Inquest into the death of Peter Owen Pilkington

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Peter Owen Pilkington TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO: 2021/5545 DELIVERED ON: 8 October 2025

DELIVERED AT: BRISBANE HEARING DATES: 3 June 2024, written submissions November 2024 - January 2025.

FINDINGS OF: T Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, avoiding being placed in custody, police shooting, siege, gel blaster, replica of a firearm, victim precipitated homicide, subject precipitated homicide, mental health, involvement of negotiators and SERT police

REPRESENTATION: Counsel Assisting: Ms J Pietzner-Hagan Commissioner of Police: Mr M Nicolson instructed by QPS Legal Unit SERT Operative 146: Ms J Jessop, Gilshenan and Luton Lawyers

Contents Findings of the inquest into the death of Peter Owen Pilkington Page 2 of 38

Introduction [1] Peter Owen Pilkington was aged 48 years when he died at the Princess Alexandra Hospital (PAH) at Woolloongabba on 6 December 2021 from a single gunshot wound. Peter had been transported by the Queensland Ambulance Service (QAS) to the PAH after he was shot by a member of the Queensland Police Service (QPS) Special Emergency Response Team (SERT) during a protracted siege, involving hostages at an office building.

[2] Peter was born in NSW and was one of five siblings. His younger brother, Shannon, provided a statement to the coronial investigation which was tendered in the coronial brief.1 [3] Peter was previously married. However, at the time of his death he was separated from the mother of his children. Peter was the father of three daughters. Sadly, his 15-month-old daughter Mikayla, passed away in November 2004.2 This loss had a profound and long-lasting effect on Peter, and compounded the trauma he experienced during his life.

[4] Peter and Shannon’s childhood and upbringing were characterised by domestic and family violence. As young children, both Peter and Shannon were placed in the care of the State. There they suffered years of significant and devastating sexual abuse by teachers and carers.3 As a survivor of sexual abuse, Peter’s education was erratic. He experienced life-long traumatic mental health implications that significantly inhibited his day-to-day functioning. Shannon reported that Peter started using cannabis and alcohol at a young age and progressed to methamphetamine, heroin, and ecstasy. Peter’s ex-wife also reported concerns about Peter’s use of prescription pain medications commencing around 2008.4 [5] As an adult, Peter converted to Islam during a period of imprisonment and adopted the name Junduallah.5 Due to concerns of possible radicalised behaviour (ideological extremism and politico-religious) through online support of ISIS and support for other violent extremist groups,6 Peter was subject to the QPS Engagement and Diversion Program . Engagement in the program was completely voluntary and Peter had about ten direct engagements.

[6] Information contained in the brief of evidence notes Peter had online images of himself holding firearms that were of concern to police.7 On 19 May 2020, Peter allegedly made threats to shoot up a mosque. Historically, Peter was considered to have prescribed to white supremacist and neo-Nazi ideology.

[7] Upon release from prison Peter faced a period of homelessness. He appealed to members of the Muslim community who supported him by providing 1 Exhibit B7. Exhibit B7.1.

2 Exhibit D7.6. Exhibit D7.4, 2. Peter had a tattoo of his daughter’s name on the inside of his right forearm.

3 Exhibit C29, 4 – 5.

4 Exhibit A6, 80.

5 Exhibit D7.4, 2.

6 Exhibit C30.

7 Exhibit C29.

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accommodation and other support.8 Peter had a recorded criminal history in NSW and Qld, primarily concerning offences of possession of dangerous drugs, property offences, assault and failing to appear.9 [8] Detective Sergeant Adam Edwards, of the Internal Investigations Group (IIG), Ethical Standards Command (ESC) led the coronial investigation. The coronial report dated 10 December 2022 was tendered at the Inquest.

The Inquest [9] Peter’s death was a reportable death under section 8(3)(g) of the Coroners Act 2003 (Qld) (the Act) as a death in custody.10 The Act required that an inquest be held.11 The primary purpose of an inquest is to inform the family and the public about the matters required by s 45 of the Act, including when, where, and how the person died and what caused the death. Section 46 of the Act empowers a coroner to comment on anything connected with the death related to public health or safety, the administration of justice, or ways to prevent deaths from happening in similar circumstances in the future.

[10] A coroner is not able to include in the findings or any comments or recommendations any statement that a person is, or may be, guilty of an offence or civilly liable. Where a coroner suspects that an indictable offence has been committed, a referral must be made to the Director of Public Prosecutions. Information about a person’s conduct in a profession can be given to the disciplinary body for that profession if the coroner believes the information might cause the body to inquire into or take steps in relation to the conduct.

[11] Following a pre-inquest conference on 12 March 2024, the Inquest was held in Brisbane on 3 June 2024. At the commencement of the Inquest, all the statements, records of interview, photographs and videos obtained during the coronial investigation were tendered. Oral evidence was heard from five witnesses: a. Detective Sergeant Adam Edwards; b. SERT Operative 146; c. Senior Sergeant Tracy Bailey; d. Sergeant Brett Meara; and e. Associate Professor Amber McKinley.

[12] During the Inquest a non-publication order was made and remains in force.12 8 Exhibit C31.

9 Exhibit C28. Exhibit C25.

10 Defined in section 10 of the Coroners Act 2003 (Qld).

11 S 27(1)(a)(i) The Coroners Act 2003 (Qld).

12 3 June 2024, T1 – 3, LL32 – T1 – 6, LL 20.

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[13] The issues for inquest were settled as:

1. The findings required by s. 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death; and:

2. Consideration of the circumstances leading up to the death including: a. Peter’s mental health treatment and care and any co-occurring substance use disorder.

b. Consideration of subject precipitated homicide, and the effect, if any, on first responders.

c. Consideration of the regulation of gel blasters (such as that used by Peter during the siege) in Queensland.

3. Whether the Police Officers involved acted in accordance with the Queensland Police Service (QPS) policies and procedures then in force, and whether said actions were appropriate.

4. Whether any changes to procedures or policies could reduce the likelihood of death occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.

[14] Following the Inquest, written submissions were received between November 2024 and January 2025. I am satisfied there is sufficient evidence to make the findings required by s 45 of the Act.

The Evidence [15] Prior to his death, Peter received a Disability Support Pension (DSP) and had a National Disability Insurance Scheme (NDIS) plan.13 In November 2020, Peter was assessed by an Occupational Therapist and found to have a functional impairment due to the impacts of his disability, and health conditions that were listed as: a. autism spectrum disorder (ASD); b. post-traumatic stress disorder (PTSD) arising from sexual abuse perpetrated against him; c. obsession-compulsive disorder (OCD); and d. bipolar disorder (BPD).

[16] Peter received approximately five hours of daily support with an additional two to three hours in the evenings on two days per week. Peter required assistance through verbal prompting as reminders to complete personal care tasks and partial physical assistance for domestic tasks. He also required a high degree of advocacy and support for navigating government systems. 14 13 Exhibit D7.3.

14 Exhibit D7.4, 1 – 3.

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[17] Peter was supported in the community by a NDIS service provider located in Stretton, Unique Oz Care. Peter’s support worker, Jamshid Jamil first met Peter at the Slacks Creek Mosque during morning prayers some years prior.

[18] Mr Jamil stated that on the day he met Peter, he had led the prayers and spoken about a verse from the Quran about how to look after orphans and poor people.

When Mr Jamil finished speaking, Peter approached him and told him he was homeless and asked for help.15 Mr Jamil allowed Peter to stay with him and his family for approximately four months.

[19] During his stay Peter requested money from Mr Jamil and his brother, and friends at the Mosque.16 Mr Jamil warned Peter not to ask for money from his friends or brother as he felt embarrassed, and they expected that Mr Jamil would repay the money. When Mr Jamil asked Peter to repay the money, Peter became aggressive and used abusive language towards him.

[20] Peter was then asked to leave Mr Jamil’s home. He did so immediately, but left his possessions behind, eventually collecting them months later.17 Mr Jamil asked Peter to repay the borrowed money before he collected his possessions. Peter called Police who considered it a civil matter.

[21] Peter allegedly became more aggressive and told Mr Jamil that he hated Muslims and would burn Qurans. He stated he would get a gun and shoot every Muslim in the Mosque. He told Mr Jamil he would put him in trouble with ASIO. Mr Jamil told Peter that ASIO were not stupid and told him to leave the house, which Peter did. Mr Jamil did not report this information to police as he formed the view that Peter was simply angry about not being given money.18 [22] Peter reportedly apologised to Mr Jamil in June 2020. Mr Jamil then started working with Peter as his NDIS support worker after the director of Unique Oz Care told Mr Jamil that Peter was eligible for NDIS support and was remorseful about his actions towards Mr Jamil. Subsequently, Mr Jamil assisted Peter with cleaning, washing, cooking, organising appointments and driving Peter to shops and outdoor activities.19 6 December 2021 [23] Around 11:00am on Monday, 6 December 2021, Mr Jamil picked Peter up from his share house in Sunnybank. He recalled Peter looked tired and was frustrated that his mobile phone was not working properly. Mr Jamil said that Peter swore and threw the phone on the floor. Peter told Mr Jamil to take him to an Op Shop in Slacks Creek.

[24] As they were driving, Mr Jamil heard Peter say: ‘I’m going to kill someone today.’ Mr Jamil stated that Peter appeared angry and aggressive, and he did 15 Exhibit B1 at [19] – [21].

16 Exhibit B1 at [33].

17 Exhibit B1 at [34] – [56].

18 Exhibit B1 at [59] – [68].

19 Exhibit B1 at [69] – [72].

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not want to say anything to make him worse. Mr Jamil saw Peter touch his backpack and heard Peter say: ‘my knife is in my backpack and it’s ready to stab someone.’ Mr Jamil said this behaviour scared him, but he did not want to show Peter he was scared.20 [25] Peter asked Mr Jamil to take him to 29 North Road, Woodridge. Upon arrival, Peter went into one of the units and quickly returned to the car. Peter sat in the car and shouted: ‘I know who is in contact with my wife and children. If I find out who the fuckin prick is in touch with my wife and children, I will cut their neck in front of their family and children.’ [26] Mr Jamil said nothing. Peter told Mr Jamil: ‘Take me to Unique Oz Care. I’m going to kill the bitch and the cocksucker.’ Mr Jamil said Peter had spoken about killing things before and he believed Peter wanted money. He did not believe Peter was going to hurt anyone.21 [27] Around 12:00pm, Mr Jamil and Peter attended Unique Oz Care at 528 Compton Road, Stretton. Unique Oz Care was located in a two-storey commercial building with a common foyer, main internal stairwell, and bathroom amenities. Unique Oz Care was located on the upper floor, in one of five office spaces.

[28] At the time of the incident, all but one of the office spaces were occupied by businesses. During business hours (9:00am to 4:00pm, Monday to Friday), any person could attend the office. The glass doors to the office from the main internal stairwell automatically locked at 4:00pm. The office was separated into two areas. There was a reception area with a meeting room to the right, and behind that area was the main office.22 [29] At the time of the incident, Ms Katherine Hoyle was employed by Unique Oz Care as the Quality Assurance Manager. Ms Hoyle’s statement was tendered at the Inquest. Ms Hoyle recalled that Peter would sometimes send abusive messages to the work phone complaining about the services provided to him.

However, she considered that this was just Peter “mouthing off” and noted that he was always respectful to her.23 [30] On 6 December 2021, Ms Hoyle recalled speaking with Peter at Unique Oz Care. Ms Hoyle described Peter as erratic, talking very fast, not making sense, agitated and unable to sit still. Ms Hoyle recalled in September 2021, she called the QAS as Peter was having a mental health episode. However, on 6 December 2021, she described Peter’s behaviour as different, and that he was making threats.24 While in the meeting room, Ms Hoyle heard Peter say: ‘I am either going to kill them, or myself, or both.’ Peter did not tell Ms Hoyle who 20 Exhibit B1 at [92] – [104].

21 Exhibit B1 at [106] – [114].

22 Exhibit B5 at [5] – [6].

23 Exhibit B5 at [11].

24 Exhibit B5 at [16].

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he meant by “them.”25 Ms Hoyle, Mr Jamil and the Director of Unique Oz Care, Mr Khalifa Ahmed, had a brief discussion about how to assist Peter.

[31] Mr Ahmed’s statement was tendered at the Inquest. He stated that Peter had a habit of attending the business and asking for food, tea, and other items. About two weeks prior Mr Ahmed designated an area as “staff only” due to concerns about Peter’s drug issues and his frequent attendance at the office and use of tea, coffee, and other items. Mr Ahmed was concerned that Peter’s access to staff areas may put staff at risk.26 [32] After Mr Jamil left the Unique Oz Care office to go to the bathroom Peter followed him and requested money. Mr Jamil told him he didn’t have any and recalled Peter walked out of the office and yelled ‘fuck you all you scumbags!’27 [33] Peter returned to Mr Jamil’s vehicle and tried to get into front passenger seat.

Mr Jamil unlocked the vehicle. Peter continued to yell and swear at Mr Jamil.28 Ms Hoyle witnessed this and approached the men. Ms Hoyle told Mr Jamil to get in the car. She recalled Peter was “mouthing off” saying: ‘you fucking cunt…I know about [redacted].’ [34] After Mr Jamil drove away,29 Peter and Ms Hoyle walked back into the Unique Oz Care offices. Mr Ahmed tried to find a different support worker for Peter.

Peter walked straight into the meeting room and Ms Hoyle went into the staff only area.30 Mr Ahmed and Administrator, Ms Abdulle, also witnessed the interaction.31 Ms Hoyle and Ms Abdulle compiled an incident report.32 [35] Ms Abdulle recalled that Peter’s visits to Unique Oz Care were friendly and he often tried to get more money or extra services. She recalled Peter was always respectful when he spoke to her and he had never been violent or threatening but could be argumentative if he did not get his way.33 She said Peter often “clashed” with Mr Jamil but they would quickly move on.34 Ms Abdulle was told by Mr Ahmed that Peter may be going through some withdrawal symptoms, and they should be aware due to Peter’s regular attendance at the office.35 [36] On 6 December 2021, Ms Abdulle saw Peter in the Unique Oz Care meeting room. He appeared angry and was marching around the table with a backpack held in front of his chest, with one strap over his shoulder. Ms Abdulle heard Peter say that one of the Unique Oz Care staff was having an affair with his former partner, and that he was going to “rip his head off.” 25 Exhibit B5 at [17].

26 Exhibit B2 at [9] – [13].

27 Exhibit B1 at [129] – [134]. Exhibit B2 at [16] – [22].

28 Exhibit B2, B1.

29 Exhibit B5 at [25]. Exhibit B1 at [146] – [151].

30 Exhibit B5 at [28].

31 Exhibit B2 at [23] – 25]. Exhibit B3 at [19] – [26].

32 Exhibit C34, 9 – 16. Exhibit B3 at [37] – [38].

33 Exhibit B3 at [14] – [15].

34 Exhibit B3 at [45].

35 Exhibit B3 at [16].

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[37] Peter threatened to kill everyone and commented angrily that they were “scattering around” and locking doors behind them.36 Ms Abdulle had not seen this side of Peter before and was scared. She recalled the way Peter had his hand inside the backpack made her suspicious that he had a weapon, although she never saw a weapon. Ms Abdulle said it was like Peter was “about to pull something out” of the backpack.37 She returned to the main office, locked the door behind her and immediately told Mr Ahmed what Peter had said.

[38] Mr Ahmed was aware that Peter had knives38 and notes from other support workers mentioned that they had previously seen Peter with a fake/toy gun39 (a black pistol) which concerned them as it looked real. Peter reportedly told them it was fake. Case notes from 11 October 2021 state that while seated in a stationary vehicle in a shopping carpark, Peter thought people were looking at him and he pulled up the ‘pistol (toy)’ and pointed it at people. When challenged by the support worker, Peter told them that he was seeking to scare the people.40 [39] At 1:15pm a Unique Oz Care worker called Triple 00041 and requested Police attend and remove Peter as he was being very aggressive towards staff. The office was then placed in lock down.42 At 2:42pm, police spoke with a Unique Oz Care worker, who informed them that Peter may have a knife, however they had not seen him with one.43 [40] Five Unique Oz Care staff sheltered in the kitchenette area of the business, awaiting directions from police who considered this a high-risk, hostage situation. Police maintained contact with the office via text message and were given information about the office to assist in planning their response.44 [41] Prior to police arrival, Mr Ahmed heard Peter yelling threats that he would kill him and “cut all of their heads off.”45 36 Exhibit B3 at [29] – [32].

37 Exhibit B3 at [33].

38 Exhibit C40, 30.

39 Exhibit C40, 32.

40 Exhibit B2 at [33] – [35]. Exhibit C40, 23.

41 Exhibit E1.1.

42 Exhibit B3 at [36]. Exhibit B2 at [28] – [29]. Exhibit B5 at [30].

43 Exhibit C13.

44 Exhibit C20.

45 Exhibit B2 at [36] – [39].

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Initial police response [42] At 2:56pm, QPS officers, Constable Hurst and Constable Powell arrived at 528 Compton Road. On approach to the scene, both officers activated their body worn cameras and entered the Unique Oz Care business premises. They observed Peter in the meeting room. Peter was wearing a face mask, black hoodie, and cap and was seated at the table.

[43] Constable Hurst and Constable Powell approached Peter and verbally engaged him in conversation to understand what had occurred. The officers told Peter to remain seated at the table and Peter complied. They asked Peter about the disturbance and his alleged behaviour. Peter told the officers that he had not been asked to leave and that he had been having issues with his support workers.

[44] The officers asked Peter about the contents of his backpack as they had been told he had a knife. Constable Hurst asked Peter to throw his bag on the table.

Constable Powell told Peter not to reach into the bag. Peter asked why they were there. Police responded that they had been told there had been a disturbance, that Peter was not willing to leave, and he was getting a bit aggressive.

[45] Constable Hurst told Peter not to reach into his bag as they did not know what was in it, and they were trying to preserve their and Peter’s safety. 46

• Peter: ‘Yeah what if I pull this out, what are youse going to do then?’

• Constable Powell: ‘What is it? Depends what it is bro.’

• Peter: ‘A gun.’

• Constable Powell: ‘Well don’t pull it out then.’47 [46] At no time did Peter tell police that the gun was fake, a toy, or a gel blaster.

Constable Hurst and Constable Powell attempted to negotiate with Peter, telling him not to be “silly” and that they were trying to get a good outcome for him. Additional police support was requested. The officers asked Peter what outcome he was looking for and he responded: ‘You dropped my mate on the motorway bro, let’s see.’48 [47] Both officers attempted to negotiate with Peter, they asked him to sit down.

Peter said: ‘I’m not sitting down mate, I’m just getting ready so I don’t drop so far.’49 Both officers continued to speak to Peter, in a calm, yet firm tone.

They maintained their distance from him.

[48] Peter told police: ‘I want you to reach for that fucking gun so bad bro.’ Constable Hurst responded: ‘Alright, I don’t, I don’t want to do it, I really don’t.’ 50 46 BWC footage of Constable Hurst, line 82 to 96.

47 Exhibit F1.1, L 96 – 101.

48 Exhibit F1.1, L 113.

49 Exhibit F1.1, L 144.

50 Exhibit F1.1, L 180 – 181.

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[49] The conversation between Peter, Constable Hurst and Constable Powell was captured on both officer’s body worn cameras:

• Peter: ‘Go and fix, as soon as I pull mine you guys have to.’

• Constable Powell: ‘We’re not going to.’

• Constable Hurst: ‘I’m not in this, mate I’m not in this job to hurt anyone, we want to help you bro.’

• Peter: ‘I can get it out before you even…’

• Constable Powell: ‘Well that would be a stupid thing to do, it would.

Have you got any family to think about?’

• Peter: ‘No.’

• Constable Powell: ‘I’ve got my family to think about.’

• Peter: ‘No. That’s what you joined up for bro.’

• Constable Powell: ‘No it’s not.’

• Constable Hurst: ‘No it’s not.’

• Peter: ‘Yeah.’

• Constable Powell: ‘No it’s not. We joined to help people.’

• Peter: ‘Well this, what do they fucking want in there?’

• Constable Hurst: ‘Mate, that’s why we’ve come in here so cool and collected, we want to help you man, we want to walk out of here with a, with an outcome.’

• Peter: ‘You can, with me in a zipper.’

• Constable Powell: ‘That’s not the outcome that any of us want to achieve.’

• Peter: ‘That’s why, I’ve dreamed so much about, this, this is going to be so much fucking fun.’

• Constable Hurst: ‘Mate.’

• Peter: ‘Where do you reckon you’ll get me, in the chest?’

• Constable Hurst: ‘Mate I’m not going to shoot you.’51 [50] Peter told Constable Hurst and Powell to fuck off and get away from him. Both officers slowly walked backwards, maintaining their view of Peter until they were outside of the reception area. Constable Powell continued to speak with Peter to build rapport and seek his compliance.

[51] Constable Hurst used his radio to update police communications that Peter was possibly armed with a firearm, had his hand in his backpack, and they were “in a bit of a standoff.” He noted that all the support workers were in the room next door.52 Constable Hurst told police communications: ‘just come in softly, this male wants us to shoot him.’53 [52] Constable Powell stepped away from Peter and spoke with Constable Hurst.

He confirmed the siting of a weapon and stated that it ‘might be a gel blaster.’54 Police communications inquired about the credibility of the firearm and 51 Exhibit F1.1, L 184 – 211.

52 Exhibit F1.1, L 233.

53 Exhibit F1.1, L 265.

54 Exhibit F1.1, L 297 – 300. Exhibit C13, 7.

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Constable Hurst told them a firearm was sited in a backpack however he could not confirm if it was a gel blaster or not, but Peter wanted police to shoot him.55 [53] Peter sat on the floor of the meeting room next to a cabinet and continued speaking with Constable Powell:

• Peter: ‘What, they’re going to shoot, they’re sniping me from, that's okay.’

• Constable Powell: ‘No they’re not going to snipe you mate, we’re going to try and talk this, we’ll talk for as long as we need to.’

• Peter: ‘There’s no fucking… no they, they caused this bro.’

• Constable Hurst: ‘I, yeah I understand that mate and we want to get an outcome for you. We didn’t, notice how when we walked in here we, we didn’t try and come over here and rough you up.’

• Peter: ‘pull, pull your guns straight away.’

• Constable Hurst: ‘Hey?’

• Peter: ‘You haven’t tried to, oh yeah your hands get itchy but I can understand that.’

• Constable Hurst: ‘That’s for my safety mate, I want to go home to my…wife and kids… But we, but we didn’t come in here and rough you up, we wanted to work out what the go was… We want to help you.’

• Peter: ‘Yeah you’ve actually treated, you are actually decent people.’56 [54] Shortly after, another QPS officer arrived. Peter saw the officer and stood up with his hand still in his backpack and moved to the far side of the meeting room. Constable Hurst calmly told the officer to “back up” and get outside the office. Constable Powell continued speaking with Peter. The officer offered to get vests from the police vehicle for Constable Powell and Constable Hurst however, Constable Hurst was concerned it might “instigate it.” [55] Constable Hurst told Peter there was no need to “be jumpy”, it was just a concerned colleague.57 Constable Powell asked Peter if there was anything he wanted? Peter said he wanted to speak to his ex-wife and said if that happened he would throw the bag to police, and they could “pat him down.” Peter expressed concern for his children and asked to facetime them.58 While speaking with Constables Powell and Hurst, Peter looked out a window and saw police outside. He said there are ‘fucking cops everywhere… let’s get this party started.’59 [56] Constable Powell and Constable Hurst continued speaking to Peter and he eventually sat down at the table. He requested water. At one point, Peter put his hands above his head while the officers tried to get a glass of water for him.

Peter told the officers: ‘I’m just going to do it myself, if you guys don’t do 55 Exhibit F1.1, L 313 – 314. L 316 – 317.

56 Exhibit F1.1, L 349 – 368.

57 Exhibit F1.1, L 370 – 393.

58 Exhibit F1.1, L 394 – 481.

59 Exhibit F1.1, L 558 – 562.

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it…there’s no safety on the fucking thing…okay, it’s the same one, model you guys have got.’60Peter again placed his hands on his head and then on the table.

[57] Constable Powell told Peter he had to come forward to give him water. Peter permitted this and Constable Powell placed a paper cup with water on the table for Peter.61 Peter told Police his Arabic name was Jundullah, but his real name was Peter Pilkington. The officers asked Peter numerous questions to engage Peter and ‘keep him talking.’62 [58] Periodically, Constable Powell would step into the meeting room so he could better hear Peter. Peter continued to speak with officers and told them ‘Somebody’s going to pull their fucking gun and somebody’s going to fucking shoot me. You know, I don’t care where the fuck you shoot me.’63 [59] Constable Powell and Constable Hurst continued speaking to Peter and suggested options for finding new support workers due to Peter’s complaints about his current workers. Peter told police to get the support workers “out of there” (the room next door) as they were aggravating him. However, police said they couldn’t because Peter had a gun and was angry. Peter stood up, hit the wall, and said he would ‘kick his way through’ and shoot ‘the little prick now.’ [60] Peter had his right arm inside his backpack.64 Constable Powell and Constable Hurst attempted to redirect Peter and engage him in further conversation. Peter paced back and forth in the meeting room. He hit the wall again before sitting down. Peter told the officers, ‘I’m going to pull the trigger’…65 ‘Can you turn away?’ Constable Powell responded: ‘No we’re not turning away mate. We can’t turn away… And I’m not going to be able to unsee what you do.’66 [61] Peter stopped talking to Constable Powell and Constable Hurst and played music on his phone.67 Constable Hurst told police communications that Peter had turned his music on and was not interested in talking anymore: ‘I don't think he wants to shoot us anymore but … if it’s a real firearm he’s contemplating shooting himself. And if anyone else comes up here he’s, he’s going to force them to shoot him I think.’68 [62] Peter stood up and raised the blinds in the meeting room. He kept his right hand inside the backpack as he moved.69 Peter became more agitated, threatening harm to a worker in the next room, hitting the office wall, and pacing. Peter spoke about shooting the worker through the wall.

60 Exhibit F1.1, L 764 – 771.

61 Exhibit F1 T05:23:40Z - T05:25:13Z 62 Exhibit F1.1, L 794-804.

63 Exhibit F1.1, L 859.

64 Exhibit F1.1, L 934 – 950.

65 Exhibit F1.1, L 1016.

66 Exhibit F1.1, L 1027 – 1030.

67 Exhibit F1, T05:38:20Z to T05:38:45Z.

68 Exhibit F1.1, L 1134.

69 Exhibit F1, T05:39:20Z.

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[63] When additional QPS officers arrived on the second floor, Peter became increasingly agitated. Constable Powell and Constable Hurst continued to calmly speak to Peter. Peter knelt next to the internal glass window. His right hand was in the backpack, and his arms were pushed out in front of him. He yelled to the new police to ‘come in or fuck off!’ before closing the glass door of the meeting room.70 [64] Constable Powell discussed the weapon with Constable Hurst and noted: ‘It looked really plastic to me…but I don’t know, it’s not worth taking the chance on it.’ Constable Hurst responded: ‘No, hundred percent. And you can modify plastic ones to make them operational.’71 [65] There was no way to evacuate the Unique Oz Care workers without walking them past the meeting room Peter was in. Constable Hurst told police communications that there were people (outside the building) in his “line of sight” behind Peter and they should be evacuated in case shots were fired.72 [66] Peter moved the table in the meeting room and shuffled chairs to obstruct the entry to the room.73 As Peter moved around the room, he kept his right arm inside his backpack. Peter stood near the windows and became increasingly agitated as he watched more police arrive. Peter adopted a “shooting stance,” with his right hand inside his bag. He pointed the bag at the window.74 [67] Peter took the gun out of his backpack and put it inside his hoodie. He stood near the window, holding the gun in his right hand, wrapped in his hoodie.75 Constable Hurst and Constable Powell told Peter to stop what he was doing.

Peter told them to leave, and he paced the room. Peter asked to speak to his children.76 Further police response [68] Around 4:00pm, QPS officers from the Public Safety Response Team (PSRT) assembled on the internal stairs of the building. When Peter noticed them he became highly agitated. The following conversation was captured by body worn camera:

• Peter: ‘You fuck off you little prick. Fuck off!’

• Constable Hurst: ‘Mate, just relax.’

• Peter: ‘What are they doing?’

• Constable Hurst: ‘Mate, they’re here for everyone, they’re here for everyone’s safety, we’ve got to work out what’s going to happen. Come here mate, come here, Madisson.’

• Constable Powell: ‘What’s that?’

• Constable Hurst: ‘Come this way.’ 70 Exhibit F1, T05:42:20Z.

71 Exhibit F1.1, L 1210 – 1211.

72 Exhibit F1.1, L 1219 – 1238.

73 Exhibit F1, T05:48:00Z.

74 Exhibit F1, T05:56:00Z.

75 Exhibit F1, T05:57:40Z.

76 Exhibit F1, T05:58:00Z.

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• Constable Powell: ‘No don’t do it Pete, stop doing whatever you’re doing.’

• Peter: ‘Then fuck them off!’

• Constable Hurst: ‘Mate we can’t just stay here.’

• Peter: ‘Go. You fucking trigger happy little prick, you want to fucking do it do it!’

• Constable Powell: ‘Pete.’

• Peter: ‘Do it cunt!’

• Constable Powell: ‘Pete.’

• Peter: ‘Fucking shoot me mate. I am Daesh,77 I am Isis mother fucker!’

• Constable Powell: ‘Pete.’

• Peter: ‘Come on cunt, I am a member of ISIS, fuck off!’78 [69] Constable Powell and Constable Hurst were directed to withdraw. They slowly moved backwards away from Peter and removed themselves from the scene.

[70] Around 4:00pm, PSRT officers indicated that QPS SERT Operatives were required. The District Duty Officer (DDO), Senior Sergeant McCarthy, and the Regional Duty Officer (RDO), Inspector Bragg, requested support and provided several verbal briefings to SERT Operatives.

[71] Police evacuated businesses and redirected traffic from the area to ensure the safety of the public. Some residents were prevented from returning to their homes while others were told to remain inside.79 [72] At 4:14pm, the on-call QPS Negotiations Team Leader, Senior Constable Heaney, arrived on scene. For continuity, Senior Constable Heaney remained in the team leader role for the entirety of the incident80 and was assisted by fellow Negotiators, Acting Sergeant Verrills, Constable Gunn and Sergeant West.

[73] At 4:27pm, Peter spread a liquid on the table and floor of the meeting room, believed to be an accelerant. QPS officers requested that the Queensland Fire and Emergency Service (QFES) and QAS attend.81 [74] At 4:30pm, the DDO was informed by the Police Communications Centre (PCC), Mental Health Intervention Co-ordinator (MHIC) that Peter was known to mental health services and had a diagnosis of borderline personality disorder, chronic suicidality, PTSD, depression, and personality vulnerabilities. He had a history of polysubstance abuse, had previously made threats to harm himself and engaged in violence, manipulation, and intimidation to get his needs met. Peter was at chronic risk of suicide.82 77 An Arabic acronym formed from the initial letters of the group name (al-Dawla al-Islamiya fil Iraq wa al-Sham).

Used to refer to ISIS.

78 Exhibit F1.1, L 1591 – 1612.

79 Exhibit C13, 22.

80 Exhibit A6, 32.

81 Exhibit C13, 12.

82 Exhibit C13, 13.

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[75] Around 5:00pm, SERT operatives arrived on scene.83 While the SERT operatives did not have body worn cameras on their person, their interaction with Peter was captured on a body worn camera placed on the floor84 and purposely angled to capture the office space where Peter had barricaded himself. The recording commenced at 5:48pm and ceased at 7:55pm.85 SERT Operative (SO) 143 was the SERT Inspector and overall commander. SO 146 and SO 103 were the Emergency Action (EA) and Containment Team Leaders.

The SERT operatives were aware of Peter’s possible radicalised behaviours, ideology related to terrorism and mental health concerns.86 [76] Peter barricaded the glass door of the reception area with furniture and did not comply with requests to open the door. Peter paced the room yelling at police, with the gun concealed around the waist band area of his pants. Periodically, Peter approached the rear door of the office, behind which hostages were located. As the walls of the office, separating the business from the internal stairwell were made of glass, Peter remained visible to SERT operatives.

[77] At 5:35pm, a determination was made that as Peter knew where the hostages were located, if he moved in a threatening manner towards them, SERT operatives would need to prevent Peter from gaining access to the hostages.87 [78] Around 5:45pm, Negotiator, Sergeant West contacted the on call mental health clinician who confirmed Peter’s last contact through mental health was in May 202088 following a suspected overdose.

[79] Peter was described as a person that tended not to engage with mental health services and had diagnoses of borderline personality disorder, chronic suicidality, PTSD, depression and a history of alcohol and substance abuse.

Peter had a history of threatening self-harm and violence to have his demands met. There were no suggestions of weapons in his mental health history.

However, he was considered to exhibit behaviours and attitudes consistent with being “anti-police.”89 [80] Around 5:50pm, Peter requested water. A QPS dog handler and dog arrived on scene. Upon seeing the dog, Peter pointed at it and moved back into the meeting room. He closed the glass door and crouched down next to the wall behind which hostages were located. Peter eventually lay on the floor for a short time, before standing on a chair and pushing up portions of the roof panelling.

[81] SERT operatives established a position at the top of the stairs and crouched behind ballistic shields. They continually observed Peter and discussed among themselves how they could gain entry to the room, and the obstructions they may encounter. This type of discussion and planning continued for the duration of the siege, based on their observations of Peter’s behaviours and the dynamic 83 Exhibit A6, 44.

84 Exhibit F3.

85 Exhibit F4, 1.

86 Exhibit A6, 38.

87 Exhibit A6, 45.

88 A further presentation occurred in July 2020.

89 Exhibit A6, 31 – 33 & 36.

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nature of the situation. This allowed the SERT operatives to develop their “actions on.” [82] At 6:02pm, Peter partially removed his hoodie. SO 103 reported Peter had a gun in his right hand. SO 167 reported having seen a black muzzle that looked like a pistol. At 6:03pm SO 146 reported Peter’s right hand was holding a firearm pistol grip, and the underside of a barrel was seen. The gun was concealed within clothing. Peter put his hands on his head, and motioned for an officer to approach the glass where he was standing. SERT operatives were told not to approach and to remain behind the ballistic shields. Peter was told to open the door. He did not comply.90 At 6:06pm, Peter knelt on a cloth and prayed, in a manner consistent with the Islamic faith.

[83] Soon after, QAS High Acuity Response Unit (HARU) Paramedics, Dr Glasheen and Critical Care Paramedic (CCP) Colen91 arrived and were briefed by QPS officers regarding the hostage situation that would likely be protracted.92 [84] At 6:08pm, SO 103 briefed SERT operatives on their “triggers for action.” If Peter moved towards the hostages in a threatening manner, or if he got into the roof cavity, SERT operatives would be required to force entry to the room and engage with Peter due to the threat to hostages.

[85] At 6:10pm, Peter closed the blinds in the meeting room. Through negotiators it was established that Peter could hear a helicopter (a media helicopter) which was asked to move away from the area.

[86] At 6:13pm, Peter held scissors to his throat and then to his wrist. He sat for a short period of time before standing, pacing the room, and kicking the glass separating the meeting room and reception area.

[87] At 6:19pm, Peter held the gun (wrapped in clothing) in his right hand and pointed it to his right temple. He yelled at SERT operatives and briefly pointed the gun at SERT operatives. Peter stood at the glass separating the meeting room and reception area and held a piece of glass to his throat. He was highly agitated and yelled and swore at SERT operatives.93 [88] QPS negotiators continued to engage Peter on the phone. When SERT operatives stood from a crouched position behind ballistic shields, Peter became agitated, stood up quickly paced around the meeting room. He kicked the glass, swore, and yelled. At one point he crouched, holding the gun in a “firing position” (with the weapon pushed out in front of him) pointed towards the SERT operatives. Peter threw furniture in the meeting room and was told by SERT operatives, to “calm down” and talk on the phone.

90 Exhibit F3, T08:04:01Z.

91 Exhibit B26 at [5].

92 Exhibit B 26 at [7].

93 Exhibit A6, 46.

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[89] At 6:31pm, a speaker was positioned to give negotiators another means of communication with Peter.94 At 6:33pm, water and a phone charger were delivered to Peter by SERT operatives, while the negotiator explained what was happening. Peter complied with the direction to place his hands on his head.

[90] When the water was placed on the floor, one of the SERT operatives quickly tested whether the main glass reception door was locked by opening it slightly.

This aggravated Peter and he quickly backed away from the door, raising his arms and yelling, before holding the gun, concealed in clothing. The SERT operatives were told by SO 146 not to touch the door, to move back and give Peter space.95 They reestablished their position behind ballistic shields at the top of the internal stairs.

[91] The negotiator told Peter to retrieve the items. Peter knelt, opened the door a very slightly , grabbed them and quickly closed it. He attempted to lock it and then barricaded the door with furniture. The negotiator called Peter on the mobile phone provided. Peter retrieved a key from the kiosk in the reception area and attempted to lock the main glass reception door.

[92] At 6:39pm Peter sat on a chair at the reception door, facing the SERT operatives. He used his right hand to point the gun (concealed in clothing) at them and yelled at them. This behaviour caused significant concern for SO 143 who reported Peter’s escalation.96 [93] At 6:41pm, Peter became very agitated after trying to lock the reception door.

He stood at the door, hit it, and yelled at SERT operatives; he used his right arm to raise the gun. SERT operatives told him not to do so and to talk to the negotiator on the phone. Peter sat on the chair at the door. Peter moved back into the meeting room and closed the glass door behind him.

[94] At 6:46pm, Peter stood on a chair in the meeting room and removed the fluorescent tubes from the lights above him. He then laid on the ground against the wall behind which hostages were located.

[95] At 6:52pm, Peter walked to the corner of the reception closest to the SERT operatives and held a note up demanding to talk to his daughters. This information was relayed to the negotiators by the SERT operatives.97 Peter was told to talk to the negotiators. QPS negotiators were unable to facilitate this demand.

[96] At 7:06pm, Peter walked into the reception room and said he was talking to his mother. Peter accused one of the SERT operatives of “laughing” at him.

He quickly escalated, yelling at the SERT operative before going back into the meeting room and laying on the floor. SERT operatives identified that Peter may be using his other phone to talk to his mother.

94 Exhibit F2, T08:31:36Z.

95 Exhibit F3, T08:34:16Z.

96 Exhibit A6, 37.

97 Exhibit A6, 37.

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[97] Around this time, QAS HARU CCP Murray and CCP Hughes were dispatched to attend.98 [98] At 7:14pm, SERT operatives observed Peter laying on the ground with his hoodie across his chest. SERT operatives reported clearly seeing a gun on Peter’s chest.99 [99] At 7:21pm, Peter stood up and opened the door of the meeting room. He held the gun in his right hand (concealed in clothing) and pointed it at the SERT operatives in a “shooting stance.” Peter walked towards the SERT operatives and yelled ‘just fucking do it cunt!’100 [100] At 7:23pm Peter had both hands on the gun, pushed forward in front of his chest. He stood near the door of the reception area, with the gun pointed at SERT operatives and yelled ‘fucking shoot me cunt, use your weapon now!’101 [101] SERT operatives commented amongst themselves during the siege that it appeared Peter wanted them to shoot him. During the siege, Peter told SERT operatives several times:

• ‘Fucking shoot me mate!’

• ‘Come on shoot me, I fucking want to…’

• ‘Shoot me fuckwit!’

• ‘Fucking worried about a gun, hey? Put your fucking weapon down or use the fucking thing, It’s not a dick mate … okay, shoot me or fuck off okay.!’ 102 [102] At 7:24pm, Peter escalated, yelling at the SERT operatives with the gun raised in front of him. He told them to shoot, he “wanted it” and pointed to his chest yelling ‘hit me cunt, hit me here!’ Peter stood facing the SERT operatives, with his arms out to his sides, and yelled ‘shoot me!... come on fucking do it!...shoot me!’103 [103] SERT operatives told Peter to calm down.104 Peter adopted a prone firing position, kneeling on the ground with his chest on furniture. He held the gun out in front of him, pointed at the SERT operatives.105 Peter stood up and walked towards the door behind which hostages were located before returning to the area closest to the SERT operatives. He raised the gun in front of him repeatedly (concealed in clothing) yelling at SERT operatives to shoot him.

Peter pointed the gun to his right temple and then back at the SERT operatives.

[104] Peter retreated into the meeting room where he repeatedly punched a white board and paced the room with the gun pointed towards SERT operatives. At 98 Exhibit B25 at [6].

99 Exhibit F3, T09:15:03Z. Exhibit F3.1, L 1445.

100 Exhibit F3, T09:22:19Z.

101 Exhibit F3, T09:23:34Z.

102 Exhibit A6, 47. Transcript of Const Spark’s BWC at [1564], [1588], [1594], [1604], [1616], [1794].

103 Exhibit F3, T09:25:28Z. Exhibit F3.1, L 1608, L 1612, L 1616.

104 Exhibit F3.1, L 1613, L 1615, L 1617.

105 Exhibit F3, T09:25:59Z.

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7:31pm, Peter hit the glass repeatedly and yelled at SERT operatives, ‘do it!’.106 SERT operatives again told him to calm down.

[105] At 7:34pm, Peter exited the meeting room and walked towards SERT operatives. He held the gun (concealed in clothing) in both hands, pushed out in front of his chest. He pointed it at SERT operatives and yelled at them to ‘bring your weapon up!’107 At 7:35pm Peter stood in the corner of the reception area closest to the SERT operatives and yelled: ‘shoot me or fuck off!’.108 Peter was told to calm down and talk to the negotiators on the phone.

[106] Peter said there was ‘no more negotiations, I’ll go through that door.’ Peter pointed to the door behind which hostages were located.109 SERT operatives told Peter to talk to the negotiators on the phone. Peter went back into the meeting room and retrieved the phone given to him. He dropped it at the reception door and then knocked on the door that separated him from the hostages. Peter sat on a chair in the reception area and pointed the gun at the right side of his head.110 [107] Around this time, QAS HARU CCP Murray and CCP Hughes arrived at the scene and were briefed by QPS that Peter’s agitation was escalating, and SERT operatives were preparing to force entry to the area Peter was in.111 Both CCPs prepared their body armour and moved their vehicle close to the scene in case they were required.112 [108] At 7:40pm, Peter sat on the floor in the reception area, cried, and placed the gun in his mouth. He proceeded to lay on his back with the gun in his mouth.113 At 7:41pm, Peter lay on his stomach and put his hands behind his back.114 This action caused the SERT operatives to think Peter may be attempting to surrender and they described Peter as being in ‘somewhat of a surrender position.’115 Peter told the SERT operatives they had three seconds to come in and get him before he “pulled his gun.” The SERT operatives were prevented from entering the room as the door remained barricaded by the furniture Peter had placed behind it to obstruct its opening.116 [109] At 7:42pm, Peter was highly agitated, he stood up and yelled at SERT operatives. Peter turned to walk away from the reception door. SO 146 “pushed past” the protection of the ballistic shields to get closer observation of Peter, as the words Peter was using led SO 146 to believe he was going to put the lives of the hostages at risk.117 106 Exhibit F3, T09:31:40Z.

107 Exhibit F3, T09:34:37Z. Exhibit F3.1, L 1776.

108 Exhibit F3, T09:35:35Z.

109 Exhibit F3, T09:36:54Z.

110 Exhibit F3, T09:39:25Z.

111 Exhibit B24 at [8].

112 Exhibit B24 at [8] – [9].

113 Exhibit F3, T09:40:02Z. Exhibit F3.1, L 1881 – L 1882.

114 Exhibit F3 115 Exhibit F3.1, L 1898.

116 3 June 2024, T 1-27, L 3-15.

117 Exhibit B17, 12.

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[110] Peter suddenly turned to face SERT operatives and raised his arms in front of him, holding the gun (concealed in clothing) in both hands, pushed out in front of his chest. He adopted a “shooting stance” with the gun pointed directly at

SO 146.

[111] Despite the gun being obscured by clothing, SO 146’s evidence was that due to the way the gun was held, he could see a slide and a pistol grip and a trigger guard Peter’s finger was inside of. Based on this SO 146 was confident Peter was holding a “pistol.”118 [112] SO 146 believed Peter was forming the intention to cause death or grievous bodily harm to him or the other officers behind him.119 SO 146 was aware that he was forward of protective cover. Through his training, he knew that a projectile could easily travel through glass.120 SO 146 attempted to “push back” to try to get behind a ballistic shield and in doing so raised his weapon, took a sight picture, to confirm his arcs of fire (knowing that hostages were in the building) and fired a single shot that penetrated the laminated glass of the reception area. The glass did not shatter.

[113] Peter walked back into the meeting room and collapsed, he dropped the gun and clothing that was covering it. SERT operatives immediately forced entry into the reception area and meeting room using multiple tools and distractions.

First aid was provided to Peter by SERT medics while the QAS HARU CCPs were brought up to the scene.

[114] At 7:44pm, QAS HARU CCP Murray and CCP Hughes assessed Peter in the meeting room. He had sustained an injury to the left side of his chest and left wrist, consistent with a single gunshot wound. No other injuries were identified.121 CCP Murray directed SERT operatives to carry Peter out of the room to the awaiting ambulance stretcher and he was immediately loaded into the ambulance that departed (Code 1) under lights and sirens122 for the PAH at 7:48pm.123 [115] Once Peter was removed from the scene, SERT operatives and PSRT operatives assisted the hostages and removed them from the scene.

Family calls to Triple 000 [116] At 7:49pm, Peter’s brother, Shannon, called Triple 000 and told the call taker that he had seen the news and his brother Peter was involved in a siege.

Shannon told the call taker that Peter had called earlier that night to ‘say goodbye’ and ‘go tell my kids I love em.’ Shannon desperately offered to help in any way that he could. Shannon told the Triple 000 call taker that Peter “would not back down.”124 118 Exhibit B17, 14.

119 Exhibit B17, 15.

120 Exhibit B17, 9 and 15.

121 Exhibit B25 at [8].

122 Exhibit B34 at [15].

123 Exhibit B25 at [9].

124 Exhibit E1.2. Exhibit E1.4, L 47.

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[117] At 8:29pm, Shannon made a further phone call to Triple 000, frantically seeking information as he had seen rumours on social media that his brother had been shot.125 Emergency medical treatment [118] Upon extraction from the scene, Peter was alert, conscious and speaking. His pulse rate was 130 and his blood pressure was 132/112. His spO2 was 100%.126 CCP Colen drove the ambulance while CCP Hughes, CCP Murray, ACP Pringle and Dr Glasheen provided emergency medical treatment to Peter.

[119] Enroute to the PAH, CCP Hughes performed an ultrasound examination and identified a pericardial effusion on subxiphoid view. Intravenous (IV) access was established, a chest seal was applied, and 15 mg of intravenous Ketamine was issued to reduce agitation.127 Around 8:01pm, Peter’s level of consciousness and heart rate decreased. Packed red blood cells were administered intravenously.128 Around 8:03pm Peter was unresponsive and CCP Murray could not find a carotid pulse.129 Peter went into cardiac arrest.130 [120] The ambulance stopped on the Gaza Road exit from the Pacific Motorway131 and Peter was removed from the ambulance to allow better access for Dr Glasheen to perform an emergency clamshell thoracotomy.132 QPS officers assisted by providing lighting and scene safety.133 [121] Initially, Dr Glasheen and CCP Murray performed left and right bilateral finger thoracostomies, the left released a large amount of blood however the right had no releases. Dr Glasheen performed the thoracotomy and identified a large haemopericardium which was decompressed via a pericardiotomy. No cardiac wound was found, and significant bleeding was identified from the superior mediastinum which was controlled with packing.134 Peter was treated with blood products and calcium gluconate. Dr Glasheen conducted internal cardiac compressions.135 Around 8:15pm, Peter was returned to the ambulance and the transport to the PAH (Code 1) under lights and sirens continued.136 [122] At 8:24pm, the ambulance arrived at the PAH137 and Peter was handed over to the awaiting trauma team in the Emergency Department (ED) resuscitation room.138 Dr Glasheen provided a verbal handover.139 Cardiothoracic surgeons treated Peter. No clear source of bleeding was identified. Intracardiac 125 Exhibit E1.3. Exhibit E1.5.

126 Exhibit C3, 1.

127 Exhibit B25 at [10].

128 Exhibit B24 at [16].

129 Exhibit B25 at [11].

130 Exhibit B24 at [16].

131 Exhibit B24 at [16].

132 Exhibit A5, 6. Observations made at autopsy relating to this emergency procedure.

133 Exhibit B26 at [13].

134 Exhibit B24 at [16]. Exhibit B26 at [14].

135 Exhibit B26 at [15].

136 Exhibit B24 at [16].

137 Exhibit C4, 1. Exhibit D4.3 44 – 45.

138 Exhibit B25 at [13]. The team in attendance included an ED team, Anaesthetics, General Surgery, Cardiothoracic and ICU (Exhibit D4.2, 42).

139 Exhibit B24 at [17].

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adrenaline was given and around five cardioversions were performed however, sinus rhythm could not be restored. Approximately an hour passed with no sustained spontaneous circulation and a consensus decision was made that further resuscitation attempts would be futile and were subsequently ceased.

At 8:55pm, Peter was declared deceased.140 Coronial investigation [123] At 7:50pm, SERT Overall Commander, SO 143, declared 528 Compton Road a crime scene. ESC and the Crime and Corruption Commission (CCC) were advised and attended. SERT operatives and negotiators were subjected to alcohol and targeted substance testing. All returned a negative result. All were interviewed, along with Constable Powell and Constable Hurst and their statements and body worn camera footage formed part of the coronial report of Detective Sergeant Edwards.

[124] QPS Ballistics Unit, Scientific Officer, Sergeant Meara attended the scene of the incident. Sergeant Meara examined several QPS weapons, including that used by SO 146, and the gel blaster (as subsequently identified) used by Peter, and the hole in the glass created by the single projectile fired by SO 146.

[125] QPS officers attempted to access Peter’s mobile phone as part of the coronial investigation. It was secured with a pin code and could not be analysed. Call charge records were obtained and police identified that during the siege, Peter made four phone calls between 5:28pm and 6:21pm to his brother. At 7:03pm, Peter telephoned his mother.141 Autopsy results and cause of death [126] Peter’s brother Shannon strongly objected to any internal examination of the body, due to Peter’s religious belief. Accordingly, no internal examination occurred. 142 [127] On 8 December 2021, Forensic Pathologist, Dr Nadine Forde conducted an external examination and a Postmortem CT (PMCT) scan. Dr Forde was aided by the Police Form 1, supplementary Form 1, body worn camera footage, QAS and PAH records.143 During Dr Forde’s external examination of the body, she observed the following injuries: ‘An entry and exit gunshot wound to the left wrist and an entry wound to the left chest. With the arm raised to the level of the chest the wounds formed a single projectile path through the wrist into the chest from the left, consistent with the direction of the gunshot as observed within the police footage. There were a number of small red abrasions to the wrist and chest, consistent with injuries from glass fragments through which the projectile appeared to pass. There were some minor superficial 140 Exhibit A1.

141 Exhibit A6, 63.

142 Exhibit A5, 8.

143 Exhibit A5, 7.

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injuries, predominantly bruises to the lower limbs. There were no other significant injuries.’ 144 [128] Dr Trevor Watkins, Consultant Radiologist reviewed the PMCT scan and noted the following internal injuries: ‘Entry wound: Anterior left chest, 38mm to the left of midline at the level of the left 1st costal cartilage.

Trajectory: Anterior to posterior; left to right (~25 degrees from the sagittal plane); horizontal plane.

Structures traversed: Skin, subcutaneous tissues and medial left pectoralis muscle of the anterior chest wall; medial 1st intercostal space and superior 2nd costal cartilage with possible disruption of the left internal mammary artery / vein; superior mediastinum and probable injury to the superior vena cava, azygos vein and aortic arch; superior right pulmonary hilar structures; right upper lobe pleura and lung with the intrapulmonary wound track extending posteriorly and laterally.

Exit wound: No exit wound Projectile fragment in the posterior right upper lobe adjacent to the pleural and oblique fissure.’ 145 ‘Wound track through the left wrist in the anterior-posterior orientation with scattered projectile fragments, however directionality is not able to be ascertained on PMCT. Fracturing of the distal left radius and ulna.’146 [129] Dr Forde opined that the small red abrasions to the wrist and chest were consistent with injuries obtained from glass fragments when the projectile passed through glass. Dr Forde noted minor superficial injuries, predominantly bruises on the lower limbs and no other significant injuries.147 Dr Forde concluded that the cause of death was a gunshot wound to the chest. 148 [130] I accept that the injuries observed by Dr Forde and Dr Watkins are consistent with Peter having suffered a single gunshot wound, where the projectile passed through glass before entering the left wrist, resulting in both an entry and exit wound, and an entry wound to the left chest. This is supported by the medical evidence, and the body worn camera footage.

[131] Toxicological analysis of a sample of ante-mortem blood obtained at 8:33pm on 6 December 2021149 confirmed the presence of Methylamphetamine (Detected <0.01 mg/L); Desmethylvenlafaxine (0.01 mg/L) an antidepressant; D9 tetrahydrocannabinol (Detected 0.002 mg/L) also known as THC, the active ingredient in cannabis; and Pregabalin (7.2 mg/L) an anticonvulsant and anxiolytic medication with multiple uses. The presence of Ketamine (1.5 mg/L) was attributed to its use as an anaesthetic administered during Peter’s hospital treatment.

144 Exhibit A5, 8.

145 Exhibit A5, 6.

146 Exhibit A5, 7.

147 Exhibit A5, 8.

148 Exhibit A5, 9.

149 Exhibit A5, 9.

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[132] Toxicological analysis of a sample of urine confirmed the presence of amphetamine and methylamphetamine. Immunoassay results were positive for amphetamines.150 Dr Forde noted in her report that interpretation of the levels identified through toxicology testing was limited due to significant blood loss and the administration of blood products during emergency medical treatment.151 [133] Evidence contained in the brief indicated Peter was prescribed Pregabalin (Lyrica) for reported neuropathic pain (56 tablets with no repeats) in December 2020, January 2021, February 2021, March 2021, April 2021 and July 2021.

On 6 October 2021 and 13 October 2021, Peter was prescribed Pregabalin (56 tablets with five repeats). On 24 January 2021, 11 March 2021 and 10 April 2021, Peter was prescribed Paracetamol and Codeine (20 tablets with no repeats).152 150 Exhibit A4.

151 Exhibit A5, 9.

152 Exhibit D2. Prescribed dosage of 150mg twice a day.

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Conclusions on inquest issues Findings required by Section 45 Coroners Act 2003 (Qld) [134] I am required to find, as far as possible, the medical cause of death, who the deceased person was and when, where, and how he came by his death. Having considered all the evidence contained in the coronial brief, I make the following findings: Identity of the deceased: Peter Owen Pilkington153 How he died: On 6 December 2021, police were called to 528 Compton Road, Stretton, in response to a call for assistance from Peter’s NDIS support workers.

A siege situation ensued, lasting from 3:00pm to 7:45pm. It ended when Peter suddenly escalated and pointed a gun at SERT operatives. A SERT operative acting in the course of his duty consequently shot Peter.

After his death, the gun was forensically examined, and it was determined that it was a gel blaster pistol.

Place of death: The Princess Alexandra Hospital, Woolloongabba, QLD, 4102, Australia.

Date of death: 6 December 2021 Cause of death: 1(a) Gunshot wound to chest.

153 Peter was identified by fingerprint evidence. Exhibit A2.

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Consideration of the circumstances leading up to the death including: Peter’s mental health treatment and care and any co-occurring substance use disorder.

[135] During the coronial investigation, Peter’s family expressed a concern that Peter was misusing prescription medication to cope with pain. They considered that if Peter had received additional alcohol and drug dependency treatment his death may have been avoided.

[136] Medical and mental health records contained in the coronial brief show Peter had a documented mental health history, with diagnoses of ASD, PTSD, OCD, bipolar disorder, borderline personality disorder with cluster B personality traits (narcissistic, avoidant, dependent, passive aggression), chronic suicidality, substance use issues and chronic pain.154 [137] On 24 April 2018, Peter was taken to the Logan Hospital under an Emergency Examination Order (EEA) following an attempt to overdose using Pregabalin.

Peter telephoned Mental Health Services (MHS) for assistance, who in turn called the QAS.155 [138] Peter was placed under a recommendation for assessment by ED staff and reviewed by a mental health clinician. The medical records indicated that Peter was dependent on prescription narcotics such as OxyContin and Endone due to issues with chronic pain. Benzodiazepine abuse was also noted.156 [139] Peter was assessed by the Psychiatric Registrar and voluntarily admitted to contain immediate risks and clarify his mental health treatment needs. On assessment, Peters stressors were listed as homelessness, not seeing his children, memories of past sexual abuse, worsening low mood, intractable back pain and a lack of social support.

[140] Peter did not display signs of thought disorder, delusions, or perceptual disturbances. He was considered to have poor insight and impulsive and fluctuating judgement in the context of personality vulnerabilities and emotional dysregulation. On 1 May 2018, Peter was discharged to Kingston House with community follow-up by the Homeless Health Outreach Team (HHOT).157 Peter did not engage with the HHOT and was closed to the service on 25 May 2018.158 [141] On 25 May 2020, Peter presented to the PAH ED with his Unique Oz Care support worker following a possible overdose. Peter was reportedly not acting normally, he appeared drowsy and had threatened suicide. Peter admitted to 154 Exhibit D4.3. Exhibit D7.4, 3. Exhibit D3.1, 130.

155 Exhibit D3.1, 42.

156 Exhibit D3.1, 43.

157 Exhibit D3.1, 49.

158 Exhibit D3.1, 81.

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taking three sheets of an unknown medication and reported concerns about his current accommodation however, he was happy with his support workers.159 [142] On assessment, Peter was found to have insight into his mental health and did not meet the criteria for involuntary treatment under the Mental Health Act 2016 (Qld). An admission to an inpatient ward was not indicated, and it was noted that prior inpatient admissions had ‘proven unhelpful in the past and may be detrimental to the therapeutic goal of fostering adaptive coping styles.’ Peter declined community mental health support and was considered to have appropriate supports in the community through his support workers and General Practitioner (GP).160 [143] Peter’s last contact with Community Mental Health Services (MHS) was through Logan in July 2020 after his NDIS support coordinator sought an urgent psychiatrist referral on 10 July 2020. Peter reportedly provided verbal consent for his support coordinator to contact a psychiatrist.161 [144] On the same day, collateral was obtained from Mr Ahmed of Unique Oz Care, when the mental health team called Peter’s phone. Peter did not answer his phone and Mr Ahmed agreed he would tell Peter to call.162 On 11 July 2020, the MHS contacted Peter’s support worker Mr Jamil who stated Peter was asleep. Peter woke and the MHS staffer heard Mr Jamil explain to Peter that it was MHS. Peter declined to speak with them.

[145] It was explained to Peter’s support worker that this was likely the last attempt the MHS would make to contact Peter. However, should he call back, he would be triaged. A text message was sent to Peter’s mobile with the MH CALL number. Mr Jamil did not object to the suggested course of action.163 A letter was sent to the Sunnybank Hills General Practice outlining what had occurred and the matter was discussed at the multi-disciplinary team review on 13 July 2020.164 Records were obtained from the Sunnybank Hills General Practice – there is no letter from the Logan MHS within those documents.165 [146] I acknowledge Peter’s family’s concerns about his alcohol and drug dependency treatment. While he may have benefited from additional treatment in the years prior to his death, the evidence before the court does not lead to the conclusion that there was a missed opportunity whereby such treatment would have changed the outcome on 6 December 2021.

[147] Peter’s last contact with mental health services was in July 2020 and he declined assistance. There is nothing within the brief of evidence to suggest Peter was not capable of seeking support as needed.

159 Exhibit D4.1, 12.

160 Exhibit D4.1, 18 – 19.

161 Exhibit D3.1, 144.

162 Exhibit D 3.1, 146.

163 Exhibit D3.1, 148.

164 Exhibit D3.1, 149 – 150.

165 Exhibit D6.1.

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Consideration of subject precipitated homicide.

[148] The coronial report of Detective Sergeant Edwards raised the phenomenon of Subject Precipitated Homicide (SPH) and determined that the body worn camera footage provided evidence of Peter’s actions and verbalisations that could be demonstrative of his “suicidal motivations” in the presence of police.166 [149] This is not the first time that SPH has been considered by this Court in the context of a police shooting. SPH may also be referred to as Victim Precipitated Homicide (VPH). In the past, the term “suicide by cop” may have been used. However, I acknowledge that this is not appropriate or therapeutic terminology and that VPH or SPH should be preferred.167 [150] In the Inquest into the death of Mark Andrew Sheppard,168 Mr Sheppard called 000 to inform police that people had been stabbed at the caravan park where he lived. Police officers attended the park and attempted to engage with Mr Sheppard who threw a tomahawk and a knife at a police officer, injuring them, before walking towards police with a machete. Mr Sheppard ignored calls from the police to drop the weapon and was shot by police, acting in the course of their duties.169 Mr Sheppard had a documented history of suicidal ideation and was facing a terminal illness. There was evidence that Mr Sheppard planned the incident to bring about his death.170 While he was affected by alcohol at the time of his death and was assessed as having a personality structure171 that made him prone to unpredictable thinking, I concluded that it was more likely that at the time of his death, Mr Sheppard acted intentionally, knowing the probable consequences of his actions were that police would fatally shoot him.172 [151] In the Inquest into the death of Luke Brian Gilbert,173 Deputy State Coroner Gallagher found that Mr Gilbert was fatally shot by police in the Airlie Beach Safe Night Precinct following a brief interaction with police. Mr Gilbert, while affected by alcohol, presented a category M weapon (a Milwaukee brand Fastback folding Camo Knife), opened the knife with a single hand and said, ‘shoot me I dare you, do it.’ Despite verbal directions from police to stop and drop the knife, Mr Gilbert continued to walk faster towards them twice yelling ‘fucking shoot me faggot’ while police attempted to tactically withdraw. Mr Gilbert did not comply with the directions and increased his pace. He was shot by police, acting in the course of their duties.174 Mr Gilbert had a documented history of suicidal ideation. There was evidence that Mr Gilbert most likely 166 Exhibit A6, 79.

167 Exhibit H1, 4 – 5.

168 2019/1231, delivered on 23 May 2022.

169 Inquest into the death of Mark Andrew Sheppard, 20.

170 Inquest into the death of Mark Andrew Sheppard at [127] to [128].

171 Resistant depressive disorder in connection with alcohol use and a cluster B personality structure, characterised by dramatic, overly emotional, or unpredictable thinking or behaviour. Despite this, Mr Sheppard was not deemed to be suffering from a major mood disorder. Inquest into the death of Mark Andrew Sheppard at [39].

172 Inquest into the death of Mark Andrew Sheppard at [131].

173 2022/4975, delivered on 11 October 2024.

174 Inquest into the death of Luke Brian Gilbert, 35 to 36.

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had an antisocial personality disorder and alcohol use disorder175 and had previously exhibited dysregulated and disinhibited behaviour in the context of alcohol use.176 [152] Counsel assisting submitted that I should accept the characterisation of Peter’s behaviours on 6 December 2021 as indicative of a person seeking to engage in SPH.177 I accept that submission.

[153] Evidence before the court, in support of this finding includes:

• The evidence of Constable Hurst and his report to police communications: ‘Just come in softly, this male wants us to shoot him.’178

• The evidence of Negotiator, Acting Sergeant Verrills that Peter was ‘goading SERT to kill him.’179

• The evidence of Peter’s behaviours in the presence of police during the siege, captured on the body worn camera footage and detailed above.

[154] This conclusion was further supported by the evidence of Victimologist, Associate Professor McKinley who provided a report180 and gave oral evidence at the Inquest. Associate Professor McKinley’s skills and professional qualifications are outlined in her report, tendered to the court.181 The effect, if any, on first responders [155] Counsel assisting submitted that on the evidence before the court, my ability to comment on the effect SPH may have on first responders, is limited.182 I accept this submission. I acknowledge an understanding of SPH by police may assist police in responding to similar situations in the future.

175 Inquest into the death of Luke Brian Gilbert at [92].

176 Inquest into the death of Luke Brian Gilbert at [101].

177 Submissions of Counsel Assisting at [88] – [90].

178 Exhibit F1.1, L 265.

179 Exhibit C17.

180 Exhibit H1.

181 3 June 2024, T1 – 49, LL 15 – T1 – 55, LL 27. Exhibit H1.

182 Submissions of Counsel Assisting at [91].

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Consideration of the regulation of gel blasters in Queensland.

[156] In considering the regulation of gel blasters in Queensland, it is important to consider the specifics of a gel blaster, such as that used by Peter on 6 December 2021.

[157] On 8 December 2021, Sergeant Meara examined the gel blaster pistol, magazine and gel balls collected from the scene. Sergeant Meara’s skills and professional qualifications are outlined in his report, tendered to the court.183 Notably, Sergeant Meara observed:

• The gel blaster, had a moveable trigger, and magazine release;

• The slide moved back and forwards under its own power when the gel blaster was fired;

• Upon firing, a single gel ball was discharged from the muzzle;

• Pushing the button on the right-hand side of the frame changed the firing rate from semiautomatic to automatic.

• The body was marked ‘Glock 18 Austria 9 x 19’ on the left-hand side of the slide;

• The overall length of the gel blaster was approximately 21.7cm;

• On the underside of the receiver was a charging port (forward of the trigger guard);

• There was a magazine release button the right side of the receiver near the trigger; and

• All other parts of the gel blaster were “moulded” including a selector switch located on the back, left hand side of the slide.

[158] Sergeant Meara noted gel blasters often replicate popular firearm models.

However, a gel blaster was designed to discharge non-lethal hydrated gel balls using compressed air generated by a spring, gas, or electric source.

[159] Sergeant Meara observed the gel blaster used by Peter was powered by a rechargeable battery. The battery powered an electric motor that cycled an internal piston-spring assembly that propelled the gel ball from the barrel.184 [160] Sergeant Meara compared the gel blaster to a Smith and Wesson calibre, Glock model 22 semiautomatic pistol.185 He found the only visual difference was a selector switch on the gel blaster and the Glock semi-automatic pistol.

[161] During the forensic examination Sergeant Meara took a series of photographs of the weapons side by side that were tendered at the Inquest and clearly show the strong likeness between the two. In the images below, the gel blaster is on the right, and the authentic Smith and Wesson calibre, Glock model 22 semiautomatic pistol is on the left.186 183 Exhibit B22 at [1] – [4].

184 Exhibit B22 at [35] – [37].

185 Exhibit G4, 38 – 39.

186 Exhibit G4 Findings of the inquest into the death of Peter Owen Pilkington Page 31 of 38

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[162] Sergeant Meara opined that the gel blaster pistol used by Peter, was captured by the definition of a ‘replica of a weapon’ (namely, a 9 x 19mm calibre Glock model 18 automatic pistol) under section 6A(1)(a) of the Weapons Act 1990 (Qld) as ‘a reasonable facsimile or copy of a weapon, even if it is not capable of discharging a projectile or substance.' 187 [163] As a replica of a firearm, it is a ‘restricted item’ in accordance with section 9(f) of the Weapons Categories Regulation 1997 (Qld). Pursuant to section 67(1) of the Weapons Act 1990 (Qld) a person must not, without reasonable excuse, possess or acquire a restricted item. It is a reasonable excuse for a person to possess or acquire a restricted item that is a replica of a firearm if:

(a) both of the following apply— (i)the person is a member of an association, whether or not incorporated, that provides recreational activities involving replicas of firearms and the activities are conducted other than in, and in a way not reasonably able to be seen from, a public place; (ii) the person’s reason for possession or acquisition of the replica of a firearm is to participate in the recreational activities; or

(b) both of the following apply— (i)the person is the holder of a collector’s licence; (ii)the person’s reason for possession or acquisition of the replica of the firearm is for it to be part of the holder’s collection of weapons.188 [164] Counsel assisting submitted that Sgt Meara’s evidence at the Inquest189 was relevant to a proper appreciation of the threat posed by Peter in possessing the gel blaster and using it in the manner that he did. This includes a consideration of how an authentic weapon may operate, the firing rate (semiautomatic or automatic) and the capacity of the magazine.190 I accept this submission.

[165] Sergeant Meara’s evidence at the Inquest was that:

• Semi-automatic firing mode is when the trigger is pulled and just one projectile is fired. The trigger must be released to “reset” the gun before the trigger can be pulled again and another projectile is fired.

187 Exhibit B22 at [38]. 3 June 2024, T1 – 44, L 4 – 14.

188 Weapons Act 1990 (Qld) section 67(4).

189 3 June 2024, T1 - 40, L 9 – T1 - 47, L 19.

190 Submissions of Counsel Assisting at [95].

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• Automatic firing mode is when the trigger is pulled and held down and the weapon continuously fires projectiles until the trigger is released, or the magazine runs out of ammunition.

• The authentic Glock has different magazines, capable of holding up to 33 rounds of ammunition. Some can be as low as ten rounds.

• The authentic Glock comes in a variety of calibres, commonly a 9millimetre Luger, a 40 Smith & Wesson and a 45 auto.

• The marking on the side of the weapon (9 x 19) is a reference to 9milimetre Luger calibre.191 [166] Sergeant Meara confirmed at the Inquest, that an authentic Glock pistol would be categorised as a Category H weapon under the Weapons Act 1990 (Qld) and considered a ‘short firearm’ meaning: ‘it’s capable of firing a projectile and causing death or injury and it’s below 75 centimetres in length.’192 A weapons licence would be required to lawfully possess such an item.193 [167] At the Inquest, Detective Sergeant Edwards gave evidence regarding legislative amendments to the Summary Offences Act 2005 (Qld) prohibiting the sale of gel blasters to juveniles in Queensland. He believed the amendments did not go far enough considering that the gel blaster possessed by Peter was ‘near identical to a real firearm,’194 and it was easy to access gel blasters as there were no licensing requirements for persons over 18 years of age. 195 [168] The statement of Inspector Barwick of the QPS Weapons Licensing Group was tendered in the coronial brief.196 He confirmed that Queensland is the only Australian jurisdiction where a person does not require a weapons licence to possess or acquire a replica firearm gel blaster from a Queensland based supplier. Gel blasters are considered a 'restricted item' under the Weapons Categories Regulation 1997 (Qld), therefore pursuant to section 67 of the Weapons Act 1990 (Qld), a person must not possess or acquire the item without reasonable excuse. As a restricted item, a gel blaster must be stored in a locked container to ensure it is not accessible to another person and when possessing a gel blaster in a public place it is not to be visible to the public, so as not to cause alarm.197 [169] I accept the submissions from Counsel Assisting and counsel for the Commissioner of Police that Sergeant Meara’s evidence regarding the capability of an authentic Glock, supported the assertion that responding police must treat the threat as real until otherwise confirmed.198 191 3 June 2024, T1 – 42, L 18 – L 43.

192 3 June 2024, T1 – 44, L 19 – 23.

193 3 June 2024, T1 – 44, L 25 – 26.

194 3 June 2024, T1 – 13, L 19 – 29.

195 3 June 2024, T1 – 13, L 45 – T1 – 14, L 15.

196 Exhibit B27.

197 Exhibit B27, 3.

198 Submissions of counsel for the commissioner of police at [8]. Submissions of Counsel Assisting at [95].

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[170] Peter’s brother expressed concern that Peter’s support workers were aware he had previously had a “toy gun”. However, they did not tell police this on 6 December 2021.

[171] I acknowledge this concern. However, as noted above, while there was reference in case notes to a “toy gun,” even if QPS officers were told the gun may be a replica, they would need to treat the threat as real in the context of all Peter’s behaviours on 6 December 2021.

[172] Peter’s access to, possession and use of the gel blaster was a significant contributory factor in the circumstances surrounding his death.

[173] Counsel assisting submitted that in the interests of public safety and in an effort to reduce the likelihood of deaths occurring in similar circumstances in the future, I should strongly consider a recommendation that Queensland legislation be amended to require that persons seeking to possess a gel blaster, hold a valid Queensland weapons licence.

[174] This would allow for appropriate screening of persons who intend to possess such items. Further, while there was some time between Peter’s last presentation to mental health services and this incident, by requiring a person to hold a valid Queensland weapons licence, it may also give rise to the further public safety measure whereby health professionals may make disclosures to police where the “threshold test” under section 151 of the Weapons Act 1990 (Qld) is satisfied.199 [175] In accordance with section 151 of the Weapons Act 1990 (Qld), a health professional may disclose certain relevant information about a patient/client to police where they are of the opinion that the person is an unsuitable person to possess a firearm because of their mental or physical condition or because the person may be a danger to themselves or someone else.

[176] This submission was supported by counsel for the Commissioner of Police, who also submitted this would provide a mechanism whereby front-line police officers would have the ability to check and clarify whether a person had a weapons licence and the specific weapons held under that licence.200 199 Submissions of Counsel Assisting at [109].

200 Submissions counsel for the commissioner of police at [12] – [14].

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Whether the Police Officers involved acted in accordance with the QPS policies and procedures then in force, and whether said actions were appropriate.

[177] In analysing this issue, the impact of hindsight bias and affected bias must be considered. As outlined in ‘The Australasian Coroners Manual’: Hindsight bias is the tendency after the event to assume that events are more predictable or foreseeable than they really were. What is clear in hindsight is rarely as clear before the fact…It is an obvious point, but one that nonetheless bears repeating, particularly when coroners are considering assigning blame or making adverse comments that may damage a person’s reputation.

… Coroners should attempt first to understand the circumstances as they appeared at the relevant time to the people who were there.

… Hindsight, of course, is a very useful tool for learning lessons from an unfortunate event. It is not useful for understanding how the involved people comprehended the situation as it developed. This distinction needs to be understood and rigorously applied.201 [178] I agree with Counsel Assisting that the police response may be divided into two parts. First, the response of Constables Hurst and Powell as the general duties officers who initially engaged with Peter. Second, the subsequent SERT response that brought an end to the siege.202 [179] At the time of the incident, Constable Hurst and Constable Powell had been sworn members of the QPS for approximately two to three years.203 [180] Counsel assisting submitted the evidence before the court, particularly the body worn camera footage, showed the efforts of Constable Hurst and Constable Powell to build rapport through conversation and de-escalate the situation for approximately one hour before additional police arrived. I agree that they should be acknowledged for their professionalism in the circumstances. This was supported by the evidence of Detective Sergeant Edwards. 204 [181] Senior Sergeant Tracy Bailey of the QPS Operational Training Services, provided a statement and gave evidence at the Inquest. As noted in the submissions of Counsel for the Commissioner of Police, Senior Sergeant Bailey considered that it was only after the siege that QPS officers were able to confirm Peter was in possession of a gel blaster.205 [182] The fact that after the siege, QPS officers were able to confirm that Peter was using a gel blaster, has no impact on the threat assessment performed by the initial responding QPS officers, or the SERT operative that fired the single round.206 201 The Australasian Coroners Manual. Hugh Dillon and Marie Hadley, Federation Press, 2015 at 10.

202 Submissions of Counsel Assisting at [102].

203 Exhibit B9.1, L 32 – 33. Exhibit F1.1, L 163.

204 Submissions of Counsel Assisting at [104]. 3 June 2024, T1 – 15, L 14 – 28.

205 Submissions of Counsel for the Commissioner of Police at [5].

206 Exhibit B23 at [104(ii)(e)].

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[183] That Peter had a gel blaster must not be considered in isolation. The body worn camera footage of the siege, coupled with witness accounts, support the opinion that Peter’s actions (including his threats and behaviours over several hours) were intended to make QPS officers believe the gun was real, capable of causing actual harm if fired.

[184] Further to this, Peter used his backpack and clothing to actively obscure a clear view of the gun, adding to the uncertainty and inability of QPS officers and SERT operatives to clearly identify the gun. On numerous occasions Peter adopted a “shooting stance” that further complicated the threat assessment for QPS officers and SERT operatives. It would not have been possible to ascertain that the gun was a replica without close examination.

[185] SO 146’s evidence was that as Peter was behind laminated glass, and had barricaded entry points into the space, less lethal options were not available.207 [186] I accept this submission on behalf of SO 146 that no adverse findings should be made with respect to him, and that throughout the duration of the events on 6 December 2021, SO 146 made all decisions in good faith when faced with a high risk and difficult situation, and the decisions made were reasonable and formed with the information available to him at the time.208 [187] I also accept the submission of the Commissioner of Police that the evidence of Senior Sergeant Bailey confirmed that Peter was an extremely high-risk individual to police at the time, including members of the public. He was in possession of what appeared to be a real firearm and police at the scene provided Peter with several opportunities to surrender and the use of lethal force by the SERT operative was justified and the most appropriate response to the threat posed by Peter at the time, as evidenced by the body worn camera footage.209 [188] Counsel for the Commissioner of Police and Counsel Assisting submitted that I would find, as noted by Detective Sergeant Edwards in his evidence and report, that the ESC investigation found that there was insufficient evidence to support a criminal prosecution against any person and no evidence to support a breach of discipline or misconduct by any police officer in respect of the death of Peter.210 I accept this submission.

[189] On all the evidence before the court, I am satisfied that the police officers involved (including the SERT operatives) acted in accordance with the QPS policies and procedures then in force and were appropriate in the circumstances.

207 3 June 2024, T 1-20, L 26 – 28.

208 Submissions on behalf of SO 146 at [13] – [14].

209 Submissions of Counsel for the Commissioner of Police at [18].

210 Submissions of Counsel for the Commissioner of Police at [17].

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Whether any changes to procedures or policies could reduce the likelihood of death occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice [190] As noted above, Counsel assisting submitted that in the interests of public safety and in an effort to reduce the likelihood of deaths occurring in similar circumstances in the future, that I would consider a recommendation that Queensland legislation be amended to require that persons seeking to possess a gel blaster, hold a valid weapons licence. This submission was supported by counsel for the commissioner of police.

Recommendation I recommend that the Weapons Act 1990 (Qld) be amended to require that persons seeking to possess a gel blaster, or a replica of a weapon, hold a valid Queensland Weapons License.

[191] I extend my condolences to Peter’s family, friends and all those who sought to support him in the community.

[192] I close the Inquest.

Terry Ryan State Coroner Findings of the inquest into the death of Peter Owen Pilkington Page 38 of 38