Inquest into the Deaths of Terry James CZERNOWSKI and Lachlan Richard Francis BOWLES

[2026] WACOR 10 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : MICHAEL ANDREW GLIDDON JENKIN ACTING DEPUTY STATE CORONER HEARD : 10 - 11 MARCH 2026 DELIVERED : 30 MARCH 2026 FILE NO/S : CORC 64 of 2023 & CORC 65 of 2023

DECEASED : CZERNOWSKI, TERRY JAMES & : BOWLES, LACHLAN RICHARD FRANCIS Catchwords: Nil Cases: Briginshaw v Briginshaw (1938) 60 CLR 336 Legislation: Coroners Act 1996 (WA) Police Act 1892 (WA) Counsel Appearing: Mr W Stops appeared to assist the coroner.

Mr M Olds (State Solicitor’s Office) appeared on behalf of the Western Australia Police Force.

[2026] WACOR 10 SUPPRESSION ORDER On the basis that it would be contrary to the public interest, I make an order under section 49(1)(b) of the Coroners Act 1996 (WA), that there be no reporting or publication of: a. The name, picture or any other identifying features of the witnesses referred to as Tactical Operator 02 and Tactical Operator 116; b. Details about the decision making criteria, response times, resourcing and any other operational aspects of the Western Australia Police Force (WA Police) Tactical Response Group (TRG), except insofar as is necessary for the Acting Deputy State Coroner to comment on communication issues, and the adequacy of mental health supports relevant to the TRG’s attendance on Mr Lachlan Bowles; c. The methodologies, response times or resourcing of the WA Police TRG Negotiators Unit; d. The sections of the WA Police Manual that are applicable to the TRG; e. The details of any of the versions of the WA Police Firearms Policy; and f. The details of any of the versions of the WA Police Emergency Driving Policy and Guidelines, including, but not limited to any cap on the speed at which officers are authorised to drive.

Order made by Acting Deputy State Coroner MAG Jenkin (10.03.26)

[2026] WACOR 10 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Michael Andrew Gliddon Jenkin, Coroner, having investigated the deaths of Terry James CZERNOWSKI and Lachlan Richard Francis BOWLES (the deceased persons) with an inquest held at the Perth Coroner’s Court, Central Law Courts, Court 85, 501 Hay Street, Perth on 10 - 11 March 2026 find that the identity of the deceased persons was as follows: Terry James CZERNOWSKI whose death occurred on 7 September 2023 at the Kellerberrin Memorial Hospital, 1 - 63 Gregory Street, Kellerberrin from gunshot injuries to the head and chest; and Lachlan Richard Francis BOWLES whose death occurred on 7 September 2023 in a wheat paddock near Morley Road, Kellerberrin from gunshot injury to the head in the following circumstances: Table of Contents

[2026] WACOR 10

[2026] WACOR 10 INTRODUCTION

1. For reasons which cannot be adequately explained, on the morning of 7 September 2023, Lachlan Richard Francis Bowles (Lachlan) drove to his workplace and fired shots at his workmate, Terry James Czernowski (Terry), who subsequently died.1,2,3,4,5,6,7

2. Lachlan then made his way to a wheatfield near Morley Road in Kellerberrin, where he was subsequently located by members of Western Australia Police Force’s (WA Police) Tactical Response Group (TRG).

During lengthy negotiations with police, Lachlan gave up three of his four firearms. However, despite repeated requests, Lachlan refused to give up his fourth firearm (a rifle), which he used to take his life.

3. At the time of their respective deaths, Terry was 44 years of age and Lachlan was 25 years of age.

4. Both Terry’s and Lachlan’s deaths were “reportable deaths”, and pursuant to section 22(1)(b) of Coroners Act 1996 (WA) (the Act) because of the possibility that Lachlan’s death may have been caused or contributed to by members of WA Police, a coronial inquest was mandatory.8

5. Pursuant to a direction by the State Coroner under section 40 of the Act,9 I conducted a joint inquest into the deaths of Terry and Lachlan Perth on 10 - 11 March 2026.10

6. Members of Terry’s family and Lachlan’s family attended the inquest, which focussed on the circumstances of both deaths, and the conduct of the police who interacted with Lachlan on 7 September 2023.

1 At the request of their respective families, the deceased men have been referred to as “Terry” and “Lachlan” in this finding 2 Exhibit 1, Vol. 1, Tab 1, P100 - Report of Death - Terry James Czernowski (07.09.23) 3 Exhibit 1, Vol. 1, Tab 1, P100 - Report of Death - Lachlan Richard Francis Bowles (07.09.23) 4 Exhibit 1, Vol. 1, Tab 2, Report - Det. Sgt. D Heller, Homicide Squad (31.01.25), p13 5 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), p29 and ts 10.03.26 (Hannan), pp53-61 6 Exhibit 1, Vol. 1, Tab 3, Life Extinct Form - Terry James Czernowski (07.09.23) 7 Exhibit 1, Vol. 1, Tab 3.1, Life Extinct Form - Lachlan Richard Francis Bowles (07.09.23) 8 Sections 3 & 22(1)(b), Coroners Act 1996 (WA) 9 Section 40 Direction: Email - State Coroner to Principal Registrar (11.09.23) 10 Section 40 Direction: Email - State Coroner to Principal Registrar (11.09.23)

[2026] WACOR 10

7. The documentary evidence tendered at the inquest comprised two volumes, and the following witnesses gave evidence: a. Dr M Hall (Consultant Psychiatrist, WA Fixated Threat Assessment Centre);11 b. Tactical Operator 02, (Attending police officer, TRG);12 c. Tactical Operator 116, (Attending police officer, TRG);13 d. Det. Sgt. J Hannan, (Author, Homicide Squad report);14 e. Sgt. J Marsh, (Negotiator Coordinator, TRG);15 f. Supt. J Kazandzis, (Author, TRG Report);16,17 and g. Det. Sen. Sgt. A Dorosz (Author, Internal Affairs Unit report).18

8. When assessing the available evidence and deciding whether to make any adverse findings in this matter, I have applied the standard of proof set out in the High Court’s decision in the case of Briginshaw v Briginshaw.19 That case requires a consideration of the nature and gravity of the conduct when deciding whether a finding adverse in nature has been proven on the balance of probabilities.

9. I have also been mindful not to insert any hindsight bias into my assessment of the actions of members of the WA Police. Hindsight bias is the well-known tendency, after an event, to assume the event was more predictable or foreseeable than it was at the time.20

10. Section 22(1)(b) of the Act is enlivened whenever the issue of causation or contribution in relation to a death arises as a question of fact, irrespective of whether there is fault or error on the part of any member of WA Police. After careful consideration of the available evidence (and for the reasons I have outlined) I have concluded that none of the actions of police (Attending Police Officers)21 caused or contributed to Lachlan’s death. Instead it is my view that for reasons unknown; after killing Terry, Lachlan took his life by shooting himself in the head.

11 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, WA Fixated Threat Assessment Centre (13.03.25) & ts 10.03.26 (Hall), pp9-27 12 Exhibit 1, Vol. 2, Tab 40, Statement -Tactical Operator 02 (25.02.25) & ts 10.03.26 (Tactical Operator 02), pp27-42 13 Exhibit 1, Vol. 2, Tab 47, Statement -Tactical Operator 116 (17.09.23) & ts 10.03.26 (Tactical Operator 116), pp42-53 14 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25) & ts 10.03.26 (Hannan), pp53-61 15 Exhibit 1, Vol. 1, Tab 20, Report - Sgt J Marsh, Tactical Response Group (29.05.25) & ts 11.03.26 (Marsh), pp65-75 16 Exhibit 1, Vol. 1, Tab 12, Report - Supt. J Kazandzis, Tactical Response Group (30.09.24) & ts 11.03.26 (Kazandzis), pp75-84 17 Supt. J Kazandzis was promoted to Commander in 2025 and is no longer attached to the TRG 18 Exhibit 1, Vol. 1, Tab 10, Report - Det. Sen. Sgt. A Dorosz, Internal Affairs Unit (24.02.24) and ts 11.03.26 (Dorosz), pp85-91 19 (1938) 60 CLR 336, per Dixon J at pp361-362 20 Dillon H and Hadley M, The Australasian Coroner’s Manual (2015), p10 21 “Attending Police Officers” means the Police Negotiators and Tactical Operators 2, 5, 17, 87, 96, 97, 98, & 116

[2026] WACOR 10 TERRY Background22,23,24,25

11. Terry was born in Northam on 6 May 1979, and he lived with his parents until he was six years of age, when their marriage dissolved. Terry and his siblings then moved to Wattleup, where they were cared for by their mother.

12. Between 1989 and 1996, Terry and his family lived in South Australia, to be closer to the family of their mother’s new partner. When the family returned to Western Australia, they lived in Armadale, and Terry completed his schooling at a high school in Seville Grove.

13. In about 2007, Terry began a relationship, and he and his partner were married in 2010. Terry and his wife moved to Kellerberrin to be closer to her family, and Terry began working at Moylan Grain Silos in various positions. Although Terry and his wife had a daughter in 2013, their relationship broke down, and they separated in 2014.

14. Terry later met a new partner, but this relationship was described as being “a roller coaster” and there were verbal arguments caused by Terry’s alcohol consumption. By August 2023, Terry was described as “very depressed” and as “being out of sorts and talking about suicide”.26,27

15. However, despite his expressions of suicidal ideation, Terry’s former wife says that when she asked Terry whether he was serious about taking his life, Terry had told her “he wouldn’t because of how it would affect his daughter”.28

16. Medical records confirm that Terry was under the care of the Kellerberrin Medical Centre, where he was being treated for depression and had been prescribed the antidepressant medication, mirtazapine.

22 Exhibit 1, Vol. 1, Tab 1, P100 - Report of Death - Terry James Czernowski (07.09.23) 23 Exhibit 1, Vol. 1, Tab 2, Report - Det. Sgt. D Heller, Homicide Squad (31.01.25), pp2-3 24 Exhibit 1, Vol. 1, Tab 21, Statement - Ms C Dixon (12.09.23) 25 Exhibit 1, Vol. 1, Tab 22, Statement - Ms D Sparrow (07.03.24) 26 Exhibit 1, Vol. 1, Tab 2, Report - Det. Sgt. D Heller, Homicide Squad (31.01.25), p3 27 See also: Exhibit 1, Vol. 2, Tabs 34 & 34.1, Statement & Handwritten statement - Mr I Jacobsen (undated & 07.09.23) 28 Exhibit 1, Vol. 1, Tab 2, Report - Det. Sgt. D Heller, Homicide Squad (31.01.25), p3

[2026] WACOR 10 LACHLAN Background29,30,31,32,33,34,35,36,37,38

17. Lachlan was born in East Fremantle on 7 July 1998. Lachlan’s family had originally lived in Yangebup, but they later moved to Kellerberrin, where Lachlan attended school until Grade 5. Thereafter he and his siblings were home-schooled.

18. Lachlan was described by his family as a “loving, bright, intelligent, funny and deeply caring young man” who had a good sense of humour, always willing to help others. Lachlan loved all types of animals, and in addition to his deep interest in military history, he collected Samurai swords, and Australian, Russian, and Nazi-era militaria.

19. From a young age, Lachlan had reportedly expressed a desire to pursue a career in the Australian Defence Force (ADF), and he made two unsuccessful attempts to join the ADF. Lachlan’s first application (in 2016) was rejected when a psychological assessment found he lacked social skills. ADF recruiters suggested that Lachlan address these issues by joining a local sporting club, doing some volunteer work, and by having some counselling to address his shyness.

20. Lachlan embraced these recommendations and in addition to undergoing therapy, he joined two pistol clubs and a darts club and was a volunteer paramedic with St John Ambulance WA.39 Despite these efforts, Lachlan’s second application to join the ADF in 2018 was unsuccessful on medical and psychological grounds.

21. Lachlan applied to join WA Police in 2022, but this application was unsuccessful due to his psychological and risk assessments.40 29 Exhibit 1, Vol. 1, Tab 1, P100 - Report of Death - Lachlan Richard Francis Bowles (07.09.23) 30 Exhibit 1, Vol. 2, Tab 32, Statement - Ms E Bowles (08.09.23) 31 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), pp4-7 & ts 10.03.26 (Hannan), pp53-61 32 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, Fixated Threat Assessment Centre (13.03.25) & ts 10.03.26 (Hall), pp9-27 33 Exhibit 1, Vol. 2, Tab 33, Statement - Mr L Bowles (20.09.23) 34 Exhibit 1, Vol. 2, Tabs 34 & 34.1, Statement & Handwritten statement - Mr I Jacobsen (undated & 07.09.23) 35 Exhibit 1, Vol. 2, Tabs 35 & 35.1, Statement - Ms S Lynch & Transcript of call with Lachlan (21.09.23 & 07.09.23) 36 Exhibit 1, Vol. 2, Tabs 36 & 36.1, Statement & Handwritten statement - Mr D Mitchell (undated & 08.09.23) 37 Exhibit 1, Vol. 2, Tab 37, Statement - Mr D Rees (13.02.23) 38 Exhibit 1, Vol. 2, Tab 48, Letter - Ms E Bowles (25.02.26) 39 Exhibit 1, Vol. 1, Tab 18, Report - Ms K Stewart, St John Ambulance WA (31.07.25) 40 Exhibit 1, Vol. 1, Tab 14, WA Police Risk Prediction Index (09.06.22)

[2026] WACOR 10

22. In her report, Detective Sergeant J Hannan (Officer Hannan) noted that these assessments found that Lachlan: (W)as considered to be 'high risk' with the following identified issues of dominance, gender and racial bias, integrity, interpersonal sensitivity, self-confidence, helping others, patience, leadership ambition, maturity, anxiety, impulsivity and gambling. He was advised he could reapply in twelve months.41,42

23. At the request of WA Police, Dr Hall (a consultant psychiatrist with the WA Fixated Threat Assessment Centre) undertook a post mortem review of Lachlan’s mental state. Dr Hall said that in his opinion, the second rejection by the ADF appears to have triggered a progressive deterioration in Lachlan’s mental health over the next few years.43

24. During his evidence at the inquest, Dr Hall said that in his opinion, it was likely that Lachlan had undiagnosed autism spectrum disorder. Dr Hall said this condition may help to explain why Lachlan was unable to understand the nuances contained within the questions in the police assessments.44,45

25. Dr Hall also expressed the view that it was likely that by September 2023, Lachlan was severely depressed and was experiencing high levels of anxiety. One manifestation of Lachlan’s depression (which emerged during comments he made to the police negotiator) was a pervading sense that he (Lachlan) was a bad person.46,47

26. On Australia Day 2021, Lachlan was presented with a community service award and had planned to complete a deep sea diving course after gaining his initial diving qualification. Lachlan started work at Moylan Grain Silos in Kellerberrin in January 2020 and Terry was one of his workmates. I note that there is no evidence before me that there was ever any significant animosity or ill-feeling between the pair.

41 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), p5 42 Exhibit 1, Vol. 1, Tab 14, WA Police Risk Prediction Index (09.06.22) 43 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, Fixated Threat Assessment Centre (13.03.25), pp8-9 44 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, Fixated Threat Assessment Centre (13.03.25), pp4-7 45 ts 10.03.26 (Hall), pp11-16 46 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, Fixated Threat Assessment Centre (13.03.25), p12 47 ts 10.03.26 (Hall), pp16-18, 20 & 24

[2026] WACOR 10 EVENTS LEADING TO TERRY’S DEATH48,49,5051,52,53,54,55,56,57,58,59,60,61,62 Lachlan arrives at his workplace

27. At about 7.40 am on 7 September 2023, Terry left home and drove to his workplace at Moylan Grain Silos. After signing on at work at 7.42 am, he began fabricating the base of a wheat silo in a large shed on the west side of the yard. When he had finished making the silo base, Terry used a forklift to move it to the side of the shed. Terry then returned the forklift to the truck shed, where he had a brief conversation with a work colleague.

28. At about 8.35 am, Lachlan drove into the yard at Moylan Grain Silos in a grey Holden Commodore. Lachlan was armed with two handguns (.357 Magnum revolver and a .22 calibre pistol), both of which were licensed to him. He was wearing a heavy jacket, a balaclava, and an armband bearing a Nazi swastika.

29. As Terry came out of the truck shed, Lachlan approached him and fired four shots at him at close range. CCTV footage confirms there was no interaction between the pair before Lachlan fired the shots. After he had been hit, Terry ran a short distance before he collapsed to the ground.

Lachlan then fired four more shots at Terry as he lay on the ground, before running to his car and driving out of the yard.

30. Several work colleagues heard the noise of the shots and rushed to where Terry was lying. Terry did not appear to be breathing, and his work colleagues loaded him into a work utility and drove him to Kellerberrin Memorial Hospital.

48 Exhibit 1, Vol. 1, Tab 2, Report - Det. Sgt. D Heller, Homicide Squad (31.01.25) 49 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25) 50 Exhibit 1, Vol. 1, Tab 3, Life Extinct Form - Terry James Czernowski (07.09.23) 51 Exhibit 1, Vol. 1, Tab 9, Medical records - Kellerberrin Memorial Hospital (07.09.23) 52 Exhibit 1, Vol. 1, Tabs 15 & 15.1-15.7, CCTV footage from various locations (07.09.23) 53 Exhibit 1, Vol. 1, Tab 23, Statement - Mr C Moylan (13.09.23) 54 Exhibit 1, Vol. 1, Tabs 24 & 24.1, Statement & Handwritten statement - Mr E Sutherland-Scott (undated & 07.09.23) 55 Exhibit 1, Vol. 1, Tabs 25 & 25.1, Statement & Handwritten statement - Mr J Johnson (undated & 07.09.23) 56 Exhibit 1, Vol. 1, Tab 26, Statement - Mr P Ruus (12.09.23) 57 Exhibit 1, Vol. 1, Tab 27, Statement - Mr J Naldo (13.09.23) 58 Exhibit 1, Vol. 1, Tab 28, Statement - Mr R Cable (12.09.23) 59 Exhibit 1, Vol. 1, Tab 28.1, Transcript of “000” Call - Mr R Cable (07.09.23) 60 Exhibit 1, Vol. 1, Tabs 29 & 29.1, Statement & Handwritten statement - Mr D Jarman (undated & 08.09.23) 61 Exhibit 1, Vol. 1, Tab 30, Statement - Mr R Tullao (15.09.23) 62 Exhibit 1, Vol. 1, Tab 31, Statement - Sgt. J Humble (11.10.23)

[2026] WACOR 10

31. At 8.39 am, an employee at Moylan Grain Silos contacted emergency services to report “an active shooter Moylan Silos in Kellerberrin”.63,64 Police arrived at Moylan Grain Silos a short time later, and as I will explain, TRG tactical operators were deployed from Perth a short time after that.65 Treatment at Kellerberrin Memorial Hospital66,67,68

32. Meanwhile, Terry arrived at Kellerberrin Memorial Hospital at 8.38 am and was taken into the emergency department. The history provided to the clinical team was that Terry had been found on the ground following an unwitnessed fall from a silo.

33. Terry was assessed as having experienced: A penetrating and haemorrhaging wound to the right side of his chest, multiple small lacerations and trauma impact to the face, a small wound on his right shoulder and elbow region, with blood in his mouth and nose.69,70

34. Although CPR was started immediately, Terry’s heart remained in asystole,71 and despite concerted resuscitation efforts he could not be revived. Terry was declared deceased at 9.10 am on 7 September 2023.72 63 Exhibit 1, Vol. 1, Tab 28, Statement - Mr R Cable (12.09.23) 64 Exhibit 1, Vol. 1, Tab 28.1, Transcript of “000” Call - Mr R Cable (07.09.23) 65 Exhibit 1, Vol. 1, Tab 31, Statement - Sgt. J Humble (11.10.23) 66 Exhibit 1, Vol. 1, Tab 9, Emergency Department notes - Kellerberrin Memorial Hospital (07.09.23) 67 Exhibit 1, Vol. 1, Tab 9, Emergency Department continuation notes - Kellerberrin Memorial Hospital (07.09.23) 68 Exhibit 1, Vol. 1, Tab 9, WACHS Death in Hospital Form - Kellerberrin Memorial Hospital (9.10 am, 07.09.23) 69 Exhibit 1, Vol. 1, Tab 2, Report - Det. Sgt. D Heller, Homicide Squad (31.01.25), p5 70 Exhibit 1, Vol. 1, Tab 9, Emergency Department continuation notes - Kellerberrin Memorial Hospital (07.09.23) 71 Asystole is the complete cessation of the heart's electrical and mechanical activity 72 Exhibit 1, Vol. 1, Tabs 3 & 9, WACHS Life Extinct Form - Kellerberrin Memorial Hospital (9.10 am, 07.09.23)

[2026] WACOR 10 EVENTS LEADING TO LACHLAN’S DEATH 73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96 Lachlan leaves his workplace

35. After he left Moylan Grain Silos, Lachlan drove to Maley Road in Kellerberrin where he abandoned his car. Lachlan then walked to nearby Mission Road, where he fired a round at a passing Landcruiser vehicle using either a .357 revolver or a .357 rifle, narrowly missing the driver.

36. After firing at this random vehicle, Lachlan continued on foot before entering a wheatfield adjacent to Morley Road in Kellerberrin. The wheat crop was green and approximately knee-high at the relevant time.

TRG deployment

37. After police had attended Moylan Grain Silos after Terry had been shot, the incident was escalated as an “active armed offender” incident at 8.52 am. The TRG was promptly notified and several TRG vehicles departed Perth for Kellerberrin shortly after 9.00 am.

38. The first TRG vehicles arrived in Kellerberrin at about 10.40 am, and these vehicle were subsequently joined by an armoured TRG vehicle (the Bearcat) and later still, by a specialist communications trailer.

73 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), p29 and ts 10.03.26 (Hannan), pp53-61 74 Exhibit 1, Vol. 1, Tab 3.1, Life Extinct Form - Lachlan Richard Francis Bowles (07.09.23) 75 Exhibit 1, Vol. 1, Tab 11, WA Police Incident Report LWP23090700629377 (07.09.23) 76 Exhibit 1, Vol. 1, Tabs 15 & 15.1-15.7, Operation Volos - CCTV footage from various locations (07.09.23) 77 Exhibit 1, Vol. 1, Tab 16, Operation Volos - POLAIR Remotely Piloted Aircraft Systems, Det. FC Const. D Muhleisen (07.09.23) 78 Exhibit 1, Vol. 1, Tab 19, St John Ambulance Patient Care Records 23108692 & 23109347 (07.09.23) 79 Exhibit 1, Vol. 1, Tab 20, Report - Sgt. J Marsh, Negotiator Coordinator - Tactical Response Group (29.10.25) 80 Exhibit 1, Vol. 2, Tab 38, Statement - Det. Sgt. J McAnder (26.09.23) 81 Exhibit 1, Vol. 2, Tabs 32 & 32.1, Statement - Ms E Bowles & Call transcript - Ms E Bowles & Lachlan (08.09.23 & 07.09.23) 82 Exhibit 1, Vol. 2, Tabs 35 & 35.1, Statement - Ms S Lynch & Transcript of call with Lachlan (21.09.23 & 07.09.23) 83 Exhibit 1, Vol. 2, Tab 37, Statement - Mr D Rees (13.02.23) 84 Exhibit 1, Vol. 2, Tab 38, Statement - Det. Sgt. J McAnder (26.09.23) 85 Exhibit 1, Vol. 2, Tab 39, Statement - Sen. Const. G Payer-Smith J McAnder (27.02.26) 86 Exhibit 1, Vol. 2, Tab 40, Statement - Tactical Operator 02 (25.02.25) & ts 10.03.26 (Tactical Operator 02), pp27-42 87 Exhibit 1, Vol. 2, Tab 41, Statement - Tactical Operator 05 (20.09.23) 88 Exhibit 1, Vol. 2, Tab 42, Statement - Tactical Operator 17 (20.12.25) 89 Exhibit 1, Vol. 2, Tab 43, Statement - Tactical Operator 87 (19.09.23) 90 Exhibit 1, Vol. 2, Tab 44, Statement - Tactical Operator 96 (21.09.23) 91 Exhibit 1, Vol. 2, Tab 45, Statement - Tactical Operator 97 (15.09.23) 92 Exhibit 1, Vol. 2, Tab 46, Statement - Tactical Operator 98 (18.09.23) 93 Exhibit 1, Vol. 2, Tab 47, Statement - Tactical Operator 116 (17.09.23) & ts 10.03.26 (Tactical Operator 116), pp42-53 94 Exhibit 1, Vol. 2, Tab 50, Report - Supt. M Gilbert, Licensing Enforcement Division (26.08.25) 95 Exhibit 1, Vol. 2, Tab 51, TRG Running Sheet (07.09.23) 96 Exhibit 1, Vol. 2, Tab 52, TRG Debrief Points to Action (undated)

[2026] WACOR 10

39. The TRG’s initial strategy was to locate Lachlan, who had appropriately been identified as an active armed offender. Using a variety of techniques (including drones), Lachlan was located lying in a wheatfield at about 1.15 pm. Lachlan was armed with four weapons (two rifles and two handguns), all of which had all been lawfully licensed to him.

40. Once Lachlan had been located, the TRG’s active shooter strategy changed to a “contain and negotiate strategy”, with the TRG response being referred to as “Operation Alpha 97”.

Key events

41. After Lachlan had abandoned his vehicle and fired at a passing motorist, the key events on 7 September 2023 may be summarised as follows: a. 11.00 am: Lachlan had the first of several phone conversations with a family friend (Mr Mitchell). During one of these calls, Lachlan said: “I don’t feel love, I don’t feel love for anybody” and “I’m not going to come in alive”;97 b. 11.06 am: Tactical Operator 02 (the Deliberate Action Commander for Operation Alpha 97) established a command post at the Kellerberrin Police station and liaised with St John Ambulance paramedics; c. 11.14 am: Lachlan received a text message from a fellow St John Ambulance volunteer (Mr Rees) who had heard about the earlier shooting. Mr Reed told Lachlan to contact him if he needed help, and at 11.16 am, they had a phone conversation during which Lachlan said “I’m not going to jail. I’ll die here today”;98 d. 11.20 am: the WA Police negotiation team arrived at Kellerberrin Police station. The team consisted of a primary negotiator (Operator

110. and a secondary negotiator; e. 11.32 am: Lachlan received a Facebook message from a person he didn’t know (Mr Mahon) who had become aware of the situation after reading a Facebook post. Mr Mahon urged Lachlan to surrender to police, and he and Lachlan then had a phone conversation.

97 Exhibit 1, Vol. 2, Tabs 36 & 36.1, Statement & Handwritten statement - Mr D Mitchell (undated & 08.09.23) 98 Exhibit 1, Vol. 2, Tab 37, Statement - Mr D Rees (13.02.23)

[2026] WACOR 10 e. 11.32 am: (continued) during their phone conversation Lachlan said: he had “Just wanted to do this all my life” and “When I was a kid, I wanted to do it”. After the call ended, Mr Mahon contacted police and reported the details of his conversation with Lachlan;99 f. 11.40 am: the primary negotiator (Operator 110) began speaking with Lachlan via mobile phone; g. prior to 12.22 pm: Lachlan had a phone conversation with his half-brother (Mr Jacobsen), during which Lachlan said he was going to “barricade himself and shoot it out”;100 h. 12.22 pm: Lachlan had a phone conversation with his mother (Ms Bowles) during which Lachlan told her he understood she loved him but “just couldn’t reciprocate that”. Lachlan also spoke with the police negotiator who was with Ms Bowles at the time;101 i. 12.25 pm: the primary negotiator (Operator 110) continued negotiations with Lachlan, who indicated he wanted bottles of water; j. 12.40 pm: Lachlan had a phone conversation with his half-sister (Ms Lynch) during which he said his plan was “to kill”;102 k. 12.45 pm: the TRG’s Bearcat arrived in the area where Lachlan is suspected to be located; l. 12.58 pm: Lachlan was observed by a police drone in a wheatfield on Morley Road, near Bencubbin Road and Kellerberrin Road. Lachlan had a firearm in his hand and was talking on his mobile phone; m. 1.04 pm: the POLAIR Police helicopter with two TRG officers aboard was airborne in the area; n. 1.13 pm: Lachlan was located by TRG officers in a wheatfield on Morley Road, Kellerberrin and the scene was contained; 99 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), pp12-13 100 Exhibit 1, Vol. 2, Tabs 34 & 34.1, Statement & Handwritten statement - Mr I Jacobsen (undated & 07.09.23) 101 Exhibit 1, Vol. 2, Tab 32, Statement - Ms E Bowles (08.09.23) 102 Exhibit 1, Vol. 2, Tab 35.1, Transcript of call between Lachlan and Ms S Lynch (07.09.23), p1

[2026] WACOR 10 o. 1.26 pm: the Police specialist communications trailer was requested due to issues with mobile phone and radio communications; p. 1.51 pm: at Lachlan’s request, the Bearcat was moved closer to him so that negotiations between the primary negotiator and Lachlan could be conducted using the Bearcat’s loudspeaker system. During these protracted negotiations, Operator 110 convinced Lachlan to surrender three of his firearms (one of his rifles, and both of his handguns) in return for bottles of water. Although relinquished, these three firearms remained in Lachlan’s general vicinity; q. 3.53 pm: following a TRG assessment, the scene risk level was reduced from “high” to “medium” on the basis that the scene was contained and negotiations were progressing; r. 4.20 pm: Lachlan suddenly moved his .357 rifle so that it rested under his chin and shot himself in the head. As Lachlan began moving his rifle, TRG officers deployed “less lethal” force options. Tactical Operators 17 and 96 deployed distraction devices towards Lachlan, and Tactical Operators 5 and 91 fired bean bag rounds at him. The aim of these less lethal force options had been to distract Lachlan so that he could be successfully arrested; s. 4.45 pm: despite first aid efforts by TRG officers and St John ambulance paramedics, Lachlan succumbed to his self-inflicted head injury and was declared deceased at the scene.103 103 Exhibit 1, Vol. 1, Tab 3.1, Life Extinct Form - Lachlan Richard Francis Bowles (07.09.23)

[2026] WACOR 10 CAUSE OF DEATH - TERRY Post mortem examination104,105

42. A forensic pathologist (Dr J Ong) reviewed CT scans and conducted a post mortem examination of Terry’s body at the State Mortuary on 14 and 15 September 2023.

43. Dr Ong found that Terry had sustained multiple gunshot injuries to his head, torso, upper limb, and back of his neck, and there was “associated fracturing of the skull, ribcage and left upper arm (humerus)”. Terry’s lungs were also noted to be congested, which is considered to be a nonspecific finding.

44. Macroscopic examination of Terry’s brain found “a linear track extending from the left temporal lobe in continuity with disruption of the right parietal lobe” which was consistent with the given history of a gunshot injury.106,107 Toxicological analysis108

45. Toxicological analysis detected tetrahydrocannabinol in Terry’s system, which indicates recent cannabis use. Alcohol and other common drugs were not detected.

Cause and manner of death

46. At the conclusion of his post mortem examination, Dr Ong expressed the opinion that the cause of Terry’s death was “gunshot injuries to the head and chest”.109

47. I accept and adopt Dr Ong’s opinion and find that Terry died from the injuries he sustained when he was shot by Lachlan. Further, on the basis of the available evidence, I find that Terry’s death occurred by way of homicide.

104 Exhibit 1, Vol. 1, Tab 5, Supplementary Post Mortem Report (24.10.23) 105 Exhibit 1, Vol. 1, Tab 5.1, Post Mortem Report (15.09.23) 106 Exhibit 1, Vol. 1, Tab 5, Supplementary Post Mortem Report (24.10.23), p1 107 Exhibit 1, Vol. 1, Tab 8, Neuropathology Report (20.09.23) 108 Exhibit 1, Vol. 1, Tab 7, Toxicology Report (02.10.23) 109 Exhibit 1, Vol. 1, Tab 5, Supplementary Post Mortem Report (24.10.23), p1

[2026] WACOR 10 CAUSE OF DEATH - LACHLAN Post mortem examination110,111

48. Two forensic pathologists (Dr J Ong and Dr J Grewal) reviewed CT scans and conducted a post mortem examination of Lachlan’s body at the State Mortuary on 13 September 2023.

49. Dr Ong and Dr Grewal found Lachlan had sustained a gunshot wound to the head, with “the entrance to the undersurface of the chin and the exit wound on top of the scalp”, along with extensive fracturing of his skull.

There was early narrowing of the vessels supplying Lachlan’s heart muscle (coronary artery atherosclerosis), and his lungs were congested, which is considered to be a non-specific finding.

50. Macroscopic examination of Lachlan’s brain confirmed he had sustained a traumatic brain injury which was consistent with a gunshot injury.112,113,114,115 Toxicological analysis116

51. Toxicological analysis did not detect alcohol or other common drugs in Lachlan’s system.

Cause and manner of death

52. At the conclusion of his post mortem examination, Dr Ong and Dr Grewal expressed the opinion that the cause of Lachlan’s death was “gunshot injury to the head”.117

53. I accept and adopt the opinion of Dr Ong and Dr Grewal and find that Lachlan died from the injuries he sustained when he shot himself in the head. Further, on the basis of the available evidence, I find that Lachlan’s death occurred by way of suicide.

110 Exhibit 1, Vol. 1, Tab 6, Supplementary Post Mortem Report (24.10.23) 111 Exhibit 1, Vol. 1, Tab 6.1, Post Mortem Report (13.09.23) 112 Exhibit 1, Vol. 1, Tab 6, Supplementary Post Mortem Report (24.10.23), p1 113 Exhibit 1, Vol. 1, Tab 8.1, Neuropathology Report (18.09.23) 114 See also: Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), p3 & 27-30 115 See also: ts 10.03.26 (Hannan), pp59-60 116 Exhibit 1, Vol. 1, Tab 7.1, Toxicology Report (18.09.23) 117 Exhibit 1, Vol. 1, Tab 6, Supplementary Post Mortem Report (24.10.23), p1

[2026] WACOR 10 ISSUES ARISING FROM THE EVIDENCE Possible explanations for Lachlan’s actions

54. In the aftermath of the tragedy that unfolded on 7 September 2023, there is an understandable urge to seek answers to the question of “Why”?

Why did Lachlan shoot Terry, and later himself? What led Lachlan to do such terrible things that have caused such pain and devastation? On the basis of the available evidence, although it is possible to make informed guesses about what may have motivated Lachlan to act as he did, ultimately, it is impossible to know with any certainty.

55. In his report Dr Hall noted that Lachlan was reported to have a negative view of immigration into Australia by “non-whites”, and that in the weeks and months before his death, his interest in history focussed on the Nazi Party. It is also the case that at one point during his interactions with the police primary negotiator, Lachlan said that he believed in some of the Nazi Party’s ideologies “but not all of them”.118

56. However, as Dr Hall noted: Notwithstanding the above, (Lachlan) was widely considered as someone who did not subscribe to Nazi ideology. He did not talk about it at home nor convey any interest when in other social contexts.

Although he possessed a copy of Mein Kampf , this was, according to his father, due to its historical significance and, according to his mother, something that he did to provoke her. (Lachlan’s) family members were confident that he would not have known nor had any type of relationship with the few people in the local area who were thought to subscribe to (Nationalist Racist Violent Extremism) ideology.119

57. In his report and during his evidence at the inquest, Dr Hall expressed the opinion that although it appeared that Lachlan had started on the pathway to Nationalist Racist Violent Extremism ideology (NRVE), “it was weakly held” and NRVE was not the driving force behind Lachlan’s actions on 23 September 2023.120,121 118 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, WA Fixated Threat Assessment Centre (13.03.25), pp3-4 119 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, WA Fixated Threat Assessment Centre (13.03.25), pp3-4 120 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, WA Fixated Threat Assessment Centre (13.03.25), p12

[2026] WACOR 10

58. In his report and during his evidence at the inquest, Dr Hall expressed the opinion that Lachlan likely had undiagnosed autism spectrum disorder, and that by September 2023, he appeared to have been severely depressed and was experiencing high levels of anxiety. In my view, the following extract from Dr Hall’s report clearly encapsulates the more likely explanation for Lachlan’s actions: There is evidence to indicate that (Lachlan) suffered from anxiety.

There is a strong family history of anxiety and depression.

(Lachlan’s) own anxiety and the family history of depression conferred upon him significant vulnerability to depressive illness.

It appears that following his rejection by Defence Force Recruiting in 2019, (Lachlan) became depressed. (Lachlan) was working for St John Ambulance but found it traumatising and upsetting, which would have aggravated any depression. His application to join the police was rejected in 2022, which would have further aggravated his depression. Information suggests he was someone that was reluctant to seek help.

(Lachlan) had held strong fundamentalist Christian beliefs for most of his life, his family having converted to Christianity when he was aged 9. These beliefs inevitably faltered with age due to countervailing rationalism strongly fuelled by undiagnosed autism spectrum disorder. With his faith wavering he reportedly swung from deeply religious to atheist, later being ambivalent and unsure. That faith eventually failed in the context of trauma, losses and depression and he was unable to find any comfort in religion.

There is strong evidence to suggest that (Lachlan) was suffering from severe depression at the time of his death. Specifically, toward the end of his life, (Lachlan) had depressed mood, was withdrawn, was not eating or sleeping properly and had suicidal ideation. His condition had been worsening for some time. In addition, there is information to suggest that in the time immediately before his death (days), and inconsistent with his usual self-concept, he had begun to identify as being evil and harmful. Cognitions around one’s own badness can be a feature of depression and when present indicate that the depression is severe.

121 ts 10.03.26 (Hall), pp21-24

[2026] WACOR 10 (Lachlan) was depressed and suicidal, affected by pathological depressive cognitions of his own badness, preoccupied with death, and angry with Christianity. Any apparent improvement in his demeanour in the days prior to his death likely reflected his resolution to end his life and the relief at that idea. In addition, he most likely had acutely impaired judgement on the day of his death due to the progression of severe depression.122,123

59. During phone calls with family members, and Mr Mahon after he had shot Terry, and during his interactions with police negotiators, Lachlan claimed to have had an interest in killing people since he was a child. As to this possibility, Dr Hall made the following observations: It is difficult to make sense of (Lachlan’s) stated long-standing desire to kill, which was never previously disclosed. (Lachlan) was to a large extent an unknowable individual. It is within the realm of possibility that what occurred was an acute or sudden failure of selfregulation, self-discipline and self-restraint that had held a longstanding and secret homicidal fantasy at bay, with that failure being due to the progression of his depression. However, this is not strongly supported by the available information and cannot be properly explored as it is not possible to interview (Lachlan).124 Availability of mental health support to negotiators125,126

60. At the Court’s request, Sergeant Marsh (Officer Marsh) the TRG’s Negotiator Coordinator, prepared a report dealing with the policies, procedures and training doctrine that guide police negotiators. In his report, Officer Marsh confirmed that during their engagement with Lachlan, police had contacted the Mental Health Emergency Response Line and confirmed that Lachlan had no recorded mental health history.

Officer Marsh also confirmed that: At the time of the incident, Mental Health Co-Response (MHCR) was a joint initiative between the WA Police Force, the Mental Health Commission (MHC) and the Department of Health… 122 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, WA Fixated Threat Assessment Centre (13.03.25), p11 123 ts 10.03.26 (Hall), pp11-16 and see also: ts 10.03.26 (Hall), pp24-26 regarding Lachlan’s possible motive 124 Exhibit 1, Vol. 1, Tab 13, Report -Dr M Hall, WA Fixated Threat Assessment Centre (13.03.25), pp11-12 125 Exhibit 1, Vol. 1, Tab 20, Report - Sgt. J Marsh, Negotiator Coordinator - Tactical Response Group (29.10.25) 126 ts 11.03.26 (Marsh), pp65-75

[2026] WACOR 10 MHCR guidelines stated their staff should not attend incidents that involve extended negotiations and/or potential tactical intervention and/or where other specialist units are in attendance. MHCR staff were not contacted to provide mental health support or advice in responding to the incident involving (Lachlan). At present, there is no formalised process for MHCR staff to attend and provide support to negotiators during extended incidents or those that may require potential tactical intervention.127

61. Officer Marsh also confirmed that “no formal process existed within the Negotiators Unit for staff to seek expert psychological and/or mental health support or guidance, should it have been considered necessary”.

During his evidence at the inquest, Officer Marsh confirmed that this was still the case.128,129

62. During his evidence, Dr Hall expressed the opinion that on the basis that Lachlan had no known mental health history, it was unlikely that mental health support during the protracted negotiation process would have been useful. Nevertheless, Dr Hall agreed that in some situations, for example where the suspect is floridly psychotic, such support could be useful.130

63. At the inquest, Officer Marsh explained that police negotiators will now receive Gatekeeper, and Lifeline training (which relates to identifying and dealing with suicidal people respectively).131

64. I commend this initiative, and to strengthen the skills of police negotiators, I have recommended that WA Police consult with suitably qualified mental health clinicians to determine whether additional mental health training would be appropriate.

65. I have also recommended that WA Police explore options by which mental health specialists may be able to support TRG negotiators responding to complex situations, especially those involving mental health issues.

127 Exhibit 1, Vol. 1, Tab 20, Report - Sgt. J Marsh, Negotiator Coordinator - Tactical Response Group (29.10.25), p7 128 Exhibit 1, Vol. 1, Tab 20, Report - Sgt. J Marsh, Negotiator Coordinator - Tactical Response Group (29.10.25), p7 129 See also: ts 11.03.26 (Marsh), pp70-71 130 ts 10.03.26 (Hall), pp26-27 131 ts 11.03.26 (Marsh), pp71-72

[2026] WACOR 10 Communication issues132,133,134,135,136,137

66. As noted, there were communication issues at the scene, which meant that mobile phone coverage was intermittent, and radio communications were patchy. Given the rural setting in which the containment and negotiation operation was conducted, these issues are understandable, but these communication issues clearly need to be addressed.

67. The Deliberate Action Commander at the scene (Tactical Operator 02) and the Tactical Commander at Kellerberrin Police station (Tactical Operator 116) were able to communicate during the operation using text messages. However, live streaming of the body worn camera footage worn by TRG officers, and reliable voice communication by mobile phone was patchy and often completely impossible.

68. This situation was addressed by the deployment of a specialist police communications trailer which partially improved communications.

However, a longer term solution is clearly required, given the vastness of Western Australia and the fact that the TRG may be expected to deploy anywhere in the State.

69. Given the non-publication order I made at the start of the inquest, I do not intend to detail the measures WA Police have taken to address the communication issues highlighted during the TRG response to Lachlan.

However, I note with approval that a number of TRG vehicles have been fitted with equipment that employs satellite technology to enable mobile phone coverage in remote areas.

70. In addition, the TRG has now been provided with access to satellite phones, and various strategies are also being progressed to expedite the rapid deployment of TRG officers to regional areas.

132 Exhibit 1, Vol. 1, Tabs 12 & 12.1-12.3, Report & attachments - Supt. J Kazandzis, Tactical Response Group (30.09.24) 133 Exhibit 1, Vol. 1, Tab 12.4, Supplementary Report - Supt. J Kazandzis, Tactical Response Group (13.05.25) 134 ts 11.03.26 (Kazandzis), pp75-84 135 Exhibit 1, Vol. 2, Tab 40, Statement - Tactical Operator 02 (25.02.25) & ts 10.03.26 (Tactical Operator 02), pp27-42 136 Exhibit 1, Vol. 2, Tab 47, Statement - Tactical Operator 116 (17.09.23) & ts 10.03.26 (Tactical Operator 116), pp42-53 137 Exhibit 1, Vol. 2, Tab 53, File Note - Update to communication upgrades to TRG’s vehicle fleet (30.03.25)

[2026] WACOR 10 POLICE INVESTIGATIONS Homicide Squad investigations

71. Detective Senior D Heller (Officer Heller) of the Homicide Squad investigated Terry’s death, and I agree with the following observations: It is difficult to ascertain whether (Lachlan) purposely targeted (Terry) or whether he shot the first person he came into contact with on arrival. The only insight into motive for the shooting come from conversations held with (Lachlan) post-incident during which he expresses a hatred for people generally and an inability to feel love.

There is no cited animosity toward (Terry) however with (Lachlan) commenting that “I thought I'd help him out in context with their previous talk of self-harm. Medical and ballistic evidence establish that (Terry) was shot several times in the torso and in the head by (Lachlan) using his two licensed handguns. The nature of the injuries sustained, particularly to the head were inconsistent with life and attempts at medical intervention were ultimately in vain. The investigation into the death of (Terry) determined sufficient evidence to establish a prima facie case that (Lachlan) committed an offence of Murder (section 279 Criminal Code) against (Terry). A prosecution for this offence was not able to be commenced prior to (Lachlan) committing suicide however.138

72. Detective Sergeant J Hannan (Officer Hannan) of the Homicide Squad investigated Lachlan’s death. In her report Officer Hannan made the following observations, with which I agree: In assessing the actions of involved officers, including TRG Tactical Operators and Police Negotiators, it is the determination of the Investigating Officer that all involved officer's actions were lawful…The psychological assessments conducted by both ADF and (WA Police) and…(Dr Hall)…in addition to the specific comments made post-incident to involved police, family and associates are a clear indication of the (Lachlan’s) attitude and intentions. It is evident from the investigation that these factors have invariably contributed to (Lachlan’s) deliberate action to take his own life.139 138 Exhibit 1, Vol. 1, Tab 2, Report - Det. Sgt. D Heller, Homicide Squad (31.01.25), p13 139 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), p29 and ts 10.03.26 (Hannan), pp53-61

[2026] WACOR 10

73. Officer Hannan also expressed the following conclusion in her report, with which I agree: In accordance with legislative provisions, as a result of this investigation there is no evidence to indicate any criminality, either on the part of the involved officers, (Lachlan’s) associates or other person that can be attributed to the death.140 Ballistics report141

74. Ballistics reports completed by Senior Constable Sloan (Officer Sloan) examined firearms and ammunition licensed to Lachlan, and the scenes at Moylan Grain Silos and the wheatfield where Lachlan took his life.

Amongst other things, Officer Sloan determined: a. Shots fired at Moylan Grain Silos: at least seven shots from two distinct weapons were fired at Moylan Grain Silos, with four 22 LT calibre fired cartridge cases and three 357/38 calibre bullets located; b. Firearms located at wheatfield on Morley Road: four weapons were located at the scene, namely: a Winchester 243 bolt action repeating rifle; a Chiappa 357 Magnum lever action repeating rifle; a Browning 22 LR self-loading pistol; and a Smith & Wesson 357 Magnum double-action revolver; and c. Shot fired at wheatfield on Morley Road: Lachlan used the Chiappa 357 Magnum lever action repeating rifle to shoot himself in the head.

Firearms licensing report142

75. At the Court’s request, Superintendent Gilbert (Officer Gilbert) of WA Police’s Licensing Enforcement Division provided a report explaining the legislative framework regulating the use of firearms in Western Australia at the time of Lachlan’s death. Officer Gilbert’s report also addressed the changes implemented by the Firearms Act 2024 (WA) and the Firearms Regulations 2024 (WA), and the “red flag initiative”, an information sharing project being progressed with the Department of Health.

140 Exhibit 1, Vol. 1, Tab 2.1, Report - Det. Sgt. J Hannan, Homicide Squad (17.03.25), p30 141 Exhibit 1, Vol. 1, Tabs 17 & 17.12, Reports - Sen. Const. G Sloan, Ballistics Unit (08.07.24 & 29.10.24) 142 Exhibit 1, Vol. 2, Tab 50, Report - Supt. M Gilbert, Licensing Enforcement Division (26.08.25)

[2026] WACOR 10

76. After examining the licensing arrangements for Lachlan’s firearms, Officer Gilbert expressed the following conclusion, with which I agree: A comprehensive review of all relevant materials and circumstances surrounding (Lachlan’s) firearm licence and his interactions with Licensing Services found no evidence indicating deficiencies in the licensing process or procedures. Furthermore, there was no information that would have triggered a review of his firearm licence by Licensing Services. (Lachlan’s) individual firearm licence…was managed in accordance with applicable legislation and policy throughout its duration. There is no policy, guideline, or procedural requirement mandating the Police Recruitment, Deployment and Promotions Division to report adverse employment application outcomes to Licensing Services.143

77. In relation to the new firearms legislation recently introduced in Western Australia, Officer Gilbert noted: The introduction of the Firearms Act 2024 and Firearms Regulations 2024, along with extensive enhancements to the (Licensing and Registration) system, comprehensive agency training regarding the significant changes between the Firearms Act 1973 and Firearms Act 2024, and dedicated resources for managing the transition and reviewing existing licence holders, has significantly strengthened the Western Australia Police Force’s capacity to administer its functions in alignment with legislative requirements.144 Negotiator Coordinator report145,146

78. As noted, Officer Marsh provided the Court with a report setting out the policies, procedures and training doctrine that guide the deployment and use of police negotiators.

79. In his report, Officer Marsh also explained the arduous selection process to become a police negotiator, and he reviewed the conduct of the primary and secondary negotiators who interacted with Lachlan.

143 Exhibit 1, Vol. 2, Tab 50, Report - Supt. M Gilbert, Licensing Enforcement Division (26.08.25), pp29-30 144 Exhibit 1, Vol. 2, Tab 50, Report - Supt. M Gilbert, Licensing Enforcement Division (26.08.25), p30 145 Exhibit 1, Vol. 1, Tab 20, Report - Sgt. J Marsh, Negotiator Coordinator - Tactical Response Group (29.10.25) 146 ts 11.03.26 (Marsh), pp65-75

[2026] WACOR 10

80. Given the non-publication order I made at the start of the inquest, I do not intend to detail any of the policies, procedures or training doctrine set out by Officer Marsh in his report.

81. However, after carefully considering the available evidence, I am satisfied that the primary and secondary negotiators who interacted with Lachlan conducted themselves in accordance with relevant policies and procedures and conducted a patient and appropriate negotiation in difficult and complex circumstances. I therefore agree with the conclusion that Officer Marsh expressed in his report, namely: While the outcome of this incident is undeniably tragic for all involved, it is my assessment that (the primary and secondary negotiators) acted to the fullest extent of their capabilities in attempting to bring about a peaceful resolution to the situation involving (Lachlan). The decision by (Lachlan) to take his own life appears to have been resolute and, despite the efforts made, he could not be dissuaded from this course of action. There is no indication that the actions of (the primary and secondary negotiators), or any other Police Officer present on the day had any negative influence on his decision. It is my considered opinion that Operator 110 (the primary negotiator) performed his duties to a high standard, in alignment with the principles of the WA Police Force Negotiators Unit and the (Australia/New Zealand) training framework. He demonstrated professionalism, dedication, and a sincere commitment to achieving a peaceful resolution.147,148,149 TRG Report150,151,152,153

82. At the request of the Court, Superintendent (now Commander) Kazandzis (Officer Kazandzis) prepared two reports in which he reviewed the TRG response in light of relevant policies, procedures and training doctrine. The order I made under section 49(1)(b) of the Act at the start of the inquest prevents (amongst other things) the publication of information about TRG policies, procedures, and training doctrine.

147 Exhibit 1, Vol. 1, Tab 20, Report - Sgt. J Marsh, Negotiator Coordinator - Tactical Response Group (29.10.25), pp8-9 148 See also: ts 11.03.26 (Marsh), pp73-74 149 See also: ts 10.03.26 (Tactical Operator 02), pp36 & 40-41 & ts 10.03.26 (Tactical Operator 116), pp51-52 150 Exhibit 1, Vol. 1, Tabs 12 & 12.1-12.3, Report & attachments - Supt. J Kazandzis, Tactical Response Group (30.09.24) 151 Exhibit 1, Vol. 1, Tab 12.4, Supplementary Report - Supt. J Kazandzis, Tactical Response Group (13.05.25) 152 ts 11.03.26 (Kazandzis), pp75-84 153 Exhibit 1, Vol. 2, Tab 53, File Note - Updates to Starlink & TRG Vehicle fleet (30.03.25)

[2026] WACOR 10

83. For that reason, I do not intend to detail the TRG’s policies or procedures relating to its deployment, risk assessment process, or incident management.

84. However, after carefully considering the available evidence, I am satisfied that the primary and secondary negotiators, and the TRG tactical operators (who deployed distraction devices and fired bean bag rounds), acted appropriately and conducted themselves in accordance with relevant legislation, and WA Police policies, procedures, and training doctrine.

85. In his report, Officer Kazandzis noted that a TRG debrief had highlighted communication challenges which affected both mobile phone and radio communications.154 At the inquest, Officer Kazandzis said that in his view these communication issues did not have a significant adverse impact on the complex and detailed negotiations being conducted with Lachlan.155,156,157

86. At the inquest, Officer Kazandzis said that face to face negotiations allow empathy and warmth to be better conveyed and would have been preferable to relying on the Bearcat’s loudspeaker system. However, in this case because Lachlan was armed, mobile phones would have been used if consistent coverage had been available.158

87. In his first report Officer Kazandzis expressed the following conclusion, with which I agree: In summary, every effort was made to continue to prioritise negotiation as the primary strategy, to give the suspect every opportunity to surrender peacefully to police. The considerations and response by the TRG were consistent with the policies and training that existed as at September 2023.159,160 154 Exhibit 1, Vol. 1, Tab 12, Report - Supt. J Kazandzis, Tactical Response Group (30.09.24), para 43, p6 155 ts 11.03.26 (Kazandzis), pp78-80 156 See also: ts 10.03.26 (Tactical Operator 02), p36 & ts 10.03.26 (Tactical Operator 116), pp48-49 157 See also: ts 11.03.26 (Marsh), pp72-73 158 ts 11.03.26 (Kazandzis), pp72-73 159 Exhibit 1, Vol. 1, Tab 12, Report - Supt. J Kazandzis, Tactical Response Group (30.09.24), para 46, p6 160 See also: ts 11.03.26 (Kazandzis), pp82-83

[2026] WACOR 10 Internal Affairs Unit investigation161,162

88. In accordance with WA Police policy, Detective Senior Sergeant Dorosz (Officer Dorosz) from the Internal Affairs Unit (IAU) investigated the conduct of the police officers who were present when Lachlan took his life. After reviewing the available evidence, Officer Dorosz did not identify any breaches of policy or legislation by any of the Attending Police Officers.

89. Following Lachlan’s death the officers most directly involved in interacting with Lachlan (including the primary police negotiator) underwent drug and alcohol testing. The results of these tests established that none of these officers had consumed alcohol or common drugs prior to the commencement of their shift.163,164

90. In his IAU report, Officer Dorosz made the following observations, with which I agree: Having reviewed the documents obtained from the Homicide Squad, TRG, negotiator recordings, witness statements and reports, I have not identified any instances of police failing to comply with policies or procedures. Negotiators tried for an extended amount of time to persuade (Lachlan) to relinquish his firearms however he failed to comply.165 Conclusions about the actions of Attending Police Officers

91. In assessing the actions of Attending Police Officers,166 I have carefully reviewed the available evidence and had due regard to the Briginshaw principle, and the concept of hindsight bias. I am satisfied that: a. The deployment of the TRG was rapid, efficient, and appropriate and all that all necessary resources (including a drone, the police helicopter, an armoured vehicle, a communications trailer, and other TRG vehicles) were appropriately deployed to the scene; 161 Exhibit 1, Vol. 1, Tab 10, Report - Det. Sen. Sgt. A Dorosz, Internal Affairs Unit (24.02.24 updated on 24.02.26) 162 ts 11.03.26 (Dorosz), pp85-91 163 Exhibit 1, Vol. 1, Tab 10, Report - Det. Sen. Sgt. A Dorosz, Internal Affairs Unit (24.02.24 updated on 24.02.26), pp7-8 164 ts 11.03.26 (Dorosz), pp88-89 165 Exhibit 1, Vol. 1, Tab 10, Report - Det. Sen. Sgt. A Dorosz, Internal Affairs Unit (24.02.24), p11 166 “Attending Police Officers” means the Police Negotiators and Tactical Operators 2, 5, 17, 87, 96, 97, 98, & 116

[2026] WACOR 10 b. Attending Police Officers167 conducted themselves in a highly professional and appropriate manner in accordance with relevant legislation and WA Police policies, procedures, and training doctrine; c. The WA Police negotiating team (and in particular the primary police negotiator, Operator 110) conducted a highly skilled and patient negotiation with Lachlan over a period of about 4.5 hours, during which Lachlan was persuaded to surrender three of his four firearms in return for bottles of water; and d. None of the actions of the Attending Police Officers caused or contributed to Lachlan’s death. Instead it is my view that after he had killed Terry, Lachlan subsequently took his own life by shooting himself in the head.

92. I note that prior to, and during the inquest some members of Lachlan’s family asked why less-lethal options had not been deployed before Lachlan shot himself, and also why a family member was not allowed to enter the TRG’s inner cordon to speak with Lachlan face-to-face. Whilst both of these concerns are understandable, I am satisfied with the explanations provided by TRG officers at the inquest.168,169

93. Less-lethal force options were not used earlier because negotiations were progressing well, and Lachlan had surrendered three of his four firearms.

The earlier use of less-lethal force options would have been a clear escalation of the situation when every effort was being made to deescalate things. Further, the safety of Lachlan and TRG officers could not have been guaranteed if less-lethal options had been deployed earlier.

94. Established TRG protocols do not permit family members to enter an inner cordon for good reasons. In this case, the safety of the family member could not have been guaranteed. Further, the police negotiators and the TRG officers at the scene cannot be expected to have known the family dynamic. Therefore, an unpredictable and potentially dangerous situation may have been provoked by bringing a family member into the inner cordon during the negotiation process.

167 “Attending Police Officers” means the Police Negotiators and Tactical Operators 2, 5, 17, 87, 96, 97, 98, & 116 168 Exhibit 1, Vol. 2, Tab 48, Letter - Ms E Bowles (25.02.26), p2 169 ts 10.03.26 (TO 02), pp39-40; ts 10.03.26 (TO 116), p52; ts 11.03.26 (Marsh), pp68-69 & ts 11.03.26 (Kazandzis), pp81-82

[2026] WACOR 10 RECOMMENDATION

95. In view of the observations I have made, I make the following recommendation: Recommendation In order to enhance the effectiveness of Tactical Response Group (TRG) negotiators, the Western Australian Police Force should consider liaising with suitably qualified mental health clinicians to determine: a. what mental health training should be delivered to TRG negotiators, in addition to the Gatekeeper and Lifeline training courses which are already being delivered; and b. whether as part of the TRG’s own capability development, mental health specialists could feasibly provide remote or command post advisory support to negotiators during complex incidents including those involving mental health issues.

Comments on recommendations

96. On 13 March 2026, Ms Bull (Judicial Support Officer) emailed a draft of my proposed recommendation to Mr Olds (counsel for WA Police). Any feedback on the proposed recommendations was requested by the close of business on 27 March 2026.170

97. On 27 March 2026, Mr Olds sent an email to the Court, attached to which was a letter in which he advised that WA Police accepted Recommendation 1(a) and that WA Police were: [P]resently considering the additional mental health training to be given to TRG negotiators and liaising with mental health clinicians in this regard.171 170 Email - Ms M Bull to Mr M Olds (13.03.26) 171 Letter - Mr M Olds to Coroners Court (27.03.26), p1

[2026] WACOR 10

98. Mr Olds also advised that WA Police are currently in discussions with Dr Hall with a view to: [D]evelop ongoing mental health awareness sessions for negotiators.

This training is proposed to be developed on a quarterly basis, as part of the Negotiator's Unit's monthly training program, ensuring continuous skill development and reinforcement.

(WA Police) considers this approach will ensure negotiators are both trained in foundational concepts and equipped with the confidence and capability to effectively engage with persons experiencing complex mental health issues in operational environments.172

99. With respect to Recommendation 1(b), Mr Olds advised that WA Police: [S]upports the intent in proposed recommendation 1(b) to enhance the effectiveness of TRG negotiators responding to complex incidents involving acute mental health issues exacerbated by drug use, but proposes different wording to the recommendation due to the unsuitability of the Mental Health Co- Response Model having direct application to bespoke TRG negotiator deployments.173

100. I have adopted the alternative suggested by WA Police for Recommendation 1(b), having decided that it appropriately addresses the issue of mental health clinicians providing support to TRG negotiators during complex incidents.

172 Letter - Mr M Olds to Coroners Court (27.03.26), p2 173 Letter - Mr M Olds to Coroners Court (27.03.26)

[2026] WACOR 10 CONCLUSION

101. This is a tragic case involving the deaths of Terry and Lachlan, two much loved family members. For reasons which cannot be adequately explained on the morning of 7 September 2023, Lachlan drove to his workplace where he shot and killed his workmate, Terry. There is no evidence that there was any significant animosity between the two.

102. Having shot Terry, Lachlan then made his way to a wheatfield near Morley Road in Kellerberrin. On the way, he abandoned his vehicle and fired at a passing car, narrowly missing the driver. Lachlan was subsequently found with two rifles and two handguns. During lengthy negotiations with a skilled highly police negotiator, Lachlan gave up three of his four weapons, but he refused to relinquish the fourth (a rifle), which he used to take his life.

103. In a letter to the Court, Lachlan’s mother explained the impact her beloved son’s death has had on the family in the following terms: The death of our son/brother has shattered our family in ways that words can hardly express. His absence has left a deep and constant ache in our hearts. Our home does not feel the same. Each of us is struggling to cope in different ways and some days it feels impossible to move forward, while other days are spent trying to hold on to the memories we have left. His loss has affected not only our emotional wellbeing but also our physical and mental health. Family gatherings are no longer the same, there is always an empty chair and a sense that something precious has been taken from us forever. We live with an overwhelming sense of grief and longing, knowing that life will never return to what it once was.174

104. After carefully reviewing the available evidence, I concluded that I was satisfied that neither the actions of police negotiators, nor the TRG’s tactical operators caused or contributed to Lachlan’s death. I was also satisfied that Nationalist Racist Violent Extremism ideology (including Nazi ideology) was not the driving force behind Lachlan’s actions.

174 Exhibit 1, Vol. 2, Tab 48, Letter - Ms E Bowles (25.02.26), p2

[2026] WACOR 10

105. Instead, in my view, it is far more likely that Lachlan’s undiagnosed anxiety and severe depression, and his overwhelming thoughts of selfloathing and suicidal ideation (in the context of his likely undiagnosed autism spectrum disorder) led to a cascade of events that culminated in him taking his life.

106. As a result of the tragic events of 7 September 2023, the families and friends of both of Terry, and Lachlan must bear the unimaginable loss of a beloved family member and loved one in truly tragic and awful circumstances.

107. It is a common misconception that at some point after a loved one’s death there is “closure”. Those who have experienced profound loss know this is not the case. The aching void left by the loved one’s death does not get filled, nor do the feelings of grief and sadness disappear.

108. However, with the passage of time, perhaps it is the case that the sense of pain and loss becomes a little easier to bear. As well, memories of happier times tend to emerge and these memories can help to deaden the ache. It is my sincere hope that the families and friends of both of Terry, and Lachlan may have this experience.

109. I wish to acknowledge that members of both families attended the inquest and I commend all of them for the dignified manner in which they participated in proceedings.

110. Finally, as I did at the conclusion of the inquest, on behalf of the Court I wish to again convey my very sincere condolences to the family and friends of both Terry and Lachlan for their respective losses.

MAG Jenkin Acting Deputy State Coroner 30 March 2026