              This could only have been done by Samantha Taylor or Ian Pennicott acting alone or in concert or by the 4 year old child in the mistaken belief that she was assisting Zack.

48.              I am unable, due to my reservations as to the reliability of any of the principal witnesses to the events of 10 and 11 October 2012, to be reasonably satisfied as to which individuals caused Zack to be bruised, scratched, or burnt, or which individuals put the talcum powder on him.

49.              Notwithstanding my conclusions as to the treatment of Zack, and the failure by adults to properly care for him, there is no suggestion (and appears unlikely) that the talcum powder was put on Zack with any intention of causing him harm.  At worse, it was put on him to hide his injuries.  At best, put on to aid his recovery or sooth the pain from injuries inflicted.

50.              The general lesson to the public is that babies require adequate supervision (a fact that all caring parents already know) and that fine powders such as talcum can cause, although very rarely, breathing problems and at worse suffocation.

DATED: this 20 day of December 2012


C P Webster