Elly Warren's Fathers Report on the Coroner's Findings.

. My report on the coroner’s findings

note; this report is still work in progress 81 completed of 191.

From the Conclusion further down is the old report I have left it there for refence to complete this new updated report.

My report on the coroner’s findings is in systematic order. Theses are the relevant points of refence from the Coroner’s findings in more detail and charily insuring all the relevant facts are mentioned which were overlooked or not explained fully in the coroners findings.

This report will mention the corresponding number refenced in the actual coroners findings which has been copied in and followed by my exploration with more clarity and detail highlighted.

20. This finding draws on the totality of the material obtained in the coronial investigation of Elly’s death, that is, the court file, the coronial brief, and other additional material that has been obtained in the course of this investigation. I have considered this material together with the transcript of the evidence adduced at inquest, the written submissions of Counsel Assisting, Elly’s family and the AFP, as well as the oral submissions of Mr Warren and the AFP.

21. All coronial findings must be made based on proof of relevant facts on the balance of probabilities. The strength of evidence necessary to prove relevant facts varies according to the nature of the facts and the circumstances in which they are sought to be proved.13

22. In determining these matters, I am guided by the principles enunciated in Briginshaw v Briginshaw. 14 The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals or entities, unless the evidence provides a comfortable level of satisfaction that they caused or contributed to the death.

I need to explain first the case of Briginshaw v Briginshaw mentioned above by Mr Cain in his findings. Below is a brief description and it is very important because this matter is used for the bases of Mr Cain’s findings when evaluating the factual evidence in our daughter’s case at the inquest of Elly Rose Warren.

Briginshaw v Briginshaw is a decision of the High Court of

Australia in 1938 which considered how the requisite standard

of proof should operate in civil proceedings.

The case in question was that Mr. Briginshaw accused Mrs. Briginshaw of adultery because she had been seen attending dances with another individual, and had been driven home and kissed by this same individual. The co-respondent to Mrs. Briginshaw was the individual she had attended the dance with, who denied that adultery had occurred.

The main point being that, adultery has only occurred when an act of sexual intercourse has occurred.

Therefore Mr Cain is evaluating whether Elly was murdered using the standard of proof set down by the high court in 1938 as his basis for his point of reference in Elly’s case.

In effect what this means is basically in the Briginshaw V Briginahaw case you can have all the circumstantial evidence there is but it’s not adultery in this case unless the facts prove the act of sexual intercourse has taken place.

Martin J in the Supreme Court of Victoria evaluated the initial

evidence at the standard of beyond reasonable doubt, and at

that standard found insufficient evidence to support the

allegation of adultery. An appeal was lodged with the high

court that was also dismissed on the grounds of insufficient

evidence.

Therefore based on the High Courts decision in 1938 which is now known as the (“ Briginshaw Principle”) Mr Cain is saying that the standard of beyond reasonable doubt, and at that standard has found insufficient evidence to support Elly was murdered!! Even though we do have very strong credible circumstantial and factual evidence which is highly suspicious and weighs heavily on the side of beyond reasonable doubt that Elly was in fact murdered given the proof of relevant facts on the balance of probabilities which means “more likely than not” in favor of murder in Elly’s case.

What Mr Cain has based his findings on is the relevant strength of evidence and in his mind the strength of evidence here is not strong enough. Therefore the factual evidence is not enough to prove the relevant strength of the facts based on the law of the balance of probabilities in Mr Cain’s mind. However, would a jury come to the same conclusion presented with the same factual evidence?!

Well you make up your own mind after looking at all the factual evidence below and determine if the evidence proves beyond reasonable doubt that Elly was murdered. I certainly feel there is a strong proof of evidence and the Mozambique police agree as they have stated to Mr Cain they are still treating Ms warren’s death as a homicide after seven long years.

The strength of factual evidence detailed below proves my daughter was murdered beyond reasonable doubt. when you look at all the pieces to the factual evidence systematically in a collective manner, this then pinpoints the facts and adds weight to the strength of evidence forming a critical path, bonding the solid facts together elevating Elly’s death to beyond reasonable doubt that our daughter was in fact murdered.

The factual evidence given at the inquest below in more detail and clarty systematically :-

Dr Klepp (South African Autopsy pathologist) and the Mozambique autopsy pathologist agree on “one “major factor of vital evidence” that Elly’s airways were “Packed Chockablock with sand” when they examined Elly’s body. “Chockablock” is the exact word Dr Klepp used at the inquest with how packed she found the sand “second hand still” after her examination of Elly’s body on the 16th November 2016 with her evidence given at the inquest in August 2023.

Elly’s airways were completely packed with sand to the lower levels of the lung trees, “chockablock” and “abundant” as stated by “both” South African and Mozambique autopsy pathologist. This is the basis for the Mozambique autopsy conclusion having initially examined Elly’s body stating this is a Violent death of Homicide. Transcript Pgs. Inquest 24th August 2023 - T, 181-182. T 249-256.

The evidence given at the inquest by Dr Klepp is “compelling” and holds weight to the fact its not possible for Elly to breath in all this packed sand “naturally”. Especially given the position of the body in the clear crime photo at the location where Elly’s body was found laying flat with her head on top of the firm sandy surface near the toilet block also stated here in evidence by Dr Klepp. Another independent pathologist was sort by the family and he totally agrees with Dr Klepp’s evidence here, Dr Byron Collins. T 182, 259

The South African autopsy photographs clearly showed marks and bruising all over Elly’s body, head and face especially around the lips of her mouth. Elly’s t-Shirt was ripped apart from her shoulder and all the way down the right side of her body clearly visible in the clear crime scene photo. This had to have happened some time after 11.30pm that night until the body was found the next morning at 5am. This is around a 6 hour window of time as a witness had spoken to Elly at 11.30pm that night and states she was just normal talking with her and her clothing was not ripped apart at this time! Elly’s top is destroyed and it is physical impossible for her to rip the top apart to this degree by herself!! There is also very strong factual evidence which indicates her body was moved after her death to the toilet block location. The factual evidence at the inquest also has ruled out falling unconscious from drugs of alcohol as there was comprehensive toxicology results from South Africa and Australia all “negative”. The coroner has also stated he is satisfied with the circumstantial evidence given at the inquest which indicates Elly was not intoxicated on the night only having a couple of drinks. A Transcript Pgs. Inquest 22nd August 2023 witness who spoke with Elly at 11.30pm - T, 55-56. (re-enactment crime scene photo attached below.)

Above are the direct facts and strength of evidence surly the

weight of evidence is beyond reasonable doubt Elly was

murdered!!!!

Mr Cain has also speculated in my oral submissions and has stated at the inquest:-

“what difference would it have made if the coroner had the

evidence and clear photo knowing about the ripped apart top

in 2016/17”. Transcript pgs. 272 My oral submissions.

The family and authorities in having been privy to all this vital evidence in 2016/18 would have given the family some “solid answers” along with the coroner and AFP. Providing a good reason for our Australian authorities and Coroner with these solid facts to act firmly which added weight to highly susphious circumstances with the death of our daughter at this early stage in 2016. Therefore applying pressure to the Mozambique authorities with these factual circumstances adding to the fact it was more than likely a crime of an Australian citizen has taken place in their country. Mr Cain I feel is totally wrong here and I am sure knowing these facts about our daughter’s death in 2016 would have made a difference to the way the investigation was handled form the start. T 267-277

However the AFP were “fully aware” that the ripped apart top exposed the Mozambique police cover up at the crime scene in 2016. Therefore is it possible this was elevated to a diplomatic issue which required some sweeping under the carpet?!!!!

The Mozambique Deputy Attorney General states to the AFP commander Smith at an official meeting held in May 2023 in Mozambique that they are still treating Elly case as a “Homicide” after 7 years of investigating and have “suspects” but not enough evidence to charge anyone. The first time the Mozambique authorities stated it was a homicide was on April the 10th 2017 with an official revised police report from “SERNIC” Mozambique’s top criminal agency.

Commander Smith’s report on his trip to Mozambique in May 2023 was sent to Mr Cain on the 19th June 2023 just before the inquest. This report states for the second time officially to the AFP and the court from SERNIC that Elly’s case is still being treated as a “homicide”. All of the above evidence was proven to be factual evidence at the inquest except for the official revised police report in 2017 stating homicide, which was “camouflaged” from the coroner along with the clear crime scene photo by the AFP and their lawyer at my oral submissions. This is all proven and explained at the inquest on 11th December 2023 by me to the court in my oral submissions where I attempt to clarify these facts to Mr Cain on the 11th December 2023. Transcript page day 4 of the inquest 11th December oral submissions - T 284 , 291 and 270.

Mr Cain was given my “signed affidavit” on the 17th January 2023. Therefore Mr Cain was fully informed about all the cover-ups by all authorities with my affidavit supported by all the factual background evidence!!! He was also fully aware of all the solid evidence from the clear crime scene photo clearly showing the top is ripped apart exposing the cover up of the Mozambique police and is possibly why its not even mentioned in his findings conclusion!!

My affidavit is under correspondence on this website.

Counsel assist Mr Ross Treverton in his submissions held little weight to the above factual evidence in fact he has addressed some of the facts in a negative manner focusing mainly on Dr Lynch’s evidence at the inquest from their VIFM!!! Mr Cain has touched on some of the factual evidence spreading it over pages of findings making it confusing and therefore difficulty to follow and piece together, not even mentioning critical pieces of evidence in the conclusion to his main findings just saying its all mentioned above basically.

Mr Cains conclusion No 157 page 35;-

No weight of the factual evidence In Mr Cain’s finding conclusion given to the strength of factual evidence of the “packed chockablock sand” in the airways and in regards to the packing of sand with the position and location of where Elly’s body was found. not even any mention of the Destroyed ripped apart top.

I consider this above solid factual evidence to be compelling evidence which was “fully explained” at the inquest and of elevated relevance which should of been given more weight in Mr Cain’s Conclusion to his findings.

Relevant page:- Coroners findings and conclusion all on page 35.

c) the death occurred in circumstances set out above;

Due to the Submissions of the counsel assist I became fully aware of how important my oral submissions to Mr Cain was and I had Mr Cain agree on three occasions that he totally agreed with two major factors of vital evidence the first was “a substantial amount of packed sand in Elly’s airways”. T250-251. The second was the ripped apart top as he clearly states in my oral submissions below;- . T 274-275

“Thats not in Dispute that the top is ripped”.

I also explained fully all the other factual evidence connected to Elly’s murder with cover ups from our authorities but he chose to ignore theses facts in his findings which I can fully prove with supporting facts. Relevant transcript pages from my oral submissions. T 249-255 packed sand, T 256-261 body moved after death, T 261-267 Mutual assistance request, T 268-272 AFP cover up crime scene photo, AFP Lawyer cover up revised police report. T 284,290-291. I am sure you will find all of my oral submissions very interesting indeed and its all facts which I can support. If you were to read my entire oral submissions here as a separate blog on the website I am sure you will have a much better understanding of all the circumstances.

I did not mention the Mozambique cover-up in my oral submissions because I felt there was some hope still that they would do more at this stage after the inquest to obtain justice for our daughter. This may have jeopardized their investigation as we had not heard back from the Mozambique Judge with the matter at this point in time. I had touched on the AFP cover-up with the clear photo but not directly accusing them in my oral submissions as Mr Cain would have closed me off. Mr Cain had clearly informed me at the inquest it’s not in the scope of the inquest in accusing anyone of wrong doing. Mr Cain further clearly informed me and said if I have any concerns with the AFP I need to take it up directly with them. T 272, 276, 290, 291.

I have sent the AFP My official report to them detailing all the families discretions with them supported by all the background facts with the case on the 27th May 2024 ( which is a Blog on this website) with no reply to date. I have followed up several times with still no reply from the AFP on this report. Also I have sent letters/emails to the Australian government and they keep referring the matter to the AFP!! It is now nearly 2026 and any hope of Justices for our daughter has really just about vanished. However by now exposing all the true facts this may create further interest forcing the Australian government to have an inquiry into our daughter’s death insuring these unjust circumstance by all authorities concerned do not accrue to another Australian families!!

After reading all the factual evidence above do you think its beyond reasonable doubt that Elly was murdered!! If your answer is yes, we then need to ask the question why did the coroner or counsel assist not see it this way. However are they looking out for the credibility of their doctor, Victorian Institute of Forensic Medicine and the exposure of the Mozambique police cover up at the crime scene!!!

The solid overview of the strength of factual evidence above is

solid facts holding weight to the factual evidence proving the

Nature and cirumstances surrounding the murder of Elly rose

warren on the 9th of November 2016.

No 30 coroner’s findings On 10 March 2021, the AFP received a request from Coroner Bracken, asking the AFP to make a formal application to the Mozambique authorities to join their investigation. That request was issued by the AFP Commissioner Kershaw to the Director General, Criminal Investigative Service in Mozambique on 8 April 2021. There has been no response (formal or informal) to this request.

This formal Application was not a “Official Mutual Assistance request” (MAR) sent from Attorney General to Attorney General. It was a “personnel letter” sent to the head of SERNIC, the National service of criminal investigation of Mozambique Mr Domingus Jofane by the Australian Federal Police (AFP).

In Commander’s Smith’s official letter/report to Mr Cain on the 19th June 2023 The Mozambique deputy Attorney General clearly states they will only except the official MAR between the two countries for the exchange of there casefile indicating how much the Mozambique government “respect” this official process of the MAR. This was fully explained to Mr Cain by me at the inquest in my oral submissions and that this request by the AFP was not the Official gov to gov Attorney General request which the Mozambique Government clearly respects it was only a personnel letter which was sent. Obviously the Mozambique Government respects the MAR/ACT between our two countries which is in use for all countries around the world to officially use as stated in the Mutual assistance ACT 1987. However obviously our Australian authorities/government does not respect or recognize this official process between our two countries of the MAR even though they do!!!

The official Mozambique police report from SERNIC on the 10th April states it is a “crime” as this revised police report clearly states Ms Warren’s death is a “Homicide” to the AFP. Transcript pgs. Inquest day 4 my oral submissions 11th December 2023, 261-268. What is very interesting here in my oral submissions is the AFP lawyer try’s to confuse the saturation by stating “its a Mozambique autopsy report Mr Warren is talking about” to Mr Cain “not an Official police report on page 13 of the AFP action sheet” given in evidence by the AFP Lawyer!!! It is in fact the official “Revised” Mozambique police report which states “Homicide” dated the 10th April!!! The Mozambique autopsy report was given to the AFP/SLO much earlier possibly in 2016 police to police and the court was given the Mozambique autopsy report from the AFP officially in February 2017. This is way before the 10th April 2017. Transcript pages my oral submissions on the 11th December 2023;- 284/5 and 291 will support these above facts!!

The main point here is it was established as a crime with this “revised” Mozambique police report which is clarification of a “Crime” by the official Mozambique police authorities (SERNIC) which was the official requirement for the AFP to send the MAR at this time. the AFP have always maintained and stated their is a active ongoing investigation by the Mozambique authorities!! However the family disagreed at this point with these two police reports as their first report was on the 6th April 2017 has stated the cause of death as Overdose. The family was furious with this police report, how can there be any honest investigation into the murder of our daughter with these two police reports!!! However Mr Cain in speculating again and states in evidence at my oral submissions;-

“what difference would the MAR have made in 2016/17”!!!

However we never sent the MAR for the Mozambique government to agree or not to agree with the MAR. If the Mozambique attorney general had of agreed for our authorities to support their police then this would have made a difference and a more cohesive and honest investigation would have been more likely at this critical early stage in the investigation. What is very interesting indeed is the AFP submissions below therefore if we had of sent the MAR in 2016/17 there was every chance they would have excepted our support at this time. Transcript pgs. 263 Line No 31 and Page 264.

It must also be noted in the AFP submissions to Mr Bracken early 2021 at No 40 that A Mozambique government official has states;-

“it was always possible for a joint operation with the AFP”.

We just never sent the Official MAR in 2016/25. This is clearly explained in my official Affidavit to Mr Cain and my oral submissions. I feel Mr Cain was wrong here again as he made judgment on our offers of assistance after the early stages of the investigation when everyone realised the Mozambique cover-up!!! Of course they would not agree later and the AFP did really not want get involved with a corrupt police force!! This is why the AFP sent a personnel letter later when instructed to send an official request for our offer of assistance by coroner Bracken at the time in 2021 and not the official MAR which adds ‘far more weight’ between our two countries!!! I tried hard to fully explain all of these factual circumstances to Mr Cain in my oral submissions on the 11th December 2023!!!

This section above on the MAR is really “very important” and

could have made a difference in the early stages of our

daughters murder investigation!! if we had of sent the official

MAR in 2016/17 to offer our assistance, then it was up to the

Mozambique government to agree or not!

No 39 coroner’s findings On 30 June 2023, Mr Warren’s representatives requested that I hear evidence from some additional witnesses at inquest. Of note, Mr Warren requested that I hear evidence from Dr Angela Jorge Miguez, the Medical Examiner from Mozambique. I asked the AFP to make enquiries on my behalf to arrange for Dr Miguez’s attendance. These efforts were unsuccessful, and Dr Migeuz did not give evidence at inquest. However, their report formed part of the coronial brief of evidence. 40. In respect of the other witnesses proposed by Mr Warren, I determined that I would not be assisted by any evidence they may give. I considered that their evidence would be repetitious of other evidence to be given by other witnesses at inquest and/or that their evidence was not relevant to the issues in scope.

No mention here that the coroner Mr Cain did not Initially want to call a very important relevant witness in Dr O’Donnell, radiogoloist who submitted his report to the court in No 39 of Mr Cain’s findings.

What was “very disappointing” was Mr Cains comments below about Dr O’Donnell at the inquest. My legal team and myself all knew we were fighting an uphill battle anyway with Mr Cain but this comment was just not expected at all for such a highly important relevant witness as Dr O Donnell. As it turned out Dr O’Donnell evidence and Dr Klepp’s were compelling at the inquest. However the evidence given by these two doctors at the inquest do not support Dr Lynch’s autopsy report conclusion of “undetermined” at all from the Victorian Institute of Forensic Medicine!! which Mr Cain was obviously worried about having to maintain credibility as he states in a hearing on February 2023 that the VIFM is the states top forensic department!!!

Inquest Page 129 T- 29,30,31

His Honour: “Yes.  Let me deal with Dr O’Donnell in the first

instance. He has an input into Dr Lynch’s report and he’s only

here because your client requested it”. 

My Lawyer sent a list of relevant witnesses initially to the court with a brief description why we require them which was requested by the court including Dr O’ Donnell ( Radiologist) at the top of the list along with Dr Klepp and Dr Collins Independent Pathologist , Mr Roos who was an crime investigator from South Africa and was well respected by Interpol and both countries. He was working for Nicole (Elly’s mother) and David (Elly’s step father) and was what we thought a “vital” witness given the circumstances as he was the only one who could give the coroner a “update on the Mozambique investigation” with inside information on the Mozambique casefile. He was mentioned in AFP Commander’s Smith official report/letter sent to Mr Cain just before the inquest in June, which states Mr Roos had a “current case update” since his last report to the court with information directly from Mozambique on the matter. He had given the court a report previously from 2019 and it was entered into the evidence brief therefore Mr Roos was a proven credible witness for the inquest in 2023.

Dr Collings as our independent pathologist and had entered a previous report into evidence was also vital and one area he agreed with entirely was the fact Elly could not possibility have inhaled the packed sand compromising her airways chockablock with her body in the position it was found and at that location on this firm surface. This concurred with Dr Klepp’s evidence given at the inquest. There was also other vital evidence we required Dr Collings to give and clarify at the inquest for the coroner and family in evidence.

Mr Charlie Bezzina former Melbourne homicide Detective had been working on the case with me for five years and fully up to date with the facts on the case was also requested by my legal team and was rejected by Mr Cain. He had also submitted a report/Statement to the court. Mr Bezzina also had some updated facts on the case with his experience from a homicide detective perspective. These witness were all mentioned at a hearing on 20th February 2023 with Mr Cain as my barrister informed Mr Cain and told him they were vital for our presentation of facts to the court at the inquest.

The changing of coroners mid stream with Mr Cain taking over from Mr Bracken caused confusion for the family 2022/23 as Mr Cain was just not up to speed with the case as the previous coroner Mr Bracken having been dealing with the case for 5 years before Mr Cain took over. Mr Bracken knew who Dr Collins was and how important he was and asked for report from Dr Collings as an independent qualified Pathologist with the case helping the family since 2019. His views were vital to the case as he had been working with the family with the matter for a number of years which Mr Bracken was fully aware of his importance and Mr Cain had no idea really. It must also be noted Dr Collings had given my legal team his updated report as new evidence had come to hand just before the doctors gave evidence on the 24th August 2023. A major advantage for as with Mr Bracken was he had experience and background as a homicide detective.

I could not understand and neither could my legal team at all why Mr Cain did not want Dr O’Donnell initially as a witness (Letter from my Lawyer attached below). I could not understand why he did not want these other vital relevant witness at the inquest. The only thing I can think of now is that he was looking out for the credibility of Dr Lynch, Victorian Institute of Forensic Medicine and the fact the Mozambique authorities had covered up Elly’s murder at the crime scene. Attached below re-enactment crime scene photo. All these facts were given to Mr Cain in my signed Affidavit dated on the 17th January 2023. Therefore Mr Cain was fully aware of ALL the facts before the inquest.

No 43 Coroners findings Mr Warren’s oral submissions expanded on his written submissions addressing specifically: • the volume of sand found in Elly’s lungs at post-mortem, • whether Elly’s body had been moved post-mortem, • whether a MAR should have been made by the AFP, • the ripped black top seen in the photo of Elly’s body in situ, and • the circumstances in which the photograph of Elly’s body in situ was provided to the Mozambique authorities.

I gave a full explanation of how packed the sand was with extra graphs sent to the court before my oral submissions explaining the Hounsfield Unit (HU) density of measurement. With the very high reading of 1290HU at the back of the nose (upper airways) and the density reading at the time of death as Dr Klepp’s washing had not dislodged this mass of sand behind the nose. Also the density reading in the Trachea of 947 lower airways and the effect of washing by Dr Klepp was possible because it was in the lower airways having completed the second autopsy before the scan. I explained 1290HU from behind the nose on the graph is equivalent to cement/pottery density.

I spoke about how compelling Dr Klepp’s evidence was around the “packed chockablock sand” as stated in evidence by Dr Klepp and that her autopsy concurred with the “abundance of sand” found in the initial autopsy examination in Mozambique on Elly’s body. I summitted to Mr Cain that it was highly unlikely Elly had inhaled all this packed chockablock sand into her airways Naturally and there would have been a third party involvement here.

I mentioned Dr O’Donnell had also given compelling evidence stating these density levels were higher than bone density and that both Lung trees were completely full with sand.

With regards to Elly s body being moved after her death also having a third party involvement I informed Mr Cain I had a recording of the chief inspector who was at the crime scene that morning and he states “the sand in her mouth was not the dark sand from the area where the body was found”. “The body had been moved there after her death as this is not the place she was murdered”. I reiterate Dr Klepp also in evidence at the inquest and Dr Collings before the inquest also state it was impossible for Elly to pack her airways in such manner with the body laying flat on this firm surface with her head on top of the sand pictured in the clear crime scene photo.

The Mutual Assistance Request (MAR) was explained fully in my oral submissions. Mr Cain said “what difference would it have made”. However we never sent the Mozambique Government the MAR who totally respects the MAR process mentioned in official letter sent to Mr Cain on the 19th June 2023. Therefore we never gave them the opportunity to agree or not to the MAR. However I knew where I stood as Mr Cain was fully aware at the time of the AFP submissions 2021 sent to Mr Bracken No 40 That an Mozambique government official states it was always possible for a joint operation with the AFP but they had not received any such request.

I fully explained the ripped apart top is ripped from Elly’s shoulder and all the way down her side totally destroyed. It is not possible for Elly to do this extent of damage to her own top by herself. This had to have been from a third party involvement. From evidence in the inquest we know for a fact the top was not ripped apart at 11.30pm so this happened between the time frame of 11.30pm and 5am when Elly’s body was found by the fisherman at 5am the next morning.

Also including in my oral submissions was a clear explanation to Mr Cain of the circumstances with the clear photo having been given to the AFP on the 24/25th November 2016 by DFAT and how this “clear photo” was never entered into the AFP/SLO’s statement or evidence brief in 2016/18 on these dates with no report to the coroner on this clear photo or ripped apart top!!! However the “blurred photo” was entered in the AFP/SLO statement on the 13th November!!! The Victorian institute of forensic medicine (VIFM) was given the clear photo in November 2016 along with the AFP yet NO report on the clear photo and ripped apart top to the coroner in 2016!!! No mention at all in Mr Cains findings here about his VIFM having the clear photo and not reporting on it to the coroner exposing the VIFM. Note the family was only ever given the blurred photo. I obtained the clear photo from my first trip to Mozambique in October 2018. This was the very first time the Family and the coroner Mr Bracken were made aware of the clear version of the crime scene photograph two years later!!!!!

Some of the solid factual evidence above is not mentioned in Mr Cains findings with any real weight or Clarity as it’s difficult to ascertain the strength of evidence which is lost in the volume of pages in his findings. It’s not even mentioned in his conclusion with any real conviction, weight or clarity.

No 52 coroners findings. The Mozambique autopsy report determined the cause of Elly's death as:18 a) mechanical asphyxiation; b) introduction of sandy material, obstruction of the upper and lower respiratory tract by sand; and c) direct suffocation.

No 53 coroner’s findings. That report concludes that the medicolegal cause of death is homicide. 19 The examination did not include drug, alcohol or sexual assault testing. Elly’s body was then embalmed prior to transfer to South Africa.

What is vital evidence left out here By Mr Cain is the Mozambique autopsy also states they found an “abundance” of sand in the airways and the first point at No 1 on their conclusion it clearly states it was a “Violent death” This is vital evidence not mentioned here at No 52 in the coroner’s findings when describing the Mozambique autopsy . The “ABUNDANCE” of sand is very important factual piece of evidence as it concurs with Dr Klepp’s evidence that the sand was still packed Chockablock even when she received Elly’s body giving you some indication of the state of Elly’s body when the Mozambique doctors received her body first hence the conclusion violent death ,Homicide with so much packed sand they found in Elly’s airways at their Initial examination. This would add weight to the vital evidence of the “packed chockablock sand” here in Mr Cain’s findings which is also clearly the cause of death in 2016!!!!!

No 60 coroner’s findings. Elly was then repatriated to Australia to the VIFM. On 22 November 2016, Dr Matthew Lynch performed a third post-mortem examination and provided a written report of his findings dated 5 July 2017. In his report, Dr Lynch noted sand in Elly's airways but was unable to confirm that it was the cause of death. He concluded the cause of death as ‘undetermined’.23

Dr Lynch notes a small residue of sand in the trachea and bronchi in his report. However in a meeting all recorded on the 7th September with consent, Dr Lynch clearly states he found NO sand whatsoever and if asked in court he would state this in evidence. He supports this again in his latest updated Supplementary report dated the 5th June 2023 to Mr Cain where he clearly states;-

“NO sand was identified on Ms Warrens body”

However in evidence given at the inquest By Dr O’Donnell the radiologist he proves there was two areas at the time in Elly’s body which had very high density readings 1290HU at the back of the nose and 947HU Bone density in the trachea with both lungs also completely filled with sand at the time Dr Lynch conducted his autopsy examination on the 22nd November 2016!! However there is “NO mention” at all of these areas of high density sand with both lungs full with sand on Elly’s body in Dr Lynch’s autopsy report!! This is not mentioned in Mr Cain’s findings here in detail at all as it exposes the credibility of his VIFM doctor.

No 63 corner’s findings. On 18 June 2019, Dr Chris O’Donnell, Forensic Radiologist at VIFM, received a verbal request from Dr Lynch to provide a written opinion on the post-mortem radiological imaging of Elly’s body that was performed on 20 November 2016 at the time of the third post-mortem examination.

This is true however this was because I asked for this radiological imaging to be conducted. I was told this would not be conducted if I did not request it myself!!

No 66 corner’s findings. Following the provision of Dr O’Donnell’s report, Dr Lynch was asked to provide a supplementary report addressing issues which arose from the findings in Dr O’Donnell’s report, including the presence of hyperdense material in Elly’s nasopharynx and bronchial tree. Dr Lynch provided a supplementary report addressing these issues on 19 September 2019.

What was really very interesting here with this supplementary report in September 2019 was that Dr O’Donnell at the time was not asked to explain his own radiology report!! The Court asked Dr Lynch to report on the radiology report in his Supplementary report. I had also asked the independent pathologist Dr Collings to review the radiology report and he said Dr O'Donnell is in the best position to comment on his own report!! Why did the court ask Dr Lynch and not Dr O’Donnell to report on his own radiology report!! Dr Lynch states its impossible to work out the volume of sand present in the radiology imagery. However the scan clearly shows we have very high density readings 1290HU and 947HU (Above Bone Density levels) with Both lung trees full with sand!!! This is not even mentioned in Dr Lynch’s Supplementary report or autopsy report!!! The sand has filled both lungs here yet no change in Dr Lynch’s cause of death as he still states the cause of death as “undetermined” in is review of the radiology report with this supplementary report in 2019!!!! However the above findings in the radiology scan is “all supported in evidence given by Dr O’Donnell at the inquest in August 2023”!! The one thing Dr Collings did say about the radiology report/imagery was, “The radiology imagine proves the sand is there in the areas shown”.

No 67 corner’s findings. Mr Warren also queried the presence of a tampon which was identified by Dr Klepp at the time of the South African autopsy. On 1 November 2019, Dr Lynch provided a second supplementary report confirming that he had spoken to Dr O’Donnell and that he was unable to identify anything in the post-mortem imaging that might represent a tampon.26

Dr Klepp in evidence at the inquest states she removed the tampon and placed it in a plastic bag inside the body with the organs for repatriation to Melbourne. In 2019 when I asked the court what has happened to my daughters tampon the court could not give me an answer!! The coroner’s assistant at the time had then rung Dr Klepp and she also stated at this time she had placed it inside the body for repatriation to Melbourne in 2019. However Dr Lynch in his first Supplementary report dated the 19th September 2019 states:-

given The coroner’s assistents conversation with Dr Klepp it is possible “that the tampon was overlooked by me, can’t be excluded”.

This is not in Mr Cains findings.

No 69 Corner’s findings. Following the directions hearing on 20 February 2023, I asked Dr Lynch to provide an additional supplementary report responding to those questions and to assist in my consideration of a cause of death. That report was provided to the Court on 5 June 2023. 70. In the June 2023 report, Dr Lynch made the following observations:

Dr Lynch was also asked to review the photos taken at the time of the South African autopsy and crime scene photos from Tofo, including the photograph of Elly’s body in situ in which she is seen wearing a ripped black t-shirt. These photos did not prompt Dr Lynch to change or alter any of his initial opinions.29

Mr Cain has also not entered Dr Lynch’s findings here with in the current Supplementary report with his comments about the ripped apart top in the clear photograph 5th June 2023 at N0 70 below. which is:-

“I have reviewed the photos and have No additional comment to make”. “I can see that the t- Shirt worn by Elly Warren appears to be torn in the right shoulder region”. “I consider the ripper t-shirt to be a piece of information of uncertain relevance”. “I am not a expert in assessing damage to clothing”. “I am not able to determine when or how the damage occurred to the t-shirt. Moreover, the photos do not depict the damage to the clothing in any detail”!!

I feel these above views from Dr Lynch of the clear crime scene photograph clearly showing the ripped apart top are not practical at all due to the clear photo showing the full extent of damage to Elly T- Shirt. There can be no question her top is destroyed and that she could not possible do this amount of damage to her own top by herself!!!

Pathologist Dr Byron Collins has stated in his report given to the family on the 24th August 2023 that-

“if the ripped top damage were resent then it could have been sustained during an assault”.

A witness at the inquest gave evidence that she spoke with Elly at around 11.30 that night and the top was not ripped apart at this time when talking with Elly and Elly’s body was found at 5am the next morning.

The other very interesting question asked to Dr Lynch in his supplementary report dated the 5th June 2023 and not mentioned in Mr Cain’s findings is-

‘Was a sand sample taken from Ms Warren body during the Melbourne autopsy”

Dr Lynch reply was-

”A sample of sand was not taken. “No sand was identified on Ms Warren’s body”!!!

Dr Lynch further states “the Fine particulate matter that was identified on post mortem Ct Scan within the airways was concealed by congealed blood clot as part of the post mortem decomposition and embalming process”.

However the radiology report taken from this CT scan has concluded that there was sand in the airways and two areas of very high density found in the airways of 1290HU at the back of the nose (Cement) and 947HU (Bone) in the trachea and that both lungs were completely full with sand to the lower levels at the time of the Melbourne autopsy.

This was solid factual evidence given and explained at the Inquest by Dr O Donnell. He had stated that some of the sand may have moved position by the time he the Ct Scan was conducted, however the sand is still in this density and position with both lungs full of sand at the time of the Melbourne autopsy. Dr Collins states he can't really moment on the radiology report as it Dr O’Donnell’s report but what he could say is the report dose indicate the sand is definitely present.

Dr Lynch was also asked that is it possible with Ms Warrens body position laying flat with her head on top of a firm sandy surface able to inhale sufficient sand to block her trachea and both lung trees with sand. Dr Lynch’s answer was;-

I would consider it possible. It is difficult from the photos to form a view as to the precise nature of the sand at the scene.

I need then to say here again that Dr Klepp with evidence given at the inquest and Dr Collings before the inquest both state it was “impossible” for Elly to fully pack her airways full with sand chockablock in this flat laying position with her head on top of the sand on this firm surface as shown in the clear crime photo.

What’s is also really very interesting about this supplement report is there is No mention at all about the abundance of packed sand in the airways causing death from both the Mozambique or South African autopsies. All that is mentioned is Dr Klepp’s findings that cause of death is asperation of sand giving no weight to how packed chockablock it was in Mr Cains findings or conclusions because Dr Lynch had found no sand as stated in this report.

I reiterate “No sand was identified on Ms Warren’s body” Dr Lynch states.

This is also not mentioned in Mr Cains findings below at No 70 with the latest supplement report submitted to the the court from Dr Lynch in June 2023.

Dr Lynch when looking at the Report of Dr Angela Miguez: dose not mention the sand found was “abundant” and that the very first point at the top in Dr Angela Miguez autopsy conclusion was that it was a “violet death” Mr Cain has also not stated this at all in his findings!!!! However it is fact as it is all mentioned in the Mozambique autopsy report!!!

70. In the June 2023 report, Dr Lynch made the following observations:

Mr Cain in No 69 above list a number of points from Dr Lynch raises in his supplementary report but not the ones I have just mentioned above, these are facts in the report and not mentioned with clarity in Mr Cains findings from Dr Lynch’s Supplementary report!!!

71. Dr Lynch was also asked to review the photos taken at the time of the South African autopsy and crime scene photos from Tofo, including the photograph of Elly’s body in situ in which she is seen wearing a ripped black t-shirt. These photos did not prompt Dr Lynch to change or alter any of his initial opinions.29

What Dr Lynch has stated in this Supplementary report about this clear photo is fully explained with clarity at No 69 above. This is not explained here in Mr Cains findings and I consider this to be Vital evidence as it not only proves that this damage to the top in this manner is impossible for Elly to do no her own.

Report of Dr Angela Miguez: 27

• Dr Miguez concluded that death was due to ‘mechanical asphyxiation with possible mechanism being strangulation or direct suffocation’ the latter being caused by introduction of sandy material obstructing the upper and lower respiratory tract. The medico-legal cause of death (sic) was determined as homicide. • The relevant findings of the examination included subconjunctival haemorrhage, excoriations of the chin and subcutaneous haemorrhage in the scalp. • There was no evidence of anogenital injury. Intramuscular haemorrhage was noted in the neck and a large amount of sand within the larynx and trachea. • The neck examination appears sub-optimal (at least based on the documentation available) as a layered neck dissection and subcutaneous dissection appear not to have been performed. A bloodless dissection of the neck was also not performed, thus introducing the possibility of artefactual haemorrhage in the neck. • The fact that the bladder was noted to be distended with urine at the time of the second post-mortem examination in South Africa would indicate that the pelvic organs were not adequately examined at the first autopsy. • It is unclear whether blood for alcohol and samples for toxicology and oral and anogenital swabs were taken at the time of the first post-mortem examination. Such specimens should have been taken. • No photos appear to have been taken at time of autopsy.

The Mozambique autopsy clear states they found an abundance of sand and that it was a violent death not mentioned here with Dr Lynch’s Report of Dr Angela Miguez.

Report of Dr Patricia Klepp: 28

• Dr Klepp concluded after examination that the cause of death was consistent with aspiration of sand, the cause of which is not determined at post-mortem examination only. • Toxicological analysis of vitreous humor and urine was undertaken, and no prescription or illicit drugs were identified. • As the body had been embalmed, measurement of ethanol was considered not possible. With the benefit of hindsight, I think there would have been value in attempting to quantify ethanol in blood and vitreous, notwithstanding the previous embalming. A negative result would provide useful information. A positive result would invite a discussion of possible embalming artefact. • At the first autopsy in Mozambique a bloodless dissection of the neck was not performed. This means that this may represent an artefact of dissection (so-called Prinsloo-Gordon artefact). • Whilst Dr Lynch was not critical of the report of Dr Klepp (who has specialist qualifications in forensic pathology, obtained in South Africa, a country with a rich tradition in academic forensic medicine), he noted that he would have postulated a cause of death of ‘undetermined’, and discussed the unusual finding of sand within the airways and its possible contribution to death. • The optimal time to take samples was at the time of the first autopsy and included blood for alcohol, samples for toxicology as well as samples for sexual. These would have included an oral swab, rectal swab, and vaginal swab and blood for DNA. It is unclear whether the facilities were available for sampling and storage. • There was no evidence of sexual assault observed but it is possible that the earlier post-mortem examination or the embalming process may have masked any otherwise observable evidence. • No conclusion can be drawn from the observation that Elly had a distended bladder post mortem.

I reiterate some vital points not mentioned here are added by me at No 69 above. Also no mention of the tampon which was lost at the VIFM!!! It was mentioned in the supplementary report 2019 by Dr Lynch.

What’s also very interesting is Dr Klepp’s qualification as stated at the inquest.

Dr Klepp's qualifications Transcript pgs. 164-165 inquest 2023.

MBBCH degree 1977, Diploma Forensic medicine 1981, Fellowship in forensic pathology 1984. Master’s degree in forensic pathology 1985. Working in Forensic Medicine and pathology 44 years. Lecturer at the university of Witwatersrand.

I don’t understand why Dr Lynch did not make contact with Dr Klepp in 2016 because he didn’t find any sand and he had the other two autopsy reports which had found an abundance of sand blocking the airways. He was fully aware he had Elly’s body third hand why not ring Dr Klepp to clarify the facts and cause of death in 2016!!!

Dr Klepp left her phone number with a convenient time to ring her about her autopsy report!!

72. Dr Lynch also made a number of additional comments, including but not limited to: 30

• a tampon was not identified in situ or otherwise at the examination of Elly in Melbourne on 22 November 2016, noting that a tampon was noted as in situ during the autopsy conducted by Dr Klepp in South Africa;

73. Dr Lynch did not alter his initial opinion as to the cause of death.

This above was in his supplementary report sent to Mr Cain before the inquest.

However the coroner had changed Dr Lynch finding as undetermined due to the compelling evidence from Dr Klepp and Dr O’Donnell at the inquest. If only Dr Lynch had contacted Dr Klepp in 2016 she would have told him the sand was chockablock in the airways then. Therefore sand blocking the airways was the cause of death in 2016!!!!

Mr Cain had no choice with the compelling evidence given at the inquest by Dr Klepp to change Dr Lynch’s undetermined cause of death to sand blocking the airways by aspirating a large amount of sand.

88. As outlined above, sand of varying amounts was observed at the time of the three postmortem examinations. Dr Klepp stated that in her experience, she had ‘never, ever…seen as much sand in the oral cavity, the trachea and the bronchi’ as she found in Elly. Dr Klepp further stated that ‘for the sand to get down as far as it had, [she] did believe that [Elly] must have been breathing at the time that it was inhaled’ to such a degree that Dr Klepp formulated the cause of death as aspiration of sand which would have created a mechanical obstruction.52

In Mr Cains findings from No 88 to 103 with the doctors it is very confusing as he is all over the place with the doctors evidence given instead of just having the relevant facts on each doctor like I have below systematically with Dr Klepp evidence. As you can see the main points above from Dr Klepp concerning the packed sand are very compelling when put together below relating to the one doctor evidence given at the inquest adding clarity and weight. My Barrister did ask the coroner could we have each doctor give evidence separately but Mr Cain refused our request. Mr Cain has not reported on each doctors evidence separately and has followed to some degree the format of questioning of the doctors all together at the inquest in his findings which is very confusing to follow for someone not aware of these circumstances!!!!

Mr Cain has not added fully and highlighted some very important comments in evidence made by Dr Klepp at the inquest which holds further weight to the fact Elly was murdered these are below. Transcript pgs. inquest 2023 181,182. below are the true facts;-

Dr Klepp states; “ she had experienced deaths which are related to sand many times before”. “The gold minds in South Africa collapse often burying people alive in sand”.

Dr Klepp states : “I have seen sand but I must say I have never in 44 years seen as much sand in the oral cavity, trachea and bronchi as I did in Ms Warren”. “For the sand to get as far down as it did she must have been breathing at the time of death”. “It was inhaled to such a degree I had formulated the cause of death as aspiration of sand”.

Dr Klepp was also ask about a witness at the crime scene who was asked to identify Elly and he had stated;- “ it was very strange to see her mouth so packed with sand”.

Dr Klepp was asked “was that an appropriate way to describe how you found her”.

Dr Klepp’s reply was:- “It is an “absolutely accurate description” her mouth was absolutely “chockablock” as was her trachea”.

90. Dr Klepp also acknowledged that there was some criticism that sand had not been collected in Elly’s case, which she had never had to do previously. Dr Klepp also acknowledged that ‘it was a good point’ as to whether the sand came from where Elly was found outside the toilet block with the rather hard-packed surface or elsewhere.56

Mr Cain has left out some important facts from No 90 here with evidence given by Dr Klepp. below is the correct evidence given by Dr Klepp. Dr Klepp is talking about the taking of a sand sample from the body and the position of the body in the clear crime photo laying flat. below is the correct evidence given-:

“I see quite interestingly enough that there’s some criticism that sand was not collected and I take that point”. “I have never had to do that but it is a good point”. “Weather that sand came from where Elly was found outside the toilet block or whether she was killed elsewhere on a different beach if she was killed and that her body had been transferred then onto that rather hard-packed surface that we look at in the picture of the body at the toilet block”

Dr Klepp also clearly states on transcript page 197-198 “You know ,laying flat doesn’t compromise your breathing”. although having your face down into sand.”

However Dr Klepp also disagrees here with one of Dr Lynch’s main possibilities and states “ you know positional asphyxia for me is if somebody for instance is involved in a car crush. They have moved through the car and they are hanging down between the seats and they can’t breath. I am not as strongly in for a compromised airways from positional point of view but her airways was compromised by mechanical obstruction by sand.

However Elly body is laying flat with her head on top of the sand on a firm surface in the crime scene photograph therefore there can be on “question whatsoever” her body was moved to this location after her death!!!As its just not possible stated by Dr Klepp here for her to fully pack her airways chockablock with sand in this position at this location on a firm surface.

I reiterate with this solid evidence given by Dr Klepp how is it possible for Elly to pack her airways laying flat with her head on top of the sand at this location on this hard packed surface that doctor Klepp has described in evidence. Why is this not explained in Mr Cains findings “holding weight” that her body was moved after Elly’s death!!! Dr Collings also agrees it is impossible for Elly to pack her airways chockablock as described by Dr Klepp in evidence with the body in this flat position and at this location!!

This above evidence form Dr Klepp questions Dr Lynch’s main possibility of Positional Asphyxia. I can’t understand why Mr Cain would “leave this critical evidence out of his findings” as it is solid evidence which proves it was highly likely the body was moved to the toilet block after Elly’s death by a third party!!!

91. When Dr Lynch was asked about his findings in relation to the presence of sand, he confirmed that he specifically commented that there was a small amount of residual sand and that he was not surprised that there was not a large amount of sand remaining after the first and second autopsies.57 Dr Lynch also conceded that when he saw the small amount of sand in the airways, he did not think to take a sample.5

This makes no sense at all from Dr Lynch, if this was the case why then did he not ring Dr Klepp in 2016 to clarify the cause of death. I did as Dr Klepp left her number at the end of her conclusion on her autopsy report for anyone to ring and talk about her report!!!

92. Dr O’Donnell also gave evidence about the findings from the post-mortem CT scan. Whilst he could not explicitly say that he saw sand in the imaging, he did see hyperdense, white material that has an appearance that is certainly consistent with sand. He noted that the material was seen in the back of the nose, and in the airways of both lungs, all the way down to the smaller bronchi within the lungs.59

Dr O’Donnell evidence was also “compelling” and there is no mention or weight given to the actual factual evidence given by Dr O’Donnell here in Mr Cains findings or clarity given to the very high density readings in his findings. Transcript pgs. 234-235,236,237

Dr O’Donnell is asked on transcript page 234 what is the density reading at the back of the nose and he states “1290HU” (Hounsfield Unit of Measurement). To put this high density reading into perspective it is equivalent to cement density which I showed and fully explained to Mr Cain at my oral submissions with graphs. As it is in the upper areas Dr O’Donnell states “it has not been dislodged by the washing by Dr Klepp”. This means it is highly likely this is the density level of sand at the time of death. Which is at the back of the nose.

Dr O’Donnell is asked to put the 1290HU into Laymen’s terms by my barrister. “You can see other white structures around it that’s bone and that density is grater than or equal to bone”.

There was another density reading in the trachea of 947HU however this may of been comprised with the washing by Dr Klepp as its in the lower airways. This proves these very high density mass areas were there when Dr Lynch examined Elly’s body but he did not find these masses of high density sand!!

Dr ‘O Donnell was also asked on transcript pgs. 237 about the lungs, “both lungs are in a plastic bag in the chest so you can see a trunk with branches that is the airway trees of the lungs and those airways are “filled with this material” (sand). Filled? “filled yes” Dr O’Donnell states for the second time at the inquest. Dr Lynch did not report that both lungs were filled with sand in his autopsy report!!

This is critical evidence stated by Dr O’Donnell and it is not mentioned Mr Cains Findings.

I am up to this point No 91/92 with my new report 22/07/2025.

still looking at some previous points to possibly add to just below.

82 Jade also gave evidence to the effect that Elly appeared to be normal and that there were no signs of bruises and that she did not recall her clothing being ripped.

83 That was the last time that anybody in the group saw Elly alive.

This is a critical time as it was the last time her friends saw Elly alive.

Therefore its very important to state what Jade really did say when giving evidence at the inquest below. Transcript Pgs. 55, 56 Inquest day one 22nd August 2023.

123. At around 5:00am that morning, Elly was found by a local fisherman deceased in an area adjacent to a toilet block near the marketplace at Tofo beach.

However not mentioned here in Mr Cains findings at No 123 is this fisherman had also taken a photograph of Elly at the toilet block clearly showing her ripped apart top at 5am. This is critical evidence of the crime scene showing “vital evidence”. why is it not mentioned here in Mr Cains findings under the heading of Events immediately proximate to death then. Because this clear photo exposes the Mozambique police cover up as it clearly shows Elly’s top is ripped apart. This is not mentioned by the Doctor and inspector who attended the crime scene that morning and it is not mentioned in any police report form Mozambique or the Australian authorities to this day!!!!

This evidence of the clear photograph is so critical yet it not mentioned at all in Mr Cains findings!!!! why not?!!!

My Conclusion on Mr Cain’s findings:-

First of all I need to explain Mr Cain’s findings and the bases for his findings he states:-

“In his findings that; “all coronial findings must be made based on proof of relevant facts on the balance of probabilities”. “The strength of evidence necessary to prove relevant facts varies according to the nature of the facts and the circumstances in which they are sought to be proved”.

“In determining these matters, I am guided by the principles enunciated in Briginshaw v Briginshaw”. “The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals or entities, unless the evidence provides a COMFORTABLE LEVEL of satisfaction that they caused or contributed to the death”.

For those who are not aware of the Briginshaw v Briginshaw case Mr Cain is referring to in his findings. Below is a brief description and it is very important because this case is used for the bases of Mr Cain’s findings:-

Briginshaw v Briginshaw is a decision of the High Court of

Australia in 1938 which considered how the requisite standard

of proof should operate in civil proceedings.

The case in question was that Mr. Briginshaw accused Mrs. Briginshaw of adultery because she had been seen attending dances with another individual, and had been driven home and kissed by this same individual. The co-respondent to Mrs. Briginshaw was the individual she had attended the dance with, who denied that adultery had occurred.

The main point being, is adultery has only occurred when an act of sexual intercourse has occurred.

Therefore Mr Cain is evaluating whether Elly was murdered using the standard of proof set down by the high court in 1938 as his basis for his point of reference in Elly’s case.

In effect what this means is basically in the Briginshaw V Briginahaw case you can have all the circumstantial evidence there is but it’s not adultery in this case unless the facts prove the act of sexual intercourse has taken place.

Martin J in the Supreme Court of Victoria evaluated the initial

evidence at the standard of beyond reasonable doubt, and at

that standard found insufficient evidence to support the

allegation of adultery. An appeal was lodged with the high

court that was also dismissed on the grounds of insufficient

evidence.

Therefore based on the High Courts decision in 1938 which is now known as the (“ Briginshaw Principle”) Mr Cain is saying the evidence is not strong enough to say Elly was actually murdered. Even though we have very strong credible circumstantial evidence which is highly suspicious and weighs heavily on the side of beyond reasonable doubt that Elly was in fact murdered given the proof of relevant facts on the balance of probabilities which means “more likely than not” in favor of murder in Elly’s case.

If Elly’s case was adjudicated by a jury with all this compelling evidence put forward I am very confident with the full extent of the factual relevant proof of evidence they would absolutely say the balance of probabilities weighs heavily on the side of murder. As there is enough factual evidence beyond reasonable doubt, with the highly suspicious circumstances to prove Elly was murdered as she just can’t breathe in this amount of sand naturally from falling over onto the sand. This factual evidence proves beyond reasonable doubt that the sand would have to have been forced in by a third party to have had the sand so chockablock as described by Dr. Klepp at the inquest.

What’s very interesting here with the coroner’s court is, does the court take the burden of proof beyond reasonable doubt into consideration. There is abundance of factual evidence which is beyond reasonable doubt that Elly was murdered. The coroner has not taken all the factual evidence into account or given full credit or weight to all of the factual evidence. I am sure nearly everyone reading and evaluating all the factual evidence we have here would have to conclude without doubt that the volume and weight of factual relevant evidence proves beyond reasonable doubt that Elly was murdered.

What Mr Cain has based his findings on is the relevant strength of evidence and in HIS MIND the strength of evidence here is not strong enough. Therefore the factual evidence is not enough to prove the relevant strength of the facts based on the law of the balance of probabilities in Mr Cain’s mind. However, would a jury come to the same conclusion presented with the same factual evidence?

Well you make up your mind and think you are on a jury to

determine if the evidence BELOW proves beyond reason doubt

that Elly was murdered. I certainly feel there is a strong proof

of evidence and the Mozambique police agree.

I feel a large proportion of the factual relevant evidence was proven with the evidence given at the inquest filling in important gaps in the evidence. Therefore what is the probability of this being a murder when Elly has inhaled a very large volume of sand packing her airways chockablock with sand as described by the witness at the crime scene, Dr. Klepp’s and Dr. O’ Donnell, evidence at the inquest with Dr. O’Donnell evidence given at the inquest also confirming that both lung trees to the lower level of the lungs is full with sand at bone density levels.

What is the probability then of Elly breathing in all the packed sand NATURALLY based on the actual factual evidence. I reiterate with very high density readings in the upper and lower airways filling up both lung trees chockablock with sand at bone density levels. It’s just not possible for Elly to pack the airways to such a degree on her own, especially laying flat on a firm surface with her head on top of the sand. There had to be a third party involved to force this large quaintly of packed sand into my daughter’s airways. This is why with the Initial strong proof of factual evidence of packed sand the Mozambique doctors were confronted with in their examination they had No hesitation in stating this is a violent death homicide.

Now you need to add the fact the top is ripped apart also adding the strong evidence of the firm surface the body was found on and that Dr. Klepp and Dr. Collins have both stated that its highly unlikely Elly could compromise her airways to this extent laying flat on this firm surface where the body was found with her head on top of the surface. We also need to add the Mozambique police conclusion and their autopsy conclusions concurring without doubt that the manner of death is homicide. We need to also add the marks and bruising on the body, head back of her head and face. We also need to add the fact Elly was not under the influence of drugs or alcohol.

You would have to say that the sheer quantity of relevant

factual evidence here proves a very high probability

supporting the fact that Elly was murdered. therefore the

strength of proof of evidence in this case weighs the balance

of probability towards the fact that Elly was murdered.

I strongly disagree with Mr Cain’s finding and thinking in this case as each case is different with the weight of factual evidence. I feel the evidence of proof is very strong in Elly’s case especially the evidence of the abundances of packed sand in Elly’s airways as it is so compelling in my book that its not probable that in this manner and volume Elly has breathed in this packed sand naturally from just falling over onto the sand.

There is not a person who has died this way in Australia from just falling over in the sand inhaling a large amount of sand obstructing the airways causing death since records have been taken over 60 years!

If the family was to take this to the Supreme Court of Australia as I am sure they would evaluate all the evidence on its merits in a logical manner. However this is far too expensive for the family. The family has already paid out a substantial amount of money for the investigation so far.

I have however contacted some people who may be able to support the family financially to take this on further to the Supreme court but I have had no reply to date.

There are also concerning aspects with the AFP letting down the family and I do have all the facts to prove this. I have exposed some of these aspects and informed the coroner of these facts in my oral submissions to the court on the 11th December 2023.

However Mr Cain said at my oral submissions that with the concerns I have with the AFP it falls outside the scope of his investigation with this matter and any concerns I have with the AFP will need to be taken up with them directly! Believe me I have tried but the AFP is aware I have all the facts. (Oral submissions transcript Pg, 290)

I feel Mr Cain’s decision here is not in the best interest of all Australians and very disappointing as it is really passing the buck as the way the AFP have handled their investigation with this matter I feel should fall within the scope of Mr Cain’s investigation to make recommendations for improvements.

Mr Cain I felt should have made recommendations to improve the direct involvement of the AFP to support Australian families when facing a crisis overseas as the AFP just turned a BLIND EYE and covered up circumstances ghosting vital evidence from the coroner in 2016/17 with Elly Warren’s colonial investigation matter.

The really disappointing factor here was I pointed out some deceitful concerns the family had with the AFP in my oral submissions on the 11th December 2023 to Mr Cain and he ignored most of these concerning issues as Mr Cain states in his findings that he is not critical of the AFP!!!

I mentioned to Mr Cain in my oral submissions below;-

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

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

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

HIS HONOUR: Sorry, I -

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

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

MR WARREN: Yep.

This means Mr Cain fully understood the circumstances and the facts I had mentioned to him directly at my oral submissions yet Mr Cain states he is not critical of the AFP’s lack of effort and the deceitful manner with which they misinformed and ghosted evidence from the coroner and family.( All mentioned in my oral submissions blog)

For me to say the AFP was horrible to the media outside court I really needed to explain why they were so deceitful and misleading.

Mr Cain has let the AFP off the hook here and now they are all hoping it will all just go quietly away.

There are three critical areas in this report: The facts about the manner and cause of Elly's death and the AFP's Involvement.

Body of my report on Mr cain’s findings:-

a) The first point i would like to mention is really the most

critical is the full impact of sand to Elly's airways.

This is really the decisive factor here and Mr Cain has not given enough weight in his findings as the compelling evidence of the abundance of densely packed sand in Elly’s airways is the contributing factor for the manner of Elly’s death.

Upon reading my report below you will understand how comprehensively the abundance of packed sand really was to the cause and manner of Elly's death.

The fact is not many people are aware of the sheer magnitude of exactly how much sand was in Elly’s airways. I feel this needs to be fully explained so people really understand just how packed Elly’s upper and lower airways were INITIALLY with sand.

In my oral submissions to Mr. Cain I tried to show and explain to him showing the density graphs for foreign materials comparisons to the high level readings of density recorded in the radiology images taken from the CT scan of Elly’s body. (See oral submissions blog transcript page 251-256)

Mr. Cain basically told me

“Mr. Warren I get the impact of sand and the ripped apart top is

not in dispute.

As it turns out I don’t think Mr. Cain really did get the gravity of what I was trying to explain to him as his findings did not really reflect the full impact of sand to Elly’s airways with the compelling evidence by Dr. Klepp and the very high density readings recorded in the radiology scan.

Mr. Cain has left out one of the most important aspects, the high density values recorded in the radiology report, out of his findings. 1290 Hu upper and 947 Hu lower airways.

This is an indication of how densely packed Elly’s airways were

at the time of death 1290Hu is equivalent to (Pottery or cement

density levels) behind the back of the nose and therefore the

sand was firmly packed into the Airways at the initial autopsy

in Mozambique.

The sheer abundance of sand has recorded in parts of the airways very high density readings of sand which was no doubt the catalyst for the Mozambique doctors conducting the initial autopsy to state this is a homicide. They realized when examining the body it was not possible to breathe in this sheer volume of density packed sand in such a manner as the radiology scan proves with the very high density readings still showing parts of high density masses of sand in the Radiology images. These readings of high density masses of sand were still present and recorded after their had been two previous autopsy examinations.

Not only did the Mozambique doctors’ say homicide, but they

added the fact it was a violent death on their autopsy report.

I told Mr Cain at my oral submissions that the most likely reason for the Mozambique doctors to say straight out this was Violent death Homicide was because of the sheer magnitude of this ABUNDANCE of PACKED sand they found in their initial autopsy. Proven by the very high density readings in the radiology report and the fact both lungs and the trachea are full with sand also with high density levels equivalent to bone density.

This is supported by their report at point 4 and 5 in the report's conclusion and fully explains that the airways are totally compromised by sand. To describe the sand the Mozambique doctors do use the term ABUNDANT sand found in the airways in the body of their report. (This is also fully explained in my oral submissions transcript Blog.)

There were some shortcomings with the Mozambique autopsy mentioned in the inquest but the abundances of sand was the one common denominator which concurred with the South Africa autopsy and the Melbourne radiology report.

Elly had a second Autopsy in South Africa and I was really surprised at the inquest how Dr. Klepp described and emphasized the sand she found in Elly’s airways in her examination.

Dr Klepp stated: The sand in Elly’s airways was “CHOCKABLOCK

WITH SAND”.

Dr. Klepp also agrees with one of the first witnesses at the crime scene that morning who was asked to official identify Elly as he was Elly’s dive instructor and he states;-

“it was strange to see Elly’s mouth so packed with sand”.

Dr. Klepp was also asked at the inquest if she agreed with the witness's observation and

Dr. Klepp’s replied was:-

“...ABSOLUTELY, I AGREE…”

Dr. Klepp also states at the inquest: “I have had plenty of experience examining bodies where they have inhaled sand”

“But I must say in all my 44 years as a pathologist I have never

seen as much sand as I did in Ms. Warren’s airways”

By now you are getting some Idea of just how much packed sand we are talking about here.

Now I am not finished as I do need to explain the high density readings in the radiology report which are very high density readings of 1290HU at the back of Elly’s nose even after the cleaning of the packed sand from the upper airways as the South African doctor said there was so much sand I needed to clean it away to do a proper examination from the upper airways.

1290HU you may think what's that? It is the same density as cement or pottery hence the charts I had shown the coroner in court for my oral submissions. This is a mass of sand at the back of Elly’s nose. (This is also explained more in my oral submissions transcript blog.)

There was a second reading in Elly’s trachea and bronchi of her lungs of 947HU. This reading is equivalent to cortical bone density levels in the lower airways.

The radiologist Dr. O’ Donnell states at the inquest that;-

“Both lung trees are FULL WITH SAND. the lower airways are

equivalent to BONE DENSITY LEVELS 947HU''.

By now you are all starting to see why I am very upset with the coroner's findings as it's not possible for Elly to just fall over in the sand and breathe these amounts of sand naturally packing it into the lower lungs with these very high density levels of 1290HU and 947HU.

I also informed the coroner at my oral submissions that since records have been taken of causes of death in Australia at the Australian Bureau of statistics in over 60 years. There has not been one person's death recorded from just falling over into sand and inhaling sand obstructing the airways for whatever reason causing death. Buried alive in sand Yes, but not from just falling over into the sand for whatever reason.

Now you add the fact the coroner has stated that drugs and alcohol are not a contributing factor in his findings to have fallen over into the sand unconscious, really what reason do you have left she is a healthy twenty year old.

The coroner was very protective of the VIFM and Melbourne Pathologist who conducted the Melbourne autopsy. However in the end Mr. Cain had no alternative to run with the South African doctor's cause of death under these circumstances because the evidence of sand obstructing the airways was so compelling from the South African autopsy doctor and the radiologist’s.

Dr. Klepp’s cause of death was;-

“Elly had aspirated a lot of sand obstructing her airways”

The Melbourne pathologist had told me in a meeting I had with him in September 2017 all recorded he did not find any sand at all and at the inquest he stated he only found a small residue of sand.

The Melbourne pathologist states at the inquest :

"I must confess I did not find much sand, only a small amount of

sand”.

I am not sure how this could be possible as the Ct Scan for the radiology report was completed just before his autopsy and it shows Elly’s airways and both lungs full with sand still at the time of his autopsy!!! Noting the very high density levels recorded and not mentioned at all in the coroner’s findings. It really makes me wonder if the Melbourne Pathologist examined the right body!

I am astounded and quite shocked that Mr. Cain did not mention

the very high radiology Hounsfield Unit of measurement (HU)

density readings in his findings.

However these high density readings don’t look good for the Melbourne pathologist because these readings are proven facts from the radiology report that Elly’s airways were still full with sand at the time he examined Elly on the 22nd November 2016.

You make up your own mind with the above facts with the impact of sand to Elly’s airways,

However in my book this proves it is more than a possibility that Elly was murdered. There is no way possible she can breathe in, as the facts show the abundant amounts of chockablock sand with High densely levels of sand to this degree on her own, there has to be a third party involvement here which has forced the sand into her airways and it should be Homicide as the finding.

b) The next point is the circumstances surrounding the clear

crime scene photo.

The Victorian Institute of Forensic Medicine was also given the clear crime scene photo as well in November 2016, but Mr. Cain has also failed to mention this in his findings as they did not examine the photo and send a report to the Melbourne Pathologist or the coroner in 2016.

I should explain here that there were two versions of the same crime scene photo which was taken by a fisherman at 5am who found Elly's body. One was a very blurred copy and the other crystal clear clearly showing Elly's top ripped from her shoulder and all the way down her right side. In reality the top is destroyed.

This is why the VIFM report would have been so important in 2016 on the clear version of the crime scene photo but there was no report sent to anyone in 2016/17 by the VIFM laboratory!!

The other very interesting point the Dr. Klepp makes when she viewed the clear crime scene photo was Elly laying flat in the position she could not possibly compromise her airways and states;-

"she is on this firm surface and could not compromise her

airways laying flat in this position. it is a point that a sand

sample from her body was important as her body may have been

moved to this area after".

This is not in the coroner's findings that she can’t compromise her airways in this position and Mr. Cain has left this out from this sentence in his findings. I feel it is a very important point made by the South African doctor endorsing the fact Elly’s body was moved after her death.

It would be interesting to have other Doctors’ viewpoints on this.

I did engage Dr. Byron Collins, another pathologist and he agrees that in his view it’s just not possible at this location with the firm surface for the body in that flat lying down position to have inhaled the amount of sand as shown in the radiology imagery.

Note;- Independent Pathologist Byron Collins was not aware at this time of Dr. Klepp’s evidence that the airways were chockablock as this viewpoint from Dr. Collins was stated in 2020 at a meeting I had with him.

c) My next point is the meeting I had with Superintendent chief

of criminal investigations in 2018.

I also told the coroner at my oral submissions that I had a meeting with the Mozambique superintendent Mr. Cudzi on my trip to Mozambique in 2018 who attended the crime scene that morning and he informed me at this meeting and states :-

“Elly was Murdered/killed at the main beach and moved to the

toilet block. the sand in her mouth was beach sand not the

dark sand found at the location where the body was found”

The coroner must not have thought too much of this evidence at my oral submissions as he was still not convinced Elly’s body was definitely moved for a fact after her death.

I knew going into my oral submissions that I needed to really try and prove this point that the body was moved after her death and I tried my best. I thought I had the sand and ripped apart top as solid evidence to say Elly was murdered but obviously not in the mind of Mr Cain. I knew I needed more factual evidence to get the body being moved after death across the line.

That's why the Mozambique Superintendent in charge of the case, comments were so important. That and the fact he even states Elly was murdered and moved after her death to the toilet block which is all on video evidence No 75 given to the court and entered into evidence in 2018 by the coroner’s assistant at the time Mr. King Taylor.

This video evidence proves the Mozambique police knew Elly was murdered right from day one with the chief inspectors comments. The AFP had meetings, exchanged emails and phone conversions with the same chief inspector in 2016/17!!

There is other evidence with plenty of marks and bruising on Elly’s face, side of her neck and back of her head. These abrasions were very prominent when I saw Elly’s body in South Africa on the 18th November 2016.

However the one factor I knew I needed to clarify at my oral submissions was the fact Elly’s body had been moved after her death, the coroner still states this is only a possibility in his findings. It is very disappointing that he did not rate my evidence highly with the meeting I had with the Mozambique superintendent Mr. Cudzi when I went over there in 2018.

I reiterate the coroner has this video with me and the superintendent stating Elly was murdered and her body was moved. The coroner's court is not governed by the rules of evidence here.

We had the ripped apart top and I thought we had the sand as solid facts however the coroner left the ripped apart top out of his conclusion!! The clear crime scene photo clearly shows the top as ripped apart so this photo tells the truth. A witness saw Elly at 11.30 that night and there was no damage to her top at this time so it happened just before or during her death.

This is mentioned in the coroner’s findings but not really given much credit, not as much as it should have as the top is completely destroyed and definitely indicates some sort of an aggressive assault or struggle has taken place before or during Elly’s death.

d) the AFP’s lack of Involvement.

First point is the Mutual assistance request as this will

concern other austraian families. followed by the deception

from the AFP.

I asked Mr Cain if he thought the AFP had enough information to state this was a crime.

Below was his answer and I was really taken back by his answer. I will explain why I was so surprised and it proves that his findings are just one man's opinion.

11 MR WARREN: Your Honour Do you agree that the AFP had

enough information to state that this was a crime at the time?

12 HIS HONOUR: Probably not.

You see the AFP not only had a police report, Mozambique autopsy report which all state Homicide but they had the clear crime scene photo of my daughter’s naked body with her top ripped apart which was given to the AFP on the 25th November 2016 by DFAT.

This is an Explicit photo of my daughter’s body which was given to the AFP and they completely ghosted this clear photo with no mention of a ripped apart top in 2016/17. In Fact there has been no mention, No report form the AFP or Mozambique Authorities about any ripped apart top to this day 2025!!

Now the Mozambique Autopsy and police report which both state homicide and obviously the AFP also had this Clear crime scene photo clearly showing Elly’s top is ripped apart.

With all this evidence the AFP had in 2016/17 this is still not enough evidence for the AFP to say we have reasonable cause this is a crime and to review and send the Mutual assistance request.

Obviously Mr. Cain did not think so!!!

I really don’t understand this at all. What more do you require to say this is REASONABLE CAUSE that a crime has been committed here!! However Mr Cain clearly did not understand the process and the requirements here and its not good enough. (There are also more facts about this in my oral transcript blog.)

I spoke about a police report in the AFP action sheet at my oral submissions which the AFP tried to DISGUISE as a Mozambique autopsy report because of the Mutual assistance request. Because this police report proves this to be a crime which is a clarification requirement for the AFP to send a MAR.

In my oral transcript its proven the AFP were still trying to make out this was an autopsy report and I caught them out here with there deception in my oral submissions at the end with the lawyer of the AFP stating this was not a police report but an autopsy report when in fact the facts prove it really is an official police report which states homicide.

This was all in front of Mr Cain in the oral submissions and I am sure he was aware just what the AFP were up to here with the wording in their action sheet. (Mozambique Document )

Mr Cain said to me the initial police report was from the local police and they had limited knowledge or it’s not their jurisdiction. Well it is still a Mozambique official police report from the top criminal Mozambique police (SERNIC) which was sent officially to DFAT and the point here is that the AFP deliberately tried to disguise this police report which states homicide. You see It only states in the AFP action sheet it was a Mozambique document and the death was by suffocation. When in actual fact it was an official police report which states homicide. This is all in my oral submissions in court and I questioned the AFP’s lawyer comments about this to Mr. Cain at the time in court near the end of my oral submissions.

The reason why this is so important is because of the chain of evidence we need to prove the AFP were aware of this police report. This is why they are making out this was not a police report as it is a chain of evidence proof they were aware it was a crime and the Mutual assistance request should have been sent on these grounds.

Surely the clear crime scene photo clearly showing the ripped apart top and autopsy report should have been enough reasonable cause when they obtained it anyway in November 2016 to prove reasonable cause that a crime has been committed.

This is one of the areas that the AFP has clearly been deceitful and this is why I have said they were horrible in the fact they have tried to cover aspects up so people will understand the full gravity of the situation the family was placed in with the AFP.

In the coroner’s findings he states he feels the MAR would not have made any difference.

However this is sheer speculation from Mr Cain ( Coroner) as it was always possible for an official request from our Attorney general to their Attorney general and if they had of said yes to the MAR the Mozambique Attorney general would have instructed there authorities on Elly's case to cooperate with the AFP as I said to Mr Cain this is then an order coming from the top in the Mozambique government informing their authorities to cooperate and allow our AFP to help and offer there assistance where possible or needed. which would have come from the Mozambique Attorney General.

It was also confirmed and stated in the AFP submissions in late

2020/21 a Mozambique government official confirmed it was

always possible to have had a joint operation with the

Australian authorities through a Mutual assistance request.

We just never sent the MAR in 2016/17.

I then stated to Mr Cain ;-

"surly then this would have made a difference Your Honour

Especially in the area for testing of evidence for DNA which is

stated in the Mutual assistance act”.

You well may ask why is the AFP behaving in this manner to an

Australian family who has just had their loved one die

suspiciously overseas.

Well we need to look at just what the AFP were aware of in 2016 to answer this question.

The facts prove the AFP had the clear crime scene photo clearly showing the ripped apart top on the 25th November 2016.

The Initial Mozambique assessment report of the crime scene on the 9th of November has never stated there was a ripped apart top discover at the crime scene scene in fact it states in there most recent report:-

There is on signs of a struggle on the body or around the area

at the crime scene.

As the AFP had the clear photo showing the ripped apart top which obviously indicating that a struggle had taken place only 16 days after Elly’s death this made them aware of the Mozambique deception at this point in time as there was no mention of any ripped apart top at this time from the Mozambique police in 2016. In fact there has ever been any acknowledgement by the Mozambique police or the AFP about any ripped apart top ever.

You see the Mozambique police had NO IDEA that the fisherman had taken the photo exposing their deception at 5am that morning ON the 9th November. However once the AFP got the CLEAR photo they then became aware of what the Mozambique police were up to here on the 25th of November 2016.

The AFP did not want to open this can of worms for diplomacy reasons exposing the deception of the Mozambique police as pursuing Justice for the family in their view here would not be in the best interest of all Australians.

This also makes it impossible to have a MAR under these circumstances. This is why the AFP were trying so hard not to expose the evidence which clarifies a review for the MAR that a crime had been committed!!

The AFP can’t be seen exposing other countries’ authorities as they may jeopardize or lose trust with other countries agencies and this may affect their communication channels of trust around the world!! This is why they say it’s in the best interest of all Australians.

E) My next point is the clothes Elly was wearing on the night in

question.

A critical factor was Elly’s clothes she was wearing when she died.

I have been told by many detectives that;- Top priority is all the trace evidence at the crime scene.

Now the AFP say they don’t get involved with another country's investigation but the coroner at the time Sara Hinchey had asked the AFP to obtain all of Elly’s possessions as mentioned in their AFP action sheet and the clothes she was wearing were still Elly’s possessions.

Normally the Investigating Police would keep the clothes, especially as the top is ripped apart for DNA testing. However the Mozambique police did not place her clothes into evidence!!! I pointed this out at my oral submissions to Mr Cain on the 11th December 2023.

This then enameled the AFP to obtain her clothes she was wearing as they were her possessions. As the clothes Elly was wearing at the time of her death were not entered into evidence by the Mozambique police because they don’t have the resources for clothes DNA testing which the AFP were fully aware of at the time. Therefore under these circumstances this is basic police work to retrieve the clothes that Elly was wearing and with the advancement of DNA technology available to the AFP in 2016. Therefore the RETRIEVAL of Elly’s clothes she was wearing at the time of her death was VITAL evidence given the circumstances of her death and damage to her top.

It was hot and very humid over there at the time all it takes is

one drop of sweat or hand grip on the top with the

advancement in DNA technology in 2016!!!

It must be noted;- A MAR was not required for the sand sample from Elly’s body as it was in Melbourne and her clothes are her possessions which were not placed into evidence by the Mozambique police but her clothes were later incarcerated!! We were informed by the the person in charge at the Maputo central hospital that no one came to pick up her clothes after her autopsy in 2016!!!!

The ramifications of the AFP not retrieving or asking for her clothes she was wearing as there is no record in any AFP file of them asking for these clothes is huge today as the Mozambique police had recently stated they have suspects but not enough evidence to charge anyone. This is also not mentioned in the coroner’s findings!

Sand sample taken at the crime scene by the AFP

The AFP had also taken a sand sample 8 days after Elly’s death from the crime scene and at the inquest the AFP officer tried to make out the sand sample may have been compromised as it was taken 8 days after Elly’s death. Really how is it possible that the sand in the area is going to change in 8 days!!! He is only trying to cover himself here as the AFP had every opportunity to take the second sample from Elly's body for comparison in Melbourne.

Why do you take a sand sample in the first instance if not to compare with the sand in the body as the AFP were well aware that sand was a major issue here well before the Melbourne autopsy.

This same AFP officer Mr Scruton was on the ground in Tofo and was informed on the 18th November 2016 at a meeting with the chief Mozambique inspector in charge of the case that they suspected Elly’s body was moved after her death and the Melbourne autopsy was on the 22nd of November 2016. This is now confirmed that the AFP were aware the Mozambique authorities suspected the body was moved four days before the Melbourne autopsy with evidence given at the recent Inquest by Mr Scruton the AFP officer in question in August 2023.

A further meeting on the same day with the Mozambique prosecutor stating to the AFP /SLO that sand is the cause of death and that this concurs with the preliminary South African autopsy report. Therefore the AFP were fully aware how important the second sand sample was from our daughter’s body!!!

There was plenty of time for the AFP to have organized the second sample to be taken from Elly’s body. This second sand sample from her body was crucial for forensically determining that Elly's body was moved by a third party after her death.

This would have been enough to convince the coroner her body was moved after her death as solid forensic evidence as there was a major difference between both sands. This is really basic police work especially after you have been told by the inspector in charge of the case they suspected the body was moved days before the Melbourne autopsy examination!!!

Elly’s body was in Australia therefore so was the sand for the second sample and the clothes were not entered into evidence. These are still Elly’s possessions. I reiterate a Mutual assistance request was not required to retain both of these critical items of evidence for forensic testing in Australia!!

I also said in my oral submissions to Mr. Cain there was very poor transparency with the family and Australia Authorities and the AFP’s Lawyer objected to this and said that there was good transparency between the family. I told the coroner I can't speak for Nicole Elly's mother, but it has not been good for me, one or two poor letters and some emails over seven years.

The AFP have only been involved in the last year or so because the coroner has instructed them to move heaven and earth, They would not bother otherwise.

The coroner Mr. Bracken when he had control of the case needed to ask the AFP in 2021 to send an official request for them to get involved with a joint operation which was not an official MAR but a personal letter sent only for a joint involvement on the matter between the two countries.

There has been no reply by the Mozambique government because this is not an official request. The Mozambique government is showing us how to do it the right way by recently asking us to send them a proper official MAR to obtain their case file!!!

Some people may not be aware that the Mozambique police have concluded In 2023 with the evidence they now have that Elly was in fact murdered and they are investigating Elly’s case as a homicide. However it was very important that the coroner here in Australia supported this conclusion as it may have had a bearing on the judge over there to continue with finding justice for Elly.

However the Mozambique Judge has obviously been waiting for the outcome here in Australia as he adjourned in June this year. This was to see if they will continue to investigate Elly's case over there with the evidence they have. They have suspects but not enough evidence hence the importance of Elly’s clothes for DNA. I feel with such a low grade finding here in Australia as only a possibility Elly was murdered they may now close the case over there and there will now be no Justice for Elly.

I am more than willing to talk to anyone about this report and I am more than happy to show anyone the concrete facts to prove and support this report. I have all the evidence to prove the facts I state here.

I have facts that the AFP have ghosted evidence by not entering critical evidence into their statements which I have also pointed out to the coroner with my oral submissions on the 11th December 2023.

I really do feel the coroner is protecting the Melbourne autopsy doctor to some degree, also the VIFM and the AFP as they all had the factual evidence in 2016. There are some circumstances with the facts which I feel are not mentioned at all in Mr. Cain’s findings and this just does not add up at all in my book!!!

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

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

The Melbourne Pathologists states he did not find any sand!!!

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

The really interesting fact here is Mr Cain has left out of

No 39 in his findings when explaining the witnesses that the

court did not initially have or want as the court did not want

Dr.O’Donnell as a witness and that I had to request that the

court change their views and included Dr O’Donnell as a

releavent witness.

Note: These above points about Dr. O’Donnell as a witness are also mentioned in my oral submissions and investigation blogs as it is critical for people to understand how the court is able to influence the proceedings.

remember it’s the coroner’s inquest not your inquest and he is

running it as he sees fit this was clearly pointed out to me by

Mr Cain in my oral submissions. My Oral submissions Transcript

pg’s 274- 275

F) further Concluding points of concern;-

The Coroner Mr. Cain has left out vital evidence from his findings.

The AFP were aware of the circumstances of the Mozambique cover up in 2016.

This is the real reason why they were not fully committed to carrying out their sworn duty to defend the rights of all Australians overseas by not supporting an Australian family when in desperate need of their full support and assistance.

It’s very disappointing Mr. Cain has stated he is not critical of the AFP in this matter, he has let the AFP off the hook here and they all just want it now to quietly all go away!!

Paul Warren