FINDINGS and RECOMMENDATIONS of Coroner McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of: Robert Edward McInerney 2 Contents FINDINGS .................................................................................................................................. 1 Record of Investigation into Death (With Inquest) .................................................................. 3 Hearing Dates ........................................................................................................................ 3 Representation ....................................................................................................................... 3 Introduction ........................................................................................................................... 3 Investigation ........................................................................................................................... 4 The role of the Coroner ....................................................................................................... 5 Scope of Inquest ..................................................................................................................... 7 Background ............................................................................................................................ 8 Personal details and life of Mr McInerney .............................................................................. 9 Mr McInerney’s physical and mental health, and contact with services prior to his death ...... 12 Circumstances surrounding death ....................................................................................... 17 Mr McInerney’s movements before his death ...................................................................... 17 The incident leading to death .............................................................................................. 20 Medical findings at autopsy .................................................................................................. 35 Comments upon the incident and investigation .................................................................. 36 Review of tactics and strategy at the scene of the incident ................................................ 39 General comments ............................................................................................................. 39 The failure of attending officers to hold a rendezvous .......................................................... 41 The presence of Sergeant Keiselis at the incident ................................................................. 43 Training for officers of Tasmania Police in respect to police provoked shootings ............ 45 Summary of findings required by s28 (1) of the Coroners Act 1995 ................................. 46 Recommendations ............................................................................................................... 46 3 Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Robert Edward McInerney with an inquest held at Hobart in Tasmania make the following findings. Hearing Dates 22, 23, 24, 25 July and 28 August 2019, final written submissions received on 9 September 2019. Representation Counsel Assisting the Coroner: J Ransom Counsel for Senior Constable William Flynn and Police Association Tasmania: G Wood Counsel for Commissioner for Police, Sergeant Steven Keiselis, Senior Constable Nicholas Lomman, Senior Constable Cameron Little, Constable Sarah Bosch, Constable Caroline McGregor, Constable Andrea Perry, and Constable Elmar Van Breda: M Miller and E Stone Introduction 1. On Tuesday 25 May 2016 Robert Edward McInerney, aged 48 years, died as a result of being shot by a police officer, Senior Constable William Flynn, who attended an incident at about 7.45pm on 24 May 2016 at Mr McInerney’s residence at Unit 3, 15 Stitz Street in Cooee (“the premises”). At that time, Senior Constable Flynn along with seven other officers, attended as the result of Mr McInerney having called ‘000’ demanding police attendance. In that call, Mr McInerney stated, among other things, that he was armed with knives and was hoping to be shot by police after throwing the knives at them. He also suggested that he would throw knives at any other person who might be present. When the police officers arrived outside of the premises, Mr McInerney did, in fact, throw knives at the attending officers, forcing several to retreat and seek cover. Senior Constable Flynn, an experienced, trained police negotiator, attempted to pacify Mr McInerney and have him disarm himself. However, Mr McInerney was 4 not receptive to negotiation and moved into an elevated and concealed position in the poorly- lit backyard of the premises. Upon being visually identified, he brandished a large knife in a menacing manner and advanced down the hill towards Senior Constable Flynn and other officers who were a short distance away. Senior Constable Flynn warned Mr McInerney that he was armed and would shoot. Mr McInerney was also not receptive to this warning. Senior Constable Flynn then fired four shots at Mr McInerney at close range with his service issue 9mm Glock 26 pistol. The injuries sustained to Mr McInerney resulted in his death the following day, 25 May 2016. Investigation 2. As the incident involved a police officer discharging a firearm at a person, Tasmania Police Professional Standards, in accordance with protocol, became involved immediately after the event with four investigators attending the scene. The coroner on duty, Coroner Duncan Fairley, was notified and also attended the scene. Professional Standards retained carriage of the coronial investigation into Mr McInerney’s death, with the officers involved in the incident being interviewed and the scene forensically examined over several days. In accordance with procedure, the evidence gathered was submitted by Professional Standards to the Director of Public Prosecutions in respect of consideration of charges arising from the incident. On 15 June 2016 Professional Standards received advice from the Director of Public Prosecutions that no charges would be laid in respect of Mr McInerney’s death on the basis that it was reasonable for Senior Constable Flynn to believe that he and Acting Sergeant Lomman (standing close to Senior Constable Flynn) were going to be stabbed and therefore suffer serious injury. The Director of Public Prosecutions advised that, in all of the circumstances, the evidence indicated that Senior Constable Flynn was acting in lawful self-defence and therefore had not committed any crime. 3. The investigation continued for the purpose of completing the coronial requirements, with Senior Sergeant (now Inspector) Troy Morrisby of Professional Standards obtaining further evidence over the following twelve months. This included material pertaining to Mr McInerney’s family background and health; medical records and involvement with services in the period before his death; affidavits of civilian witnesses and police witnesses relevant to the incident; the opinion of the State Forensic Pathologist regarding cause of death, scene walk- throughs, drone footage and virtual tour of the scene; photographs of the scene and Mr McInerney; toxicological evidence, biological examination of scene exhibits by Forensic Science Service Tasmania; opinion of police ballistics experts; results of forensic analysis of mobile 5 phone usage; affidavits of investigators; and evidence of police policies and training regarding operational tactics. 4. On 16 April 2017, Senior Sergeant Morrisby submitted the evidence to the Commander of Internal Investigations together with a comprehensive report summarising and analysing the evidence. On 17 April 2018, after review by the Commander, Sergeant Morrisby’s report and the files of evidence were submitted to the Coroner. 5. Upon receipt of the report and evidence, I directed further investigations, principally in respect of a review of the actions and tactics employed by officers of Tasmania Police in the incident. I therefore sought an opinion from a qualified officer of Victoria Police. The role of the Coroner 6. Section 21(1) of the Coroners Act 1995 (“the Act”) gives a coroner jurisdiction to investigate a death where it appears to the Coroner that the death is reportable. Mr McInerney’s death was a reportable death. The death occurred in Tasmania, and was an unnatural death resulting from injury, and occurred while police attempted to detain Mr McInerney.1 7. There is little doubt that, at the time the officers arrived at the premises and engaged with him, they were attempting to detain him. It is inconceivable that, having encountered him wielding knives, they would not have had such intention. 8. The Mental Health Act 2013 allows a police officer to take a person into protective custody without warrant upon holding a reasonable belief regarding the following three matters: (a) the person has a mental illness; and (b) the person should be examined to see if he or she needs to be assessed against the assessment criteria or the treatment criteria; and (c) the person's safety or the safety of other persons is likely to be at risk if the person is not taken into protective custody.2 1 Section 3 of the Act. 2 Section 17 of the Mental Health Act 2013. 6 9. Further to the protective custody powers, when Mr McInerney