Coronial Inquest 1949

The first Coronial Inquest was held over two days, on the 17th and 21st June 1949.

"The resumed inquest into, the body of an unknown man, found on the beach at Somerton on December 1st, was yesterday adjourned *sine die* by the City Coroner Mr. T. E. Cleland on the ground that the evidence before him was too inconclusive to warrant a finding. 'I would be prepared to find that the deceased died from a particular poison of a group mentioned in evidence, and that it was not accidentally administered.'' the Coroner said in his summary of the evidence. 'But I cannot say whether it was administered by the deceased himself or by another person. 'There is no evidence who the deceased was. Although he died during the night of November 30th-December 1st. I cannot say where he died.'' None of the witnesses who had seen the man on the beach on November 30th had seen his face, or any part of his body which they could identify with the body found on December 1st. Mr. Cleland added. It is understood that the Police Department will ask the Museum to exhibit the plaster cast of the head and shoulders of the body there, in the hope that further evidence of identification will come forward. The name of a group of poisons, and of two poisons of that group, suggested in medical evidence as the cause of death, were suppressed by the Coroner. Evidence was given by Sir Stanton Hicks, Professor of Human Physiology and Pharmacology at Adelaide University, that the poison was easily procurable by the ordinary person. It might have been secured from a case under treatment, he said. Its use implied intelligence and shrewd observation, but not necessarily a knowledge of the way in which it caused death.

Prof. J B. Cleland. Professor Emeritus of Pathology at Adelaide University, said that he had examined the clothing of the deceased and the contents of a suitcase left unclaimed at the Adelaide Railway station. Orange-coloured thread in the suitcase corresponded, on microscopic examination, with the colour and size of fibre in similar thread used to mend clothing is the suitcase and on the body. Death was almost certainly not due to natural causes. Probably some poison was taken with suicidal intent. The discovery of the piece of paper with the words "*Tamam Shud*" (meaning 'the end ') in the deceased's pocket reinforced this supposition. Questioned by the Coroner as to deceased's choice of a frequented place, witness said he thought that the poison might have begun to have a soporific effect before deceased had gone as far along the beach as he intended. Witness thought it unlikely that a common poison had been used and destroyed in the body so as to leave no trace. Deceased had taken the trouble to conceal his identity and might have gone to equal trouble to find a poison which was unlikely to be discovered. The absence of money in deceased's pockets suggested that he had deliberately emptied his pockets, unless he had been robbed before or after death. Sir Stanton Hicks said that a massive dose of any barbiturate would have been needed to cause death between 7 p.m. and 2 a.m. In the case of a barbiturate, death would be due to respiratory failure, and the left ventricle of the heart would be enlarged, which was not the case. Witness suspected a certain group of poisons for three reasons: — The heart was contracted; the lungs and particularly the liver and spleen, were engorged with blood; the wall of the stomach was not only engorged, but was bleeding into the cavity. These facts suggested the action of a poison which caused the heart ultimately not to relax and fill in the normal way. Before stopping in the unfilled condition there must have been some time when its filling was growing less and less, which meant that more and more blood was remaining on the input side, leading to the engorgement of the organs.

"Toxic" Witness confirmed the Coroner's suggestion
of a group of poisons and two poisons of that group as producing these effects. One of these would be particularly toxic in relatively small doses by mouth, would be completely missed by any of the tests applied and would in fact be extremely difficult, if not impossible, to identify, even if it had been suspected in the first instance. The only missing facts which would have confirmed this conclusion were the absence of signs of vomiting, or of convulsions. There was, however, sufficient variation in the reaction of individuals to account for the absence of vomiting. The gesture with the arm mentioned in evidence would be consistent with convulsions, which would be mainly of the arms, and not necessarily violent. Evidence of examination of the body at 9.30a.m. on December 1st, and of the fixing of the time of death at more than eight hours previously, was given by Dr. John Berkely Bennett, of Fullarton."

http://trove.nla.gov.au/ndp/del/article/74647022

## Coronial Inquest - 1949

**Coronial Inquest**

**Cover page**

*Coroners Act, 1935, South Australia (To wit).*

An inquisition taken for our Sovereign Lady the Queen at Coroner's Court, Adelaide, in the State of South Australia, on the 17th & 21st June, 1949, 14th day of March, 1958, before Thomas Erskine Cleland a Justice of the Peace and a Coroner for the said State, concerning the body found on the shore at Somerton on the 1st December, 1948.

And I, the said Justice of the Peace and Coroner, do say that I am unable to say who the deceased was. He died on the shore at Somerton on the 1st December, 1948. I am unable to say how he died or what was the cause of death.

In witness whereof the said Coroner has hereunto set and subscribed his hand and seal the fourteenth day of March, 1958.

(T. E. Cleland's signature) J.P., Coroner.

**Opening: Friday, 17th June 1949**

*Inquest into the death of a body located at Somerton on December 1st, 1948. Remarks of the city coroner on the opening of the inquest.*

**Thomas Erskine Cleland:** The report I have received indicates:

1. that the identity of the deceased is quite unknown;2. that his death was not natural;3. that it was probably caused by poison;4. that it almost certainly was not accidental.

The alternatives to be considered, therefore, are whether the deceased died by his own act, or by the act of someone else.

Because we do not know who he was we are ignorant of the motives, which may have actuated him or someone else. This ignorance is a disadvantage in investigation, and it emphasizes the necessity of ascertaining what is known and of recognizing what is only inference.

The natural and simple explanation of the circumstances, which will be detailed in the evidence, may be that the deceased died by his own act; but as we are dealing with circumstances, which are not ordinary, it may be that the natural explanation is not the true explanation.

Until the circumstances exclude the possibility that the deceased died through the act of someone other than himself, the possibility of murder must remain under consideration.

Consequently, it is most necessary that in giving evidence, witnesses should be careful to distinguish between what they know of their own knowledge, and what they infer from what they know.

I am required to find, if I can, who the deceased was and how, when, and where he died. I will, I fear, be unable to answer these questions unless further evidence should be obtained. For this reason I have directed that a cast be made of the deceased's features, and that the cast be photographed. These photographs may give a better idea of the deceased's appearance than those which have been published previously[1], and they will be available for publication.

The deceased remains unknown despite the energies of the police, and the wide publicity the death has received. It would seem that the deceased has not been missed by anyone who knew him. Perhaps he has not been missed because there appeared to sufficient reason for his disappearance from his usual surroundings—such as the expressed intention of going elsewhere to live.

If the photographs, or the suggestion I have first made, should lead any member of the public to believe he can supply information which may be of assistance, will he please communicate with the police.

(T. E. Cleland's signature)

**Adjournment: Tuesday, 21st June 1949**

*Inquest into the death of a body located at Somerton on December 1st, 1948. Remarks of the city coroner at the adjournment of the inquest.*

The body of the deceased was found on the shore at Somerton at about 7:00 am on December 1st, 1948. Dr Bennett, who examined it at 9:40 am was of the opinion that death occurred around about 2 am.

The body was clad in clothes of fairly good quality. All tags, which might have led to the discovery of identity, had been removed. The deceased as lying on his back with his feet towards the sea, his head and shoulders supported by the sea wall. The head was inclined to its right and between the right cheek and the right lapel of the coat was a partly smoked cigarette, but the coat was not scorched nor the cheek blistered. The only articles in the clothing were some cigarettes and matches, two hair combs, a packet of chewing gum, a single uncanceled railway ticket from Adelaide to Henley Beach, a bus ticket which was proved to have been issued at about 11:15 am on the 30th November on the Adelaide-Somerton bus and which would have carried the holder from Adelaide to Somerton, and lastly a piece of paper on which were printed the words *Tamám Shud*. This paper, which was in the fob pocket of the trousers, and which was not found for some time afterwards, was, I am satisfied, torn from a copy of the second edition of FitzGerald's translation of the*Rubaiyat of Omar Khayyam*. The printed words are the concluding words of the poem and mean "The End."

At 7 pm on the 30th November, a man was seen lying precisely where the body was found and in a similar position. He was seen to raise his right arm to its full extent. The arm fell limply. At about 7:30 pm a man and a girl saw the man in the same place. They did not see him move, but one of them gathered the impression that his position changed somewhat, and that in a way that they could not define he was lying unnaturally.

A little over a month later an unclaimed suitcase was found at the luggage office at the Adelaide Railway Station. There was internal evidence that it had either belonged to the deceased, or was connected with his death. Tags had been removed from clothing, the clothes were of a size with those found on the body, a similar and rather unusual thread had been used to mend clothes in the suitcase and those on the body, and there was other evidence which led to the conclusion.

It was thought that the decease must have arrived by train at the Adelaide Railway Station, left his case at the luggage room, purchased a ticket for Henley Beach but missed his train, and then travelled to Somerton by bus. Neither the luggage room attendant, nor the officer who issued the Henley Beach ticket, not the bus conductor can remember seeing him. No one has come forward to say that he was seen at Somerton between the arrival of the bus and 7pm.

A postmortem examination was made. Small vessels not commonly observed in the brain were easily discernible with congestion. The stomach was deeply congested; there was superficial redness; small haemorrhages were present beneath the mucosa. The heart was normal--the heart of a man in good physical training. The muscle was quite tough and firm. It was, if anything, contracted. There was extensive congestion of the liver and spleen. A microscopic examination revealed that the centres of the liver globules were destroyed. Dr Dwyer who made the postmortem examination was of the opinion that the immediate cause of death was heart failure, he concluded that death was unnatural; and he retained appropriate specimens from the body for analysis. But on analysis no common poison was found.

Three medical witnesses are of the opinion on the postmortem findings that death was not natural. The words "Tamam Shud" support this conclusion, and indeed put its accuracy beyond reasonable doubt. There was no indication of violence, and I am compelled to the finding that death resulted from poison. But what poison?

No doubt minimal doses of certain common poisons could have caused death and have been eliminated from the body before death.

No doubt minimal doses of certain common poisons could have caused death and have been eliminated from the body before death. But on the expert evidence no such minimal dose could have caused death so quickly, and a more massive dose would certainly have left traces which would have been detected on analysis.

The only person which Sir Stanton Hicks can think of, and which is consistent with the postmortem findings, is one of the group he mentioned. But there again there are difficulties. There was no vomit, although there was some evidence of convulsion.

I have been discussing the circumstances on the footing that the body found on the morning of the 1st December was that of the man seen in the evening of the 30th November. But there is really no proof that this was the case. None of the three witnesses who speak of the evening of the 30th saw the man's face, or indeed any part of his body that they can identify. If the body of the deceased was not that of the man mentioned and if the body had been taken to the place where it was found, the difficulties disappear. If this speculation, for it is nothing more, should prove correct, the original assumption that it was the deceased who left the suitcase at the luggage room, bought the rail tickets, removed the clothing tabs, and put the printed words "Tamam Shud" in a pocket, would require revision.

The evidence is too inconclusive to warrant a finding. There is no evidence as to who the deceased was. Although he died during the night of the 30th November-1st December, I cannot say were he died. I would be prepared to find that he died from poison, that the poison was probably aglucoside and that it was not accidentally administered; but I cannot say whether it was administered by the deceased himself or by some other person.

(T. E. Cleland's signature)

I therefore adjourn this inquest sine die.

**Page 1**

*South Australia, Deposition of Witness, Under the Coroners Act No. 2248, 1935.*

South Australia (To Wit) The examination of the undermentioned witnesses taken and acknowledged on behalf of our sovereign Lord the King, touching the death of the body of an unknown man located at Somerton on 1-12-48, at the house of the Coroner;s Court at Adelaide on the Seventeenth day at Adelaide o the seventeenth day of June one thousand nine hundred and forty nine before me, Thomas Erskine Clelandone of His Majesty's Coroners for the said State, on an inquisition then and there taken.

Coroner calls: John Bain Lyons of 52 Whyte St., Somerton, Jewellery store proprietor.*Sworn*.

**Question by coroner Thomas Erskine Cleland:** Please describe what you observed the night of the 30th November and the following morning.

**John Bain Lyons:** I live at Somerton. It is my practice in summer to out on to the seafront every evening. My wife and I every evening took a walk along the seafront, and on the evening of the 30th November we did so. I remember that day. During my walk I saw a man lying on the shore, on our return. We had been to the Broadway, and on our return my wife pointed out the man saying “Look at the way the man is slumped”. He was lying adjacent to the steps in front of the crippled children’s home, within a yard of the steps. It was in quite an open position. I should say the closest I was to the man was 15 to 20 yards, on the beach. We had walked along the beach. I could not see his face from that distance. I did not see his face until the following day. There is a seawall up there, and he was leaning up against that, supporting his shoulders and head. While looking at him, he moved. I had a watch on my wrist, I said “I will report this to the police” in a jocular way, and as I said that his right arm moved, his right arm, moved upwards and fell down.

**Page 2**

**John Bain Lyons:** I assumed he was drunk and was sleeping it off, and took no further notice of it that night. My remark about informing the police was quite jocular. I had no intention of doing so then. I did not suspect anything unusual at the time. He was lying on his back, with his feet crossed, and towards me. I was on the sea side of the man. I do not think he was wearing a hat. As he moved his arm, I should say it extended fully upwards, and then dropped. I passed on without taking any further notice. We just stopped momentarily to make the observation and remarks. In the summer time I indulge in an early morning swim. On the 1st December I went down the sea early, at approx. 6.35 a.m. I had my swim first, and then went along to meet a friend, (3 of us swim together). He was further along towards Glenelg. I met him and we were speaking together, then I saw some men on horses looking at the body. I had not noticed it before that. I then became suspicious, and then went over and told them that I had seen the body the previous night. After that I went back and communicated with Constable Moss of Brighton Police. I just casually examined the body without touching it. I made sure he was dead as I did not see the face the previous evening, I could not identify the man, nor could I recognise the clothes, as I was not close enough the previous evening. I would however (say) that it was definitely the same person.

**Question by Prof John Burton Cleland:** Was there anyone else on the beach at the time? Was there any disturbance in the sand around the decease? Did you see the deceased do anything such as smoking? Did the position of the body change from one day to the next?

There was one man on a horse, and another leading a horse, 2 jockeys. When Constable Moss came down, he looked to see if there was any disturbance of the sand and the body, and he was sure there had not been. When the hand went up, there was no cigarette in it. I feel sure I could have seen a cigarette if there had been one, as it was fairly light. The following morning, when Constable Moss was there we found a cigarette just above his ear, which he may have been trying to get. That cigarette had not been lit.

I should say his head and top portion of the shoulders were against the wall, using the wall as a support. The body was in the same position the next morning, with the legs crossed.

**Page 3**

Coroner calls: John Moss, Police Constable stationed at Brighton. *Sworn.*

**Question by coroner Thomas Erskine Cleland:** Please describe what you observed the morning of the 1st December.

**John Moss:** At about 6.45 a.m. on 1st December 1948 in consequence of a telephone message I received at the Brighton Police Station, I proceeded to the beach at Somerton, where I saw lying near a sea wall opposite the Somerton Crippled Children’s Home the body of the deceased which was fully clothed, lying on its back with feet towards the west, with the head resting against the sea wall, slightly inclined to the right. His right arm was doubled over, palm upwards, and fingers bent towards the palms. His left arm was lying on the sand alongside the body. There was a portion of a cigarette on the right collar of his coat, and held in position by his cheek. I inspected the body, but found no mark of violence. I conveyed the body in a police ambulance to the Royal Adelaide Hospital, where life was pronounced extinct by Dr Bennett. The body was later conveyed to the City Morgue. Dr Bennett made a statement. He said “In my opinion death had occurred 8 hours previously. I am unable to ascertain the cause of death.” The cigarette I found had been partly smoked. I made it my business to make an accurate record of what I found, and I am quite sure it had been partly smoked. More had been smoked than what remained. I was unable to form any opinion as to whether it had been kept behind his ear, or whether it had come out of his mouth. It is my opinion that it may have been in his mouth, he was smoking it, with his head sideways in the positioning which I found the head. If found nothing near the body which gave me any suspicion. There was no undue disturbance of the sand. There was no hat found at all. The face was quite visible from a distance, from the right. The spot was quite open, not secluded. Anybody lying there might expect that they would be seen easily by anyone going up the steps to the esplanade to the beach. Those steps are used a lot, particularly on a summer evening.

**Page 4**

**John Moss:** I was not on duty on that particular evening. I know the locality very well. At 7 o’clock on a summer evening, there would be many people about, and that night was a warm night. I do not remember what the weather during the preceding week was like, but I remember it was hot on this morning. I searched the clothing, found a railway ticket to Henley Beach, also a bus ticket, a tramway bus ticket. There were cigarettes on the body, which were in a packet. I did not compare them with the one that was partly smoked. The packet produced looks like the cigarettes I found. The comb produced was on the body, also the chewing gum and the metal comb. The bus ticket produced and the railway ticket produced are similar to the tickets I found on the body I did not find the slip of paper with the words “Taman Shad”.

Packet containing these articles put in, marked Exhibit C.1.

The body was taken to the City Mortuary. What I have told you is all I know of the incident.

**Question by Prof John Burton Cleland:** Were there signs that the cigarette had scorched the man's cheek? Are you able to say if the body was warm or not?

**John Moss:** The cigarette was not smoked as far as it could have been smoked an ordinary person would have smoked it further. There was no sign of blistering or scorching on the cheek. I examined the cheek, and found no sign of blistering or scorching. The body was cold when I examined it, cold, damp and stiff.

**Page 5**

Coroner calls: Edmund Leslie Hall, Claim's Officer's Assistant, 13 Canterbury Avenue, Trinity Gardens. *Sworn.*

**Question by coroner Thomas Erskine Cleland:** Please tell the court what you have been able to determine regarding the tram ticket possessed by the deceased.

**Edmund Leslie Hall:** I am employed by the Municipal Tramways Trust. The bus ticket produced appears to be a ticket issued by a conductor employed by the Municipal Tramways Trust, it is an M.T.T ticket. I can tell by the punch mark and the serial number when it was issued. It was issued by conductor Holdernesse, his running journal for Tuesday 30th November 1948 shows that his 7d. ticket Sericla C B 88708 was sold by this conductor somewhere between the railway station on North Terrace and the intersection of West Tce and South Tce while the bus was en route to St. Leonard's departing from the Railway Station at 11.15 a.m. On that particular trip there were 9 7d. tickets issued between the Railway Station and West Tce-South Tce, which is the only area where 7d. tickets could be issued. This ticket was the sixth of the 9 sold. I can only tell you the total number of passengers on the trip, not how many were on the bus at any one time. The 7d. tickets would have been sold on leaving Adelaide. Just over 40 tickets were sold on that journey, that is the total number of passengers on the whole trip, but how many of those were on a one time I cannot say.

**Question by Prof John Burton Cleland:** Can you tell us if their was an earlier bus that left for St. Leonard's?

**Edmund Leslie Hall:** Offhand I cannot say when the previous bus left for St. Leonard's I think it is about a 30 minute service. There may have been a Somerton bus before this, but this would be the first St. Leonard's bus to leave after the 10.45 a.m. train to Henley Beach.

**Page 6**

CORONER CALLS:

ARTHUR ANZAC HOLDERNESSE Of 67 Tynte St. North Adelaide. Tram Conductor. SWORN

BY CORONER: I am employed by the Municipal Tramways Trust. In November last year I was employed as a bus conductor. I was not interviewed during December about a trip in November, I was first interviewed last Saturday about that. I have no recollection about the trip in November apart from the records of the Tramways. I have seen the log for that day, and have heard what Mr Hall has said. Apart from those 2 things, I have no recollection of the trip at all. Having looked at the log, and having heard what Mr Hall stated, it would be still hard to say whether the bus was heavily loaded or not. I cannot remember having seen a man like the plaster cast in Court.

**Page 7**

CORONER CALLS:

PAUL FRANCIS LAWSON Of 12 Cane St. Prospect. Taxidermist. SWORN

BY CORONER:

I carry out my work at the museum, North Terrace. On 7th June 1949 I went to the City Mortuary with Det. Brown and he pointed out a body to me. I proceeded to make a cast of the features of the body. I first made a mould, and reproduced in that mould the cast. The cast in Court is the cast which I made. It should be a perfect reproduction of the deceased. There would a slightly(sic) difference in the appearance of the dead when alive than at the time when I made the mould. The naturally fleshy parts of the face would have shrunk and sagged slightly. The formalin which was used to embalm him would shrink it (in) a general direction. It was the effect of the embalming substance more than death which caused the shrinking. I examined the body. Hiss feet were rather striking features, suggesting, this is my own assumption, and he had been in the habit of wearing high-heeled and pointed shoes; I base that on the fact that the calf muscle was high and well developed, such as found in women. The feet were comparatively broad at the joints of the toe and the foot, but the big toe and the little toe were joined together towards a common apex, in other words wedge shaped. That peculiarity I found more pronounced than is usual. His shoes had been of a good fitting quality as there were no undue callouses. I noticed nothing unusual about the toe nails or finger nails. I should say they had been reasonably cared for. I would not like to say if he had been in the habit of cutting or filing the nails. They were not broken as though he was nervous. I could not say if they were broken by manual work or not. I have not seen the tendency of his calf muscle so pronounced in others as in this case. I had occasion recently to take a cast of a girl’s legs, and she had the habit of wearing low-heeled shoes. I have also studied legs fairly critically. From that observation I would say heels will not develop the calf to such an extent as high heels.

**Page 8**

BY PROFESSOR CLELAND

The neck of the cast presents an unusual appearance, and I would attribute that to the post mortem exam and lying on the block. Apart from that, that is the replica of the body that I saw. I have made a study of making casts for museum purposes, so I have had reasons for making investigations and comparisons of calf muscle.

**Page 9**

CORONER CALLS:

GORDON KENNETH STRAPPS Of 5 Seymour Tce. Woodlands Park Inspector SWORN

BY CORONER:

I remember the 30th November 1948. I was spoken to about it I think on the next night. I do recollect the evening quite clearly. I was at Somerton that evening. We arrived at about 20 or 30 past 7, I was with Miss Neill. We stopped on the road, left our motor bike, and went down the steps. We sat on the seat in the landing by the wall. I should say we were about 10 yards behind him, and to the side – in other words, to the south east of the body. Being on the landing, we were somewhat above him. I suppose it would be 5 mins after arriving at the beach that we sat down on the seat. I noticed a man lying there when we got there. I could only see him from the waist downwards. He was lying on his back. When I walked along the landing I saw his left hand, and it was stretched out. I did not see him move once before leaving. We left at about 8 o’clock. I did not see him move once. However, I thought I noticed a difference in his position. That night I did make a remark to my girl friend that as there were mosquitoes there he must have been dead to the world in not noticing them. It attracted my attention that he was lying there still notwithstanding that there were a lot of mosquitoes there, and I thought he must have been asleep. I should say he had brown striped trousers on. I thought they belonged to a suite, although I did not see his coat. It was getting dusk at the time. When we left at 8 o’clock, the street lights were on. We could still see 20 yards away, I suppose. The man was lying on his back when we arrived there. He was on his back all the time we were there, he (did) not shift to his side at any time. I should say we were about 10 yards from him, on his south-east. I think we would have been in a position to hear him if he coughed, as we kept on taking glances at him. We were curious but not suspicious. We did not hear any sound at all.

**Page 10**

I suppose his position would be natural. I thought it was natural at the time. His legs were stretched straight out.

BY PROFESSOR CLELAND They were straight out when we got there, not crossed. I only took a casual glance when I walked up the steps, his left leg had been drawn up, taking it up the sand a bit.

**Page 11**

CORONER CALLS: JOHN MATTHEW DWYER Of 105 Port Road Hindmarsh L.Q.M.P SWORN

BY CORONER: At 7.30 a.m. on 2nd December 1948 in the presence of Const. Sutherland I made a post mortem examination at the City Mortuary on the body pointed out to me as being that found on the foreshore at Somerton on 1st December. The body was that of a tallish man, I thought about 45 years of age, with greying hair, and he was in good physical condition. Thee was every sign of his having had taken care of himself in the way that his fingernails and feet were looked after. There were no exterior markings of note. The nails were I thought just carefully trimmed, probably with scissors, not with a file or nail clippers. The general impression I gained was that he was a man whose bearing you would take notice of, by reason of his general appearance. There was the expression about his face as though he might have been an educated man. The post mortem rigidity was intense, and there was a deep lividity behind particularly above the ears and neck. Several teeth were missing in the jaws. I later handed a chart of the missing teeth to Constable Sutherland. The chart produced is in my writing, that is the one I handed to Const. Sutherland. It would be simpler to say that there were more of the central teeth remaining. Those remaining were the central teeth in each jaw. Anyone looking at him in the ordinary way, if he were to laugh, would notice the teeth were missing. If he were speaking, the missing teeth were not noticeable. The pupils were smaller and unusual, uneven in outline and about the same size. Certain drugs may be associated with a contraction of the pupils. Even barbiturates may do it, but it is by no means a distinguishing point, except in broad groups. There was a small patch of dried saliva at the right of the mouth. The impression was that it ran out of his mouth some time before death when he was probably unable to swallow it, probably when his head was hanging to the side. It would run vertically. It had run down diagonally down (sic) the right cheek.

**Page 12**

Sunburn markings were present up to the level of the crotch, and they were probably from the previous season. The fingers were cyanotic, there was sand in the hair, but none in the nostrils or mouth. The scalp, skull and brain were normal, except that small vessels not commonly observed in the brain were easily discernible with congestion. There was congestion of the pharynx, and the gullet was covered with a whitening of the superficial layers of the mucosa with a patch of ulceration in the middle of it. The stomach was deeply congested, and there was superficial redness, most marked in the upper half. Small haemorrhages were present beneath the mucosa. There was congestion in the 2nd half of the duodenum continuing through the thin part. There was blood mixed with the food in the stomach. Both kidneys were congested, and the liver contained a great excess of blood in its vessels. The heart was of normal size, and normal in every way. The impression it gave me was that it was the heart of a man in good physical training. The reason why I say that is that the muscle was quite tough and firm. Both lungs were dark with congestion. The heart, if anything, was contracted. The question had been raised of xx taking of an overdose of a drug which would cause the heart to contract. I could not say that that did not happen, but I feel there is not enough evidence for me to say that that was the cause. I would not like to be dogmatic on the question, but I feel that the explanation is that the man was in good physical condition, and his heart was in keeping with that. I could not rule out the other possibility. Both lungs were dark with congestion, but otherwise normal. The spleen was strikingly large and firm about 3 times normal size. The points to which I gave consideration in my summary were the acute gastritil haemorrhage, extensive congestion to the liver and spleen, and the congestion to the brain. There was food in the stomach. I would say that the food had been in the stomach for up to 3 or 4 hours before death. It is difficult to give an opinion on that, because if the person is in a state of anxiety, that digestion may be suspended. I have made microscopic examination of the disease, and there was pigment in it, although I cannot say of what disease. It does not resemble malarial pigment, and I can only keep an open mind on the matter.

**Page 13**

The blood in the stomach suggested to me some irritant poison, but on the other hand there was nothing detectable in the food to my naked eye to make a finding, so I sent specimens of the stomach and contents, blood and urine for analysis. There was one point in the microscopic examination which was fairly definite, in that there was destruction of the cenxxx of the liver lobules revealed under the microscope, and apart from signs of congestion there was nothing else in the other organs. There was a peculiar cellular reaction under the oesophageal mucosa, but I have not found and answer to that. I am quite convinced that the death could not have been natural, as there is such a conflict of findings with the normal heart. Some factor must have influenced the heart to bring about that state of affairs, or alternatively the centre which controls the breathing. I feel quite certain that the death was not natural. I think the immediate cause of death was heart failure, but I am unable to say what factor caused heart failure. Something stopped the blood from being pushed along, because of the cyanosis. When I sent in my report the poison I suggested was a barbiturate or a soluble hypnotic, and I think that is still consistent with the finding. Assuming Dr. Cowan found no barbiturate or any common poison, I was astounded that he found nothing, as I thought he would. I know he is a chemist of considerable experience, and if he did not find any I accept his finding. There are changes which could occur, particularly with certain quick acting barbiturates. There are other poisons which do come into the picture which would be decomposed very early after death. In support of my statement concerning the disappearance of certain barbiturates, I can put in an extract from a book dealing with the matter.

Teeth chart put in marked Exhibit C.2. Extract put in marked Exhibit C.3.

The substance of the extract is that in certain cases although it seems certain barbiturates have been ingested, there is no sign on analysis.

**Page 14**

I think that is a possible explanation, that barbiturate was taken or administered, it caused death, and became decomposed. That must be considered, but I do not think it is under ordinary circumstances a likely explanation. It is a possible explanation, but an unusual one. If the man was alive at 7 o’clock and dead by midnight, if it were a carefully judged dose of barbiturate – there are records of barbiturates, in one case 72 grains of sodium amytal, which is quite a heavy dose and one would expect it to leave signs, and the patient recovered. Nembutal has been stated to cause death in cases of 7 ½ and 6.7 grains, another one is a name which I will not mention, and it has caused 6 cases of death in doses of 30 to 38 grains. There are poisons which act very quickly, but most poisons require some time to cause death. Barbiturate in usual cases of suicide may not cause death for 36 to 48 hours, and usually those barbiturates are taken in large doses. There is a big variation in the amount which people can stand. Even the quick acting one would require a massive dose to produce death by midnight if the man were alive at 7 o’clock, one would think. If the dose were massive, one would expect to find it on analysis. On the whole, I think it is probably correct that barbiturate is not the cause of death, except that as I said earlier it is a possible explanation. It is my opinion that in view of the chemist’s findings it is unlikely that barbiturates are responsible for death. On the other hand, being driven as far as one can possible go, I find that the cause might be the cause which I originally suspected.

BY PROFESSOR CLELAND

A large number of the back teeth were missing. I think from the food that it was probably a pie or pasty which he had eaten as his last meal. I did not get the impression from looking at his mouth that he was in the habit of a dental plate. Dental plates were not present when I examined the body. I would not stress the size of the pupils in the case of a dead man, it is my habit to point out the findings as I find them.

**Page 15**

The blood in the stomach, I would have noticed that if it was produced by the post mortem. It was present prior to the post mortem, and because there were numerous haemorrhages I formed the opinion it was mixed with food during life. I think the question is still open, but in view of the congestion I think failure of the heart is more likely than failure of the respiratory centre. I looked to see if the man had been vaccinated. There was a slight scar on the left upper arm. In my experience, the man might have been a member of the forces and had been vaccinated, and it did not leave much sign. I saw no evidence of a hypodermic needle having been used. I considered the possibility of one having been used, especially if it were used in an unusual place. There were 2 marks between the knuckles and the back of the right hand they appeared to be recent abrasions just before death, they were in the hollows of the knuckles, but they did not appear to be significant. I do not think there was any injection of curare or tubariu, which cause death from asphyxia. I do not think it is possible there had been an overdose of insulin, as there was no evidence of disturbance. I think the question of insulin can be discounted on the findings of the liver. If a man had access to diphtheria toxin, that certainly could be a possible explanation, but it would be very unusual. He would have to have access to a place where a diphtheria toxin were being manufactured. A very small amount of that would cause the haemorrhages. Botulism can be ruled out because of time, the death in those cases do not occur shortly after administration. Deliberately taken by mouth, the poison of botulism could be fatal. On the other hand there would be an incubation period of 12 hours. I hardly think it worthwhile going into the question, but it did enter my mind the possibility of poisoning by nicotine, but Mr. Cowan said none was found. There are possibilities of the aconite or aconitine being used, and there are chemical difficulties about their isolation. I do not think I can say anything else. Knowing how reliable Mr. Cowan is in his analyses, I have to think along the lines that poison was the cause of death, which cannot be found on analysis.

**Page 16**

The poison must have been taken a few hours before death, and I have to find out a cause for the change. Apart from the special case of barbiturates, there is no case of poison known to the average person which would not be discernible on analysis. I can think of prussic acid, but its action is so rapid that death is practically instantaneous, so that there would not have been time for the finding in the organs to have developed, particularly the microscopic finding. The legs were sunburned right up to the crotch. The trunk was not sunburned. It appeared that he had gone about with a shirt on, and his bathing trunks. The sunburn was definitely the previous summer’s sunburn or earlier.

If he had been burned on this summer it would have been much more pronounced. If he had been sunbathing I would have expected the trunk to have been burned as well. It is possible that the browning of his skin was due to his occupation, but he had not been indulging in that occupation for some time if that was the case. I would say that the skin had not been burned by the some for some months. If he had been burned in October or November, the sunburn would have been darker. It might have been even further back than the previous summer when the sunburn was sustained. It would have been the previous summer or longer when he sustained the sunburn.

**Page 17**

CORONER CALLS. ROBERT JAMES COWAN Of 128 Fisher St. Fullarton Deputy Govt.? analyst

BY CORONER:

On 2nd December 1948 I received from P.C.C. Sutherland a glass jar containing stomach and contents, one containing liver and muscle, a bottle containing urine, and a bottle containing blood. Mr. Sutherland told me they were taken from the body of an unidentified man found at Somerton the previous day. At his request I carried out analyses on those specimens, but was unable to find any signs of any common poison in any of them. I tested for common poisons. Cyanides, alkaloids, barbiturates, carbolic acid, are the most common poisons. If any of the poisons for which I tested were the cause of the death, they would not be absent from the body after death if they were taken by mouth. There are cases of which I heard in which barbiturates are the cause of death and yet are absent on analysis. I think is unlikely if they were taken by mouth that they would not be detected in the stomach contents. I cannot say if a man were alive at 7 o’clock in the evening and dead about midnight, it would need a massive dose to cause death. I found no common poison present, and I do not think any common poison caused death. I cannot suggest anything, other than I think it is most unlikely that a common poison caused his death. Offhand I am not aware of poisons which can cause death but decompose in the body so that they are not discernible on analysis. I would say that it would be highly probably that any poison causing death would be discoverable on analysis. I am still speaking of poisons taken orally, as distinguished from poisons injected. The difference would be that on injection some of those poisons would be destroyed in the tissue, by the liver, and even by the kidney, whereas in the stomach, you would expect to find that which was in excess to that required to kill the person.

BY PROFESSOR CLELAND

**Page 18**

I feel quite satisfied that if the death were caused by any common poison, my examination would have revealed its nature. If he did die from poison, I think it would be a very rare poison. I mean something rarely used for suicidal or homicidal purposes. I cannot make any suggestions as to what that might be. I think that death is more likely to have been due to natural causes than poisoning. I failed to detect any poison in the stomach or organs, and this causes me to make that statement.

BY CORONER Insulin is not rare, but used as a poison for homicidal or suicidal purposes it would be rare. I was not taking insulin as being a poison I just do not know how a poison could be defined. When I spoke of rarity of poisons, I was speaking of rarity of their being used as poisons, not the rarity of their existence.

**Page 19**

CORONER CALLS OLIVE CONSTANCE NEILL Of 54 Parkway Colonel Light Gardens Telephonist

BY CORONER I was with Mr Strapps on the evening of the ?th November at Somerton. We got there about 20 past 7, and we were walking down the steps when we noticed a person on the beach, but did not take much notice. We sat there, and naturally did not notice him very much. We saw that he was lying there, and later on I said I would have a look at him, I suggested that to Mr Strapps, and he told me in effect to mind my own business. I do not know what made me suggest that, whether he might be dead, but at the time that suggestion seemed silly. When first arrived, I only saw the man’s legs, and I gained the impression that he was lying on his back. The position of his legs did not alter while I was there that I know of. I did not see his legs move. I saw no difference in his position from the time we arrived until the time when we left. I did not take any notice of his position. I saw Mr Lyons this morning, but I do not remember having seen him on that evening. I did think something was wrong with this man, but I had no foundation for it. It was because he was lying still. I have seen people lying still on the beach before, I saw this man’s hand, and it seemed to be in a funny position, although I cannot remember actually how it was. I did in fact think this at the time, and made the remark to my companion that perhaps the man was dead. There were not very many people about at this time. Other people must have seen him, I should think. There was one man up on top of the road, but apart from that no other people took any notice of this man. There were other people further down, at the water’s edge. Where he was lying was a fairly public place, no the sort of place a man would be likely to choose if he wanted to go somewhere and die quietly.

No questions by Professor Cleland.

**Page 20**

CORONER CALLS: HAROLD ROLFE NORTH

Of 21 Hackett Terrace Marryatville Senior porter, Cloak room, Adelaide Railway Station

SWORN

BY CORONER:

I have had enquiries made by the police. I produce luggage ticket G. 52703 issued on November 30th, 1948 to some person. I have examined this ticket, and find that it bears a stamp on the back which indicates to me that the ticket was issued on 30th November 1948 at 11 a.m. This could mean that the ticket was issued any time between 11 a.m. and 12 midday. This suitcase and contents remained unclaimed. The ticket was issued in respect of a suitcase, not by me. I know the man who actually issued the ticket, but he is away on holiday snow. R. Craig is his name. The stamp on the back of the ticket is the clock stamp, when it is issued, it is stamped under the clock, indicating the date and time of issue. At the Railway Station there is not now a place where a man arriving from the country could bath and shave. He would either have to go to an hotel or to the City baths. Mr. Craig is away on holidays now. I do not know whether or not he has been approached during the last 6 months to have enquiries made. I know the ticket produced represents the suitcase which I gave to the police.

BY PROFESSOR CLELAND

The other half of the ticket would be retained by the person who tendered the suitcase, depositing it. There are many articles of this kind which remain unclaimed from time to time. They are in good condition, such as this case. I have no idea what time the Melbourne Express arrived on this morning, or the Broken Hill express.

BY CORONER

There was another article lodged on 30th November which was unclaimed. There re articles lodged in December which have not been claimed, but I cannot say with regard to this particular date. This suitcase has never been claimed. I would know if it had been, definitely(?).

**Page 21**

I have already looked at the records, but there was no overcoat on this particular day lodged at the cloak room.

**Page 22**

CORONER CALLS

RAYMOND LIONEL LEANE DETECTIVE-STATIONED AT ADELAIDE

SWORN

BY CORONER:

I have been making enquiries concerning the identify(sic) of the deceased person, since about the 14th January of this year. The clothing produced are the clothes found on the body, coat, shoes, shirt, pullover, a pair of Jockey underpants, singlet, pair of socks, pair of trousers, one tie. They are the ones he was wearing when found on the beach. The shoes now are roughly in the same condition as they were when found. They are practically new, and very clean. They look as though they had been polished that morning, or later. On the 14th January I made a search of the luggage office of unclaimed luggage, and on a rack I found a number of cases, placed in on different days, but this particular one on 30th November. It bore the ticket produced by Mr. North.

Ticket Marked Exhibit C.4.

The cigarette packet was “Army Club” but the contents were Kensitas, a different brand, there was also found a box of Bryant and May’s matches, ¼ full, a packet half full of Juicy Fruit chewing gum, 2 combs, and Professor Cleland found a slip of paper bearing the words “Taman Shud”. That was found on the body.

On the 19th January I took possession of the case. I had seen it on the 14th, and took it a week later. The case contained a dressing gown and cord, one laundry bag with the name “Keane” printed on it, one pair of scissors, in sheath, one knife in sheath, one stencil brush(?), 2 singlets, 2 pair underpants (Jockey type), 2 ties, one tie bearing the name “T. Keane”, one pair slippers, 2 pair underpants (ordinary type), one pair trousers bearing dry cleaning marks, one sports coat, one coat shirt, one pair pyjamas, one yellow coat shirt, one singlet, bearing the name “Kean”.

**Page 23**

It is a possibility that the “e” on “Kean” might have been washed or rubbed out. There was also one singlet, with the name torn out, one shirt, name tag gone, six handkerchiefs, one piece of light board, 8 large and one small envelope, 2 coat hangers, one razor strop, one cigarette lighter, one razor, one shaving brush, one small screwdriver, six pencils, and 6d. in cash found in trousers pocket, one toothbrush and paste, one glass dish, one soap dish containing one hair pin, 3 safety pins, one front and one back collar stud, one brown button, one tea spoon, one broken scissors, one card of tan thread, one tin of tan boot polish, 2 air mail stickers, one scarf, one towel. The name tabs were missing from the coat, they have been torn out of the pocket of the coat which he was wearing, and I think they are gone from the shirt. The makers brand is on the trousers. The trousers in the suitcase are not the same make as those he was wearing, but they are identical in size. Those he was wearing are of Crusader Cloth, they could have been made in any state in Australia. The clothes in the case were well kept and tidy. I interviewed Hugh Pozza, tailor, of Gawler Place, and he is of the opinion that it is an American type coat, because there is a gusset in front of the coat as shown in American catalogues. He pulled the coat to pieces and viewed the stitching, and there is a feather type stitch in it which he stated could be made only in America, where the only machines which would do that were. The coat was partly made, then fitted. It was mass produced but made to measure. The body work is performed, and then the person is fitted before it is completed. He thought it was made in the United States, it could not be made by someone who was in Australia but who had learned the trade in America because of the machine. Such clothes are not imported. He had either been in America, or had bought the clothes off somebody who had been there. Most of the pencils are Royal Sovereign, 3 of them H type, which would be a drafting pencil. The knife, stencil brush, and scissors, were found in the case. I interviewed Mr Gray, the headmaster of the School of Arts and Crafts, North Tce Adelaide and after studying catalogues he came across a knife the replica of this one in shape.

**Page 24**

It is an ordinary table knife cut down. Inside the folders produced is tinned zinc, an alloy used for stencilling. Mr Gray then produced a piece of similar zinc, not quite so heavy, and stated that in his opinion the knife was used to start the letter off, he then finished the letter by cutting around with the scissors. The brush is used for stencilling the brands cut out. Mr Cowan made a test on the brush, and found that it had been used. He could not find out what the substance was, but a black substance came out of it. The case is practically new. Wherever it came from has been taken off the end of it; the luggage label has been removed, I mean. A number of the articles in the case are minus the tags. He noticed that the coat has been stitched with brown cord. That coat was being worn by the deceased. In the suitcase was found a needle and thread of similar texture. The trousers pocket in the case had been mended with a similar thread. It appears to be rather a masculine mending. The trousers worn by the deceased were mended with a similar thread, he had sewn buttons on his trousers with a similar thread. The thread is a common thread. The shirt in the suitcase and the shirt the deceased was wearing were similar shirts, also a pair of Jockey underpants found in the case were of a similar brand to those worn by the deceased. There was one brand new handkerchief in the case, which is similar to the handkerchief found on the body. The trousers and the coats were of a similar size. The trousers were an identical size – they were measured. The coat in the case was smaller. The fitting of the coat he was wearing might have been a little bit large, and the one in the case might have been a little small. They could have been the coat of one man. The dressing gown is of reasonable quality, and there is a pair of slippers to match. They have been worn fairly well. I did not find an overcoat. I have checked at the railways, but there were no numbers 02 or 04 which were for overcoats.

**Page 25**

CORONER CALLS PATRICK JAMES DURHAM Police Photographer and Fingerprint Expert Stationed at Adelaide SWORN

BY CORONER

On December 3rd 1948 in company with M.C. Knight I went to the City Morgue Adelaide, and I was pointed out a body by M.C. Knight, who said the body had been found on the Somerton beach. I photographed the body full face and side face. I produce these photographs.

Photographs marked C.5 and C.6, C.7 and C.8

I also fingerprinted the deceased, and later sent copies of these fingerprints and photographs to all States in the Commonwealth and New Zealand, also the important fingerprint bureaus overseas. The reply was “the person is not known to us.” I also have some copies of the writing found on the deceased.

(Exhibits C.7 and C.8 returned to Mr Durham)

I took a photograph of the paper found on the deceased, and I produce copies of that.

**Page 26**

Resuming at 2.30 p.m. this day.

CORONER CALLS: WILLIAM WEST Of 6 Tram St Kensington Recorder SWORN

BY CORONER: I am employed by the S.A.R and it is my duty to be aware of the times of arrival and departure of trains. On 30th November 1948, the train from Bowmans arrived at 8.30 a.m., from Robertstown, 8.47; from Willunga, 8.49; Angaston, 9.05; the Melbourne express, 9.15; the Broken Hill express, 9.17; the Mt Pleasant 9.30; the Angaston at 10 o’clock; the South-East at 10.54; Departing trains for Henley Beach, 5.13, 5.23, 6.03, 6.38, 6.59, 7.11, 7.27, 8.02, 8.15, 8.53, 9.30, 10.50, and 11.51. All were on time with exception of the last which was one minute late.

**Page 27**

DETECTIVE LEANE CONTINUING BY CORONER:

On 30th November 1948 the day was warm, 72 degrees maximum, cloudy during the day, visibility fair to goo. During the early evening, clouded, and at about 8 p.m. it was hazy. On 23rd November the maximum was 79.9 degrees, clear day and clear night. On 24th it was 91.7 degrees, clear during the morning, afternoon was overcast. On 25th the maximum temperature was 70., and overcast during the day and evening. On 27th 79. degrees, clear during day and evening. On 28th, the temperature was 69., clear during the morning and cloudy during the afternoon and evening. On 28th, the temperature was 69., clear during the morning and cloudy during the afternoon and evening. On 29th, the temperature was 67.4, cloudy during the morning, and clear during the rest of the day and evening. The luggage ticket could have been in the overcoat, if he had had an overcoat and discarded it somewhere. There is no comment I wish to make on the clothing or the suitcase. A large number of people have viewed the body. The deceased was 5 feet 11 ins tall, well-built, broad-shouldered, square on the shoulders, he had well developed limbs, large hands, hair slightly receding in front, ginger but mousy coloured. The hair was fairly coarse, turning grey on the sides and back behind the ears, slight wave in the hair, no distinct part. He was approx. 45 years of age, grey eyes, clean shaven. Natural teeth, I think there were 16 missing, 8 on top and 8 on bottom. There was no evidence that he had worn a denture. There were scars in the body – 3 small scars inside the left writs, one scar inside left elbow curved and about an inch long, one scar or boil mark about an inch in size in the upper left forearm. The description, fingerprints and photographs have been circulated all around Australia and New Zealand. The fingerprints and photographs were sent to all the English speaking countries in the world, such as Africa, England, America. The case has had a good deal of local publicity. It has been published in every state of Australia.

**Page 28**

In response, we have had people coming forward to identify the deceased. I believe one man did identify the deceased as a man named McLean, but it was not positive. It has not been shown to be wrong. Personal particulars did not tally with this man. In all cases where people have written the particulars supplied do not tally, because of teeth, age or other personal particulars. This man said that McLean was a pipe smoker. There was no evidence either on him or in his suitcase to indicate that this man was a pipe smoker. McLean had never been known to smoke cigarettes, and this man was an inveterate smoker, because of the stain on his fingers. This man’s hands were hard, but were not rough from performing manual work, and McLean was a labourer. I was not present when the man said the deceased was named McLean. Everything possible has been done to identify the man, but without result. There is no fact that I know of which points towards suicide and abolishes the possibility of murder. I believe he died an unnatural death, but how I cannot say. A physical specimen as he was would not just go to the beach and die. The words “Taman Shud” mean the end, or the finish. That could have been placed in his pocket by the person who caused his death, so I cannot attach any special significance to that.

**Page 29**

CORONER CALLS: LEONARD DOUGLAS BROWN DETECTIVE STATIONED AT ADELAIDE SWORN

BY CORONER: The clothing found on the body, mainly the shirt, the handkerchief and the pair of Jockey underpants, are identical with a shirt and pair of underpants, handkerchief and the underpants found in the suitcase. I would say they are identical and (sic) size and in manufacture. From the layman’s point of view, I would say they are even identical in material.

In the cuffs of the trousers found in the suitcase were particles of white beach sand. I saw the slip of paper “Taman Shud”. I received that from Det. Leane with instructions to make enquiries about it. It was found in the fob pocket of the trousers on the body by Professor Cleland. I received information that the words “Taman Shud” appeared at the conclusion of a poem known as the “Rubaiyat” which was written by a Persian philosopher and mathematician, know as Omar Khayam, which had been translated into English by a man named Fitzgerald. I went to Beck’s Book shop in Pulteney St. Adelaide where I looked through a number of copies of the poem, until I found one copy at the end of which appeared the words “Taman Shud” in the same font of type as the words on the slip of paper I possessed. I held that copy up to the light, and passed this slip of paper over the words “Taman Shud” in that copy, and they are identical in size and length. That copy was published by Collins Press of England, and is distributed to Australian distributors although printed in England. I was not able to find a copy which did not have printing on the back of it as from the slip of paper produced. I made enquiries at the public library, the lending library, and the circulating library, and also the University library, in an endeavour to find a copy that might have the words “Taman Shud” torn from it. I caused enquiries to be made interstate, and also at Brighton, Somerton, Glenelg, but no copy can be found with the words “Taman Shud” torn from it.

**Page 30**

The paper on which the word are written is know as coated wood free art paper, substance of 23 x 36, 58 lbs to the 500 sheets. That is the paper which is before me. I did not compare this paper with that in the Collins book. If this is a Collins impression, the one which I saw would be a different impression. The type of paper I have is the type used in book manufacture. It appeared to be much the same sort of paper as appeared in Collins book. Different impressions of the same book might be printed on different paper. These words appear at the end of the first edition, at the end of the second edition the word “Taman” appears.

Piece of paper put in the marked Exhibit C.9.

I have made enquiries as to the meaning of the words. I made enquiries from Mr Whiting, of the public library, and in a Persian-English dictionary complied(sic) by a man named Wallerston the words “Tam shudan” appear and these words mean, “To end or to finish”. In another copy of the Rubaiyat written by another translator the ending of the poem merely states “Finis”. I take it “Taman shud” means the same - “shud” appears to be the verb, and “Taman” the noun “to end”. The poem itself simply means that we know what this world has in store for us, but we do not know what the other world has in store, and while we are on this earth we should enjoy life to the fullest, and when it is time for us to pass on, pass on without any regrets. It does not seem to have any bearing on the case, or any meaning as to the cause of this death. As far as this death is concerned, there is no context into which the words can fit.

**Page 31**

Photographs of the cast of the deceased marked Exhibits C.10 to 14. (C12,C13 & C14 handed to press for publication)

CORONER CALLS: DOUGLAS GEORGE TOWNSEND Of 464 Cross Rd Edwardstown Student

SWORN

BY CORONER On 30th November 1948 I was temporarily employed by the S.A.R. as a ticket clerk. On that particular day I was engaged in selling tickets on the Port line and North line. Looking at the ticket from Exhibit C.1., I can say that I issued that ticket on 30th November. There would be no one else issuing tickets that day from that box. The 2 stars on the ticket indicate that it came from the double star box in which I was working, so I can say from that that I issued the ticket. On this day I issued 3 tickets to Henley Beach from the box. It is a 2nd class ticket, there are no first class tickets on suburban lines. Of the 3 tickets, that must have been the first to be issued. There is an ink mark through the number which indicates that this was the last ticket left in that box from the previous day. I commenced work at 6.15, and knocked off at about 2 o’clock. That ticket must have been issued during that time. I have no independent memory of my work on that day. It would be impossible to say what time the ticket was issued. I could not remember the man to whom I sold the ticket from the photos in the paper. It is possible I did not even look at him, but only just took the money, gave the ticket and the change without looking up.

**Page 32**

WITNESS RAYMOND LIONEL LEANE RECALLED. Clothing found on the body of the deceased put in marked Exhibit C.15. Suitcase found at the station put in marked Exhibit C.16. Bust made from the body of the deceased put in marked Exhibit C.17. (Coroner orders that exhibits be kept in the custody of the Police).

At this stage adjourned to Tuesday 21st June at 10.30 a.m.

**Page 33**

Resuming on 21st June 1949 at 10.30 a.m.

CORONER CALLS:

JOHN BURTON CLELAND 1 Dashwood Road Beaumont Legally Qualified Medical Practitioner Professor in Emeritus of Pathology at Adel Univ SWORN

BY CORONER: I made an examination of the clothing which was on the body of the deceased, and also the contents of the suitcase found at the Adelaide Railway Station, and many of my observations have already been expressed in evidence. In the suitcase was an orange coloured linen thread. I found a similar thread in the clothing on the body and in the clothing in the suitcase. I the suitcase was some orange coloured linen thread. This was examined microscopically and corresponded in colour and size of fibres to similar thread used to sew up a trouser pocket in the suitcase, buttons on the trousers taken off the deceased, and to repair where the coat collar of the deceased had given way. The colour was a warm sepia colour, which is an unusual colour. I put on the deceased’s double-breasted coat, and it buttoned on me with some difficulty, and a sports coat in the suitcase similarly could be buttoned with a squeeze. The sleeves of each of these garments came down on the hand to about the same extent thought perhaps the sports coat sleeves were not quite as long. The trousers in the suitcase and those worn by the deceased seemed to be of equal length. The shoes taken off the deceased mad an excellent fit for Mr. Cowan, but the slippers in the suitcase he thought were a trifle smaller. The coat in the suitcase may have been a trifle smaller that the one the deceased was wearing. The sleeves were shorter. Both were too small for me. For a smaller chested or smaller abdominal man, the coat on the body might have been a trifle too large, and the one in the case a little too small, in other words, they would have both fitted the one man. I found the stump of a blade of barley grass in the inside of the lower part of the trouser leg in the suitcase, and another stuck in a sock worn by the deceased, but I do not pay much attention to that, at barley grass is widely distributed at that time of the year, in all the States.

**Page 34**

It is a grass which throws up its seeds as one walks through it. I agree with Dr. Dwyer’s estimate that the man was somewhere between 40 and 45; I would say he was between 40 and 50. I saw the body after it was embalmed. I could not say if it were possible that the deceased had been in the habit of wearing a beard moustache, and had recently shaved. I considered the fingernail and toenails very well cared for. They were clean, and many people who find their way to the morgue have toenails which are dirty and unattended to. His were clean. I saw indications that the deceased took some trouble about his cleanliness and appearance. The shoes on the body were remarkably clean. They looked as though they had just been polished. There was a little sand around the toe marks, but they were not quite what one would have expected had the deceased been walking about Glenelg from noon until he was seen lying on the beach. I would expect them to have shown loss of gloss in such circumstances. The deceased looked to me like a European, I would say he looked very much like a Britisher. His hair was brushed back from the forehead and there was no part in it. In examining the clothes, in a fob pocket which was rather difficult to find, just on the right of the fly, I found a piece of paper. After I found it and put the paper back, it took me a good deal of time to find it the second time, as it was a pocket which could be easily missed. I cannot add anything to the evidence which has already been given on that. I did not feel too convinced about the tags on the clothes – it appeared that they had been removed. I have considered the circumstances disclosed in the evidence, and I came to the opinion, taking all the circumstances into account, that death was almost certainly not natural, and in all probability that some poison had been taken, with suicidal intent. I came to that conclusion before I found the piece of paper bearing the words “Taman shud”. Bearing in mind that those words mean something like “the end” that supports my opinion considerably; I think the words were put there deliberately and indicated that intention that he was fed up with things.

I have read the account of the post-mortem, and there is nothing to indicate death from natural causes. He was a comparatively young man. The vessels of the heart and of the brain are described as free from atheroma, so that if his death was to be attributed to natural causes, one would have to think of some vagal inhibition, which would mean a sudden and unexpected death for which no preparation could be made, or possible something like diabetic coma, which would begin to overcome a person anywhere before they had time to retire to a place in which to lie down. Death from vagal inhibition is quite sudden, and is the result of a shock. If he died from such a cause as that, the shock must have occurred in the spot where he was lying when he died. Of course, people from time to time die of a natural death, and we cannot find any organic lesion to account for it. I agree that the words “Taman shud” would excluse(?) a natural death, one would not expect that they would be on the body if the death were natural, also because of the circumstances of the position of the body. I think if he did commit suicide whatever he took commenced to have a soporific effect on him before he had made his way as far along the beach as he had intended; that he had only time to descend the steps, found he was becoming drowsy and lay down with his head and shoulders resting against the seawall, in position which is within a yard of steps, on a summer evening, which would be frequented by several people at least. I do not remember if there was any post-mortem evidence of lividity of the neck and shoulders. Supposing the respiration was failing, his face might get dusky, and the blood might gravitate down to the ears after death. The lividity around the ears and neck was perhaps surprising in view of his position, but it was explainable. It would depend on how much his head was supported, it may have been only slightly supported, perhaps no more than one’s head is supported on a pillow. My opinion is that not only was death not natural, but was probably caused by some poison. I would accept Mr. Cowan’s evidence that he found no poison present, as he is a competent analyst. It is possible for certain poisons to be excreted from the body before death so that are not noticeable on analysis.

**Page 36**

Barbiturates and alkaloids may not be detectable on analysis. On the other hand, such negative findings must be rare, and if they had been taken, it would be a very remarkable incidence that common poisons of that nature should have given that difficulty in detection, and at the same time the person concerned seemed to have taken undue trouble to hide his identity. It makes on rather think that he may have gone to equal trouble to use something which caused a quiet death, something unusual, which was unlikely to be found. It would presuppose some knowledge, either a medical man or someone associated with a laboratory, or possible as Sir Stanton Hicks suggested, an illness in the family for which some drug had been prescribed which would achieve the result intended. If a common poison were used and not found, even in the presence of ordinary circumstances, the dose must have been enough, and just enough, to cause death. As far as I can estimate he probably died at or before midnight, and that is a comparatively quick death for poisoning, barbiturate and so on, and one would infer that to produce death so quickly a large dose had been taken, and that would be readily detected. Every poison we have suggested seems to be discounted. We found no evidence of vomiting. A possible stain on his trousers did not look like vomit, and we did not detect any evidence of potato, and he had been eating potato. The internal organs were somewhat congested, but not deeply congested as might be expected from failure of respiration. If he had given himself a hypodermic injection of tuberine, which is curare, he should have died a death from asphyxia. It does not seem that there is sufficient evidence from the post-mortem to suggest that. Most of the common poisons would give vomiting or evidence of convulsions, something which would have drawn attention to the deceased. Cyanide would be very quick, and not bottle was found, nor was there any smell of cyanide. Barbiturates are the things which could have caused death, if only they could have been found. If a barbiturate, it would probably be a sodium compound, which are absorbed faster and broken down more rapidly, but even in such a case it would appear that 50% would remain and be detectable.

**Page 37**

A drug which had been prescribed medicinally, as I have mentioned, would be difficult for the ordinary person to obtain. Of course, the man may have been a chemist or pharmacist. There was no sign of vomiting, and any trace of those substances would be difficult to detect. They would require a hypodermic injection, or I suppose they might be taken by mouth. It is difficult to find any poison which fits the circumstances. There always seems to be some little point which prevents us from accepting any particular poison as being the cause of death. It is impossible to be certain, but in my mind there is very little doubt but that the death was unnatural. The man was not circumsized, which would point to his not being a Mohammedan or Jew and I could not be certain that there was no vaccination mark. Of course, all persons serving in the forces would be vaccinated, but in some cases the vaccination marks are hard to see. A mark made by a hypodermic injection could be overlooked, notwithstanding all care. Of course, he would have had to do away with the syringe and bottle. Apparently he had discarded most of the contents of his pockets, including his money. The absence of money suggests he had deliberately emptied his pockets. One can hardly think of the last penny as having been expended in his last meal or whatever his last purchase was, unless of course he had been robbed after his death.

BY DETECTIVE LEANE

In the event of a man taking an overdose of insulin by injection, if one had thought of the possibility, the heart blood might have shown an unusual low percentage of sugar. I think Dr. Poynton told me of a case which he had seen where a man had taken a large dose of insulin, and he was supposed to have died in an hour and a half or two hours of taking it. I am just trying to remember what he told me. It may have been a peaceful death, or it may have been hypo-glycemic. Some patients who go into that type of coma do have convulsions. I think it is probably quite possible to inject into the finger and leave no puncture mark.

**Page 38**

BY CORONER

I examined a microscopic section of the liver, but it did not seem to me to offer any explanation as to the cause of death. Insulin has to be taken by injection. A lot of people take insulin nowadays, and if they got hold of the idea that it could be used for suicidal purposes, they might do so.

**Page 39**

CORONER CALLS: CEDRIC STANTON HICKS Of “Woodley” Whitington Avenue, Glen Osmond. University Professor of Physiology and Pharmacology.

SWORN

BY CORONER: I have become aware of various facts in connection with the death of this unknown man.

Coroner reads portion of Dr. Dwyer’s evidence.

At this stage evidence of Dr. Bennett interposed.

**Page 40**

CORONER CALLS: JOHN BARKLY BENNETT Of 19 Fullarton Rd. Fullarton. L.Q.M.P SWORN

BY CORONER:

I have been away from Adelaide for some time, and only arrived back this morning. I have a few notes which I made at the time, at 9.40 on 1st December, 1948. I examined the body in the ambulance outside the Adelaide Hospital, in a police ambulance. Life was extinct when I examined the body. I thought the death could have occurred up to 8 hours before my examination, not more than 8 hours. I would put the time of death at 2 o’clock at the earliest. I based the opinion on the rigor mortis but I did not make a note of the extent of it at the time.

BY SIR STANTON HICKS I formed the opinion as to the cause of death from just a cursory look at him, from the cyanosis. There is nothing else about the body which I noticed.

**Page 41**

SIR STANTON HICKS CONTINUING. BY CORONER

I have formed an opinion as to whether death was natural or not. I think it was not a natural death. I am in agreement with the other medical evidence with regard to that. Being no signs of violence about the body, first of all I accept the findings of Mr Cowan, who is a very competent and conscientious chemist, and then acting on the possibility of there still being an undiscovered barbiturate, I would expect to find death from respiratory failure and an enlarged left ventricle of the heart, which was not the case. The post-mortem findings excluse the possibility of barbiturates being the cause of death, in my opinion. I accept the evidence that the man probably died at 2 o’clock at the earliest, and that he was seen to move at 7 o’clock the previous evening. I consider that a dose of morphine which would have killed a man in that time would have been easily detectable and measurable. In cases where death has been said to be due to barbiturates, and in which the barbiturates have not been found, in cases mentioned, the poison is sulphonal. It is a possibility, but not in this case because of the condition of the heart, and I might add because of the viscera. There have been cases where death has been known to be from barbiturates, but such has not been found on analysis. In the case of sulphonal, it is possible that the dose was the bare minimum sufficient to cause death and to leave no trace on analysis. It is my opinion that to cause death in 7 hours the dose would have to be massive. I could perhaps give my reasons for suspecting a possible group, they are, one that the heart was contracted, and two, that the lungs and in particular the liver and spleen were engorged, and three, that the wall of the stomach was not only engorged but there had been blood extravxxxated into the cavity of the stomach. These facts, because they are facts, suggest to me the action of a poison which caused the heart ultimately not to relax and fill in the normal way, and that prior to its stopping in the unfilled condition, there must have been some time during which its filling was getting less and less. If the heart was filling less and less as time went by, that would mean that more and more blood would be remaining on the input side of the heart, and that would explain the engorgement of the viscera found at the post-mortem.

**Page 42**

The fact that there was blood in the gastric contents suggests to me that there had been some violent contractions of that organ, or that there had been some inflammation of the organ. No inflammatory agents were detected by Mr. Cowan, nor did the post-mortem examination suggest that some irritant metallic poison might have been involved, or an acid. Therefore I incline to conclude that a member of a group of drugs causing the heart to stop in systole might have been used. The first word on the exhibit is the name of the group, and the other words are members of the group.

Paper marked Exhibit C. 18.

Of the members of the group, I would say that there are several variants of number 1, and I had in mind more particularly number 2., which be extremely toxic in relatively small dose, I mean even in an oral dose, and would be completely missed by any of the tests applied and would in fact be extremely difficult if not impossible to identify even if it had been suspected in the first instance. I mean it would not be identifiable by ordinary chemical tests. Such a substance would be quite easily procurable by the ordinary individual, I do not think even special circumstances would be required. They might even have been procured from a case under treatment, but I do not think you would have to prove that to a chemist. It would imply intelligence and shrewd observation, but not necessarily a knowledge of the way in which it would cause death because that might have been very unpleasant. The only missing fact which would have made me confident is the absence of signs of vomiting, but there is sufficient variation between individuals to account for it or he may have vomited before he took up his position by the seawall, but I confess that I would have been more confident in drawing a frank conclusion had there been signs of vomit somewhere about him. I have been proceeding on the assumption that this was self-administered.

**Page 43**

If it had not been self-administered, and the body brought there, this would remove any doubts as to the time at which death took place, as well as my other difficulties. If death had occurred 7 hours after the man was seen to move, it would imply a massive dose. The drug which I have mentioned in a massive dose could have caused death in that time, and could still have been undiscoverable. The circumstances are consistent with its administration, and some of them even suggestive of it. Nothing is inconsistent with it. There is one point in Dr Dwyer’s evidence in which he refers to some changes in the liver lobules. He has not extended his observations upon that, and I therefore infer that they are not very significant. I infer that if they had been significant, he would have laid greater emphasis upon them, and then one might have had to consider something which had been operating over a longer period of time. My own conclusion is that these are not significant. I can think of no other group of which the two poisons are two representatives, there being several others, which could have caused death in the way in which it occurred.

BY DET. LEANE There would have been convulsions with poisoning in the group mentioned. I understand there was no sign of disturbance in the sand, and I can only assume that so many people had walked in the sand that there was no evidence that there had not been convulsions. I am only going by what I was told, that there had been a lot of people and the body, and sand being what it is it would be impossible to draw my conclusions. That is something as well as the vomiting about which I would have liked further evidence. There must have been convulsions, which of course does not mean that there would be violent movements of the body, but there must have been convulsions. If told that he was in the same position at 7 o’clock the night before he was found, and still in the same position when found, I could not draw any inference from that, because he could have had convulsions without changing his position.

**Page 44**

BY CORONER

Convulsions may precede death, they do not necessarily precede death, but I would expect them to. The question of whether or not convulsions precede death would relate to the physical state of the individual. If he were in a dilapidated condition I would expect convulsions, but in this case I would expect some convulsions mainly of the arm. I suppose you would call the movement which you described to me as a convulsive movement. The popular idea of convulsion is that it is violent, but it does not necessarily mean movements of the arm, although they can be strong movements. The convulsion is a movement, not just a stiffening. This movement at 7 o’clock could well have been the last convulsive movement. The state of the liver would exclude insulin. It is not possible the man was a diabetic who died in a diabetic coma, because the state of the liver did not support that. Further, there would have been noticed on his breath the smell of products associated with diabetic coma, after his death. It would be noticed around his body when it was opened. The finding of glycogen in the liver excludes the possibility of insulin causing death. A very factual description was given by Dr. Bennett, who said the man appeared to just like a person who had had a coronary seizure, and that is also in keeping with the conclusion that I have come to. The substance could have been taken orally. Had it been taken by injection it would have acted more rapidly.