Coroner's Finding: DUFFIELD Clinton John

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 3rd day of June 2020 and the 2nd day of June 2021, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Clinton John Duffield.

The said Court finds that Clinton John Duffield aged 35 years, late of 84 Penrice Road, Penrice, South Australia died at Vinpac International, 773 Stockwell Road, Angaston, South Australia on the 8th day of February 2017 as a result of an unascertained cause. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Clinton John Duffield was born on 7 March 1981 and died on 8 February 20171 at Angaston. He was 35 years old.

1.2. Mr Duffield’s death occurred in police custody, after he was arrested and physically restrained by police. An inquest must be held to ascertain the cause and circumstances surrounding each death in custody.

1.3. A post mortem examination was conducted by specialist forensic pathologist Dr Karen Heath on 9 February 2017. The cause of Mr Duffield’s death could not be ascertained.

Various samples collected at autopsy were tested for the presence of a wide range common drugs and poisons. A low level of alcohol was detected. THC detected in the blood was consistent with recent use of cannabis. Methylamphetamine was detected, but only in hair samples, in keeping with previous but not recent use.2 1 Mr Duffield was pronounced deceased by an ambulance officer at 12:35am 2 Exhibit C2a

2. Background and personal circumstances 2.1. Mr Duffield was born in Kilmore, Victoria to Gail and Christopher Duffield. His halfsister Justine was 10 years older. Christopher Duffield was in the Australian Army and the family lived in several locations around Australia according to his postings. They moved to Tanunda in 1989 and about 18 months later, when Clinton was 10 years old, his parents separated. Clinton was devastated and did not cope well.3

2.2. Mr Duffield experienced episodes of anger during his teenage years and was a heavy user of cannabis.

2.3. He left school at age 16 and worked in hospitality, then in various jobs with mainly long-term employers, the last of which was Vinpac International (Vinpac) at Angaston, where he was a forklift driver at the time of his death.

2.4. Between 2000 and 2005 Clinton Duffield was in a relationship with Kate Spencer.

Their child, Imogen, was born in July 2004. The couple separated about a year later.

2.5. Mr Duffield had one other serious relationship, with Rebecca Smith4, for about five years from 2009. She ended the relationship due to Mr Duffield's use of drugs, including ice, ecstasy, cannabis and magic mushrooms, and alcohol. She gave an account of a man whose lifestyle was dominated by drug use.

2.6. Mr Duffield was known, amongst family, friends and workmates to grow cannabis, and smoke it heavily, from the age of about 15 years. His regular and excessive use of other drugs was also well-known amongst those who knew him.

2.7. Mr Duffield's medical history is very limited. On 20 April 2012, he was taken by ambulance to the Royal Adelaide Hospital after collapsing. Rebecca Smith stated that Mr Duffield had been taking methamphetamine.5 He had been awake for about seven days to guard his cannabis crop, believing that someone wanted to steal it. Ambulance notes indicate that Mr Duffield lost consciousness for about 10 minutes and then was very confused, agitated and violent. Police were called and a restraint net was required.

Mr Duffield was seen by a doctor at the hospital but discharged himself before any tests were conducted. There is no other relevant medical history.

3 Exhibit C11, Statement of Gail Edge (formerly Duffield) 4 Exhibit C7 5 Exhibit C7, page 2

3. Circumstances surrounding Mr Duffield’s death 3.1. A comprehensive investigation was undertaken by Detective Chief Inspector Robert Papworth of the Commercial and Electronic Crime Branch of South Australia Police.

In his report, Detective Chief Inspector Papworth suggests, and I find, that in the weeks prior to his death Mr Duffield's mental health was deteriorating, although he was not seeking medical treatment for any diagnosed mental health illness or condition.6 Mr Duffield's behaviour, especially his social media activity, became increasingly unusual from about December 2016 until his death.

3.2. During the year before his death, Rebecca Smith received four unsolicited and unwelcome letters7 from Mr Duffield, professing love for her and a deep desire to be with her again. She did not respond. About a week before his death, Ms Smith accidentally called Mr Duffield on Facebook Messenger, inspiring calls from Mr Duffield which she did not answer, and a stream of messages effectively begging her to resume a relationship with him. In this exchange Ms Smith made it very plain that she would not do so and that Mr Duffield’s attention was unwelcome.8

3.3. Mr Duffield’s mother, Gail Edge, last saw Mr Duffield in September 2016 when she visited him at his home, finding him well and in good spirits, and pleased that he was about to be made permanent at work. In the months following, however, Mr Duffield posted rambling and unusual comments on Facebook and sent similar text messages to his mother.9 In December 2016, Ms Edge texted Mr Duffield, expressing concern about him and he responded saying he had ‘never been better’. Sometime in January 2017 Mr Duffield changed his name on his Facebook profile to ‘Kunton Kreamy Kickerfieldinsiderco’. A rambling Facebook post in January 2017 concluded with a statement that he was ‘on a deleting frenzy to get rid of haters drama queens and liars from my life cause ya worthless dooshbags that need to get a life’. On 5 February 2017 Ms Edge expressed concern to Mr Duffield by text message that he might resign from his job. He told her not to worry and said ‘if any1 wants to shit on me I’ll peck their brains out’. She urged him not to put all his thoughts on Facebook. On 7 February 6 Exhibit C84 7 Exhibit C7, Appendix A 8 Exhibit C7, Appendix B 9 Exhibit C11

2017, Ms Edge blocked Mr Duffield on Facebook, to avoid receiving phone alerts at all hours of the night of Mr Duffield’s ramblings.

3.4. Mr Duffield’s father also received rambling messages from Mr Duffield throughout January and into the first week of February 2017, shortly before his son’s death. His efforts to settle his son are evident in the copies of messages attached to his statement.10

3.5. In the days prior to his death Mr Duffield was also displaying unusual behaviour in public. On 5 February 2017 police attended to various complaints of wheelie bins with pot plants on top of them having been placed on a crest in the middle of Penrice Road, Nuriootpa causing a traffic hazard. Jace Falkenberg11 was one of the drivers who had to brake heavily when confronted by this traffic hazard, and his dash cam footage shows Mr Duffield standing nearby, displaying apparent agitation and observing the reactions of drivers. Mr Duffield was spoken to by police and issued with an expiation notice.

3.6. Mr Duffield's neighbour, Benjamin Hilditch, spoke about the bins on the roadway to Mr Duffield, who responded, 'Shh, I know what I'm doing but I can't tell you'.12 Later that evening he said to Mr Hilditch, 'It's all right, I know what I'm doing. Facebook's bugged'. Mr Hilditch said that Mr Duffield seemed more agitated than normal.

3.7. Also in the days prior to his death, Mr Duffield was involved in a workplace dispute with a work colleague at Vinpac, Andrew McKay.13 Mr McKay alleged that at the conclusion of an exchange between them, Mr Duffield had intentionally driven his forklift too close to him, and Mr Duffield asserted that Mr McKay had deliberately got in the way. During a disciplinary interview on 2 February 2017, Mr Duffield said that there was a big drug problem in the Barossa Valley, that there were drug dealers in the Vinpac workforce and that he was going to name them.14 Gary Milhench, the Supply Chain Manager at Vinpac, conducted a further meeting with Mr Duffield the following morning in which Mr Duffield named several employees he asserted were involved with illegal drugs – Mr McKay was not one of them – but he was not prepared to make a statement detailing anything he claimed to know about their activities.15 As to the workplace dispute, Mr McKay and Mr Duffield were both given three-day suspensions 10 Exhibit C12 11 Exhibit C16 12 Exhibit C19 13 Exhibit C10 14 Exhibit C41 15 Exhibit C15

and formal employment warnings. Arrangements were made to ensure that they no longer worked together and information was provided about the Employee Assistance Program, and how to access it.

3.8. During this period Mr Duffield's friends noticed that he had begun to distrust those in his friendship group and he appeared to become increasingly paranoid.

3.9. Tuesday, 7 February 2017 was Mr Duffield’s first day back at work following the suspension. He worked a 12-hour shift, until 8pm. A truck driver, Kevin North, spoke to Mr Duffield at Vinpac shortly after 6pm on that day.16 Mr Duffield was swearing at him and acting aggressively. Mr North recalled that Mr Duffield's eyes were glazed and his demeanour appeared uncoordinated and ‘as if he wasn't all there’. He suspected that Mr Duffield was under the influence of drugs.

3.10. Garry Falkenberg, one of the supervisors at Vinpac, knew Mr Duffield quite well, through working with him and having been his supervisor at times.17 Mr Duffield had not been on his team since being made permanent in August 2016, but still worked with Mr Falkenberg’s crew during some shifts, and would join them on occasions for their weekly after-work beer. Mr Falkenberg knew that Mr Duffield ‘liked a drink’ and had troubles in his past. However, he did not display any issues at work and Mr Falkenberg regarded Mr Duffield as a very good worker.

3.11. At 7pm Mr Duffield pulled up his forklift outside Mr Falkenberg’s office and made it clear that he wanted to talk to him. He expressed anxiety about some messages on his phone and apparent tensions between himself and other persons on social media.

Mr Falkenberg tried to calm Mr Duffield down and offered to catch up with him at 8pm, the end of shift, at which time Mr Duffield came back to his office and sat down, plainly anxious, agitated and paranoid. He wanted to show Mr Falkenberg messages on his phone but Mr Falkenberg declined. He spent 15 to 20 minutes trying to calm Mr Duffield down. He shook Mr Duffield’s hand, told him he was a good bloke and that he could see the good in him but that whatever was going on in his head he needed to ‘dial it down’. At 8:20pm he saw Mr Duffield drive out of the car park in his green Subaru. Mr Falkenberg received some bizarre text messages from Mr Duffield at about 9:30pm.

16 Exhibit C18 17 Exhibit C43

3.12. After Mr Duffield left Vinpac he was driving erratically in the vicinity of Penrice. For the purposes of my findings, it is necessary to refer only to a few of the many statements from members of the public who witnessed Mr Duffield’s reckless and dangerous driving between 9:30pm and 10:30pm.

3.13. At about 9:30pm his neighbour, Ben Hilditch, heard him rev his vehicle loudly, before driving off from his house.

3.14. Carl Sedgwick heard a loud vehicle going back and forth past his house four or five times and, after walking out to the street, recognised Mr Duffield's vehicle as it suddenly braked and then hit the kerb outside his house.18

3.15. Lara Goudie was packing up furniture outside Wanera Wine Bar at 9:50pm when Mr Duffield drove towards her, screeching the vehicle’s tyres, driving in what she describes as an ‘S’ formation and then doing a 360-degree circle.19 The vehicle stopped about a metre and a half in front of her, whereupon she told him, in a word, what she thought of him, to which he just laughed. She watched as he sped off, narrowly missing two cars, as he sped between them at the intersection of Murray Street and Penrice Road.

3.16. Malcolm Schmidt was in his vehicle delivering newspapers at Angaston between 10pm and 10:30pm.20 He describes the green Subaru screeching and roaring towards where his vehicle was parked in the business area of Murray Street before coming to a screeching halt, and then accelerating away, generating wheelspin and a lot of smoke.

A short time later, when he was about to turn his vehicle into Penrice Road, the same vehicle approached rapidly from Penrice Road and cut the corner at speed onto Murray Street, narrowly avoiding a collision with an approaching white Ford. He then watched the green Subaru drive west along Murray Street for about 100 metres before conducting a sudden U-turn, with significant wheelspin and smoke, and crossing onto the wrong side of the road, heading straight towards Mr Schmidt’s vehicle. The Subaru then passed between his vehicle and the white Ford, which it had narrowly missed moments earlier, before again conducting a screeching U-turn and driving straight 18 Exhibit C35 19 Exhibit C29 20 Exhibit C39

towards another oncoming vehicle, which it avoided by swerving, at the last moment, onto the correct side of the road.

3.17. At about 10pm police officers Senior Constable First Class Donna Waldhuter21 and Constable Dennis Geraghty22 attended the home of Bianca Ottawa23, who had reported the green Subaru knocking over the wheelie bin outside her house and then apparently intentionally using the bin to push her parked vehicle on a number of occasions, in the process of which the Subaru also clipped her husband’s vehicle. When the police left, to look for the vehicle and its driver, they were hailed by Benjamin Hilditch, from whom they learned that the green Subaru was driven by his neighbour. He did not exactly know Mr Duffield’s name. The police were still in their vehicle, talking to Mr Hilditch, when the Subaru was heard approaching, revving loudly with tyres screeching. As Mr Hilditch retreated into his house and Constable Geraghty activated emergency lights and started driving the police vehicle away, the green Subaru drove directly at their vehicle. Constable Geraghty swerved to avoid a collision and then conducted a U-turn, but moments later the Subaru undertook a U-turn and accelerated rapidly directly at the police vehicle, which Constable Geraghty had to drive in reverse, to retreat into a small side street to avert a collision. Mr Hilditch and another witness, Matthew Downes24 provided estimates that the Subaru drove at the police vehicle at a speed of more than 100 kilometres per hour.

3.18. Senior Constable Waldhuter then got out of the police car. She warned some members of the public to return to their houses.

3.19. Constable Geraghty was extremely concerned that other members of the public who were out on the street were in immediate danger from the reckless manner in which the green Subaru was being driven, and the driver’s apparent poor control of the vehicle during the many extreme manoeuvres being undertaken. He decided to try to get the driver of the Subaru to actively follow the police vehicle, to reduce the risk of the vehicle mounting a kerb and hitting a pedestrian. Constable Geraghty deliberately allowed the Subaru to get a little closer to him on Penrice Road heading north before pulling the police car out to head north, ahead of the Subaru. He then drove along Penrice Road towards the quarry, with the Subaru following. However, the driver then 21 Exhibit C57 22 Exhibit C58 23 Exhibit C26 24 Exhibit C32

appeared several times to attempt to ram the police vehicle. This was observed by a witness, Luke Rider.25 Constable Geraghty to decide to pull over suddenly, in front of a parked vehicle and he allowed the Subaru to drive away. The precise location of the green Subaru was then unknown to police for a time, despite efforts to locate it, until receiving information about the vehicle’s arrival at Vinpac.

3.20. Detective Chief Inspector Papworth, in his investigation report, suggested that Constable Dennis Geraghty demonstrated exceptional initiative and courage, during the driving incident at Penrice, by drawing Mr Duffield away from bystanders. I agree with that suggestion.

3.21. In the meantime, Mr Rider saw the vehicle driving on its own at approximately 70 kilometres per hour on Penrice Road, this time towards Angaston, with the sound of metal on bitumen indicating that the Subaru had at least one flat tyre.

3.22. Garry Falkenberg was still working at Vinpac at about 10:30pm when the screeching of tyres was heard coming from the car park. He saw Mr Duffield get out of his green Subaru and spend about a minute hitting and damaging a black Holden Commodore that was parked in the Vinpac car park. The engine of the Subaru was still running and music was blaring. Mr Duffield was yelling profanities, missing one shoe and hobbling. Mr Falkenberg asked him what he had done and Mr Duffield said something to the effect of ‘fixing all the crackheads'. Mr Falkenberg contacted the shift manager, Jason Young26 who arrived with Mark Burgess27, and the three men ushered Mr Duffield to the smokers’ hut, a small freestanding structure surrounded on three sides by a 2.4 metre high Colorbond fence with a single entrance and exit point and bench seating inside. Mr Falkenberg went to the Subaru and turned off the engine, before returning to the smokers’ hut.

3.23. In the hut, Mr Duffield was raving incoherently. He told the men that he had been involved in a police chase driving at 170 kilometres per hour. He stated, 'The police can't catch me, the police are running away from me'. He was rambling about drug dealers and UFOs.

25 Exhibit C21 26 Exhibit C41 27 Exhibit C42

3.24. Mr Falkenberg describes him as wide-eyed and frantic, and ‘about to explode’ but said he was able to calm him down.

3.25. Mr Burgess states that Mr Duffield's demeanour was very up and down; he would go from being quite calm to very erratic, distressed and even aggressive.

3.26. Mr Young left the smokers’ hut and called police at 10:31pm. He saw that Mr Duffield's vehicle had a rear wheel off and a flat front tyre. This was later confirmed upon examination by police. Clearly it was undriveable. He states that he and Garry Falkenberg kept Mr Duffield calm for about 15 minutes, before the police arrived.

3.27. Sergeant Philip Carlson28 was on duty as supervisor in the police station at Nuriootpa.

At 9:58pm on Tuesday, 7 February 2017 he became aware that police officers Waldhuter and Geraghty were attending Ms Ottawa’s address at Penrice as a result of the property damage complaint I have previously referred to. At 10:20pm he received a call from an off-duty police officer advising that there was a vehicle doing burnouts in the Penrice area. At about the same time, he heard Constable Geraghty’s radio transmissions, initially that a vehicle was driving at his police car and then that the vehicle was driving at and trying to ram the police car and he was taking evasive action.

Sergeant Carlson was also aware that a second police patrol had been tasked to the area as backup. He left the station and commenced urgent duty driving to the area.

3.28. At about 10:37pm Sergeant Carlson was advised by SA Police Communications Centre (COMCEN) that Mr Duffield had arrived at work at Vinpac. Sergeant Carlson attended there immediately and set up a loose cordon, awaiting further police, who quickly arrived. Sergeant Carlson received further information via COMCEN that the man had damaged another vehicle in the car park, was in the smokers’ hut with other workers and was agitated.

3.29. Sergeant Carlson received a call from Brevet Sergeant Barry Shedden, who said that he was a police crime scene member at Holden Hill and that Clinton Duffield was his brother-in-law. Mr Shedden said that he and his wife knew that Clinton Duffield had been on a two-day drug bender, that he hated police and would fight if arrested.

28 Exhibits C59 and C59a

3.30. Brevet Sergeant Shedden29 had been monitoring his police radio and heard an urgent request for assistance, relating to a green Subaru that was ramming or attempting to ram a police vehicle. He then heard over the radio that the suspect was named Clinton James May or similar. Brevet Sergeant Shedden telephoned his wife. He confirmed her brother's details, including name, date of birth and that he owned a green Subaru WRX.

It is obvious that Brevet Sergeant Shedden assumed that the man then thought perhaps to be ‘Clinton James May’ was in fact his brother-in-law Clinton John Duffield. Brevet Sergeant Shedden then provided those details by telephone to Sergeant Carlson. In his addendum statement, dated 11 June 2020, Brevet Sergeant Shedden said that although he could not by then recall telling Sergeant Carlson that Mr Duffield had been on a twoday drug bender, hated police and would fight if arrested, he did not dispute that he said these things. He said that he had spoken with his wife (Mr Duffield’s sister) about Mr Duffield earlier that evening and although he could not remember details of the conversation, Mr Duffield’s drug use had been mentioned. He said his statements that Mr Duffield hated police and would fight if arrested were based on his own observations and limited interactions with Mr Duffield from 2009 and from discussions over the years with his wife.

3.31. I infer from all the circumstances that Brevet Sergeant Shedden had gleaned information from his wife, which was known amongst Mr Duffield’s extended family, of Mr Duffield’s bizarre recent communications with his mother and father and ramblings on Facebook, and that it was believed by some in the family, and not unreasonably by Brevet Sergeant Shedden, that Mr Duffield was on a drug bender.

3.32. In fact, toxicology testing undertaken upon Mr Duffield’s post mortem drug samples did not support the assertion that he had been on a drug bender, in that no evidence was found of recent use of stimulants such as methamphetamine or cocaine, although it did find evidence of recent use of cannabis.

3.33. A police briefing was held soon after 10:37pm at the Stockwell Road entrance to the Vinpac facility. It was conducted by Sergeant Carlson and attended by Senior Constable Waldhuter, Constable Geraghty, Constable Tonkin, Senior Constable Stevenson, Senior Constable Bevis, Senior Constable Twiggs, Detective Brevet Sergeant Grayshon and Detective Brevet Sergeant Davies.

29 Exhibits C60 and C60a

3.34. Sergeant Carlson directed that Mr Duffield’s arrest would be effected with an initial direction to comply, and if there was no compliance there was to be an immediate ‘hands-on’ arrest, to subdue him as quickly as possible. Constable Geraghty was to be the arresting officer.

3.35. Mr Duffield’s father raised with the Court, through counsel assisting Mr Plummer, a concern that the apparently false information that Mr Duffield had been on a two-day drug bender played a pivotal role in a decision to effect a hands-on arrest, and that if a hands-on arrest had not been undertaken, Mr Duffield’s death may have been avoidable, as Mr Duffield died whilst subject to physical restraint by police.

3.36. Sergeant Carlson’s addendum statement30, dated 9 June 2020 explains the decision to effect a ‘hands-on’ arrest if Mr Duffield did not initially comply voluntarily. He asserts that he would have ordered a ‘hands-on’ arrest in the event of initial non-compliance, regardless of the information provided by Brevet Sergeant Shedden. He already had a lot of information about Mr Duffield’s dangerous and reckless behaviour that evening, which indicated to him a readiness to cause harm to police and recklessness as to the welfare of bystanders. The occasions of driving at police indicated to him that Mr Duffield would not be likely to cooperate with police. Sergeant Carlson was aware that Mr Duffield was unarmed and was not, at the time of police arrival, acting violently within the smokers’ hut. However, he was also aware that other employees were in the hut and neither he nor other police could see inside the hut. He considered that if police were to ‘cordon and contain’ Mr Duffield in the smoking hut and then proceed to negotiate with him (rather than to proceed with an immediate, hands-on arrest) there was a greater risk to both Mr Duffield and the other employees in the hut, as Mr Duffield might become erratic and violent upon becoming aware of police presence, without police being aware of this because they could not see inside.

3.37. I accept Sergeant Carlson’s assertion that although he took into account what he had been told by Brevet Sergeant Shedden, he would have ordered a ‘hands-on’ arrest in the event of initial non-compliance, even without that information. I find that Sergeant Carlson’s decision that police would enter the smokers’ hut and effect a hands-on arrest in the absence of Mr Duffield’s immediate cooperation was appropriate and reasonable 30 Exhibit C59a

in the circumstances, with or without regard to the information which Sergeant Carlson received from Brevet Sergeant Shedden.

3.38. My findings as to what then occurred when police entered the smokers’ hut, arrested Mr Duffield and emerged carrying him, restrained, into the car park, are based on the statements of those who entered, namely police officers Carlson, Geraghty, Waldhuter, Twiggs31, Bevis32, Tonkin33, Stevenson34, Davies35 and Grayshon36, together with statements of several Vinpac employees who left the hut upon police entry and were outside, nearby.

3.39. At about 10:47pm police entered the smokers’ hut where they saw Mr Duffield sitting with Mr Falkenberg, Mr Young and Mr Burgess. They were asked to leave.

Mr Duffield was sitting on a bench with a gold vape in his hand and was talking about drug dealers and having to lock his dog in his house because of them. He told police that he drove at them to get them off the street. Constable Geraghty directed Mr Duffield to drop his smoking implement and Mr Duffield refused. At about 10:49pm Constable Geraghty took Mr Duffield by the right arm to place him under arrest but he struggled and resisted immediately. The police present were involved to different degrees in restraining and subduing Mr Duffield as he resisted, kicking at police and thrashing his body and legs. Handcuffs were applied to Mr Duffield's wrists, to the rear of his body. Flex-cuffs were placed on his lower legs. Mr Duffield was yelling at and abusing the police. Several of them described him as exhibiting super strength. They were aware of the (incorrect) information that Mr Duffield had been on a drug bender. It is unsurprising that at least some of them assumed that his conduct, including his ‘super strength’, was drug-related.

3.40. Sergeant Carlson saw that Mr Duffield had a small cut and some blood on his forehead.

This, together with Mr Duffield’s extremely erratic and dangerous behaviour and the prior information that he had been on unknown drugs for possibly up to two days, led him at 10:52pm to request the attendance of an ambulance to assess and treat 31 Exhibit C61 32 Exhibit C62 33 Exhibit C63 34 Exhibit C64 35 Exhibit C65 36 Exhibit C66

Mr Duffield prior to conveyance to police cells. At 11:03pm he requested an estimated time of arrival.

3.41. During the arrest, from outside the hut, Jason Young heard Mr Duffield screaming at the police, who were telling him to cooperate and not to resist. He said the sounds of a struggle went on for about five minutes. He saw a police officer come out of the hut and return with plastic restraints.

3.42. Garry Falkenberg described leaving the smokers' hut with about eight police inside and more outside, and then ‘all hell broke loose’ inside the smokers’ hut. Mr Duffield was screaming and yelling, and police were yelling at him to stop resisting.

3.43. Mark Burgess heard Mr Duffield saying, ‘Get off me you’re hurting me’ and police saying, ‘Stop resisting’.

3.44. Matthew Stamford37 arrived at Vinpac to begin nightshift as police were inside the smokers’ hut. As he parked his motorcycle next to the hut and took off his helmet, he could hear police officers talking to Mr Duffield telling him to calm down.

Mr Stamford remained next to the hut for the duration of the incident and although he could not see inside, he was closer than the other men and had the best position of any of the civilian witnesses to hear what was occurring inside. He describes police telling Mr Duffield repeatedly to calm down. He heard Mr Duffield swearing and yelling abuse at the police and screaming loudly, ‘What have I done, what have I done’, over and over. Within about a minute it turned into a commotion in the smokers’ hut. He said it sounded like the officers were wrestling and trying to restrain Mr Duffield.

Mr Stamford stated that while Mr Duffield was being carried out of the smokers’ hut, face down and handcuffed behind his back, Mr Duffield was still kicking and moving about and yelling abuse at the officers.

3.45. Unquestionably police were exercising a lawful power of arrest. I find that the arresting police acted lawfully and appropriately in exercising force to arrest and restrain Mr Duffield.

3.46. I have considered the statements of the various police and civilian witnesses as to the removal of Mr Duffield from the hut and what then occurred.

37 Exhibit C44

3.47. Mr Falkenberg saw police come out of the hut and heard Mr Duffield continue to carry on screaming for about 15 minutes before it went quiet.

3.48. Mr Young described Mr Duffield being carried out of the hut with his hands restrained behind his back and legs restrained together. He could see that Mr Duffield was conscious, and could hear him yelling and screaming. He said that Mr Duffield was making animalistic sounds ‘like squirrels’ and was saying 'Help me, leave me alone'.

3.49. Mr Burgess said that when Mr Duffield was being carried out of the smokers’ hut he was face down with hands restrained behind his back. He was breathing heavily as he was being carried out, but not necessarily resisting.

3.50. I find that Mr Duffield was carried out of the hut horizontally and placed on the ground, in the first instance face down. He was quickly rolled onto his side by police who were aware of the risk of positional asphyxia, and he was thereafter prevented from rolling over. Mr Duffield continued to struggle and was rambling incoherently. Senior Constable Bevis used Mr Duffield's own belt to secure his thighs together.

3.51. A video camera was activated by Senior Constable Waldhuter at 11:13pm, a little over 20 minutes after Mr Duffield was taken into custody.38 File 00004 is a video file which runs for 25 minutes 14 seconds. Initially this file records Constable Geraghty reading Mr Duffield his rights upon arrest. Mr Duffield can be seen lying on his side in the recovery position with a flex-cuff around his ankles and belt around his legs. One police officer is kneeling on Mr Duffield's legs. Constable Geraghty is first heard to ask Mr Duffield for his attention, and Mr Duffield may be seen nodding his head, apparently in response.

3.52. Constable Geraghty said: ‘You have been arrested for acts to endanger life x 2, engaging in police pursuit, property damage and resist. At this stage there may be further charges.’ This took about 35 seconds, during which time Mr Duffield muttered continuously, saying: ‘You’re gonna get fucked up, I’m gonna make you toast, I’m gonna fucking fuck you up.’ 38 Exhibit C84f, File 00004

There were a few further words which I could not discern but which appeared to be in the same vein. While there was a rambling quality about what he said, it is at least clear that that Mr Duffield was conscious, understood he was being spoken to, and was responding.

3.53. Constable Geraghty continued: ‘As an arrested person, you have the following rights. You are entitled to make in the presence of a member of the police force one telephone call to a nominated relative or friend to inform them of your whereabouts. Do you understand?’

3.54. Mr Duffield said, ‘Fuck you’ during the early part of Constable Geraghty’s words but did not otherwise respond. This was the last verbal response by Mr Duffield to the reading of his rights, during which Constable Geraghty invited a response from him on ten occasions. On each of those ten occasions, Constable Geraghty is heard to say, ‘No response’ to indicate that there was no response from Mr Duffield.

3.55. The reading of Mr Duffield’s rights took about three minutes, during which time police clearly became concerned about Mr Duffield’s diminishing responsiveness (although he is still plainly breathing) and a police officer is seen at various times to tap Mr Duffield on the chin, shake him by the shoulder and squeeze his ear.

3.56. By about 11:17pm, after completion of the reading of rights upon arrest, police were clearly concerned about Mr Duffield’s condition. An officer is heard to ask if SAAS (South Australian Ambulance Service) can be asked to hurry up because Mr Duffield was ‘not really responsive any more’, although it was noted that he was still breathing.

It was also observed by a police officer that Mr Duffield had urinated. Police can then be seen attempting, unsuccessfully, to rouse Mr Duffield and at about 11:18pm a police officer is seen checking his pulse and announcing that Mr Duffield is snoring. The belt was removed from Mr Duffield’s knees, the flex-cuffs were removed from his lower legs and he was released from the handcuffs so his arms could be placed in front of him whilst he was maintained in a position on his side. The care and concern of attending police was evident, as calls were made to ensure that the ambulance now attended as a matter of urgency, and the question of whether Mr Duffield’s condition might be drugrelated, or the product of exhaustion, or something else, was discussed. Police continued throughout to monitor Mr Duffield’s pulse and respiration and 15 minutes after the commencement of the recording, at a time which I find to have been about

11:28pm, the three police who had been monitoring his pulse and respiration agreed that CPR was required, and it was immediately commenced. It was clear that Mr Duffield had a pulse and was breathing until then. After the first round of chest compressions and ventilation through a laryngeal mask, Mr Duffield was said to have a faint pulse and it was decided to connect an automatic electronic defibrillator, which was obtained from Vinpac and was in place by about 11:33pm, with chest compressions and ventilation continued in the meantime. Thereafter, police continued to perform CPR in accordance with the instructions delivered by the defibrillator.

3.57. At 11:40pm an ambulance arrived and ambulance officers took over and continued resuscitation efforts. Dr David Adams39, a general practitioner from the Angaston Medical Centre arrived at 11:45pm. When he arrived, a police officer was performing cardiac compressions and an ambulance officer was ventilating Mr Duffield. Dr Adams was satisfied that cardiac compressions and ventilation were being undertaken appropriately. He noted that the cardiac monitor showed the heart to be in asystole (no rhythm at all). He inserted an intravenous line and administered adrenaline. The heart was still in asystole so a second dose of adrenaline was administered about five minutes after the first dose, followed by a further dose four or five minutes later. These efforts to restart a heart rhythm were also unsuccessful. In consultation with intensive care paramedic Patrick Millar, Dr Adams instructed that CPR be ceased. This occurred at 12:15am.

3.58. At 12:35am on 8 February 2017 Mr Duffield was pronounced ‘life extinct’ by Mr Millar.

4. Were the resuscitation efforts appropriate?

4.1. A detailed review and analysis of Mr Duffield’s care and the efforts to resuscitate him by police and ambulance personnel, as shown in the video recording in Exhibit C84f, was undertaken by Wayne Stoddard, SAAS Operations Manager for Clinical Development, a qualified intensive care paramedic who, at the time of providing his statement in March 2017, had been employed by SAAS for 16½ years.40

4.2. Mr Stoddard observed that in the first phase (of some 15 minutes), prior to commencing CPR, the police had called for an ambulance and continually monitored and assessed 39 Exhibit C46 40 Exhibit C50

Mr Duffield. They had Mr Duffield in the correct recovery position and, other than monitoring and recognising in due course that there was no pulse, there would be nothing else that an ambulance paramedic could expect a bystander or first-aider to do.

4.3. Mr Stoddard examined in detail the CPR provided by police to Mr Duffield. It is not necessary here to reproduce the detail of that analysis. It suffices, for present purposes, to refer to Mr Stoddard’s opinion that the police provided good and effective CPR to Mr Duffield.

4.4. I note also that Dr Adams, in his statement, commended both the police and ambulance officers present for their CPR efforts and the standard of the CPR given by both police and ambulance officers.

5. Delay in ambulance arrival?

5.1. The first request for an ambulance was made at 10:52pm, immediately after Mr Duffield was restrained and taken into custody. A volunteer crew at Hamley Bridge was dispatched at 11:01pm. It was 49 kilometres away. At the time of the dispatch there was a closer volunteer crew available at Kapunda, 31 kilometres away. Neither of the Barossa dedicated paramedic crews was available as they were tasked to other events. At this stage the tasking was a Priority 3. The initial request was to assess and treat Mr Duffield before he was placed in a cage car and taken to police cells.

5.2. The situation was evolving. At 11:14pm SAPOL provided information to say that Mr Duffield was deteriorating and was unconscious and at 11:18pm the event was upgraded to Priority 2, requiring a lights and sirens response.

5.3. At 11:32pm, the tasking was upgraded to a Priority 1 and the ambulance from Hamley Bridge arrived on the scene at 11:40pm, a response time of 39 minutes.

5.4. The Kapunda crew was dispatched at 11:27pm and arrived at 11:58pm, a response time of 31 minutes. It may be seen that the Kapunda crew was able to arrive more quickly than the Hamley Bridge crew, but arrived later due to later dispatch. However, priority was initially allocated based upon the initial information provided by SAPOL of Mr Duffield’s condition upon arrest. As Mr Duffield’s condition deteriorated, this was communicated to SAAS and the event priority grading was upgraded accordingly.

5.5. Most significantly though, the first-aid rendered by police officers at the scene was considered good and effective, and I find it to have been so.

5.6. There is no basis upon which to find that earlier ambulance arrival would have provided a greater chance of survival for Mr Duffield.

6. Pathologist’s evidence as to the cause of death – Dr Heath 6.1. As I stated at the outset, a post mortem examination was conducted by specialist forensic pathologist Dr Karen Heath on 9 February 2017. Dr Heath gave evidence during the inquest to explain her investigations and elaborate on her findings. Her evidence was of considerable assistance to the Court and, I am sure, to members of Mr Duffield’s family, in facilitating an understanding of the matters which might have contributed to Mr Duffield’s death, even though she could not firmly express an opinion as to the cause of death.

6.2. During the autopsy Dr Heath collected blood and other samples which were sent for toxicological analysis at Forensic Science SA.41 Professor AC Thomas conducted a detailed examination of Mr Duffield’s heart.42 Mr Duffield’s brain was subjected to specialist examination by neuropathologist, Professor PC Blumbergs.43 Dr Heath had their reports available to take into account during the preparation of her opinion and report. Her post mortem report was received at the outset of her evidence.44

6.3. Dr Heath explained that she had been provided with, and carefully viewed, a copy of the video recording files 00004 and 00005.45 She had also been made aware by investigating officers of the circumstances of Mr Duffield’s behaviour in the days and hours leading to his arrest, as well as the circumstances of his arrest, including his resistance and the police response, and the restraints which were applied. She was also aware that at some stage police had received information suggesting Mr Duffield had been on two-day drug bender.

41 Exhibit C2a, Toxicology Summary Report, 42 Exhibit C4a, Anatomical Pathology Report, 43 Exhibit C3a, Macroscopic Brain Report, 44 Exhibit C90, Post Mortem Report 45 Exhibit C84f

6.4. Under the heading ‘Anatomical Findings’ Dr Heath listed eight findings, none of which, in her view, had any bearing on the cause of death.46

6.5. The first finding was of moderate coronary artery atherosclerosis involving the left main and left anterior descending coronary arteries. The narrowing at each of the measured sites was 54% and 56%. She explained that to be considered anatomically significant and a potential cause of death, the narrowing is generally accepted to need to be 75% or greater, or otherwise associated with clear evidence under the microscope of death of cardiac muscles. There was no evidence of death of cardiac muscles under microscopic examination by Professor Thomas of Mr Duffield’s heart. Dr Heath stated that in her opinion the narrowing of Mr Duffield’s arteries made no significant contribution to the cause of his death.

6.6. The second anatomical finding was of focal interstitial fibrosis in the superior aspect of the intraventricular septum. This was ascertained by the specialist cardiac pathologist Professor Thomas. Dr Heath stated it is a common finding in the intraventricular septum and was only a very small area of connective tissue around the heart muscles themselves which, she explained, of that small size and in that location, is not considered to be significant.

6.7. The third anatomical finding was a small right frontal parasagittal meningioma with compression of underlying cerebral cortex. This was a finding in the brain, ascertained by Professor Blumbergs. She explained that this was a small benign tumour within the brain, but of the covering surface of the brain not of the brain cells themselves, just slightly to the side of where the brain divides into the right side and the left side. It is a type of ‘very, very, very slow-growing tumour’47, which is not an uncommon finding at post mortem examination and when people have CT scans for other reasons. These tumours, she explained, generally do not cause any symptoms until they become ‘very, very large’ and because they grow so slowly the brain around them can compensate and move out of the way with no effect on the surrounding brain. Dr Heath expressed the view that this finding had ‘nothing to do with Mr Duffield’s death’.

46 Exhibit C90 47 Transcript, page 40

6.8. Dr Heath’s fourth anatomical finding was of scattered superficial abrasions and bruising of the face, upper and lower limbs. These she said she regarded as consistent with having occurred during the struggle during and after apprehension.

6.9. The fifth and sixth anatomical findings were subcutaneous bruising of the upper back in the region of the shoulder blades and subcutaneous bruising of the right side of the mid to low back. These she considered may have occurred during a struggle and also may have occurred during resuscitation attempts, particularly from the quite forceful compressions which are required in CPR, which she considered would have exerted pressure between Mr Duffield’s back and the hard surface which he was lying on.

6.10. The seventh anatomical finding was of circumferential red bruises around both wrists and around the left ankle, which Dr Heath considered to be consistent with the application of restraints.

6.11. The eighth and final anatomical finding was of right-sided rib fractures, a common finding in people to whom chest compressions have been applied during CPR.

6.12. Dr Heath answered some questions about positional asphyxia, a matter about which some of the police involved in the arrest and subsequent restraint and treatment of Mr Duffield expressed concern. Positional asphyxia, she explained, generally refers to when a person is in a position that hampers either oxygenation of blood or blood supply to the brain.48 Typically, it occurs when a person is suspended upside down. It can also occur as a result of the position or method of restraint. Dr Heath gave evidence that there was ‘no evidence of any asphyxia’ in the post mortem findings.49 Further, in determining whether positional asphyxia played any role in the cause of Mr Duffield’s death, Dr Heath had the benefit of viewing the video in Exhibit 84f. She referred to Mr Duffield’s position lying on his side on the ground, as shown in the video from soon after its commencement at 11:13pm and expressed the opinion that asphyxia was ‘not a component’ which contributed to Mr Duffield’s death. The recovery position or the lateral position, as she described it, was not a position which would hamper either blood flow to the brain or hamper Mr Duffield’s breathing. Neither, she said, could asphyxia have resulted from being carried from the smokers’ hut to the car park, face down, with hands cuffed behind his back, thighs restrained with a belt and legs restrained with a 48 Transcript, page 42 49 Transcript, page 42

flex-cuff. This opinion was based on two factors. Firstly, Dr Heath said that if one were to argue that being in the prone position caused or contributed to his death, then the death would have needed to occur either whilst Mr Duffield was ‘in that position or very, very close to the time that he was in that position’.50 In her view, the fact that Mr Duffield was demonstrably alive and breathing and talking and conscious for a substantial period after being carried in the prone position, excluded the possibility that positional asphyxia from being carried prone was a contributing factor to Mr Duffield’s death. Dr Heath also referred to literature regarding multiple randomised controlled double-blind studies involving volunteers placed into prone maximal restraint positions, with numerous physiological measurements taken. The conclusions were that the prone maximal restraint position causes no significant change to the physiology in these people. Vigorous exercise before the testing made no difference.

6.13. Dr Heath also expressed the opinion that having his lower legs leant on by a police officer, as shown on the video could have no impact.51

6.14. When asked whether the fact that the arrest was physical, with restraints, could have contributed to Mr Duffield’s death, Dr Heath expressed doubt that the nature of the arrest would have contributed, but explained that any physical activity or physical struggle might be a contributing factor linked with other features namely the agitation, the unusual behaviour, the aggression, and the disordered thinking.52 Dr Heath explained that it is also clearly documented in the medical literature that there are people who have died suddenly under similar circumstances without restraint, who have also suffered a sudden cardiac arrest.

6.15. Dr Heath also explained that Mr Duffield’s unusual behaviour leading up to his death raises the possibility that he may have had an underlying psychiatric disorder, or that there may possibly have been a drug-induced psychosis or alteration in mental state.

She gave evidence that people with primary schizophrenia have an increased risk of sudden cardiac death over the risk existing in the general population.53 She said that the mechanisms or the reasons why are quite poorly understood, but such people are more prone to having cardiac arrhythmia, or an abnormal rhythm of the heart and the way it beats, than the general population. They are also known to have an increased 50 Transcript, page 44 51 Transcript, page 46 52 Transcript, page 46 53 Transcript, page 47

risk of long QT syndrome, a specific abnormality of cardiac rhythm.54 She explained that if Mr Duffield did have an underlying psychiatric disorder, that might be a factor predisposing him to an abnormal cardiac rhythm. Similarly, if there had been any underlying illicit drug use, contributing to a drug-induced psychosis or alteration in mental state, this might have contributed in the same way. She clarified that her reference to drug use might include drug use in the days and weeks beforehand rather than necessarily immediately before death, which would lead to an elevated level of that drug in the blood at the time of death. These were possibilities she considered to be raised by the reports of Mr Duffield’s behaviour, but were not things she could unequivocally confirm from the autopsy findings.

6.16. Dr Heath was then asked to explain the concept of ‘excited delirium’ and to address whether, in the circumstances of this case, it could be regarded as a cause of death. She explained excited delirium is a term used to describe a particular set of circumstances, in which a person has a behavioural disturbance which could be described as an acute psychosis, so there are abnormalities of behaviour and thought and reasoning. It is often associated with violent behaviour, sometimes necessitating restraint but restraint is not always a feature. Illicit drug use is often a feature, particularly stimulants such as cocaine and methamphetamine, as is a documented psychiatric illness, usually with psychotic features. It is commonly recognised in hospital emergency departments where people can present with very disordered thinking, disordered behaviour and agitation. Dr Heath explained that excited delirium does not always cause sudden death but there is an association between the two.55 She described it as a term used to describe a kind of collection of a certain type of features rather than being a formalised diagnosis.

Other features which are part of excited delirium include that people are often unresponsive to verbal reasoning or requests; they often have what has been described as ‘super-human strength or appear to be very, very strong’ and continue to struggle and be physically active beyond what they normally could; they are often very tolerant to pain; sometimes but not always they may exhibit hyperthermia or elevated temperature.56 She said that in a certain subset of cases these people are known to have a sudden cardiac arrest similar to what happened in Mr Duffield’s case. Dr Heath was only aware of one case in Australia where ‘excited delirium’ had been given as a cause of death. She said that in any event, she would not give excited delirium as a cause of 54 Transcript, page 47 55 Transcript, page 51 56 Transcript, page 52

death in this instance because it is not a medical diagnosis and does not explain what is actually happening in the body that has led to the cardiac arrest (or the heart stopping beating).57 She said there was some features in Mr Duffield’s case similar to what she described as the ‘so-called excited delirium syndrome’, namely the apparent acute psychosis and the violent behaviour necessitating restraint, but there were also some features which did not fit, such as the absence of stimulant drugs and the absence of a clearly documented psychiatric illness.

6.17. Dr Heath also referred to the possibility that where a person has so-called excited delirium, as can happen with athletes who have undergone extreme physical exertion, their potassium levels rise substantially, perhaps leading to hyperkalaemia and then, upon stopping exercise and resting, the potassium levels can fall very, very rapidly.

Potassium is an important electrolyte in the blood, or components of blood, which helps control cardiac rhythm, and people with either extremely high or low levels of potassium can suffer cardiac arrhythmias. So, Dr Heath stated, it has been postulated that in excited delirium one of the possible causes for cardiac arrest is an abnormality of potassium levels, which increase when the person is struggling and exerting and then possibly drop suddenly when the exertion ceases.58

6.18. Dr Heath referred to another theory, that changes in adrenaline or noradrenaline levels, as a result of extreme exertion during excited delirium syndrome, is another proposed mechanism for causing abnormalities of heart rhythm.

6.19. Finally, on excited delirium or excited delirium syndrome, Dr Heath said that these various postulated or proposed mechanisms of sudden death during excited delirium syndrome have not been able to be validated by randomised controlled trials because this setting is not one in which you can conduct an experiment on someone whilst they experience this distressing syndrome.

6.20. In conclusion, in stating her opinion that the cause of Mr Duffield’s death could not be ascertained, Dr Heath gave the following answer which, in my view, satisfactorily states and explains the lack of certainty: ‘In Mr Duffield’s case, I believe that his cause of death is multifactorial or the combination of lots of different factors together. There are multiple possibilities and I don’t think that anyone can say whether it’s one factor alone which has caused it, more importantly than another. In fact, it is possibly more like a domino effect where there are multiple factors 57 Transcript, page 53 58 Transcript, page 54

where it may be exertion and an abnormality of potassium function arising on a background of someone who may have an underlying genetic predisposition to, say, long QT interval, so it may be a combination of either pre-existing genetic factors with other factors on top of it and there is a domino effect that each one on its own would not have caused a cardiac arrest but put them all together and it’s had a terrible outcome. It’s impossible to pinpoint which factor started it or which factor was the most significant but all of them together, potentially, have resulted in Mr Duffield’s heart stopping beating and that’s what has ultimately caused his death.’59

7. Conclusions 7.1. There was no evidence disclosed during the investigation or the inquest to suggest that there should have been any intervention by SAPOL or any other agency or health provider, if Mr Duffield was suffering from a mental illness prior to 7 February 2017.

7.2. The police response to Mr Duffield’s conduct after leaving work on 7 February 2017 was appropriate and neither the investigation nor the inquest revealed any failure to comply with applicable legislation, SAPOL General Orders, practices and procedures.

7.3. Mr Duffield’s driving on the evening of 7 February 2017 was aggressive, dangerous and posed a considerable threat to the safety of police and bystanders. Neither the investigation nor the inquest revealed any departure, during police operations in response to Mr Duffield’s driving, from the SAPOL General Order, Operational safety – high risk driving.

7.4. Sergeant Carlson and Constable Geraghty had reasonable cause to suspect that Mr Duffield had committed various serious criminal offences during the evening of 7 February 2017 and they were lawfully empowered to arrest him.

7.5. Regardless of the incorrect information that Mr Duffield had been on a two-day drug bender, at least insofar as this suggested use of stimulant drugs rather than cannabis, Sergeant Carlson’s decision to effect a ‘hands-on’ arrest in the event Mr Duffield did not immediately cooperate, was lawful and appropriate, having regard to all of the other circumstances known to him.

7.6. The force used in effecting Mr Duffield’s arrest and his restraint thereafter was lawful and appropriate and did not cause Mr Duffield’s death.

59 Transcript, page 55

7.7. The evidence does not support a finding that there was a significant or unacceptable delay in ambulance arrival, in the particular circumstances. In any event, however, the first-aid rendered to Mr Duffield by police officers was of a high standard. Their efforts, and those of the ambulance officers and Dr Adams, gave Mr Duffield as good a chance of survival as could have been expected outside a hospital.

7.8. Mr Duffield’s death was not reasonably foreseeable or preventable.

7.9. Although the ultimate mechanism of Mr Duffield’s death was the common one of cardiorespiratory arrest, I accept the evidence of Dr Heath that the underlying cause or causes of Mr Duffield’s death cannot be ascertained, and I accept the reasons she has given for her opinion. I conclude that the cause of Mr Duffield’s death is unable to be ascertained.

8. Recommendations 8.1. Pursuant to section 25(2) of the Coroners Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the Inquest.

8.2. In this matter, I make no recommendations Key Words: Death in Custody; Police; Unascertained Cause In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 2nd day of June, 2021.

State Coroner Inquest Number 24/2020 (0238/2017)