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Office State Coroner 2011-2012

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Office State Coroner 2011-2012 OOffffiiccee OOff tthhee SSttaattee CCoorroonneerr Annual Report 2011-2012 10th floor, Central Law Courts State 501 Hay Street PERTH WA 6000 Telephone : (08) 9425 2900 Coroner Facsimile : (08) 9425 2920 Website : www.coronerscourt.wa.gov.au Western Australia 30 June 2012 Our Ref : A-1 The Honourable Michael Michin LLB(Hons) BJuris(Hons) MLC Attorney General 10th floor, Dumas House 2 Havelock Street WEST PERTH WA 6005 Dear Minister In accordance with Section 27 of the Coroners Act 1996 I hereby submit for your information and presentation to each House of Parliament the report of the Office of the State Coroner for the year ending 30 June, 2012. The Coroners Act 1996 was proclaimed on 7 April, 1997 and this is the 16th annual report of a State Coroner pursuant to that Act. Yours sincerely Alastair Hope STATE CORONER Table of Contents State Coroner’s Overview ...................................................................................................................... 4 Principal Registrar’s Overview ............................................................................................................ 10 Counselling Service.............................................................................................................................. 15 Coronial Ethics Committee .................................................................................................................. 16 Counsel To Assist Coroners................................................................................................................ 18 Inquests................................................................................................................................................. 19 Sandra Mccarty; Pia Bosso; Sandra Kokalis; Deboragh Gruber and Carmelo Vinciullo (Operation Lantana) ......................................................................................................................... 22 Christmas Island Tragedy................................................................................................................. 24 Mark Anthony Fryer.......................................................................................................................... 36 Shaun Michael Ian Price................................................................................................................... 37 Ashton Michael Sunfly; Mitchell Nanala, Lewis John Kalions; Jason Milner and Liam Tchooga (Balgo Community Deaths) .............................................................................................................. 38 David Peter Ellery............................................................................................................................. 51 Josephine Wilma Troy...................................................................................................................... 57 Shar Rose Benfield .......................................................................................................................... 59 Ricardo Maderia Da Silva................................................................................................................. 63 Simon James Brazier ....................................................................................................................... 68 Andrew Ian Allan .............................................................................................................................. 69 David James Lee.............................................................................................................................. 70 Deaths In Care....................................................................................................................................... 73 Involuntary Patients Within The Meaning Of The Mental Health Act 1996....................................... 73 Warwick Andrew Ashdown............................................................................................................... 73 Deaths possibly caused or contributed to by actions of members of the Police Service.............. 81 Shaun Ryan Cronin.......................................................................................................................... 81 Matthew Tjoe.................................................................................................................................... 82 Victoria Sumabat Shepherd.............................................................................................................. 85 Elliott Peter Watt............................................................................................................................... 85 Benjamin David Daly ........................................................................................................................ 87 Andrew Richard Collard.................................................................................................................... 92 Inquests – Deaths In Care – Department For Corrective Services ................................................... 94 Brian William Edwards...................................................................................................................... 96 Declan John Brennan....................................................................................................................... 96 Christopher Peter Barnes (Aka Moore) .......................................................................................... 105 Bruce Jason Garrett ....................................................................................................................... 109 Freedom of Information Act Direction to Police acting as Coroner’s Investigators ....................... 94 State Coroner Annual Report Page 3 of 112 . State Coroner’s Overview The year 2011‐2012 commenced very badly for the Coroner’s Court, but finished on a very positive basis as a result of additional funding being committed for the court in March 2012. The extreme problems for the Coroner’s Court and great stress and excessive workloads for staff described in the Annual Report of 2010‐2011 continued into the start of 2011‐2012. The two full‐time coroners were involved in the mega inquests, the Christmas Island inquest and Operation Lantana inquest, for a significant portion of the year. For much of that time there were no coroners available to do the day‐to‐day work of the office during normal business hours. Cases which would normally be finalised by way of administrative findings were not being completed in sufficient numbers to limit the backlog. The worst position was reached in the first quarter of the financial year when the number of backlog cases (cases over 12 months old) rose to 951. While that number was slightly reduced in the second quarter of the year, the position continued to be dire until the decision of government to provide additional funding which took place in late March. The position in respect of cases identified as requiring a public inquest was also similarly extremely serious and by the second quarter of the year over 126 of these cases were in backlog. The position changed dramatically in March 2012 when the Treasurer and Attorney General, the Hon Christian Porter MLA, advised me that a decision had been made to provide an additional $509,000 for the 2011‐2012 year and $1,015,000 for the 2012‐2013 year to the Coroner’s Office. The decision was confirmed by letter dated 16 March 2012 in advance of finalisation of the budget process. While expressed to be non‐recurrent this was new funding for the Coroner’s Office and the commitment was made in anticipation of a comprehensive review being conducted of the needs of the Coroner’s Court expected to take place in the latter part of 2012. This funding was in addition to continuation of the ongoing provision of non‐recurrent funding, some of which has been provided in that form for almost a decade, but in respect of which about $300,000 to $400,000 was first provided in 2009‐2010. The new funding was allocated to provide for: ¾ 2 additional coroners; ¾ 1 principal registrar; and ¾ 4 administrative support staff. The allocation for the current financial year was made to allow the Coroner’s Court to commence employing coroners immediately prior to finalisation of the 2012‐2013 budget. Immediate action was taken to take advantage of this important development. Mr Dominic Mulligan, who had recently been appointed to assist with completion of administrative findings, was appointed to act as a coroner until 30 June 2013. State Coroner Annual Report Page 4 of 112 . In respect of the other coroner’s position, and the ability to access significant funding in the remaining 3 months of the year, steps were taken to appoint two people as coroners, Mr Barry King and Mr Peter Collins. As there was money to continue with only one of those positions from 30 June 2012 until 30 June 2013, in order to ensure that both persons would have an opportunity to conduct inquest hearings as well as complete administrative findings, each person was appointed for a further six months of that 12 month period. In other words, each person was appointed as a coroner for a period of approximately 8 ½ months. In respect of Mr Mulligan, he has a wealth of experience as counsel both in New Zealand and in Australia. He was the first counsel assisting appointed for the Coroner’s Court in 1997 and after that time, while working in private practice and as a barrister, has been retained as counsel assisting for a number of important
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