As Elly’s father, I have prepared a report on the inquest and Coroner’s findings from an industrial engineering perspective, examining several key elements. It identifies serious flaws in evidence handling, inconsistencies in official accounts, and concerns that critical material was not properly disclosed, tested, or properly assessed. Key forensic opportunities appear to have been missed, while some evidence presented or relied upon appears to have been misleading or incomplete, raising fundamental questions about the reliability and integrity of the findings. There are also serious concerns regarding potential institutional bias, given the involvement of a VIFM pathologist linked to the Coroner’s own medical body, calling into question the independence and objectivity of the expert evidence relied upon. In addition, relevant witnesses were either not initially called, called only after significant delay, or not called at all, despite the apparent importance of their evidence to key factual issues under examination.