In the matter of three deaths of AFP appointees in the Australian Capital TerritoryInquest into the Death of Richard RobertsInquest into the Death of Samantha BaglinInquest into the Death of Dominic Coleman

CORONER’S COURT OF THE AUSTRALIAN CAPITAL TERRITORY PUBLISHED SUMMARY OF FINDINGS Case Title: In the matter of three deaths of AFP appointees in the Australian Capital Territory Inquest into the Death of Richard Roberts Inquest into the Death of Samantha Baglin Inquest into the Death of Dominic Coleman Citation: [2023] ACTCD 12 Decision Date: 4 October 2023 Before: Coroner Archer Findings: See [Summary page 2], [16], [71] – [101] Catchwords: CORONIAL LAW – mental health, death by suicide with AFP firearm – gun safety and mental health – mental health governance within the AFP – matters contributing to the cause of death.

Legislation Cited: Australian Federal Police Act 1979 Coroners Act 1997 (ACT) sections 34A, 52 Firearms Act 1996 (ACT) Cases Cited: R v Coroner Doogan; ex parte Lucas-Smith [2005] ACTSC 74 Texts Cited: The AFP Commissioner’s Order on Operational Safety (CO3) Abernethy, Baker, Dillon and Roberts Wallers Criminal Law and Practice in NSW 4th ed Freckelton & Ranson Death Investigation and the Coroner’s Inquest (Oxford University Press) ANAO Report No. 31 2017-18 Phoenix Australia AFP Structural Review, Reform and Policy Development on Mental Health: Final Report January 2018 Counsel Assisting: Ms P Bindon File Numbers: CD 271/2018

CD 302/2018 CD 148/2019

CORONER ARCHER: Summary This summary sets out the findings made in respect of the deaths of three people who were appointees of the Australian Federal Police (AFP) at the time they died.1 Each took their life by the use of an AFP issued firearm.

Richard Paul Roberts (Richard) was a Protective Services Officer (PSO) with the AFP. He was 57 years old when he took his own life on 28 October 2018 at the AFP headquarters at Barton ACT. He had over 20 years of service with the AFP.

Samantha Baglin (Sam) had similar period of service with the AFP. She took her own life at AFP Headquarters at Barton ACT. She died on 9 December 2018 and was 44 years old at the time of her death.

Dominic Coleman (Dominic) was at the time of his death an appointee of the AFP and an Air Security Officer (ASO) since 2016.2 He was on duty as an ASO in Canberra when he took his life on 2 July 2019 in a hotel room he was staying at. He was 52 years old.

Each death was tragic. Each of the deceased were deeply loved by their family and friends and held in high regard by their colleagues.

The matters were investigated together because of common features of their death including their employment, access to firearms and the fact that each was most probably suffering a mental illness at the time of their death.3 The manner and cause of their death was also clear in each case.

In each instance a hearing was dispensed with.

I make the findings required by section 52(1) of the Act as follows: 1 An AFP appointee has the meaning given in section 4(1) of the Australian Federal Police Act 1979 (Cth). Relevantly, it includes all AFP employees including AFP members (police officers). In these reasons the terms “appointee” and “member” are both used to reflect the use of that term in the source material being discussed or to reflect the use of that term in a given context by parties in these proceedings (for example, in submission).

2 In response to the September 11 attacks, the Commonwealth instituted an Air Security Officer (ASO) program under the Australian Federal Police in December 2001.

3 AFP legal advises that since 2000 there have been 10 known deaths by suicide of serving AFP employees. This figure includes the 3 deaths subject to this inquest.

(a) Richard Roberts died on 28 October 2018 in the Core 5 armoury located in room G.5.8 on the ground floor of the EBB, AFP Headquarters, Barton, ACT. He died of injuries caused by a gunshot wound self-inflicted with the intention of taking his own life.

(b) Samantha Baglin died on 9 December 2018 in the Core 5 armoury located in room G.5.8 on the ground floor of the EBB, AFP Headquarters, Barton, ACT. She died of injuries caused by gunshot wound self-inflicted with the intention of taking her own life.

(c) Dominic Coleman died on 2 July 2019 in a hotel room in Forrest, ACT. He died of injuries caused by a gunshot wound self-inflicted with the intention of taking his own life.

In each matter a finding is made that matters of public safety arise. Recommendations are made as to how those safety issue might be addressed.

Those recommendations, made pursuant to section 52(4) of the Coroners Act 1997, are common to each matter:

1. The AFP consider simplifying the circumstances in which a COHNF is required to be submitted to remove ambiguity and/or reduce the need for an AFP appointee to exercise judgment about whether submission is required. In particular, if the COHNF is intended to be one of the central means by which mental health issues are raised, then it should be required whenever an AFP appointee is diagnosed with or treated for such conditions.

2. The AFP consider amending CO3 to refer explicitly to: a. The need for AFP appointees to submit a COHNF in the circumstances required; b. The ability of the AFP Chief Medical Officer or Principal Psychologist or the AFP appointee’s manager to direct an AFP appointee to submit a COHNF, given the revocation powers under section 22; c. An obligation of the AFP appointees to participate in any applicable regular mental health review processes as part of the overall framework of ensuring safe use of force.

3. The AFP consider incorporating into CO3, provision for the temporary removal of access to AFP equipment, including firearms, for periods when an AFP appointee will not, or should not, be required to use it (such as periods of approved leave).

4. The AFP consider ways in which existing paid leave entitlements be used for situations in which supervisors or managers consider it necessary for an AFP appointee not to attend work due to concerns about wellbeing or fitness for work.

I have made a decision not to publish the full text of the decision. I am satisfied that the publication of the full text of this decision would cause great distress to some of the families involved. A detailed and public record of the decision of each of the deceased to take their own lives may cause others to undertake acts of self harm.

I am able, by publication of this summary, to sufficiently expose the findings I have made both as to the manner and cause of death and the matters of public safety that arose from the inquest.

The full text of the decision will be placed on the court file. Pursuant to section 40 of the Coroners Act 1997, being of the opinion that it is desirable in the public interest to do so, I by order prohibit the publication or disclosure of the evidence in the inquest not contained in this summary.

A. JURISDICTION & REQUIRED FINDINGS

1. Each of the deaths fell within the terms of section 13(1)(a) of the Coroners Act 1997 (“the Act”) being deaths that were “unnatural” or “violent”. The coroner was required to hold an inquest into the manner and cause of the death of each of the deceased and make the findings required by section 52 of the Act. That section of the Act relevantly provides: 52 Coroner’s findings (1) A coroner holding an inquest must find, if possible—

(a) the identity of the deceased; and

(b) when and where the death happened; and

(c) the manner and cause of death; and

(d) in the case of the suspected death of a person—that the person has died.

-------- (4) The coroner, in the coroner’s findings—

(a) must –

(i) state whether a matter of public safety is found to arise in connection with the inquest or inquiry; and (ii) if a matter of public safety is found to arise—comment on the matter

B. PROCEDURAL HISTORY

2. In each case, the referrals to the ACT Coroner’s Court were made on the day of the respective deaths.

3. A substantial brief of evidence was produced by investigators acting on behalf of the coroner. On two occasions during the investigation the coroner wrote to the Commissioner of the Australian Federal Police (AFP) asking questions relevant to the issues in the inquest that arose from the evidence that was then available.

The AFP responded to those requests by letters dated 28 June 2019 and 1 December 2021.

4. The totality of the material produced by investigators was ultimately distributed to the families with some limited redactions to meet concerns around the release of sensitive information.

5. Ms Prue Bindon of counsel was appointed counsel assisting.

6. A decision was made by Coroner L. E. Campbell to aggregate the inquests and conduct them as one.4 The matters were reallocated to me after my appointment as the dedicated coroner in March 2022.

7. By that time, the process of evidence gathering was at an end and counsel assisting had been requested to prepare submissions.

Decision to Dispense with a Hearing

8. Section 34A of the Act relevantly provides: 34A Decision not to conduct hearing (1) A coroner may decide not to conduct a hearing into a death if, after consideration of information given to a coroner relating to the death of a person, the coroner is satisfied that–

(a) the manner and cause of death are sufficiently disclosed; and

(b) a hearing is unnecessary.

-------- 4 The aggregated inquests are hereafter referred to as a singular inquest. Likewise, the investigation in each case and the brief produced in respect of each death under consideration is referred to in the singular.

(3) A coroner who decides not to conduct a hearing into a death must give to the Chief Coroner and a member of the immediate family of the deceased written notice of the decision including the grounds for the decision.

9. Based on the information received in the brief of evidence, Coroner L.E. Campbell was satisfied, subject to the views of interested parties, that the manner and cause of each deceased’s death were sufficiently disclosed and, therefore, a hearing was unnecessary. That provisional view not to conduct a hearing and the reasons for that decision were provided to the AFP and representatives of each family. The AFP and families of Richard and Sam expressed a desire not to have a hearing. The family of Dominic sought a hearing.5 On 6 August 2021 the coroner, through counsel assisting, communicated by letter to each family, Coroner L.E. Campbell’s view that a hearing was unnecessary and that it would be dispensed with.

Submissions

10. Counsel assisting, the families of Richard, Sam and Dominic and the AFP made submissions as to the findings that should be made.

11. In respect of matters going to the narrative of each death and detail surrounding relevant governance issues, the submissions of counsel assisting were detailed and, save for some factual issues that were raised by the Baglin and Coleman families, accepted by the parties.

12. Counsel assisting made submissions urging me to make recommendations in relation to certain public safety issues that arose from the inquest.

13. The families supported or did not oppose the making of those recommendations. The AFP opposed the making of some of the recommendations to the extent set out below. In addition, the Coleman and Baglin families urged me to find (respectively) that the AFP and Sam’s husband contributed to the relevant death. I declined to make such findings.

5 The names that are used in the judgment reflect the preferences of the families of the deceased.

The families were afforded the opportunity of providing a biographical history and an in-court reflection about their loved one.

C. MATTERS OF PUBLIC SAFETY – CORONERS ACT 1997 – SECTION 52(4) Introduction

14. The terms of section 52(4) of the Act establish the parameters of a coroner’s power to examine issues of public safety. To comment on a matter, it must ‘arise’ in connection with the inquest or inquiry.

15. The adequacy of the AFP’s governance in respect of mental health issues in 2018 and 2019 provides the broader context to the inquest before me and is addressed below [18]. The AFP has provided information [25] to the court about the progress of much needed reform and change in this space. Whilst consideration of that issue provides a necessary backdrop to the consideration of each death [27], a fair and comprehensive review of that issue is beyond the scope of being a matter ‘arising’ from each death.

16. However, each appointee whose death I am considering used their own AFP issued revolver to take their own lives. Regulation of access to AFP firearms by certain of its employees is, in my view, a public safety issue that arises in connection with each inquest. That being so, I am required to comment on that matter.

17. The submissions of counsel assisting crystalized the public safety issues that arise from the material in the inquest. Interested parties, including the families and the AFP had an opportunity to indicate a position in relation to the comments and recommendations that counsel assisting invited me to make.

Background Issues – Mental Health Governance within the AFP

18. Managing employee mental health issues is obviously a matter of ongoing concern for management within the AFP. As first responders dealing routinely with events of a confronting and traumatising character, the AFP is faced with the challenge of ensuring that staff well-being and mental health is properly addressed. This challenge is shared by all employers of first responding emergency services officers, front line workers and those regularly dealing with sensitive and distressing material. Safe Work Australia’s Work-Related Mental Disorders Profile 2015 found that first responders, including the police, were the occupational group most likely to attract compensation claims based on mental health injury.

19. Since 2016 the AFP’s performance in addressing mental health needs has been the subject of a number of reviews. In September 2016, the AFP developed a draft Mental Health Framework and associated Mental Health Strategic Action Plan.

20. To inform the development of that strategy, the AFP engaged Phoenix Australia Centre for Posttraumatic Mental Health (Phoenix Australia) to undertake a review of mental health governance within the AFP. The work of Phoenix Australia included surveying employees of the AFP to gain their views as to matters of governance and culture within the AFP that affected its capacity to effectively manage the mental health of it’s workforce. Some of the outcomes of that survey relevant to these inquests were:

21. Adequacy of current wellbeing supports: There were strong perceptions that mental health support services are poorly integrated and under resourced, and that this has worsened in recent years.

22. Attitudes to mental health reflect stigma: There were widespread perceptions that it is hard for people to raise their hands if they are concerned about their mental health. Appointees worry about confidentiality, adverse career impacts, and losing composite pay. There is a general perception that management does not promote help-seeking or take action to support the health and wellbeing of staff.

23. Psychological assessment: There were perceptions that current psychological assessment procedures are bureaucratic, inconsistently applied, and do not reflect a genuine concern for appointee wellbeing. Staff were supportive of increasing wellbeing assessment, commensurate with role and risk of exposure to critical incidents, provided it would lead to meaningful support.6

21. The findings from the review conducted by Phoenix Australia included that:

(a) whilst there were supports available to AFP staff, there was little internal coordination of those supports and accountability as to performance; and

(b) managers were not well equipped to deal with mental health issues that were identified in the workplace.

22. In 2017- 2018 the Australia National Audit Office (“the ANAO”) undertook a performance audit of the AFP’s management of the mental health of its employees: Managing Mental Health in the Australian Federal Police.7 The audit report was tabled in March 2018. Some of the conclusions reached by the ANAO were critical of the AFP, for example: While currently developing a mental health framework, the AFP has not established a clear governance structure for decision-making, information 6 AFP Structural Review, Reform and Policy Development on Mental Health: Final Report January 2018 pg 13 7 ANAO Report No. 31 2017-18

sharing and oversight in relation to employee mental health arrangements.

Reporting into the governance structure is not comprehensive or risk-based, making it difficult to identify emerging mental health related risks and to utilise this reporting to inform decision making in resource prioritisation to address increasing mental health risks.

The AFP does not have in place an organisational health and wellbeing strategy which incorporates policies, programs, and practices to address mental health risks. The AFP is developing a draft Mental Health Framework and Mental Health Strategic Action Plan, and finalisation of these is dependent upon the outcome of a review of AFP mental health services that was not yet finalised at the time of drafting this report.

The AFP does not currently have in place mechanisms or sufficient data to appropriately align resources with key mental health risks.

The AFP formally recognised mental health as a strategic risk to the organisation and began developing treatment actions in October 2016. This strategic risk identification has not led to substantive engagement by all functional areas. Employee mental health has not been consistently identified as a risk in the AFP’s functional risk assessments and it is not evident that the AFP is co-ordinating the management of mental health as a shared risk (that is, between Organisational Health and functional areas).

23. A series of recommendations were made by the Auditor General that were accepted by the AFP.

24. An AFP Health and Wellbeing Strategy 2018-2023 was launched by the AFP Commissioner in November 2018.

25. In its December 2021 response to the coroner, the AFP outlined the progress of the implementation of improvements arising from the ANAO process. In the AFP’s submissions made at the end of my investigative process (December 2022), further information was provided to the court about the implementation of that strategy and commitments that the Federal Government had made to fund a new AFP health model known as SHIELD:

26. The AFP continues to place significant focus on improving mental health outcomes for AFP appointees. Since the AFP’s last response to the Coroner in December 2021, the AFP has continued to implement a number of key measures and improvements to its wellbeing framework…8

27. In late 2020, the Government committed $65 million to the AFP over four years to implement a new AFP health model known as SHIELD. As a result of the steps taken by the AFP over the past two years to implement SHIELD, 8 A reference to an attachment is deleted.

there has been a significant increase in the proactive health and wellbeing services aimed at prevention and early intervention.

14. SHIELD has shifted the AFP’s health and wellbeing program from a limited, centralised model focused on rehabilitation to the SHIELD model which delivers expanded services in each Regional Command, with an emphasis on delivering a holistic approach to supporting AFP members’ health, including prevention and education.

15. The SHIELD services are delivered in each Regional Command and provide AFP appointees with access to professionals according to their needs, such as a doctor, nurse, exercise physiologist or psychologist. AFP appointees can arrange in-person or online health check, consultation, or education session through a simple booking system.

16. SHIELD services in each state and territory offer access to a dedicated team of clinicians and health professionals who understand the unique nature of the AFP’s work. The Phoenix Review (2018) reported an ideal ratio of 1:250 in respect to mental health practitioners to AFP members. As of 7 December 2022, the number of SHIELD psychologists has increased by 72%, and the ratio of internal mental health practitioners (inclusive of psychologists, nurses, and social workers) is now 1:217.

17. To date, 9 out of 10 SHIELD Hubs have commenced. SHIELD Southern Command will commence enhanced services in May 2023.

18. Save for what follows below, I make no findings as to the sufficiency of the AFP’s:

(a) mental health strategy and governance in the years before the deaths I am considering,

(b) mental health governance during the period covered by the dates of the deaths before me; or

(c) the adequacy of its implementation of the recommendations of the ANAO review at the time of and after the deaths of Richard, Sam, and Dominic.

27. Those issues were beyond the scope of the findings that could be said to arise from the inquest. However, the cultural and governance issues that are identified in the reviews outlined above form part of the essential background to the deaths I am considering. This is particularly so in relation to the reluctance each of the deceased had to divulge their mental health difficulties within the workplace or to AFP mental health clinicians because (at least in part) of a lack of trust and out of fear of being stigmatised.

Gun Safety and Mental Health Access to Firearms within the AFP

28. Access to AFP equipment including firearms is controlled by two sets of requirements:

(a) Administrative access: access is limited to those granted authorisation by the AFP to be issued with and possess an official firearm; and

(b) Physical access: access is limited by measures in place to regulate physical storage of official firearms.9 Part 1 – Administrative Access to Firearms

29. The Australian Federal Police Act 1979 (“the AFP Act”) provides the legal framework for the operation of the AFP generally and provides the structure around which the AFP internally regulates the use and possession of firearms by AFP appointees (a concept that includes operational police).

30. The AFP Commissioner has the power under section 38 of the AFP Act to issue written orders in respect of the general administration of, and the control of the operations of, the AFP.

31. An AFP appointee is required by section 39 of the AFP Act to comply with the AFP Commissioner’s orders.

32. Such an order, the AFP Commissioner's Order on Operational Safety (“CO3”), has been issued by the AFP Commissioner with respect to operational safety, and was in force at the time of each of the deaths which are the subject of these findings. It sets out the AFP's policy and procedures in relation to operational safety and use of force practice, reporting, training, assessment, qualification, and administration. CO3, with some redactions, is a publicly available document. AFP appointees must comply with CO3 unless

(a) they have applied for a variation from compliance, and approval in writing of the variation has been granted, in accordance with section 8;

(b) they have been granted a medical exemption; or

(c) they are an exempted AFP appointee under Schedule 1.

9 This inquest has been concerned with storage issues that arose in respect of members engaged in the national aspect of the AFP’s operation. Comment is made at [103] in respect of how and to what extent the findings I have made have relevance to the AFP in its role in providing community policing services in the ACT.

33. Access to firearms is not predicated on the likelihood of that person having to use a firearm.10 AFP appointees are under an obligation to maintain an operational safety qualification. To be entitled under CO3 to access firearms appointees must maintain an operational safety qualification (which is an annual competency testing process which tests practical and theoretical competency).11

34. There are some exemptions that apply to the need to maintain an operational safety qualification. Relevantly for present purposes:

(a) AFP appointees whom the AFP Chief Medical Officer or Principal Psychologist has recommended for medical, psychological, or organisational health reasons be:

(i) exempt from completing the operational safety assessment; or (ii) exempt from carrying an item or items of AFP equipment.

(b) AFP appointees who have applied for a variation from compliance with CO3, and approval in writing of the variation has been granted.

35. In respect of an exemption for medical, psychological, or organisational health reasons, the procedure is:

(a) The AFP Chief Medical Officer or the Principal Psychologist may request, in writing, evidence from the AFP appointee’s treating health practitioner to assist in making a recommendation.12

(b) If a recommendation for exemption is made, the AFP Chief Medical Officer or the Principal Psychologist must in writing:

(i) advise the AFP appointee of the recommendation including the reason, duration, and process to be followed to address the issues leading to the recommendation; (ii) advise the AFP appointee’s supervisor, manager, and Manager Security of the recommendation including the duration and process to be followed to address the issues leading to the recommendation.13 10 During this investigation the AFP were asked why it was necessary for all AFP appointees to maintain their operational safety qualification (and thereby have access to firearms). The response was that it is to ensure the AFP has the ability to deploy use of force qualified appointees rapidly, and beyond the cohort of its workforce which is deployed for day-to-day policing activities where the use of firearms may be contemplated.

11 CO section 5.12.

12 CO3 section 22.19.

13 CO3 section 22.20.

(c) The manager of the AFP appointee must then consider revoking the AFP appointee’s operational safety qualification in accordance with section 22.10.14 If the manager decides not to revoke the AFP appointee’s operational safety qualification, the AFP’s Chief Medical Officer or Principal Psychologist must be advised of the reasons for the decision. The manager may also consider granting the AFP appointee a variation from compliance in accordance with section 8.15

(d) The AFP appointee’s operational safety qualification may be reinstated by the revoking officer, a manager or higher. The reinstating officer must not do so unless the AFP Chief Medical Officer confirms in writing that the issues leading to the revocation have been resolved.16 Psychological Testing and Operational Safety Qualification

36. Psychological testing does not directly form part of the operational safety qualification process. However, that statement is subject to the following qualifications:

(a) OSA Declaration of Health Prior to attending an operational safety assessment, AFP appointees are (and were at the time of each of the deaths) required to submit an “OSA Declaration of Health” form to identify any medical or psychological issues that would put themselves or others at risk by participating in the OSA process.

(b) Change of Health Notification Form (COHNF)

37. AFP appointees are (and were at the time of each of the deaths) also required to submit a “Change of Health (medical or psychological illness/injury) Notification Form” whenever a medical issue arises which may give rise to risk to themselves, colleagues, or the public. This requirement derives not from CO3 but from the AFP National Guideline on Health for AFP appointees. Relevantly, the COHNF contains the following instructions: Appointees are required to submit a COHNF if they:

• Have an injury and or illness which may affect their ability to undertake their role safely 14 CO3 section 22.21.

15 CO3 section 22.22.

16 CO3 section 22.24.

• Require a health exemption for OSA and OH do not already have this information

• Have been recommended to do so by an Organisational Health clinician Examples of illness/injury which may require a COHNF:

• Major surgery

• Commencement of medication that may affect your cognition and decision-making capability

• Illness or injury that affects your ability to undertake the physical requirements of your role safely ….

• You are not required to complete this form if you have previously provided this information to Organisational Health. ….

38. In cases where a temporary health exemption is required, Occupational Health will advise AFP Security of the temporary health exemption, in accordance with the above AFP Governance. The reasons for the exemption are not included in this notification.

39. Once received, the COHNF will be reviewed by an Occupational Health delegated clinician who will identify any potential health risks which may affect the ability of the appointee to undertake their role safely. The appointees may be contacted by Occupational Health to provide additional information.

40. If there are no identified potential health risks, the appointee will be notified by email and the COHNF retained to form part of the appointee’s Occupational Health record.

41. The AFP indicated that the COHNF “serves to ensure that members notify the AFP in a timely manner when there are any factors that may impact on their ability to hold an operational safety qualification”. In the view of the AFP, it enables the AFP Chief Medical Officer and medical team to identify potential health risks and provide appropriate and timely health advice to the affected person in order to reduce potential health risks.

Revocation of Access to a Firearm

42. CO3 provides a mechanism for revoking administrative access to a firearm. Section 22 relevantly provides:

22.7 An AFP appointee's operational safety qualification may be revoked at any time by an appointee performing the role of Manager or above including if: …..

b. the appointee is considered to be unfit or unsuitable to carry or use AFP equipment.

22.8 If an AFP appointee is suspended from duty the suspending officer must, in writing, advise the appointee's Manager of the suspension including the reason and process to be followed to address the issues leading to the suspension.

22.9 The Manager of an AFP appointee who is suspended from duty must immediately revoke the appointee's operational safety qualification.

22.10 If an AFP appointee’s operational safety qualification is revoked for any reason, apart from the appointee being unable to demonstrate competence in an operational assessment item, the revoking officer must, in writing: a. advise the appointee of the revocation including the reason and process to be followed to address the issues leading to the revocation; b. advise the appointee’s supervisor of the revocation including the reason and process to be followed to address the issues leading to the revocation; c. advise COSP of the revocation including the reason and process to be followed to address the issues leading to the revocation; d. advise Manager Professional Standards of the revocation including the reason and process to be followed to address the issued leading to the revocation; e. advise the CMO and Principal Psychologist of the revocation; f. advise Manager Security of the revocation including the reason and process to be followed to address the issues leading to the revocation; g. advise the relevant issuing Registrar of the revocation and the requirement for the appointee to immediately return their personally issued AFP equipment.

….

22.18 The AFP CMO or the Principal Psychologist may for medical, psychological or organisational health reasons:

a. recommend that an AFP appointee’s operational safety qualification be revoked; b. recommend that an AFP appointee be exempt from completing the operational safety assessment; c. recommend that an AFP appointee be exempt from carrying an item or items of AFP equipment.

….

22.21 The Manager of an AFP appointee who is subject to a recommendation under sub-section 22.18(a) or 22.18(b) must consider revoking the appointee’s operational safety qualification in accordance with section 22.10 of this Order.

Part 2 – Physical Access to Firearms Local Law

43. Before addressing how AFP appointees access their firearms, the legal context in which that occurs must be understood. The three deaths occurred in the ACT. The possession and use of firearms is regulated by the Firearms Act 1996 (ACT) (“the Firearms Act”). The lawful possession of the firearms that were issued by the AFP to each of the deceased would normally only be possible if they were licenced to possess a firearm of that type. However, the Firearms Act exempts an AFP member from it’s terms in respect of “possessing or using firearm in exercise of person’s functions as a member”. Therefore, unless an AFP appointee possesses or uses an AFP issued firearm in accordance with their duties, they will be exposed to potential criminal liability. When a person is possessing or using their firearm in the exercise of their functions as an appointee is defined by CO3, other relevant AFP governance and relevant Commonwealth, state, or territory laws (that might impose restrictions on the possession and use of firearms in particular situations).

44. Possession and use of firearms by appointees whilst they are on leave without some authority otherwise being granted would expose them to potential criminal liability, as they are not possessing the firearm in the exercise of their functions as a member (appointee).

AFP Governance – General Matters

45. CO3 requires that AFP appointees are individually accountable for the security of AFP equipment issued to them.

46. CO3 also requires that all AFP equipment must be stored in accordance with the AFP National Guideline on Controlled Items attachments A and B (“the National

Guideline”), unless complying storage facilities are not available and approval has been granted for alternative storage.

47. The National Guideline details obligations for all business areas, supervisors and AFP appointees for the procurement, issue, custody, management, disposal and reporting of controlled items. It provides that AFP appointees issued with or in possession of controlled items must only be in possession of a controlled item while on operational duty or where approval is received from their supervisor.

48. All operational safety qualified AFP appointees have, in accordance with AFP policy, a security pass that is configured to allow them to access to an AFP armoury where they are to store their personally issued AFP equipment.17 At the time of Richard’s and Sam’s death, an AFP appointee simply needed to swipe the security pass in order to access the relevant armoury.

49. In early 2018, several months prior to Richard’s death, the AFP implemented a “dual swipe” trial for accessing AFP armouries in Cairns and Brisbane Airports. It was implemented in direct response to other critical incidents involving the loss of life in AFP premises.

50. In December 2018, in response to the deaths of Richard and Sam, the AFP took urgent action to implement the enhanced armoury access control measures at all major AFP sites. The enhanced armoury access control measures restrict access to AFP armouries through one of two methods:

(a) Time restricted method: an armoury operating with time restriction capability means that during core business hours a qualified appointee may access the armoury. However, outside core hours, the card reader to access the armoury is deactivated and after-hours access must be approved by a supervisor in writing to the AFP Operations Coordination Centre AOCC; and

(b) Dual-swipe access method: an armoury fitted with dual-swipe access capability requires two qualified appointees to swipe their security pass across the card reader within seconds of each other before access may be granted.

This process applies at all times (including during core business hours) and provides an opportunity for appointees to observe the entering appointee's general wellbeing. The same must occur to exit the armoury.

17 June 2019 AFP Response at p 5.

51. As of June 2019, enhanced armoury access controls had been implemented nationally across all major AFP sites (22 locations), applying to 33 individual armouries covering 80% of all sworn police and PSOs.

52. For remaining sites, the AFP advised that risk is mitigated by the small team environment, different controls (as there is not an AFP access-controlled armoury) or reliance upon partner access control and security requirements.18 With respect to ACT Policing specifically, the AFP advised:19 ACT Policing has undertaken a review of personal firearms storage, issue and return, and has not implemented enhanced access control measures to its armouries due to the existing firearms storage configuration across ACTP sites.

While review recommendations are to be finalised, ACT Policing operates on a 24/7 small team environment which involves regular critical incident debriefing; close support and supervision of staff and 24/7 visibility over the majority of firearms storage containers in open environments.

53. Additionally, on 21 January 2019, the AFP commenced a National Firearms Access Review. The purpose of the National Firearms Access Review was to examine extant national level policy, practices, processes, and governance in relation to firearms storage and access by qualified AFP appointees, and to recommend/implement reforms to reduce corporate risk and strengthen safeguards for at-risk officers.20

54. The National Firearms Access Review was finalised in June 2019. The AFP advised that the following changes were made as a result of that review:21

(a) Risk assessment treatment plans were conducted regarding sites where firearms were stored.

(b) A list of endorsed firearm storage containers was published internally.

(c) Reporting measures were implemented which allow supervisors and managers within the AFP to monitor compliance with firearms surrender procedures when an appointee is not authorised to retain possession of a firearm.

(d) Revision of the National Guideline on Controlled Items to enhance processes around approval of home or off-site storage of controlled items.

18 June 2019 AFP Response at p 13. For example, a small AFP Protection Defence Establishment site has no dedicated armoury. Revised access control measures have been enabled via the senior officer having sole access to a safe key, with firearms signed in and out, at the commencement and finalisation of a shift. General individual access is not permitted. The site involves a small team environment where supervision of members’ ongoing welfare is practiced.

19 June 2019 AFP Response at p 14.

20 June 2019 AFP Response at p 12.

21 December 2021 AFP Response at p 7.

Possession of Firearms – Specific Operational Need – ASOs

55. The AFP has advised that, at the time of Dominic’s death, the standard procedure was for ASOs to store their firearms at an appropriate AFP armoury. In the case of ASOs staying overnight in Canberra, the appropriate armoury would be the armoury at the AFP Airport Station. That procedure remains in place.

56. At the time of Dominic’s death, the documentation of relevant procedure for ASOs to follow in this context was piecemeal and lacking in specificity.

57. The evidence in the inquest diverged as to storage of firearms when not in use. Some appointees suggested that normal practice was for AFP appointees to utilise an AFP armoury located either at an AFP Office or at an AFP Airport Station to store their firearms while not in use. However, some AFP appointees stated that this practice was not always followed, and appointees would sometimes store their firearms in their hotel room. Dominic’s colleagues indicated that there was no standard operating procedure to govern this.

58. The evidence of some AFP appointees also confirmed that to access an AFP armoury at an AFP Office or AFP Airport Station located in the travel destination, ASOs make a request to the relevant “Duty Sergeant”. Other appointees were of the understanding that all ASOs have swipe access cards for the armouries and can access them independently. In any event, it appears that AFP appointees located in the AFP Airport Stations are not notified generally about incoming/outgoing ASOs who will need to store their firearms in the armouries.

59. The AFP confirmed that there is no mechanism or process by which the storage of firearms by ASOs on arrival at an overnight location can be automatically checked and verified. Rather, the system “requires appointees to comply with the directions and obligations with regard to firearms storage set out in relevant governance”.

60. Following Dominic’s death, the AFP conducted a full review of governance, procedures, recruitment, tactics, and training relating to the ASO capability, which included updating governance and standard operating procedures for SRG DO (which has subsumed what was previously the ASO operations). Specifically:

(a) in relation to ASO firearm handling, there is a revised directive which provides a more robust process for securing firearms at armouries;

(b) further training and mandatory reporting have been rolled out to ensure that all AFP appointees are fully aware of requirements around weapons storage,

and that those requirements are reinforced as part of recurring compulsory training; and

(c) governance around these topics is being revised to place greater emphasis on the obligation of AFP appointees to report failures by other AFP appointees to follow governance around firearm use and storage. A breach of these governance obligations is potentially a serious professional standards issue.

Part 3 – Removal of Physical Access to a Firearm

61. In the event that an AFP appointee’s operational safety qualification is revoked, CO3 requires that:

(a) the revoking officer must inform the issuing Registrar of the need for the AFP appointee to immediately return their personally issued AFP equipment;

(b) the AFP appointee must immediately return all personally issued AFP equipment to the issuing Registrar in accordance with section 18;

(c) the supervisor of the AFP appointee must ensure the appointee returns all personally issued AFP equipment in accordance with section 18 or, if the appointee is unable for medical or other justifiable reasons to do so, the supervisor must take possession of the equipment and ensure it is returned;

(d) the Manager Security must be notified of the revocation in accordance with clause 22.10(f) and the Security Access Control team will deactivate the appointee’s security pass armoury access.

62. In this regard, the AFP provided a copy of the procedure that the Security Access Control team follows with respect to security passes. It is apparent from the procedure that once the Security Access Control team receives instructions from one of the relevant sources, revocation of physical access to armouries can be effective immediately (at least in the vast majority of locations where access to armouries is by way of security pass).22

63. Ultimately, the practical steps for revoking physical access to a firearm may not be difficult to manage where access to armouries is by way of security pass. Everything 22 So much appears to have been illustrated by the events that transpired in the death of AFP employee Malcolm Scott as was observed in the Finding into Death without Inquest of Judge Sara Hinchey, State Coroner of 4 November 2017 at [29]: “AFP staff were sent to AFP Headquarters to conduct a welfare check on Mr Scott, after attempts to contact him via his phone had failed. Mr Scott's swipe card access to the Armoury was removed.”

hinges on the Security Access Control team receiving an email from the appropriate person for a reason recognised in the procedure.

64. For armouries where access is not by way of security pass, the position is somewhat less clear as to the last step in revoking physical access (given that the step mentioned in paragraph [61 (d)] above would not apply). If in those locations, firearms are stored in lockers within the relevant AFP station, the equivalent of the Security Access Control team deactivating the appointee’s security pass would presumably be the AFP appointee surrendering the key to the locker(s) to someone authorised to take custody of it. Logically, if the AFP appointee must return the firearm to the Registrar, the Registrar would also be in a position to take custody of the locker key.

65. It is worth noting again that in the December 2021 AFP Response, the AFP indicated that as a result of the National Firearms Access Review new reporting measures were implemented which allow supervisors and managers within the AFP to monitor compliance with firearms surrender procedures when an AFP appointee is not authorised to retain possession of a firearm. The specific detail of these measures was not provided.

Access to Firearms by Each of the Deceased Part 1 – Administrative Access

66. Richard, Sam, and Dominic were AFP appointees and therefore required to maintain an operational safety qualification. Dominic’s duties as an ASO required him to carry a firearm.

67. At the time of their deaths each had a valid operational safety qualification, and no exemptions were in place. Therefore, each had administrative access to firearms.

68. Each of the deceased were obliged to report the change of health circumstances that were required by the COHNF process. As has been addressed [in the full text of these reasons], it is clear that the disclosures that Richard and Dominic were required to make were not made. Clearly, they did not want the AFP to know.

69. In Sam’s case, her mental health challenges were known to her supervisors. She had been “stood down” but not suspended.23 Supervisors adverted to the question of whether Sam should have access to her firearm and came to the conclusion that revoking access was not necessary. Therefore, no conclusion was reached for the 23 The AFP has confirmed that there were no specific documented procedures around “stand down” at the time Sam was stood down, nor around excluding “stood down” employees from entering the workplace (or armouries specifically).

purposes of section 22.7 of CO3 that she was unfit or suitable to carry or use a firearm (notwithstanding she was considered to be unfit to be at work).

Part 2 – Physical Access

70. Both Sam and Richard used their security passes to access the armoury at the EBB where their firearms were stored. In Dominic’s case he possessed the firearm in the context of his ASO duties and most probably avoided leaving his gun at the armoury located either at an AFP Office or at an AFP Airport Station to facilitate an act of self harm that he had planned.

D. COMMENT AND RECOMMENDATIONS

71. I address the possible public safety issues arising from the above in the same structure adopted by counsel assisting in submission.

The COHNF System & CO3

72. Counsel assisting submitted that the COHNF system has several vulnerabilities:

(a) It places the onus entirely on the AFP appointee to come forward and disclose the relevant information. Richard, Sam and Dominic should have submitted a COHNF to disclose the mental health conditions present at the time of their deaths, but none of them did so. All of them appear to have intentionally avoided disclosing their mental health issues to the AFP.

(b) The terms of the COHNF in place at the time did not make clear that mental health issues (as distinct from deterioration in physical health) were required to be disclosed. It is stated that the COHNF must be submitted when AFP appointees “have an injury and or illness which may affect their ability to undertake their role safely”. The examples given include “major surgery”, “[c]ommencement of medication that may affect your cognition and decisionmaking capability” and “[i]llness or injury that affects your ability to undertake the physical requirements of your role safely”. However:

(i) a mental illness does not necessarily affect an AFP appointee’s ability to undertake their role safely (especially if it is being effectively treated); (ii) even if it does, AFP appointees themselves may not necessarily recognise that to be the case; and

(iii) AFP appointees may not necessarily be apprised of the full details of any medication they are prescribed including its impact on cognition or decision-making capability.

(iv) The requirement to submit a COHNF is not referred to anywhere in CO3. This seems anomalous given that the grounds for revocation include:

(i) the AFP Chief Medical Officer or Principal Psychologist has recommended that it be revoked; and (ii) where the AFP appointee’s manager considers the appointee to be “unfit or unsuitable to carry and use AFP equipment”.

(v) CO3 contains no reference to the requirement to submit a COHNF.

73. I accept these submissions. I make the following recommendations: Recommendation 1

74. The AFP consider simplifying the circumstances in which a COHNF is required to be submitted to remove ambiguity and/or reduce the need for an AFP appointee to exercise judgment about whether submission is required. In particular, if the COHNF is intended to be one of the central means by which mental health issues are raised, then it should be required whenever an AFP appointee is diagnosed with or treated for such conditions.

Recommendation 2

75. The AFP consider amending CO3 to refer explicitly to:

(a) the need for AFP appointees to submit a COHNF in the circumstances required;

(b) the ability of the AFP Chief Medical Officer24 or Principal Psychologist or the AFP appointee’s manager to direct an AFP appointee to submit a COHNF, given the revocation powers under section 22;

(c) an obligation of AFP appointees to participate in any applicable regular mental health review processes as part of the overall framework of ensuring safe use of force.

24 The ability of the AFP Chief Medical Officer or delegate to direct an AFP appointee to complete and submit a COHNF is referred to in the AFP National Guideline on health for AFP appointees but not CO3.

76. The making of these recommendations was supported by the AFP.

Regular Mental Health Reviews

77. Counsel assisting submitted that the AFP consider expanding the regular mental health review process to all AFP appointees who are not exempt from CO3. This recommendation was supported or not opposed by each of the families.

78. As noted [36], mandatory psychological assessment is not part of the annual operational safety assessment process. The AFP indicated in its December 2021 response that they do not intend to introduce such a process because “members are motivated to pass” and “linking the OSA process with psychological screening is unlikely to encourage candour and open engagement with the screening.”25The AFP went on to say that the psychological health of an AFP could be addressed in other ways:

(a) the current COHNF system, “which serves to ensure that members notify the AFP in a timely manner when there are any factors that may impact on their ability to hold an operational safety qualification”; and

(b) the “current periodic mental health review process” which is intended to be expanded “to a greater number of AFP appointees when additional mental health clinicians are engaged under SHIELD”.26

79. In their December 2022 submissions the AFP indicated that it had “introduced a periodic mental health review process for high-risk roles. Those reviews are focused on AFP appointees in business areas that are considered ‘high risk’ due to the presence of significant psychosocial hazards in the workplace”. The submissions went on to say that “there would likely be resourcing and quality implications in requiring all AFP appointees to undertake regular mental health 25 December 2021 AFP Response at pp 4-5.

26 “SHIELD” is described as follows in the December 2021 AFP Response at p 1: “In October 2020 the federal government announced funding to the AFP of $65.3 million over four years for the delivery of the SHIELD program. SHIELD revolutionises the delivery of health services to AFP members, reserves, former members, and families through forward-leaning approaches in education, prevention, early intervention, treatment, transition support and a centre of excellence. These services are designed to identify the early signs of distress in staff members and to either deliver best practice interventions or facilitate access to appropriate care. Under SHIELD, AFP members will have access to a range of clinical health professionals (including Psychologists, Social Workers, and Mental Health Nurses) who understand the nature of the AFP's operating environment. SHIELD clinicians will be embedded throughout the AFP workforce rather than being restricted to a clinic. This approach is designed to increase opportunities for early intervention, and to increase access and visibility of these support resources.”

assessments unless exempt under CO3” and that the proposal would require an additional estimated 2553 reviews take place each year and the employment of an additional seven psychologists to perform that role.

80. In reply counsel assisting submitted that:

(a) whilst increasing support to people within that category was a commendable goal, the coverage provided by the new processes would depend on what is considered to be a “high risk role”;

(b) the AFP submissions did not make clear whether the roles played by each of the deceased would be considered “high risk roles”. It is likely that Sam and Dominic performed such roles. It is not as clear in respect of Richard.

(c) Psychological services could be provided by external psychologists.

(d) Given that annual operational safety assessment involves certification of fitness and competence to maintain their operational safety qualification, then it is hard to see why psychological fitness is not seen as equally necessary to test.

81. Given the vulnerabilities of the AFP workplace to psychological disorder, improving the provision of psychological services is clearly a commendable goal. The provision of a greater level of psychological and/or psychiatric care to each of the deceased was likely to have been of therapeutic benefit (and perhaps considerable benefit).

82. However, the submissions made by counsel assisting seek to link improved firearm safety to a process of psychological assessment that would occur annually in the context of maintaining operational safety qualification. It is not clear on the evidence before me what the practical benefits of that proposal would have because:

(a) It involves a point of time assessment of the person’s psychological health which may not have relevance to their fitness to have access to a firearm.

(b) It may involve the devotion of resources (either by the need to employ extra salaried psychologist or the retention of external consultants) that may be better employed elsewhere.

(c) It is not clear what levels or types of “psychological unwellness” would operate to exclude an employee from operational safety qualification and therefore access to firearms. If the threshold (or at least one threshold) is “risk of selfharming behaviour” there is a great deal of evidence that suggests that

suicide is hard to predict. Assessment tools to detect risks of self-harming behaviour have proven to be generally unreliable.

83. I note the issue was enjoined properly only at the stage of submissions. Evidence on the issue properly attributed was not received, noting also that a hearing was not conducted.

84. I am not satisfied that the available evidence allows me to make me the recommendation in the terms suggested by counsel assisting.

Temporary Removal of Firearms

85. At the time of their deaths, Sam and Richard were on forms of leave. In Sam’s case, she had been “stood down” for welfare reasons (against a background of severe psychological distress). Richard was not considered to be physically well enough to be at work. Under CO3 an AFP appointee either has a valid operational safety qualification (and access to firearms) or they do not (because of a failure to qualify or because the qualification had been revoked). Revocation of access to firearm seems to carry a significant stigma within the AFP, a consideration that influenced the decision not to remove Sam’s firearm. In light of these considerations, counsel assisting submitted: In any event, at least in situations such as those affecting Mr Roberts and Ms Baglin where it was already clear that they were not fit to be at work for health or welfare reasons, it seems unnecessary to impose an obligation on the manager to make a further “judgment call” about how likely an AFP appointee is to self-harm in order to then activate the revocation steps under CO3. If the AFP appointee should not be performing duties at work, there would seemingly be no useful operational purpose served by the appointee having access to a firearm.

This suggests that there may be merit in CO3 including a further category of situation in which an operational safety qualification is not revoked but rather (administrative and physical) access to a firearm is nonetheless temporarily removed for a period when it is known that the AFP appointee will not, or should not, be required to use it. Being on leave (whether annual leave, long service leave, personal leave, parental leave or otherwise) fits obviously into such a category.

86. The families either indicated support for this recommendation or did not oppose it. In answer to this submission, the AFP indicated they opposed the substance of the recommendation. The AFP acknowledged that the proposal had the potentially significant advantage of normalising the removal of firearms across the AFP. In addition, the proposal has the benefit of protecting AFP appointees “from the risk they

might inadvertently commit an offence under, for example, the Firearms Act 1996

(ACT)”.

87. However, put against these benefits was that the proposal would inhibit “the ability of the AFP to quickly deploy AFP appointees in response to an emergency situation or incident”. The relevant Enterprise Agreement provides that an employee is not to be recalled to duty on any form of approved leave unless warranted by “exceptional” circumstances. It was put (I assume correctly) that the AFP does recall AFP appointees from leave at short notice for operational reasons. For that reason, “a broad prohibition on AFP members access to firearms while on leave would impose an additional administrative process to deploy AFP appointees”.

88. The submissions made by the AFP on this issue bear scrutiny. If a person is recalled to duty, they are no longer on leave. Even if it is considered a possibility that someone such as Sam or Richard would be recalled from leave, the suggestion advanced by counsel assisting would require that access to an armoury would be granted when a person is so recalled only if approved by a supervisor. The proposal of counsel assisting requires the AFP to do no more than discourage it’s employees from potentially breaching the criminal law by possessing firearms when not on duty. This could be achieved a number of ways; for example, by a stop being placed on swipe access when on leave or by human intervention (by notification to those with responsibility for monitoring access to the armoury when a person is on leave).

89. The administrative burden such a system would impose are not obviously substantial, involving no more than a notification that would occur when the call to duty is made that would allow these barriers to be removed.

90. The proposal to generally deny access to firearms when on leave would obviate the need for supervisors to consider the issue of access to firearms when considering whether to grant leave on welfare grounds.

91. As noted, and as conceded by the AFP in submission, normalising the process would help remove or reduce the stigma associated with not having access to firearms. This shift in culture is an important step in improving gun safety within the AFP.

92. I accept counsel assisting’s submission on this issue. I make the following recommendation:

Recommendation 3

93. The AFP consider incorporating into CO3 provision for temporary removal of access to AFP equipment, including firearms, for periods when an AFP appointee will not, or should not, be required to use it (such as periods of approved leave).

An Additional Form of Discretionary Paid Leave

94. Those who supervised Sam felt it important for welfare reasons that she should not be at work. She was “stood down”. Counsel assisting submitted that in those circumstances there should be consideration of an additional form of discretionary paid leave when a supervisor or manger deems it necessary for an appointee not to attend work including situations where there is a concern for the person’s welfare.

95. The families either supported or did not oppose the making of this recommendation.

96. The AFP supported the intent of the recommendation but did not support the creation of separate leave entitlement on the grounds that it would involve a complex process that would require variation of relevant Enterprise Agreements. The AFP indicated that it was considering how existing leave entitlements to miscellaneous leave can be more flexibly accessed in the circumstances contemplated by counsel assisting.

Considering that indication, and consistent with the reply submissions made by counsel assisting, I make the following recommendation: Recommendation 4

97. The AFP consider ways in which existing paid leave entitlements be used for situations in which supervisors or managers consider it necessary for an AFP appointee not to attend work due to concerns about wellbeing or fitness for work.

Security Clearances for Psychologists

98. The Coleman family made submissions in the following terms:

75. The fact that psychologists did not have security clearance raises the question about their utility. In order to treat psychological issues arising from traumatic incidents, it is necessary to describe and discuss them. This would deal with the root cause of the trauma or mental condition being treated. Without security clearance, adequate clinical investigation of the root cause of the issue, discussion of it and adequate treatment of it is not feasible.

76. The coroner should recommend that the AFP need either to have in-house psychologists who have the security clearance or make it a requirement of their

contract with the provider that security-cleared psychologists are available where the particular patient needs to discuss classified/sensitive information.

This would be an effective and useful recommendation.

99. The AFP provided a detailed response to this suggestion outlining the level to which AFP mental health clinicians are security cleared and pointing to recent developments that have seen some mental health clinicians embedded into operational areas to increase their understanding of the work demands of those areas, and increasing the opportunities for them to engage with members as to their psychological needs. It was indicated that notwithstanding these initiatives “the AFP recognizes that the level of security clearance of mental health clinicians may be a barrier for some members to engage with a clinician.” The response indicated that the AFP is currently reviewing the viability of increasing the security clearance level of a significant percentage of clinicians.

100. I make the following recommendation: Recommendation 5

101. The AFP further progress its review of the viability of increasing the security clearance level of a significant percentage of mental health clinicians and contracted psychologists.

E. REPORTING OF THESE FINDINGS

102. Section 57 of the Act permits a coroner to report his or her findings to the Attorney General. Relevantly, the section provides: (3) A report by a coroner to the Attorney-General—

(a) must be in writing; and

(b) must set out the coroner’s findings about any serious risks to public safety that were revealed in the inquest or inquiry to which the report relates; and

(c) may make recommendations about matters of public safety if the recommendations—

(i) relate to the coroner’s findings about a cause of death, fire, or disaster; and (ii) would, in the coroner’s opinion, improve public safety.

(4) If a report under this section contains comments or recommendations about a matter of public safety, or findings about a risk to public safety, the AttorneyGeneral or another Minister must—

(a) present the report to the Legislative Assembly not later than the first sitting week after the end of 6 months after the day the Attorney-General receives the report; and

(b) present a response to the report on the same day the report is presented to the Legislative Assembly.

103. The Attorney-General referred to is the Attorney General for the ACT. The AFP provides policing services to the ACT pursuant to an agreement between the AFP and the ACT Government last signed in September 2022. 27 The recommendations made here have implications for the AFP in the national and ACT aspects of its operation. I will provide the report of my findings to both the ACT and Commonwealth Attorneys-General, the Federal Police Commissioner, and the Chief Police Officer for the ACT for a response in a manner that, so far as is possible, satisfies the requirements of section 57 and the Policing Agreement.

F. CONCLUDING OBSERVATIONS

104. The disposition of the inquest into the deaths of Richard, Sam and Dominic has taken an inexcusably long period of time.

105. As I have observed in other cases, section 3BA of the Act requires inquests to be carried out in way that recognises that the death of a person and an inquest into the person’s death, has a significant impact on the person’s family and friends. That statutory obligation has not been discharged in this case.

106. On behalf of the Coroner’s Court an apology is made to the family for that delay and the poor levels of communication with them as to the progress of the inquest.

107. I acknowledge the considerable assistance that counsel assisting, Ms Prue Bindon, has played in the conduct of this inquest.

I certify that the preceding one hundred and seven [107] numbered paragraphs are a true copy of the Published Summary of Findings of his Honour Associate: Samuel Collett Date: 27 Agreement between the ACT Government and the Australian Federal Police for the provision of policing services to the Australian Capital Territory September 2022