Two hours after the case against him was dropped, Adrian Attwater packed his bags and left town.

He had no real plans, nor any real choice.

The courts might not hold him responsible for the calamity that took place on the beach in the early hours after Australia Day in 2011, but others would attempt to take matters into their own hands, provoked by the circumstances around the death of the woman who can only be legally identified as “Norma”.

In Maclean – a northern New South Wales town on the banks of the Clarence river, where racist epithets like “coons” and “darkies” can still be heard in everyday banter – Norma, an Indigenous woman, and Attwater, a white concreter, had bonded for years over alcohol.

“They were friends,” a woman who knew the pair says. “They looked after each other.”

Norma was “beautiful, happy-go-lucky” but simply had “no direction”, she says.

Attwater was from a decent family of “battlers”, could be rowdy on the drink but was essentially “harmless”, the woman says.

The pair, friends for about five years, moved between Maclean’s three watering holes, “depending on which venue they were barred from at the time”, another mutual acquaintance says.

In the last year of Norma’s life, when she had no fixed address, she alternated between the homes of close relatives, who cared for her seven children, and Attwater, whom she had begun seeing.

She used to stay in the second bedroom of his parent’s modest rented house, a stone’s throw from the river that Attwater’s father Richard once worked as a commercial fisherman.

“I fed her. I used to make sure she had a shower and was clean,” Attwater’s mother Margaret says. “She stayed here for weeks on end.”

Margaret Attwater says she tried to talk Norma into seeing a doctor about her drinking, which was constant. The 33-year-old, who had suffered physical abuse at the hands of other partners, would sometimes show up with bruises and welts from other men, she says. Margaret Attwater said her son, then 36, whose “on-again, off-again” relationship with Norma carried over about nine months, was “brought up not to hit women”.

“He never hurt a woman in his life,” she says. “He never hurt her.”

The events of Norma’s final hours, according to findings by the NSW state coroner, emphatically show this last statement to be untrue.

An inquest in November 2014 found Norma bled to death after a sexual encounter with Attwater and his friend Paul Maris on an overnight camping trip on Ten Mile Beach, half an hour’s drive from Maclean. The trio had been camping around the coast and drinking together over three days prior.

A sex act performed by Attwater in the back of Maris’s 4WD ruptured an artery inside Norma. Medical experts attested she was likely in severe pain before she fell unconscious and died on a blood-stained mattress in the back of the vehicle.

Norma suffered internal injuries that one forensic pathologist said were “more severe than those which occur in even precipitous childbirth”.

It was not those injuries but a “jagged” 45mm laceration on the outside of her vagina that would likely have left Norma in extreme pain in her final conscious moments.

Attwater later told a paramedic they had had “wild sex”.

It was not their first sexual encounter.

But coroner Michael Barnes ruled Norma, whose blood showed up alcohol content exceeding 0.33% as well as traces of methamphetamine, was too intoxicated to give “meaningful consent” to the sexual exchange, which abruptly ended when Attwater showed Maris blood on his hand.

Barnes rejected Attwater and Maris’s claims that Norma did not cry out in pain, that she remained conscious after the sex and only later collapsed after going for a swim to wash the blood from her legs.

It was Attwater’s failure to seek medical attention for the helpless woman that led to her death, Barnes found.

Instead, Maris siphoned fuel from his 4WD tank and burned Norma’s blood-stained clothing and the foam mattress. He claimed he did so because of the foul smell of the blood.

Barnes concluded this was among the lies both Attwater and Maris told out of fear the truth would reflect badly on them.

While acknowledging Norma’s death as accidental, Barnes rounded on the men, expressing “the court’s contempt and disgust for the callous disregard for her welfare shown by her supposed friends”.

Margaret Attwater recalls her son being “in shock” in the aftermath of Norma’s death.

“He was devastated. For three days he didn’t talk. He just sat there,” she says, pointing to his old bedroom.

By the time Barnes’s damning assessment brought the disturbing details of Norma’s death into the public light, both Maris and Attwater had left the Maclean region – the latter working in mines in central Queensland.

Finding himself in the crosshairs of a dogged Grafton detective called Grahame Burke, Attwater had been charged with manslaughter, and Maris as an accessory, more than three years earlier.

Both cases were dropped by the office of the NSW director of public prosecutions (DPP) before reaching committal in March 2012.

But Maclean is a small town and enough word had spread about the case to make Attwater an obvious target of hostility for some.

“He had to leave town,” Margaret Attwater says. “He got threatened with his life.”

Margaret Attwater says she witnessed some of the threats. She and her husband were separately met with abuse and pelted with objects as they walked the street.

“They shouted, ‘You fucking killer’, to me and Margaret, throwing shit at us,” his father Richard Attwater says.

Neither Norma’s dismayed family nor police were satisfied with the DPP’s dropping the case and immediately pressed for the inquest.

Detective Sergeant Burke was singled out for praise by Barnes for his “tireless efforts” in leading the death investigation.

“A less compassionate officer might have concluded that someone who habitually consorted with people such as Maris and Attwater should have been aware of the risk of being mistreated,” Barnes said.

“Sergeant Burke did not shirk the burdens of his oath of office by selectively valuing human life: he undertook a thorough and professional investigation for which I commend him.”

The coroner’s referral to the DPP to once again consider renewing charges against Attwater and Maris went unanswered for over a year.

Then the Daily Telegraph reported this week that the DPP, Lloyd Babb, had “come under fire” after recently advising Norma’s family that his office’s position on charging the men was the same as in 2012. They would not be pursued, in spite of the coroner’s recommendations. It did not reveal his reasons.

However, the next day, the Sydney-based tabloid reported that the NSW attorney general, Gabrielle Upton, had approached Babb and secured an agreement that he would “review the matter”.

“This is a truly horrible case and my thoughts go to the family and friends of Norma,” Upton said.

It is not clear why the DPP first dropped the case in 2012, nor why Babb had decided not to proceed in 2016 before Upton’s representations.

Former NSW DPP Nicholas Cowdery says the basic test prosecutors apply before deciding was “the same in every case”.

First, they need to show a prima facie case, proving the elements of the offence “on the admissible evidence”.

Second, they needed to judge whether there was a reasonable chance of a conviction.

Finally, even if there were a reasonable chance, prosecutors must consider whether it was “in the general public interest” not to proceed, with the prosecutor’s guidelines alone giving 23 examples of such scenarios.

Cowdery says it is the point about “admissible evidence” that can sometimes show the gulf between coronial findings and what is a likely verdict in a criminal case.

“It is going to vary depending on the case and it’s an area where there is a bit of controversy from time to time,” he says.

“The problem is this … the coroner can act on any information the coroner thinks is appropriate to come to his or her decision.

“That includes usually a whole a lot of material that is not necessarily able to be proved in a criminal case … second-hand hearsay and rumour and unsourced reports and all kinds of information which … don’t satisfy the legal test of admissibility of evidence in a criminal proceeding.”

The same issues arise when the DPP gets referrals for possible charges from the Independent Commission against Corruption, the Police Integrity Commission or a royal commission, Cowdery says.

“When the matter’s referred to the DPP, the DPP has to start again,” he says.

Cowdery says the DPP is obliged to maintain two-way communications with a victim’s family but will generally not mount a public explanation of a decision – unless the question of public confidence arises.

“I frequently ignored the front page of the Daily Telegraph – there’s nothing new about that and I think more people should,” he says.

“But if I thought there was a risk the community was being seriously misled by reports that really were wrong, then I ventured into the fray.”

In this case a newspaper front page coupled with a request from an attorney general proved difficult to ignore.

It remains to be seen whether the DPP will air for public understanding his office’s reasoning upon its third review of the death of Norma – a shocking event where the details of a coroner’s report appear to cohere with a tabloid morality tale.

But it provokes from Richard Attwater, his head bowed as he contemplates the renewed public vilification of his son, the same question surely in the minds of Norma’s parents and siblings, who have to explain to their children why she no longer comes to see them, not even to visit.

“Tell me this – what’s going to happen now?” he says.

The best answer probably lies in something his wife says minutes earlier – again, a sentiment likely shared by Norma’s family: “It’s been a nightmare for years. It just won’t settle down.”