Deceased
Cameron Anthony Fyfe
Demographics
27y, male
Coroner
State Coroner Fogliani
Date of death
2021-06-20
Finding date
2024-05-28
Cause of death
gunshot injury to the head
AI-generated summary
A 27-year-old Western Australian police officer with a longstanding history of depression and anxiety took his own life using his police-issued firearm stored at home. He had struggled with mental health since 2017, attended by suicidal ideation, but avoided seeking help from police services due to perceived stigma and career consequences. He privately saw a psychologist from February 2021 but ceased medication and disengaged from psychological therapy. On the night before his death, he consumed alcohol, contacted multiple people showing marked deterioration in mental state, and made his firearm readily accessible from its storage cabinet. The coroner found the lack of mental health risk assessment before authorising home storage of a firearm contributed to preventability. Recommendations focus on comprehensive pre-deployment mental health risk assessments, reducing stigma in help-seeking, proactive engagement with officers, and better education about confidentiality protections in mental health services.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
[2024] WACOR 24 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : Rosalinda Vincenza Clorinda Fogliani, State Coroner
HEARD : 12-13 SEPTEMBER 2023 DELIVERED : 28 MAY 2024 FILE NO/S : CORC 1564 of 2021
DECEASED : FYFE, CAMERON ANTHONY Catchwords: Nil Legislation: Nil Counsel Appearing: Ms S Tyler assisted the State Coroner Ms R Hartley (State Solicitor’s Office) appeared on behalf of the Western Australia Police Force Case(s) referred to in decision(s): Nil
[2024] WACOR 24 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Rosalinda Vincenza Clorinda Fogliani, State Coroner, having investigated the death of Cameron Anthony FYFE with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 12-13 September 2023, find that the identity of the deceased person was Cameron Anthony FYFE and that death occurred on 20 June 2021 at 16 Pinnacles Place, Ballajura, from gunshot injury to the head, in the following circumstances: Table of Contents
[2024] WACOR 24 SUPPRESSION ORDER Non-Publication Order in respect of any reference to the Covert Unit, any person working in the Covert Unit and any procedures or practices of the Covert Unit.
Cameron Anthony Fyfe was a Senior Constable of the Western Australia Police Force when he died on Saturday 20 June 2021 at his home address as a result of gunshot injury to the head. His death occurred by way of suicide. He used his police issued firearm to inflict the gunshot injury that ended his life. He was 27 years old.
At the request of his family, he is referred to as Cameron in this finding.
Cameron was not working on 20 June 2021, but at the time of his death, his status with the Western Australia Police Force was that of a police officer on operational duties. In other words, he was not on extended leave.
Cameron had experienced depression and anxiety for some years prior to his death. He had consulted his GP and his private psychologist and been treated with a range of medications and therapies. His moods fluctuated and he had become increasingly agitated in the period before his death. His family, partner and friends were to varying degrees aware of his struggles, and they endeavoured to support him.
Cameron had been a police officer with the Western Australia Police Force since 2013 working in various roles. Shortly before his death he transitioned from the Regional Operations Group to the Traffic Motorcycle Group, a move that he was pleased about.
After joining the Traffic Motorcycle Group, he was authorised to commute to and from work on his marked police motorcycle. As part of this authorisation, he was also authorised to take home his police issued firearm.
The authorisations were given pursuant to prevailing policies that applied in connection with his duties.
In the days before his death, Cameron was unsettled. To some people, he appeared future focused, making travel plans with his partner. However, the night before his death, a series of communications from him showed a marked deterioration in his mental state.
Cameron stayed up late in his home on the night of Friday 19 June 2021, drinking alcohol and contacting various persons. He spoke with his parents, who offered their comfort and support. He kept contacting friends late into the night and early the next morning. He became particularly distressed when he was unable to contact a former partner, between approximately 1.00 am and 3.36 am on 20 June 2021. Given those hours, the likely outcome is that successful contact would not be achieved, but he nonetheless became preoccupied by her lack of response.
Cameron’s last attempt to contact someone was at 3.37 am on the morning of 20 June 2021, when he rang his partner, but there was no response from her either. She was understandably, asleep. It appears Cameron was last active on Facebook at approximately 4.00 am on 20 June 2021. After that time, there is no evidence of Cameron’s movements, nor of him being alive.
Later on the morning of 20 June 2021, Cameron’s parents and partner commenced trying to contact him by telephone, with no response from him.
They spoke with each other and realised neither party had been able to make contact. At approximately 3.00 pm on 20 June 2021, Cameron’s concerned parents drove to his home. His partner followed shortly afterwards.
Cameron’s parents arrived there first. At approximately 3.15 pm Cameron’s father entered the home and found Cameron deceased in a chair with an apparent gunshot wound to his head, and his police issued firearm in his right hand. It must have been shocking for him, and then he had to inform Cameron’s mother. They were grief-stricken.
The ambulance and police were promptly called for. The paramedics checked Cameron and confirmed that he was deceased.
Cameron was born into a loving family, in Perth on 23 February 1994. He was one of three children. He spent his early life with his family in Kalgoorlie, until the family moved back to Perth in 1999 when he was six years old. His schooling was completed in Perth. As a teenager he worked at the local supermarket. He was very social and enjoyed the company of his friends. His hobbies included bike riding, skateboarding and gaming.1
At school Cameron excelled in the subjects of mathematics, and law and politics. He had intended to do a double degree in teaching and mathematics but dropped out after one semester at university. He decided to join the Western Australia Police Force and was proud about being accepted on the first occasion that he applied in 2013.2
Cameron’s father reported that Cameron “loved” the police academy and had positive relations with his squad, making numerous friends. After graduating he was stationed at a number of locations including Warwick Police Station and later Albany Police Station. However, his father also reported that in the course of his work at Albany, Cameron experienced some incidents that upset him.3
One incident concerned Cameron’s attendance upon the death of a baby, that made him very sad. Another concerned Cameron’s attendance upon an incident involving allegations of domestic violence in 2016, where Cameron claimed the male alleged perpetrator hit him twice in the face.
Cameron experienced a sense of outrage and wanted the perpetrator to be punished.4
2 Ibid.
3 Ibid.
4 Ibid.
5 Ibid.
In 2019 Cameron moved back to Perth, from Albany, to work in the Regional Operations Group. Initially Cameron moved in with his parents but after approximately ten months he purchased his own home, where he lived on his own. His father reported that in the course of his work with the Regional Operations Group an incident occurred that upset him. In 2020 a person that he was arresting allegedly spat at Cameron, with the result that Cameron needed to undergo testing for HIV and Covid.6
In accordance with the prevailing procedures, Cameron was placed into “lockdown” pending the outcome of the medical testing. In addition to again feeling disillusioned about this outcome, Cameron felt particularly isolated during lockdown. This feeling was magnified when his computer broke down while he was in isolation. He did receive some text message contact from his Officer in Charge and the Health, Welfare and Safety Division reached out to him, but it did not allay those feelings for him.7
During his lockdown period, Cameron’s father received a telephone call from Cameron one night just after 2.00 am which caused him concern. His father went straight to Cameron’s home and stood outside to speak with Cameron to offer support and comfort. Cameron’s father was aware his son was experiencing difficulties and would routinely keep his telephone close by at nighttime in case Cameron rang him.8
Over time, Cameron had been urged by his parents to seek help from the Employee Assistance Program of the Western Australia Police Force.
However, Cameron told his father that there was a “stigma” attached.
Specifically, he felt that if he talked to the Employee Assistance Counsellors about self-harm, there could be ramifications for where he could work, he would be “stuck at a desk” and he would lose his “shift allowances.”9
7 ts 143.
8 Exhibit 1, tab 7.
9 Ibid.
[2024] WACOR 24 the Employee Assistance Counsellor would ultimately be communicated to his supervisors and that he would be removed from operational duties.10
Eventually Cameron did so, informing his father that the private psychologist had diagnosed him with major depression. This is outlined in more detail later in this finding under the heading: Mental Health History.
Cameron told his father his medications (believed to be anti-depressants) were not working, and it appears that shortly before his death he had ceased taking them.11
Cameron had told his father he was unhappy about his working environment at the Regional Operations Group. He decided to transition to the Traffic Motorcycle Group. Cameron was passionate about motorcycles and his father recalled that when he underwent the intensive training for acceptance to the Traffic Motorcycle Group he was “extremely excited.” As will be seen later in this finding, Cameron was accepted into that group.12
In the couple of months prior to his death Cameron had commenced a new relationship. His parents met up with Cameron and his new partner on a few occasions and felt that Cameron was very happy in that relationship.
The last time they all met up, Cameron was in high spirits. His partner also recalled him generally being happy during their short time together, though it was clear to her that his moods fluctuated. She observed that on the occasions when Cameron drank alcohol to excess, it tended to exacerbate his low moods.13
11 Exhibit 1, tab 7.
12 Ibid.
13 Exhibit 1, tabs 7, 8, 9 and 10.
14 Exhibit 1, tab 7.
It should also be remembered that Cameron, though unhappy towards the end of his life, had experienced many joyful occasions throughout his life, that he was productive, ambitious and successful; that he had decided to dedicate his life to the protection of the community; that he was socially connected and fun to be around with; and that he had the unwavering love and support of his parents, family, partner and friends.
Cameron’s death was a reportable death within the meaning of s 3 of the Coroners Act 1996 (WA) (the Coroners Act) and it was reported to the coroner as required by the Coroners Act. By reason of s 19(1) of the Coroners Act, I have jurisdiction to investigate the death.
On 28 July 2022 I determined that an inquest was desirable, within the meaning of section 22(2) of the Coroners Act to explore the circumstances surrounding Cameron’s death. In particular, the reasons for Cameron having access to his police issued firearm within his home and the safety considerations attending that access, in the context of the mental health services available to police officers.
At the inquest I heard from 7 witnesses and at the outset received one exhibit into evidence containing 26 tabs.
During the inquest I received a further two exhibits into evidence, being Exhibit 1, tabs 27 and 28.
My primary function is to investigate the death. It is a fact-finding function.
Under s 25(1)(b) and (c) of the Coroners Act, I must find, if possible, how death occurred and the cause of death.
Under s 25(2) of the Coroners Act, in this finding I may comment on any matter connected with the death including public health, safety or the administration of justice. This is the ancillary function.
Section 25(5) of the Coroners Act prohibits me from framing a finding or comment in such a way as to appear to determine any question of civil
[2024] WACOR 24 liability or to suggest that any person is guilty of an offence. It is not my role to assess the evidence for civil or criminal liability, and I am not bound by the rules of evidence.
Pursuant to s 44(2) of the Coroners Act, before I make any finding adverse to the interests of an interested person, that person must be given the opportunity to present submissions against the making of such a finding.
At the close of the inquest, on 13 September 2023 counsel assisting me circulated to the Office of the State Solicitor a written outline of my proposed potential adverse findings related to the Western Australia Police Force, together with my proposed recommendations, for comment.
On 24 October 2023 the Western Australia Police Force provided its response to me in connection with the potential adverse findings and proposed recommendations. I subsequently received this into evidence as Exhibit 1, tab 29.
In making my findings I have applied the standard of proof as set out in Briginshaw v Briginshaw (1938) 60 CLR 336 per Dixon J at 361 - 362 which requires a consideration of the nature and gravity of the conduct when deciding whether a matter has been proved on the balance of probabilities.
Cameron was a troubled young man. It may not have been apparent to anyone newly meeting him, or persons with whom he worked. However, those close to him knew, to varying degrees, that he struggled with his mental health.
Over time Cameron had endured a number of stressors, some personal and some within the context of carrying out his policing duties. As far back as 2017, Cameron had gone to The Gap in Albany and contemplated taking his life. People close to Cameron offered their support and recommended he seek the assistance of a clinician or therapist. However, as will be seen below, it was not until October 2019 that Cameron sought that assistance
[2024] WACOR 24 of his GP for his mental health, and he first consulted a psychologist in February 2021.15
Cameron separated from a previous partner in 2017 and commenced a new relationship with a partner in late 2018, which was not stable. They broke up and recommenced their relationship several times, until finally separating in February 2021. These partners were aware that Cameron struggled with his mental health and drank heavily on his rostered days off.16
On 4 October 2019, after his transfer back to Perth (from Albany) Cameron saw his GP to talk about his low moods, and anxiety about his policing work. It appears to be the first occasion upon which he sought assistance for his mental state.17
He was assessed by the GP and diagnosed with depression, anxiety and stress, at varying degrees of severity. Records reflect that he appeared calm and without perceptual disturbance during this consult. He was prescribed the antidepressant Pristiq and provided with a medical certificate in support of four days off work.18
Upon the expiry of his medical certificate, on 8 October 2019 Cameron again saw his GP and advised that he was still anxious about going back to work. He was assessed and again, he appeared calm and without perceptual disturbance during this consult. He was provided with a medical certificate in support of a further seven days off work, with a review planned for the following week.19
On 16 October 2019 Cameron again saw his GP due to his depression and anxiety. His medication was reviewed and his dosage of Pristiq was increased. The GP discussed a mental health care plan with Cameron, who expressed his agreement and advised he would make an appointment with a psychologist. Cameron appears to have returned to work at or around 16 October 2019.20 15 Exhibit 1, tabs 7 and 9.
16 Exhibit 1, tab 10.
17 Exhibit 1, tab 19.
18 Ibid.
19 Ibid.
20 Ibid.
On 10 December 2019 Cameron saw his GP because he was experiencing back pain after lifting a heavy object. He was prescribed anti-inflammatory medication, referred to a physiotherapist and given a medical certificate in support of four days off work. In connection with his mental health, at this consult Cameron told his GP that he had reduced his alcohol intake and weaned himself of Pristiq and felt much better. He reported to his GP that his moods and anxiety were much improved.21
On 21 January 2020 during an appointment with his GP for another ailment, Cameron again agreed to make an appointment with a psychologist and to then inform the GP of his Mental Health Care Plan. On 13 November 2020 during a telehealth consult, Cameron’s GP gave him the results of the blood testing done following the incident where the person that Cameron was arresting allegedly spat at him (referred to previously in this finding). It was a satisfactory outcome with all relevant testing being negative, though it was undoubtedly an uncomfortable waiting period for Cameron.22
On 30 November 2020 Cameron saw his GP for a consult regarding a Mental Health Care Plan. His mental state had deteriorated, and, on this occasion, he reported having had low mood and anxiety since his teens, that had worsened recently. He said that his then partner had left him due to him not seeking help for his mental health, he referred to an “incident” at work, and he referred to the past incident of suicidal ideation (though he had no active plans). He admitted to binge drinking. The GP discussed lifestyle advice, advised him on a range of therapy options and set up a “safety net” process for him. He was prescribed the antidepressant Sertraline.23
On 12 February 2021 Cameron saw his GP for a consult regarding, in part, his depression and anxiety. On this occasion he reported that his mood had improved, and he had cut down his alcohol intake. However, he did not consider he was gaining a benefit from the antidepressant Sertraline. The GP again discussed a safety net process with him. The Sertraline was ceased, and he was prescribed the antidepressant Fluoxetine. He reported poor sleep and the GP discussed sleep hygiene with him, together with a trial of Melatonin. He was concerned he may have contracted malaria as a 21 Ibid.
22 Ibid.
23 Ibid.
[2024] WACOR 24 result of an overseas trip in 2019, and his GP ordered blood testing that included a malarial parasites screen.24
On that same day, 12 February 2021 Cameron had his first appointment with his psychologist (sourced privately and not through the Employee Assistance Program). It appears to be the first time he consulted a psychologist. Cameron outlined some of his history and reported feeling miserable and flat with no happiness and no motivation. This was discussed, with a plan for the next session to be focused upon emotion processing. This next session with the psychologist took place on 2 March 2021.25
On 9 March 2021 Cameron’s psychologist reported back to his GP. The psychologist felt that Cameron would benefit from focused psychological therapy, to develop his thinking and coping strategies. A further session was held with Cameron on 23 April 2021. On this occasion Cameron was more relaxed and it was noted he had started a relationship with a new partner.26
Cameron spoke with his psychologist about matters personal to him and follow up had been arranged after his last appointment. However, he later indicated to his father that he was not seeing his psychologist “so much.”27
In the months prior to his death Cameron contacted one of his former partners (with whom he had maintained a friendship) and some old friends of his, on a number of occasions. They observed that Cameron’s moods were volatile; sometimes he appeared friendly and settled, and on other occasions he spoke of having troubling thoughts of self-harm. He told a former partner that he had thought about retrieving his police issued firearm and shooting himself, but in the same conversation said he would never do it. She did not believe he would shoot himself and thought it was “just talk.”28
Cameron’s friends and former partner remained supportive of him, checked in with him, went to see him, but when pressed he was reluctant to talk 24 Ibid.
25 Exhibit 1, tab 20.
26 Ibid.
27 Exhibit 1, tab 7.
28 Exhibit 1, tabs 9, 11 and 16.
[2024] WACOR 24 about his feelings with them. They considered Cameron to be a genuine and honest friend and were concerned about him.29
He had elected to privately seek mental health support through his GP and psychologist. He did not feel comfortable accessing that support from the Employee Assistance Program, or the Psychology Unit of the Western Australia Police Force due to his perception that it would prejudice his employment and/or promotion prospects.
One of the more positive developments in Cameron’s life concerned his transition to the Traffic Motorcycle Group, which had commenced as a new organisational business area within the Western Australia Police Force on 7 September 2020. It centralised all police motorcycles from Traffic Enforcement Groups One to Three. It also included a traffic training unit.31
Cameron was keen to transition from the Regional Operations Group to the Traffic Motorcycle Group. A vacant position came up and, having successfully completed the motorcycle preselection course, he applied. He was the successful applicant, ranking in the top three of the riders and impressing the trainers.32
Cameron’s transfer notice was approved on 28 April 2021. On 10 May 2021 he was formally attached to the Traffic Motorcycle Group as a traffic enforcement officer, and he underwent his induction the same day.33
On 24 May 2021 Cameron commenced his Motorcycle Response Course, which included classroom theory on that date, a skills day on 25 May 2021, 29 Ibid.
30 ts 18.
31 Exhibit 1, tab 14.
32 Ibid.
33 Ibid.
[2024] WACOR 24 a practical riding assessment on 27 to 28 May 2021, an advanced skills day between 31 May and 2 June 2021. At the material time several instructors reported that Cameron had passed all the requirements to a high standard.34
During some components of his training Cameron was required to wear his firearm and accoutrements. At other stages he was required to secure them in the armoury. The Officer in Charge of the Traffic Motorcycle Group (Officer in Charge) checked Cameron’s compliance with these requirements and found it to be satisfactory.35
The Officer in Charge saw Cameron as a “good fit” for this team. He did not hold any concerns with respect to his wellbeing and felt that he was very enthusiastic. His early experiences with Cameron were that he learnt well and that he was able to impart his knowledge on to other officers. He testified that he saw “…. absolutely no red flags whatsoever.” The Officer in Charge was at the material time, a peer support officer, so he had some training and experience in warning signs, to assist in identifying officers who may be struggling.36
Accordingly, following consultations with the training team, the Officer in Charge decided that Cameron could commute to and from home on his assigned police motorcycle. This practice applied to successful students, to increase their confidence and familiarity with motorcycles, before undertaking future training in the area of emergency driving.37
This was in accordance with the applicable policies. At the material time, Traffic Motorcycle Group Officers were permitted to commute to and from home on their assigned police motorcycle, subject to compliance with the Motorcycle Commuting Guidelines (TR-07.02.1). It was not a compulsory practice. If desired, the police officer could make an application to commute to and from home. Cameron made such an application, and it was granted by the Officer in Charge.38 34 Ibid.
35 Ibid.
36 Exhibit 1, tab 14; ts 50; ts 55 to 57.
37 Exhibit 1, tab 14.
38 Exhibit 1, tabs 13 and 14.
The Motorcycle Commuting Guidelines imposed a range of conditions, including parking and securing of the motorcycle at the Traffic Motorcycle Group Officer’s residence (with appropriate inspections for compliance).
Ordinarily the Traffic Motorcycle Group Officers are deemed to have commenced duty on arrival at the designated Traffic Enforcement Group location and completed such duty upon departure from that location.39 However, under the Motorcycle Commuting Guidelines, while commuting to and from home, it is also expected that the Traffic Motorcycle Group Officer will attend to any breaches of road traffic legislation, or requests for assistance if safe to do so. It follows that while commuting, as outlined in the Motorcycle Commuting Guidelines, such officers are required to carry at least three force options, one of which includes their police issued firearm.40
This is how Cameron came to have a police issued firearm at his home. The details appear immediately below.
The Western Australia Police Firearms Policy (FR-01.02) contains a part that addresses compliance requirements for firearms at home, designated: Taking Home Western Australia Police Issue Firearms or Ammunition (FR01.02.6). Authorisation is required for a police officer to keep such firearms or ammunition at a private residence. This is as an exception to the general rule that they are not to be kept at home.41
The authorisation can only be granted when certain specified criteria are met. Members who are allocated a police motorcycle pursuant to the Motorcycle Commuting Guidelines are one of the groups that may receive authorisation to keep police issued firearms or ammunition at their home upon certain conditions that include: a) the written authorisation of their Officer in Charge; and 39 Exhibit 1, tab 13.
40 Exhibit 1, tab 13; ts 52 to 53; ts 76.
41 Exhibit 1, tab 14.
[2024] WACOR 24 b) compliance with the relevant Firearms Regulations 1974 (Firearms Regulations), including storage in an approved storage cabinet, that is inspected and certified. Initially the inspection was required to be undertaken by the Licensing Enforcement Division (prior to authorisation being granted). Further, the storage cabinet needed to be inspected once a year by the relevant Officer in Charge to ensure its continued compliance.42 Amended policy
On 23 October 2020 the Officer in Charge of the Traffic Motorcycle Group requested an amendment to FR-01.02.6 referred to above, to alter the procedure for approval of the gun storage cabinet. Specifically, the Officer in Charge requested that the authority to grant approval be delegated from the Licensing Enforcement Division to him. There were quite a number of gun storage cabinets awaiting inspection, and he was taking on an onerous responsibility. The delegation was granted to him, which then required the formal approval for the variation to FR-01.02.6.43
On 14 December 2020 approval was granted to vary FR-01.02.6 to require that the initial inspection of the gun storage cabinet be undertaken by the Officer in Charge of the Traffic Motorcycle Group. This inspection was to occur prior to the authorisation to carry and store a police issued firearm in a home, and afterwards, once every year, through the provision of approved photographs.44
However, as it transpired, Cameron’s Officer in Charge did not personally inspect his gun storage cabinet, as required by the varied FR-01.02.06.45
As an additional complication, the actual policy itself was not formally updated on the Corporate Knowledge Base of the Western Australia Police Force, until 22 September 2021, being after the date of Cameron’s death.46
The details of how Cameron came to be authorised to keep his police issued firearm at home are outlined below.
42 Ibid.
43 Exhibit 1, tabs 13 and 14.
44 Ibid.
45 Ibid.
46 Exhibit 1, tab 14; ts 27 to 28.
[2024] WACOR 24 Verbal authorisation
As outlined previously, Cameron commenced his duties with the Traffic Motorcycle Group on 10 May 2021, and advised he wished to commute to and from work. He was allocated a police issued gun storage cabinet and related equipment. It was his responsibility to install it to the requirements of the Firearms Regulations.47
On 17 May 2021 Cameron sent his Officer in Charge photographs of the gun storage cabinet that he had installed. His Officer in Charge formed the view, based upon the photographs, that the gun storage cabinet had been installed correctly. The Officer in Charge had intended to personally inspect the installation of the cabinet before Cameron’s commuting started, or as soon as possible afterwards.48
On 2 June 2021 Cameron’s Officer in Charge verbally authorised Cameron to commute to and from work. He made plans with Cameron, for the personal inspection of the gun storage cabinet.49
However, due to his workload and impending leave arrangements, the Officer in Charge did not have time to undertake the personal inspection of Cameron’s gun storage cabinet before going on leave. On 8 June 2021, on an examination of internal records, it became apparent to the Officer in Charge that Cameron was now storing his police issued firearm at his home.
In discussion with Cameron on 13 June 2021, the Officer in Charge again made plans with Cameron to personally inspect the gun storage cabinet, this time upon his return from leave.50
48 Ibid.
49 Exhibit 1, tabs 13 and 14; ts 59 to 61.
50 Ibid.
51 Ibid.
[2024] WACOR 24 IAU investigation
The Internal Affairs Unit (IAU) of the Western Australia Police Force subsequently conducted an investigation to examine the adequacy of and compliance with, the relevant policies of the Western Australia Police Force, including FR-01.02.6. The IAU’s investigation exonerated the Officer in Charge of the allegations of non-compliance. Specifically, the IAU determined that: a) the fact that the Officer in Charge did not provide a written approval, but instead verbally authorised Cameron to take home his police issued firearm was considered a minor non-compliance and did not attract any adverse finding; and b) on the matter of the Officer in Charge failing to conduct a physical inspection of the gun storage cabinet, regard was had to the fact that the photographs provided by Cameron showed that the gun storage cabinet had been properly secured within his home, the fact that the gun storage cabinet was provided to him by police (and it therefore met the construction requirements under the Firearms Act) and that the process for compliance by members of the public does not involve a physical inspection.52
On the basis, broadly, of the above considerations the investigation report reflects that the IAU exonerated the Officer in Charge, commenting that the failures did not play any part in Cameron subsequently taking his life.53
At the inquest Detective Senior Sergeant Glenn Swannell, one of the authors of the IAU Report, explained that while there was some “technical” non-compliance as outlined above, they did not meet the criteria for a sanction, and therefore the result was that the Officer in Charge was exonerated by the IAU.54 52 Exhibit 1, tabs 13 and 14.
53 Ibid.
54 ts 25.
[2024] WACOR 24 Comments on compliance
I am relevantly informed, but not bound, by the outcomes of the IAU investigation. Within the context of this inquest, I am satisfied that any non-compliance by the Officer in Charge with the terms of the relevant policies of the Western Australia Police Force, including FR-01.02.6, did not contribute to Cameron’s decision to take his life.
Furthermore, there is some confusion over the precise timing of the changes to FR-01.02.6, having regard to the passage of time for it being uploaded onto the Corporate Knowledge database, which adds to the uncertainty around the nature of any non-compliance.55
The police issued firearm was at Cameron’s home, and on one argument, had strict compliance been required or enforced, it would likely not have been at his home on the date of his death (as it would have been pending a written authorisation and the physical inspection of the gun storage cabinet). On the “but for” argument, Cameron might not have had his police issued firearm available to him on 20 June 2021, when he took his life.
However, such an argument would oversimplify the complexity of the circumstances surrounding Cameron’s death. On balance I am satisfied that any non-compliance was not material to the factors contributing to Cameron forming his intention to take his life. My concerns generally in connection with the storage of police issued firearms within the home appear later in this finding under the heading: Safety considerations.
It is now known, following the coronial investigation, that the gun storage cabinet at Cameron’s residence had been properly installed by him. It was found to be locked when police officers attended.56
It is nonetheless important that the policies be complied with, and a tragic case such as this one shows that even seemingly minor instances of noncompliance could potentially have unintended and serious consequences.
55 ts 27 to 28.
56 ts 13; ts 17.
The Western Australian Police Force have now taken a number of steps to reinforce the importance of compliance with the policies with all of the business units that have police officers who may take home police issued firearms.57
The Officer in Charge of the Traffic Motorcycle Group reported that, following Cameron’s death, there was an increase in the police’s monitoring of sign out registers and work commenced to develop an electronic accountability system to track and record assets, including firearms, for compliance with policies while they are stored at homes.58
An agency wide review of home storage of police issued firearms was conducted by the Western Australia Police Force as at April 2022, to identify and reconcile the number of authorised police officers, with approved storage cabinets. After Cameron’s death, an assessment identified that all gun storage cabinets complied with the Firearms Regulations.
The Detective Inspector undertaking this review formed the view that compliance with FR-01.02.6 was “very high” and that there was no present need for action concerning adherence to the relevant policy.59
This tragic incident resulted in a significant degree of distress and selfreflection amongst the police officers who knew Cameron and within the Western Australia Police Force itself. I am satisfied that it has resulted in a redoubling of efforts to monitor authorisations, storage and ongoing compliance with the policies, where police issued firearms are concerned.
It is important that this monitoring be ongoing and that compliance be rigorously enforced.
58 Exhibit 1, tab 14.
59 Ibid.
[2024] WACOR 24 Karijini National Park and Broome. They planned to leave on 24 June 2021, and return by 7 July 2021. His parents agreed to assist with looking after his dog. There were some exchanges about his new job, but nothing to especially indicate an impending and marked deterioration in his mental state.60
He was unhappy and agitated. Some years previously it appears Cameron had initiated the break-up of this relationship, but they had maintained a friendship and she occasionally checked in on him. Initially, shortly after midnight, she was not able to engage with him, explaining that she was out at a venue. Cameron did not react well to this.61
At 12.41 am Cameron’s former partner did contact him to talk about how he was feeling. It was clear from his preceding text messages that he was upset. A series of further text exchanges between Cameron and his former partner until approximately 1.00 am show him becoming increasingly distressed. Despite her attempts to address or acknowledge his angst, he remained dissatisfied with what he felt was a lack of responsiveness on her part.62
Shortly after 1.00 am he contacted his current partner and had a short conversation. There were some positive exchanges between them.
However, she also thought that, from the sound of his voice, he was intoxicated, and she suggested he should stop drinking. The conversation ended on good terms.63
61 Exhibit 1, tabs 7, 9 and 16.
62 Exhibit 1, tab 16.
63 Exhibit 1, tab 8.
64 Exhibit 1, tab 7.
This resulted in Cameron’s father ringing him back very shortly afterwards and offering to come to his home. Cameron declined that offer but was prepared to explain how he was feeling. Cameron told his father he was unhappy with the side effects of his medication for his mental state, and he was despondent about having tried three different types of medication with none of them working. They spoke about a range of matters and after this telephone conversation his parents agreed they would contact him at lunchtime the next day.65
At approximately 2.20 am Cameron’s mother sent him a number of text messages, to which he responded. She offered support and encouragement, particularly in respect of potential new medications to assist with his mental state.66
Cameron remained unhappy, and it would appear he stayed up, rather than going to bed. Between approximately 3.15 am and 3.30 am he sent his former partner some further text messages, remonstrating with her, and insisting that she ring him, or respond to his telephone calls. By this time, she was asleep and was unaware of these until she woke up the next morning.67
Between that same period of time (approximately 3.15 am and 3.30 am) Cameron also endeavoured to contact his current partner by text message, about their upcoming holiday. She slept through these messages, and remained unaware of them until she woke up the next morning.68
It appears that Cameron may have been active on Facebook at approximately 4.00 am. After this time, there is no record nor indication of him being alive.69
At a point between approximately 4.00 am on 20 June 2021 and when he was found deceased at approximately 3.15 pm on 20 June 2021, Cameron used his police issued firearm to inflict a gunshot injury to his head. The injury was non-survivable, and he died instantly.70 65 Ibid.
66 Ibid.
67 Exhibit 1, tab 16.
68 Exhibit 1, tabs 8 and 16.
69 Exhibit 1, tab 8.
70 Exhibit 1, tabs 2 and 5.
His injury was deemed incompatible with life.71
Police entered the residence, inspected the scene, secured the firearm and ammunition, and conducted their investigation. A note reflecting upon Cameron’s intention to take his life was found on the desk near him. Items located near him indicated that he had been drinking alcohol, and this was borne out later in the toxicology findings.72
The gun storage cabinet was found, locked. Police searched for the keys to the locked gun storage cabinet. The keys were not able to be located either within the house or on Cameron. At the inquest the Officer in Charge explained that the keys to the gun storage cabinets should be kept on the police officers’ key rings, and carried with them at all times, especially when they are at home, so that no other person can obtain or copy those keys.73
There appeared to be no other items stored in it. An inference that may be drawn, from the absence of the keys to the gun storage cabinet, is that Cameron may not have ordinarily been keeping the police issued firearm in the locked cabinet. Another inference canvassed at the inquest is that they were removed by attending police and misplaced, but I consider this to be a less likely possibility.74
72 Exhibit 1, tabs 1, 3 and 7.; ts 12.
73 ts 61.
74 Exhibit 1, tabs 1 and 14; ts 13.
75 Exhibit 1, tab 1.
[2024] WACOR 24 body and a CT scan. From a review of the medical records, they noted a long-standing history of depression, and they were aware of the note of his intentions (suicide note) present at the scene.76
Both the external examination of the body and the CT scan showed traumatic skull and brain injury. There were no defensive type injuries.
The CT scan also showed an enlarged, fatty liver.77
On 24 June 2021 Dr White and Dr Downs formed the opinion that the cause of death was gunshot injury to the head. They ordered toxicological testing which became available on 28 June 2021. This showed alcohol in the blood at 0.214% and in urine at 0.292%. Common drugs (including antidepressants) were not detected. Cannabinoids by immunoassay were negative. Post mortem examination results were reviewed on 4 April 2022 and the forensic pathologists’ opinion remained the same.78
I accept and adopt the forensic pathologists’ opinion. I find that the cause of death is gunshot injury to the head.
Cameron had a long-standing history of depression and had experienced instances of suicidal ideation in the past. He had ceased taking the medication that was prescribed for him for his depression, and he was not especially motivated to continue with his psychological therapy.79
At a stage during the night of 19 June 2021, and the time of his death on 20 June 2021, Cameron wrote a note that reflected upon his intention to take his life and his wishes in respect of some of his money after his death. It was found on the desk, near where his body was located.80 76 Exhibit 1, tab 5.
77 Ibid.
78 Exhibit 1, tabs 5 and 6.
79 Exhibit 1, tabs 1, 6 and 7.
80 Exhibit 1, tabs 1and 17.
There were no signs of forced entry to Cameron’s house such as to give rise to any suspicion and he bore no defensive type injuries. There were no signs of a struggle.81
Cameron’s communications throughout the night and early morning prior to his death are consistent with a marked decline in his mental state.
The investigating officer, Detective Senior Constable Greg Holt, at the conclusion of his investigation, determined that the gunshot wound was self-inflicted.82
The processes within Western Australia Police Force for assessing and monitoring the suitability of police officers to possess police issued firearms within their homes is a relevant safety consideration. Allied to this is the willingness of police officers to seek help for their mental health.
At the inquest Detective Senior Constable Holt outlined his conclusions regarding his investigation into Cameron’s death, stating: “it was a culmination of a few different things that affected his life, including bouts of depression, not taking prescribed medication, alcohol consumption on the night and ready access to a firearm.”83 Cameron’s concerns about mental health support
There is evidence before me, from a range of sources, about Cameron’s fears for his policing career, if he were to access mental health support from within the services offered by the Western Australia Police Force. At the inquest Detective Senior Constable Holt summarised his investigations into this aspect as follows: “It was explained to me that he had recently purchased the house and he was fearful that if it came to light that he had some mental 81 Exhibit 1, tab 2.
82 Exhibit 1, tab 2; ts 11.
83 Exhibit 1, tab 2; ts 11; ts 20.
[2024] WACOR 24 health struggles that he would not be on his usual duties and he would be put at a desk, and subsequently not available to obtain overtime or weekend shift penalties and the like, which would be a monetary issue for him paying his mortgage.”84
This was an unfortunate stance for Cameron to take, and he missed a significant opportunity to receive understanding and support for his mental health struggles. Potentially, his fears around seeking help were a manifestation of his mental health condition. One area that came up repeatedly during the inquest, and is addressed later in this finding, is the desirability of processes for proactively reaching out to the police officers to generate the confidence and willingness to seek help.
Whilst it cannot be known what the outcome would have been had Cameron sought help from the mental health services offered by the Western Australia Police Force, it is instructive to understand his fears of the consequences and learn from this incident in order to maintain and improve the services offered in this area.
It would also appear such concerns are not necessarily unique to, or confined to, Cameron. At the inquest one of the experienced police officers commented about officers’ fears in this area, but also noted that he has observed more recent positive changes in help seeking behaviour, which he has personally supported: “…. officers don’t want to be outed, if you like, in seeing a psychologist because there’s that stigma and then if the – the supervisor or the business unit OIC becomes aware then they could, as Constable Fyfe feared, be stood down from duties or stood aside from duties, office bound, and therefore they would lose those monetary benefits that were referred to before. There is – there is some belief of that, but I think there is a – a growing acceptance to reach out to professional help.85
Another one of the experienced police officers at the inquest, who also supported the more positive changes in help seeking behaviour, explained that removing a police officer from “active patrol” for mental health 84 ts 19.
85 ts 31 to 32.
[2024] WACOR 24 reasons is a significant step and measures are taken to address the changes in the working environment to avoid as far as possible, an “outing”: “…. that can be done carefully and considerately and confidentially, and officers can sometimes be moved, or they can be placed on short leave, and there’s all sorts of ways with which we can deal with officers. It’s not just, suddenly, you’re behind a desk. It may seem like a perception; not actually how it happens, in my experience.”86
At the inquest Acting Commander at State Traffic Operations Alyson Brett (A/Commander Brett) spoke about the cultural shift within the Western Australia Police Force and the change in the messaging so as to support the sharing of vulnerabilities, that historically may have been attended by shame. The willingness of some police officers to openly discuss past experiences with mental health illnesses: “…. sends a powerful message that people can heal from these conditions, and they can go on.”87
A/Commander Brett explained that this approach, which she feels they could do more of, would help to allay potential concerns about the loss of money while being on non-operational duties. It would show that the change in work environment is temporary, it allows for time to heal, during which there would be wrap around support for the police officer. The A/Commander outlined some examples of pathways for police officers receiving mental health support and then returning to full operational duties in an incremental way. Others may still be working towards operational duties.88
This is different to the more punitive approach that Cameron had anticipated and feared. A/Commander Brett confirmed that at the time of Cameron’s death, this approach was emerging, but there was not enough of it then. Since then, it has been improving and increasing.89
At the inquest I heard from the Western Australia Police Force’s Chief Psychologist, Dr Janelle Hawes (Dr Hawes), who commenced in this newly created role in October 2021. Dr Hawes was questioned about the 86 ts 47.
87 ts 92.
88 ts 92 to 95.
89 ts 93.
[2024] WACOR 24 perception of police officers being made non-operational following engagement with the Psychology Unit. Dr Hawes testified that she has worked towards dispelling this fear though various means, including education and training: “…. the majority of officers who come to see us regularly are operational and working. They’re not all off while they’re seeing us, so it’s absolutely possible to identify a mental health issue; address it, treat it, provide support alongside people continuing their duties in a safe manner.”90
On the matter of the concern about losing shift penalties and/or overtime work from being made non-operational, Dr Hawes felt that concerns around those risks may also be mitigated by confidential financial counselling that is available through their Employee Assistance Program.91
At the inquest Acting Assistant Commissioner Bradley Jackson (A/Assistant Commissioner Jackson) was asked about his views regarding the perception amongst some police officers, that if they seek mental health assistance, they may be taken off operational duties, with adverse impacts upon their financial position and/or progression as a police officer.92
Relevantly, within the context of the flow on effects of a mental health assessment where a level of risk has been identified, A/Assistant Commissioner Jackson placed some emphasis on the difference between permanent non-operational duties and temporary non-operational duties as follows: a) a police officer may be considered as permanently non-operational when it is determined, following an appropriate assessment, that the person does not have the psychological capacity to be a frontline police officer; and b) on the other hand, following such assessment a police officer may be considered as temporarily non-operational, pending the support from the Health, Welfare and Safety Division, whose clinicians: “work really really hard” to help the person become mentally well again; in such a case the police officer is not typically removed from their work environment; there might be some temporary 90 ts 115.
91 ts 123.
92 ts 133 to 134.
[2024] WACOR 24 changes to their duties; there may still be flexibility to do certain shifts, to maintain the access to shift penalties (namely the increased rate of pay for a shift worker), depending on the business area.93
Further comment regarding measures to mitigate concerns around stigma, and encourage help seeking behaviour, appear later in this finding under the heading: Recommendations.
Between 2017 and Cameron’s death in 2021, the Western Australia Police Force was moving towards a clearer understanding in the area of mental health support for police officers, and a greater commitment of resources to enable this support to occur, in a de-stigmatised environment.
In this regard they were largely in step with the many other entities that have grappled with this issue in recent years and that have made significant gains in the understanding of, and commitment to, mental health support for their staff. It has been a process of continual improvement.
Before Cameron’s’ death, the Western Australia Police Force had already committed resources to mental health support. After Cameron’s death they held the Suicide Prevention Forum, and further improvements occurred, particularly in the area of proactive engagement. Details appear later in this finding under the heading: “Mental health resources and improvements.” Suitability to possess a firearm
Detective Inspector Andrew Martin (Detective Inspector Martin) of the Major Crime Division reported to the court that assessment of a police officer’s suitability to possess a firearm commences prior to employment as part of the recruitment process, continues during their training at the Police Academy and continues throughout their employment by way of supervision and training.94
After recruitment and initial training police officers are deemed suitable to possess a firearm, provided they maintain their skills and there are no circumstances giving rise to their capacity or suitability. Factors that may affect the assessment of their capacity or suitability include: 93 ts 134; ts 141.
94 Exhibit 1, tab 13.
[2024] WACOR 24 a) concerns around their health or wellbeing; and b) an allegation of misconduct; and/or c) the issue of a Family Violence Restraining Order.95
Unless there is approval to keep the firearm at the home, as outlined previously in this finding, police issued firearms are kept in a secure armoury within a business area, and subject to control processes governing removal and return of the firearm from and to the armoury.96 Risk mitigation strategies
In connection with possessing a police issued firearm generally (including with authorisation, at a home) an annexure to FR-01.02.6 entitled: Responsibilities, outlines the responsibilities of police officers in possessing and/or carrying police issued firearms in the performance of their duties (FR-01.02.2). Within these responsibilities are matters concerning occupational health and safety including the following: a) police officers issued with firearms ensuring they are free from fatigue or the effects of illicit or licit substances or other medical grounds that would prevent them from undertaking their duties in a safe manner; b) police officers declaring, to their supervisor: i. any prescription or other substances that may adversely impact upon their performance, in order for their supervisor to assess and determine the police officer’s suitability to carry a firearm; ii. any existing psychological or physiological conditions that may impact upon performance; and 95 Ibid.
96 Ibid.
[2024] WACOR 24 c) supervisors considering the impacts of fatigue, and utilising rostering practices that manage it.97
At the inquest A/Commander Brett explained that if police officers express that they are struggling or in a crisis, managers should always, tactfully, and sensitively, make sure that they restrict access to police issued firearms and provide support including through the Psychology Unit, stating: “…. it is always front of mind now ….” and adding “it’s probably more openly discussed and considered now than it has ever been ….”98
Police Officers who are considered to be “at risk” are brought to the attention of the Health, Welfare and Safety Division. A range of persons may refer a police officer to this division, including the police officer themselves or their supervisor. Relevantly, due to confidentiality, the counsellors from the Employee Assistance Program, which is provided by the Western Australia Police Force, are not named within the list of persons who may refer a police officer to the Health, Welfare and Safety Division.99
When the Health, Welfare and Safety Division receive a referral, they are required to act to mitigate risk and this may include an immediate risk assessment (including with an occupational physician, psychiatrist, or psychologist), a fitness for duty assessment, an admission to hospital or a mental health unit and/or a referral to a counsellor from the Employee Assistance Program.100
Detective Inspector Martin reported to the court that, following Cameron’s death, the Health, Welfare and Safety Division have been working on a risk assessment framework to facilitate ongoing monitoring of risk to self and others, for police officers who have received authorisation to store a police issued firearm at their home.101
There is an existing process for denial of access to police issued firearms, where police officers are classified as being at risk due to health reasons, 97 Ibid.
98 ts 85.
99 Exhibit 1, tab 13.
100 Ibid.
101 Ibid.
[2024] WACOR 24 contained within HR-08.18 entitled: Seizure of firearms owned by Western Australia Police Employees identified as at Risk.102
When the Health, Welfare and Safety Division determines that a police officer is at risk due to health reasons, they will notify the Officer in Charge or the police officer’s line manager of the identified risk. An inquiry commences to ascertain the status of access to a police issued firearm for that police officer and steps are required to be taken to restrict such access.103
Within this process is the finely balanced decision making attending the confidentiality requirements and the mitigation of risk to the police officer, and to others.
Fitness for duty
Detective Inspector Martin reported on the process for undertaking a fitness for duty assessment for a police officer where there is: “objective evidence that an officer may be unable to safely or effectively perform a defined job due to a potential psychological condition, impairment, personality traits or stress reactions.” A broad range of matters are referred to as giving rise to such objective evidence and they include (within the context of this inquest) suicidal statements or behaviours, severe distress, self-reported symptoms of anxiety or depression.104
Where it is determined that a police officer is unable to safely and effectively perform their essential job functions the Health, Welfare and Safety Division is tasked with supporting and assisting the police officer.
Options may include finding meaningful work for the police officer that is safe for them and their workplace and providing support in finding an alternative placement.105 102 Ibid.
103 Ibid.
104 Ibid.
105 Ibid.
[2024] WACOR 24 Confidentiality
One of the concerns expressed at the inquest (and referred to previously in this finding) was that police officers feel reluctant about seeking help for their mental health from the Health, Welfare and Safety Division, due to a perception that their supervisors will be informed of the outcome, and it will impact adversely upon their jobs and/or promotion prospects.
I have included this aspect under the main heading: Safety considerations because confidence in the psychological services of the Health, Welfare and Safety Division and/or Psychology Unit is critical to police officers’ help seeking behaviour.
I am informed that the Western Australia Police Force’s intranet pages, and their internal media content, outline the confidentiality aspects of the services provided through the Health, Welfare and Safety Division.
Aspects of the assurances regarding confidentiality, and the limits of confidentiality, are as follows: a) Self-referral to the Police Psychologist and information given to them will be held securely in the same way as when the police officer would visit an external psychologist; b) All psychologists (whether internal or external) have obligations to report risk of self-harm or harm to others, and are required to release information when subpoenaed; c) Subject to b) above, under all other circumstances psychologists can only disclose information with the police officer’s express written consent; d) An exception operates when the Western Australia Police Force is conducting an agreed assessment of a police officer, for example in respect of fitness for duty referred to above (though this will be evident from the referral itself).106
[2024] WACOR 24 troubled, or distraught. Dr Hawes addressed police officers’ exposure to traumatic circumstances in the course of the policing role, describing it as an “inherent risk.” The importance of psychological support cannot be understated, and allied to that, a respect for its confidential nature.107
On the matter of confidentiality, Dr Hawes confirmed that the contacts with the Psychology Unit are confidential, unless there is a concern about an “imminent risk” in connection with a police officer. Imminent risk can comprise information from a police officer that they are going to hurt themselves or hurt someone else. Dr Hawes explained that in such a case, the psychologist would be required to share that, but there is always collaboration with the police officer who has come forward. The psychologist would share: “…. only what is absolutely required for safety” and would stay involved in terms of helping with conversations, such as with their supervisor.108
In other cases, Dr Hawes explained that a police officer might be experiencing fleeting thoughts of suicide (with no plan to take action) and the psychologist might make a different plan around risk and safety, involving persons whom the police officer may want to have involved in their care (such as family members). Throughout her evidence Dr Hawes emphasised the importance of collaboration with the police officer who has come forward.109
Dr Hawes cited a study that analysed the incidence of PTSD, anxiety and depression for first responder groups across Australia, which included police officers. Dr Hawes addressed suicidality, which she recognised can be impulsive, or planned. She explained that suicidal ideation can be experienced in a manner that is acute and sudden, or that is experienced in a manner that is chronic and over time.110
In respect of suicide risk assessments Dr Hawes recognised that they are a complex tool, and that they can be fluid and ever-changing: “I think your assessment is moment in time and there can be other contributors that change that in an hour, a minute, a day, a week.”111 107 ts 100.
108 ts 101; ts 104; ts 114.
109 ts 104; ts 116.
110 Ibid.
111 Ibid.
In connection with specific stressors, Dr Hawes explained that matters such as childhood bullying, or workplace bullying can be a stressor for an individual for their mental health, but that it would be: “…. dangerous to link that directly to high-risk behaviour or suicidality.”112
In this respect, I have considered the evidence concerning an allegation of workplace bullying that may have affected Cameron. It was not in connection with the Traffic Motorcycle Group. I have also considered the summary of the Workplace Review Report authored by an external consultant, dated 21 July 2023, in respect of the allegation. The author did not find evidence of any work related matters that directly contributed to Cameron’s death.113
Taking account of the outcome of the Workplace Review Report, and Dr Hawes’ evidence regarding the danger of linking bullying directly to suicidality, I am satisfied that any unhappiness that Cameron experienced in the workplace is not directly related to his death.
In connection with encouraging help seeking behaviour by police officers, Dr Hawes confirmed that there are internal and external services made available by the Western Australia Police Force. Dr Hawes explained that this has been a conscious decision, in response to feedback by police officers to the Health, Welfare and Safety Division, that they want choice in accessing a psychological service. By offering some control in these decisions, the hope is that it will remove as many barriers as possible to service and treatment.114
However, in her experience over recent years, Dr Hawes has seen more police officers opting to use the services of the internal Psychology Unit, instead of the external services. She attributes this to there being more accurate information about the internal Psychology Unit, a trust in privacy and confidentiality, and an understanding amongst police officers that it is not the goal of this unit to make officers non-operational. Dr Hawes has seen police officers engage with the Psychology Unit, and whilst some have 112 ts 102.
113 Exhibit 1, tab 25.
114 ts 103.
[2024] WACOR 24 been made non-operational, she has also seen them return to operational work and have fulfilling careers with the Western Australia Police Force.115
The Western Australia Police Force in its submission informs the court that the Health, Welfare and Safety Division is one of their most featured areas in their internal media content and that they undertake presentations across the agency to speak about mental health and share information on the services available. This includes discussions on confidentiality, privacy, being bound by the Australian Health Practitioner Regulation Agency and the Psychology Board, and the secure, encrypted storage of client records.116
They submit that this provides the Health, Welfare and Safety Division with a visibility in their workplace and an opportunity for less formal conversations, which builds relationships and encourages police officers to reach out to engage more.117
I am satisfied that there have been significant steps taken in the dissemination of information about the mental health services offered by the Health, Welfare and Safety Division, and that such information properly and fairly balances the confidentiality assurances as against the rarer occasions where private information must or should be disclosed in another forum.
Nonetheless this is an area of pressing need, and further comment is made later in this finding under the heading: Recommendations: Mental Health – education on confidentiality.
116 Exhibit 1, tab 29.
117 Ibid.
[2024] WACOR 24 opportunity to respond to those, as part of the requirements for procedural fairness under s 44(2) of the Coroners Act.
Their responses were provided on 24 October 2023, and I received that document into evidence.118
The first of my concerns related to the adequacy of the Western Australia Police Force’s level of inquiry and risk assessment of Cameron before he was allocated a police issued firearm for storage at his home. Their existing policies did not require such a risk assessment.
The Western Australia Police Force’s response focused on the following aspects: a) They acknowledge a breach of the policy FR-01.02.6 in that Cameron’s gun storage cabinet was not physically inspected, and the approval to store his police issued firearm at his home was given verbally rather than in writing; b) They submit that the photographic evidence showed that the gun cabinet was properly installed; and c) They submit that the Officer in Charge makes a point of working with his officers to get to know them, which assists him to identify health or welfare related concerns, and further submit that the Officer in Charge had just begun to get to know Cameron when he tragically took his life.119
It is on this final point that there is room for improvement on the part of the Western Australia Police Force. Getting to know an officer, in the expectation or hope that it will elicit information as to their health or welfare related concerns does not sufficiently mitigate the risk. It is a sound process and should continue, within the context of a supervisor’s positive working relationship with their team, and peer support. However, an officer in charge is not a clinician, they may miss cues, and the more junior officer may be reluctant to disclose, to their supervisor, information that might give 118 Ibid.
119 Exhibit 1, tab 29.
[2024] WACOR 24 rise to a health or welfare concern. They may actively seek to conceal it, which appears to have been Cameron’s approach.
There is no dispute that the Officer in Charge’s approval to Cameron to store the police issued firearm at his home should have been in writing, and that the Officer in Charge should have personally inspected the gun storage cabinet. As outlined previously, I am satisfied that neither of these omissions contributed to Cameron’s death.
My second concern related to a lack of information and guidance in the policies of the Western Australia Police Force, as to how to conduct an inquiry or risk assessment in respect of individual police officers, to consider suitability to store a police issued firearm at their home.
In their response, the Western Australia Police Force drew my attention to the sections of the Police Manual that focus on the physical security of the firearm to ensure it cannot be accessed unlawfully, which is certainly an important consideration. In connection with the assessment of the individual police officer, they referred to the matters reported by Detective Inspector Martin and that are referred to previously in this finding under the heading: Safety Considerations.
There is room for improvement to the Western Australia Police Force’s policies, to implement a risk assessment process focused on the police officer’s mental health and wellbeing before authorisation to store a police issued firearm at their home and including a process for ongoing monitoring. This is addressed later in this finding under the heading: Recommendations: Risk assessment – storage of firearm at home.
I have considered whether the Western Australia Police Force should have foreseen the risks of an officer, such as Cameron, taking their firearm home, and mitigated this by policies requiring a prior mental health assessment.
However, being mindful of hindsight bias, I have determined that there is no failure on their part that elevated Cameron’s risk.120 120 Hindsight bias is the tendency to perceive events that have occurred as being predictable than they were at the time. www.britannica.com/topic/hindsight-bias
The general tenor of the evidence from the police officers at the inquest, most of whom had decades of experience, was that significant steps have been made towards the de-stigmatisation of psychological support, and the availability of that support since the time of Cameron’s death. At the inquest A/Commander Brett acknowledged the progress made, and offered her insights in this area: “-So I think, historically, there – there has been a stigma. I think we’ve come a long way to – to remove that. I think it’s – it’s obviously still a work in progress. We talk very openly and – and like I’ve indicated, you know, I will have Psychology Unit or Health and Welfare attend and speak to my, you know, supervisors and – and my OICs. I – we take mental health very, very seriously, in terms of wanting to support our people. So I think it – it’s a much safer environment now, to be able to talk about needing help and getting help early, as well.”121
A/Assistant Commissioner Jackson spoke about the changes he has seen in the preparedness of police officers to discuss mental health issues. He acknowledged there can be stigma attached but felt that they are heading in the right direction, with more open conversation on the topic. There is a new generation of police officers coming through. It is not something that would have been so widely discussed when he first joined the Western Australia Police Force. He has seen positive changes even in the last three to five years.122
WAPOL Suicide Prevention Forum
122 ts 133.
123 Exhibit 1, tab 13.
The forum sought to gain a better understanding of officers’ experience of the agency, with discussion topics including: “What’s missing”, “What could be improved” and “What’s working?” in the area of mental health support for police officers.124
Positive outcomes from the forum include: a) a range of recommendations that included increased mental health training, agency culture and the resourcing of the Health, Welfare and Safety Division; and b) a recruitment initiative to facilitate the location of psychology resources to the Police Academy with the aim of embedding psychological review processes throughout a police officer’s career.125
At the inquest Dr Hawes elaborated on the mental health training, which is agency wide, and includes a face to face component, so as to be able to connect with people. Dr Hawes explained that the training had commenced at leadership level, so that they would understand the rationale for the training, and its importance, and thereby support it as it is rolled out to the rest of the agency.126 Pre-deployment assessment and wellbeing review
There is already in place an early stage psychological assessment that is to be satisfactorily passed, before an individual is eligible to be a police officer. This is a standard procedure carried out in compliance with the Regulation 505 of the Police Force Regulations 1979. At the inquest A/Assistant Commissioner Jackson explained that the psychological assessment is administered by an external entity.127
The Western Australia Police Force inform me of two processes they propose to implement to support the safety and wellbeing of police officers 124 Ibid.
125 Ibid.
126 ts 110.
127 ts 130 to 131.
[2024] WACOR 24 who are or may be authorised to store police issued firearms in their home, as follows: a) a Pre-Deployment Assessment, being a formal psychological assessment comprising testing and interview components with a psychologist, investigating risk factors including history of mental illness, trauma exposure, recent and historic stressors and personality factors; the psychologist is to submit a report to the referrer which includes an assessment of whether or not psychological or personal factors could make an applicant vulnerable to severe and ongoing emotional distress; and b) a non-mandatory Wellbeing Review, to identify any psychological distress, assess the working environment, track the police officer’s wellbeing and propose interventions such as counselling; these reviews are not reported back to the business unit unless the police officer consents, or there is an “extreme risk.”128
At the inquest Dr Hawes explained the current process for periodic wellbeing reviews, in other policing areas that are considered more high risk. They include an opportunity for a conversation with a police officer to see how they are travelling, and they involve the use of screening tools to look for main clinical areas around anxiety, depression, trauma and in particular burnout. They are voluntary or strongly encouraged, having regard to the importance of respecting the choices of the police officers in deciding to participate.129
Dr Hawes also explained that discussions have commenced with a number of additional business areas, including the Traffic Enforcement Group, about embedding similar periodic wellbeing reviews into their business area having regard to exposure around traffic and fatalities.130 Increased resourcing – Health, Welfare and Safety Division
The Western Australia Police Force informed me of improvements to their Health, Welfare and Safety Division, in the form of increased personnel and 128 Exhibit 1, tabs 24 and 29.
129 ts 111.
130 Ibid.
[2024] WACOR 24 increased service options, so as to enable a greater proactive engagement with business areas and individuals, and increased attendance at critical incidents. They draw attention to a broad range of services, some in existence in 2021 and prior to Cameron’s death, but expanded since that time and some new ones: a) Employee Assistance Program, a 24/7 counselling service offered to police officers and their families, facilitated by an external provider, aimed at complementing the in-house Psychology Unit, and focused upon resolving personal problems; the service provider operates independently from the Western Australia Police Force and offers a confidential service; this service was in existence in 2021;131 b) Psychology Unit, offering a full suite of evidence based psychological services for police officers, including those of clinical and counselling psychologists (and in the case of crises, emergencies and medical incidents, available 24/7); this service was in existence in 2021; however, more recently clinical oversight and leadership has been added through the introduction of a Clinical Psychologist – Senior Supervisor position, and a Chief Psychologist’s position (the latter focusing on organisational activities that promote psychological wellbeing, including destigmatising the accessing of mental health supports); the Chief Psychologist Dr Hawes has contributed to the range of services of which I am advised, and her evidence has been referred to previously in this finding; c) Employer funded private psychologists, for work and non-workrelated conditions; this service was in existence in 2021; however, more recently, to facilitate early treatment and engagement, the Western Australia Police Force has removed the requirement for GP referral as a prerequisite for payment for these services; d) Pre-Deployment psychological assessments conducted prior to deployment into high risk/high psychological demand business areas in order to determine suitability for the role and/or any psychological risks of working in that role; this service was in existence in 2021, but not in connection with Traffic Motorcycle Group officers who would be storing their police issued firearms at their homes; more recently 131 Exhibit 1, tabs 24 and 29.
[2024] WACOR 24 the Western Australia Police Force are reviewing the motorcycle commuting practices, with an expected outcome of including a PreDeployment Assessment for them.132
The Western Australia Police Force inform me that the Health, Welfare and Safety Division plan an agency wide mental health training framework with the objectives of reducing stigma, enhancing resilience, discussing different coping strategies and increasing mental health literacy, including the monitoring of self and others. The plan will involve face to face training, it will be embedded within recruit training and incorporate an annual refresher training. The greater engagement will be supported by an improved electronic case management system that brings together information on health, wellbeing and safety so as to track trends and identify interventions, particularly around officers’ attendance at critical incidents.133
At the inquest Dr Hawes referred to this improved electronic case management system which is separate to the Psychology Unit’s own encrypted client management system. By way of example given by Dr Hawes, the electronic case management system will allow them to monitor how often police attend critical incidents, their nature and severity, so they can triage support and offer services to the involved police officers.
It would also include information about assaults on police officers, with the aim of generating a welfare check.134 Psychologist at Police Academy
He said the recruits would have somewhere to go if they are feeling challenged, or if they feel they need to talk to someone, and spoke of the benefits of normalising discussion around mental health: 132 Ibid.
133 Ibid.
134 ts 112 to 114.
135 ts 146.
[2024] WACOR 24 “…. the more exposure that all of our police officers have to the therapeutic – therapeutic areas and all of the mental wellness services that we provide, it goes some way to normalising mental health, which to my way of thinking is the barrier. It’s – it has to be normalised. Then people are free to talk about it. And they’re comfortable seeking help. And in fact, they will seek it out.”136
The Western Australia Police Force sought and obtained approval for the position of Organisational Psychologist at the Police Academy. As at the time of receipt of their Submissions, an incumbent had been selected, to commence this role.137
This has been achieved within the context of the acceleration in the recruitment and training of additional police recruits and staff (the 1000 Plan project). The aim is to ensure that Psychological Services are engaged at an early stage, to assess resilience and mental health of applicants and recruits.138
It is hoped, with justification, that by openly addressing mental health early in a police officer’s career and providing ready support when required, the Western Australia Police Force can foster a change in culture towards mental health attitudes, build resilience, and destigmatise health seeking for mental health issues.139
The Organisational Psychologist at the Police Academy will provide specialised psychological assessments, interventions and support, and specialist advisory and consultancy services to supervisors and managers.
The evident importance of adequate support systems from an early stage is recognised by the Western Australia Police Force in their Submissions: “The mental health of police officers in Australia is a pressing concern, as the demanding nature of their profession coupled with exposure to trauma and high stress levels takes a toll on their psychological wellbeing. Research indicates that rates of depression, anxiety and Post-Traumatic Stress Disorder (PTSD) among Australian police officers are notably higher than those in 136 ts 137.
137 Exhibit 1, tab 29.
138 Ibid.
139 Ibid.
[2024] WACOR 24 the general population. Factors such as work-related stressors, critical incident exposure, organisational culture, and lack of mental health support contribute to these challenges. Several Australian studies, including research by the Victoria Police and Beyond Blue, have highlighted the need for improved mental health initiatives within law enforcement agencies, including increased access to confidential psychological services, better training in dealing with trauma, and fostering a culture that destigmatises seeking help for mental health issues. For many recruits, this is the first exposure they have had to the realistic demands and expectations place[d] upon police officers. The physical and mental demands they experience may have a significant impact on their wellbeing and is a critical concern for the WA Police Force. This emphasises the need for adequate support systems and interventions. It is imperative that ongoing efforts are made to prioritise proactive/preventative and ongoing mental health supports and training adjustments to mitigate the adverse effects on police trainees' mental wellbeing and to ensure a resilient law enforcement workforce.”140
RECOMMENDATIONS Risk assessment – storage of firearm at home
I initially considered the desirability of a recommendation that the Western Australia Police Force take all reasonable steps to cease the practice of police officers within the Traffic Motorcycle Group storing their police issued firearms at home. At the inquest I explored issues of concern surrounding the presence of a police issued firearm in the home.141
The potential higher risks of having a police issued firearm in the home were acknowledged by A/Commander Brett due to it being accessible, in a private environment, with no one having the ability to intervene or stop or support the police officer. The combination of alcohol, untreated mental health illnesses and/or other medications, can impair judgment. There is a 140 Ibid.
141 ts 67.
[2024] WACOR 24 risk of the police officer making choices that may be harmful, to themselves. 142
Dr Hawes’ evidence was that access to a firearm in the home is always a significant factor, but that it is important to look at the entirety of the picture: “I don’t think access alone is a sole contributor to the outcome.” However, Dr Hawes went on to elaborate: “But if someone is unwell and there’s other risk factors at play, access can contribute or can exacerbate.”143
It was posited that allowing police officers to commute on their motorcycles has benefits. A/Commander Brett reported upon the number of occasions that a police officer has been required, whilst commuting to and from work, on a police motorcycle, to attend to breaches of road traffic legislation or requests for assistance. It is clear from the agency records that there are substantial attendances.144
At the inquest A/Commander Brett spoke of the benefits of the uniformed police officers being a visible presence in the community when they commute to and from work on their marked police motorcycles. She described them as a very agile resource explaining that, for example during the commute, they might be diverted to a traffic crash accident to provide first response and mitigate traffic congestion at peak hour. As outlined previously, in order to undertake these tasks during their commute they must carry three force options, one of these being their police issued firearm.145
A/Commander Brett explained that the commuting practice also provides the police officers with the opportunities to upskill and become very familiar with their police motorcycle. In the Superintendent’s experience, the commuting practice has helped to attract and retain police officers in the Traffic Motorcycle Group. When the police officers are on leave, the motorcycle and accoutrements are stored in the appropriate policing location.146 142 ts 90; ts 97.
143 ts 108.
144 Exhibit 1, tab 23.
145 ts 76 to 77.
146 ts 81; ts 96.
On balance have decided not to make a broad recommendation to the effect that the commuting practice be ceased. I accept that there is a policing benefit. I have taken account of the Western Australia Police Force’s submission on the following aspects: a) that the practice of commuting to and from work enables these police officers to provide a fast and agile response to traffic incidents and other tasks, that cannot be completely replicated by other business areas or transport mediums; and b) that whilst this practice is based upon an arrangement that has been in place for some time, as part of their review of the Traffic Motorcycle Group community practices, the Western Australia Police Force will in any event consider whether it is appropriate for this to continue.147
In the meantime, and for the foreseeable future whilst this practice continues, I consider it appropriate to mitigate the risk of misuse of police issued firearms stored in the home, through a robust process of safety and wellbeing reviews for those police officers. At the inquest A/Commander Brett expressed her support for an approach that included psychological testing for police officers who are authorised to take home police issued firearms.148
Dr Hawes’ evidence was that an assessment before a police officer takes a firearm home, together with a yearly check in could be helpful, but that this should also be accompanied by cultural change which she described as: “….
a collaborative and shared effort of everyone in the agency to check in on people and make sure they’re travelling okay.”149
148 ts 86; ts 90 to 91.
149 ts 107.
[2024] WACOR 24 required. In such a case, Dr Hawes would consider they are participating willingly in that.150
I have therefore proceeded with this alternate recommendation for which I had sought input.
The Western Australia Police Force inform me that they support Recommendation Number 1, below. One of their expected outcomes from their review of the motorcycle commuting practices is the inclusion of a Pre-Deployment Assessment of the police officers, as a prerequisite.151
They anticipate that the likely changes to the Traffic Motorcycle Group commuting policy will bring this area in line with other areas where police officers are authorised to store police issued firearms at their home. These other areas already include Pre-Deployment Assessments and annual Wellbeing Reviews (referred to previously under the heading: Improvements) as part of the risk assessment relating to the nature of the work undertaken.152 Recommendation No.1 That the Western Australia Police Force take all reasonable steps to ensure a comprehensive mental health risk assessment is prepared in relation to every individual police officer who is to join the Traffic Motorcycle Group and who is to be authorised to store their police issued firearm at their home address, before they are authorised to do so, with a further comprehensive mental health risk assessment taking place every year it is proposed the authorisation to store their police issued firearm at their home address will be renewed.
In the case of police officers who are already in the Traffic Motorcycle Group and who have already been authorised to store their police issued firearm at their home, they should be strongly encouraged to participate in the above comprehensive mental health risk assessments.
150 ts 127 to 129.
151 Exhibit 1, tab 29.
152 Ibid.
[2024] WACOR 24 Mental health – reduction of stigma
At the inquest, I heard evidence about stigma that adversely impacts upon the willingness of police officers to seek help from mental health and wellbeing services offered by the Western Australia Police Force.
The Western Australia Police Force acknowledge this stigma within the context of it being a societal issue and point to a range of efforts over the years to address this and to increase the willingness of their employees to engage with mental health and wellbeing services. The range of increased health and wellbeing service options, and training, are referred to previously in this finding under the heading: Improvements.153
The improvements are significant, and I have only referred to the ones that may be relevant to the circumstances of Cameron’s death. There are numerous other improvements.
Nonetheless the reduction of stigma in relation to seeking help in the mental health area is an important and ongoing need. The positive impacts of the many services offering assistance can be undermined or negated if there is a felt stigma in accessing them. Noting that a lot of work has been done in this area, I make the following recommendation in support of this work, and so that it remains in front of mind: Recommendation No.2 That the Western Australia Police Force consider the development of a comprehensive and ongoing strategy to reduce stigma within the Western Australia Police Force in relation to conversations regarding mental health and help seeking.
Mental health – proactive engagement
[2024] WACOR 24 Division is already undertaking, and contemplates a checking in process with individual police officers.
They draw attention to the evidence of their Chief Psychologist Dr Hawes at the inquest, as follows: a) “…. people have the best treatment outcome when they have choice and autonomy, and when they’re supported in a way that’s comfortable for them, not – there’s no one size fits all with clinical service …… having the person’s choice and control at the forefront of what we’re doing for them, essentially;”154 and b) “So if we’re forcing people into one way of operating and they don’t want that way or need that way it can actually rupture relationships or cause unnecessary distress or damage. I think it’s just balancing out that people have options. Yes, it would be great if we could check in with everyone periodically.”155
Recommendation No.3 That the Western Australia Police Force explore further options for proactively checking in with police officers in connection with their mental health and wellbeing at various stages of their employment with the Western Australia Police Force, and that resources be allocated for this to occur. This checking in should be done in a way that allows for choice and autonomy.
154 ts 126.
155 ts 125.
[2024] WACOR 24 Mental health – education on confidentiality
As outlined under the previous heading: Safety considerations: Mental Health – education on confidentiality, confidence in the use of the Health, Welfare and Safety Division’s services is an area of pressing need. The Western Australia Police Force informs the court that this division will continue to work with Corporate Communications to identify opportunities to highlight care for officers and reinforce the message that the care is confidential.156
I make the following recommendation in the acknowledgement that steps are already under way and in support of them on an ongoing basis: Recommendation No.4 That the Western Australia Police Force consider ways of disseminating further information emphasising how confidentiality provisions apply when police officers access their mental health resources, including information regarding the steps that may be taken should a mental health practitioner form a concern for a police officer’s wellbeing.
Judging by the many positive assessments and/or comments made about Cameron by his supervisors, both during his life and after his death, it is clear that he was held in high regard at the Western Australia Police Force.
It is unfortunate that Cameron felt he could not disclose his mental health struggles at an earlier stage, when he first experienced suicidal ideation in 2017, either to a private clinician, or to a clinician from the various psychological support services of the Western Australia Police Force.
Ultimately it was a choice that he made.
[2024] WACOR 24 counselling could have been augmented if Cameron had been more open to disclosing how he felt and confronting the extent of his struggles. This would have taken time, and commitment, on his part.
Since 2017 there has been significant progress made by the Western Australia Police Force in tailoring its psychological services and fostering a culture of open discussion about mental health. Cameron’s death precipitated a lot of reflection and self-analysis within the Western Australia Police Force. Many of the improvements to their psychological services, and culture of open discussion, are generated from the outcomes of their Suicide Prevention Forum in August 2021, after Cameron’s death.
Within the context of choice and autonomy, whilst noting the evidence about police officers being more willing to use the in-house psychological services, it nonetheless remains important to continue to offer the option of support for the use of external services, to maximise help seeking behaviour.
Cameron’s fears about the impacts to his policing career, of seeking help, may have been exacerbated by his mental health condition, and may have been quite excessive, but they were not completely without foundation.
However, he may not have appreciated that any impact may have been temporary. Had Cameron expressed suicidal ideation and been assessed at risk, his access to his police issued firearm would likely have been removed, potentially for a period of time. But this, along with psychological support, would have been to his benefit.
R V C Fogliani State Coroner 28 May 2024
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