My report on the coroner’s findings

Introduction
Background to Elly Warren’s Death
Early Evidence and Homicide Classification
Forensic and Medical Evidence
Crime Scene and Physical Evidence
Mozambique Homicide Investigation
AFP Involvement and Investigative Failures
AFP Non-Disclosure of Critical Evidence
The Coronial Inquest
Witness Exclusions and Procedural Failings
Bias and Systemic Failures
Application of the Briginshaw Principle
Outcome and Ongoing Concerns
Conclusion
References and Verified Records
Appendices

Introduction / Coronial Investigation Analysis

This report examines a coronial investigation spanning more than a decade (2016–2026), involving multiple jurisdictions, expert disciplines, and successive stages of forensic review. It brings together the available forensic, medical, and investigative evidence in chronological and thematic form to assist the reader in understanding the full scope of the case.

Elly Rose Warren died overseas in November 2016 under highly suspicious circumstances. From the outset, multiple independent lines of evidence including forensic pathology, radiological imaging, eyewitness accounts, and official reports from Mozambique authorities indicated that her death was not accidental.

Despite this, it took more than seven years for only some of the key evidence to be properly examined. During that time, critical material was overlooked, expert witnesses were excluded, and investigative opportunities were missed. These failures delayed recognition of the true nature of Elly’s death and caused prolonged distress to Elly’s family.

From 2016, the available evidence supported serious concerns regarding the circumstances of her death. This included:

A Mozambique autopsy report concluding the death was violent and consistent with homicide, noting an “abundance” of sand in the airways.
Two official reports from the National Criminal Investigation Service (SERNIC) concluding homicide (including one issued by the Director General).
Crime scene photographs showing Elly’s clothing ripped apart and her body partially unclothed.
The chief Mozambique inspector stating in 2018 (recorded) that Elly was believed to have been moved post-mortem, and that the sand packed in her mouth did not match the scene location.
Early forensic observations from two autopsies describing extensive packed sand (“chockablock”) within the airways.
Severe facial abrasions around the cheeks, nose, mouth, and lips.

This information was provided to the Australian Federal Police (AFP) and the Department of Foreign Affairs and Trade (DFAT). However, the clear crime scene photograph was not provided or reported on to the Coroners Court of Victoria, Pathologist or the family in 2016–2017 by the AFP. As a result, key material was not fully considered at the earliest stage of the investigation.

In the years that followed, further expert analysis reinforced the same conclusion. Independent forensic pathologists and radiologists consistently found that Elly’s airways and lungs contained large volumes of packed sand. The volume, density, and distribution of this material were not consistent with accidental inhalation.

Radiological imaging in 2019 confirmed both lungs contained high-density material comparable to bone or cement. Forensic pathology findings described the airways as completely obstructed with sand. These findings were consistent across multiple independent examinations, except for the Melbourne pathologist’s initial report, which stated no significant sand was present.

At the same time, critical evidence was either excluded, misrepresented, or not fully examined. Key expert witnesses were not initially called to give evidence at the inquest. Important forensic material, including trace evidence and potential DNA items, was not preserved, was lost, or was not analysed in Mozambique or Australia. This significantly limited the ability to fully reconstruct the circumstances of Elly’s death.

These limitations materially affected the scope of the coronial inquiry.

Ultimately, the Coroner amended the cause of death to “aspiration of a large amount of sand.” However, the mechanism by which this occurred, and whether it was accidental or non-accidental, was not fully resolved despite substantial evidence indicating a non-accidental explanation.

This report therefore sets out the forensic, medical, and investigative evidence in structured form to assist in understanding the full evidentiary picture.

Coronial Investigation Analysis

From the very beginning, I believed my daughter had been murdered, and the factual evidence I obtained in 2016/17 fully supported this belief. I repeatedly informed the Australian Federal Police (AFP), the Department of Foreign Affairs and Trade (DFAT), and the Coroners Court of Victoria, providing detailed evidence and raising urgent concerns! Despite this, the authorities failed to properly investigate or take meaningful action, compounding the injustice and suffering experienced by Elly’s family over many years.

Evidence known was both significant and compelling. This included:

A clear photograph showing Elly’s body half naked with her top completely destroyed ripped apart from her right shoulder and all the way down her torso.
A 2017 SERNIC revised police report concluding homicide
A second SERNIC police report from their “Director General” in 2020 reaffirming the homicide determination.
An official meeting with the AFP and the Duty Attorney General in Maputo in May 2023, during which the homicide classification was “reconfirmed” for the third time officially.
A Mozambique autopsy report concluding violent death and homicide. Early forensic findings identifying an “abundance” of packed sand in Elly’s airways
Both Mozambique and South African autopsies “concurred” that they found large quantities “ABUNDANT ” sand which was “CHOCHABLOCK” packed in Elly’s airways.
In 2016 both autopsies doctors highly suspected foul play. Dr Klepp conducted the second autopsy informed me of this over a phone conversation and in an email to DFAT.
Independent pathologist Dr Byron Collins reviewed the evidence shortly before the Inquest and stated that, if the court accepted the sand findings together with the crime scene photograph, it was his robust opinion that Elly’s death was a “homicide”. Despite the family formally requesting his inclusion, Dr Collins was never called to give evidence. Instead, the Coroner relied on a peer review conducted by colleagues of the Melbourne pathologist at the Victorian Institute of Forensic Medicine (VIFM), based within the Coroners Court system, rather than permitting independent expert testimony from Dr Collins regarding the medical conclusions in Elly’s case.
A sand trace evidence sample taken from the crime scene by the AFP/SLO that was never compared with the high-density sand later identified in Elly’s body in the radiology report from a CT scan prior the Melbourne autopsy on the 22nd November 2016.
The Melbourne pathologist initially found no sand of any significance, however later in 2019 a radiological analysis conclusively proved otherwise with denesty levels of cement and Bone.
Missing critical evidence from the VIFM: a lady’s sanitary item that was never recovered or DNA tested. Dr Klepp states with her evidence given at the inquest that she:
“placed the tampon in a plastic bag placing it inside Elly’s body for repatriation to Australian”.

Mozambique authorities also informed the AFP that Elly’s body was suspected to have been moved post-mortem. Despite this, no forensic comparison was conducted between sand from the scene and the material (SAND) found in her airways representing a critical missed investigative step.

Despite the importance of this trace evidence, it was misrepresented, incompletely disclosed, or not properly analysed during the initial stages of the investigation.

In September 2017, following a meeting with the Melbourne pathologist, the family, and AFP representatives, the coronial process relied on findings that were later shown to be incorrect. A Melbourne based forensic pathologist stated that “no sand was present in Elly’s airways”. This meeting was recorded with consent, providing a verifiable record of the statement made at the time that,” No sand was found by the Melbourne pathologist”.

This assertion directly contradicted multiple other sources of evidence, including:

• The Mozambique autopsy findings, which recorded a “violent death” and classified the manner of death as “homicide”.
• Dr Klepp’s forensic examination, which documented packed sand and abrasions, particularly around the lips and mouth, and raised concerns consistent with possible foul play in 2016.
• Later radiological findings indicating high density material consistent with sand throughout the airways, with both lung trees from the imagery clearly filled with sand.
• The evidence provided by Dr Klepp and Dr O’Donnell (Radiologist) during the inquest described high density material equivalent to “bone” density and extensive sand packed throughout the airway passages and both lungs filled with sand. Dr Klepp also described the airways as being “chockablock” with sand during her evidence given at the inquest.

These compelling findings highlight a material conflict regarding the presence of sand in the airway and the forensic interpretation of the airway contents, with significant implications for the reliability of the conclusion reached by the Melbourne pathologist from the Victorian Institute of Forensic Medicine (VIFM), who stated that no sand was present or identified during his examination.

Most significantly, several key witnesses were excluded from the inquest. These included forensic specialists, investigators, and independent experts who had direct knowledge of the case with boots on the ground and whose evidence supported a finding of homicide.

Their exclusion was not a minor procedural issue it fundamentally limited the evidence available to the Coroner at the inquest and prevented a full and fair examination of the circumstances surrounding Elly’s death.

Taken together, the failure to properly analyse early evidence, the reliance on incorrect findings, and the exclusion of critical witnesses significantly compromised the integrity of the coronial process. The issue in this case was not a lack of evidence, but a failure to properly engage with the evidence that was available from the outset.

Dr. Klepp Forensic Pathology Findings Summary – Inquest

Qualifications and Experience

MBBCh degree, 1977
Diploma in Forensic Medicine, 1981
Fellowship in Forensic Pathology, 1984
Master’s degree in Forensic Pathology, 1985
44 years of experience in forensic medicine and pathology
Senior specialist lecturer, University of Witwatersrand
Extensive experience with cases of individuals buried alive, including mining accidents and collapses in South Africa

Dr Klepp, a highly experienced forensic pathologist with 44 years of professional practice, provided decisive and compelling forensic evidence at the inquest. She confirmed that Elly’s oral cavity, airways, and lungs were completely packed with sand. During her testimony, Dr Klepp used the word “CHOCH-A-BLOCK” to describe the extent to which the sand filled these spaces. This level of sand aspiration is highly significant and indicates that the material was inhaled in a manner that was unnatural and forcible, rather than consistent with a natural or accidental process.

Elly’s body had been transported over four days along dirt roads due to monsoonal flooding, with airports closed, prior to an initial autopsy in Maputo on 14th November 2016. Despite this prolonged transport and prior autopsy, Dr Klepp’s examination on 16th November revealed that the oral cavity and airways remained fully obstructed with sand. This persistence demonstrated that the sand was firmly lodged and physically impossible to have been inhaled accidentally.

Dr Klepp emphasised that accidental aspiration of sand to this degree was not physically possible while lying flat on the firm surface depicted in the crime scene photograph. She also highlighted that it is a point that no sand sample was taken from the body, which was a significant missed opportunity. Drawing on her extensive experience examining victims buried alive in mining accidents and structural collapses in South Africa, she stated that in her 44 years of practice she had never encountered airways so densely packed with sand, describing Elly’s case as the most severe she had ever seen.

A primary witness at the crime scene observed that Elly’s mouth was so tightly packed with sand as to appear highly suspicious. Dr Klepp agreed with this observation:

“I absolutely agree with that witness, as that is how I found her oral cavity, CHOCK-A-BLOCK.”

Her conclusions were further supported by Jade O’Shea, who was with Elly that night and confirmed that the ground surrounding the toilet block where Elly was found was firm-hard and rocky, not loose sand.

Dr Klepp also stated at the inquest that during her examination she removed a lady’s sanitary item from Elly’s body and placed it in a plastic bag with the organs for repatriation to VIFM. This item was potentially significant forensic evidence for DNA but was largely ignored in the Coroner’s findings, was not detected by the Melbourne pathologist at VIFM, and has never been recovered!!

Dr Klepp’s conclusions were further corroborated by the Mozambique autopsy report, which recorded abundant sand in the airways, supporting the finding that significant sand aspiration had occurred while alive.

In addition, two Mozambique criminal police reports from SERNIC (Servico Nacional de Investigation Criminal) dated 10th April 2017 and 20th August 2020 both concluded that Elly was a victim of “HOMICIDE.” The second report and more comprehensive was issued by the “Director General” of SERNIC, further reinforcing the seriousness of that determination.

Importantly, these reports also stated that the exact place of death was “unknown.” This official police finding indicates that Mozambique authorities did not determine or formally establish the precise location where the fatal events occurred, including the toilet block area where Elly’s body was discovered. It reflects that the precise place of death was not established within the investigation record, leaving the location of death unresolved on the available evidence.

Despite this, Mr Cain stated in his findings that there was no investigative material available from Mozambique authorities relating to the case file. However, he was in possession of a comprehensive police report provided directly by the Director General overseeing the Mozambique police investigation, which specifically recorded the place of death as “unknown.”

Taken together, these records indicate that the Mozambique authorities must have evidence that they believe Elly’s murder did not take place at the location where her body was found to have come up with place of murder Unknown. The official finding of “unknown” in relation to the place of death means that the investigation record does not provide a determination that the toilet block area, where Elly’s body was discovered, was the location where the fatal events took place.

Mr François Roos, a private investigator with on-site experience in Mozambique, was involved in work alongside SERNIC police during the reopening of the investigation in 2021/22 and provided operational support during aspects of the renewed inquiry, including efforts relating to the identification and apprehension of persons of interest shortly before the 2023 inquest.

It is stated that Mr Roos was not called to give evidence at the inquest, despite his involvement and his capacity to explain aspects of the SERNIC investigative process and reports, including references to the conclusion recorded within those materials that the exact location of death was “unknown.”

Mr Roos has further conveyed to the family his view that the evidence obtained during the reopened investigation, including material developed through SERNIC, is consistent with a finding of homicide. This reflects his professional opinion based on his involvement in the investigation process.

Mr Roos testimony could have clarified whether Elly’s body had been moved post-mortem and supported Dr Klepp’s forensic opinion that the presence of sand packed within the airways (“chock-a-block”) was not consistent with the body position and firm surface depicted in the crime scene photograph at the toilet block location where Elly was found. Dr Klepp further stated in evidence that, in her forensic assessment, it was highly unlikely that the fatal events occurred at this location given the combination of findings. Such evidence would have provided the Coroner with a clearer understanding of the competing forensic interpretations and the investigative position of the Mozambique authorities.

When considered alongside crime scene photographs showing ripped clothing, bruising, and abrasions around Elly’s mouth and lips, Dr Klepp’s evidence strongly supports the conclusion that Elly’s death was not accidental and is highly indicative of foul play.

Dr Klepp did not agree to provide testimony until only days before the inquest, and the Coroner explicitly stated he would not compel her attendance, limiting the inquest’s engagement with critical expert evidence. Had her testimony been secured earlier through a formal AFP statement to the Coroner in 2016/17, she would have had access to decisive forensic findings regarding the densely packed sand highlighting the highly suspicious nature of Elly’s death early from the onset.

Importantly, it is contended that this evidence, including photographic material depicting the condition of clothing at the scene, was not included or referenced in the AFP/SLO statement provided to the Coroner dated 17th October 2017. This contention is based on comparison with the official record of material provided to the inquest during the relevant period.

It is further stated in official correspondence from DFAT that the clear scene photograph was provided to the Chief Inspector by the AFP/SLO on 8th December 2016 as part of the investigative material, indicating that the material was formally shared within the Mozambique investigation process and provided within the AFP/SLO investigative material.

This material is not referenced in the AFP/SLO statement provided to the Coroner dated 17th October 2017, based on comparison between DFAT correspondence and the contents of the AFP/SLO statement tendered to the inquest.

Taken together, these records indicate a discrepancy between material formally shared within the AFP/SLO investigative material and material subsequently referenced in the AFP/SLO statement provided to the Coroner!!!

Contradictions with the Melbourne Pathologist

The Melbourne pathologist reported he found “no sand whatsoever” in the airways at autopsy and expressly stated this position during a meeting with the family and the Australian Federal Police on the 7th September 2017. That meeting was recorded with consent and occurred prior to the radiology report being issued later in 2019.

This finding stands in direct contradiction to Dr Klepp’s forensic examination and the Mozambican autopsy, both of which documented the oral cavity, airways, and lungs as abundantly packed, “chock-a-block” with sand.

The concurrence between Dr Klepp and the Mozambique pathologists is medically significant. Their independent findings establish that the volume and density of packed sand present in the airways could not plausibly have been inhaled accidentally, rendering an inadvertent or self-induced aspiration virtually impossible.

In 2019, the family requested the radiology report taken from the CT scan which was conducted immediately prior to the Melbourne autopsy on 22 November 2016. Upon discovering that sand had been detected all the way down Elly’s airways, the family engaged independent forensic pathologist Dr Byron Collings to review the radiological findings.

I asked Dr Collings how it was possible for the Melbourne pathologist to have missed the extensive sand identified within the radiology report.

Dr Collings replied:

“I cannot explain to you, Paul, how this was not reported in his autopsy findings. What I can tell you is that the radiological imaging clearly demonstrates foreign material consistent with sand extending throughout the airways and deep into both lung trees. Dr O’Donnell would be in a better position to explain his own report.”

At the inquest, Dr O’Donnell’s testimony directly addressed this issue. He stated that the density levels recorded in the imaging were consistent with bone-density material, and that both lower lung trees were filled with foreign material identified as sand. The evidence given by Dr O’Donnell was compelling, however this was ultimately not reflected in the Coroner’s findings!!!

The coroner did not initially want Dr O’ Donnell to give evidence possibility because it went his own VIFM doctors findings!!

Dr Christopher O’Donnell – Radiology Evidence

Dr Christopher O’Donnell, a senior radiologist specializing in forensic imaging, conducted detailed pre-Melbourne autopsy CT scans, including post-mortem lung imaging and quantitative forensic analysis.

CT imaging confirmed that both lung trees were completely filled with sand, with densities of 1290 HU and 947 HU, comparable to cement and bone.
These findings directly contradicted the Melbourne pathologist’s September 2017 assertion that “no sand was found whatsoever.” The CT scan was taken just prior the Melbourne pathologist autopsy on the 22nd November 2016.

Despite acknowledging “gaps in the evidence,” Coroner Mr Cain initially excluded Dr O’Donnell from testifying initially. Only after repeated representations from the family and our legal counsel, including a formal letter requesting reconsideration, was Dr O’Donnell’s testimony revisited. This caused Mr Cain to change his mind and reinstate Dr O’ Donnell as a witness.

At the inquest, evidence given by Dr O’Donnell supported the findings of the South African and Mozambique autopsies and was independently compelling. Dr O’Donnell confirmed that both lungs were filled with sand, with areas of very high density equivalent to bone density, a pattern consistent with forcible introduction. These findings fully corroborated the conclusions reached by Dr Klepp and the Mozambique pathologists.

This convergence of expert forensic evidence demonstrated that Elly could not have inhaled the sand accidentally.

Dr Byron Collins – Independent Pathologist (Not at the Inquest)

Independent forensic pathologist Dr Byron Collins conducted a separate assessment. Based on Dr Klepp’s findings, he agreed with Dr Klepp and concluded that it would have been impossible for Elly to compromise her airways to such an extent while lying flat as depicted in the crime scene photograph.

Prior to the Coroner’s determination, Dr Collins provided a formal assessment stating that if the findings of Drs. Míguez and Klepp were accepted as accurate and reliable, it would be reasonable to accept their conclusions regarding cause of death. He further noted that, in conjunction with the scene photographs, the manner of death was consistent with homicide:

“If it were accepted by the court that the various injuries and findings identified by Drs. Míguez and Klepp were accurate and reliable, then I am of the robust view that it would be entirely reasonable to accept the cause of death and associated comments in these reports and, in conjunction with the scene photographs, the manner of death is consistent with HOMICIDE.”

Despite the significance of his conclusions, Dr Collins was “not called to testify” as we asked for by my barrister at a hearing in February 2023. The coroner then stated that he was happy to have an independent assessment of all the medical evidence at the time but changed his mind later. Instead, the Coroner relied solely on a peer review conducted by doctors from the Victorian Institute of Forensic Medicine. The family formally objected to this approach in correspondence to Mr Cain, expressing concern that the peer review was inherently biased because it was conducted exclusively by VIFM colleagues, without independent external scrutiny. Mr Cain responded that he had full confident in the peer review being undertaken by other VIFM doctors!!!

The exclusion of Dr Collins, together with other independent witnesses, prevented the family from presenting a coherent and fully integrated evidentiary case. This limitation obstructed the proper synthesis of pathological findings, crime scene photographs, and investigative material capable of supporting a determination of homicide.

Combined Expert Conclusions

Taken together, the evidence from Dr Klepp and Dr O’Donnell demonstrates that it was physically impossible for Elly to have inhaled this amount of sand on her own. There is no logical or natural explanation for such extensive aspiration to occur voluntarily or accidentally. The only rational conclusion supported by the evidence is that an external force caused the airway obstruction while Elly was alive, making her death non-accidental!!!

The fact that Dr Klepp was only agreed to be a witness shortly before the inquest, together with the Coroner’s decision not to compel her attendance, and the initial exclusion of Dr O’Donnell, limited the extent to which key expert evidence was fully obtained and examined during the proceedings. These factors are raised as matters relevant to the completeness and testing of expert evidence during the inquest process.

It must be noted that the Melbourne autopsy report records that no sand was found within Elly’s lungs or airways on examination by the court’s own VIFM, located within the same building. This raises questions as to how the available expert evidence was assessed in light of the evidentiary record available to the inquest. It is further noted that Dr Klepp and Dr O’Donnell ultimately provided compelling evidence during the inquest. It is contended that their participation occurred following concern raised by the family regarding their initial non-inclusion in the earlier stages of the proceedings, particularly in relation to Dr O’Donnell. These matters are raised in the context of the evolving scope of expert evidence available to the inquest.

It is further contended that the initial non-inclusion of Dr O’Donnell affected the early scope of expert evidence considered, and that his subsequent involvement followed formal representations made on behalf of the family, resulting in his forensic conclusions being placed before the inquest!!!

Importantly, given the compelling evidence given by Dr Klepp and Dr O Donnelly the Coroner later amended the cause of death from “Undetermined” to “Aspiration of a large amount of sand,” validating the concerns I raised in 2016. The factual evidence I disclosed at that time accurately identified the nature and significance of Elly’s airway obstruction, highlighting the authorities’ initial failure to act!!!

Bias and Procedural / Systemic Failures

The inquest’s omissions allowed flawed conclusions to stand, contributed to years of uncertainty and anguish for the family, and undermined public confidence in the coronial process. The failure to fully consider compelling expert evidence reflects a systemic breakdown in investigative rigor and procedural fairness, leaving Elly’s family without definitive answers despite overwhelming factual evidence regarding her manner of death.

Before the inquest, the Coroner was aware of the Mozambique authorities’ classification of Elly’s death as a homicide. At a hearing in February 2023, he acknowledged that there were “gaps in the evidence.” Despite this, the Coroner did not initially call crucial expert witnesses, including Dr Christopher O’Donnell initially!!!

It is further noted that additional witnesses, including Mr Francois Roos, Dr Bryon Collings, and Mr Charlie Bezzina, provided material or evidence relevant to aspects of the investigation. Their involvement is relied upon as part of the broader body of evidentiary material considered in relation to investigative developments, expert interpretation, and procedural context throughout the course of the investigation and inquest process.

The family’s legal team formally requested Dr O’Donnell’s inclusion through a letter dated 9 August 2023 (attached), emphasizing that his testimony was vital to clarify the radiology findings, particularly regarding the presence and volume of sand in Elly’s lungs, trachea, and larynx, and its relevance to determining Elly’s cause of death.

Dr O’Donnell’s evidence at the inquest was compelling. He confirmed that both of Elly’s lungs were effectively filled with sand, with very high-density radiological readings equivalent to bone density, a finding absent from the Melbourne autopsy report.

The Melbourne pathologist later reviewed the radiology in a supplementary report in 2019 and stated that he could not quantify the presence of sand. However, the radiologist who compiled the report had, at the inquest, quantified the sand density as equivalent to bone density and was not asked to review or clarify his own 2019 report, leaving this critical discrepancy unresolved for years until the inquest in 2023.

This discrepancy directly supports Dr Klepp’s autopsy findings and testimony given, which demonstrated mechanical airway obstruction caused by sand, consistent with deliberate external action rather than accidental inhalation.

Furthermore, Dr O’Donnell’s findings demonstrated that it was possible to obtain a forensic sand sample from Elly’s body, enabling potential comparison with sand collected from the crime scene by the AFPP/SLO. At a meeting in November 2016, the Mozambique Chief Inspector informed the AFP/SLO that authorities suspected Elly’s body had been moved post-mortem.

Despite this information, no forensic sand sample was taken from Elly’s body at that time, representing a serious investigative failure. This omission materially limited the Coroner’s ability to assess scene correlation and deprived Elly’s family of evidence critical to establishing the truth and the circumstances of her death, particularly the fact that her body had been moved post-mortem. Significantly, this failure was neither mentioned nor clarified in the Coroner’s findings!!!

The Coroner’s initial reluctance to call Dr O’Donnell may have been influenced by procedural considerations. Both the Melbourne pathologist and Dr O’Donnell worked within the same building as VIFM, creating a potential conflict of interest. Nonetheless, the formal request from the family’s lawyer compelled the Coroner to include Dr O’Donnell, ensuring that independent expert evidence was fully presented.

Additional Procedural Concerns – Conduct of the Inquest

During the inquest, my barrister formally requested that Mr Cain allow the doctors to be cross-examined separately. Questioning all three at once, he explained, would be confusing and risk obscuring critical discrepancies. Mr Cain said he would consider the request and adjourned proceedings for lunch.

During that adjournment, however, another person representing a separate authority followed Mr Cain into chambers. This was highly irregular and improper, and it may have influenced his decision. When proceedings resumed, Mr Cain denied the request.

This decision was significant. Separate cross-examination would likely have exposed serious contradictions in the evidence particularly regarding the presence of sand in Elly’s airways. Dr Klepp confirmed a significant amount of packed sand, while the VIFM Melbourne pathologist reported finding none. At the time, I was unaware of the coroner’s discretion in this area, but both my barrister and solicitor immediately raised serious concerns and explained the potential implications.

That evening, my barrister consulted colleagues. The following morning, he advised that there were grounds to seek Mr Cain’s removal advice that was confirmed by senior legal counsel. However, pursuing this would have required a completely new inquest before a different coroner, effectively restarting the process. After careful consideration, and under immense pressure, I chose not to proceed. Restarting after an already seven-year process would have caused further trauma to our family. As a result, despite the seriousness of the irregularity, we continued, and all three doctors were cross-examined together.

Despite acknowledging “gaps in the evidence,” Mr Cain initially excluded several key witnesses. Most concerning was his refusal to call Dr O’Donnell, the senior radiologist whose report had objectively confirmed high-density sand in Elly’s airways prior to the Melbourne autopsy. Only after strong submissions from my lawyer did Mr Cain reluctantly allow Dr O’Donnell to give evidence.

(Inquest transcript, 23 August 2023, page 129)

29, His Honour: “Yes. Let me deal with Dr O’Donnell in the first
30, instance. He was an input into Dr Lynch’s report and he’s only
31, here because your client requested it.”

Initially treated as a supporting contributor rather than an independent expert, Dr O’Donnell went on to confirm that both lungs were filled with sand, with imaging density levels fully supporting that conclusion.

The involvement of the Australian Federal Police was also limited. Despite a seven-year involvement, only Commander Smith who joined much later was called to give evidence. Key decisions made between 2016 and 2018, including evidence handling and the failure to issue a Mutual Assistance Request (MAR), were not examined. The AFP personnel directly involved in the early stages of Elly’s suspicious death were never called to testify.

These failures in witness management significantly restricted the evidence before the court. This was despite Mr Cain acknowledging that there were “gaps in the evidence” and that these witnesses were relevant to addressing them. Each of these witnesses had already submitted reports to the court, all independently concluding that Elly’s death was a homicide, with clear explanations supporting that finding. Yet, despite their expertise and the consistency of their conclusions, they were initially excluded.

Witness Exclusions and Investigative Oversights

Despite acknowledging gaps in the evidence, Mr. Cain initially excluded several key witnesses:

Dr Byron Collins, Independent pathologist, confirming manner of death consistent with homicide.
Charlie Bezzina, Former Victoria Police senior detective, whose review of investigative material indicated homicide.
Critical Witness Exclusion and Procedural Failings – Mr. Francois Roos
Francois Roos, a private investigator with direct, on-site knowledge of the Mozambique homicide investigation, was uniquely positioned to provide critical insight into the circumstances surrounding Elly Warren’s death. He actively supported the homicide conclusions reflected in official communications and worked alongside the Mozambique police in an attempted to apprehend key suspects shortly before the inquest an involvement confirmed in a letter sent to Mr. Cain by the AFP on 19th June 2023.
Despite his pivotal role and firsthand knowledge, Mr. Roos was not called to give evidence at the inquest. He could have explained the context and meaning of the SERNIC reports, including the crucial finding that the exact location of death was “UNKOWNEN.” His testimony would have clarified that Elly’s body had been moved post-mortem, providing the Coroner with a clear understanding of the investigative position of the Mozambique authorities information central to determining the circumstances of her death.
Mr. Roos had informed the family that he wished to give evidence and had a significant update relevant to the case. This information was submitted to Mr. Cain in the witness list prior to the inquest. The court’s refusal to call him effectively excluded this vital testimony from consideration.
This exclusion occurred alongside the family’s formal protest over the absence of an independent assessment of the medical evidence. The family had requested the involvement of Pathologist Dr. Byron Collings and Mr. Charlie Bezzina both of whom had extensive engagement with the investigation over five years to provide independent scrutiny. Instead, Mr. Cain chose to rely on a peer review conducted by VIFM doctors, against the family’s absolute protest due to a clear conflict of interest. The court’s failure to facilitate independent review compounded these procedural shortcomings.
The combined effect of excluding Mr. Roos’s testimony and failing to allow an independent medical assessment represents a significant procedural failing. It prevented the Coroner from receiving a complete and accurate account of the evidence, leaving critical questions regarding Elly’s death unresolved and undermining the integrity of the inquest process.

Dr Klepp agreed to testify only days before the inquest, following direct intervention by Elly’s mother. Dr O’Donnell was ultimately permitted to testify after persistent advocacy.

Absent this evidence, the inquest would have relied solely on the Melbourne pathologist from VIFM, whose findings remained undetermined and asserted that there was “no sand found whatsoever.” Such a position would have severely distorted the evidentiary matrix before the Court and rendered the inquest fundamentally prejudicial and potentially disastrous for the family.

Key trace evidence, including Elly’s clothing and the missing sanitary item, was never obtained for DNA testing. Mozambique authorities had prime suspects but lacked sufficient evidence to prosecute. The AFP had the opportunity to retrieve these items from Maputo Central Hospital but failed to do so; the evidence was eventually destroyed.

These oversights, coupled with the failure to provide Melbourne pathologist access to crime scene photographs including the South African autopsy photos showing the ripped-apart T-shirt and injuries, demonstrate gross procedural failures. Note the AFP had all this evidence in 2016/17 but not the coroner, family or Melbourne pathologist!!!

AFP Non-Disclosure of Critical Evidence

On 7th September 2017, Dr Lynch was asked by me during a recorded meeting attended by the family, three AFP personnel, and the Coroner’s Assistant about the blurred photograph. At that time, 11 months after Elly’s highly suspicious death, neither the pathologist, the family, nor the Coroner or Coroner’s Assistant, Mr King-Taylor, had been provided with the clear photograph by the AFP, despite the AFP having obtained a clear version from DFAT in 2016 clearly showing Elly’s top ripped apart!

Importantly, not even the Coroner’s Assistant, Mr King-Taylor, who was present at the meeting, was aware of the existence of this clear photograph, which clearly depicted vital evidence relating to the damaged clothing at the scene. Elly’s clothing can clearly be seen ripped apart in the photograph.

Dr Lynch replied at this recorded meeting that he “could not take or make anything” from the “blurred” image because it was too grainy to properly assess.

As a result, only the blurred photograph was effectively considered and placed into evidence at this time. This was later confirmed and supported in the AFP/SLO official statement supporting the Coroner’s coronial investigation dated 17th October 2017, which makes no mention whatsoever of the clear photograph provided to the AFP on 25th November 2016, nor that this clear photograph had been passed on to the Chief Inspector on 8th December 2016!!

This is also documented in official correspondence confirming that the clear photograph was provided to the Mozambique Chief Inspector on 8th December 2016 by the AFP/SLO, as stated in an official letter provided to the family on 22nd March 2019 by Assistant Secretary of DFAT Claire McComish.

However, it was not until correspondence provided to the Coroner on 16th June 2023, shortly before the inquest, that it was officially confirmed that DFAT had supplied the AFP with the clear photograph on 25th November 2016. This meant the AFP had been in possession of this critical piece of evidence for almost seven years before its existence and retention were formally acknowledged.

Despite receiving the photograph in November 2016, it was not provided to the Melbourne pathologist, the family, or the Coroner during the early stages of the investigation. As a result, important aspects of the scene were not available for consideration during the initial forensic and coronial review!!

I also asked Dr Lynch at this recorded meeting whether he had seen any autopsy photographs. His response was, “No, I had not seen any autopsy photographs of the body.”

However, the AFP had been provided with the South African autopsy photographs in 2016, and this is clearly documented in the AFP Action Sheet on page 11.

Importantly, three AFP officers were present at this recorded meeting, yet not one of them disclosed the existence of either the clear photograph depicting the ripped-apart top or the South African autopsy photographs showing the highly suspicious severe marks and abrasions to Elly’s cheeks, mouth and lips!

This factually recorded meeting demonstrates that the Melbourne pathologist, Coroner’s court and family were not aware of this vital evidence, while the three AFP officers seated at the table were fully aware of all this vital evidence, yet not one word was said about either the clear photograph or the South African autopsy photographs!!!

I reiterate that this meeting was recorded with consent. Therefore, the above facts support the the families major issue of non-disclosure by the AFP as they did not want to be accountable!!

Despite these matters, which the Coroner was fully aware of through the recorded evidence in the brief and my statements, reports and my affidavit involving the Melbourne pathologist with the meeting concerned.

Another “very serious matter” emerged during the meeting with the Melbourne pathologist. After the pathologist left the room, the meeting continued with the family, AFP officers, and the Coroner’s Assistant, Mr King Taylor.

During this discussion, which as I have mentioned was fully recorded, I directly asked the AFP whether there was an “active homicide investigation being conducted by Mozambique police”. The AFP officers answered unequivocally that there was “an active homicide investigation by Mozambique police”.

This was an extraordinary admission, although its full significance was not immediately apparent at the time. It later became increasingly troubling for the family as we became aware of AFP options that were available but not pursued or communicated. It confirmed that the AFP knew Mozambique authorities were actively investigating Elly’s death as a homicide. A homicide investigation is not commenced lightly; it is initiated where law enforcement authorities have identified circumstances sufficiently serious to warrant investigation into a suspected homicide.

This appears difficult to reconcile with submissions later made by the AFP Commissioner to the coroner at the inquest, dated 18th December 2023, in which it was stated that Mozambique police did not classify Ms Warren’s death as a homicide prior to May 2023. This is inconsistent with the account given in this meeting and with earlier police reporting in 2017 and 2020 from the Director-General, which recorded Ms Warren’s death as a homicide, and raises questions about the consistency, accuracy, and completeness of the material relied upon by the Coroner in considering the evidence at inquest by the AFP.

The AFP’s acknowledgment demonstrates that they were aware the responsible law enforcement agency in Mozambique was treating Elly’s death as a homicide investigation. This was not a matter being treated as a simple accident or misadventure, but one being investigated as a potential unlawful killing.

Despite possessing this knowledge prior to 7th September 2017, no Mutual Assistance Request (MAR) was ever submitted. The AFP again maintained that the matter was outside its jurisdiction. However, the family was not informed of the MAR process, a mechanism through which the AFP could become involved once aware of a suspected crime against an Australian citizen overseas.

The failure to disclose this process during such a significant meeting is deeply concerning. While confirming the existence of an active homicide investigation, the AFP simultaneously did not inform the family of the very process that could have facilitated Australian assistance to that investigation. As a result, the family was not made aware of an important avenue that was directly relevant to how the matter could have been progressed at the time.

On the material available, this is difficult to reconcile with the position later advanced in the inquest process and appears to be inconsistent with the information conveyed during the meeting itself. It raises serious questions about whether the existence, purpose, and practical relevance of the Mutual Assistance Request process was properly communicated to the family at the time it was most critical.

This is another example of the AFP being aware of significant operational options in response to a suspected homicide involving an Australian citizen overseas, yet those options were not raised with the family at an early stage. Had they been disclosed at the outset, they may have influenced how the investigation was pursued and what avenues of assistance were considered available.

Outcome

What is particularly concerning for Elly’s family is that the AFP Commissioner’s submissions to the Coroner in December 2023 appear to be inconsistent with the documentary record and with earlier official statements and recorded material.

Based on the available evidence, there are multiple contemporaneous records which indicate that Mozambique authorities had already treated Elly Warren’s death as a homicide well before May 2023. These include:

The Mozambique autopsy findings recording a violent death/homicide;
The Mozambique police report dated 10th April 2017 classifying Elly’s death as a crime/homicide;
The SERNIC report dated 11th August 2020, issued by the Director-General of SERNIC, confirming Elly Warren as a victim of crime/homicide;
Recorded statements from AFP officers during a meeting on 7th September 2017 acknowledging that Mozambique police were conducting an active homicide investigation.

In addition to these records, concerns arise from the handling and disclosure of key evidentiary material during the early stages of the investigation. In particular, correspondence and official records indicate that a clear version of a critical scene photograph was obtained by the AFP in November 2016 and later provided within the investigative chain; however, this image was not made available to the pathologist, the Coroner, or the family at the time, with only a blurred version being considered in early forensic review.

At a recorded meeting on 7th September 2017, the Melbourne pathologist confirmed he had not seen any autopsy photographs, despite AFP records indicating that such material had been obtained. This raises questions about the extent to which all relevant visual forensic material was appropriately shared with independent medical experts and the coronial process during the early investigative phase.

Taken together, these issues raise concerns about consistency, completeness, and transparency in the information provided to the Court regarding the classification of the death and the evidentiary material available at relevant times.

The apparent inconsistency between the AFP Commissioner’s submission that no Mozambican authority had classified the death as a homicide prior to May 2023, and the documentary record outlined above, is significant. If, as the contemporaneous records suggest, the death had already been treated as a homicide by Mozambican authorities years earlier, then the factual basis upon which later submissions were made requires careful scrutiny.

The documentary record, including official police reports, autopsy findings, and recorded statements, suggests that the homicide classification existed well before the timeframe relied upon in the AFP Commissioner’s submission. This raises questions about how that material was assessed and presented to the Coroner during the inquest process.

For Elly’s family, these inconsistencies remain unresolved. The concern is not only the classification itself, but whether all relevant information, including earlier foreign police determinations and key forensic material, was fully and accurately reflected in the submissions and evidence presented to the Court.

The Coroner ultimately stated in his findings that he was not critical of the AFP. However, in light of the documentary record and the issues outlined above, the basis for that conclusion is a matter that continues to be of concern to the family.

Application of the Briginshaw Principle

Coroner’s Findings (No. 22)

Mr Cain stated:

“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.”

Background

The Briginshaw Principle comes from the 1938 High Court case Briginshaw v Briginshaw. In that case, Mr Briginshaw accused his wife of adultery, but the court ruled that adultery requires proof of sexual intercourse, suspicion or circumstantial evidence alone is not sufficient. From this, the High Court established that the more serious the allegation, the stronger and more compelling the evidence must be. Even in civil cases, which normally rely on a “balance of probabilities” standard, serious claims must be supported by clear, reliable, and consistent evidence.

Application to Elly’s Case

In Elly’s inquest, the allegation of homicide required the strongest, most compelling evidence, all of which is present:

Forensic findings:
- Mozambquie autopsy Drs Míguez found “ABUNDANCE” of sand in the airways and concluded Ellys death as “Violent/Homicide”.
- Dr Klepp identified packed, “CHOCHABLOCK” sand in Elly’s airways, which could not occur accidentally.
- Dr O’Donnell’s radiology showed extremely high-density levels of 1290 HU and 947 Hounsfield units, equivalent to bone density, with both lungs completely filled with sand to the lower levels.
- Dr. Klepp concurred with a witness present at the crime scene, who had remarked that it was unusual to see Elly’s mouth packed with sand and considered this suspicious. Dr. Klepp stated that she agreed with the witness, noting that when she examined Elly’s oral cavity seven days later after the Mozambican autopsy she found it still “chockablock,” with sand consistent with what the witness had observed at the scene.
- Dr Klepp stated that, given the body’s position laying flat on her front on the firm surface in the photo, it was physically impossible for the airways to become packed at that location, indicating likely post-mortem movement. She also noted that it was appoint a sand sample was not taken for comparison.
- Dr Byron Collins, although never called as a witness, reviewed the evidence and fully agreed with Dr Klepp, confirming that it was physically impossible to compact the airways with sand to that degree in that position and location. Dr Collins stated:
  “If it were accepted by the court that the various injuries and findings identified by Drs Míguez and Klepp were accurate and reliable, then I am of the robust view that it would be entirely reasonable to accept the cause of death and associated comments in these reports and, in conjunction with the scene photographs, the manner of death is consistent with homicide.”
Crime scene evidence: Photographs documented a ripped-apart T-shirt and facial injuries, consistent with a struggle and incompatible with accidental death.
Trace evidence: Clothing and sanitary items were never collected or analysed, despite being potentially critical.
Sand from the scene: The AFP Senior Liaison Officer collected sand samples, but these were never compared to Elly’s body to assess post-mortem movement. The Mozambique Chief Inspector informed the AFP/SLO in November 2016 that they suspected the body had been moved after death.
Elly’s murder was reconfirmed again to Mr Cain by the duty Mozambique attorney general in May 2023 that they are treating Ms Warren’s death as a homicide at a meeting directly with the AFP in Maputo. An official letter sent to Mr Cain confirms this by the AFP on the 19th June 2023.
Independent expert testimony:
- Dr Bezzina and Dr Roos provided key insights confirming circumstances inconsistent with homicide.
- Dr Collins, although not called as a witness, provided prior reports and statements concluding that the evidence overwhelmingly supports that Elly’s death was a homicide.

Misapplication in the Inquest

Despite overwhelming evidence:

Key expert witnesses were excluded or delayed, and Dr Collins was never called, even though his report corroborated Dr Klepp’s findings.
Crime scene photographs were withheld from experts, preventing full evaluation of the evidence.
Strong forensic and radiological evidence was subordinated to a weaker, undetermined opinion.
Investigative failures were treated as neutral rather than recognized as probative evidence.

Under the Briginshaw Principle, the strongest, clearest, and most compelling evidence must carry the greatest weight. The Melbourne pathologist’s undetermined conclusion cannot outweigh the objective findings of Dr Klepp, Dr O’Donnell, Dr Collins, Dr Bezzina, and Dr Roos. Once the cause of death was amended to aspiration of sand, it became physically impossible for this to have occurred accidentally, further demonstrating that critical evidence supporting homicide had been disregarded.

When all evidence forensic, radiological, crime scene, sand, trace items, and independent expert testimony is considered together, it forms a cohesive, compelling, and undeniable case of homicide. Every piece of evidence aligns to show that Elly’s death could not have been accidental.

Conclusion

Mr Cain’s conclusion that the evidence was insufficient to classify Elly’s death as homicide misapplied the Briginshaw Principle. The evidence is overwhelming, clear, and consistent, far exceeding the threshold required for serious allegations. A proper application of the law would have unequivocally determined that Elly Rose Warren’s death was a homicide, and the inquest failed to recognize this!

Key Procedural Failings

Melbourne pathologist’s undetermined report relied on without reconciling contradictions.
AFP did not pursue a Mutual Assistance Request (MAR).
Crime scene and autopsy photographs withheld from coroner and experts.
Witness management restricted critical testimony.
Trace evidence lost or destroyed.

Compelling Evidence of Homicide

Packed, chockablock sand in airways by two autopsies 2016 (Dr. Klepp) (Dr. Míguez)
High-density (BONE) with full lung obstruction (Dr O’Donnell).
Physical impossibility of accidental aspiration.
Witness account No damage to top at 11.30pm ,5-6 hours before the body was discovered.
Ripped T-shirt and facial abrasions prior death.
Body relocation post-mortem confirmed by Mozambique police chief and official report.
Independent professionals in their fields medical, law enforcement and investigative analyses corroborating Homicide.

These facts satisfy Briginshaw and support the determination that Elly’s death was a homicide.

Conclusion

The coronial investigation, as conducted by Mr Cain, profoundly failed Elly’s family. Despite seven years of evidence being available, critical witnesses were restricted, radiological and forensic evidence sidelined, and procedural avenues such as the MAR were never pursued.

Dr Klepp and Dr O’Donnell’s testimony was decisive, demonstrating packed sand in the airways, physically impossible to occur accidentally, supported by crime scene evidence. The exclusion or limitation of other qualified witnesses further undermined the completeness of findings.

Under Briginshaw, the evidence met and exceeded the threshold for serious allegations. The coroner’s reliance on the Melbourne pathologist’s undetermined conclusion failed to fully assess the strongest evidence, depriving the family of justice.

In sum, the inquest should have recognized overwhelming evidence of homicide, yet procedural failures, witness exclusions, and misapplication of Briginshaw resulted in a fundamentally flawed outcome.

References and Verified Records Entered Into the Brief

Case No: COR 2016/5474, Coroner’s Court of Victoria
Coronial Transcripts: 11/12/23, 24/08/23, pp. 164–165, 181–182, 184–185, 197–198, 234–240, 235, 237–238, 268–273
DFAT Correspondence: Claire McCormish, 22 March 2019
Australian Government Solicitors Letter: 16/06/2023
AFP Commander & Mozambique Authorities: Trip to Maputo; Mozambique Deputy Attorney General reaffirmed Homicide, aligning with AFP police reports 10 April 2017 and 20 August 2020
Radiology Report: Dr Christopher O’Donnell, June 2019
Mozambique/South Africa Autopsy: Dr Klepp, November 2016
AFP Action Sheets: Mr Scruton, November–December 2016
Letter Requesting Dr O’Donnell as Witness: 9 August 2023

Appendix

Letter dated 9th August 2023 requesting Dr Christopher O’Donnell as a witness:

“We request that Dr Christopher O’Donnell be called as a witness for the inquest. His testimony is vital to clarify the radiology findings, including the presence and volume of sand in Ms Warren’s lungs, trachea, and larynx, and its impact on her cause of death.”

Letter to mr cain to reconsider Dr O’Donnell from my lawyer

2 Proposed witness list

2.1 We have had an opportunity to consider the proposed witness list provided to our office on 3 August 2023. We are instructed to request that the Court reconsider its decision not to call Dr Christopher O’Donnell as a witness at the inquest in this matter.

2.2 Mr Warren is concerned that the absence of Dr O’Donnell as a witness in this matter may lead to the questions of whether sand was present in Ms Warren’s lungs, trachea and larynx, the volume of sand present and the likely impact of that sand on Ms Warren’s cause of death, being underdeveloped at the inquest. The radiology report prepared by Dr O’Donnell is complex and we consider the Court would be assisted by Dr O’Donnell being able to fully explain and clarify the matters contained within his report.

2.3 Mr Warren considers the presence of hypertense foreign material in areas of Ms Warren’s lungs, larynx and trachea as identified in the radiology report as critical evidence relating to Ms Warren’s cause of death. We understand that the bright white areas in the images produced in Dr O’Donnell’s report are of very high density. On this basis it appears that the sand identified in Ms Warren’s lungs, trachea and larynx is denser than some of Ms Warren’s bones in the surrounding areas. In our view, this suggests that there may have been a significant blockage to Ms Warren’s airways. This is relevant to determining Ms Warren’s cause of death.

2.4 Further, we understand that the density of the material identified on the scans, may be quantified using the Hounsfield system of measurement. For example, in his report, Dr O’Donnell has allocated a density of 1290 HU to the material located in Ms Warren’s larynx. The ability to quantify the density of the material identified in Ms Warren’s airways may have significant bearing on determining Ms Warren’s cause of death. The Hounsfield system of measurement is not explained in Dr O’Donnell’s report and accordingly there is no material presently before the Court which explains what conclusions can be drawn from the density values Dr O’Donnell has ascribed in his report.

2.5 Finally, Mr Warren feels that Dr O’Donnell is the most appropriate person to speak to the contents of his report and opine on the likely density of the material identified in the images contained within that report. This belief is supported by the fact Dr Lynch in his report dated 5 July 2017 was only able to identify some residual sand in Ms Warren’s trachea and bronchi. Further, Dr Lynch’s supplementary report dated 19th September 2019 states that ‘it is not possible to quantify the amount of sand identifiable on the CT images.’ Accordingly, any clarification regarding the likely quantity of sand found in Ms Warren’s airways will require Dr O’Donnell’s evidence as to the Hounsfield system of measuring density and the meaning of the density values attributed to the material found in his report.

2.6 In these circumstances, we are instructed to request Dr O’Donnell’s inclusion as a witness for the inquest. We are grateful to His Honour Judge Cain for his consideration of Mr Warren’s request.

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