Judge Sara Hinchey was at her family holiday home reflecting on how quiet the New Year's break had been when the phone rang. It was a solicitor from her office who simply said, "Oh Judge I am so sorry." It was Friday, January 20, and the State Coroner was needed in the city as there had been multiple deaths in Bourke Street.
No stranger to crime scenes and looking at sights others turn from, the judge drove from the Mornington Peninsula preparing for scenes of "overwhelming grief". By the time she arrived the cries of the wounded, the emergency sirens and the stunned mutterings of witnesses had long dissipated.
But the dead (three at that stage but the toll would rise to six) were still there as forensic photographers recorded the scene for the inevitable prosecution and coronial briefs.
She was guided along Bourke Street by homicide investigators who briefed her on what they knew and what they suspected. Judge Hinchey observed as much as possible knowing that some time in the future she will minutely examine what happened in those few minutes of destruction and in the hours and days that preceded it.
Sometimes the recollections of others are not enough. As revered author and journalist Les Carlyon has often said, to truly understand you must walk the terrain.
There are now two independent but connected investigations. The criminal brief of evidence is built to allow a court to examine who did what while the Coroner will try to determine how it happened and if there are lessons for the future.
The judge has spent most of her working life in the legal quarter just blocks from where the accused Dimitrious "Jimmy" Gargasoulas was finally arrested after his car was rammed by police. By now it was 5pm when the streets would normally be packed with shoppers, commuters and workers about to have end-of-week drinks.
"An area that is usually so lively was deserted and silent. It was an eerie scene," she recalls.
While she understands we all want answers, she will not rush, saying the inquest will look at all the circumstances that led to Bourke Street and will probably wait until criminal matters are completed. "It is better that it be done properly than quickly." To make sure she keeps an open mind she has made a conscious decision to avoid all media reports.
So how did a Broken Hill born, Ballarat educated Catholic schoolgirl with a passion for physics and chemistry end up as Victoria's most senior coroner? In the early 1980s she took to watching the Australian period drama Carson's Law, which centred on Jennifer Carson (played by Lorraine Bayly) as a lawyer overcoming sexism to succeed in the male-dominated world of the 1920s.
"I loved Lorraine Bayly; I thought she was really pretty, dignified and successful and I thought that's what I want to do."
In her early days at the bar Hinchey found nothing appeared to have changed when a client, assuming she was an office assistant, asked, "What do you have to do to get a cup of tea around here?"
Despite her ambitions to become a latter-day Jennifer Carson she continued studying science at school, ultimately completing a law-science double degree at Monash (which was an interesting choice as most barristers' passion for chemistry goes no further than learning the compounds that make a gin and tonic garnished with cucumber).
As a barrister Hinchey found her science background an asset, often gravitating to cases with a technical bent. "I loved cross-examining experts. The science side helps form the right questions."
Which is why in her wide-ranging practice she regularly appeared at the Coroners Court, representing a variety of clients as well as acting as counsel assisting. In one case she saw the parents of the deceased in court looking overawed and while they were not her clients she went over to explain her role and invite them to approach her during breaks with any questions.
"Over many years I have seen families bewildered in what can be a very confronting experience. They can go to an inquest looking for answers but end up feeling as if they have been overlooked."
Often, she says, relatives attend when the thrust of the case revolves around what happened, which means the deceased may hardly be mentioned. Now, as State Coroner, she is reinforcing to staff that relatives are a priority. "There is a grieving family behind every death."
It was a brush with ill health several years ago that brought home to her how stress plays with the mind. The daughter of a doctor, scientifically savvy and a professional questioner, she says she failed to absorb what her doctors were saying. "I now know what it is like to want to ask questions and not take in the information." And so stressed relatives will be taken through the coronial process as often as necessary so they can understand the process and outcomes.
The work of the Coroner is not to rubber stamp police investigations. Hinchey was counsel assisting in the tragic case of Freddy Williamson who in 2008 was found dead in the Austin Hospital psychiatric unit bathroom. Too quickly police concluded suicide but the coronial inquiry established he had been killed.
"The scene had not been preserved and the third party could not be identified, but for Freddy's family there was some vindication because they did not believe he would have taken his own life."
Death is grim and coronial work is deadly serious but Judge Hinchey is known for her sharp wit mixed with a healthy dose of irreverence. Her office in the Coroners Court is filled with artwork, including landscapes from her painter mother, photographic portraits of her husband and Jack Russell dogs ("my hairy children"), work files and memorabilia. In the background is soothing classical music.
She says if you are to spend so much of your day at work she wants a part office, part lounge feel.
Early in her legal career she was appointed the associate to the impressively stern Supreme Court judge Hartley Hansen. Before court one day she said she was considering sliding down the court bannister just as she had done at school. Despite the judge counselling that such a move would be most unwise, she did so while wearing her court gown. "He did laugh but I only did it the once."
In a career filled with achievements she raised an unusual one at her official welcoming to the County Court when appointed in 2015.
When she was a young law reader a fellow student from Papua New Guinea became a little smitten with her and at a course dinner confided to others he considered her to be a "19-pig woman".
"To fully understand the magnitude of this compliment one needs to know that in usual circumstances a dowry for a bride would be in the order of five to six pigs or perhaps up to 10," she said in her welcome speech.
The court was told her nickname in legal circles was Tiger because of her determination and she could remain upbeat even in defeat, once telling a client just sentenced to 12 months' jail the time would surely fly by as there would be plenty of courses in prison to help pass the time.
Known as a hard worker with an impressive range of legal skills (she appeared in the High Court as well as the Institutional Responses to Child Sexual Abuse and the 2009 Victorian Bushfires royal commissions) both she and her barrister husband Tom Pikusa have always pursued outside interests and briefly considered careers outside the law – he as a yoga teacher and she running a cooking school.
Looking for a niche in a crowded market she became known as the Truffle Hound, an expert on Victorian-grown truffles. While still passionate on cooking and fine wines, she shelved her commercial culinary ambitions when elevated to the bench.
They turned their peninsula property from what she says was "rattlesnake county" to a productive Mediterranean-style fruit and vegetable garden, photos of which would appear in their own annual calendar. The property's olive trees (along with those of a few friends) produce around 16 litres of what she says is "the world's most expensive olive oil".
From being the most junior County Court judge she became the state's most senior coroner when appointed in December 2015.
The coronial service deals with 6500 reported cases with more than 3000 ending in investigations. She says with 10 coroners, each is expected to deal with 300 cases a year in 229 working days with 80 per cent of the cases dealt with within 12 months and 45 per cent of those concluded within three months.
The judge also wants staff to join shared recreational activities to deal with stress and support morale.
Because of the potential for "vicarious trauma", staff now undergo mandatory debriefing sessions. They have also joined in lunchtime boxing classes and had a month-long step-off challenge with staff from the adjoining Victorian Institute of Forensic Medicine.
"We have such a good staff here we want to avoid burnout."
The story Looking for answers - the coroner investigating the Bourke Street carnage first appeared on The Age.