Deceased
Tina Louise Greer
Demographics
32y, female
Coroner
O'Callaghan
Date of death
2012-01-18
Finding date
2023-12-21
Cause of death
Unknown
AI-generated summary
Tina Louise Greer, 32, disappeared on 18 January 2012 and is presumed deceased, killed by her partner Leslie Sharman who was involved in her coercive and controlling relationship, including domestic violence. The coroner found inadequate responses by Queensland Police (poor investigation of three DV incidents in 2010, failure to recognise pattern of abuse, lack of DVO applications despite legislative requirements), Salvation Army Fairhaven (failure to refer Tina to DV support services despite her clear disclosures of abuse), and Department of Child Safety (failure to assess DV risk adequately when Lili self-placed with Tina in 2011, lack of holistic assessment despite awareness of DV pattern). While preventative interventions cannot be confirmed to have altered the fatal outcome, the inquest identified systemic failures in recognising and protecting a domestic violence victim. Clinical and procedural lessons centre on integrated DV training, victim-centred care, holistic risk assessment, and inter-agency communication.
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CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the suspected death of Tina Louise Greer TITLE OF COURT: Coroners Court
JURISDICTION: BRISBANE FILE NO(s): 2015/3321 DELIVERED ON: 21 December 2023 DELIVERED AT: Brisbane
HEARING DATES: 5 May 2023, 6 July 2023, 13 - 22 September 2023 FINDINGS OF: Kerrie O'Callaghan, Brisbane Coroner CATCHWORDS: Coroners: Inquest, Missing Person, Child Safety, Domestic and Family Violence, Department of Child Safety, Seniors, and Disability Services, Queensland Police Service, Drug and Alcohol Rehabilitation
REPRESENTATION: Counsel Assisting: Ms Stephanie Williams with Ms Angelica Monardez Police Officers: Mr Troy Schmidt (instructed by Gilshenan & Luton Legal Practice) Commissioner of Queensland Police: Ms Emily Cooper (instructed by Queensland Police Legal Services) Department of Child Safety, Seniors, and Disability Services: Ms Karen Carmody (instructed by DCSSDS legal) The Salvation Army: Ms Kristi Reidel (instructed by Carter Newell Lawyers) Ms Lili Greer: Ms Anna Cappellano (instructed by Townsville Community Law) Findings of the inquest into the death of Tina Louise Greer Page 1 of 68
Contents ISSUE 1 - Sections 45(1) and (2). Findings, whether Tina Greer is deceased ISSUE 2 - The adequacy of the QPS response to allegations of domestic and ISSUE 3 - The adequacy of the QPS investigation into Tina’s disappearance ISSUE 4 - What improvements have been made by QPS into the investigation of domestic violence and the disappearance of women who are suspected or known victims of domestic and family violence (including by reference to the policies and procedures in place at the time of Tina’s ISSUE 5 - The adequacy of the response by Salvation Army Gold Coast Recovery Services, Fairhaven to disclosure of domestic and family violence ISSUE 6 - What improvements have been made by Salvation Army Gold Coast Recovery Services, Fairhaven to help support victims of domestic and ISSUE 7 - The adequacy of services and support provided to victims of DFV by the Department of Child Safety when assessing whether a child is at risk ISSUE 8 - Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety and the administration of
She had a 13-year-old daughter, Lili Greer. Tina had recently ended a relationship with her partner of some years, Leslie Sharman. Mr Sharman was the last person to have seen Tina. She went missing after going to see him at his property on 18 January 2012. Mr Sharman told police Tina drove away from his property on the morning of 19 January and was not seen again. Mr Sharman died in a car accident in 2018. Tina’s body has never been found.
Tina’s disappearance was treated by police as a homicide from the outset, and the initial investigation involved detectives from the homicide unit. The investigation included coercive hearings conducted by the Crime and Corruption Commission (CCC) in 2012, a further investigation in 2018, reward offering and further coercive hearings in 2020.
On 23 May 2020, Coroner Roney delivered findings into the suspected death of Tina. Coroner Roney concluded that Tina was deceased, that she died on or about 18 January 2012, that she died in Clumber, that Mr Sharman was involved in, or caused Tina’s death, and that he concealed any evidence of his involvement and Tina’s body. No inquest was held.
Tina’s daughter, Lili, applied to the State Coroner for an inquest to be held into her mother’s death. The holding of the inquest was supported by the then Attorney-General and Minister for Justice, Women and the Prevention of Domestic and Family Violence.
In November 2022, the State Coroner determined it was in the public interest to hold an inquest into Tina’s death and granted Lili’s application.
The inquest commenced before me on 13 September 2023 and concluded on 22 September 2023.
her disappearance which was out of character. This report enlivened the jurisdiction of the State Coroner to investigate Tina’s suspected death.
A coroner has jurisdiction to inquire into the cause and circumstances of a suspected death. The Coroners Act, in Section 45(1)(2), provides that when investigating a suspected death, the coroner must, if possible, find:-
whether the death happened, and if so,
the identity of the deceased,
how, when and where the death occurred, and
After considering all the evidence presented at the inquest, findings must be given in relation to each of those matters to the extent that they are able to be proved. An inquest is not a trial between opposing parties, but an inquiry into the death.
The focus is on discovering what happened, not on ascribing guilt or attributing blame. The purpose is to inform the family and public of how the death occurred with a view to reducing the likelihood of similar deaths. As a result, insofar as it is relevant to the death being investigated, the Act in Section 46(1) authorises a coroner to “comment on anything connected with a death investigated at an inquest that relates to public health or safety, the administration of Justice or ways to prevent deaths from happening in similar circumstances in the future”.
The Court can inform itself in any way it considers appropriate 1. A coroner should apply the civil standard of proof, namely the balance of probabilities, but the approach referred to as the Briginshaw sliding scale is applicable
1 Coroners Act Section 37 2 Anderson v Blashki [1993] 2 VR 89 at 96 per Gobboj 3 Briginshaw v Briginshaw (1938) 60CLR336361 per Sir Owen Dixonj Findings of the inquest into the death of Tina Louise Greer Page 4 of 68
Tina’s mother, Margaret, passed away in 1996 when Tina was 17. This led to Tina using alcohol and cannabis as a coping mechanism which unfortunately continued into her adult life. Throughout her life, Tina was the victim of domestic and family violence at the hands of several partners.
Tina’s daughter, Lili, was born in July 1998. Neither Tina nor Lili had any contact with Lili’s father from around 2002.
Tina did a hairdressing apprenticeship when Lili was three or four. During this time Tina had regular contact with Phillip and his second wife, Rosemary Greer, who often looked after Lili. In 2005, Tina drove with Lili to Phillip and Rosemary’s house whilst intoxicated. Lili had a bleeding lip and bruises on her arm. Tina was charged with assaulting Lili and Child Safety took custody of Lili. When Lili was six, Phillip and Rosemary were granted long term guardianship of Lili. During the time that Lili lived with her grandparents she maintained a very close relationship with Tina. They had regular contact via a secret phone that Tina gave Lilli, they wrote letters to each other and secretly met up outside of their scheduled contact. It was always Tina’s intention to be reunited with Lili.
In 2006, Tina commenced rehabilitation at the Salvation Army Gold Coast Recovery Services, known as Fairhaven Rehabilitation Centre. Tina started rehabilitation at Fairhaven several times up to the time of her disappearance, often leaving before finishing the program. While at Fairhaven she met a fellow patient, Edward Ngawhika, and they struck up a friendship. They had a short relationship in 2007. They reconnected again at Fairhaven shortly before Tina’s disappearance.
In 2008 and 2009, Tina’s drug and alcohol dependency continued. In 2008, Tina met Leslie (‘Grumpy’) Sharman, a well-known member of the Finks motorcycle gang. He was 26 years her senior. He worked as a cleaner and a tip truck driver. He lived on an acreage property on Spicers Gap Road, Clumber, near Boonah. Tina moved in with Mr Sharman (it’s not clear when this was). Lili would have overnight visits on occasions. She didn’t like Mr Sharman because he was violent and abusive to her mother. Lili was aware that Tina feared Mr Sharman, but that she relied on him financially and emotionally.
Findings of the inquest into the death of Tina Louise Greer Page 5 of 68
During the period from June to December 2010, police at Boonah obtained information regarding three incidents that indicated domestic violence was being perpetrated by Mr Sharman against Tina. Tina’s father, Phillip, was also aware that Mr Sharman was violent towards Tina.
In July and September 2011, Tina attended Fairhaven for drug rehabilitation. The case worker in the rehab unit spoke to her about her plans. Tina said that she was trying to get custody of Lili back from her parents, and also to “escape” from her boyfriend with the help of one of her friends. It was apparent to the case worker that Tina was fearful of her boyfriend. Mr Ngawhika was also back at Fairhaven at that time and reconnected with Tina. She told him she came to Fairhaven because she needed a break from taking drugs. She spoke about Mr Sharman having bashed her during their relationship. She said she wanted to get away from Mr Sharman. Before she left, Mr Ngawhika gave her his phone number, which she said she would have to hide from Mr Sharman.
Tina called Mr Ngawhika a few weeks after she left Fairhaven in September and told him she was running away from Mr Sharman. She said: “if you don’t hear from me, I’ll probably be six feet under.” Mr Ngawhika thought she may have been drinking and didn’t pay too much attention.
On 23 September 2011 Lili ran away from her grandparents’ home. Phillip suspected that Mr Sharman had picked her up from their house while he was out for a short period. Phillip contacted Child Safety and advised that he wanted Lili returned to his and Rosemary’s custody. This did not happen. Instead, Lili, went to live with her mother and Mr Sharman.
Lili’s best friend at school was Dakota Williams. When Lili went to live with Tina and Mr Sharman, Tina met Dakota’s mother, Lina Williams, and they became close friends. Tina confided in Ms Williams about Mr Sharman’s violence towards her. Tina called Ms Williams once for help when Mr Sharman had punched her in the face and left her in a car park. Ms Williams also noted that Mr Sharman would constantly call or text Tina when Tina was visiting her.
Tina and Lili moved into a granny flat in Brushbox Road Lower Beechmont, in December 2011. Tina’s landlord at the granny flat was John Drummond.
He lived in the upstairs part of the house. Mr Drummond met Mr Sharman Findings of the inquest into the death of Tina Louise Greer Page 6 of 68
within the first week that Tina and Lili moved in. Tina introduced Mr Sharman as her boyfriend. Child Safety records show that discussions were had with Tina on 16 December 2011, and Tina advised Departmental Officers that she had broken up with Mr Sharman and wanted to focus on her life with Lili.
When they moved in together, Tina told Lili that she was trying to break up with Mr Sharman because she was sick of his abuse and knew that it wasn’t safe for her or for Lili. Tina told Lili that Mr Sharman had once hit her in the head with a barstool. Lili told police that “whenever mum would say ‘it’s over’ she would cop non-stop calls from Mr Sharman.”
Within a week of moving in with Lili, Tina rang Mr Drummond just before midnight concerned that she could hear a person outside her windows on the balcony. Mr Drummond went outside but couldn’t see anyone. A few days later Tina told Mr Drummond that Mr Sharman had kicked in her front door. She showed Mr Drummond the damage and said that Mr Sharman was going to repair the door.
Tina again reported a prowler to Mr Drummond about two or three weeks after the incident with Mr Sharman. About a month before Tina disappeared, someone poured paint stripper over her car which was parked on the street outside Mr Drummond’s property. Tina reported this to the police.
On 14 January 2012, Mr Ngawhika got a voicemail message from Tina, saying that she had her own place with Lili and that she would like to catch up with him. He recalls that she sounded happy. He called her back and they made arrangements for Tina to visit him at chapel at Fairhaven on Tuesday 17 January, and maybe meet up somewhere the following Saturday.
On Monday 16 January Tina called Ms Williams some time before lunch and told her that she and Mr Sharman “were over”, and he was going to let her get on with her life. They organised to meet that Wednesday, 18 January, to take the girls shopping for school uniforms.
On Tuesday 17 January, Mr Ngawhika sent Tina a text message saying it would be good to see her at chapel that night. She did not reply and did not attend chapel.
Findings of the inquest into the death of Tina Louise Greer Page 7 of 68
On Wednesday 18 January, Tina and Ms Williams and their daughters met at Canungra at 11am and drove in Tina’s car to the girls’ high school to buy school uniforms. After this, they went to Westfield at Helensvale and bought school shoes. They got back to Ms Williams’ car at Canungra at about 2:30pm. Lili was sleeping over at Ms Williams’ house that night, as Tina was going to Mr Sharman’s house to do some washing and to use Mr Sharman’s tools to sand the damaged paint on her car. She said she would pick Lili and Dakota up for a sleepover at her place at around 5pm on Thursday afternoon.
Tina did not contact Ms Williams on Wednesday afternoon to tell her she arrived safely which she would usually do. Mr Ngawhika sent Tina a text message at 10:53pm on Wednesday night to which he did not receive a response. Mr Ngawhika received two phone calls from Tina’s number at 11:13pm that night: 12 seconds and 11 seconds duration. Mr Ngawhika doesn’t recall speaking to Tina that night and thinks that he answered the calls and there was no one there.
Ms Williams did not hear from Tina on Thursday 19 January. At 4:57pm that afternoon, she sent Tina a text asking her what time she could expect her to pick up the girls. Tina did not reply which Ms Williams said was out of character. Ms Williams tried to call her several times that afternoon and evening and left voice messages. Ms Williams continued to try and contact Tina on Friday 20 January but by around about 3pm, the phone stopped diverting to message bank and Ms Williams could no longer hear a ringtone. Ms Williams, Lili, and Dakota went to Tina and Lili’s house at about 4:30pm, but she was not there, and Mr Drummond had not seen her.
When Ms Williams and the girls returned to Ms Williams’ place, they talked to Ms Williams’ flatmate Martin Kramer. He said that Tina might still be at Mr Sharman’s, and he would try and get in touch with Mr Sharman before they called the police to report Tina missing. They tried to contact Mr Sharman through mutual contacts that night and the following morning. Mr Sharman called Mr Kramer at 11:30am on Saturday 21 January. Mr Sharman said that Tina had got to his place on Wednesday afternoon and had left at about 9:30 or 10am on Thursday morning. He had not seen her since. Ms Williams then called the police to make a missing person’s report.
On Thursday afternoon at around 4pm, visitors to the Governors Chair Lookout at the end of Spicers Gap Road saw a car parked in the car park.
They could see a handbag open on the front seat and a wallet inside the Findings of the inquest into the death of Tina Louise Greer Page 8 of 68
handbag. It was still there when they came back from the walks, and they took a photo of it. Other visitors had noticed the car over the next few days.
When Tina was reported missing police attended on 22 January and confirmed that it was Tina’s car.
I do not intend to set out in detail the full nature of the investigation. The brief of evidence contains voluminous material evidencing the investigation.
A summary of the investigation can be gleaned from the QPS Missing Person report provided to the Coroner in August 20154, the further QPS report provided in March 20195, the statement and oral evidence of Detective Inspector Jason Hindmarsh6, the statement and oral evidence of Detective Senior Sergeant Glen Kite7, and the statement and oral evidence of Detective Senior Sergeant Steven John Williamson8.
This is as follows-: The investigation was allocated the codename Operation Kilo Footwork. An investigation centre was established at the Yamanto Police Station under the supervision of Detective Senior Sergeant Gary Dixon. The operation was managed on the Queensland Police Service investigation management system (IMAC). There were 500 individual taskings recorded in IMAC and over 100 statements obtained 9.
Detectives from homicide investigation were involved in the investigation into Tina’s disappearance from the outset. The initial investigations and searches included an air and land search in the area in which Tina’s car was located. The cliff faces and area at the bottom of the cliffs where Tina’s car was located were extensively searched. A re-enactment using a police vehicle was conducted on the Cunningham Highway to generate public interest. Witness Statements, door knocks, and CCTV collection were undertaken. Mr Sharman’s vehicle was also seized for forensic examination. Numerous searches were undertaken at Mr Sharman’s 4 Ex A1 5 Ex A2 6 Ex C17 T3 87-114 7 Ex C21 T3 82-86
8 C28 T4 27-37 9 T4 34 at 15 Findings of the inquest into the death of Tina Louise Greer Page 9 of 68
property at Clumber including searching an underground water tank. Lake Moogerah in the area was searched by water police.
These hearings involved Mr Sharman, his friend Mr Frandsen, and a colleague of Mr Frandsen’s’.
No fresh information in relation to Tina’s disappearance was uncovered at the CCC hearings or the searches.
In 2018, a review was conducted by QPS of the investigative material to date. Detective Senior Sergeant Glen Kite from the Homicide Investigation Unit was tasked with that review. The principal suspect was Mr Sharman.
Detective Senior Sergeant Kite gave evidence at the inquest 11. He said that when he became involved, it had been six years since the matter was originally investigated and it was considered that opportunities may have then existed for further evidence to be given by persons associated with Mr Sharman in relation to his or others’ involvement in Tina’s disappearance. It was intended that covert methodologies would be put in place to elicit further information.
These operations were to commence in early 2019. However, unexpectedly, Mr Sharman was killed in a car accident on 13 November
Accordingly, the covert investigations involving Mr Sharman could not proceed. The investigation continued nonetheless with a continual focus on trying to locate Tina’s body.
A media release was conducted and a $250,000 reward for information was offered.
As a result of the media release, information was obtained indicating that Tina’s body had been buried on a three-hectare property at Bonogin.
Persons of interest were identified, and a crime scene warrant was 10 Ex C8, C17 - 27.
11 T3 82 at 35 Findings of the inquest into the death of Tina Louise Greer Page 10 of 68
obtained for the property at Bonogin. An extensive search was conducted over several days. However, no signs of Tina being buried on the property were located.
Further CCC hearings were conducted. Persons of interest connected to the Bonogin property were required to attend and give evidence. However, no fresh information in relation to Tina’s disappearance was uncovered. Mr Fransden was again the subject of CCC hearings to clarify his trip to the Willawong transfer station in the days following Tina’s disappearance. He did disclose that he had disposed of a queen-size mattress and black plastic bags from Mr Sharman’s property which Mr Sharman had asked him to dump on 20 January 2012. He was unable to remember anything of note about the mattress although when giving oral evidence at the inquest12, Mr Fransden said he thought it may have been the mattress Mr Sharman had used as a bed for his dog, as the dog had died a few weeks earlier. He did not know what was in the black plastic bags.
The investigation into Tina’s disappearance and suspected homicide remains open.
21 witnesses gave oral evidence over the period of the inquest. Lili also addressed the court in relation to the impact on her of her mother’s disappearance and presumed death.
Counsel Assisting made oral submissions at the close of the evidence. All parties were given the opportunity to, and did, provide written submissions in response.
A pre-inquest hearing took place on 6 July and the following issues for the inquest were determined:
12 T1 1-63 Findings of the inquest into the death of Tina Louise Greer Page 11 of 68
The findings required by Section 45(1) and (2) of the Coroners Act 2003: namely whether or not Tina Louise Greer is in fact deceased and, if so, how, when and where she died, and what caused her death.
The adequacy of the Queensland Police Service (QPS) response to allegations of domestic and family violence (DFV) perpetrated against Tina by Les Sharman.
The adequacy of the QPS investigation into the disappearance of Tina Greer.
What improvements have been made by QPS into investigating allegations of DFV and the disappearance of women who are suspected or known victims of DFV including by reference to the policies and procedures in place at the time of Tina’s disappearance.
The adequacy of the response by Salvation Army Gold Coast Recovery Services, Fairhaven to disclosures of DFV by Tina.
What improvements have been made Salvation Army Gold Coast Recovery Services, Fairhaven to help support victims of DFV who engage with Salvation Army Recovery Service.
The adequacy of services and support provided to victims of DFV by the Department of Child Safety when assessing whether a child is at risk of harm.
Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.
ISSUE 1 - Sections 45(1) and (2). Findings, whether Tina Greer is deceased and if so, when, where how she died and what caused her death.
• Is Tina deceased?
Tina has not been seen since her disappearance on 18 January 2012. In the missing person’s report given to the Coroner’s Court in August 2015 13, Senior Constable Stephen Williamson found that it was believed that Tina was deceased as she had not been in contact with Lili or any of her family since her disappearance, which was out of character. Her bank accounts had not been accessed since her disappearance and there is simply no evidence that she is alive.
Counsel Assisting and other parties at the inquest submitted that a finding should be made that Tina is deceased.
13 Ex A1 Findings of the inquest into the death of Tina Louise Greer Page 12 of 68
• When, where, how did Tina die and what caused her death.
The finding made by Coroner Roney in her findings was that there was sufficient evidence to find that Tina was killed by Les Sharman on or about the 18 January 2012. The evidence at the inquest supports the same findings. The evidence relevant to such a finding is well summarised by Counsel for Lili in her written submissions14. I accept those submissions and adopt the summary of the relevant factors as follows- : a) the history of domestic and family violence perpetrated by Les Sharman against Tina.
The Domestic and Family Violence Death Review Unit (DFVDRU) within the Coroner’s Office provided a report to the coroner in May 2017 following a review of the material in relation to Tina’s disappearance15. The report noted 16, that witnesses described significant acts of domestic violence perpetrated by Les against Tina. Those witnesses include: Lili Greer:
Tina told her that Mr Sharman had hit her over the head with a barstool and that she had to clean up her own blood off the floor.
She recalled on one occasion after they had moved into the Brushbox Road granny flat, Mr Sharman had tried to force Tina into the bedroom and Lili stood in his way. Mr Sharman told Lili “fuck off Lili or I’ll smash your face in”.
Lili also gave evidence that she observed coercive and controlling behaviour on the part of Mr Sharman when Tina attempted to leave the relationship. Mr Sharman had attempted to isolate and control Tina’s daily 14 Submissions on behalf of Lili Greer 24 October 2023 15 Ex A7 16 Ex A7 - 11 17 Ex B24; Ex B24.1; Ex B63; T1 Findings of the inquest into the death of Tina Louise Greer Page 13 of 68
activities, for example, by monitoring her movements and obsessively calling her on her phone. Lili gave evidence that Mr Sharman made threats to her mother such as “I’ll ruin your life”, “you’ll never be able to get a job” and “I’ll kill you”.
Phillip and Rosemary Greer:
Tina made disclosures to Phillip and Rosemary about the abuse Mr Sharman had perpetrated against her18. Tina had told her father that she had been shot at, her arm was broken, and she was hit her over the head with a barstool.
Phillip Greer confirmed in oral evidence at the inquest that he knew that Les had inflicted physical violence up on Tina19.
Rosemary Greer in her statement20 said that she recalled an incident where Tina told her she had had a fight with Les. She showed her arm, and it looked out of shape. She said that Les had thrown a stool across her arm. She also told her that Les had randomly shot at her as she drove away in a vehicle. She said that she knew Tina had tried to leave Les on several occasions and live independently, but that that had been unsuccessful as Tina was dependent on Les for money and finances 21.
Lina Williams:
She recalled another occasion when Tina came around to her house and told her that she had her car keys in her hand and Les had ripped it off her removing a layer of skin. She said that whenever Tina was at her house, Tina’s phone would ring constantly. Tina told her that it was Les calling her. Lina said that she had a phone conversation with Tina on 16 January 18 Ex B27; Ex B28; T1- 35
19 T1 - 35 20 Ex B28 21 Ex B28 22 Ex B50; B50.1; B50.2; T1 - 53 Findings of the inquest into the death of Tina Louise Greer Page 14 of 68
(two days prior to her disappearance) when she told her that she and Les were over and that he wasn’t going to annoy her anymore.
Edward Ngawhika:
He said Tina was concerned about Les and knew she needed to get away from him. She told him Les had physically assaulted her and that that was a common thing. After Tina left Fairhaven in September 2011, he received a call from her. She was crying, and she said that she had her bags packed and was running away. She told him “if you don’t hear from me, I’ll probably be six foot under”.23
• On 29 June 2010, Tina was heard on a public telephone speaking to her father saying that Mr Sharman had threatened her by holding a gun to her head.
• On 15 September 2010 24, at about 4pm, three people came to the Boonah Police Station to report that they had witnessed Mr Sharman attempting to drive his car off at speed in the direction of Tina who was walking on the side of the road. He then attempted to force Tina into the car with him.
• On 29 December 2010, two police officers located Tina and Mr Sharman on the side of the road in the Lake Moogerah area after having received a report that a female had been seen running down the road screaming with blood on her face, and a male running after her. The officers noted that Tina’s left eye was completely closed from swelling and bruising, her right eye was also swollen and bruised, and she had laceration across the middle of her nose.
(b) the stalking behaviour 23 Ex B38 - 29 24 Ex C11.5 Findings of the inquest into the death of Tina Louise Greer Page 15 of 68
Shortly after Tina and Lili moved into Brushbox Road, Tina told her landlord Mr Drummond, that she could hear a person outside her window. A week after that incident, Tina reported to Mr Drummond that Les had kicked in her door to force his way into her home 25.
Tina told Mr Drummond that she thought someone was watching her in the property and shortly afterwards, her car was extensively damaged by what appeared to be paint stripper. Mr Drummond reported that sometime in the 10 days before Tina’s disappearance, Les stayed over at the property and Tina said that someone had tampered with his car by loosening the wheel nut. A serviceman from RACQ checked Les’ vehicle but he could not find any evidence of damage to the vehicle 26.
There is evidence that Mr Sharman was one of the few people who knew where Tina and Lili were living27.
Lili gave evidence that Mr Sharman stayed over a few nights, armed with a baseball bat to protect Tina and Lili from the stalker. On those nights they did not notice any stalking behaviour28.
Counsel for Lili submits that on the evidence before the court it is more likely than not that Mr Sharman was responsible for the stalking that Tina and Lili experienced in December 2011-2012. That submission is supported by the review conducted by the DFVDRU. The report writer noted that there was a possibility that prior to her death Les had been stalking Tina and may have been responsible for the paint damage to her car29.
The report writer concluded that “a potential and perhaps reasonable assertion, given Les’ history of obsessive behaviour, which may warrant consideration is that Les may have been stalking Tina during a period of conflict in the relationship and because of his ongoing fears that Tina was going to leave him or have a relationship with another man”. The report concluded “it is not inconceivable that Les manipulated Tina by creating a sense of fear that someone was stalking her, when in fact this was an attempt to re-establish the relationship. In this sense, it could be said that this strategy was effective as Tina not only reinvited Les into her home to stay with her out of fear of stalkers, but she also attended his house on the 25 Ex B13 26 Ex B51 27 Ex B63; C50 28 Ex B63 29 Ex A7 - 13-17 Findings of the inquest into the death of Tina Louise Greer Page 16 of 68
day of her disappearance to repair the vehicle (which he may himself have damaged) 30.”
(c) Tina distancing herself from Mr Sharman in the weeks prior to her disappearance.
Tina moved out of Mr Sharman’s property and into the granny flat with Lili on 14 December 2011. She told Child Safety officers at this time that she was no longer in a relationship with Mr Sharman. She had told them she did not have time for a relationship and wanted to devote all of her time with Lili 31.
Tina had also re-engaged with Mr Ngawhika. He had given Tina his mobile number prior to her discharge from Fairhaven in September 2011. In the days prior to her disappearance, Tina and Mr Ngawhika had made plans to catch up on Tuesday 17 January 2012 at the chapel at Fairhaven and at the Currumbin rock pools on the weekend of 21 and 22 January 2012. Tina had given him the option of staying over at her place if he wanted to 32. Mr Ngawhika’s phone records indicate that he sent a text message to Tina at 10:53pm on Wednesday 18 January 2012 asking Tina if she wanted to catch up. His phone records also indicate that he received two calls from Tina’s phone at 11:13pm that night. He doesn’t recall speaking to Tina. He thought that he may have answered the call, but no one was there33.
In the weeks prior to her disappearance, Mr Sharman sent Tina a lot of text messages which indicated a sense of desperation in response to Tina distancing herself from him. Examples of these are taken from the submissions received from Counsel on behalf of Lili, as follows-:
• But now you won’t talk to me.
• You don’t want 2 talk 2 me you’ve already got some one lined (up).
• If you love me, you will ring me.
• I really thought you loved me.
• I wish you loved me.
• I don’t want 2 break up with you.
• Talk 2 me tina I love you not fair do you love me i love you.
30 Ex A7 - 16 31 Ex A7 - 39 32 Ex B38 - 33 33 Ex B38 - 38 Findings of the inquest into the death of Tina Louise Greer Page 17 of 68
• You are my girl and thats your mine I love you tina your mine.
• Your my dream and thats that I will kill anyone else your mine love les.
• Im madly in love with you i will kid nap you tina love les.
• Believe me I will kill any one you are mine i love you.
• I will fight die go 2 jail for you your mine.
• I’m sad suicidal you are my life support tina. I will go 2 jail over you fuc this I love you are my girl.
• Your mine tina.
• You wont answer you are mine tina you are coming home 2moro im coming to get no questions asked you will cum home where you should be i love you.
• Maybe I should come 2 yours now take u home.
• Fuck this you are mine tina.
• The kid will do as it’s told it might rule you it won’t rule me it will do as its told its only a fucking kid abt time it learnt who was the boss not it.
• Everyone will do as they are told there is only one king 2 many kings and you have no organisation nothing get done someone has to be in control and your not in control.
• When will u learn im not the enemy and I love you.
• I cant live without you tina im in love with you pls talk 2 me I want you 2 come back i deserve to be spoken 2 you say you love me I need to.
• Im so in love with you tina but so empty at the same time, i really just want the tears of pain 2 go away im in so much pain gotta have drink. numb the pain.
• Really miss my tina ill always love you i’m sorry for the violence that occurred in our relationship.
• I love u tina where not broken up I love you your not getting away that easy.
(d) Mr Sharman was the last person to see Tina alive.
Findings of the inquest into the death of Tina Louise Greer Page 18 of 68
(e) Mr Sharman’s actions in the days following Tina’s disappearance.
He would know through his criminal activities and his criminal associates that at that stage, 2012, we could track phone movements by cell tower locations”.
On 19 and 20 January 2012, Mr Sharman made several trips to the Shell service station in Aratula to purchase petrol36. On 19 January at 9:05 am, he filled his utility up with fuel. He returns at around 10am and again fills up his ute. On 20 January at 5:50am he fills a jerrycan with fuel and steals black garbage bags from the service station shop. That evening at 6.22pm, he returned to the service station and refuelled the vehicle.
Mr Sharman purchased a new mattress on Thursday, 19 January at around 3pm. His first phone call (after turning his phone back on) was to his friend Kim Fransden early on Friday morning 20 January. He told Mr Fransden Tina was missing37. On Mr Sharman’s version of events, to police, he only found out that Tina was missing when he was contacted by Lina Williams’ friend, Mr Kramer, on Saturday 21 January 201238.
Mr Fransden went to Mr Sharman’s property on 20 January and collected rubbish which he took to the dump, including a bed mattress39.
34 Ex C100
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Mr Fransden told the inquest that Mr Shaman would burn rubbish in the incinerator on his property40.
Early in the morning on Saturday, 21 January, Mr Sharman rang another friend, Mr White, and asked him what he knew about border gate cameras41. Mr Sharman then went out to Mr White’s property on Sunday, 22 January. He told Mr White Tina was missing and he appeared upset42.
He said she had taken off somewhere43. Mr White told Counsel Assisting at the inquest that he didn’t ask Les what had happened but when he thought about it later, he remembered that Les’ ute was very clean when he came out on the Sunday morning. He thought that was strange because his car was always muddy because he had to go through muddy paddocks to get to the gate on his property44.
g) Location of Tina’s car.
h) No other plausible explanation for Tina’s disappearance.
Tina’s car was found at Governor’s Chair Lookout. That area is known as a suicide point46.
Searches were carried out on cliff faces and below. It was difficult terrain and Detective Inspector Hindmarsh’s evidence was that it could not be said with absolute certainty that Tina was not located down there, but that extensive searches were carried out. There was no credible evidence that Tina had ever expressed any suicidal ideations. She had reached a point in her life that she had been working towards for many years: that is the reunification with Lili. It is not at all probable that Tina took her own life.
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I find that Tina died on or about 18 January 2012 and that Mr Sharman was responsible for her death.
I accept Counsel Assisting’s submission that there is insufficient evidence for me to make findings about where and how Tina died. However, it is likely that Tina’s death was a violent one47.
Counsel for Lili submits48 that Mr Sharman’s purchase of a new mattress on Thursday afternoon, combined with forensic photos which appear to show blood in the bedroom is sufficient for me to find that Tina was killed in that room.
I accept that the purchase of the new mattress and the apparent disposal of the old mattress suggests that the old mattress would have provided evidence of what had happened to Tina. However, without the original mattress and evidence of Tina’s blood, it is difficult to conclude even on the balance of probabilities that Tina was killed in the bedroom.
Whilst the purchase of what is apparently an excessive amount of petrol by Mr Sharman and some evidence by Mr Fransden that Mr Sharman burnt rubbish on his property, I am unable to conclude that Tina’s body was burnt by Mr Sharman.
I accept Counsel Assisting’s submissions49 that the lack of evidence in relation to Tina’s death is attributable to Mr Sharman’s ability to conceal evidence and conduct criminal activity in an undetected way.
Detective Inspector Hindmarsh described Mr Sharman in these terms: “we had quite a challenging investigation to try and get evidence…with a career criminal, a member of a motorcycle group, it quite depends on who we spoke to...when we returned (his vehicle) from forensic examination, his solicitor, in front of our investigators, told Les Sharman quite openly that there would be listening devices in the car. So we had a lot of challenges to try and gather evidence due to all these factors. He really knows his tradecraft of being a career bikie member, being tried for murder, convicted of multiple offences previously, so we knew straightaway it was a very hard target”50.
47 I do not consider my finding that Tina’s death was likely violent and at the hand of Mr Sharman offends s.45(5)(a) because Mr Sharman is dead.
48 Page 15 submissions
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ISSUE 2 - The adequacy of the QPS responses to allegations of domestic and family violence perpetrated against Tina by Les Sharman.
Responses to the incidents
(i) The incident on 29 June 2010.
The woman had left by this stage.
Sergeant Boyce said they identified the female as Tina Greer52. He said he was aware that she was connected to Les Sharman53 and that Mr Sharman was involved with the Finks Outlaw Motorcycle Club54.
He said he referred the matter to Ipswich CIB55. He did not try and contact Tina. He understood the CIB were contacting her father as they believed that was who she was talking to on the phone56. Sergeant Boyce told the inquest his predominant concern was for Tina’s welfare57.
The job card58 for the job indicates that the Ipswich Communications Office made contact with Phillip Greer, and he confirmed Tina had phoned him to tell him that her “bikie boyfriend had given her a hard time”. Phillip Greer said Tina had been known to exaggerate. He said she didn’t come to his place, and she was going to a friend in Tweed Valley but that he hadn’t heard from her.
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The job card records the conversation as “no complaint from a female more welfare concerned for Sharman – Boyce to contact Sharman”59.
At 10:30am, at the request of Sergeant Boyce, Mr Sharman came into the Boonah Police Station to discuss the incident. The conversation with Sergeant Boyce was recorded60 and the recording was played at the inquest.
The tone and content of the conversation reflect concern by Sergeant Boyce for Mr Sharman’s welfare as opposed to Tina’s. The submissions provided by Counsel on behalf of Lili include a transcript of that conversation61. It includes the following:
• Sgt B How are you going mate? Sorry about this.
• Sgt B Mate, the reason we are mainly concerned for your safety.
• Sgt B Well, what was the story last night?
• LS Bit of a break down. Well, she can’t drink like that.
• LS She’s gone. She’s coming back tonight. I’m laying down some ground rules.
• Sgt B I’m going to ask you a frank question too now Les. Is there any firearms at your place?
• LS Nope. There were gun shots. I heard gun shots
• LS There were some scallywags out the front of my place on Sunday night.
• LS There were a couple of cars, about 8 of them. They were all fucken- There were some shots fired.
• LS No there’s no firearms.
• Sgt B But unfortunately, on what we’ve been told was overheard and that sort of stuff, we just need to confirm, and if we can speak to her then it will put it to bed. If she doesn’t want to tell us anything, that is fine, it is up to her.
• Sgt B If she can just ring us and let us know everything is fine.
• LS She is alright.
• Sgt B yep, that’s all we need to know, and we’ll be happy with that hey.
59 Ex C43 60 Ex C29 61 Appendix B Findings of the inquest into the death of Tina Louise Greer Page 23 of 68
Sergeant Boyce62 said he did receive a call from a female person the next morning identifying herself as Tina Greer saying that she was at a friend’s and was okay.
When asked about the nature and tone of his conversation with Mr Sharman, Sergeant Boyce said he deliberately adopted a laid-back tone to elicit information from him63 but in fact, his main concern was for Tina’s welfare.
In relation to the possibility that Mr Sharman had possession of firearms, Sergeant Boyce said that whilst he did not believe Sharman’s story about scallywags and the gunshots, he did not arrange a search of Sharman’s property for any weapons.
His evidence as to the reason for this was that he believed Mr Sharman would have removed any weapons before police arrived because of his criminal background and knowledge of policing64.
Sergeant Boyce did not make an occurrence report in relation to this incident. He did make a job card entry which read “Sharman attended station he is fine. Stated that Tina Greer can’t hold her alcohol - she went off last night at him and left the premises. She rang him this morning. She is returning to the address tonight. Arrangements made for Boonah Police to make phone contact tomorrow morning. Denied any weapons being at the property and did state that there were shots fired around the location last night, but this is not unusual as shooters frequent the area. Nil concerns for safety65.
In oral evidence, Sergeant Boyce agreed with Counsel Assisting that he had a suspicion that an act of domestic violence had occurred with the gun being held to Tina’s head66 and that he had a duty to investigate that.
However, subsequently when asked why no application for a domestic violence order was made, he said he probably didn’t look at the incident from a domestic violence perspective67.
63 T3 - 16 64 T3 - 11 65 Ex - C43
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a search warrant68. He was still not sure if he would apply for a domestic violence order, but he would be engaging the support services and the Vulnerable Persons Unit69.
(ii) the incident on the 15 September 2010.
• The woman was walking along the road. She looked distressed.
A vehicle swerved off the road towards her.
• The woman had a split lip and a limp.
• The woman was distraught and told one witness as she was getting into Mr Sharman’s car “he’s going to kill me”70.
• Another witness recognised the man as Les Sharman71.
Sergeant Boyce went to the scene and took photographs of the skid/tyre marks. He gave evidence that he had experience and qualifications in traffic accident investigation. He considered, having looked at specific marks and photographs that Mr Sharman’s vehicle had slid down an embankment rather than driving directly at speed at Tina.
His evidence at the inquest was:“my opinion was that they’d had an argument, Ms Greer had been walking away. Mr Sharman is trying to get her back in the car. He’s moved up to where she is, tried to get her to get in the car. He has left then and has come back and has done the same thing. The skid marks, I’ve taken a photo of them, to me the skid marks show he’s pulled off to the side of the road and his car…has skid down that hill. The movement of that vehicle hasn’t been his intent72.
Later that evening Sergeant Boyce and Senior Constable Noffke went to the Mr Shaman’s house. He was not there but Tina was. Tina denied being
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injured by Mr Sharman. She said they had an argument. She had a cut lip and she said that that was from dryness73.
On 17 September, Mr Sharman was spoken to by police and denied any domestic incident. He admitted they had a verbal argument and Tina wouldn’t get in the car which did cause some issues but denied attempting to run Tina down.”74
Sergeant Boyce did make an occurrence report in relation to this incident75.
It records “At 1920 hours 15/09/2010 Boyce and Noffke attended at 149 Spicers Gap Road and spoke with Greer. Greer stated that they had a heated verbal argument. Greer was very agitated and constantly moving as indicated was the case at the time of the incident. This could be because of current drugs in the system or due to past drug use. Greer denied there had been any domestic and also strongly denied Sharman had attempt to run her down with his ute. When asked about cut lip Greer stated this was a cracked lip from dryness. It cracked a couple of day previous and had reopened about the same time of the incident. There were no readily visible signs of any visible abuse of Greer, and she stated that there had been nil.
After this contacted DDO went by mobile phone authorised no DV.
(iii) the incident on 29 December 2010.
73 T3 - 25 74 Ex C11.5 75 Ex C11.5
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Their interaction with Mr Sharman and Tina was recorded by Senior Constable Edbrooke77.
Senior Constable Edbrooke described Tina as “black and blue”. He saw that her left eye was swollen, her right eye blurred and puffed up and she had a laceration on her nose78.
Senior Constable Edbrooke gave evidence at the inquest that he believed Tina had been a victim of domestic violence79.
He interviewed Mr Sharman at the scene and Constable Lambert interviewed Tina. They were interviewed in close proximity so they could be overheard by the other.
Tina told Constable Lambert that she injured herself mowing. She said there was a family disturbance. She was uncooperative with police.
Mr Sharman made comments in his conversation with Senior Constable Edbrooke which were indicative of him having assaulted Tina.
Counsel for Lili Greer has helpfully provided a transcript of the recording in her submissions80.
• I ain’t proud, all right.
• You looked at me in the face, I’m not good.
• We erupted.
• Let’s cut to the chase, let’s cut to the chase. I’m a piece of shit.
• Right, at the moment I feel like a piece of shit. Right. You look at me in the face.
• Tina’s a good girl. She’s the kindest motherfucker I’ve ever known in my life. She’s the fieriest girl and Boycey, Boycey said to me one day, he pulled me over and said, Les 17 years and you lived out here and we’ve heard nothing from you.
• She’s a good chick man. I fucked up. Peter I fucked up.
77 Ex C31 78 Ex C11.9 R4C
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• She’s a good chick. If you arrest me man, come arrest me. Listen, just hear me, just hear me.
• You think I’m happy with (ui) Peter you think I’m happy.
• SC Edbrooke So all I am asking for is what happened today?
How did she get those injuries? Your version.
• SC E Well, is there any domestic violence here?
• LS no
• LS I’ve got nothing to say
• LS Do you want me to look at you in your face bro? Do I feel fucking good?
• SC E I don’t know what you feel Les. That’s up to you.
• LS No I don’t Peter
• LS Man to man.
• LS Nothing mate, trust me. Can I look, can you look me in the eyes?
• LS Can I give you my word? As a man?
• LS Man to man, I won’t touch her.
• SC E Can we give you or her a lift somewhere so I’m comfortable it’s not going to happen again?
• SC E Tell Tina to settle down a bit
• SC E We’re only going to be as good as what you guys tell us, and at the moment, you and I both know the score here Les.
• LS Yep
• SC E Okay, I’m hearing what you’re telling me. My eyes are telling me a lot of different things. But I can’t prove nothing. If she’s going to tell us that she’s got those injuries from the ride on mower and crash and that, I can’t do a great deal about that.
• LS I don’t feel proud of it, Peter. I’m not proud of it. That’s all I’ll say.
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• LS Do you hear me? Do you hear me? I’m not proud of it.
• SC E All right, well make sure when you do stuff in the future, it doesn’t happen.
• SC E Your family disturbance is finished. It’s finished
• SC E I know what’s happened. I just can’t prove nothing.
• LS And I know it too. I’m not denying it. I’m looking you in the face.
Do you think I feel good?
• There’s been some sort of minor traffic crash on side of the road. She has one busted eye, completely closed her left eye. Her right eye badly bruised. Laceration on her nose. Spoke to Les Sharman. He denied any domestic violence tonight, any physical violence against her. There are no witnesses, we’re on a dirt road. Must be near 2195 Lake Moogerah Road, and I believe she is denying. She has had a run in with a ride on mower, crashed it and fallen off and that is how the facial injuries have occurred.
Greer was constantly moving around and saying that she was okay. Greer was questioned about injuries to her face where Greer claims she had been involved in an accident while mowing her property earlier that day. Greer claims she has rolled the mower down an embankment whilst mowing into a dam hitting her head on the front of the mower causing the injuries to her face. Greer has strongly denied that any incident of DV has occurred or Sharman assaulting her.
Police have contacted the informants in relation to the matter where the informants have told police that they have not seen Greer being assaulted 81 Ex C11.6R3.
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by Sharman or anyone else. Nil witnesses, and both Greer and Sharman constantly sticking to the same version of events. Nil complaints.
The previous incident on 15 September was referred to in the report in these terms82 “On this occasion Greer appeared to be under the influence of substances and was not willing to provide police with any information about what had happened strongly denying DV had occurred”.
As to the likelihood of further DV occurring, the report notes “both Greer and Sharman appear to be in a relationship where DV is occurring however both parties constantly deny any DV incidents when police attend. The likelihood of DV occurring is moderate. On previous occasions when police have attended both parties have appeared to be under the influence of substances on each occasion”.
Senior Constable Edbrooke told the inquest that in all of the circumstances, there was not enough evidence to support an application for domestic violence order. He was aware of the incident on 15 September being recorded on the system as a no DVO.
He said if this incident occurred today, he would contact the Vulnerable Persons Unit to see if there was sufficient evidence to support an application for a domestic violence order83.
Were the police responses to these incidents adequate?
This issue has to be considered in the context of the legislative framework that existed at the time.
In 2010 the relevant legislation was the Domestic Family Violence Act of 1989.
In order to make a protection order, a court had to be satisfied, on the balance of probabilities that: 82 Ex C11.6 R3
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a. A domestic relationship existed between the aggrieved and the respondent and b. The respondent had committed an act of domestic violence in the course of that relationship and c. Either i. The respondent was likely to commit an act of domestic violence again or ii. If the act was a threat, was likely to carry out the threat85
“Domestic violence” was defined in the Act as a. Wilful injury b. Wilful damage c. Intimidation and harassment of the other person86
It’s also useful when considering this issue to note the findings of the DFVDRU writer concluded. Review into Tina’s disappearance and suspected death. The review was conducted in May 201787.
The review writer concluded that there were missed opportunities for police to intervene prior to Tina’s disappearance88.
“Although significant reform has occurred in an attempt to improve police responses to reports of domestic and family violence subsequent to Tina’s disappearance, it is salient to note the obligation of police officers to protect victims has remained a core principle of police practice: which was in place at the time they responded to the episodes of violence in 2010 between Les and Tina.
Section 9.3 of the QPS, QPM’s current at the time of Tina’s contact (issue 37) required police officers to investigate all allegations of domestic and family violence with the paramount aim of protecting victims: and require that officers should actively enforce the legislation and ensure appropriate support referrals were made to victims.
85 Section 20 Domestic Family Violence Act 1989 86 Section 11 Domestic Violence Act 1989 87 Ex A7 88 Ex A7 paragraphs 50-75 Findings of the inquest into the death of Tina Louise Greer Page 31 of 68
• A failure to thoroughly investigate matters and pursue criminal charges where appropriate.
• No evidence of any additional steps being taken to protect Tina from further harm despite the officer’s assessment that it was likely she had and would experience violence in the relationship.
• Evidence of poor policing attitudes towards victims of domestic and family violence which may have influenced their response.
57 With respect to the first contact on 15 September 2010 police had multiple independent witnesses…
These allegations are significant and indicative of extreme levels of danger and would, despite Tina and Les’ denial when officers took up with them later, have been likely to have satisfied the criteria for a range of criminal offences under the Criminal Code as well as meet the threshold for a civil protection order (with or without Tina’s admission, based on the available evidence and witness reports).”
In evidence at the inquest, Sergeant Boyce and Senior Constable Edbrooke placed significant weight on the fact that Tina denied any domestic violence in their reasoning for not any action to protect her89.
The DFVDRU report noted further-: “70. Finally, pursuant to section 9.6.1 of the QPS OMS police officers are required to apply for a protection order and take any other action
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deemed necessary when they believe a person is aggrieved: there is sufficient reason to take action, and there is sufficient evidence to a civil standard - irrespective of whether the victim denies or agrees that they require protection.
It is questionable as to whether the above criteria were not readily satisfiable on both occurrences when police responded to reports of violence between the couple. However, it is also the case that police officers are still required to take action if they find there is insufficient evidence to justify making an application on the aggrieved party’s behalf after reasonable investigation.
In accordance with Section 9.6.3 officers in these circumstances are required to provide advice to the involved parties about the DFVP Act and their options for making a private application: advise the parties about support agencies: create a domestic violence occurrence on QPRIME: and also advise the parties that if they do make a private application a police prosecutor may be available to assist the applicant in court”.
• Incident 29 June 2010.
It was submitted for Counsel for the police officers that Sergeant Boyce was relieved of any further dealing in the matter once it was referred to the officer in charge at Ipswich CIB.
It would seem on the evidence that Sergeant Boyce himself did consider he still had some responsibility. He did follow up with Mr Sharman and he told Mr Sharman to get Tina to call and let them know she was ok. He told Mr Sharman “That’s all we need to know, and we’ll be happy with that. “If we can speak to her that will put the matter to bed”90
It is submitted that in the context of the legislation at the time without the cooperation of Tina, there was no evidence of a domestic relationship between Tina and Mr Sharman, let alone evidence of any likelihood of future violence91.
Counsel for the Commissioner of Police also submitted that it was of critical importance that the police response to the incidents was analysed on the 90 Ex C29 91 Submissions on behalf of investigating police and Boonah Police.
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basis of the knowledge, information, level of training, and resources regarding DFV in place in 201092.
It is accepted that police are now trained to investigate domestic and family violence allegations within a holistic lens which involves investigating the entirety of the relationship as opposed to the investigative method of being “incident focused” which existed in 2010.
It is also accepted that police are now more appropriately trained to analyse facts lying beneath a situation where the aggrieved misrepresents the truth of a situation in denying the existence of domestic and family violence.
Counsel Assisting and Counsel for Lili submit that Sergeant Boyce’s response to the 29 June 2010 incident was inadequate even making allowances for the legislative framework, policing practices and training available to police in 2010.
It is submitted that there was an opportunity at this time to offer Tina support and referral to a domestic violence service. Further there was a missed opportunity to investigate the possession of firearms by Mr Sharman, a known bikie member with a history of discharging and carrying weapons.
I do not accept that Sergeant Boyce had no evidence of a domestic relationship between Mr Sharman and Tina. In the discussion with Mr Sharman on 30 June, Sergeant Boyce says to Mr Sharman “mate the reason we’re mainly concerned for your safety apparently a girl was with you, or you used to live with your girlfriend. Greer maybe?93. Further, at the inquest when asked whether he knew they were in a relationship he said, “I’m fairly sure I did”.94
Sergeant Boyce also agreed that upon receipt of the report of a woman having a gun held to her head, that he suspected an act of domestic violence had occurred and that under the domestic violence legislation he had a duty to investigate that95.
I accept the submissions from Counsel for Lili that the conversation Sergeant Boyce had with Mr Sharman should have raised concerns with him for Tina’s welfare. Sergeant Boyce maintained that the casual nature 92 Submissions on behalf of the Commissioner of Police 10 November 2023 paragraph 30 93 Ex C29
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of the conversation and apparent concern for Mr Sharman’s welfare was a tactic to obtain information.
I agree that information was in fact obtained during the conversation but was not further investigated or acted upon.
Mr Sharman told Sergeant Boyce in the context of her being unable to “drink like that” that:
• She’s gone. She’s coming back tonight. I’m laying down some ground rules.
• She’s a good - good girl - but she’s fucking violent…
• And I tell you Peter, you could knock her out, plain, and as soon as she come to, she’ll be straight back. She’s got more balls than a fucking bull elephant”96.
Mr Sharman admitted to Sergeant Boyce that he heard gunshots, but denied he had guns. Sergeant Boyce agreed in evidence that he did not believe that.
At this stage, Sergeant Boyce knew they were in a domestic relationship and despite the person (who he assumed was Tina) telling him she was okay, I find that the police should have followed up with Tina in subsequent days to check on her welfare.
I accept the focus of policing was incident-based at that time, but Sergeant Boyce agreed that the report of the incident indicated apparent domestic violence. I accept that without further evidence of previous violence from Tina or other sources, it may have been difficult to provide enough evidence to satisfy a court of the criteria necessary to make a DVO.
Nonetheless, checks on Tina’s welfare once she was expected back at Mr Sharman’s could and should have occurred. Sergeant Boyce agreed in evidence that the referral of the matter to CIB did not prevent local police from following it up97.
96 Annexure B submissions of Lili Greer
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Sergeant Boyce’s explanation for not conducting any search was that Mr Sharman would have hidden any weapons. That explanation does represent a failure to investigate a potential criminal offence.
Sergeant Boyce also explained that it was too dangerous for uniformed police to attend Mr Sharman’s property because of his association with outlaw motorcycle gangs. I agree with counsel for Lili’s submission that that perceived danger should have in itself raised concerns for Tina’s welfare and steps taken to refer that search to CIB if that was necessary.
Sergeant Boyce did not make an occurrence report of the incident. That should have happened. It was particularly important in the context of the domestic violence legislation at the time which required proof that domestic violence “was likely to occur in the future”. Records of acts of domestic violence were an important tool in establishing likely future conduct.
• Incident on 15 September 2010.
The submission on behalf of Sergeant Boyce is to the effect that accepting Sergeant Boyce had knowledge of the June incident, his failure to record the incident as domestic violence and take any action was adequate. This was because Tina’s father had previously told police that his daughter sometimes exaggerates and further, that Sergeant Boyce’s own assessment was that Mr Sharman had not tried to run Tina down but only tried to get her into the car.
The comment by Tina’s father was in relation to reports of Tina that Mr Sharman had held a gun to her head. Sergeant Boyce knew there were independent witnesses to Tina’s level of distress when reporting this incident to her father.
The submission from Counsel for the Police Commissioner was that it was relevant to note that Tina denied any domestic violence and that Sergeant Boyce was considering this incident in isolation from the June 2010 incident.
I accept that he did look at the incident in isolation but in my view he should not have. Even in the context of incident-based policing, the fact that Mr Sharman had reportedly held a gun to Tina’s head three months earlier should have been taken into account when considering Tina’s welfare in September some three months later. Even if (as Sergeant Boyce concluded) Mr Sharman had not attempted to run Tina down, he had aggressively tried to get her in the car. Witnesses had spoken of his Findings of the inquest into the death of Tina Louise Greer Page 36 of 68
aggressive demeanour and that Tina had said “He’s going to kill me”. Mr Sharman himself told police that they had had an argument and that Tina would not get in the car, and that that “caused issues”.
An act of domestic violence was defined in the 2010 Act (on which police had received training) included “intimidation and harassment”. I find that this behaviour of Mr Sharman should have been recognised as domestic violence.
Tina’s denial of domestic violence was a relevant factor in whether an application for a domestic violence order would have been successful.
However, unlike the June incident, there were independent witnesses to this incident and Sergeant Boyce was aware of the previous incident in June. The evidence of these independent witnesses combined with the incident on 29 June may have been sufficient to satisfy the criteria for the making of an order.
• Incident on 29 December 2010
Submissions on behalf of Senior Constable Edbrooke point to him having no knowledge of the 2010 incident and again no complaint by Tina of being assaulted by Mr Sharman.
Senior Constable Edbrooke was aware of the 15 September incident (although I note the finding of no domestic violence) and despite Tina’s explanation that her injuries were caused by a mower, Senior Constable Edbrooke believed Sharman had assaulted her.
He recorded in the occurrence report that: “Greer and Sharman appear to be in a relationship where domestic violence is occurring…the likelihood of domestic violence occurring as moderate”98.
During Mr Sharman’s recorded conversation with Senior Constable Edbrooke, he made several indirect admissions to assaulting Tina. None of those admissions were entered in the occurrence report. Tina’s denials are recorded in the report, but the report should have accurately reported the whole of the interaction, particularly, Mr Sharman’s indirect admissions.
98 Ex C11.6R3.
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It was inappropriate for Senior Constable Edbrooke to offer Tina and Sharman a lift home together in circumstances where he reasonably suspected Tina had suffered injuries as a consequence of being assaulted by Mr Sharman.
Senior Constable Edbrooke was of the view that there was insufficient evidence to support an application for a domestic violence order principally because Tina denied any assault.
He said if he had known about the incident in June 2010, “it might have been useful” but he didn’t think it would have affected his view that there was insufficient evidence to apply for a domestic violence order99.
Concerningly, Senior Constable Edbrooke’s evidence was that even today, he was not sure he would have enough evidence to support an application100.
He did agree that in the circumstances today, he would at least contact the Vulnerable Persons Unit.
I accept the submission of Counsel on behalf of the Commissioner of Police that it would appear that Constable Lambert who attended the incident with Senior Constable Edbrooke did complete a referral to a domestic violence service101.
The evidence available at the time of the December incident (including evidence of previous incidents) may well have been sufficient to satisfy the criteria for the making of a DVO.
It is not known whether a different response to these incidents by QPS would have prevented Tina’s death. I cannot conclude that it would have.
I do agree however, with Counsel Assisting that each incident did present an opportunity which was missed for local police to recognise the existence of domestic violence within the relationship and to take some more proactive steps in ensuring Tina’s protection.
I note the evidence of Detective Inspector Hindmarch at the inquest when asked about the allegations of domestic violence in the relationship. He
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said the existence of the domestic violence heightened their suspicion that it was a homicide and not a missing person. He said he obtained versions from officers involved, and that he spoke to local management about their response to that domestic violence and that was a matter for local management to follow up.
On face value, yes, by reviewing our computer systems, and for that reason I briefed local management for them to deal with it, review it, and take whatever sort of actions or training or upskilling that they needed to do”102.
It’s accepted that there is no evidence that any disciplinary action was taken against Officers Boyce or Edbrooke in relation to their investigation into allegations of domestic violence.
I accept Counsel Assisting’s and Counsel for Lili’s submission that the incident based investigative approach to domestic violence in 2010 coupled with a lack of training as to the nature of domestic violence is not a sufficient explanation for the inadequate responses by Sergeant Boyce and Senior Constable Edbrooke.
As pointed out in submissions the incidents involved reports of threats of and actual violence which should always have been recognised by police officers as domestic violence, warranting adequate investigation with a focus on Tina’s protection and welfare. This would have at least involved advice and referrals to Tina about supports and the consideration of applying for a protection order following the September and December incidents.
Even if they were not trained in or directed towards conducting a holistic investigation, they were trained in the legislation and the legislative requirements. It should have been evident that it was important to record apparent acts of domestic violence to inform future actions.
I find that the responses by Sergeant Boyce to the incidents on 29 June and 15 September, and the response by Senior Constable Edbrooke to the incident on 29 December were inadequate.
I accept as submitted by Counsel Assisting and Counsel for Lili that no criticism should be made of Officers Noffke and Lambert in relation to their involvement in the incidents in 2010. They were junior officers and any
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decision about those investigations fell to Officers Boyce and Edbrooke as senior officers.
It is submitted on behalf of Lili that because of the inadequate response by Sergeant Boyce and Senior Constable Edbrooke to the incidents in 2010 and evidence of a continuing lack of insight into domestic and family violence by the long-standing and senior officers at Boonah Police, I should recommend all officers at Boonah Police Station take part in a targeted mentoring process with a suitable domestic and family violence specialist.
Whilst it was concerning that Sergeant Boyce did not readily accept Mr Sharman’s actions on 15 September to involve acts of domestic violence and Senior Constable Edbrooke was not sure that there was enough evidence (even today) to apply for a domestic violence order following the 29 December incident, I do not consider it necessary to make the specific recommendation.
As submitted by counsel for the Commissioner of Police, the targeting mentoring of those officers is unnecessary given the extent of domestic and family training still to be rolled out, including a further two-day holistic approach extension course and a five-day specialist course for all officers in charge (which would include Sergeant Boyce).
The officers did acknowledge that they have changed their approach and understanding in relation to policing domestic violence and today would at least take appropriate steps for Tina’s protection, for example: referrals and contacting the Vulnerable Persons Unit. It would be hoped that the officers through this inquest have gained more understanding of the nature of domestic violence and the ways in which a victim may behave.
ISSUE 3 - The adequacy of the QPS investigation into Tina’s disappearance
• The investigation was prompt and extensive.
• From the time Tina was reported missing she was considered a highrisk missing person.
• Substantial police resources were expended during the active investigation and search including covert strategies, forensic strategies, CCC hearings.
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• Following Mr Sharman’s death, the investigation refocused on locating Tina. A second round of CCC hearings were held and a reward was offered for information.
• The investigation remains open.
Whilst accepting that the investigation was adequate, Lili submits there are identified three areas where the investigation could have been improved:
A reward for information could have been offered earlier in the investigation.
Acting Detective Chief Superintendent (ADCS) Morrow reviewed the investigative material and was of the view that the investigation was “very adequate”103. He did, however, note that there may have been an opportunity at an earlier stage to offer a Government reward104. He did not know why it was not offered. I note, as pointed out by the Commissioner of Police in submissions, that no cogent evidence was received after the reward was offered following Mr Sharman’s death. I agree that it could be inferred that if no one was willing and able to provide evidence when Mr Sharman was deceased, it was highly unlikely that a reward would have had any positive impact on gathering evidence prior to his death.
Police did interview Lili after Tina was reported missing, but not again until
ADCS Morrow said that if there had been a need to re-interview Lili (or any other witness) then that should have been done.
I note that (as raised by the Commissioner in submissions) the operation running sheet105 contains an entry on 13 February 2012 that a further 93A statement should be taken from Lili following disclosures to Lina Williams .
An entry on 23 February 2012 notes that Lili declined to provide that further statement106.
A missing person’s report to the Coroner should have been made earlier than 2015.
ADCS Morrow agreed that the report should have been submitted when the initial investigation was winding down (April 2012). I accept that this amounted to a procedural failure but was not a failure in the investigation.
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ISSUE 4 - What improvements have been made by QPS into the investigation of domestic violence and the disappearance of women who are suspected or known victims of domestic and family violence (including by reference to the policies and procedures in place at the time of Tina’s disappearance)?
• Improvements in the investigation of domestic violence
Assistant Commissioner Jory has recently been appointed to the role of Executive Officer, Assistant Commissioner for the DFV and Vulnerable Persons Command.
Assistant Commissioner Jory explained that the DFV and VP Command was set up two years ago to provide strategic overlay and direction to QPS in relation to responses to domestic and family violence and vulnerable persons.
The submissions on behalf of the Commissioner of Police helpfully summarised the improvements in the investigation of domestic violence since 2010.
It is noted that the domestic and family violence landscape across government and non-government sectors has been “evolving heavily” since 2015. This began with the Queensland Government’s Special Task Force Domestic and Family Violence Report of “Not Now, Not Ever: Putting an End to Domestic and Family Violence in Queensland” and the Women’s Safety and Justice Task Force “Hear Her Voice” reports that recommended changes in policing of domestic and family violence.
This inquest follows findings and recommendations regarding police response to domestic and family violence and adequate training in that area in the Baxter/Clark and the Langham/Heley coronial inquests in 2020/2021.
107 Ex C22 and T4 - 6-26 Findings of the inquest into the death of Tina Louise Greer Page 42 of 68
Additionally, the report of the Independent Commission of Inquiry into Queensland Police Service Responses to Domestic and Family Violence in November 2022 contained a number of recommendations which are being adopted108.
The focus of training provided to QPS members on investigation of domestic and family violence has changed.
Acting Commissioner Jory gave evidence that in 2010-2012 training was in basic investigative skills and was around compliance with legislation, policy and procedures whereas today the recommendations from inquests and inquiries and the Commission of Inquiry have framed the current and future training in a holistic approach to investigating domestic and family violence109.
The submissions from the Commissioner of Police also adequately and appropriately summarise the training which has been and will be provided, as follows110: I. DFV training for recruits extended to 21 days from 15 May 2023, including face-to-face training as well as scenario-based training and assessments, theory-based learning, and lived experiences - this training to incorporate the “holistic approach” which is now being adopted as the appropriate model by the QPS, as opposed to the traditional model of “what’s important now”.
II. The three-day “DFV: the holistic approach” training program, incorporating the trauma-informed, and victim centric approach, rather than identifying a particular occurrence in isolation, being rolled out for all police up to the rank of Chief Superintendent.
III. A further two-day extension course to be delivered during the 20232024 QPS training calendar. This course is designed to reinforce the learnings of the three-day training program particularly in relation to coercive control and patterned behaviours, as well as educating members on implementing good practice in holistic investigations whilst prioritising victim safety and perpetrator accountability: IV. The five-day specialist training course - this is a mandatory course for all members performing DFV specialist roles. The course builds the capability of members in these roles in coordinating inter-agency responses, case management, understanding the roles and responsibilities, and problem-solving skills and reinforces the 108 Ex C22 paragraph 20
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adoption of a holistic approach building on the three-day holistic approach course. The course is co-facilitated by experts from the DFV support and service sector, researchers, academia and policing to ensure evidenced-based broad subject topics including, perpetrator tactics, targeted perpetrator intervention strategies, proactive case management, DFV related internal investigations, information sharing, complex investigations, the gendered nature of DFV, person most in need of protection, intimate partner sexual violence, vulnerable groups, including culturally and linguistic diverse communities and First Nations.
V. A further five-day face-to-face training course has been developed and aimed at officers in charge, district duty officers and shift supervisors to improve leadership responses and decision-making processes.
VI. A further five-day face-to-face specialist course is being developed for police communication centre staff and to police link staff.
It is also noted that co-responder models were not in place in 2010. These include the model whereby a DFV specialist police officer is embedded within an existing non-government DFV support service.
I find that the improvements made by QPS to investigation of domestic and family violence are appropriate and importantly further improvements in training are to be rolled out as outlined in Assistant Commissioner Jory’s evidence.
• Improvements in respect of missing persons investigation.
ADCS Morrow gave evidence in relation to current practices and procedures in relation to missing persons investigations.
The missing persons chapter of the QPS Operational Procedures Manual (OPM) has been updated. As part of the risk assessment, if the disappearance of the person is domestic violence related, the case it is automatically considered high risk.
It is noted that although that automatic assessment process was not in place at the time of Tina’s disappearance, she was categorised as highrisk because of the record of domestic and family violence perpetrated by Mr Sharman against her.
Counsel on behalf of Lili submits that the evidence supports a finding that there are two areas where recommendations could be made to improve QPS policies and procedures in relation to missing persons investigations.
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Policy and procedure regarding communication with family members of high-risk missing persons.
One of Lili’s concerns was that she did not receive updates and information from QPS during the investigation.
Lili was 13 at the time of Tina’s disappearance. Lili spoke to police and provided a s93A statement when Tina was reported missing. She said she received no further contact or updates from police until 2019. (As referred to above a request for a further s93A statement from Lili was apparently made in February 2012 but declined. It may have been that Lina Williams declined this request on behalf of Lili).
It was not until the inquest that Lili obtained an understanding of the extent of the investigation into Tina’s disappearance or that her disappearance was considered a homicide from the early stages.
Lili told the inquest of the trauma and stress that she has endured in not knowing what happened to her mother.
It is noted that Detective Inspector Hindmarsh said in evidence that when he was involved in the initial stages of the investigation, he provided updates to Phillip Greer.
I accept that depending on the age of the child, and family circumstances, it would usually be appropriate for police to update an adult family member rather than the child. There may be circumstances for example where the child is not in contact with the family (as in Lili’s case) where appropriate updates and information could be given to the child.
It appears from QPS material that one of the QPS investigators involved in Tina’s case (Officer Miers) was appointed as the victim liaison officer. Lili had no contact with him. It is not known how much contact he had with Phillip Greer.
The OPM in place at the time of Tina’s disappearance provided for updates to be given to the parents of the missing person at least weekly for the first two months, and thereafter as the officer considered necessary.
The requirement to make contact regularly, at a minimum on a weekly basis for the first two months, has been subsequently removed from the current OPM.
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ADCS Morrow was not aware of the reason for the change. He also accepted that the provision of contact with “the parents” was too narrow and that the use of the word “next of kin” was probably more appropriate.
It is submitted that I recommend that “the QPS amend subsection (iv) of the ongoing responsibilities of case officer at page 4 of chapter 12 of the OPM to read: “provide regular updates on the police investigation to the informant, family and next of kin of the missing person (where appropriate) and update the QPRIME occurrence accordingly. Contact with the informant, family and next of kin should be at least weekly for the first two months of the investigation and then maintain contact as the officer considers necessary.”
The Commissioner of Police supports the recommendation to the extent that the cohort of people considered by police for contacting and providing information should include the next of kin or family.
It is submitted that the decision as to who should be contacted be left with the case officer.
It is also submitted that it is not appropriate to prescribe weekly contact as there may be circumstances that arise which would mean that contact cannot take place, and suggests that the use of the word “regular” would suffice.
I find that it is appropriate to increase the cohort of persons receiving information to include “family and “next of kin””. The use of the words (where appropriate) gives the case officer discretion to decide to provide information or not. The case officer would have the option to decline to provide information in certain circumstances for example where it may be suspected that a family member is involved in the disappearance. Any concerns about circumstances preventing weekly contact can be addressed by including the words “if possible”. I note ADCS Morrow agreed in evidence that it was useful for officers to have some guidance about the frequency of contact with family111.
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probably has a large investigative workload) to a designated Family Liaison Officer.
The evidence of ADCS Morrow notes that while a Family Liaison Officer was sometimes involved with families in missing person cases there was no formal guidelines governing the appointment of a Family Liaison Officer.
The evidence of ADCS Morrow and Detective Inspector Hindmarsh was that Family Liaison Officers often get appointed in homicide cases, deaths in custody, and deaths in police operations112.
The Police Commissioner generally accepts the recommendation. The submissions on her behalf note that for all missing persons investigations the case officer is also the Family Liaison Officer. It is submitted on behalf of the Commissioner that I could consider recommending that “Family Liaison Officer” be included in the definition of a case officer in a missing persons investigation.
I do not think that would provide a solution to the issue raised on behalf of Lili , namely that the case officer is usually the investigating officer and may not have the capacity to also be the Family Liaison Officer. I note the OPM for Homicide Investigations provides for the consideration of the appointment of a Family Liaison Officer to assist the victim’s family113.
I consider Chapter 12 of the OPM should be updated to similarly provide that in the case of a high-risk missing persons investigation, consideration be given to appointing a Family Liaison Officer for the missing persons family. The update should also outline the responsibilities of the Family Liaison Officer and provide guidance on the frequency of contact with the family. This should be no less than the frequency of contact by the case officer in other missing persons investigations.
Counsel on behalf of Lili submitted improvements could also be made in the practices and procedures in relation to QPS reporting cases to the National Public Register for long-term missing persons.
There is currently no QPS policy on the requirement to submit details of missing persons to the National Register. It was submitted on behalf of Lili
112 T3 - 110-112 113 QPS OPM 2.6.2(iii) Findings of the inquest into the death of Tina Louise Greer Page 47 of 68
that Chapter 12 of the OPM should be updated to provide guidance on the reporting.
It is appropriate and the recommendation should be made that “the QPS update Chapter 12 of the OPM to provide guidance for officers by outlining the circumstances in which QPS officers are required to report a missing persons case to the National Public Register of long-term missing persons.”
It is noted that Tina is listed on the National Register, but that that is because Lili reported her mother’s case to the register in January 2023.
ISSUE 5 - The adequacy of the response by Salvation Army Gold Coast Recovery Services, Fairhaven to disclosure of domestic and family violence by Tina.
Fairhaven is operated by the Trustee for the Salvation Army (QLD) Property Trust (TSA). It offers alcohol and other drug services, including withdrawal management and residential rehabilitation114.
Representatives of TSA gave evidence that the organisation acknowledges that domestic and family violence is often experienced by people accessing alcohol and other drug services115.
• In 2006 for seven months 116
• In 2007 for five months117
• Between 5 July 2011 and 13 July 2011 to the withdrawal program 118
• Between 31 August 2011 and 8 September 2011 to the withdrawal program.
Tina’s assessment and case extract exhibited to the statement of Harriet Crisp120 (the state manager of Alcohol and Other Drugs (AOD) TSA).
It is apparent from the material in evidence that staff (particularly Ms Gilmore) suspected Tina had been subjected to domestic and family violence.
Ms Gilmore died in 2014 and as such, could not provide any further clarification of her knowledge of and response to Tina’s experience of domestic and family violence.
• In July 2011 Tina disclosed that she was in an unhealthy, abusive relationship and that she had a long-range Plan B to get some money saved and a job so that she could be financially independent. She was fearful of retaliation by her partner if she leaves him 121.
• Tina was observed during a phone conversation with Mr Sharman. It was recorded that she was ‘visibly shaking and twisting her hair tightly throughout their conversation’, and she, ‘had to reassure him several times that she loved him and was not going to leave him’122.
• Tina told Ms Gilmore she had an escape plan in place where her girlfriend was going to help her get away 123.
• Ms Gilmore (in the context of discussions with Tina about Les) told Tina she should go to the police to help her get away. Tina told her she couldn't trust the police to protect her from him124.
• Tina’s discharge notes in September 2011 the record that: “Tina is in an abusive relationship and doesn’t have the skills or selfconfidence to break away”125.
120 Ex B55 121 Ex B19 122 Ex B19 123 Ex B19 124 Ex B19 125 Ex B55.16 – 440 Findings of the inquest into the death of Tina Louise Greer Page 49 of 68
There is evidence that Ms Gilmore did assist Tina in contacting Centrelink and referrals to employment agencies126.
Counsel for TSA submits that because I cannot clarify with Ms Gilmore that the records in evidence represent the totality of Fairhaven's interactions with Tina, I cannot conclude that domestic and family violence referrals, counselling and discussions about same were not had with Tina.
I disagree. I accept the submission of Counsel Assisting that the records of Fairhaven as they relate to other information about Tina and the treatment, she was provided with at Fairhaven are fulsome. The referrals to other support services were recorded. Ms Gilmore, in her statement, says she advised Tina to go to the police for help, but that Tina didn't want to.
I find that Tina was not provided with specialised counselling or referrals to specialist domestic violence services.
The report noted the recorded suspicions regarding Tina being subject to domestic and family violence, and the report writer notes, “Despite these observations, there is no evidence of support being offered to Tina whilst on site or that attempts were made to link her with appropriate referral of specialist services. Given her unwillingness to engage with police officers, these open disclosures represent significant missed opportunities for intervention, and may have assisted her to separate from Les”127.
Evidence was given at the inquest by Miss Huia Prichard, a communitybased case manager with Fairhaven. She was at Fairhaven in a receptionist role in 2011 when Tina was there. She became a case manager about eight years ago. Her evidence was that during her time at Fairhaven, she had not been provided with any domestic and family violence training. She was aware that a training program was being rolled out in the near future.
In those circumstances, I am able to infer that Ms Gilmore as at 2011 had not received and training from Fairhaven in domestic and family violence.
I accept the submission of Counsel Assisting, having regard to the correlation between domestic and family violence and alcohol and drug 126 Ex B55.16 - 419-420 127 Ex B17 - 104 Findings of the inquest into the death of Tina Louise Greer Page 50 of 68
addiction, it was incumbent upon Fairhaven to equip and train staff with the skills to assist victims of domestic and family violence who disclose their experiences whilst recovering during drug and alcohol treatment.
ISSUE 6 - What improvements have been made by Salvation Army Gold Coast Recovery Services, Fairhaven to help support victims of domestic and family violence engaged with Salvation Army recovery services.
• In 2018, TSA introduced four separate streams - AOD, youth, homelessness, and family violence.
• The development of the family violence stream was a recognition of the need to prioritise that service129.
• All potential clients of Fairhaven undergo an initial assessment and during that process the person is asked whether there are any concerns about family violence130.
• Following the initial assessment, if the client is assessed as suitable for the program, they undergo a further assessment process whereby the case manager uses a comprehensive assessment template which includes a risk assessment to identify domestic violence concerns131.
128 T6 - 9; Submission on behalf of Lili Greer page 39
129 T2 - 43 130 Ex B54 131 Ex B54 Findings of the inquest into the death of Tina Louise Greer Page 51 of 68
• staff have not been provided with specialist domestic training prior to completing the assessment.
The training package was still being developed.
• Following the comprehensive assessment clinical review meetings concerning clients are held regularly.
• Strategies have been adopted to help the client if domestic and family violence concerns are identified132
• There are discussions between staff at meetings concerning risk assessment for domestic and family violence133.
• Referrals are made to domestic violence and family support services with the client's permission134.
• External service providers, for example, DV Connect can come to TSA centres to provide information sessions at no charge. However the evidence was that to date they have not attended regularly at Fairhaven because of the distance required to travel135.
• A specialist from the Family Violence stream has recently attended Fairhaven to provide information sessions to staff and clients136. There is capacity for specialists to provide face-to-face training for AOD staff, but this is limited by lack of available funding137.
• A best practice guideline for supporting victims of domestic and family violence within the AOD services was being developed.
When asked about any training about domestic and family violence, Ms Prichard gave evidence that she was aware that some training was coming “to bring us up to speed”. She said, “we have had e-learning that we have been able to look at, but nothing specific - that would really give us what we need to give us greater depth of knowledge in that area”138.
Ms Crisp gave evidence that staff received some minor training when the comprehensive assessment process was introduced but acknowledged that it could be improved139.
Despite the lack of formal training, Mr Bosworth was: “confident that every staff member is quite aware… of the threat of domestic and family violence and the vulnerability of people engaged in the AOD stream... They are very 132 Ex B54 - 29; T2 - 17
133 T2 - 59 134 T2 - 59 135 T2 - 49 136 T2 - 20 137 T2 - 21; T2 - 65 138 T2 - 54-62 139 T2 - 50 Findings of the inquest into the death of Tina Louise Greer Page 52 of 68
clear on how to respond in the event that they hear that someone is at risk of currently having that perpetrated against them”140.
He believed that the correlation between domestic and family violence and AOD abuse would be “common knowledge”.
Ms Prichard said she had personal experience of domestic and family violence, which informed her techniques for interacting with clients141.
Submissions on behalf of TSA provided on 10 November 2023 provide an update on developments since the Inquest:
• The best practice guideline has been finalised and effective as of 25 October 2023142.
• Training on the guideline was provided to Fairhaven staff on the 30th of October 2023143.
• Further training sessions were to be conducted in November.
• Training is in process of being uploaded to TSA’s online training platform for future access. Completion of this training is mandatory144.
Counsel Assisting and Counsel for Lili have submitted that I make a number of recommendations based on their submissions that little improvement has been undertaken by TSA to support victims of domestic and family violence engaged with their services.
Counsel Assisting submits that I recommend that TSA immediately prioritise the training of all staff at Fairhaven in domestic and family violence, and, in particular, prioritise training on how to support victims of domestic and family violence engaged with the services.
At the time of the inquest, minimal formal training had been provided for staff on recognising domestic and family violence and supporting victims.
It would seem that in the months following the inquest, progress has now been made in finalising the practice guideline and providing mandatory training on the guideline to all staff.
140 T2 - 26 141 Day 2, 56 142 Submissions on behalf of TAS page 18 143 Submissions on behalf of TAS page 18 144 Submissions page 18 Findings of the inquest into the death of Tina Louise Greer Page 53 of 68
• TSA engage specialist domestic and family violence staff from the DV stream to provide onsite support to clients at Fairhaven.
TSA acknowledge such a resource would enhance their ability to assist AOD clients who are victims of domestic violence. In Victoria, the AOD section has DFV advisors. The restriction on having the same service in Queensland apparently relates to funding145.
TSA says it will work towards the introduction of that role in Queensland given the recognition of the correlation between domestic and family violence and alcohol and other drug abuse. In the circumstances, it is not necessary to make a specific recommendation. Given the general recognition of the importance of the need to address the impact of domestic and family violence in our society, I would hope the funding will be made available.
• TSA commence using the Family Violence Multi-Agency comprehensive risk assessment tool (MARAM) at Fairhaven.
• TSA conduct an evaluation after 12 months to assess whether the changes can be implemented organisation wide.
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In light of the very recent, in my view overdue, developments in staff training and the development of the guidelines and procedures for review and continual training, formal recommendations with respect to issue 6 are not necessary.
It is hoped, being part of this inquest has given TSA the opportunity to review and reflect on the importance of supporting victims of domestic and family violence presenting with substance misuse issues, and to be able to do that it is vital to ensure that their staff are trained in the best practices to be able to provide that support.
ISSUE 7 - The adequacy of services and support provided to victims of DFV by the Department of Child Safety when assessing whether a child is at risk of harm.
b. On 16 November 2005, a notified concern was received. It was reported that Lili was observed by a family member to have blood coming from her mouth, and she disclosed that Tina had punched her in the mouth and the chest.
c. In December 2006, Tina reported that she was exposed as a child to domestic and family violence between her parents.
d. In 2008, Tina spoke about her experience of violence perpetrated by Lili’s biological father and indicated that she did not want Lili to have contact with him due to, amongst other things, his violent behaviour towards herself and Lili previously. The paternal 147 Ex B52 Daniel Conder, paragraph 18 (e) Findings of the inquest into the death of Tina Louise Greer Page 55 of 68
grandfather advised the department that Lili’s father was subject to a domestic violence order. A copy of this order was not sought by the Department.
e. In September 2010, Ms Rosemary Greer, Lili’s step-grandmother reported that Mr Sharman was a member of a bikie gang and a violent man, that he had shot an empty gun next to Tina Greer’s head, that he had hit her with a stool, that Mr Sharman had held Tina Greer against her will, and that the violence had occurred in the presence of Lili. She also reported that Mr Sharman had a “way of making things happen to people he knows”.
From the history provided, there were five reports which involved some level of domestic and family violence which were received by Child Safety and have been documented in the records provided.
The evidence indicates the Department of Child Safety, had an opportunity to work with Ms Greer to address the child protection concerns in the period of 2005 to 2007. During this time, the Department was aware that Ms Greer had been in a domestically violent relationship and that Lilly had been exposed to same. The evidence during the inquest given by Dr Crawford was that the child protection assessment’s primary focus was working with Ms Greer to support her to address her substance abuse issues.
The records provided by the Department indicate that in or around September 2005, the Department became aware that Tina Greer had a partner, Daniel Conder, who was violent to Tina Greer and the allegations were that he hit her148. Dr Crawford’s evidence from reviewing those documents was that in an interview that the Department undertook with Lili, she said that she had witnessed the hitting between her mother [Tina Greer] and Mr Conder. This resulted in an investigation and assessment which resulted in an unsubstantiated outcome. The Department says this may have been due to the fact that both Tina and Mr Condor denied any violence149. It is conceded by the Department in their submissions that if the notification was received today there may have been different outcome.
Following the September 2005 investigation outcome, the Department received further concerns in November 2005, that Tina Greer had punched Lili in the mouth, whilst intoxicated. This incident was not assessed as a domestic violence incident by the Department. It is noted that Tina Greer was later charged with assault occasioning bodily harm.
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This incident is what led the Department to seek and be granted a Temporary Assessment Order150 on 14 November 2005. This was when Lili first entered the child protection system. Dr Crawford’s evidence was that the main concern at the time of seeking the Temporary Assessment Order was Tina Greer’s level of drinking, her instability of living arrangements and her lack of engagement with supports. There was no reference to domestic and family violence in that application151.
Following the Temporary Assessment order, other orders followed including a short-term order on 14 March 2006.
During the period between September 2005 and 14 March 2006, the Department had knowledge of alleged domestic violence incidents involving Tina and her previous partners. The Department’s only focus was on Tina’s alcohol use and falls short of what the Department should have considered as child protection concerns to be addressed by Tina. Domestic violence was present in Tina’s life and should have been a concern for the Department. This is particularly so when all decision-making regarding Lili’s safety, was within the Chief Executive’s power between 2005 and 14 March 2008, but particularly more so when the goal of Departmental intervention was reunification between 2006 and 2007.
Additionally, the Department’s records note that in December 2006, Tina Greer made disclosures that she was exposed to domestic violence as a child which was perpetrated by her father. This was also consistent with the evidence of Dr Crawford152.
It is accepted that in August 2009, long-term guardianship of Lili was granted to her maternal grandfather, Mr Greer and his partner Mrs Greer.
The Department having no decision-making authority over Lili during this time, by virtue of the guardianship order that was in place, was not responsible for contact decisions between Lili and Tina Greer. The responsibility sat with her guardians which were Mr and Mrs Greer.
150 Section 27 Child Protection Act 1999
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The evidence given by Dr Crawford was that once this information was received by the Department, there were no supports provided to the Greers [guardians] given they were the persons allowing contact, to make sure that Lili wasn’t exposed to domestic violence.
The Department says that the fact that Mrs Rosemary Greer made the report about Mr Sharman was evidence to the Department that Phillip and Rosemary Greer were acting protectively towards Lili153.
The Department submit that no doubt following this disclosure, a discussion would have followed between Child Safety and the Greers to the effect that Lili should not see her mother because of the DV concerns, or if she did, Lili’s safety must be ensured154. I cannot be satisfied that discussion took place. There is no evidence of it. Further any concern that the Department had about contact with Tina because of exposure to domestic violence was apparently not front of mind for the Department when Lili ran away from the Greers.
The evidence given during the Inquest suggests that at the date that Mrs Greer reported the information to the Department in relation to Les Sharman in September 2010, the Department had knowledge of the following allegations: a. There was domestic and family violence between Tina Greer and Lili’s biological father, hence the reason why Tina Greer did not wish Lili to have contact with him.
b. There was domestic violence between Tina Greer and her previous partner Mr Conder, to which Lili was exposed.
c. Tina Greer made disclosures of being exposed to domestic violence as a child perpetrated by her father Mr Greer; and d. Tina Greer’s boyfriend, Les Sharman, was a violent man. Mr Sharman had shot an empty gun next to Tina’s head and had hit her over the head with a stool and held her against her will and that also that this violence was or had occurred in front of Lili.
153 Submissions, paragraph 37 154 Submissions, paragraph 37 Findings of the inquest into the death of Tina Louise Greer Page 58 of 68
When Mr and Mrs Greer expressed their desire to revoke the guardianship order in December 2011, there appears to be no pro-active approach by the Department to ensure that Lili had someone making guardianship decisions for her, one of those being where Lili was to reside, who she had contact with and that she was not at a further risk of harm from domestic and family violence as a result of exposure to same.
At the time that Lili self-placed with Tina, there was no evidence from the Department that there had been an updated assessment for Tina to suggest that the child protection concerns had changed, that being that she was not a parent willing and able to protect Lili from harm in the foreseeable future.
The Department’s written submissions maintain that at this time, domestic and family violence was not a concern. The Department’s submissions remain that at the time they had contact with Tina, they only focused on her substance abuse namely alcohol.
It is observed that a part of the Department’s own material, domestic violence informed child protection practice handout155, which notes that “parenting problems rarely occur in isolation. Instead, they tend to be part of a complex and inter-related group of problems” and acknowledges that “the co-occurrence of multiple and complex parenting problems— particularly parental substance misuse, domestic violence and parental mental health problems—are the norm for Australian child protection clients. Including Alcohol and other drugs may also be used by victims of domestic violence to relieve the physical and emotional pain of abuse”.
This article is dated 2010, and so was available to the Department at least at the time that the Department commenced work with Tina in 2011, and therefore it would appear that focusing only on Tina’s alcohol use was not only a missed opportunity, but also not in line with the research relied upon by the Department and its own domestic violence informed child protection practice handout156.
Lili was self-placed with her mother from September 2011. It is not clear when the Department became aware of this. The Department in submissions say that information gathered by police indicated Lili was living with her Uncle Peter after she left the Greers, and that he was known to 155 Exhibit B52.11 156 Exhibit B52.11 Findings of the inquest into the death of Tina Louise Greer Page 59 of 68
the Department as Lili had stayed with him previously. This information came from a statement Peter had given to Police in September 2011157.
However, in Philip Greer’s statement given to police on 23 September, he said “Tina and Les Sharman have Lili with them.” He said he approached ‘Docs’ about this and wanting to take Lili into their custody again. He was told this couldn’t happen because Lili had made an assault complaint against them158. What is clear is that the Department was aware of Lili’s whereabouts by the time of the home visits in December 2011 and 13 January 2012.
During the time that Lili was living with Tina, there was no independent evidence that Tina had addressed the previously identified child protection concerns. Dr Crawford’s evidence was that no parental strengths and needs assessment was undertaken and no household safety assessment was undertaken159.
The record of interview on 7 December 2011, indicated160 Mr Greer disclosed that that Tina Greer lies, that she was secretive, and there was reference made to her boyfriend “Les”. Mr Greer further expressed concerns that Tina was unstable, and it is recorded that “Police know where both of Tina’s boyfriend’s houses are”. The Department were put on notice that Mr Sharman was still part of Tina’s life.
The record of interview form also notes that the matter was not referred to the Suspected Child Abuse and Neglect System (SCAN). The only explanation referred to was that the matter did not meet the referral criteria.
The purpose of the SCAN system is noted in the Child Protection Act 1999 at Section 159J. The purpose is primarily to allow information sharing between agencies such as but not limited to Queensland Police Service, but it also notes that: The purpose is to be achieved by facilitating— a) the sharing of information under part 4 between members of the system; and 157 Ex C100 158 Ex C100
159 T2 - 89 160 Ex B64 Findings of the inquest into the death of Tina Louise Greer Page 60 of 68
b) the planning and coordinating of actions to assess and respond to children’s protection needs; and c) a holistic and culturally responsive assessment of children’s protection needs’161.
b. Ongoing intervention - Child Safety is responsible for ongoing intervention through a support service case, intervention with parental agreement or a child protection order.
It is unclear why this matter was not referred to SCAN given that in accordance with the Department’s practice manual, the criteria could have been met given that there was a notification and ongoing investigation and there was ongoing intervention with an IPA.
Had the Department referred the matter to SCAN, information could have been obtained from QPS to assist the Department in assessing the risk to Lili.
In accordance with the Child Safety Practice Manual – Investigate and Assess162 chapter, investigation and assessment involve a process of investigating whether the child has experienced, is experiencing, or is at risk of experiencing significant harm, and assessing whether the child is in need of protection163.
The Statutory obligations of the Department is to assess a child’s need for protection and/or take actions considered appropriate. In order to ensure this is done, the practice manual notes that all relevant information should be gathered including and not limited to: a. the presence and impact of risk factors, such as domestic and family violence; problematic alcohol and drug use, mental illness and parental childhood abuse 161 my emphasis 162 Ex B52.6 163 my emphasis Findings of the inquest into the death of Tina Louise Greer Page 61 of 68
b. information needed to complete the safety assessment, and if required, an immediate safety plan; and c. any complicating factors affecting the family.
Whilst the Department undertook a safety assessment for Philip and Rosemary Greer, as a result of a notification in regards of their care of Lili, the Department should have also undertaken a safety assessment for Lili and Tina Greer’s household when the decision was made for Lili to remain in Tina’s care. This was not done. The purpose of the safety assessment is to ensure that Departmental officers consider a range of family and environmental circumstances that impact upon a child’s safety.
Additionally, it is noted that in accordance with the practice manual164 in order to assess the likelihood of the child suffering harm in the future, the Department is to consider: a. the interaction of risk and protective factors identified as present within the family.
b. past patterns of abuse or neglect experienced by the child.
c. attitudes and beliefs of the parent.
d. parental ability and willingness to protect the child; and e. demonstrated acts of protection by a parent.
Having reviewed what is required in the practice manual, had the Department undertaken a holistic assessment, including the information contained in their own documents, the Department may have placed some consideration on the following matters: a. Tina’s lack of supports, previous lack of consistent engagement with services and a history of not addressing previous case plan goals; and b. Past patterns of abuse experience in her family and two previously reported domestically violent relationships and the further reports about Les Sharman.
At the time of the home visits, Departmental officers did not appear to have challenged the information provided by Tina regarding her use of alcohol and being in a relationship. The Department did not independently verify the information being told to them by Tina and Lili, to sufficiently assess any risk to Lili of exposure to domestic and family violence. As noted, the 164 Ex B52.6 Findings of the inquest into the death of Tina Louise Greer Page 62 of 68
Department was aware Mr Sharman was still involved with Tina through their discussions with the Greers on 7 December.
The information about Tina was based on self-reporting. The Department’s Practice Guide indicates that from the information gathered, an analysis needs to be undertaken including considering whether information that has been provided by the person they are worried about has been verified and if not, should make all attempts to check the information for validity. This was not done.
The Department appears to have placed a high evidentiary value on Tina’s self-reporting, despite the Department’s last assessment that she was not a parent willing and able in the foreseeable future to protect Lili from harm165.
The Department placed much weight on the fact that Tina had interactions with staff members in respect to Lili’s needs including requesting financial assistance. This respectfully, should perhaps have raised some concerns about Tina’s capacity to meet Lili’s needs. There is no reference in the material about what other information was considered by the child safety officers at the time to verify the information or not, and what if any attempts were made to check for validity.
Despite the Department having access to the information sharing provisions of the Act166, no request for information to QPS was made to validate Tina’s claims. Had they done so, the Department would have become aware of those incidents in 2010. In particular, one on the 15 September 2009 and the 29 of December 2011 as outlined in the information provided by QPS167 that recorded the following incidents: a. 15/09/2010 - incident between Les Sharman and Tina – alleged that he had attempted to run her down.
b. 29/12/2010 – incident between Les Sharman and Tina – it was reported that a woman was seen running down the road, screaming and blood on her face.
cycle of domestic and family violence that they were aware or should have been aware that she had been in during Lili’s life, and this posed an unmitigated risk to Lili. The Department did not sufficiently, in that period, satisfy itself that Lili was not in need of protection from exposure to domestic and family violence.
Domestic and Family Violence Training
In respect of training provided by the Department, it is accepted that since the time of Tina’s disappearance, the Department has implemented many changes including a range of training for staff to support their practice in working with families that are impacted with domestic and family violence.
Dr Crawford’s evidence was that new child safety staff are to complete mandatory training in a self-paced 150-minute eLearning course168. She also confirmed there is non-mandatory training related to domestic and family violence practice available for all staff169.
It is noted that the Department of Child Safety, Seniors and Disability Services has accepted the recommendations to review its current training policies in regard to the non-mandatory training for all staff and consider this training to be mandatory, not just mandatory to new staff.
In the written submissions, the Department accepts that Counsel Assisting’s recommendation that all staff should be required to undertake mandatory face-to-face training on domestic and family violence informed practice.
In the circumstances, it is appropriate to recommend that the Department of Child Safety, Seniors and Disability Services require all staff to complete mandatory face-to-face training on domestic and family violence informed practice.
ISSUE 8 - Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances 168 Ex B52 169 Ex B52 Findings of the inquest into the death of Tina Louise Greer Page 64 of 68
or otherwise contribute to public health and safety and the administration of justice.
Section 46 of the Coroners Act enables me to comment and make recommendations in relation to this issue.
The inquest enabled the revelation of the full extent of the police investigation into Tina’s disappearance and suspected homicide.
The investigation was thorough, but unfortunately, the exact cause and place of Tina’s death and her whereabouts cannot be determined. This is principally due to Mr Sharman's ability to conceal evidence and avoid police.
Tina Greer had been the victim of domestic violence at the hands of Les Sharman, and he ultimately took her life.
I have found there were inadequate responses by local police, Fairhaven, and Child Safety to the evidence that Tina was a victim of domestic violence. This does not mean that I am able to find that more appropriate responses in providing support and referrals would have prevented Tina’s death.
Despite the passage of time since Tina’s disappearance and the developments in agency responses to domestic violence during that period, the inquest has provided an opportunity to recognize, emphasise and where a gap exists, make recommendations for training of various agencies’ staff in the recognition of and support for victims of domestic violence. This may prevent deaths occurring in circumstances similar to Tina’s in the future.
Further, recommendations can be made in the policy and procedures adopted by police in the investigation of missing persons and liaising with the person’s family. This may assist in the administration of justice and ensure family members (like Lili) are better informed about the investigation into their loved one’s disappearance.
I have referred throughout these findings to Counsel Assisting and other parties’ submissions on possible recommendations.
As indicated in these reasons, I make the following recommendations.
Findings of the inquest into the death of Tina Louise Greer Page 65 of 68
QPS amend Chapter 12.4 section (iv) page 4 of the OPM “ongoing responsibilities of case officer” to read ‘provide regular updates on the police investigation to the informant, family and next of kin of the missing person (where appropriate) and update the QPRIME occurrence accordingly. Contact with the informant, family and next of kin should, if possible, be at least weekly for the first two months of the investigation, and then maintain contact as the officer considers necessary.’
QPS update Chapter 12 of the OPM to provide that in the case of a highrisk missing person investigation consideration be given to appointing a Family Liaison Officer for the missing persons family. The update should also outline the responsibilities of the Family Liaison Officer and provide guidance on the frequency of contact with the family. This frequency of contact should be no less than the frequency of contact by the case officer in other missing persons investigations.
QPS update Chapter 12 of the OPM to provide guidance for officers by outlining the circumstances in which QPS officers are required to report a missing persons case to the National Public Register of Long Term Missing Persons
The Department of Child Safety, Seniors and Disability Services require all staff to complete mandatory face-to-face training on domestic and family violence informed practice.
I again wish to acknowledge the determination and persistence of Tina's daughter, Lili, in advocating for her mother and other victims of domestic and family violence. Although a number of Lili's questions in relation to her mother’s disappearance could not be answered in this inquest, I hope she has obtained some benefit and comfort from the information disclosed and the outcomes of the inquest.
FINDINGS REQUIRED BY s. 45 Identity of the deceased – Tina Louise Greer How she died – Unknown Place of death – Unknown Findings of the inquest into the death of Tina Louise Greer Page 66 of 68
Date of death– On or about 18 January 2012 Cause of death – Unknown
Kerrie O’Callaghan Coroner
BRISBANE 21 December 2023 Findings of the inquest into the death of Tina Louise Greer Page 67 of 68
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