Inquest into the death of C D

CORONERS COURT NEW SOUTH WALES Inquest: Inquest into the death of CD Hearing date: 30 September 2019 Date of findings: 4 October 2019 Place of findings: NSW State Coroner’s Court, Lidcombe Findings of: Magistrate C Forbes, Deputy State Coroner Catchwords: CORONIAL LAW self-inflicted death in a remote country town-police response File number: 2017/286401 Representation: Mr P Aitken, Counsel Assisting instructed by Mr A Bell, Crown Solicitors Office Mr S Robinson, instructed by Office of the General Counsel New South Wales, representing the Commissioner of Police and the New South Wales Police Force Findings: I find that CD died on 20 September 2017 at the Royal North Shore Hospital, St Leonards, NSW as a result of burn wounds he received when he set his house alight. The manner of his death was intentionally self-inflicted.

NOTE: PURSUANT TO S 75 OF THE CORONER’S ACT 2009 I DIRECT THAT THERE BE NO PUBLICATION OF ANY MATERIAL THAT IDENTIFIES THE DECEASED PERSON OR HIS FAMILY

IN THE NSW STATE CORONER’S COURT LIDCOMBE SECTION 81 CORONERS ACT 2009 REASONS FOR DECISION Introduction

1. This is an inquest into the death of CD who died on 20 September 2017 as a result of severe burns.

On 19 September 2017, he barricaded himself into his house in the remote township of Gloucester NSW and set it alight.

2. The primary duty of a Coroner, as described in s.81 of the Coroner’s Act 2009 (“the Act”) is to make findings as to:

(a) the identity of the deceased;

(b) the date and place of the person’s death;

(c) the physical or medical cause of death; and

(d) the manner of death, or in other words, the circumstances surrounding the death.

3. This inquest is not a criminal investigation or proceedings intended to determine fault or lay blame.

It is an examination of the circumstances of the manner of CD’s death, to understand how the situation developed and what was being done to address the situation at the same time.

CD

4. CD moved to Gloucester in about 2015 and had a dream of running a bed and breakfast. He had spent $8000 on towels and sheets and $10000 on antique furniture.

5. He was separated from his wife with whom he had three sons.

6. He had a history of alcohol abuse and mental health issues. His son explained to this court that he was proud of his father, who towards the end of his life had stayed dry for a two year period and was making great efforts to clean up his life.

7. Hospital records from the early 1990s show that CD had several admissions for treatment of suicidality arising from what was variously described as schizophrenia and schizoaffective disorder, on a background of abuse of alcohol and benzodiazepines. In 2014 he was briefly hospitalised at the Mater Hospital for mental health reasons after refusing to take medication. More recently however

there is little evidence of any ongoing mental health condition, which is consistent with his son’s observations.

8. CD’s local general practitioner (“GP”) in Gloucester stated that CD did not disclose his history of mental illness, and denied having depression, when he was first seen. The GP described CD as showing no signs of mental illness in their initial appointments.

Background

9. CD was in a relationship in 2017. According to his then partner, he resumed drinking in May 2017.

She reported that they broke up shortly after. Nevertheless, CD asked to see her on her birthday, in late June 2017. On that day, she took him to Taree hospital as he appeared suicidal and paranoid to her. CD became angry and departed when medical staff called for mental health assistance, as he believed he would be scheduled. CD returned to Gloucester and attended an Alcoholics Anonymous meeting the next morning.

10. Mr Adam’s partner stated that CD continued to demand large sums of money, and appeared paranoid and irrational. In the weeks prior to his death, he said that he had a private detective following her.

11. CD also had regular phone contact with a woman he met at Alcoholics Anonymous (his “AA Sponsor”). In about August 2017, CD called his AA sponsor and asked her in a long argumentative conversation to guarantee in six to nine months that she would enter into a romantic relationship with him. She explained that they were just friends, at which point he “cancelled” their friendship the next night by text, saying that she didn’t fit into his plans.

12. On 30 August 2017 a council surveyor inspected a garage at CD’s property and found it to be unsatisfactory (CD had purchased the property without a final inspection certificate for the garage).

CD appeared reasonable but spoke very rapidly. He said he was a builder of 43 years’ experience.

The council surveyor left after asking CD to follow up the engineering plans for the garage.

13. In early September CD called his son and was verbally aggressive. His son knew immediately that his father had started drinking again. He appeared paranoid. His son arranged for a local in Gloucester, to check on his father. She reported back a few days that CD had attended an AA meeting but had sat at the back, disengaged.

14. On 8 September CD attended his GP. CD appeared unwell and stressed. He said that one of his sons had tried to commit suicide (which appears to have occurred several months before) and that his partner had left him and stolen all his money. His diabetes was poor as he was drinking soft drinks; he denied consuming alcohol within the preceding five weeks. The GP gave him a small quantity of Valium, to assist with his stress and anxiety, and asked to see him in a few weeks. The GP did not think that CD was suicidal or depressed.

15. On 12 or 13 September, CD called a local electrical company to whom he owed money about an outstanding bill. He sounded agitated and was talking rapidly. He said his ex-partner had taken

money from him and that he had met a woman on a train to whom he’d loaned $80,000 which she had not returned and that she had given him a signed statutory declaration that she owed him the money and he was taking her to court. That Friday night he called a fellow Alcoholics Anonymous participant, saying he was drinking again and that he was having some financial difficulties. He sounded “manic”, talking rapidly, but also appeared calm.

16. On 15 September, CD saw his GP again. His impression was that CD was very angry at his partner and expressed vague thoughts about harming her for having allegedly robbed him and treating him badly. He said he had been in touch with his lawyers. He had no specific plans. He denied depression and suicidal thoughts. The GP thought he was possibly hypomanic (but CD denied a history of bipolar disorder) but did not consider that he was exhibiting thoughts of significant harm to self or others, such that he should be scheduled. The GP tried to arrange urgent follow up with the local psychologist and prescribed Seroquel to assist sleeping and settle his mood, as well as Zoloft.

17. In subsequent statements, the GP has explained how in hindsight he failed to appreciate how disturbed CD was and considered, at the time, his speech to be coherent and cohesive albeit pressured. The GP accepted CD’s outrage at his ex-partner at face value as a real rather than imagined concern. In hindsight, he thinks that CD’s mental state may have been subsequently exacerbated by drinking alcohol.

18. On about 16 September a neighbour saw CD taking 3 gas bottles into his house.

19. On 17 September CD called his ex-partner and accused her of stealing $25,000 from him. He threatened to shoot her or a member of her family if she did not provide the funds. He said he had no money left and was getting money from Centrelink and the Salvation Army. He said he had been drinking for a fortnight.

20. On 18 September, CD made a call to the Catholic diocese in Newcastle (and another the next morning) and also to the Department of Human Services Sickness and Disability line. Long calls to other unknown numbers occurred the same day. The contents of those calls are unknown.

19 September 2017

21. At approximately 2.30pm on Tuesday, 19 September, CD angrily confronted his neighbour about alleged damage from stormwater flowing from their property.

22. On the same afternoon at about 2.35pm, the Council surveyor returned a call from CD about the garage. The surveyor recorded that CD was very angry and frustrated, describing himself as bankrupt and possibly having to sell the property in the near future. He was talking very quickly.

23. Later that afternoon CD, now calmed down, phoned his neighbour to discuss the stormwater. CD said he had been drinking heavily lately. The neighbour suggested that CD call Alcoholics Anonymous.

24. He rang his AA sponsor and she relayed concerns to his son via a number of text messages. First she messaged that she was talking to CD, that he was in financial trouble and she was trying to find out if he was drinking. The next message asked him to call the police as CD was threatening to kill himself.

25. The AA Sponsor later told police that in the first call CD said he had just borrowed $250 from a neighbour, he was down to his last $1.85 and he had enough alcohol for the next three days. She described him as having a racing mind, switching from topic to topic.

26. In the second call, CD said he was drinking. He said the pension had sent him a letter questioning where all his money was coming from, the council were after him about an approval and stormwater was coming in from next door. He said, “Are you ready for it, here comes the bang now, are you listening” and that he was going to shoot himself. She kept him talking for twenty minutes while texting his son to ring the police. She then ended the call to do the same. As she was doing so, CD said he did not want to talk to her again.

27. The matter did not progress to a point where the police obtained the contact details of CD’s son and use them. CD’s son did not directly contact the police.

28. The AA Sponsor then called “000” at approximately 9.20pm, and then called CD back. CD said he was very tired, wanted to lie down and have a cup of tea, and had not eaten for three days. CD said that he had been to Court in Newcastle on the 18 September. He said he had ran into an AA friend, borrowed $100, and that his house insurance expired at midnight and he did not have the money to pay for it.

29. The AA Sponsor subsequently received a further call from CD. This was clearly after police arrived and spoken to him because he said “you caused all this, you stabbed me in the back, you betrayed me and called the police”. He said something like “I’ve got enough gas to blow the police and neighbours up and half of Gloucester” and that she was going to read about him in the paper. She told him the police were only there to help him and to let them in. He said he couldn’t talk as they’d see the light (presumably from his phone). He sounded very angry and then hung up. The AA Sponsor called 000 back and reported what she had been told. She then texted his son telling him to contact the police.

30. Police received the first 000 call at 9.20pm. Sergeant Kirk, the shift supervisor at Taree, asked Senior Constables Mitchell and Abbott, in Taree, to support Senior Constable Chester who was the only officer available at Gloucester. Those officers arrived after approximately forty minutes at 10PM.

Senior Constable Chester, who was off-duty and received the call to attend at approximately 9.20PM, arrived at approximately 9:50PM, after first going to the police station to retrieve his appointments.

31. At 10.07pm Senior Constable Chester broadcast by VKG, “This bloke barricaded himself in the house won’t let me in. Stated if I kick the door or try to enter, he stated he has gas cylinders ready to ignite and blow us all up”. A minute later Senior Constable Chester noted via radio that there was only old intelligence in relation to firearms: “He’s got nothing I’m aware of – old intelligence there about

firearms. Just an angry old man at the moment. Everything is locked right up. Verandah is barricaded and I got to the front door before he made threats. There is a close house right next door on the corner we will be evac the next door neighbours. Form up Ravenshaw St - will sort it out when they get here - will need them pretty close if it does turn - lives alone - I believe he is alone - Can’t hear or see anyone else so just assuming it’s him”.

32. Senior Constable Chester later told critical incident investigators that he jumped the fence, as the gate was locked, and that the blinds were drawn. He asked CD to come to the front door, as they had reports of concerns for his welfare. CD told him to “fuck off and go away” and that he wasn’t coming to the door, he wasn’t in a good space and come back tomorrow, and he just wanted to go to bed.

33. The Fire Brigade received a call at 10.07pm and were on scene at 10.21pm. They were asked by police to meet them in the nearby Ravenshaw St. The message they received was that the AA Sponsor had received a call from CD at about 9.10pm, saying there was a conspiracy against him and that he would pull a gun on himself.

34. At 10.13pm a broadcast for ambulances to attend with no lights and sirens and go to Ravenshaw St was broadcast, with the comment “it appears we have a siege on our hands”.

35. The door was barricaded from the inside and out.

36. At 10.16pm, Sergeant Kirk broadcast that he was on his way and estimated that he would arrive in 30 minutes. At 10.17pm, the radio operator asked Sergeant Kirk “who is onto the negs [negotiators]? I have contacted the on-call DO [duty officer] just waiting for them to call me back”.

The on-call duty officer that night was Chief Inspector Fidock. At 10.22pm police VKG reported that they were on the phone to the informant (the AA Sponsor) who was on the phone to CD and he was saying that if he hears police rattle the keys and try and get in he has enough gas to blow everyone up and that the informant has stabbed him in the back. Senior Constable Chester broadcast that he had formed up Ravenshaw St and that he’d unlocked the gate to get access to the front door.

37. The Northern Region Co-ordinator, Senior Sergeant Lawson, first became aware of the incident at 10.22pm, when he received a call from police radio saying that negotiators had been requested. In his role as co-ordinator, it was Senior Sergeant Lawson’s job to manage the deployment of negotiators and tactical police. If an incident was defined as high risk, it requires the use of tactical operations police to support any negotiators.

38. It appears that it was Senior Sergeant Lawson’s job to make recommendations at to what was required to the Assistant Commissioner, Assistant Commissioner Mitchell, who had the ultimate authority to authorise deployment of negotiators and tactical operations officers. Both were located remotely.

39. Senior Sergeant Lawson’s information at that stage was that CD was threatening to shoot himself and that he had a warning for firearms from 2003 and a ‘mental health event’ from Belmont in

40. Senior Constable Chester was on scene and Sergeant Kirk was about 25 minutes away. At

10.25pm he phoned Senior Constable Chester, and was told that CD had said “I’ll just get my pants on,” then “I just want to go to bed, come near the place I’ll blow the place up. I have 40 litres of petrol and a cigarette lighter”. Senior Constable Chester said he could hear CD saying to someone, possibly the AA Sponsor, “blow the place up” and “gas stove”. Senior Constable Chester said he had spoken to neighbours who said that CD was back drinking alcohol and he said that CD won’t be going peacefully. Senior Sergeant Lawson became aware that Chief Inspector Fidock was trying to ring Senior Constable Chester, so he got off the phone.

40. It appears from Chief Inspector Fidock’s statement that he was first alerted about the incident shortly before 10.25pm, when he then asked for the police Computer Aided Dispatch (“CAD”) information to be read back to him. He called Senior Constable Chester at 10.30pm, and was told that the front door was barricaded with various objects including a lounge, mobility scooter and trolleys, and that CD had said he had gas cylinders and forty litres of fuel and a cigarette lighter. CD had refused to open up the blinds on the house. As that information was obtained by phone, it was not shared on police radio at that point.

41. Chief Inspector Fidock asked Senior Constable Chester to have Senior Constable Mitchell contact the informant and accurately define the reason for the call and the information. Chief Inspector Fidock then gathered some clothes and got ready to drive to Forster police Station. Senior Sergeant Lawson recalls that he called Chief Inspector Fidock at 10.37pm, while he was still at home. Senior Sergeant Lawson recalls that they discussed that the information was conflicting-that he told the AA Sponsor that he would shoot himself but hadn’t made that threat to police, that he wanted to go to bed but was threatening to blow the place up if police entered. They apparently discussed the option of leaving the place and refer to mental health in the morning or deploy negotiators and tactical police and deal with possible scheduling of CD. Chief Inspector Fidock said that he would get Senior Constable Chester to contact Senior Constable Mitchell to clarify.

42. At 10.40pm Senior Constable Chester radioed that he had evacuated some residents but not other houses some slight distance away and they were trying to organise emergency accommodation; he said they weren’t sure if CD even had gas but he claimed to have 40 litres of petrol and gas cylinders. At 10.47pm Chief Inspector Fidock spoke again to Senior Constable Chester by phone who advised that CD had said, “Fuck off or I will blow the place up”.

43. At 10.57pm the other Senior Constables at the scene confirmed to police radio that there was no gas connected to the premises. At 11.01pm the radio advised that the informant (the AA Sponsor) had spoken to CD son who advised that his father had schizophrenia but it was unknown if he was medicated and that he was a recovering alcoholic who also suffered from diabetes.

44. At 11.04pm Senior Constable Mitchell informed Chief Inspector Fidock by phone that he had spoken to the AA Sponsor and that CD had apparently been on a three day drinking bender and believed there was a conspiracy against him. It appears that shortly after this Chief Inspector Fidock began to drive towards Gloucester from Forster.

45. At 11.07pm Senior Constable Chester advised radio that they had spoken to neighbours and CD had been seen taking in gas bottles a few days ago. He said they tried phoning him but the phone went to voice mail.

46. At 11.16pm the other senior constables advised radio that Sergeant Kirk, who was now on scene, was “talking through door at moment” (in discussion with CD). In his interview, Sergeant Kirk said that he and Senior Constable Chester went to the front door and CD was talking over the top of them and saying that he didn’t want them to come in and if they did he’d kill them by blowing them up. Sergeant Kirk said he had no intention of coming in as he had four children. They tried to get him to come to the door. CD was talking about the council contacting him about something and said if you think I’m going to sleep I have one hand on the gas tap. It appeared to Sergeant Kirk that CD had been drinking. CD concluded by saying “turn the torch off, get off the verandah because I’m opening the gas tanks up, I’m going to kill the lot of you.” Police then left the house verandah and retreated to the opposite corner.

47. Senior Constable Chester recalled recalled CD saying that he wouldn’t negotiate.

48. At 11.26pm Sergeant Kirk came on police radio, saying that CD was ranting and raving and threatened to open up the gas valves in the house and was very angry. Chief Inspector Fidock recalls that Sergeant Kirk relayed this information to him by phone at 11.29pm.

49. At 11.35pm Chief Inspector Fidock rang Senior Sergeant Lawson and said that the incident would require negotiators. This is the point at which it appears a decision was first made at a senior level to request that negotiators attend. It is also the point at which Senior Sergeant Lawson says he first learnt that CD may have schizophrenia. Senior Sergeant Lawson gave evidence that he was not able to listen to the radio broadcast from his location.

50. At 11.38pm Chief Inspector Fidock called Superintendent Thurtell and briefed him, seeking approval to deploy specialist units. Verbal approval was given for Chief Inspector Fidock to make that request to Northern Region, who then relayed that to Senior Sergeant Lawson at 11.41pm.

51. Sergeant Kirk says that he then got in contact with Chief Inspector Fidock to make sure that he’d contacted the tactical police and negotiators. Chief Inspector Fidock recalls this call coming at 11.43pm. It appears that police on the scene at that stage expected that decision to have been made. Sergeant Kirk’s memory is that when this conversation was happening that he then noticed the house was on fire.

52. At 11.58pm, Senior Sergeant Lawson called Chief Inspector Fidock back and said that approval for negotiators had not yet been given as further assessment of the scene was required. Assistant Commissioner Mitchell felt that it was critical that a senior officer such as Chief Inspector Fidock be at the scene given the lack of clarity in the available information, as he could not decide on the conflicting and limited information available to him (including CD having said he wanted to go to bed versus making threats to blow up the house with gas) whether it was high risk or self-harm. He was also under the impression that Chief Inspector Fidock was only minutes away from the scene when the request for his approval came through. He did not however consider it appropriate for

police to simply leave the scene and return in the morning. Assistant Commissioner Mitchell also noted that negotiators generally work in teams of four. It appears that resources would have had to come from various areas including Newcastle, involving a 90 minute travelling time. Tactical operatives with breathing apparatus would have had to come from Sydney back in 2017.

53. At 11.56pm, the Fire Bridge radio reported that the house had “just gone up”. Further resources were requested. It apparently took about an hour to extinguish the fire. The home was described as a weatherboard. Chief Inspector Fidock, still driving to the scene, learnt at about that time from Senior Sergeant Lawson that further assessment was required. He did not arrive on scene until 12.13am.

54. Senior Constable Chester and Sergeant Kirk ran to the house when the flames started. Senior Constable Chester heard what he thought was CD moving in the house. The two officers heard gas hissing and told everyone to evacuate

55. The RFS arrived on scene at 12.35. Access is reported on the fire brigade radio as having been gained at 01.01am and that at that time CD was showing signs of life (a paramedic attended at that point and found CD unconscious). He was stretchered out about 1.13am and taken to Gloucester Hospital, then airlifted to Royal North Shore Hospital where he passed away from his burns at 9.10am on 20 September 2017. The pathologist at autopsy described the cause of death as “burn wounds and the consequences thereof”.

56. On inspection of the home, fire brigade officers found inside the premises three nine kilogram gas bottles, two five-litre lawn mower petrol cans and a lawn mower with the fuel cap off.

Conclusion

57. The Court heard oral evidence from Senior Sergeant Lawson that he performs the Northern Region’s Operations Coordinator role both during shift hours and in an on-call capacity after hours, and when performing the role at home and out of business hours, he does not have use of, or access to the VKG radio or CAD system. He gave evidence that while he is updated regularly over the phone during an incident, that co-ordinating an incident such as this would be enhanced by access to one or both of those methods of communication. Senior Sergeant Lawson expressed interest in having access to the CAD systems after hours, if it was feasible and permitted. This court has not heard any evidence about the feasibility of making those systems available to coordinators working after hours and accordingly, it would be inappropriate to make any recommendations in that regard. I do however encourage the Commissioner of Police to consider this suggestion for any future high risk situations in remote country townships. At the hearing, the solicitor for the Commissioner indicated that he would raise the issue with the Commissioner of the Northern Region Command.

58. Before the Court were the Australia New Zealand Guidelines for Deployment of Police to High Risk Situations 2016 (“the Guidelines”). The Guidelines describe principal response strategies for High Risk situations such as this one. There was no suggestion that the police officers involved in this incident departed from the Guidelines.

59. Assistant Commissioner Mitchell provided written evidence which explained his decision to require Chief Inspector Fidock to attend the scene, after he had received a briefing from Senior Sergeant Lawson, before he would authorise the deployment of negotiators to the scene. Assistant Commissioner Mitchell’s evidence explained that the initial information relayed to him was that CD made no threats to shoot himself and simply wanted to go to bed. His decision regarding Chief Inspector Fidock was made because the lack of clarify of information prevented him from being able to decide whether the matter could simply be handled as a concern for welfare. He also considered the time for tactical police and negotiators to reach the remote location. Risk and threat assessment, which could be provided by Chief Inspector Fidock, could assist to determine other mitigation strategies to resolve or calm the situation whilst awaiting tactical Police.

60. Senior Sergeant Lawson also gave oral evidence that since September 2017, tactical support police in Newcastle have been trained and given the appropriate breathing equipment to enter a house such as the one barricaded by CD. This has been arranged so that police in areas such as Gloucester are no longer dependent on the Sydney-based tactical response team to attend.

61. At the hearing, CD’s son raised a concern that police did not directly contact him, and indicated that he could provide information as to the likelihood of CD having a gun. The Police gave evidence that they discounted the possibility of a gun as a primary concern early in the incident, and that had the matter progressed further they would have contacted CD’s son. CD’s AA sponsor was the primary contact for police as she seemed to have the best line of communication with CD.

62. Nothing further could have been done by the officers involved in this tragedy. Each of them carried out their duty in a professional and appropriate manner.

Findings: s 81 Coroners Act 2009 I find that CD died on 20 September 2017 at the Royal North Shore Hospital, St Leonards, NSW as a result of burn wounds he received when he set his house alight. His death was intentionally self-inflicted.

Magistrate C Forbes Deputy State Coroner 4 October 2019