Inquest into the death of DE

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of DE Hearing dates: 9 September 2025 – 10 September 2025 Date of findings: 17 December 2025 Place of findings: State Coroners Court, Lidcombe Findings of: Magistrate Kasey Pearce, Deputy State Coroner Catchwords: CORONIAL LAW – death as a result of police operation –– police pursuit – compliance with policies and procedures – manner of death – police in-car-video File number: 2023/00051396 Representation: Mr A Wong, Counsel Assisting the Coroner, instructed by N Self of the Crown Solicitors Office Mr R Coffey, instructed by A Wooldridge of the Office of the General Counsel of the NSW Police Force, representing the Commissioner of the NSW Police Force Mr B Docking, instructed by C Hatzigeorgiou of the Police Association of NSW representing Senior Constable Tracey Bolam Non publication order: A non-publication order has been made pursuant to section 74(1)(b) of the Coroners Act 2009 (NSW) over specified sections of the NSW Police Force Safe Driving Policy.

Further non-publication and pseudonym orders have been made pursuant to s75(2)(b) and s75(4) of the Coroners Act 2009

(NSW).

Orders restricting access to the court file have been made pursuant to section 65 of the Coroners Act 2009 (NSW).

Copies of these orders are on the Registry file.

Findings: Identity The person who died was DE.

Date DE died on 11 February 2023 Place DE died on the Newell Highway at Forbes NSW 2871 Cause of death DE died of multiple injuries Manner of death DE died during a police pursuit, when he drove Nissan Navara motor vehicle registration DZL 98J into the path of a semi-trailer travelling in the opposite direction with the intention of taking his own life.

Table of Contents

1 Introduction 1.1 DE was experiencing several stressors in his life in the time leading up to his death: in relation to work, his finances, his relationship, and his immigration status. On the afternoon of 11 February 2023, the day of his death, DE’s partner, CB, called police to report that DE had assaulted her at the home they shared in Forbes.

1.2 DE took CB’s car, a white Nissan Navara, and left the house just as police were arriving. Soon afterwards, Senior Constable (SC) Tracey Bolam saw the vehicle and pursued it along the Newell Highway towards Forbes, until it abruptly veered onto the wrong side of the road and collided with an oncoming vehicle, a semi-trailer. DE suffered catastrophic injuries and died at the scene of the accident. He was 48 years old.

1.3 On behalf of the Coroners Court of NSW I acknowledge the tragic circumstances of DE’s death and extend my deepest sympathies to his friends and family for their loss.

2 Why was an inquest held?

2.1 Under the Coroners Act 2009 (the Act) a coroner is responsible for investigating all reportable deaths. This investigation is conducted primarily so that a coroner can answer questions that are required to be answered by section 81 of the Act, namely, the identity of the person who died, when and where they died, and the cause and manner of that person’s death. A secondary function of a coroner is to make recommendations, if appropriate, that arise from the evidence, in relation to any matter connected with the death.

2.2 The combined effect of sections 23(c) and 27(1)(b) of the Act is that it is mandatory for a senior coroner to hold an inquest in circumstances where, as in this case, a person has died as a result of a police operation. This is because in such cases, it is important to examine whether the significant power that the state places in the hands of police officers, is used in a way that is both lawful and appropriate.

2.3 An investigation into DE’s death was conducted by the NSW Police Force (NSWPF) and the coronial team assisting the inquest, and a significant volume of evidence was obtained. In this case, there was no controversy in relation to DE’s identity, and the date and place of his death. The only issues explored at the inquest were:

(a) the cause and manner of DE’s death;

(b) whether the actions of SC Bolam complied with the NSWPF Safe Driving Policy (SDP); and

(c) the use of in-car video (ICV) and why footage of the incident involving DE was not available.

2.4 The inquest took place over two days. Evidence obtained during the coronial investigation was tendered at the commencement of the inquest in the form of a four-volume brief of evidence which included electronic material. Due to the narrow focus of the issues to be explored during the inquest, only two witnesses were called to give oral evidence:

(a) Detective Inspector (DI) Geoffrey Kendall; and

(b) Detective Sergeant (DS) Derrick Fenton.

3 DE’s early life 3.1 While any inquest inevitably focuses on the circumstances of the death of a person, it is important to recognise and acknowledge the life of the person the subject of the inquest in a brief and hopefully meaningful way, in order to better appreciate what their life, and their loss, meant to those who knew and loved them.

3.2 DE’s life was difficult in many respects. He was the youngest of three children and was around ten years old when his parents separated. DE’s mother, LJ, described her relationship with DE’s father as both physically and emotionally abusive. After the couple separated, DE’s older siblings remained with their mother. However, according to LJ, DE’s father prevented her from seeing DE. During the divorce proceedings she was denied custody of DE, and ultimately lost contact with him.

3.3 In 1987 LJ married PJ, and in 1990, along with DE’s older siblings, they moved to Australia.

They later became Australian citizens. The family did not have any contact with DE until around 2013, when DE’s sister contacted him on Facebook. By the time his sister contacted him, DE was living in Wales. He had married FC and had a child, EC. He later had another child, JC.

3.4 After contact was re-established, LJ and PJ arranged for DE and his family to visit Australia for three weeks in about 2015. This was the first time in 28 years that DE had seen his mother and siblings. According to LJ, the family reunion was positive. She said, ‘it was like we had never been apart.’ Unfortunately, soon after DE’s return to Wales, his relationship

with FC broke down. About three months later DE came to Australia on a two-year holiday visa. Initially DE lived with his mother and stepfather in Cooyar, Queensland, before moving to Armidale to study Environmental Science at the University of New England (UNE).

3.5 By the time of DE’s death, he had lost contact with his former wife and his children in the United Kingdom (UK). While the estrangement caused pain for FC and their children, FC told the inquest, that she had positive memories of DE. When FC was pregnant with the couple’s daughter, she recalls it was a difficult birth, but DE was completely supportive and excited throughout and was a very hands-on father. When their son was born, FC recalls DE got two tattoos, one on each forearm bearing the name of each of his two children in italic script.

3.6 LJ said that DE’s death has left a huge void in her life. She says that her family was privileged to have had him in their lives and that DE will always remain a loved and cherished family member.

4 Events leading up to DE’s death DE’s relationship with CB 4.1 While he was studying in Armidale, DE met CB, and they began a relationship. They moved in together in Armidale in October 2017 and married in April 2019.

4.2 DE completed his degree at UNE in 2019. After graduating he was unemployed for a period of 12 months before obtaining employment as a geo-technical officer at Ground Truth in Armidale.

4.3 In January 2021, DE and CB moved to Griffith after DE obtained employment as a surveyor with Atkin Rowe Testing Laboratories. In August 2021 DE resigned from this job. He told CB he was unhappy with how his employer treated him and commented on unsafe working conditions. From August 2021 to November 2021, DE was unemployed.

4.4 In November 2021 DE commenced employment with Evolution Mining at the Lake Cowal Mine in West Wyalong. His roster required him to work up to a week at the mine before returning to Griffith during his time off. The travel and time away from home placed a strain on the relationship between DE and CB.

4.5 DE’s criminal records show that on 2 March 2022 he was charged with two domestic violence offences involving CB that occurred on 28 February 2022. It appears that DE

pleaded guilty to these offences and on 31 March 2022 he was sentenced at Griffith Local Court to two concurrent community corrections orders for a period of 18 months. An Apprehended Domestic Violence Order (ADVO) was made for CB’s protection. The ADVO did not prevent DE from continuing to live with CB, although he was prohibited from approaching or contacting her within 12 hours of consuming drugs or alcohol. In June 2022 DE was charged with breaching the ADVO. He received a fine for this offence.

4.6 In August 2022, DE and CB moved to Forbes, into a house that was leased by Evolution Mining. The move meant that DE could travel to the mine for work and return home in the evenings.

DE’s employment issues 4.7 From June 2022 Shaune Finn was DE’s manager at Evolution Mining. According to Mr Finn, there were several issues with DE’s work performance, which included:

• attendance issues – on 6 separate occasions DE reported that he would not be attending work;

• failure to complete accurate data recording – data collected by DE in relation to water quality was reviewed and inconsistencies were found;

• failure to complete records in a timely manner – DE did not submit compliance records relating to data collected to the EPA on time.

4.8 As a result of these issues, in late December 2022, DE was placed on a work performance plan. A meeting was planned for 31 January 2023 where the plan would be reviewed. DE failed to attend work on 30 and 31 January 2023 and advised his employer that he was sick.

He then failed to attend work on 1 February 2023 and advised that he was in hospital. Over the next five days, there was phone contact and text communications between DE and Grace Derrick (supervisor), Merridy Case (superintendent) and Tammy Rawson (senior environmental advisor). On 4 and 5 February 2023, DE advised that he was still in hospital.

4.9 On 7 February 2023 at 11:51am, Merridy Case sent DE a text message: Hi [DE] how are you. Are you able to send the medical certificate through please.

On 7 February 2023 at 12:41pm, DE replied: Sorry on late reply back in hospital here having a lot of problems will keep you informed

On 7 February 2023 at 12:42pm, Merridy Case sent DE a text message stating: Thanks are you able to please provide proof of absence.

4.10 The next day, 8 February 2023, at 8:34am, Merridy Case sent DE another text message stating: Hi [DE], it is a requirement to notify us if you are not presenting to work. You haven’t done this for the last few days and I have had to reach out to you. You have also shown no proof of absence. Shaun tried to contact you yesterday. You are required to send through a medical certificate. We will be calling your next of kin to do a welfare check.

4.11 At 8:40am the same day (three days before he died) DE replied to Merridy Case: I quit! Leave me alone.

4.12 The text message exchanges between DE and his managers at work show that he was not attending work and lied about his absence by stating he was in hospital, which he was not.

4.13 CB knew that DE was not working, however she believed that he was on annual leave. It also appears that DE did not want his mother to know about the difficulties he was having at work. Although by 8 February 2023 DE had sent the text message in which he resigned from his job, on 10 February 2023, he texted his mother: Hey mum just got back in the office here been up to my neck in work, having to work this weekend to install the tripods as only time we have been able to get a break with all the storms on the lake. But booked all next week off so will call Monday for a big catch up xo loves you both stay outta the heat xo.

DE’s visa issues 4.14 DE was granted a Bridging Visa A (subclass 010) on 8 August 2020. This Bridging Visa was associated with DE’s application for a Combined Partner (subclass 820/801) Visa, lodged on 8 August 2020, which was sponsored by CB.

4.15 On 31 October 2022, the Department of Home Affairs (DHA) refused DE’s Combined Partner Visa application seemingly because DE failed to provide all the information required for the application to be considered. DE was required to satisfy Public Interest Criterion 4001, which involved assessing applicants against a ‘character test.’ It was for this reason that DE was required to provide the DHA with a police certificate (criminal record check) from

Australia as well as each country he had lived in for over 12 months in the last 10 years. DE provided the DHA with the relevant police certificate from the UK but failed to provide a police certificate from Australia. The decision record noted that on four separate occasions (15 March 2021, 29 January 2022, 3 March 2022 and 19 March 2022) the DHA wrote to DE and requested an Australian Federal Police National Police Certificate.

4.16 After his visa was refused, DE contacted Gold Migration Lawyers in Melbourne to act on his behalf in an appeal to the Administrative Appeals Tribunal, which was lodged on 21 November 2022. CB understood that DE was advised the appeal process would cost $16000 and that a $3000 upfront payment was required. According to CB, DE did not have $16000.

She understood that DE took out a personal loan to cover this cost.

5 Events of 11 February 2023 The incident at 19 Wyndham Avenue, Forbes 5.1 On 11 February 2023, Constable (Cst) Huw Moore was rostered to work at Forbes Police Station with Probationary Constable (PC) Isabella Hudson and Leading Senior Constable (LSC) Robert Ellis. At 2:16pm PC Hudson received a phone call from DE’s partner, CB, who resided at 19 Wyndham Avenue in Forbes, in which she reported that DE had breached the ADVO that had been put in place for her protection and had assaulted her. PC Hudson recalled CB stating, ‘My husband is still in the house and I’m hiding from him in the bedroom.’ 5.2 PC Hudson asked Cst Moore to broadcast the job on the NSWPF Computer Aided Dispatch (CAD) system and he did so. PC Hudson and Cst Moore left Forbes Police Station in Forbes 16, a marked police caged truck and travelled ‘code red’ (lights and sirens on) north on the Newell Highway towards Wyndham Avenue. As they drove west along Wyndham Avenue, Cst Moore switched off the sirens when they reached Lachley Street as he did not want to alarm any offender.

5.3 As Forbes 16 approached 19 Wyndham Avenue, Cst Moore saw a white Nissan Navara utility reverse out of the driveway. Cst Moore suspected that the driver of the white Nissan Navara was the alleged offender, so he followed the vehicle with lights on but without sirens. The Nissan Navara turned right onto Alder Street, then right again on Calarie Road, then left (travelling east) on Wyndham Avenue. When it reached Wyndham Avenue, the Nissan Navara was 150 metres in front of Forbes 16. As Forbes 16 travelled east and

reached the end of Forbes High School, Cst Moore re-activated the siren. As the Nissan Navara reached Lachley Street it slowed down and Cst Moore was able to read the number plate out to PC Hudson. Once the number plate of the Nissan Navara was recorded (DZL 98J), Cst Moore slowed down, pulled over, and turned off the lights and sirens on Forbes 16.

5.4 PC Hudson conducted a licence plate check and ascertained that the Nissan Navara was registered to CB and was linked to the job they were attending at 19 Wyndham Avenue. PC Hudson broadcast a ‘keep a lookout for’ message over the police radio in relation to the Nissan Navara and advised that the vehicle was travelling north on the Newell Highway and had failed to stop. Forbes 16 did a U-turn and travelled back to 19 Wyndham Avenue. As Forbes 16 drove through the Calarie Road/Wyndham Avenue roundabout, Cst Moore saw SC Bolam travelling in the opposite direction.

5.5 Later, during his directed interview, Cst Moore was asked about his decision to turn around and head back to 19 Wyndham Avenue after he had followed the Nissan Navara. Cst Moore said that after the driver ignored his signal to stop, he decided the victim’s welfare was of a higher priority. In addition, he said one of the reasons he decided not to pursue the Nissan Navara was because 5.6 Cst Moore and PC Hudson attended 19 Wyndham Avenue and went inside. They called out and did not get an answer before they located CB sitting on the bed in the main bedroom.

Cst Moore and PC Hudson then cleared the house to make sure no one else was present.

After this occurred, CB told them that her car, a Nissan Navara licence plate DZL 98J was missing and had been stolen.

5.7 Cst Moore and PC Hudson spoke to CB. She told them that DE had thrown her across the ground, screamed at her, put his hands around her throat and choked her, and told her he was going to kill her. CB also told police that prior to his assault upon her, DE yelled in her face ‘You have cost me my visa. You have cost me my visa.’ 5.8 Cst Moore and PC Hudson took photographs of CB’s injuries and noted bruising to both outer forearms, her left inner forearm, her right inner bicep, a bump on her right upper forearm and redness under her right ear and upper neck.

The Pursuit of DE’s vehicle

5.9 When Cst. Moore and PC Hudson left Forbes police station to attend to the job at 19 Wyndham Avenue, SC Bolam was also at the station and left at the same time in Macquarie 225, a fully marked sedan. SC Bolam recalled hearing Forbes 16 saying over the police radio that a white Nissan Navara had just got away from them. As she drove east on Wyndham Avenue, she saw Forbes 16 travelling west with lights on and heard the broadcast that the Nissan Navara had failed to stop.

5.10 SC Bolam broadcast over the police radio that she would head to the Newell Highway ‘code red.’ The Newell Highway in Forbes is primarily a two-lane highway with one lane in each direction. SC Bolam activated lights and sirens and when she reached the highway she turned left. She recalled driving past the Daroobalgie pits and overtaking two cars that pulled over to the side of the road. At that point she saw a white utility vehicle coming towards her travelling quite fast, heading back in the direction of Forbes. She saw the utility vehicle was travelling on the wrong side of the road and thought the driver may be drunk or asleep. As it came closer, she thought it might be the offending vehicle from 19 Wyndham Avenue. As the utility continued to travel towards her, she thought the driver was going to kill her as he drove directly at her and she was forced to veer off to the side of the road.

5.11 Once the white utility vehicle travelled past her, SC Bolam immediately turned around and called over the radio, ‘Macquarie 225 – Urgent – I am in pursuit.’ SC Bolam advised police radio of the location and registration of the vehicle and the speed it was travelling. She said in her directed interview that she was ‘following him and catching him,’ implying that she was making ground during the pursuit. She then said the utility vehicle went onto the right side of the road and drove directly into an approaching semi-trailer.

5.12 In her directed interview, SC Bolam agreed that when she followed the utility, the lights and sirens of her vehicle were activated. She was asked about what she was thinking when the utility vehicle first drove towards her. She replied, ‘He’s gunna kill me… just smash into me’ and said that she believed that if she did not veer away, the utility would have hit her head on. SC Bolam also explained why she felt the need to apprehend the driver of the Nissan Navara. She said, ‘I was thinking, he's, he’s just tried to kill me…He’s just been in a violent domestic…. We have to stop him.’ Later she said, ‘I thought he might’ve been going back to the location…maybe to kill her.’

5.13 SC Bolam’s evidence was that she reached a speed of 148 km/hr during the pursuit and that she was making up distance and believed that the Nissan Navara was travelling at 140km/hr. The speed limit was 110km/hr, except during the roadworks near the heavy vehicle station where the speed limit was 80km/hr.

5.14 SC Bolam agreed that as she pursued the utility vehicle, she was catching up to it, and that it did not overtake other vehicles and remained in the left-hand lane up until the point that it veered onto the wrong side of the road and collided with the semi-trailer. Her view was that DE ‘committed suicide’ and ‘drove into it [the semi-trailer] on purpose.’. SC Bolam’s evidence was that she did not see any brake lights or skid marks prior to the Nissan Navara colliding with the semi-trailer.

5.15 The driver of the semi-trailer, Joshua Shuttleworth, provided a statement. His evidence was that he was travelling north on the Newell Highway following a small white car. He recalled the white car braking slightly and then saw the red and blue flashing lights of a police car about 200 metres ahead. He said that the police car was ‘going pretty fast’ and continued north until it was out of sight. The next time he saw a police car was near the weighbridge on the north side of Forbes. His evidence was that he saw a white utility vehicle in front of a police car that had flashing lights. He estimated that the vehicles were 200 – 300 metres in front of him. As the utility came closer, it suddenly turned right and drove straight in front of his truck.

6 Investigations after DE’s death Police attendance at the accident scene 6.1 Cst Cooper Crouch-Mackinnon and Cst Ryan Veasey were working at Parkes police station when they heard about the job at 19 Wyndham Avenue over the police radio. They both drove towards Forbes and as they approached, they heard broadcasts from SC Bolam, namely ‘P WHITE UTE HAS TRIED TO RUN US OFF THE STH HWY,’ followed by ‘SERIOUS MVA

FUEL LEAKING NEED FB – PERS TRAPPED IN VEH TRUCK DRIVER IS OUT.’ 6.2 Cst Crouch-Mackinnon and Cst Veasey arrived at the scene of the collision and LSC Ellis attended shortly after, at about 2:35pm. The officers at the scene observed significant damage to both the Nissan Navara utility and semi-trailer. DE was trapped in the vehicle.

The officers saw that he had sustained serious injuries and was barely moving. Shortly after,

it became clear to the officers that DE had died. DE was formally declared deceased by paramedic, Linda Ayers, at 2:51pm.

6.3 Cst Crouch-Mackinnon approached the driver of the semi-trailer. The driver was crying and said that he ‘tried to move, and he came straight for me.’ Later Cst Veasey also spoke with the truck driver, who described what happened just before the collision, ‘I saw him chasing and start swerving and I was like okay where the fuck you going, but he just kept coming… Yeah, she was chasing him, and he started coming over and come into the turn lane and he kept coming in and I had nowhere to go.’ 6.4 Because the collision that resulted in DE’s death occurred in the context of a police pursuit, a Level 2 Critical Incident was declared. Detective Inspector (DI) Geoffrey Kendall was appointed as the Senior Critical Incident Investigator (SCII).

Crash Investigation 6.5 Investigation of the collision site was overseen by Sergeant (Sgt) Burlin of the Crash Investigation Unit (CIU). Among the findings made by Sgt Burlin at the scene were:

• SC Bolam’s vehicle was on the correct side of the roadway;

• DE’s vehicle was on the incorrect side of the roadway;

• no brake marks were identified.

• Issues were identified with the in-car-video (ICV) with no footage of the incident able to be obtained;

• the speedometer on DE’s vehicle was indicative of the speeds called on police radio by SC Bolam; and

• DE was not wearing a seatbelt at the time of the collision.

Autopsy 6.6 On 20 February 2023, forensic pathologist, Dr Alison Ward, conducted an external postmortem on DE and determined that the direct cause of DE’s death was ‘multiple injuries.’ Among the multiple injuries observed was a catastrophic injury to DE’s head.

Blood tests 6.7 A sample of DE’s preserved blood showed a blood alcohol level of 0.043g per 100ml.

Screening tests conducted on his blood sample found the absence of any illicit drugs

including, amphetamines, benzodiazepines, cannabinoids, cocaine metabolite or opiates.

This suggests that neither alcohol nor drugs played a part in DE’s driving.

6.8 Joshua Shuttleworth, the driver of the semi-trailer, also had blood and urine samples taken.

His blood sample showed the presence of 0.06mg/L of Phentermine. Mr Shuttleworth told police that he had been prescribed the medication ‘Duromine’ but had stopped taking the medication about one week prior to the collision.

6.9 Pharmacologist, Alec Lin, confirmed that the drug Phentermine is available under the trade name ‘Duromine’ and that it functions as an appetite suppressant and is a central nervous system stimulant. Mr Lin also found that the level of Phentermine in Mr Shuttleworth’s blood was on the lower end within the reported general therapeutic range and may be consistent with a person who has taken a therapeutic dose.

6.10 Ultimately, Mr Lin found at the time of driving, Mr Shuttleworth was not under the influence of any drug detected to the extent that his driving ability was impaired.

6.11 As an ‘involved officer’ SC Bolam was also subject to blood and alcohol testing. All tests returned a negative result.

Mechanical Examination 6.12 On 8 June 2023, the Nissan Navara that DE was driving was examined by a qualified motor mechanic, Cst Adrian Russo, of the Engineering Investigation Unit. Cst Russo carried out a forensic mechanical examination. He found that prior to the impact, the vehicle had no mechanical defects or faults that may have contributed to the collision.

7 Consideration of issues The manner of DE’s death 7.1 A finding that DE’s death was self-inflicted should not be made lightly, however, there is considerable evidence to support a finding that DE intentionally drove his vehicle in front of Mr Shuttleworth’s semi-trailer and that he did this intending to end his own life.

7.2 The evidence suggests several stressors in DE’s life that may have had a negative impact on his mental health in the time leading up to his death: i. Shortly before the collision, CB alleged that DE had physically assaulted her, and she told DE that she had called the police. In the 12 months prior to his death DE and CB

had been having relationship issues, which included DE being charged with criminal offences involving CB in March and August 2022.

ii. DE was also under significant stress at work. Prior to his death he was placed on performance management and in the immediate lead-up to his death, DE was not attending work and lied about the reason he could not attend. Three days before his death DE resigned from his job via text message.

iii. DE was experiencing issues with his immigration status and there was clearly a question as to whether he would be able to remain in the country. The visa process was also very expensive. It appears that DE did not have the $16000 required to appeal the refusal of his Partner Visa and it is understood that he took out a personal loan to cover the costs. The fact that DE had resigned from his job likely exacerbated the financial stress he was under.

7.3 In addition to the underlying stress DE was facing, the account of DE’s driving given by SC Bolam and by Mr Shuttleworth suggests that DE suddenly swerved the Nissan Navara into the path of the semi-trailer: i. Mr Shuttleworth’s description of the collision suggests deliberate action on the part of DE: ‘All of a sudden, the white coloured ute turned right and straight into the front of my truck. I heard a loud bang and smashing sounds…’ ii. When SC Bolam first saw DE’s vehicle, she saw that he was driving on the wrong side of the road. Initially she thought he may have been drunk or asleep and she had to veer off the side of the road to avoid a collision. Her evidence was that if she had not veered away, she was confident the Nissan Navara would have hit her head on. The fact that DE was driving on the wrong side of the road even before the collision, supports the proposition that he was deliberately engaging in dangerous driving.

iii. SC Bolam witnessed the collision and said that DE had been on ‘the right side of the road, all the way, all along and then I saw a semi-trailer coming and um, still all right, he’s, and then he just instant, bang, straight into it.’ When asked how she would describe DE’s sudden turn towards the semi-trailer, SC Bolam said, ‘I reckon he committed suicide. He drove into it on purpose.’ She also said that she did not see any brake lights or skid marks prior to DE’s vehicle colliding with the truck.

7.4 While there is no evidence that DE expressed an intention to commit suicide, I am satisfied that he made what was likely a spur of the moment decision to intentionally take his own life in circumstances where he was experiencing significant stress, and he believed that he was about to be apprehended by police.

7.5 This finding ultimately makes it less likely that the pursuit itself was causally related to the collision.

SC Bolam’s compliance with the Safe Driving Policy 7.6 At the time of DE’s death, version 9.2 of the NSWPF SDP was the policy document that provided guidance to police officers in relation to police pursuits. A ‘pursuit’ is defined in the SDP as: ‘an attempt by a police officer in a motor vehicle to stop and apprehend the occupant(s) of a moving vehicle, regardless of speed or distance, when the driver of the other vehicle is attempting to avoid apprehension or appears to be ignoring police attempts to stop them.’ There was no issue in the inquest that SC Bolam engaged in a pursuit of DE’s vehicle.

7.7 Part 7.2.1 of the SDP provides: The decision to initiate and/or continue a pursuit requires weighing the need to immediately apprehend the offender, against the degree of risk to the community and police as a result of the pursuit.

7.8 Part 7.2.2 of the SDP sets out the matters that a police officer should consider prior to a pursuit being initiated. These considerations include danger to police, other road users and the offender; weather and road conditions; traffic density; time of day, day of week (e.g.

active school zones, road works); manner of driving including speed of offending driver and the level of control; suitability of police vehicle to pursue; and distance between the police vehicle and offending vehicle.

7.9 Part 7.2.3 of the SDP provides: If after consideration of the circumstances of the pursuit prior to it being engaged concludes that the need to immediately apprehend does not outweigh the degree of risk to the community, police or offenders the pursuit should not be engaged.

7.10 During her directed interview SC Bolam was asked why she pursued the Nissan Navara. She answered, ‘I think I was thinking, he’s, he just tried to kill me…he’s been involved in a violent domestic…we have to stop him.’ Later in the interview, SC Bolam added, ‘I thought he might’ve been going back to the location…maybe to kill her. I don’t know...I knew he didn’t want to stop…or, well, he’s tried to kill me.’ 7.11 In SC Bolam’s written statement, she stated that she was aware of Part 7 of the SDP, including parts 7.2.1 and 7.2.2, and that when she initiated the pursuit, she considered the following factors: i. she was aware DE had committed an assault on CB and had left the scene, and she believed he was intending to return to Forbes to further assault CB; ii. the traffic was light, it was Saturday, and there were no roadworks and limited heavy vehicles on the road; iii. the weather conditions were fine and would not affect her driving; iv. she was driving on the National Highway in Newell; v. she was driving a fully marked Highway Patrol sedan (white BMW)- ; and vi. she was a silver certified driver.

7.12 The evidence makes clear that SC Bolam turned her mind to the risks inherent in her undertaking a pursuit of DE. The only concern that could potentially be raised about SC Bolam’s decision to initiate the pursuit was the fact that DE had shown himself willing to cross to the wrong side of the road before the pursuit was initiated and so it could be argued that if a pursuit was initiated, he may engage in similar driving.

7.13 During the inquest, DI Kendall gave evidence as an officer who has extensive experience in police pursuits and is well versed in the application of the SDP to practical situations. His view was that although DE’s manner of driving before the pursuit was initiated might mitigate against commencing a pursuit, equally it might provide a reason for initiating the pursuit, to apprehend DE as quicky as possible so that he didn’t pose a continuing risk to the public. DI Kendall’s opinion was that the need to pursue DE was greater than the risk he posed to the public and police. This was because, at the time SC Bolam initiated the pursuit, DE’s vehicle had changed direction and was heading back to Forbes, and if not

apprehended quickly there was a risk of him re-offending. In the view of DI Kendall, the protection of the victim was paramount.

7.14 It is important to keep in mind that in the context of the inquest, consideration of SC Bolam’s actions was undertaken with the benefit of hindsight. Although reasonable minds may differ as to whether SC Bolam should have initiated the pursuit, I am satisfied that she engaged in the necessary weighing exercise, and that in the circumstances, it was reasonably open to her to pursue DE’s vehicle. I am satisfied that in this respect, she complied with the NSWPF SDP.

The speed of the vehicles 7.15 Sgt Derrick Fenton provided expert evidence as to the speeds the Nissan Navara driven by DE, and Macquarie 225 driven by SC Bolam, were travelling at a time proximate to the collision. Sgt Fenton was provided with CCTV footage from a warehouse located on the Newell Highway. He carried out the following calculations to ascertain the speed of relevant vehicles:

(a) He ascertained that the CCTV footage had a frame rate of 15 frames per second, so that each frame of the footage was equivalent to 0.0667 seconds.

(b) He then selected two reference points and using mapping software and laser scan data collected from the scene, calculated the distance between the two reference points as approximately 37.7 metres.

(c) He conservatively determined that there was a progression of not more than 15 frames as the Nissan Navara travelled between the two reference points, which equated to a journey time between the two points of no more than 1 second (15 x 0.0667 seconds).

(d) Based on these calculations, he determined the speed of the Nissan Navara as it travelled between the reference points was 135 km/hour.

(e) He conservatively determined that there was a progression of not more than 16 frames as Macquarie 225 travelled between the two reference points, which equated to a journey time between the two points of no more than 1.0067 seconds (16 x 0.0667 seconds).

(f) Based on these calculations, he determined the speed of Macquarie 225 as it travelled between the reference points as 127 km/hour:

7.16 While it cannot be known with certainty if the Nissan Navara and Macquarie 225 were travelling at 135km/hr and 127 km/hr respectively at the time of the collision, I accept the evidence of Sgt Fenton that the vehicles were travelling at these approximate speeds shortly before the collision.

7.17 Part 7.2.13 of the SDP states: All vehicles involved in a pursuit will maintain a minimum two second gap.

7.18 In her statement SC Bolam states ‘I believe the gap between my vehicle and the deceased’s vehicle was at all times at least two to three seconds, in line with Part7-2-13 of the SDP.’ 7.19 Chief Inspector (CI) Darnell reviewed SC Bolam’s actions in the context of her compliance with the SDP. His evidence was that: ‘Senior Constable Bolam was driving too close behind the offender and contrary to the SDP…’ He added, however, that in his opinion ‘…the proximity behind the offender did not contribute to the deceased actions in driving into the path of the heavy vehicle.’ 7.20 CI Darnell appears to base his opinion on calculations made by Sgt Fenton, who calculated that as the two vehicles passed the two reference points, Macquarie 225 was travelling approximately 1.0667 seconds behind the Nissan Navara, and that there was 40 metres separating the two vehicles.

7.21 DI Kendall agreed that based on his viewing of the relevant CCTV footage and Sgt Fenton’s calculations, SC Bolam did not maintain the required two second gap. However, like CI Darnell, his opinion was that this breach of the SDP played no contributory role in the collision.

7.22 I accept the combined evidence of Sgt Fenton, CI Darnell, and DI Kendall that between the two points that formed the basis of Sgt Fenton’s calculations, SC Bolam breached the two second rule. For the reasons I have already given in relation to the manner of DE’s death, I also accept the opinions of CI Darnell and DI Kendall, that this breach did not contribute to the accident that resulted in DE’s death.

7.23 I appreciate the difficulties that might attend a police officer, particularly in a changing and stressful situation, calculating with any precision whether they remain two seconds behind a vehicle that they are pursuing. It is notable that the wording of the current version of the

SDP, the Safe Driving Response and Operations Guideline, which came into operation in June 2024, includes the words ‘All police vehicles involved in a pursuit should maintain a minimum two second gap.’ The change of the wording from ‘will’ in the previous policy, to ‘should’ in the current policy, is possibly a recognition of the practical realities that might attend an officer complying with the two second rule.

The absence of in-car video 7.24 The third and final issue explored during the inquest related to the lack of ICV from Macquarie 225 of the incident involving DE.

7.25 After the collision, Detective Senior Constable (DSC) McGowan advised DI Kendall that the ICV from Macquarie 225 had been inspected but it did not capture the pursuit. CIU investigators found that the last footage was timestamped at 12:07pm on 11 February 2023, that is, more than two hours prior to the commencement of SC Bolam’s pursuit of

DE.

7.26 The evidence in the inquest was to the effect that there were known issues with the ICV system and hard drive in some Highway Patrol cars as due to their positioning they were prone to overheating, which then caused a fault in the recording capabilities of the system.

CI Darnell’s evidence was that ‘ICV equipment on issue to Traffic and Highway Patrol (HWP) vehicles is aging and was initially introduced into HWP vehicles in 2004 with no major subsequent upgrades.’ 7.27 Evidence from Inspector (Insp) Mark Stevens from the Traffic and Highway Command was that NSWPF were in the final stages of an ICV procurement process and that there has been progress in relation to the upgrading of the ICV technology. He advised that contract negotiations with the preferred supplier were ongoing and once the contract has been executed the NSWPF would comply with its disclosure obligations and publish the details of the contract.

7.28 Insp Stevens’ evidence was that since October 2024 there had been improvements to police ICV systems. There is now a new system using three cameras, two of which are front facing (one a wide fixed angled lens and the other a manual rotatable lens) and the third rear facing. All cameras actively record when the system is in operation. In addition, the video resolution has been upgraded resulting in higher clarity recordings.

8 Conclusion 8.1 Police officers are often required to make difficult decisions in very short periods of time.

In the course of their work, they encounter situations that are physically or psychologically confronting, or which involve people with mental illness, those who are drug or alcohol affected, or individuals who are violent, unpredictable, or emotionally heightened. By contrast, inquests are conducted in the relative calm of a courtroom, with the benefit of time and the clarity brought by hindsight.

8.2 There must be oversight of the use of the considerable powers given to police, particularly when, in the exercise of those powers, there is loss of life. However, the focus of an inquest is not to speculate about what could have happened if different decisions had been made, but to consider whether there has been a failure of policy or procedure, or non-compliance with policy and procedure and, if so, to make recommendations as to how best such failures can be remedied. In this case no failure of policy or procedure was identified, and except for SC Bolam’s breach of the SDP’s two second rule, no non-compliance with policy and procedure.

8.3 I am satisfied that although DE’s death occurred in the course of SC Bolam’s pursuit of him, it did not occur because of her pursuit of him.

9 Findings required by s81(1) 9.1 I make the following findings in relation to DE’s death.

Identity The person who died was DE.

Date DE died on 11 February 2023 Place DE died on the Newell Highway at Forbes NSW 2871 Cause of death DE died of multiple injuries Manner of death

DE died during a police pursuit, when he drove Nissan Navara motor vehicle registration DZL 98J into the path of a semi-trailer travelling in the opposite direction with the intention of taking his own life.

10 Close of Inquest 10.1 I thank counsel assisting, Andrew Wong, his instructing solicitor, Nicholas Self, and before him, Imogen Pearson, of the Crown Solicitor’s Office, for all the assistance they have provided to me in the preparation and conduct of this inquest. I also thank Detective Inspector Geoffrey Kendall for the very comprehensive investigation he conducted into the circumstances of DE’s death.

10.2 Once again on behalf of the Coroners Court, I offer my sincere and respectful condolences to DE’s friends and family.

10.3 I close this inquest.

Kasey Pearce Deputy State Coroner 17 December 2025