Inquest into the death of Michael

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Michael (a pseudonym) Hearing dates: 15 January 2026 Date of findings: April 2026 Place of findings: Coroners Court of New South Wales at Newcastle Findings of: Magistrate Joan Baptie, Deputy State Coroner Catchwords: CORONIAL LAW – death as a result of a police operation – death self-inflicted – response by police to complaint of breach of apprehended domestic violence order – police powers of arrest – deceased left scene of police attendance prior to being arrested File number: 2 022/00038989 Representation: Counsel Assisting James Herrington instructed by Agrima Shrestha Non publication order: Orders pursuant to s. 75 of the Coroners Act 2009 have been made prohibiting the identification of the deceased and his relatives. A copy of these orders is available from the Registry.

Findings: Identity The person who died was Michael Date Michael died on 4 February 2022 Place Michael died at , Williamtown NSW Cause of death In keeping with hanging Manner of death Self-inflicted with the intention to end his life Recommendations: N/A

Table of Contents Contents Introduction 1 The role of the Coroner and the scope of the inquest 1 List of issues considered during the inquest 2 Michael’s background 2 Factual Background relating to the incident 3 Triple zero calls and Computer Aided Dispatch (CAD) messages 6 Attendance of the paramedics 7 Response of the NSW Police Officers 9 Text messages from Michael on the morning of 4 February 2022 13 Cause of Death 14 Considerations regarding the Issues 14 Issue (i) Whether it was appropriate for police to leave Michael unattended? 14 Issue (ii) Whether the police search for Michael was adequate? 16 Family statements 17 Conclusions 17 Findings pursuant to section 81(1) of the Coroners Act 2009 (NSW) 18

Introduction 1 This inquest concerns the death of Michael on 4 February 2022.

2 Michael was born on , at the John Hunter Hospital in Newcastle.

He died at , Williamtown on 4 February 2022, at the age of 28 years.

3 Michael’s death was described as being “In keeping with Hanging” 4 The cause of his death, his identity and place of his death are not in dispute. This inquest has focused on the manner and date of Michael’s death, particularly the circumstances of his death at a time that NSW Police had been called to, and attended the premises at Williamtown, to investigate assault allegations.

5 Michael was clearly a much-loved son, grandson, brother, nephew, partner and friend.

6 Members of Michael’s family have advocated on his behalf, both during these proceedings and prior to the commencement of this inquest. Various family members and friends have participated and contributed during these proceedings, and I acknowledge the profound loss and anguish felt and experienced by his family and friends.

7 I would like to express my sincere condolences to Michael’s family for the loss of their much-loved family member who was described as having a “loving, playful nature, his beautiful heart that never left him, and his swagger and unique personality grew with him.” 8 I hope that Michael’s memory has been honoured by the careful examination of the circumstances surrounding his death and the lessons that have been learned from the circumstances of his passing.

The role of the Coroner and the scope of the inquest 9 A coroner is required to investigate all reportable deaths and to make findings as to the person’s identity; as well as when and how the person died. A coroner is also required to identify the manner and cause of the person’s death. In addition, a coroner may make recommendations, based on the evidence presented during the inquest, which may improve public health and safety.

10 The holding of this inquest in relation to the death of Michael is mandatory as his death occurred as a result of a police operation. Sections 23(1)(c) and 23 (2) invoke the Court’s jurisdiction and section 27 (1) (b) imposes an obligation to hold a mandatory inquest where the death occurred pursuant to section 23. A “police operation” is defined in section 23(2) as “any activity engaged in by a police officer while exercising the function of police officer other than an activity for the purpose of a search and rescue operation.”

Classification DLM 11 During these proceedings, a brief of evidence containing statements, photographs and other documentation, was tendered in court and admitted into evidence. No oral evidence was received.

12 All the material placed before the Court has been thoroughly reviewed and considered. I have been greatly assisted by the oral submissions prepared by counsel assisting, Mr James Herrington. At times, I have embraced his comments and assertions in these findings.

List of issues considered during the inquest 13 The following list of issues was prepared before the proceedings commenced and were considered and provided focus during the inquest, namely: a. Were the actions of the police officers attending , Williamtown on 4 February 2022 adequate and appropriate, and in accordance with applicable NSW Police Force policy and procedure, including:

(i) Whether it was appropriate for police to leave Michael unattended upon their arrival at the property; (ii) Whether the police search for Michael at the property following their decision to arrest him was reasonable and appropriate.

Michael’s background 14 In 2015, Michael’s mother, Elizabeth leased a rural property at Williamtown.

15 Michael resided at the property with his mother, stepfather, and sisters, Margaret and Sarah until mid-2020.

16 In mid-2020, his sister Margaret was granted an Apprehended Domestic Violence Order (ADVO), naming Michael as the restrained person. Although Michael was not prohibited from residing at the premises, he rarely stayed at the home.

17 The ADVO prohibited Michael from assaulting, threatening, stalking, harassing or intimidating Margaret, as well as damaging any of her property. Michael was also prohibited from approaching Margaret within 12 hours of consuming alcohol or illicit drugs. The ADVO remained in force for a period of 18 months.

18 Michael commenced a personal relationship with Jack in 2019 and resided at Jack’s mother’s home in Shortland, as well as staying at other premises in the Hunter region.

19 The relationship between Michael and Jack was described as being unsettled, “rocky” and at times, volatile. Both men had experienced mental health issues during their relationship.

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Classification DLM 20 Michael described his significant use of alcohol, illicit and recreational drugs to his treating doctors.

21 Michael had a history of attempts to self-harm, including an attempted overdose in 2021, as well as deliberately crashing his car while intoxicated.

22 Michael had been diagnosed with anxiety and depression in 2016. He was prescribed anti-depressant medication, including Desvenlafaxine and Mirtazapine.

23 Michael sought treatment for his anxiety and depression from his local General Practitioner (GP). On 20 October 2021 and 10 January 2022, Michael consulted with his GP, regarding his anxiety. He was commenced on venlafaxine, an antidepressant, provided with a mental health plan and a referral to ‘Headspace.’ 24 On 18 November 2021, he again consulted with his GP. He advised his GP that he had “passive” thoughts of suicide, but no active plan. His daily dose of venlafaxine was increased.

25 At a consultation with his GP on 13 December 2021, Michael stated that he was “going well” on his medication, although he was experiencing insomnia. He denied any thoughts of self-harm.

26 On 10 January 2022, Michael told his GP that he had had a good Christmas and felt stable on his medication regime. He requested a repeat of his anti-depressant medication script.

27 The medical notes do not suggest that Michael was at an acute risk of self-harm or in crisis, in the three months prior to his death. It is clear from the medical records that he had suffered from a history of anxiety and depression for a number of years.

28 In his medical notes, Michael described his work history to include “retail, managed bistro, electrical apprenticeship, farmhand, building and construction, training horses, forklift work.” 29 At the time of his death, he had been unemployed for approximately two months.

Factual Background relating to the incident 30 The property at , Williamtown is a 37-acre rural property.

The buildings on the land consist of a main house and two sheds which house a double garage and a triple garage. There is a barn located approximately 70 metres from the house, although it was described as being in disrepair and “falling down”. In addition, there are four individual sheds about 40 -50 metres from the house, which were described as being in a dilapidated state. These sheds cannot be seen from the main house due to hedges and the large garages.

31 In early February 2022, Michael’s mother Elizabeth was residing at the property, with her youngest daughter Jane. In addition, Elizabeth’s daughter Margaret Classification DLM FileNumber TrimDoc

Classification DLM resided with her partner Alex. Her other daughter Sarah also resided at the premises, as did Michael. A tenant, Dennis, also resided in the house.

32 On 3 February 2022, Michael, his mother and her partner Ron, Sarah and Jane went to dinner at the Jesmond Hotel in Newcastle. After dinner, the group returned to Ron’s house in North Lambton at around 9pm.

33 At the same time, Jack went out with four friends to the Newcastle Hotel.

34 Prior to 9pm, Michael and Jack exchanged text messages.

35 Later that night, Michael and Sarah played cards and continued drinking together after they arrived back at Ron’s house. Elizabeth and Ron retired to bed at 1am.

Sarah said that Michael appeared to be “happy and in good spirits”, although she could see that he was upset by the messages he had received from his partner.

Sarah indicated that in “terms of intoxication, [Michael] wasn’t messy, but I would describe him as buzzed.” Sarah recalled that Michael wanted to go home, and she arranged an Uber, which arrived at 3.55am to collect him.

36 Jack arrived home at Williamtown at around midnight, in the company of a friend, Frank. Jack stated to police that he had consumed about 5 or 6 cruisers during the night and then stopped drinking when he arrived home.

37 Jack indicated that Michael’s sister Margaret her partner Alex and another friend, were also at home.

38 Jack stated the Michael arrived home at around 2am, which appears to be at odds with Michael’s sister Sarah’s memory. He recalled Michael arrived at their bedroom holding two alcoholic cider drinks, and that he appeared to be affected by alcohol. Michael and Jack engaged in a verbal argument, which according to Jack, became physical, with Michael allegedly pulling Jack to the ground and pulling him out of the bedroom.

39 Jack stated that Margaret and Alex walked out of their bedroom and attempted to separate Michael and Jack. Alex indicated that he was calling the police and then Margaret and Alex retreated into their bedroom with Jack.

40 Police records indicated that Alex first contacted the police at 4.52am. He reported to police that Michael had breached his ADVO and had also assaulted Jack. Alex stated that an ambulance was not required. The operator asked Alex, “Anyone with mental health?” and another voice can be heard stating, “Yeah, basically everybody in this house.” 41 The statements provided to police by the occupants of the house, suggest that there then ensued a series of arguments and confrontations between Michael and the others in the house. One of these interactions was recorded on a mobile phone. The mobile phone footage was tendered in evidence.

42 Further calls were made to triple zero by Michael, Margaret and Alex.

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Classification DLM 43 At 5.27am, an ambulance arrived at the property. The two paramedics undertook an assessment of Michael’s partner, Jack, and then left the premises.

44 At 6.37am, two police officers, Senior Constable (SC) Annie Danda and Constable Jayden Clarke arrived at the premises and then made their way to the house. Both officers were wearing Body Worn Video (BWV) cameras, which were activated and recorded their attendance at the premises. All the occupants of the house were introduced to the officers and the police then decide to “speak to the victims first.” 45 The police then arranged to speak with Margaret and Alex. They told Michael to wait inside the house.

46 Margaret indicated to the police that Michael was in breach of the current ADVO.

This complaint was recorded by Constable Clarke on BWV, from 6.51 – 7.08am.

47 At 6.49am, SC Danda asks “So is he [Michael] upstairs?” 48 At 6.51am, Michael sent a text message to his mother stating, “I’m hiding in a bush down the back of the property.” He sent a similar message to his other sister Sarah.

49 At 7.19 am, SC Danda is recorded on her BWV asking, “He’s definitely still in the house, yeah?” 50 Between 7.20 – 7.33am, Constable Clarke obtained a video statement from Jack.

51 At 7.41am, SC Danda’s BWV showed the police officers preparing to arrest Michael as they mount the stairs of the house. Constable Clarke asked SC Danda, “Are we getting him for the breach as well”, to which SC Danda replied, “Yes because he’s assaulted someone.” 52 The BWV then recorded the actions of both officers inside and outside the house in their attempt to locate and arrest Michael until 7.56am.

53 The evidence does not confirm the precise time that the two police officers left the premises, although it appears that they waited for some time in their vehicle.

54 At 8.19am and 8.55am, Michael sent text messages to his mother, stating that the police were still at the property.

55 Michael’s family attempted to contact him over the ensuing days, without success.

56 On 7 February 2022, the family reported to police that Michael was missing.

57 On 8 February 2022, Michael was located deceased in one of the sheds on the property. The shed was one of four sheds which were located approximately 100 metres from the main house.

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Classification DLM Triple zero calls and Computer Aided Dispatch (CAD) messages 58 The first triple zero call to police was made by Alex at 4.52am on 4 February

2022. The CAD message stated: “INFT WANTS SOMEONE REMOVED FROM PREMISES – FOR BREACHING AVO – [Michael] – 28 OLD – THERE IS AVO IN PLACE BTW POI AND SISTER – POI HAS ATTACKED HIS PARTNER [Jack] WHO IS 18

OLD – MARKS ON HIS ARMS FROM BEING GRABBED AND DRAGGED – POIS HAVE BEEN DRINKING – NIL WEAPONS – NIL THREATS OF WEAPONS OR FIREARMS – NIL CHILDREN – TOTAL 7 PEOPLE AT THE LOC – POI IS STILL OS – THEY ARE SEPARATED HE IS IN HIS OWN ROOM – POI LIKELY TO BE AGGRESSIVE TO POL” 59 At 5.02am, Michael called triple zero to say that he was having an argument with his boyfriend and had tried to get Jack to leave his bedroom and that his housemates had become involved, believing that he was trying to hurt Jack. He stated that they were all yelling at him and he was asking them to get out of his bedroom and to leave him alone. He went on to tell the operator that Jack “is suicidal and he has a big history of mental health” which had included “severe depression, anxiety and borderline personality disorder.” Michael requested that an ambulance be dispatched to assess Jack. Michael did not raise any concerns for his own mental health at this time.

60 Michael’s phone call resulted in a message being sent over the CAD system (emphasis added): “INFT HAVING AN ARGUMENT WITH PARTNER [Jack] 18OLD – NSW –

POI HAS DEPRESSION ANXIETY & BPD AND IS IP ON ALCOHOL AND DRUGS – INFOT IP ON ALCOHOL – CURRENT AVO BTW INFT & POI – INFT REQ AMBOS FOR POI FOR MHA DUE TO ERRATIC BEHAVIOUR – INFT SISTER [Margaret] AND HER PARTNER [Alex] – OTHER PERSONS AA ARE Megan], [Frank], [Margaret] AND [Dennis] WHO HAVE ALL

BECOME INVOVLED IN ARGUMENT – NIL CHILDREN – NIL PHYSICAL TONIGHT – NIL ACCESS TO WEAPONS OR FARMS – CHS OTW COVID 19 – NIL TO ALL QUESTIONS” 61 It is apparent that the reference in the CAD message to “POI HAS DEPRESSION ANXIETY & BDP” is a reference to Jack’s mental history, rather than Michael.

62 In addition to Michael’s call at 5.02am, calls were also made by Alex, Margaret and Michael at 5.21am, 5.27am, 5.44am and 6.16am.

63 Due to the number of calls to triple zero that morning from the same residence, some confusion prevailed in terms of the information that was being broadcast over the CAD system following each of the triple zero calls.

64 For example, in the CAD messages, Michael is interchangeably identified as the “informant” as well as the “person of interest” (POI). In one of the CAD messages broadcasts after Alex’s call to police at 4.52am, Michael is identified as the “POI”.

In another CAD broadcast, following Michael’s call at 5.02am, he is listed as the Classification DLM FileNumber TrimDoc

Classification DLM informant, and Jack as the “POI”, for whom a mental health assessment has been requested.

65 At 5.27am, Alex made another call to triple zero. The CAD system broadcast the following:

“INFT STATED THAT AMBOS ARE ON SCENE AND ASSESSING THE SITUATION – POSS GOING TO TAKE THE POI TO HOSP – NK WHY – INFT WANTING AN ETA OR FOR SOMEONE TO RING Her – CHECK ON

PRVIO CAD” 66 The “POI” in this message is not further identified. Previously, both Michael and Jack have been described as the “POI”, although it is clear that Michael called triple zero at 5.02am, asking for paramedics to assess Jack’s mental state.

67 At 5.44am, a CAD message recorded the following (emphasis added):

“INFT SISTER AND PARTNER WERE TRYING TO GAIN ENTRY INTO THE INFT ROOM – INFT REQUESTING POLICE ATTD – AMBBOS HAVE ATTENDED B4 – INFT IS IN HIS BEDROOM TRYIN GTO HOLD THE BEDROOM DOOR – THE INFT SISTER [Margaret] INTERVENED AND SO DID THE INFT SISTERS PARTNER [Alex] 20 (ID AS A M BUT NOT

CHANGED YET) NIL WEAPONS – AVO AGAINST THE INFT PARNTER – ALL PARTIES ARE OS THE INFT DOOR IN THE HALLWAY AND THE INFT IS LOCKED INISIDE HIS ROOM – NIL ACCESS TO FIREARMS NIL CHILDREN AT THE LOC – ALCOHOL INVOLVED AND DRUGS - INFT PARTNER SUFFERS MENTAL HEALTH AMBOS HAVE ATTD AND CHECKED ON THE INFT AND HIS PARTNER THEY HAVE LEFT NOW.” 68 It is again unclear who the informant is in this CAD message, although it is consistent with Michael’s call made to triple zero at 5.02am, requesting an assessment of Jack’s mental health.

69 At no time during the morning of 4 February 2022, did there appear to be any triple zero call made, or CAD message broadcast, that raised concerns about Michael’s mental health, or suicidal ideation.

70 Given the multiple calls made by Michael, Alex and Margaret that morning and the confusing nature of the CAD messages, it is accepted that the attending police officers would not have been on notice, prior to their arrival at the premises, that Michael was at any particular risk of self-harm or suicide.

Attendance of the paramedics 71 Paramedics Mr Byron Wall and Ms Nikita Jago arrived at the premises at 5.22am.

72 Both officers provided statements in these proceedings, dated 14 November 2024 and 15 November 2024, respectively. Both officers sought to refresh their memories regarding their attendance by gaining access to the NSW Ambulance Electronic Medical Record (eMR), the Patient Health Care Record (PHCR) and the NSW Ambulance Incident Detail Report (IDR).

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Classification DLM 73 The eMR and the PHCR were not able to be produced by NSW Ambulance (NSWA) to assist in the preparation of their statements. Numerous attempts were made by senior NSWA staff to locate these records without success. The absence of these records is an issue outside the scope of this inquest.

74 Officer Wall listened to two radio transmissions provided to him regarding the 4 February 2022 call out and was able to confirm that it was his voice in both recordings. The first recording was the acknowledgment to attend the job and the second was to advise control that they were leaving the scene.

75 Officer Wall confirmed in his statement that he had reviewed the IDR, which stated “we mobilised to the job at 05.09am and arrived on scene at 05.22am. This sounds accurate given the distance to the location from the ambulance station.

The IDR state we completed the job at 05.32am. I have no reason to believe these numbers are not correct.” Officer Wall had no independent recollection of attending the call out.

76 Similarly, Officer Jago reviewed the IDR. The only independent memory Officer Jago could recall was that the “house had some kind of veranda that wrapped around the outside of the house. I remember we spoke to around 3 or 4 young adults who were sitting on that veranda. There was a small room behind them with a mattress on the floor. I don’t remember their names or what we discussed, or if this group of people included [Michael] but I don’t recall anyone in this group identifying as the patient or requesting our assistance.” 77 The triple zero calls and statements from those present provide some further details regarding what may have transpired during the attendance of the paramedics.

78 The evidence is clear that Michael contacted triple zero at 5.02am, requesting the attendance of an ambulance to assess Jack. At 5.27am, Alex called triple zero to enquire when the police might be attending. He stated to the operator that Michael had “called an ambulance for himself and it looks like he might be getting taken away in an ambulance.” Alex’s assertion appears to have been factually inaccurate, as it is clear that Michael had made the request for the ambulance for Jack and not himself in the earlier call.

79 In this triple zero recording at 5.27am, other voices can be heard in the background. The triple zero operator asks Alex if anyone is being taken to the hospital and Alex can be heard asking the paramedics, “The dude on the phone wants to know if you are taking him to hospital or not.

Who will you be taking, [Michael] or [Jack]?

The response, presumably from Officer Wall is: “Are you all family? I might not be taking anyone, just let me assess the situation.” 80 At 5.31am, Officer Wall made a radio broadcast stating, “We understand this one’s for the [police?]. We’re clear. It’s a [non-event].

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Classification DLM 81 At 5.44am, Michael contacted triple zero again. He spoke with the operator for ten minutes. During the call, he is recorded as saying: “The ambulance were here about 20 mins ago or so now. They checked on me, checked on my partner because I’ve got some bruises on my arm and my forehead from my sister. They checked on my partner as well and they come and see me out in the driveway and said, “He’s ok, he looks alright. Just wait outside for the police, they won’t be long.” 82 Margaret indicated in her statement to police dated 8 March 2022: “I saw the ambulance turn up, I think they spoke to [Michael] for a little while, then they came over to us. They told us [Michael] had called them for a mental health assessment on [Jack]. I saw them speak with [Jack] for a period of time. They left a short time later.” 83 Alex gave his account to the police in his statement dated 8 March 2022, stating: “A short time later an ambulance turned up. I saw them approach [Michael], not long after, they walked over to us…The ambulance asked [Jack] if he was mentally ok and had let us know that [Michael] had called them and said that [Jack] was suicidal. We explained to them that we were waiting for the police and that we were all mentally ok, they should check on [Michael]. They assured us that he was ok, and they left.” 84 It is questionable whether Alex request to the paramedics that they “check on” Michael provided any proper basis for the paramedics to conduct an assessment in those circumstances.

85 The evidence appears to disclose that the paramedics were in attendance that morning solely due to Michael’s request to triple zero that an assessment be conducted on his partner Jack. It is also clear that the paramedics did not appear to perceive that it was necessary in the circumstances to conduct an assessment on Michael due to his appearance or presentation.

86 The absence of the ambulance records is concerning, however, is beyond the scope of this inquest.

Response of the NSW Police Officers 87 On 4 February 2022, SC Danda and Constable Clarke were rostered on duty together and commenced their shift at 6am.

88 SC Danda provided two statements for this inquest, dated 29 March 2022 and 1 August 2023. Constable Clarke has also provided two statements, dated 25 March 2022 and 6 August 2023.

89 At the commencement of her shift, SC Danda noticed a job which had been broadcast on Police radio at 4.52am, requesting police attendance at Williamtown. The two officers arrived at the premises at 6.37am.

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Classification DLM 90 SC Danda confirmed in her first statement that she had read the additional CAD messages with the times 5.02am, 5.03.27am, 5.03.53am, 5.21am, 5.27am, 5.29am, 5.44am and 5.45am.

91 The two officers arrived at the premises at 6.37am. Both police officers activated their BWV cameras at 6.42am as they approached the house and continued to record various events on their BWV until 7.56am. SC Danda noted that police policy required that their BWV should not be activated when a witness was participating in a Domestic Violence Evidence in Chief (DVEC) statement.

92 SC Danda stated in her second statement that when she first attended the property, and after a brief conversation, “I did not consider arresting [Michael]. I formed the view that I needed to speak to the other parties involved first to ascertain what had occurred.” 93 SC Danda explained, “The CAD job that I had observed was, to me, very confusing. The informant on the CAD job was listed as [Alex] and she alleged [Michael] had breached his ADVO. However, subsequent updates on the job had a number of CAD jobs merged, a number of updates, and referred to “INFT” and “POI” but did not specifically list who each party was. This made it difficult for me (to) ascertain who each update referred to. An example of this is an update at 5.02.53 that suggested [Michael] (although not named) was having an argument with his partner and that there was a current ADVO between them.” 94 SC Danda noted, “An update at 5.44.50 referred to the “INFTS SISTER AND PARTNER WERE

TRYING TO GAIN ENTRY INTO THE INFT ROOM. INFT IS IN HIS BEDROOM TRYING TO HOLD THE BEDROOM DOOR – THE INFT AND HIS PARTNER [Jack] (SIC) 18 OLD WERE FIGHTING FIRST THEN THE INFT SISTER [Margaret] INTERVENED AND SO DID THE INFT SISTERS PARTNER. The update indicated [Michael] may have been a Victim.” 95 SC Danda continued, noting, “In addition to the above reasons, the property is a semi-rural property and the house itself was 2 storeys and very large. The CAD job referred to 7 people being at the location with “POIS HAVE BEEN DRINKING”. I formed the view, from the CAD job that there might be more than one POI. For safety reasons, I did not separate from Constable Clarke until we could work out who the POI’s were, who the Victims were, and I could determine we would be safe to be separated.” 96 Constable Clarke indicated in his second statement that, “The information I obtained in relation to mental health prior to attending the location was mentioned in CAD 140482-04022022 which was broadcast at 5.02am. However, due to the CAD being merged by Police radio it doesn’t list who the “INFT” and “POI” was in the comments.” 97 Constable Clarke stated that, Classification DLM FileNumber TrimDoc

Classification DLM “Based off the information listed above (the CAD message) the informant was potentially [Michael] and the CAD provided was referring to the informant calling (an) ambulance to conduct a Mental health assessment on the “POI” which I formed the view that [Michael] was referring to his partner [Jack].” 98 Constable Clarke also noted that, “I did not consider arresting [Michael] at first interaction. At the time of my first interaction with [Michael] I was unaware of the situation which had taken place. The original informant was [Alex]. It is my usual practice to make all efforts to speak with the original informant first. Multiple calls were made prior to my arrival at the location, by others, and those calls had been merged by Police radio. The number of CADs merged did not list who the INFT and POIs were, which made it confusing for me as to what had actually occurred at the location. There were several updates in the CAD where it was believed [Michael] was also a victim but not confirmed.” 99 Both police officers approached the house and activated their BWV cameras.

They both recall being greeted by Michael as they approached the front door of the premises. Constable Clarke began asking him what had happened, and SC Danda suggested that they speak with the initial informant, being Alex first.

100 At this time, both police recollected Michael’s demeanour.

101 Constable Clarke stated, “After speaking with [Michael] at first interactions at the front door at 6.42am, I did not observe in [Michael] signs of disturbed mental health. [Michael] was compliant and cooperative when I spoke to him. After speaking with all parties at the location, none of those parties raised any concerns as to [Michael’s] welfare or mental health.” 102 SC Danda stated that at, “no stage did any person present at the property raise any concerns with me that [Michael] may have been considering self-harm. After speaking with [Michael] when I saw him when we arrived, his behaviour and demeanour raised no concern with me that he was going to self-harm. He appeared cooperative and friendly from the brief interaction we had.” 103 Both police officers recall that immediately after the initial introduction to Michael, a woman, now known to be Margaret, opened the door that was immediately behind Michael. SC Danda asked Michael to wait inside the house and he complied with this request.

104 Margaret invited the police inside the house where her partner, Alex was located.

She provided a version of events and told police that Michael had breached his ADVO as he came to the house “with alcohol.” Alex also spoke to the police at this time and indicated that he had videos of the events. Alex then “airdropped” three videos to SC Danda’s phone.

105 SC Danda deactivated her BWV while Constable Clarke left the house to retrieve his Mobipol device from the police vehicle. He returned with the Mobipol and obtained a DVEC statement from Michael on his Mobipol device.

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Classification DLM 106 At the conclusion of this interview, Margaret and Alex left the room, and Jack and his friend entered the room. SC Danda reactivated her BWV while Constable Clarke spoke with Jack. He agreed to participate in a DVEC with Constable Clarke.

107 Prior to the commencement of the DVEC, SC Danda recalled that she spoke with Margaret and Alex, who were, “situated in the hallway behind a closed door. From their location, they could see the staircase that led upstairs to where I believed [Michael] was. I told them that if they see [Michael] go to leave the house to interrupt our statement so that we could stop him. They said they would tell us.” 108 Constable Clarke then obtained a DVEC statement from Jack on his Mobipol. At the conclusion of that interview, Alex and Margaret returned to the room. The police asked them where Michael was, and they indicated that he was still in the upstairs area.

109 SC Danda activated her BWV, and together with Constable Clarke, went upstairs to locate Michael with the intention of arresting him, based on the DVEC statements provided by Margaret and Alex. They were unable to locate Michael.

110 SC Danda stated that after asking Michael to wait inside the house, “I was of the belief that he was upstairs at the time I was inside the house. My belief was premised on the fact that prior to Constable Clarke and I entering the house we had told him to wait in the house, I saw Michael enter the house, and I did not see him leave the house. I do not recall seeing or hearing anything that would have suggested to me that Michael had left the house.” 111 Sometime later the police were informed that one of the occupants of the house had just seen him “upstairs on the balcony”. The police returned upstairs and searched the upstairs rooms and general area; however, they could not locate him.

112 The police BWV and their statements indicate that they searched the house and one of the sheds for “just under 20 minutes.” 113 The shed that was searched appears to be the larger shed or garage which is located closest to the house. Michael was eventually located in one of the four dilapidated sheds further away from the house.

114 The police provided their contact details to the occupants and asked them to notify the police if Michael returned to the premises.

115 The police officers returned to their car, however, remained in the Williamtown area as they suspected that Michael would return home after observing or becoming aware that the police had left.

116 SC Danda noted that “we called ‘back on’ at 8.07am”, although she had no independent recollection of the exact time they left the premises.

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Classification DLM Text messages from Michael on the morning of 4 February 2022 117 Sarah stated that from 4.34am she had four missed calls from Michael, and between 5.17 until 6.25am she had a further four missed calls.

118 At 5.17am, Michael sent Sarah a text message saying, “I’m going to kill myself”.

119 At 6.36am, Michael sent Sarah a text message saying, “Jack and Alex can all get fucked the pieces of shit called the police on me and tried to get me arrested.” 120 At 6.50am, Michael sent Sarah a text message saying, “The police asked them if they’re aware that there is an AVO and the repercussions because I’ve been drinking, and they told them that I was drinking before I became physically violent.” 121 At 6.51, he sent another text message saying, “I’m hiding in a bush down the back of the property.” 122 At 9.02am, Michael called Sarah, and they had a short conversation. Sarah recalled that Michael was sobbing and very distressed and said, “I’m hiding in one of the sheds, the police are here, they’re going to lock me up, I have a noose around my neck.” Sarah told him not to do anything and that she would speak to Margaret and call him back.

123 Sarah then called Margaret at 9.05am. They had a heated six-minute conversation. Sarah recalled that she didn’t tell Margaret about her conversation with Michael as she was worried that Margaret would tell the police, and he would be arrested.

124 Sarah then woke her mother, Elizabeth and told her that something was happening at the house. Elizabeth then called Margaret and had a heated conversation. Elizabeth then tried to call Michael. Shortly, afterwards, Sarah also tried to call Michael.

125 Elizabeth then looked through her missed calls and messages from Michael, totalling about 13 calls or messages.

126 Both Elizabeth and Sarah continued to try to contact Michael that day, as well as the ensuing days.

127 At around 10am on Saturday 5 February 2022, Elizabeth was told that a friend of Michael’s had spoken to him on previous evening, being Friday 4 February 2022.

This gave Elizabeth some hope that Michael had just “gone to ground.” 128 On 7 February 2022, Elizabeth was told that the friend may have confused the day that he spoke with Michael, and that he may have spoken to him on the Thursday rather than the Friday.

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Classification DLM 129 Elizabeth then reported Michael as a missing person to the Raymond Terrace Police later that day.

130 On 8 February 2022, Michael and Sarah returned to the property and searched the dilapidated sheds, where they located Michael.

Cause of Death 131 Dr Donovan Loots, Forensic Pathologist performed an external examination, together with a toxicological examination on 14 February 2022.

132 Dr Loots performed post-mortem CT imaging and confirmed that Michael’s injuries were consistent with hanging.

133 Dr Loots confirmed that post-mortem toxicology from a sample of femoral blood detected “a blood alcohol concentration of 0.104 g/100mL (an elevated alcohol level but considered a non-lethal level). Toxicology further detected the metabolite of cannabis (Delta-9-THC) and a low level of the antidepressant drug mirtazapine (<0.05 mg/L). I am of the opinion that the toxicology did not contribute to the cause of death.” 134 Michael’s cause of death will be recorded as “In keeping with Hanging”.

Considerations regarding the Issues Issue (i) Whether it was appropriate for police to leave Michael unattended?

135 The evidence indicated that the CAD messages available on the morning of 4 February 2022, were confusing. The police officers noted that a number of CAD messages had been merged, making it difficult to decipher who was the informant, the alleged victim or victims and who was the perpetrator or perpetrators.

136 In addition, the CAD messages were also confusing as to who was requiring mental health assistance or an assessment by paramedics. It is now clear that none of the known information contained in the CAD messages regarding mental health concerns related to Michael.

137 Given this state of confused information, the police have stated that they believed that they needed to investigate the matters further before effecting an arrest. It was for those reasons that Michael was not immediately arrested on the arrival of police.

138 The evidence is clear that the police made a conscious decision to formally interview Margaret and Jack before concluding that it was appropriate to arrest Michael.

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Classification DLM 139 In addition, Michael’s demeanour at the time of the police officer’s arrival was pleasant and cooperative, according to the contents of the BWV and witness statements. He was not exhibiting any signs of concerning behaviour or mental health issues, and they had no information from the other occupants of the house that he had made any threats to harm himself.

140 Noting Michael’s demeanour and his apparent acquiescence with the police request to wait inside the house, both police indicated that they believed that he would wait until they were ready to take his version of events.

141 In addition, both police indicated that they believed that they should remain together, given the unknown variables at play in the house and with the occupants.

142 Police were appropriately constrained by a long line of authority regarding the lawfulness of an arrest.

143 In these circumstances, if the police officers on their arrival at the premises had told Michael that he was not free to leave the property, he would effectively been under lawful arrest.

144 The Law Enforcement (Powers and Responsibilities) Act 2002, (LEPRA), sets out the powers available to police to effect an arrest without a warrant in section 99.

The section requires that: a. The police officer must suspect on reasonable grounds that a person is committing or has committed an offence; b. The police officer is satisfied that it is reasonably necessary to arrest the person for any one of a number of reasons, including,

(i) to stop the person committing the offence or another offence, (iv) to ensure that the person appears before the Court in relation to that offence, or (vii) to protect the safety or welfare of any person (including the person arrested), c. The person arrested has been informed of the reason for the arrest (pursuant to section 201 LEPRA, as it then was) 145 In New South Wales v Robinson (2019) 374 ALR 687, the High Court considered the police officer’s intention at the time of arrest. The majority of the court held that the “officer could not rely on the power of arrest under section 99 unless the officer intended at the time of arrest to charge the person arrested with an offence or to take the person before an authorised officer to be dealt with for an offence.” In that case, the High Court held that the arrest was unlawful.

146 This Court has been greatly assisted by the BWV recordings of both police officers to determine this issue.

147 It is clear that the officers sought further information from the occupants of the house to determine who was the informant, victim and perpetrator, prior to exercising their powers of arrest for an offence(s) pursuant to section 99.

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Classification DLM 148 In addition, there was no basis on which the officers could have detained Michael to protect his own safety and welfare, or of anyone else present.

149 I accept that there is no power in Part 6 of the LEPRA, which deals with police powers in the context of domestic violence offences, or Part 11 of the Crimes (Domestic and Personal Violence) Act 2007, to direct an alleged perpetrator of a domestic violence offence to remain at the scene of a suspected offence.

150 There are four New South Wales Police Force (NSWPF) policies which are relevant to assessing the police officer’s behaviour during their interaction with the occupants that morning. Consideration was given as to whether both officers were compliant with these policies.

151 The four policies are: a. NSWPF Domestic and Family Violence Policy, and b. NSW Police Handbook, in particular the chapter relevant to arrests c. Code of Practice for the NSWPF Response to Domestic and Family Violence d. Body-Worn Video Standard Operating Procedures.

152 The evidence discloses that the two police officers engaged with the occupants in a professional and an appropriate fashion.

153 It is accepted that the CAD messages did not assist them in determining, prior to their attendance at the property, who was the informant, alleged victim or perpetrator.

154 In those circumstances, and in accordance with the abovementioned police policy, police are required to undertake appropriate investigations, including obtaining statements and formal DVEC interviews regarding an alleged domestic violence incident, prior to exercising their powers of arrest.

155 The two police officers appeared to activate their BWV in accordance with police policy. It is noted that SC Danda stated that she stopped recording just prior to Constable Clarke conducting the two DVEC interviews, which is also compliant with police policy.

156 The policies also provide guidance to police officers regarding their safety and the safety of their colleagues. It is noted that the two officers considered whether they should separate or remain together once they had arrived at the premises and determined that they should remain together given a number of unknown circumstances. Again, this decision was compliant with the police policy.

Issue (ii) Whether the police search for Michael was adequate?

157 The evidence, including BWV, civilian and police statements and text messages, indicates that the two police officers spent between 20 – 30 minutes searching the upstairs area of the house, the back garden and the large nearby shed.

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Classification DLM 158 It does not appear that the police officers searched all of the outbuildings on the property, including the four sheds where Michael was eventually located.

159 Importantly, the police were not aware that Michael may be at risk of self-harm during the police presence at the property or during the searches. In those circumstances it can be inferred that the police were searching for Michael in order to arrest him, rather than attempting to prevent him from self-harming.

160 Clearly, the police officers could have attempted to have searched all outbuildings, although it is noted that the group of four sheds were in a dangerous and dilapidated state. Again, it appears apparent that the police concluded that Michael was simply attempting to avoid arrest.

161 The searches conducted by the police did not appear to be inadequate in the known circumstances.

162 The evidence suggests that Michael died shortly after his last phone call at 9.02am on the morning of 4 February 2022.

Family statements 163 At the conclusion of the evidence, Michael’s mother and sister, Sarah provided a family statement, which was read onto the record in Court.

164 They told us that “Every day, from childhood into adulthood, when you were with him you were always having fun, he never failed to put a smile on your face and make you laugh until you were in stitches. Now as kids a lot of the time that meant getting into trouble of some sort or destroying the house and furniture to some extent, whether that was a ninja fight with pencils and Christmas baubles, WWE matches in the loungeroom, riding our Shetland pony into the loungeroom, or propping the trampoline on the side of the pool so you can slam dunk a ball into the basketball hoop.” 165 They continued, stating “Me and my family have so many memories like that, that resonate with us in the ways he went to the ends of the earth to help you no matter how big or small the thing was that you needed, he was there. [Michael] and the people that made memories with him were making the best gifts that money can’t buy, without even realising it. They’re a gift that I, my Mum, and our family and everyone who knew him, cherishes and holds dear, for that is a gift Michael gave us all.” Conclusions 166 Michael was a vibrant, creative and fun-loving person. He had also had to confront very significant trauma in his life. He had recognised his mental health issues and had sought assistance over a number of years.

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Classification DLM 167 Whilst he had engaged in previous acts of self-harm, most recently in the months before his death, he was not obviously exhibiting suicidal ideation when he returned home in the early hours of 4 February 2022.

168 The situation escalated very quickly between some of the occupants of the house and police were contacted by Alex. Multiple calls were then made by Michael, Alex and Margaret to the police.

169 It is accepted that the two police that responded to the CAD messages had received confusing and at times, contradictory reports as to who was the informant, victim and perpetrator.

170 It is further accepted that the two police conducted themselves appropriately and professionally. In addition, they were compliant with the police policies that were in force at that time. No criticism is directed at the two police officers.

171 Before turning to the Findings that I am required to make, I would like to acknowledge my gratitude to Mr James Herrington, Principal Solicitor for the NSW Crown Solicitor and Ms Agrima Shrestha, Senior Solicitor, for their significant assistance, commitment, support and preparation of this case.

172 Finally, I would like to again record my most sincere condolences to both families.

Findings pursuant to section 81(1) of the Coroners Act 2009 (NSW) 1 I make the following findings pursuant to section 81 (1) of the Coroners Act 2009

(NSW): Findings The identity of the deceased 2 The person who died was Michael Date of Death 3 Michael died on 4 February 2022 Place of Death 4 Michael died at , Williamtown Cause of death 5 The cause of Michael’s death was “In keeping with Hanging” Manner of Death 6 The injuries were self-inflicted with the intention of ending his life I now close this inquest Classification DLM FileNumber TrimDoc

Classification DLM Judge Joan Baptie Deputy State Coroner 21 April 2026 Classification DLM FileNumber TrimDoc