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IN THE CORONER'S COURT )

AT CANBERRA IN THE ) Case No. CD 196 of 1995 AUSTRALIAN CAPITAL TERRITORY )

IN THE MATTER OF THE DEATH OF

WARREN GEOFFREY I'ANSON

Findings of Chief Coroner R.J. Cahill

Delivered on 26 February 1999

Warren Geoffrey I'Anson died on Friday 17 November 1995 from gunshot wounds to the mid back region of his body as a result of the discharge of the police service firearm of Constable Christopher Michael Sheehan.

ORDERS IN RELATION TO THE SUPPRESSION OF NAMES OF WITNESSES AND EVIDENCE

On the basis of the material and the affidavits already provided, I make the following ruling:

"The question of whether or not a suppression order should be made, in this case it relates to the name of the witnesses, an order has been enforced on a temporary basis since the commencement of the inquest. It involved the balance of the right of the public to know and the normal situation that everything held in the court is publicly available and free to be published. That is in the public interest and it is also in the interests of the administration of justice as is mentioned in the relevant statute - the Evidence Act 1971 section 83, which provides:

"83. (1) Where it appears to a court that --

a) the publication of evidence, given or intended to be given, in a proceeding before that court, is likely to prejudice the administration of justice; or

b) in the interests of the administration of justice, it is desirable that the name of a party to, or a witness, or intended witness, in such a proceeding be not published,

the court may, at any time during or after the hearing of the proceeding, make an order --

c) forbidding the publication of the evidence or a specified part of the evidence, or of a report of the evidence, either absolutely or subject to such conditions as the court specifies or for such period as is specified; or

d) forbidding the publication of the name of such a party or witness.

(2) ...."

Penalties for non-compliance with such an order are prescribed in section 84 of the Act.

"In this particular case it has been put before me that the witnesses concerned are professionals involved in therapeutic relationships with a number of people. Out of those therapeutic relationships the question of confidentiality and trust in that relationship is extremely important in them being able to conduct their professional duties and are able to best help the people who are in crisis and need their assistance. There are other matters raised in the affidavits that I do not wish to go into here that add to that particular question, at least in one of the cases in respect of the witness, to be known as, 'A'.

"Balancing all the matters I have mentioned, I am of the view that in this particular case the non-publication of the names of the workers involved, or any material that would actually identify their identity should be prohibited because I believe in this case the public interest and the interest in the administration of justice balances out in favour of that in the protection of their professional duties for the reasons I have indicated, and that material is well documented in the affidavits that have been submitted.

"In respect of the witnesses - 'A', 'J', 'K' and 'S' - their names are prohibited from publication, as is any material that would seek to identify them personally. 'The Clinic' and information about the services provided therein, as well as Warren I'Anson's attendance there is also suppressed. That does not mean there should be any restriction about reporting any evidence of what occurred, conversations etcetera, but it is simply that there could be a situation where publication of an address or something like that, but I make that order for more abundant caution, and that order remains in force until other order is made."

THE ROLE OF THE CORONER IN THE A.C.T.

The jurisdiction of the Coroner in the ACT is contained in section 12 of the Coroners Act 1956. Section 12 provides as follows:

"12. (1) A Coroner shall, subject to this Act, hold an inquest into the manner and cause of the death of a person who -

a) is killed;

b) is found drowned;

c) dies a sudden death the cause of which is unknown;

d) dies under suspicious or unusual circumstances;

e) dies during or within 72 hours after, or as a result of -

i) an operation of a medical, surgical, dental or like nature; or

ii) an invasive medical or diagnostic procedure;

f) dies, and a medical practitioner has not given a certificate as to the cause of death;

g) dies, not having been attended by a medical practitioner at any period within 3 months prior to his or her death;

h) dies within a year and a day from the date of any accident where the cause of death is directly attributable to the accident;

i) dies -

(ii) while the subject of emergency procedures, or while subject to a mental health order, under the Mental Health (Treatment and Care) Act 1994;

j) dies under circumstances that, in the opinion of the Attorney-General, requires that the cause of death and the circumstances of death should be more clearly and definitely ascertained; or

k) dies in custody."

Subsections (2), (3) and (4) are not relevant to this inquest. Section 24 of the Coroners Act 1956 provides that:

"24. The Coroner holding an inquest into a death in custody shall include in a record of the proceedings of the inquest findings as to the quality of care, treatment and supervision of the deceased person which, in the opinion of the

Coroner, contributed to the cause of death."

"Death in custody" does not apply in this case, but I have treated this case as such in view of the questions raised as to the quality of care, treatment and supervision of Warren I'Anson and whether they may have borne any relationship to his ultimate demise.

Section 28 of the Coroners Act 1956 provides the power for the Coroner to order a post mortem examination. This step occurred in this case and a post mortem examination was conducted by Dr Jain in conjunction with one of the ACT forensic pathologists, Mr Paul Reedy.

Part V of the Coroners Act 1956 sets out the provisions relating to the conduct of inquests. Section 50 provides that inquests in the A.C.T. are held by the Coroner without a jury.

Thus the role of the Coroner is principally to make a full enquiry into the cause of death of the deceased person and examine, on oath, relevant witnesses.

Section 53 of the Act provides as follows:

"53. A Coroner may grant leave to a person -

a) who has been summoned to give evidence at an inquest or inquiry; or

b) who, in the opinion of the Coroner, has a sufficient interest in the subject matter of the inquest or inquiry,

c) to appear in person at the inquest or inquiry or to be represented by counsel or solicitor and to examine and cross-examine witnesses on matters relevant to the inquest or inquiry."

The High Court of Australia in Annetts and Anor v. McCann and Ors, emphasised the need for a Coroner to comply with the rules of natural justice in respect of the question of permitting representation of parties whose interests may be affected in the conduct of an inquest and, in particular, giving those parties the right to be heard and to make submissions in respect of the coronial inquiry. Those that sought leave to either appear personally, or for an individual, group or agency - and were granted that leave - in what became "Part I" of the inquest were:

Mr T. Buddin SC, instructed by Ms P. DeVeau, from the Office of the Department of Public Prosecutions, Counsel Assisting,

Mr K. Horler QC and Mr J. Pappas on behalf of Mr Brian I'Anson father of the deceased,

Mr T. Howe, of the Office of the Australian Government Solicitor, on behalf of the Commissioner of the Australian Federal Police,

Mr R. Bayliss, of the Office of the ACT Government Solicitor, on behalf of the ACT Health and Community Care Service and the Department of Health and Community Care,

Mr I. Bradfield on behalf of Sergeant Sly and Constables Sheehan, Walls, Muir and Finck, and

Ms H. McGregor, the Community Advocate.

The Australian Federal Police (AFP) were permitted representation as having an interest in the matter as the investigating agency appointed pursuant to section 49 of the Act on behalf of the Coroner, and also the agency against whom some criticisms had been levelled. Section 49 provides as follows:

"49. (1) A Coroner may, in writing, request the chief police officer for the assistance of a police officer in an investigation for the purpose of an inquest or inquiry.

(2) The chief police officer shall, as far as practicable, comply with a request under subsection (1)."

In this case, Detective Sergeant Dieter Tietz and Dectective Constable Danny Kindermann of the Australian Federal Police were vested with the delegation to investigate the death of Warren I'Anson and whether a person or persons may have been held culpable pursuant to section 59 of the Act.

Federal Agent (formerly Detective Sergeant) Brendan McDevitt of the Australian Federal Police was empowered, under my direction, to enquire into protocols, practices and procedural matters raised as a result of the death of Warren I'Anson and in "Part II" of the inquest.

Section 54 of the Act provides that:

"54. (1) A Coroner shall not be bound to observe the rules of procedure and evidence applicable to proceedings before a court of law.

(2) Where the procedure for taking any step in an inquest or inquiry is not prescribed in this Act or the law under which the step is to be taken, a Coroner may give directions with respect to the procedure to be followed as regards that step."

As the State Coroner of New South Wales, Mr Kevin Waller, states in his work "Coronial Law and Practice in NSW" a coronial proceeding has a particularly unique quality of being inquisitorial rather than accusatorial. The ordinary rules of procedure and evidence are eschewed in favour of a system which allows a Coroner to endeavour, by fair means, to discover the truth. Of course, the general application of law regarding to evidence and procedure is desirable. The recognised formula of examination, cross-examination and re- examination is a safe course to follow. Irrelevant material, comment in the guise of evidence, inexpert opinions, unduly prejudicial hearsay evidence and evidence the prejudicial effect of which outweighs its probative value (e.g. evidence of bad character) will not usually be permitted. The key advantage of the system as it stands is that the Coroner may take the advantage of hearsay evidence to explore a previously unexplored line of inquiry.

However, the Coroner, in exercising his function under section 59 of the Act as to whether any person should be committed for trial, will, in that regard, necessarily follow the strict rules of evidence in his consideration. Section 59 provides as follows:

"59. (1) If a Coroner is of opinion, having regard to all the evidence given at an inquest or inquiry, that the evidence is capable of satisfying a jury beyond reasonable doubt that a person has committed an indictable offence, the Coroner shall -

(a) ...

(b) ... (2) ... (3) ...

4) When the person who has been arrested is brought before a Coroner, the Coroner shall proceed in the same manner as the Magistrates Court proceeds under the Bail Act 1992 or Part VI of the Magistrates Court Act 1930 when it is satisfied that the evidence before it is capable of satisfying a jury beyond reasonable doubt that an accused person has committed an indictable offence.

5) The provisions of the Bail Act 1992 and Part VI of the Magistrates Court Act 1930 apply, mutatis mutandis, to and in relation to a person against whom a Coroner has found that the evidence before the Coroner is capable of satisfying a jury beyond reasonable doubt that the person has committed an indictable offence.

6) In this section, "jury" means a reasonable jury properly instructed.

Although at this inquest the powers of the Coroner to go beyond the normal rules of evidence and procedure have been applied, my task pursuant to section 59 of the Act in determining

whether or not there is a case for committal against any person has to be performed pursuant to the rigid rules of evidence and procedure which apply in the hearing of any criminal indictable case against any person. That task necessarily involves looking at the material before me and applying the normal criminal jurisdiction rules of evidence and procedure to the material in making my decision.

Section 56 of the Coroners Act 1956 provides as follows:

"56. (1) A Coroner holding an inquest shall find, if possible -

a) the identity of the deceased;

b) how, when and where the death occurred;

c) the cause of death;

d) the identity of any person who contributed to the death; and

e) in the case of the suspected death of a person -- that the person has died.

(2) ....

3) At the conclusion of an inquest or inquiry, the Coroner shall record his or her findings in writing.

4) A Coroner may comment on any matter connected with the death or fire, including public health or safety or the administration of justice."

Sub-section (2) is not relevant to this inquest.

In the context of sub-section (4) "Part II" of the inquest was conducted. Finally, section 58 of the Coroners Act 1956 provides as follows:

"58. (1) A Coroner may report to the Attorney-General on an inquest or inquiry which the Coroner has held.

(2) A Coroner may make recommendations to the Attorney-General on any matter connected with an inquest or inquiry, including matters relating to public health or safety or the administration of justice."

THE DEATH OF WARREN I'ANSON

The circumstances surrounding the demise of Warren I'Anson may best be summarised by portions of the oral submission relating to the death presented by Counsel Assisting - Mr Terry Buddin SC:

"Warren I'Anson led something of a troubled life. There was a history of admissions to hospital and other places where care was administered. He was a long term sufferer of schizophrenia, which - in the words of Crisis Team member witness 'K' - 'was exacerbated by

frequent use of drugs and alcohol', and the evidence reveals a pattern of deterioration in his condition and behaviour in the weeks and days preceding his death.

"There were a number of factors in addition to his pre-existing circumstances. He suffered grief over the deaths of both his wife and his best friend; obviously a major precipitating factor. He had expressed concerns in relation to a perceived inadequacy of the autopsy process relating to his wife Susan's death, because there was no toxicological report. He had concerns relating to the possible contraction of a life-threatening illness, about which he learned only two days before his death.

"He had concerns about his role both as a client and support worker for the Mental Health Foundation. He also expressed concern about conflicts, as he perceived them, between the Mental Health Foundation and the ACT Mental Health Services. He also exhibited unusual or morbid patterns of behaviour during the period prior to his death.

"There was a reference to his jumping off the high tower at the local swimming pool that was discussed with a third party as being 'practice'. There were a number of discussions with people about the futility of life, and unusually agressive behaviour. There was the visit to the cemetery on the morning of his death and the unusual encounter with the worker there.

Together with a certain degree of profligacy in relation to money and possessions. This particularly unusual behaviour escalated as the time of his death approached and those nearest and dearest to him began to have increasing concerns.

"Warren's behaviour in the hours preceding his death revealed that he was highly disturbed and/or suicidal. He refused entreaties by his father, by Witness 'K' , by police, and by a neighbour who knew him well, to voluntarily come out of his unit and go to hospital. The evidence suggests, and it is agreed on all sides, that the police at this stage acted appropriately, with patience and understanding. There was also the question of the bizarre apparel that he was wearing, and the frightening behaviour - when he had possession of the knife - towards both Witness 'K' and Constable Walls. The neighbour was also frightened for his safety. There were concerns that he was intoxicated by drugs and alcohol, and there were concerns that he would harm himself, or others, by committing suicide - throwing himself from the balcony, using the knife, ingesting drugs, or some other undefined way. The fact remains - that not all information was available to those outside.

"It was in those circumstances that the Mental Health Crisis Service formed the view that the time had been reached to take Warren I'Anson to hospital for assessment; a view shared by those who knew him best. They informed the police that they were not leaving the area without him because - in the words of Witness 'A' - 'they could not just walk away from the situation'. The police considered a number of options but believed that time was of the essence, and acting on advice from the Mental Health Crisis Team - that Warren would commit suicide - decided to effect forceful entry. The gist of their evidence was that 'they were damned if they did take action and tragedy occurred, and damned if they didn't take action and tragedy occurred'.

"Two pieces of vital information were missing from the considerations by the decision- makers that forcible entry should be effected. Firstly, that Warren had said that as he did not want police blazing their guns through the door, he would put a mattress against the door, and secondly, Warren had said that he would be shot. The recipient of that information inferred that it would be at the hands of the police, in circumstances he described as 'committing

suicide by proxy'. It is also not an insignificant fact that the police were unable to effect entry with the first kick.

"These pieces of information had the potential to affect the quality of the decision that was made. Clearly, the better informed the decision maker, the better informed is the decision itself. No criticism should be made that there was any failure on the part of the AFP or its officers for not being aware. If the officers had been privy to that information, then the decision to effect entry at that time may not have been made. To go beyond that proposition would be to engage in speculation. It is to be hoped that a reasonable police officer would at least reflect upon the situation given those circumstances. It is a daunting task to include a number of variables in an equation of known factors and then seek to draw conclusions from the composite picture thus created."

THE INQUEST

The following witnesses gave evidence on the dates shown in relation to the investiga-tion or events subsequent to the incident:

Detective Sergeant Dieter Tietz, gave evidence on 14 and 15 February 1996, and whose statements were Exhibit 1A - relating to the investigation (dated 20 November 1995) and Exhibit 1B - relating to his familiarity with the deceased for a period over 25 years (also dated 20 November 1995).

Detective Superintendent Ian Prior, gave evidence in relation to the forensic and ballistic investigation on 15 February 1996. His statement in regard to that investigation is Exhibit 33.

Detective Constable Kindermann, gave evidence on 16 February 1996 in relation to the investigation. His statement in relation to that investigation is Exhibit 37, and the Report of Death to the Coroner prepared by Detective Constable Kindermann is Exhibit 38.

Dr Sanjiv Jain, gave evidence on 16 February 1996 as having performed the autopsy upon the deceased - Warren I'Anson. His report and statement is Exhibit 39.

Sergeant Graham Tulk gave evidence on 16 February 1996 as to his having produced a re- enactment video of the scene. His statement is Exhibit 40, and the re-enactment video and transcript are Exhibits 32A, 32A-1 to 32A-3.

Detective Constable Therese Barnicoat, gave evidence on 15 February 1996, and her statement is Exhibit 35.

Sergeant Ronald McDonald's evidence is in relation to forensic matters and the taking of photographs.

Constable Julian Slater's evidence is in relation to forensic matters and the taking of photographs. His statement is Exhibit 4A. The photographic evidence are Exhibits $b, 4C and 4D.

Dr Klaus Czoban declared the life of Warren I'Anson extinct. His documentary evidence is Exhibit 9.

Robert Barnes gave evidence in relation to forensic tests on 10 May 1996. His reports are Exhibits 70B and 70C.

Constable Edwin Fuderer prepared a scale plan of the scene. His statement and documentary evidence are Exhibits 5A dnd 5B.

Constable Michael Turner conducted interviews with witnesses. His statement is Exhibit 3.

Constable Peter Ingram conducted interviews with witnesses. His statement to that effect is Exhibit 2.

Sergeant D. Reece fingerprinted the deceased. His statement to that effect is Exhibit 7.

Sergeant Robert Hanisch produced evidence in relation to the continuity of a blood sample obtained from Constable Sheehan. His statement is Exhibit 8.

Paul Reedy's evidence is in relation to the toxicology report. His statement is Exhibit 29A, and the additional statement is Exhibit 29B.

Adam Starr is an ambulance officer and produced evidence of his activities at the scene. His statement is Exhibit 12.

Chris Barry is an ambulance officer and produced evidence of his activities at the scene. His statement to that effect is Exhibit 11.

Detective Sergeant Brendan McDevitt was specifically tasked to investigate the role of the police, protocols and procedures.

The following witnesses gave evidence on the dates shown. Their knowledge of events leading to, or involvement in, the death of Warren I'Anson is summarised in the evidentiary part of these findings:

Witness 'K' , a Registered Mental Health Nurse and General Nurse, and authorised Mental Health Officer, gave evidence on 29 February, 1 March and 12 March 1996 as having been on duty as a member of the Mental Health Crisis Team on 17 November 1995. His statements relating to his involvement are Exhibits 46A and 46B and his curriculum vitae is Exhibit 47.

Witness 'A', gave evidence on 22 March 1996 as having been on duty as a member of the Mental Health Crisis Team on 17 November 1995. Her statement as to her involvement is Exibit 7.

Witness 'J' gave evidence on 1 April 1996 in relation to the psychiatric assessment of Warren I'Anson and her observations leading up to his death. Her statement is Exhibit 56A and the Psychiatric Rehabilitation Service case notes are Exhibit 57.

Patrick Fleming a member of staff of the City Community Mental Health Team gave evidence on 1 April 1996 in relation to his contact with Warren I'Anson prior to his death. His statement as to his involvement is Exhibit 59A.

Dr Les Drew was the Psychiatrist treating Warren I'anson prior to his death. He gave evidence on 8 May 1996. His statement and response to questions are Exhibits 68A and 68B.

Constable John Angus McDonald gave evidence on 28 February 1996 as to having been present as an Acting Sergeant in the Communications Room when the first communications from the workers of the Mental Health Foundation requested police assistance. His statement to that effect is Exhibit 41.

Mr Brian I'Anson, Warren's father, gave evidence on 28 February 1996, and 29 February 1996. His statement is Exhibit 42.

Witness 'S', a support worker employed by the Mental Health Foundation, gave evidence on 29 February 1996 as having had contact with Warren in the days leading to his death. Her statement is Exhibit 45.

Andrew Kazar, a reporter employed by the Canberra Times conducted an interview with Glenn Chapman, gave evidence on 7 May 1996. The audiotape and transcript of that interview are Exhibits 14B and 14C. His statement is Exhibit 67.

Sergeant Brian Sly gave evidence on 7 May 1996. .

Constable Christopher Sheehan gave evidence on 8 May 1996. Constable Robert Walls gave evidence on 7 May 1996.

Constable Julianne Finck gave evidence on 6 May 1996. Constable Robert Muir gave evidence on 6 May 1996.

Residents residing in the block of flats were interviewed by police, gave statements and oral evidence on the dates shown, as follows:

William Barry gave evidence on 21 March 1996. Melanie Cheshire gave evidence on 21 March 1996. Gloria Gilson gave evidence on 21 March 1996.

Kevin Harrow gave evidence on 21 March 1996. Glenn Chapman gave evidence on 1 March 1996.

Also tendered was the following documentation relating to protocols, guidelines or procedures pertaining to emergency situations existing either within or between the Australian Federal Police and the Mental Health Services at the time of Warren I'Anson's death:

Exhibit 30 - Protocol Memorandum Documents between AFP and Mental Health Services, executed on behalf of Mental Health Services by Dr S.J. Rosen

Exhibit 31 - Extracts from ACT Mental Health Service Psychiatry Unit Policy Manual - Extract entitled "Protective body armour" at page 28.

MFI-8 - "Assess and Re-assess - A Conflict De-Escalation Model" Book, comprising training notes dated January 1996

MFI-9 - Regional Instruction 22/93 - Mental Health Patients MFI- 10 - Lesson Plan "Dealing with the Mentally Ill"

MFI-11 - Police Practices - training syllabus - "Dealing with the Mentally Ill"

Exhibit 36 - ACT Regional Instructions 19/91 - Callout procedures - "Police hostage negotiation team call-out procedures"

Also tendered was the following documentation in relation to Warren I'Anson: MFI-5 - Summary of Care provided to deceased

MFI-12 - View of the Incident - extract of computer entry by Constable Gibbs Exhibit 26 - Statement of Emergency Action, executed by Witness 'A'

Exhibit 48 - Log Book of Mental Health Crisis Team telephone calls Exhibit 49 - Hospital Clinical Notes

Exhibit 57 - Psychiatric Rehabilitation Services file Exhibit 60A - City Health Services file

Exhibit 60B - 3-page Summary of City Health Services file

Following is a summary of the factual evidence of the incident compiled with the assistance of the Summary Chronology annexed to the "Issues Paper Analysing and Raising Systems Issues" dated 23 May 1996 as submitted by the Community Advocate.

"SUMMARY CHRONOLOGY

* a best guess or discrepancy in evidence

14.11.95 WI keeps his appointment with CMH psychologist who notices increased agitation and has been concerned since 7.11.95. WI mentions jumping of(f) high board at pool."

"15.11.95 5.10pm CT receives a call from PRS psychologist; Warren not well and may end up in hospital."

"15.11.95 9.45pm CT receives a call from WI who sounds elevated and delusional and is worried about a serious medical condition - he is advised to contact CT "prn"."

"16.11.95 6.10pm MHF support worker visits WI."

Witness 'S', a support worker employed by the Mental Health Foundation, gave evidence of having visited Warren's flat at approximately 6pm. She received no response from inside upon knocking, although Warren could be seen to be asleep inside the flat. She found the verandah door to be unlocked, so she opened it and went inside. (Witness) 'S' and Warren I'Anson had a lengthy discussion about a number of topics, during which she expressed her concerns and her belief that he should consider the possibility of being admitted to hospital as a voluntary patient for 'two or three days'. He offhandedly agreed. She contacted the Mental Health Crisis Team.

"16.11.95 6.35pm CT receives a call from MHF worker, CT member speaks to WI - does not appear to be in crisis - discussion about voluntary admission and attendance at emergency department."

Witness 'S' spoke with Witness 'K' of the Crisis Team, who had known Warren I'Anson from his period of residency at Watson Hostel. She explained Warren's mental state, her concerns and her belief that he should be considered for hospitalisation as a voluntary patient.

Warren I'Anson and Witness 'K' had a discussion on the telephone, during which Warren told (Witness) 'K' that he had drunk 5 beers, was taking his medication and that he was being anti- social.

Witness 'K' spoke again with Witness 'S', giving it as his opinion that Warren did not appear to be in any immediate danger and that he was scheduled to see his psychiatrist on the following Monday. It was under these circumstances that a bed was not available for Warren I'Anson to be admitted. Witness 'S' was told by Witness 'K' that it would be easier to facilitate a voluntary admission the next day, and that she should contact the Mental Health Service the following day for a re-assessment of Warren's need for further treatment, to which Warren I'Anson was agreeable. (Witness) 'S' was at the flat for a period of approximately 90 minutes.

"17.11.95 *am BI phones MHF worker saying he's had two strange calls from Warren - she will ring Warren and CT again - she tries WI several times."

According to his statement Mr Brian I'Anson and his wife returned to their home "round lunch time". There were a number of messages on the answering machine from both Warren and Witness 'S' which gave Mr I'Anson further cause for concern. (Witness) 'S' expressed her concern about Warren's condition and mentioned that she had arranged for the Mental Health Crisis Team to speak with Warren and that he was willing to be admitted as a voluntary patient to hospital. Unfortunately, Warren had been told that a bed was not available and therefore he would not admitted.

During her conversation with Mr Brian I'Anson, Witness 'S' said that she would again attempt to phone Warren and the Crisis Team.

"17.11.95 2pm PRS psychologist visits WI - did not advise CT."

Following a phone call from a worker at the PRS Program that Warren I'Anson had not kept an appointment, Witness 'J' went to Warren's flat at about 2 p.m. and knocked on the door. After knocking several times, Warren answered the door and invited Witness 'J' inside.

During the conversation, in which several subjects were discussed, Witness 'J' concluded that two issues caused Warren to become antagonistic. The first issue was his perception of a conflict between ACT Mental Health Services and the Mental Health Foundation, where confidential information had been requested and was unable to be provided. It was Witness 'J's opinion that part of Warren's antagonism could be attributed to being both a client of Mental Health Services and a support worker for the Mental Health Foundation. The second issue related to his dissatisfaction with the Coronial process associated with his wife's death.

Witness 'J' discussed Warren's medication and suggested that his medication be adjusted. Warren intended discussing the matter with his treating psychiatrist Dr Drew. It was also Warren I'Anson's intention to initiate contact with the Crisis Team during the night. Witness 'J' left the flat at about 3.15 p.m., arranging to make contact with Warren the following morning.

"17.11.95 4.36pm CT called by MHF worker, worried about WI expressing concerns about his needing admission."

Witness 'K', a member of the Crisis Team, stated that he received a telephone call from Witness 'S' at about 4.30pm. (Witness) 'S' told Witness 'K' of her belief that Warren I'Anson was at risk because of his recent behaviour and mental condition. Witness 'K' told her that the Crisis Team would respond if required and that Warren should go to the Woden Valley Hospital Emergency Department as a voluntary admission.

"17.11.95 4.51pm BI phones CT very worried."

In his statement Mr Brian I'Anson stated that he phoned the Crisis Team, at about 5 pm, having left messages. He spoke with Witness 'A' and Witness 'K' who had previously interviewed Warren, expressing his amazement that Warren had not been admitted to hospital when he had gone with Witness 'S' to the psychiatric ward a day or two before. He mentioned the swimming pool as an example of Warren's recent odd behaviour and suicidal tendency as well as the need for psychiatric attention. Mr I'Anson, in his evidence on 28 February 1996, elaborated upon the 'swimming pool' incident - of Warren's jumping from the high tower - and that he had personally formed the view that Warren required hospitalisation.

In cross-examination by Mr Bayliss, Mr I'Anson said that the Crisis Team "may have" said that they could try to contact Warren, but he "formed the view" that they were going to act.

As the message tape is in chronological order, the following message was left on Warren I'Anson's answering machine:

"Hi Warren, it's Jenny. I'm just ringing to see how you were, I'm really sorry I couldn't make it last night, so I hope everything's okay, can you give me a call back if you're able at some time bye."

Mr I'Anson was unable to identify "Jenny", but believed that she may have been a fellow patient.

This message does not appear to bear any relevance to the death of Warren I'Anson. "17.11.95 5.21pm CT leaves message on WI's answering machine."

"17.11.95 *5.45pm MHF worker phones WI - WI talks about visit to cemetery, being refused access to NAC, spending more money, knew how friend felt when suicided, mattress at door, guns blazing."

Witness 'S' then attempted to again phone Warren I'Anson. It was while she was leaving the message

"Hi Warren, it's (Witness) 'S' again. Um I'm having trouble contacting you. Um, how about trying to give me a message on my answering machine, if not I'm going to try and pop round and see you, um, yeah and chat about what options are open"

that Warren I'Anson picked up the telephone receiver. While Warren appeared to be happy to speak with her, he indicated that he was unhappy at being interrupted during the cricket which was being televised at that time. Warren told Witness 'S' that he had gone to see his wife's grave at Gungahlin that day, and that he had lain naked in the fields, taken photographs of himself, and left the film at the cemetery. He related other activities during the day, prior to mentioning his friend - Graham, who had committed suicide - and that he knew how his friend had felt. He mentioned putting a mattress across the front door as he did not want people breaking into the flat. When questioned, Warren said that he did not want police blazing their guns through the door, or words to that effect. He repeated the words when requested, and hung up the telephone. Witness 'S' immediately phoned the Mental Health Crisis Team.

"17.11.95 5.55pm CT phoned by MHF worker very worried, WI says friend's suicide the way to go - advised to contact AFP as CT busy."

Witness 'S' spoke with Witness 'A', a member of the Crisis Team. Witness 'A' decided that the situation sounded serious, but she advised (Witness) 'S' that the Crisis Team was currently admitting a patient and could not respond immediately. She suggested that (Witness) 'S' call the police.

In her evidence, Witness 'S' admitted that she had forgotten to mention to the Crisis Team of Warren talking about placing the mattress against the door and about police 'blasting through the door'.

Witness 'S' then telephoned the police.

"17.11.95 *5.58pm MHF worker phones AFP, won't attend without CT."

Constable John McDonald - at that time an Acting Sergeant on duty in the Communications Branch - gave evidence of having been present in the Communications Room when the a telephone call was received - at 1757 hours - from Witness 'S' - a worker employed by the Mental Health Foundation requesting police assistance in relation to a mental patient. He spoke to Witness 'S', continuing the conversation Constable Gibbs - who had received the initial communication - had been having with her. The transcript of that conversation was tendered as Exhibit 27B - the audiotape recording being Exhibit 27A. During this conversation (Witness) 'S' requested that police attend an address in Red Hill and take a male person - Warren I'Anson - to Woden Valley Hospital Psychiatric ward. (Witness) 'S' said that she thought Mr I'Anson may be suicidal and should receive treatment.

Following a discussion as to the powers of the police in restraining persons or depriving them of their liberty and the consequences of that exercise, Constable McDonald advised Witness 'S' that police would attend as long as the members of the Mental Health Crisis Team also attended. He indicated that, as they - the Mental Health Service - had had previous dealings with Mr I'Anson, it was appropriate that they attend. Witness 'S' said that she would contact the Crisis Team and ask them to contact police.

"17.11.95 6pm MHF worker phones CT advises this."

Witness 'A' received the phone call to this effect from Witness 'S' at approximately 6pm.

"17.11.95 *6.02pm MHF worker phones BI to advise CT will attend when possible and will involve police - message left on answering machine."

"17.11.95 6-6.30pm BI visits WI but refuses to open door - there about 10 minutes."

Initially in his evidence Mr Brian I'Anson suggested that the visit took place at approximately

6.30 pm, but in later evidence, gave it as his belief that the visit took place "sometime between 6 and 6.30".

Mr I'Anson suggested in his evidence "it was a fairly laconic conversation from Warren's perspective, and it sounded as if - while he was communicating, he was doing it in very brief sentences". Mr I'Anson went on to give evidence that the (approximately 3) short communications were along the lines of:

(Brian I'Anson knocks) Warren - "Who's there?"

Brian - "Dad. I want to speak to you". Warren - "Go down the coast".

or "I'll see you later".

Warren's tone became more irritated and he would not respond to the request to open the door.

In his statement Mr I'Anson said that Warren told him that he (Warren) had given his car to his brother, Mark, and that Brian I'Anson and his wife should go back down to the coast. Mr I'Anson felt that Warren was implying that he was not there to help Warren when needed. In clarification, in his evidence given on 28 February 1996, Mr I'Anson said that it was his belief that from the tone in Warren's voice and the rather distant form of communication, that Warren had decided that he (Mr I'Anson) was not of any help to him. Mr Brian I'Anson decided to leave. It was his belief that he had been at Warren's flat for about 10 minutes.

"17.11.95 6.05pm CT phones WI, engaged."

At approximately 6.05pm, Witness 'A' twice tried to call Warren's home. On the first occasion, the phone was engaged.

"6.10pm CT phones WI, leaves message on machine."

"Warren, it's (Witness) 'A' from the Mental Health Crisis Team. I don't want you to get back to me ... I want you to talk to me now, could you pick up the phone."

Witness 'A' and Witness 'K' decided to attend Warren's home, arriving at approximately 6.45pm.

"17.11.95 6.30pm CT phoned by MHF worker, WI leaves balcony door unlocked."

Witness 'S' telephoned the members of the Crisis Team at approximately 6.45pm and advised them that Warren I'Anson habitually left the balcony door to his flat unlocked.

"17.11.95 6.45pm CT arrives at WI address, both members attempt to talk to him through the door, WI angry and abusive, incoherent (about 15 minutes) - decide that WI needs to be taken to hospital to be assessed."

In his statement Witness 'K' states that Warren would not open the door to them, but spoke to them through the closed door. He told them to go away, sounding angry and agitated. Both members of the Crisis Team persisted in trying to talk with Warren, asking him to let them in as they were concerned for his safety. The request was met with a hostile response. He told them, again - in an abusive manner - to go away. He sounded as though he was under the influence of alcohol or drugs. His speech was at times incoherent and bizarre. The members of the Crisis Team walked down the stairs and Witness 'A' contacted the police. The transcript of the conversation is Exhibit 28B and the Audio Tape Exhibit 28A.

"17.11.95 6.58pm CT phones AFP requesting assistance."

Witness 'A' requested assistance to transport Warren to Woden Valley Hospital, as it was their intention to admit Warren under an Emergency Action. The Statement of Emergency Action was completed by Witness 'A' at 7.30pm.

"17.11.95 7.05pm AFP advises CT all cars busy."

Constable McDonald gave evidence that he changed his mind in regarding to sending police assistance on receiving the request from the Crisis Team, and authorised the allocation.

Constable Gibbs who received the call annotated the 'job' on the computer, a police vehicle driven by Constable Walls became free and it was dispatched immediately.

"17.11.95 7.09pm AFP advises CT car there soon."

"17.11.95 7.20pm Constable Walls arrives and is briefed by CT."

Witness 'A' and Witness 'K' explained the situation to the police, and that it was their intention to take Warren to the hospital. At this time, Witness 'K' was of the opinion that Warren was under substantial risk to himself.

"17.11.95 7.22pm Constables Muir and Finck arrive - Finck stays downstairs with CT - Walls and Muir go upstairs."

Constables Muir and Finck arrived at the scene. Constable Finck remained standing on the grassed area outside of the flats with the two members of the Crisis Team, while Constable Muir went upstairs with Constable Walls to the flat. Finck saw Walls climb over a small guardrail and stand on the balcony. Muir stood on the adjacent landing.

"17.11.95 *7.25pm Walls tries to talk to WI from balcony, Muir watching, WI lunges at glass with knife."

Constable Finck saw both Constable Walls trying to talk through the window, and a bare chested male approach the window holding an object orange in colour. Walls "tried" the door handle but it would not open. Constables Walls and Muir attempted to speak with Warren I'Anson. The police officers asked Warren to let them in as they wanted to talk to him.

Warren would not let them in, telling them to 'go away.' Warren I'Anson lunged at the window with the knife that he was holding. Constable Walls climbed back over the guardrail on to the landing. Muir and Walls returned to where Constable Finck and the members of the Crisis Team were standing.

"17.11.95 *7.28pm Three police and two CT discuss situation, query is there anybody who could get through to WI."

"17.11.95 7.30pm CT member decides to try to talk to WI on balcony with Walls and Muir watching, WI lunged at glass with knife - three go back downstairs."

Witness 'K' went upstairs with Constables Walls and Muir. Stepping from the stairwell onto the balcony, Witness 'K' tried to reason with Warren. He could see Warren inside the flat, restlessly pacing back and forth. Warrren was bare chested and was wearing a divers mask on his forehead and a necklace around his neck. He was holding a large knife with an orange handle in his hand; the blade was approximately 20cm long. Warren was waving the knife around in a threatening manner. As Witness 'K' was talking to him, Warrren lunged at Witness 'K' with the knife. He struck the glass door between himself and Witness 'K'. As he lunged, he was speaking incoherently, but loudly. Witness 'K' withdrew, as did the police officers, and returned downstairs.

"17.11.95 7.35pm Walls and Muir agree that it is too dangerous to go in - Constable Muir rings supervisor for assist- ance."

The police stated that they considered that extra help was required and that possibly a police negotiator ought to be called upon to assist. It was agreed between the three police officers and the two Crisis Team members that assistance should be called for. Constable Muir used the police radio to call for assistance.

"17.11.95 7.40pm BI receives call from CT asking to assist, BI says he's been there and can't help."

In his statement Brian I'Anson stated that shortly after his return from Warren's flat, he received a phone call from Witness 'A'. In answer to a question put to him by Mr Bayliss, Mr I'Anson replied that his guess would be that the phonecall "would be around about 7 o'clock"; however, to the suggestion that the phonecall took place at 7.35, Mr I'Anson said:

"I was so unaware of the time that I wouldn't argue with it. If she said that was recorded, then that would be fine."

Mr I'Anson was unable to say how long the phone conversation was other than to vary the duration to "maybe two minutes, three minutes at the most .... and it may well be that it went for five minutes". Witness 'A' said that she was at Warren's flat and that they were going to try to get him to hospital. She asked Mr I'Anson if he would like to act as an intermediary because Warren would not open the door. Mr I'Anson replied that he had just been at the flat, that Warren's tone was angry and he probably would not open the door to him, and that it was his belief that his further attendance would not help in any way. However, when questioned by Mr Bayliss, Mr I'Anson said:

"And at that stage had you told them you'd been at Warren's flat before, and not been of any success in trying to talk to him? --- That's right. I did offer to go if they needed. I made that offer at the end of the conversation in case there was no other way. That was certainly made.

"Are you saying that you offered to attend? --- Yes, if they wanted me, they could call me back.

"To call you back? --- That was the only way of achieving ---

"Sorry I just - I'm not certain whether you're saying that you offered to have them call you back or offered to attend? --- No. I asked them to call me back and I would come if I got that call."

In answering further questions put to him by Mr Bayliss, Mr I'Anson was unable to say whether police were in attendance at Warren's flat, but thought that Witness 'A' mentioned Warren as being in possession of a knife.

"17.11.95 7.40pm Constable Sheehan notices job on computer indicating his partner is at Warren's address."

"17.11.95 7.42pm Constable Sheehan contacts Sgt Sly who is on his way to Warren's address."

"17.11.95 *7.45pm BI receives call from WI re living will, saying he will not suicide but would be shot."

In his statement Mr I'Anson stated that it was at about 7.30 pm when he received a phone call from Warren. Warren said that he wanted his father to record his living will; that he wanted the remainder of his insurance policy to be bequeathed to his three step children. Mr I'Anson gave it as his belief that Warren

"was clearly suicidal and I urged him not to do anything of that kind. He (Warren) said that he would not suicide but that he would be shot. I'm not sure if he said by the police but that was the implication I got. He had earlier made a reference to people looking in to the flat and trying to get in. I urged him to have regard to the person who would be shooting and that it was an extremely violent act and that they would have to live with it, but he hung up."

Mr I'Anson gave it as his opinion that

"the only time I had any meaningful conversation was about the car, and then, you know, he did actually respond to my query and I got some sensible answer from him."

Mr I'Anson went on to give evidence that Warren appeared to be "very matter of fact", his speech was not slurred, nor was he unable to express himself clearly.

This evidence from Brian I'Anson can be contrasted, not only with his earlier evidence that Warren was 'angry' and 'clearly suicidal', but that of the Crisis Team members, Witness 'K' and Witness 'A' , who both gave evidence of Warren's behaviour being 'agitated and abusive', 'at times incoherent, bizarre and out of context to the situation at that time'.

"17.11.95 *7.50pm BI phones WI back, no answer, leaves message on machine to accept help from CT and police."

Mr I'Anson phoned back immediately (within 1 - 11/2 minutes) after the conversation with Warren and left the following message on the answering machine:

"Hi Warren, it's ah Dad. I'm just wanting you to know that ah you've helped other people who have been equally ill um, and ah helped them to ah survive and, and ah, grow again and I think ah you should allow other people to do the same for you when you're not well um, so please be helpful to anyone who's trying to help you at this time when you're going through such pain. Okay?"

"17.11.95 7.50pm Sgt Sly arrives at WI's address, talks to CT and goes to WI's door with Muir and Walls."

Both Witness 'K' and Witness 'A' spoke with Sergeant Sly. They reiterated what they had told the other police officers when they had first arrived. The four police officers - Sergeant Sly, and Constables Walls, Muir and Finck - then went back upstairs.

"17.11.95 *7.53pm Sgt Sly attempts to talk to WI."

Witness 'K' and Witness 'A' could hear the police talking to Warren through the closed door, asking him to let them in as they wanted to talk to him. Warren was again incoherent and angrily shouting at the police to 'go away'. Witness 'K' could see Warren pacing in his flat as he was near the window. He then moved away from the window.

"17.11.95 *7.55pm Constable Sheehan arrives at WI's address and goes upstairs to Sly." "*7.56pm Sheehan looks over balcony railing."

"*7.57pm Sly positions Walls near railing of balcony."

"*7.58pm Sheehan and Sly examine neighbour's door to determine best way to forcibly open."

"17.11.95 8pm front door kicked in by Sheehan with Sly and Muir pressing behind him."

"8.01pm WI lunged at Sheehan twice with knife, WI shot." Witness 'K', in his statement, then heard two gun shots. "17.11.95 8.05pm BI advised WI dead."

"17.11.95 8.17pm ambulance arrives."

"17.11.95 8.35pm Kinderman and Tietz, investigating police arrive."

Sgt Tietz gave evidence that on his arrival Constables Robert Muir and Julianne Finck were standing at the entrance to the stairwell in order to restrict unauthorised access. He saw a male and a female, Witness 'K' and Witness 'A' - members of the Mental Health Crisis Team - sitting on a concrete step at the entrance/exit to the building. Sergeant Brian Sly told the investigating police officers briefly the circumstances that had led to the death of Warren I'Anson. Sergeant Ronald McDonald and Constable Julian Slater of the Forensic Services Branch, Officers Chris Barry and Adam Starr - members of the ACT Ambulance Service - and the Duty Officer Acting Superintendent Jeffrey Brown were also in attendance.

Constable Slater took Detective Sergeant Tietz and Detective Constable Kindermann up stairs to the first floor flat. Standing at the doorway of the flat were Constables Chris Sheehan and Scott Walls. Constable Sheehan had a field dressing applied to the area of his left elbow.

In cross-examination by Mr Horler, Detective Constable Kindermann acknowledged that while he was at Warren I'Anson's flat, he did not see any other person - specifically Witness 'A' and Witness 'K' (members of the Mental Health Crisis Team) - inside the flat.

The security door was being held ajar by its locking device, and the front door to the premises was also half way ajar. Detective Sergeant Tietz saw a 10cm diameter hole towards the bottom right hand corner of the door, consistent with it having been kicked. Detective Constable Kindermann, in cross-examination, stated that he saw evidence of damage to the front door - while remaining on its hinges - it had obviously been kicked in.

By standing at the doorway and looking into the flat, Sergeant Tietz could see the upper body of a male person lying face down on top of a brown coloured mattress, with his head facing towards the doorway.

The upper part of the body was unclothed, and there was an amount of blood around the back and left shoulder area of the body. There was a red handled knife, about 30cm long, lying on the floor near the left hand of the body. Detective Sergeant Tietz recognised the deceased as Warren Geoffrey I'Anson, a person he had known since his schooling days and with whom he had come into contact throughout the following years. The latest contact had been in May 1995 when the Detective Sergeant had spoken briefly to the deceased following the death of the deceased's wife.

Arrangements were made or confirmed for various resources of the Australian Federal Police to attend - including the Chief Medical Officer, Dr Czoban, members of Forensic Services, Ballistics, Video Unit, Internal Investigations Division - and the notification to the Coroner, District and Regional Officers in Charge.

Detective Constable Kindermann commenced a door knock of the entire complex in order to locate any person who heard or saw anything which related to the incident. A number of people were identified and later that evening, statements were obtained from them. Those persons, together with a summary of their evidence, were:

William Barry lives in the same block of flats and above the deceased. Mr Barry stated that the deceased had been agitated recently and drinking heavily. Mr Barry assisted the police and the Mental Health Crisis Team in trying to talk to Warren and to get him to open the door. His statement is Exhibit 51. He had also suggested that Warren's father Brian I'Anson be contacted in an attempt to get Warren to open the door.

Kevin Harrow is a resident of nearby flats who witnessed the attendance of police and of the Mental Health Crisis Team and the subsequent events. Mr Harrow recounted his observations of the events and conversations between the deceased, police and the Mental Health Crisis Team, confirming that William Barry had suggested contacting Brian I'Anson. He also recounted the conversation between Warren I'Anson and police prior to their entering the flat. His statement is Exhibit 54.

Gloria Gilson was the resident of the flat above that of the deceased. She described Warren's character and noticed changes in his behaviour over the preceeding period. In particular, earlier that day, she had heard him swearing loudly, and that it sounded as though Warren was kicking the door of his flat. The deceased had also been drinking heavily recently. Her statement is Exhibit 53.

Glenn Chapman resided in the flat above that of Warren I'Anson. Mr Chapman's oral evidence was that on the evening of 17 November 1995 he heard, but did not see, the door of Warren I'Anson's flat 'kicked in', Warren I'Anson yell out "don't hurt me" - or similar - and then two gunshots. The gunshots sounded half-way through what Warren I'Anson was saying. Mr Chapman's oral evidence was contrary to that given in both his typewritten and adopted statements containing his signature. Mr Buddin questioned Mr Chapman in relation to an interview he gave to the Canberra Times reporter Andrew Kazar. Mr Chapman admitted that he had given this taped interview prior to being interviewed by police and that it was at his suggestion that he receive monetary benefit by doing so. Chapman's evidence is contrary to that of all other witnesses. His statement is Exhibit 14A; the Tape recording of the Interview between the Canberra Times Reporter - Mr Kazar - and Glenn Chapman is Exhibit 14B, and the Transcript of that interview Exhibit 14C. I will make further comment upon Mr Chapman's evidence in the summary of my Findings.

Andrew Kazar- a cadet journalist employed by the Canberra Times - gave evidence that when he interviewed Glenn Chapmann, he asked Chapman whether he had been interviewed by investigating police. Chapman did not directly answer - but evaded answering the question, leaving Kazar with the impression that he had already supplied police with a statement. Chapman had not gone into specific terms as to what he did tell the police, but said that he told them what he thought, and that he had answered the questions that they had asked. Kazar neither enquired of the police as to whether Chapman had spoken them or what he had said to them; nor consider that he was impeding the investigation in any way by not volunteering the production of the tape until requested by Sergeant Tietz. Nor did Kazar not see any impediment to his employer paying prospective witnesses - particularly as in this case Chapman had requested the payment and it had not been an offer. Kazar also considered that any information he gained from investigating police may have information omitted and that

Chapman may have been able to give more information than police might do - or vary in some way - so early in the investigation. Mr Kazar's statement is Exhibit 67, and the audiotape of the interview and the transcript thereof Exhibits 14B and 14C. Mr Kazar was vigorously cross-examined by counsel during which agreed that he had not questioned Chapman's credibility, his sobriety or whether he may have been under the influence of drugs at the time. The Editor of the Canberra Times - Jack Waterford - prepared an unsworn statement in relation to the issues considered by him in regard to the interview with Mr Chapman. The unsworn statement of Mr Waterford is Exhibit 130A and the correspondence is Exhibit 130B.

Melanie Cheshire was a resident of the flats - and the de facto partner of Chapman - who heard the gunshots and provided background information in relation to the deceased whilst he was a resident. Her statement is Exhibit 52.

Chris Barry was an ambulance officer who attended and made the first examination of the deceased, and also treated Constable Sheehan for his injury. His statement is Exhibit 11.

Adam Starr was an ambulance officer who attended the scene and made the first examination of the deceased, and treated Constable Sheehan. His statement is Exhibit 12.

Dr Klaus Czoban was the Doctor attending, and who declared the life of Warren I'Anson extinct. His statement is Exhibit 9.

Eileen McEntee was a Receptionist at Gungahlin Cemetery. She saw the deceased on the day of his death and described his demeanour at that time. Detective Constable Kindermann accompanied Ms McEntee to the grave site of Warren I'Anson's friend. She indicated a roll of 35mm Kodak film which was situated under a flower stand at the head of the grave.

Constable Kindermann took possession of the film and later handed it to Constable Slater of Forensic Services Branch. Ms McEntee's statement is Exhibit 10.

Dr Les Drew was the Psychiatrist treating the deceased Warren I'Anson prior to his death. Warren I'Anson had been a patient since "the early 90's" and that he did not believe that Warren "would ever have a recurrence" of the schizophrenia in November 1995, but that he was continuing medication. Dr Drew, however, gave it as his opinion that while Warren "was not very depressed in a psychiatric perspective, he certainly was depressed enough to warrant being in hospital for support and to help him overcome his grief at the loss of his wife." He did not believe that Warren was suicidal at the time of his death. Dr Drew confirmed that he had been in Canberra the night of the incident and would have attended if notified by the Regisrar or should Warren I'Anson have specifically wanted him to attend. It was otherwise not his practice to attend.

Witness 'J' assessed Warren I'Anson on 2 November 1995 on referral from Dr Drew. During the period 2 November 1995 and 17 November 1995 she had occasion to record 13 separate entries on his Progress Notes. As a result of her visit to Warren I'Anson on the afternoon of 17 November 1995 and the conversations held with him, it was Witness 'J's opinion that he was in a state of exteme tiredness and that he was depressed. At that time she was not of the opinion that Warren was at risk of harming himself or others. She noted that there had been no evidence of overuse of alcohol or other drugs; he was coherent and there was no evidence of psychotic symptoms such as delusion, hallucinations, thought disorder or other strange behaviour. Witness 'J' considered that Warren would need further daily monitoring and

support, and possible hospitalisation within the next few days. Witness 'J' anticipated contact with the Crisis Team, and/or assistance from his family and the Mental Health Foundation. She was also aware of Warren I'Anson's forthcoming appointment with his psychiatrist Dr Drew. A joint daily monitoring plan had been made earlier in the week with Patrick Fleming at the City Community Mental Health Team.

Mr Bayliss asked questions of the witness in relation to 'an intent to commit suicide' as follows:

"If a person has, I suppose, a plan for the future and discusses that with you, would that be consistent with an intention to suicide later, or inconsistent? ---Both.

"Well, could you explain that to the court? --- Yes. If a person has an intent - a premeditated intent to commit suicide, then it may be that they give the impression that they are making plans for the future. However, in most cases, if a person is not intending to commit suicide, then they do stop making plans.

"He may give incorrect, answers to questions to hide that premeditated intent? --- Yes. That's correct.

"On the other hand, if Warren did not have a premeditated intent, then one would not expect him to make plans for the future? --- Yes. It's usually taken as an indicator that the person is not intending to commit suicide, but may still be depressed."

and further:

"Having regard to your dealing with Warren I'Anson, do you consider that Warren could have been disguising his true intentions to commit suicide? --- There's always a small possibility, but no, I do not. Given the context and other signs, indicators, symptoms, that was not my belief.

So that, having regard to all that you know now, and when you left Warren's flat, do you consider firstly whether he was suicidal? --- I assessed him as not being suicidal at the time.

"Between 3.15 and approximately 7 o'clock that eveing - I want you to assume that at 7 o'clock that Warren's condition had changed to the state where the Mental Health Crisis Team considered that Warren should be taken to the hospital for assessment. In the space of that approximately three and three-quarter hours, can you tell this court what kind of things would cause the degeneration in Warren's condition? --- Things like overuse of alcohol, use of other drugs. Things like conflict, information that he may have been given, environmental factors. So primarily medication, drugs and environmental factors like conflict, or receiving information that was threatening or anxiety producing."

Patrick Fleming came into contact with Warren I'Anson in June 1995 and conducted grief counselling sessions with him from that time until his death. Attending routine clinical appointments, Warren came into contact with other mental health clients with whom he was supporting in his role as a support worker with the Mental Health Foundation. This appeared to cause Warren concern and a more informal routine and venue was arranged for counselling sessions. Warren appeared to respond positively to the regime and discussed other issues with Mr Fleming, for example the deaths of his wife and friend. To quote Mr Fleming:

"He (Warren) was going through aspects of a normal grief process ncluding elements of depression. His grief process was exacerbated by his experiences with psychotic illness and a sense of futility about the future. He clearly said to me things which suggested that he thought he had a bleak persective as to what his prospect of life were and the apparent futility that the future held for him. I addressed the topic of suicide to Warren and he made it plainly clear to me that he was not likely to kill himself. However, on a subsequent occasion he did talks about jumping from a high board at a swimming pool as practise, but this was done with Warren trying to convey a not so serious attitude, one more of a joke than the real thing. I did form the opinion that because of the way Warren had discussed certain things with me, he was of a suicidal risk to some degree. ... That opinion was formed on 15 November 1995, the last time I saw him, as a result of Warren raising the subject."

In answer to a question put to him by Mr Howe that the fact that Warren I'Anson had said to his father that he would not suicide but that he would be shot, Mr Fleming gave it as his opinion that taking all of the associated factors into account his view about Warrem's suicidal ideation was strengthened.

Gregory Dudley was a friend of Warren I'Anson. He contacted Police of his own accord, and provided a statement outlining a conversation he had with the deceased the day prior to his death. His statement is Exhibit 13.

Dr Sanjiv Jain performed an autopsy on the body of Warren I'Anson on 18 November 1995 at the Kingston Forensic Medicine Centre. His report is Exhibit 39.

In summary, Dr Jain found that there was a bullet entry wound present on the posterior aspect of the left shoulder. A crescentic skin burn was present on the superior aspect of the bullet entry wound. The bullet exit was through a laceration in the left axilla in the posterior axillary fossa. A second bullet entry wound was present on the left side of the back medial to the left scapula. A crescentic skin burn was present on the superior aspect of the bullet entry wound. The direction of the bullet entry in the skin was slightly oblique towards the midline. A gunpowder scatter burn - oval in shape - was present surrounding this bullet entry. The bullet entering the skin of left back entered the left paraspinal muscles, shattering the 8th rib posteriorly and causing laceration of the superficial portion of the left lung lower lobe posteriorly with fragments embedded into the laceration of the left lung. The aorta was lacerated into two at level of the diaphragm with the bullet track extending through left lobe of liver posteriorly at approximately middle level and exiting anteriorly through lower tip of left lobe of liver near the midline, entering the anterior abdominal wall to right of midline with the bullet lodged in subcutis.

Dr Jain gave it as his opinion that death was caused by transection of the aorta with exsanguination caused by bullet injury through the mid back region.

Despite a lengthy consideration of various hypothetical reconstructions of events the evidence of Dr Jain left me in a situation of difficulty in attempting to reconstruct the actions of parties from the wounds and pathology findings on Warren I'Anson's body.

Paul Reedy of the A.C.T. Government Analytical Laboratory conducted toxicological examination upon specimens of blood and tissue obtained by Dr Jain at post mortem. His initial statement in relation to his toxicology findings is Exhibit 29A, and the additional statement is Exhibit 29B.

In summary, his findings were that blood samples were found to contain the drug Diazepam in a concentration of 0.06mg/L and Nordiazepam at a concentration of 0.07mg/L, Benztropine at a concentration of 0.07mg/L and ethanol at a concentration of 94mg/100mL. No other drugs or poisons were detected.

Diazepam is a Benzodiazepine tranquilliser available on prescription. Nordiazepam is a major active metabolite of Diazepam. Benztropine is an anticholinergic drug available on prescription. Blood concentrations of Diazepam, Nordiazepam and Benztropine were all in the therapeutic or subtherapeutic range in the deceased. The blood level of ethanol was in the range of moderate intoxication.

Police officers who participated in the investigation processes and gave evidence were:

Sgt Ronald McDonald is attached to the Forensic Services Branch and examined the scene and took photographs.

Const Julian Slater is attached to the Forensic Services Branch and examined the scene and took photographs. His statement is Exhibit 4A; the Photographs: (Book 1) Exhibit 4B, (Book

2) Exhibit 4C; and the Photoboard Exhibit 4D.

Sergeant Graham Tulk photographed by means of video the scene of the shooting incident which was tendered as Exhibit 40B. He also photographed by means of video the post mortem of Warren I'Anson, which was tendered as Exhibit 40C. Sergeant Tulk photographed a re-enactment video of the scene, during which Detective Constable Kindermann 'played' the part of Warren I'Anson according to the directions indicated by Constables Sheehan and Walls. Sergeant Sly and Constables Sheehan, Walls, Muir and Finck also took their parts.

There were also two persons from the Internal Investigation Division present. His statement as to the performance of his duties was tendered as Exhibit 40.

There was objection from Mr Horler in relation to the tender of the re-enactment video and transcript on the basis that it was a re-enactment of what the police officers did - not giving the deceased the opportunity to give a contrary version of events - and therefore self-serving and sanitising their actions during the incident.

I believe that the video and subsequent transcript is relevant. There is an expansion, and an attempt to better explain, what the police officers say occurred. Whether it is self-serving, or sanitising, makes no difference because of its status as a video. It is simply an expansion of the evidence that they give, and the transcript is in the same category. I do not believe the question of unfairness comes into the equation. It is a proper expansion of the witness' endeavour to give evidence of the events, and it really amounts to the question of weight, after cross-examination, about the defects of the ability to re-enact. I am not bound by the rules of evidence in any event, but even if I were, I believe it is relevant, and I do not believe the unfairness outweighs that relevance.

The three videos became Exhibit 32A1-3, and the transcript Exhibit 32A.

Detective Superintendent Ian Prior examined the firearm used in the shooting, and undertook ballistic testing of the firearm, projectiles and other items. His statement in relation to that examination is Exhibit 33.

Those items examined were:

Exhibit 18A - Projectile located from the body Exhibit 18B - Projectile located in the mattress Exhibit 19 - One magazine and 15 live rounds Exhibit 20 - Additional shells

Exhibit 21 - Accoutrements belt

Exhibit 22 - Glock Pistol Model 17 S/No. BH448 Exhibit 23 - Single shell from chamber of firearm Exhibit 24 - Cartridge Case Corridor "B"

Exhibit 25 - Cartridge Case Coffee Table "A" Exhibit 34A - Photograph of bullet entry to shoulder Exhibit 34B - Photograph of bullet entry to abdomen Exhibit 34C - Transparencies

Exhibit 34D - Test chart

In summary, Superintendent Prior test fired the Glock pistol for: function; recovery of fired cartridge cases; recovery of spent projectiles; accuracy and proximity comparison with powder tattooing around the wounds of the deceased.

The pistol functioned without fault. He microscopically compared the fired cartridge cases recovered from the scene with those recovered from the test firing of the pistol. From individual markings on the cases Superintendent Prior formed the opinion that they had been fired from the subject Glock pistol. Similarly, from microscopic comparison of the spent projectiles recovered from the mattress at the scene and from the body of the deceased, Superintendent Prior formed the opinion that they had been fired from the subject Glock pistol. The pistol shot to the point of aim at the test distance of 7 metres. Superintendent Prior compared test firing patterns of the burning powder discharged from the pistol and with the burnt powder tattooing around the bullet wounds of the deceased. He formed the opinion that the shot fired into the deceased's left shoulder was fired when the muzzle of the pistol was approximately 20 centimetres from the point of impact of the bullet and that the muzzle of the pistol was approximately 25 centimetres from the point of impact of the bullet when it entered the left back region of the deceased.

Robert Barnes - a forensic consultant - conducted a forensic examination of the accoutrement (pistol) belt belonging to Constable Sheehan. In summary, his Report dated 10 May 1996 (Exhibit 70C) confirmed the following:

a) The pistol holster had sustained abrasion (graze) damage to the forward exterior patterned surface;

b) Artifacts of a shallow cut with a relatively blunt instrument are present superimposed upon the abrasion (graze) damage;

c) The shallow cut extends from the region of the forward edge of the pistol holster (where it is most pronounced) towards the rear;

d) The trailing edge of the cut (in the centre of the external patterned face of the holster) is jirregular and serrated; and

e) The width of the shallow cut was comparable to the width of the blade of the orange handled knife in the region of the cutting edge.

Constable Peter Ingram conducted interviews with William Barry, Melanie Cheshire and Glenn Chapman. His statement to that effect is Exhibit 2.

Constable Michael Turner conducted an interview with Gloria Gilson. His statement to that effect is Exhibit 3.

Constable Edwin Fuderer took measurements and prepared a scale plan of the scene. His statement is Exhibit 5A and the Scale Plan Exhibit 5B.

Sergeant D. Reece was requested to fingerprint the deceased. A set of palm prints was taken along with the impression of the left thumb. The prints were compared with a set of inked impressions in the name of the deceased and resulted in a positive identification. A knife handed to him by Constable Slater was examined. However latent marks developed on both sides of the blade near the hilt were not suitable for comparison. The knife was also swabbed for blood sampling should it become an issue. His statement is Exhibit 7.

Sergeant Robert Hanisch produced evidence as to continuity of a blood sample labelled "SHEEHAN Christopher Venous Blood" received from Const Sheehan and handed to biologist Julie Sutton. His statement to that effect is Exhibit 8.

Detective Constable Therese Barnicoat gave evidence that while on duty at Woden Crime Branch, the office received a telephone call from Detective Sergeant Tietz, shortly before

9.25 pm, during which he informed the Branch that there had been a shooting incident at the Red Hill location and that the assistance of that Branch was required. As a result of that telephone conversation with Sergeant Tietz, she went to the Woden Valley Hospital Emergency Department, arriving at approximately 9.40 pm, was shown to a treatment room within the Emergency Department, where she saw Constables Sheehan and Walls. She noticed that Constable Sheehan had an injury to his arm, and that Constable Walls was 'visibly upset' and 'stressed'. She had a conversation with Constables Sheehan and Walls. As a result of this conversation Constable Sheehan remained in the treatment room and Constable Walls moved to the Nurses' Meal room of the Emergency Department. She later conveyed both Constable Sheehan and Constable Walls initially to 32 Cygnet Crescent Red Hill and later to the City Police Station. Her statement is Exhibit 35.

Constable Sheehan, the officer who shot the deceased and Constable Walls, the officer who maintained observation of the deceased from the balcony, were both interviewed on tape in the presence of officers of the Internal Investigation Division. Constable Sheehan was interviewed by Detective Sergeant Tietz in the presence of Sergeant Wallensky of the Internal Investigations Division; Constable Walls was interviewed by Detective Constable Kindermann in the presence of Sergeant Jacques of Internal Investigations Division.

In her evidence, Constable Barnicoat said that the statements of Constables Sheehan and Walls outlined their fears that the deceased was likely to do himself serious harm without their intervention. Their statements also explained how entry was gained by Constable Sheehan who kicked the front door in and how he was then attacked by the deceased who had re-armed himself with a large fishing type knife. When Constable Sheehan had been unable to withdraw from the deceased, and after he was stabbed at twice - once to the stomach area which was deflected by his police belt, and once to the left inside upper arm causing a five centimetre laceration - he fired two shots from his service pistol which caused the deceased to drop to the floor.

The Evidence of Sergeant Sly and Constables Sheehan, Walls, Muir and Finck

Sergeant Sly - Transcript of evidence 7 May 1996, pages 2-31 Constable Finck - Transcript of evidence 6 May 1996, pages 2-26. Constable Muir - Transcript of evidence 6 May 1996, pages 27-60. Constable Walls - Transcript of evidence 7 May 1996, pages 32-61. Constable Sheehan - Transcript of evidence 8 May 1996, pages 20-71.

Constable Sheehan - the patrol partner of Constable Walls - was at the City Police Station completing paperwork. Constable Walls was returning to the police station when directed to attend the scene by Police Communications. He was first on the scene.

The Crisis Team informed Constable Walls that the person inside the flat was suffering from schizophrenia, that he had not been taking his medication, that he was consuming a large amount of alcohol, that his wife had died recently, that he had difficulty sleeping, and that they were extremely concerned for his welfare and wanted police assistance to take him to the psychiatric ward at Woden Valley Hospital.

Constables Muir and Finck were returning from a patrol duty and attended the scene at approximately 7.22 p.m. to assist Constable Walls as he was attending alone.

Following the initial attempt by police to talk to Warren and persuade him to come out in order that he might be taken to hospital, they returned downstairs - a period of 5 to 10 minutes - and consulted the Crisis Team. Constables Walls and Muir again went upstairs to the flat - accompanied by a member of the Crisis Team - in order to reason with Warren.

Constable Walls attempted to open the balcony door that police had been told was generally unlocked. On sighting police Warren approached the door holding an orange handled knife. Unsuccessful at attempting to speak with him, the party returned downstairs and again consulted.

Amongst themselves, the members of the AFP discussed alternative methods of entering the flat, and what might happen if they obtained entry.

That which followed might best be found in the evidence of Constable Muir, on being questioned by Counsel Assisting:

"Well, the conversation went along the lines of other alternative methods of getting into the flat and if we got into the flat what we were going to do. We talked about that and we talked about plastic shields. We just thought that the situation that was occurring, there had to be some action taken rather quickly. I'd spoken to the Mental Health at this stage and said to them, 'Mr I'Anson seems very agitated and upset, what if we just went away? What if we left now?' And their response was basically - or it was, 'We aren't leaving without him.' So, then we decided we had to take some sort of action as to how we were going to handle it when we got in, because the decision had been basically made for us, that we had to go in.

"When you say the decision was made for you, by whom was the decision made? --- The Mental Health people had already explained to us that an emergency order would be completed if necessary."

...

"I meant to mention something else. We did think about SOT as well but given the time - we just felt that - the Mental Heath people's advice was that the matter was getting - becoming urgent. We had to make a decision immediately. There was no time to be waiting around for SOT or for anything else and whatever we decided to do had to be made almost immediately. So that's why we - I called for the supervisor.

"Why did you do that? --- Well, in this situation, unless it's a definite person's being killed in front of you or what have you, it's general practice to contact your supervisor who gives the subordinate officer permission or on his advice to go in, make these decisions.

"So you're talking about a forcible entry? --- Yes.

"And did you in fact converse with Sergeant Sly? --- Yes, I did, on the police radio."

In his evidence Sergeant Sly stated that the conversation was fairly short; that Muir had said "that he was at present in an incident at Red Hill at Cygnet Crescent. They were dealing with a very disturbed mental patient who had locked himself in his flat. An emergency order was being completed. He (the patient) was offered medical attention; he had refused that attention. He would not come out and he had made threats to police and mental health people through the window, with a knife".

"And what was the effect of that conversation? --- I spoke to him and explained to him basically that we had Mental Health people at the flats and a mental patient who was wielding a knife and that we didn't feel comfortable going into the place and that they were of the opinion it was urgent and we would need to make a forcible entry. Sergeant Sly's response to that was that he'd be there as soon as he could.

"And the decision in relation to the making a forceful entry, was that something that had come from the Mental Health Crisis Team? --- Not directly. I think their emergency order

was our instructions to make a forceful entry, however, up to this point we were still hoping that we would not need to do that"

Sergeant Sly arrived at the scene at approximately 7.50 p.m. Sly was told by Constable Walls that he could hear a knife banging against a window; Witness 'K' -who was visibily shaken at being threatened - had known Warren I'Anson for some twelve years and that prior to this incident, had not seen him in this state; and that Witness 'A' feared that Warren was in 'acute mental torment', suicidal and that she feared for people in the vicinity. Sergeant Sly was also told that Mr Brian I'Anson had attended the flat approximately one hour earlier.

After being briefed by Constables Walls, Muir and Finck and the Crisis Team, Sergeant Sly returned to the flat, accompanied by Constable Sheehan - who had just arrived - and Constables Walls and Muir. Constable Walls went to the balcony. Sergeant Sly knocked on the front door of the flat after opening the unlocked security door.

Sergeant Sly - speaking in a calm voice - identified himself as being Sergeant Sly from City Police Station and that he wanted to speak to Warren, and asked him to come outside. Warren I'Anson - seemingly annoyed at their presence, but speaking normally - was initially evasive in his replies, but made what Constable Muir interpreted as a threat:

"Well, myself, I took it as a being a threat that if we came inside there was to be some harm come to us or attempt to harm us in some way."

Constable Walls, however, stated that he had greater fear for Warren's safety than his own. It was also Walls' opinion that Warren's condition was deteriorating.

Sergeant Sly again attempted to speak with Warren in order to get him to speak to the Crisis Team but again entry was denied.

"After a conversation with Sergeant Sly, who was conversing with Sergeant Sly at that time, at about 8 pm?A number of us were, the - Sergeant Sly had a conversation with the gentleman opposite the flat, he actually came out and spoke to Mr I'Anson through the door, he apparently knew him, there was a conversation with him. There was also a conversation

This conversation with William Barry and the attempt made by Mr Barry to speak with Warren I'Anson was confirmed by Sergeant Sly.

"But that bore no fruit?No.

In the sense that he wasn't coming out and he wasn't letting anybody in?That's correct.

I think I might have distracted you from answering the question that I had asked initially. You refer in your statement to a conversation with Sergeant Sly, who was present during the conversation with Sergeant Sly?Is this - of what

If I can perhaps direct you to your statement, page 3, second paragraph and it reads: "About 8 pm on" the relevant date, "after a conversation with Sergeant Sly, Constable Sheehan then attempted to do various things", what I am wanting to get from you is who was present during the conversation with Sergeant Sly?I believe myself, Constable Sheehan and Sergeant Sly.

Right?I don't know whether Constable Walls heard or not.

Right, what was the effect of the conversation?The effect of the conversation was that it was decided that Constable Sheehan would be the person to get initial access to the house, to the flat.

And what were the remaining police officers to do?Well, Constable Walls placed himself on the balcony with one leg on the balcony and one leg on the landing. Constable Finck was downstairs, outside the flat, she could see in the windows apparently with the Mental Health people.

Yes?Constable Sheehan was going in the door first followed by Sergeant Sly and myself.

So, the three of you were going in but Constable Sheehan was to be first in the door?That's correct.

Who made the decision that Constable Sheehan was to first in the door?It was one of those decisions that was agreed to. Sergeant Sly basically made the decision however Constable Sheehan, there was no sort of words spoken that he didn't want to go in, it was basically agreed that he would go in and that was understood and there was no problem with that."

Constable Walls - in his Record of Interview - said that "Sergeant Sly made the decision that we'll go into the flat. Chris Sheehan said 'its not a problem, I'll kick the door open fairly quickly and we'll run in and grab him cause otherwise he's going to do something and we can't sit out here and watch him cut his wrists or something in his flat', so Sergeant Sly decided that Constable Sheehan being SOT trained should be the first person in there to grab him".

Sergeant Sly explained that in his statement that the conclusion "to delay positive action any longer would detract from any element of surprise which remained" referred to 'time' being a problem. Warren had had a lot of time, "and the more time went on the more depressed he got, and the more chance he had to ingest drugs, the more chance he had to drink more alcohol, and he'd had two very serious recent traumas in his life. His father had been there and spoken to him and he couldn't do any good. I took that on board as a very serious concern, and he'd had time to prepare, and I thought to leave it any longer would give him more time and he would deteriorate even further. I thought that he was going to take his own life very, very shortly." Sly also considered the existence of the Emergency Order and in view of that, immediate treatment was required and therefore forcible entry was indicated.

"But Sergeant Sly was directing traffic, if I can use that expression?Yes. As the ranking officer?Yes.

And there specifically for the purpose of making those sorts of decisions?That's correct. And particularly the decision about forcible entry?Yes, that's correct.

In the circumstances if Warren wasn't going to come out or let police officers go in, then the decision to effect forcible entry, is that right?Yes, that's correct.

And that was all under Sergeant Sly's control?It was, yes.

You make reference to him using his right leg to try and to effect the kicking of the door in?That's correct.

That was unsuccessful?Yes, it was."

Constable Walls from his vantage point on the balcony could see Warren and the knife was still on the table. As Constable Sheehan commenced to kick the door on the second occasion, Warren grabbed the knife and went straight for the door. As the door was forced open, he was leaning against it, the knife in his hand, leaning against the mattress and attempting to keep the door closed. Constable Walls did not see the mattress until Warren pushed against the door. Constable Sheehan entered the flat - the door opening approximately 12 to 18 inches - and Walls saw Warren lunge at Sheehan and stab at him twice in the stomach region. As Warren made two stabbing motions there were two gunshots and he fell to the ground.

"He turned his back and then you just - what, his left foot?I'm not sure. Right. But he turned his back and used the back of one of his feet?Yes.

What was the time lapse between those two events?Almost immediate, it was one kick, the door didn't seem to move, he spun straight around and back up to the door and kicked it with the back of his foot and door just popped open.

He then entered the flat?Immediate - yes, almost immediately, it was a split second.

Are you able to say in relation to him going over the threshold, do you know that quaint old expression of going over the threshold?Yes, I do.

You do? Well, in relation to that, when was it that he drew his revolver, if you're able to say?I remember him his drawing his revolver, it was an instantaneous action it wasn't in his hand when he kicked the door from what I can remember. From what - what my recollection was that it was drawn as he spun around, from the door popping open to going through the door, it came out of his holster then.

You said that after you heard him say "put it down, police" how long elapsed before he'd said, "put it down, police", if you're able to say?A matter of two seconds maybe.

And at that stage you saw an arm with a knife in the hand, Trevor passed the front door in a southerly direction?That's correct.

Well, I'm afraid you're going to have to explain that because I'm not sufficiently familiar with the geography of the unit? The door opened which way?From right to left.

From your right to your left?Yes.

Okay. Now, relative to that, in what direction did the knife or the arm with the knife ?From behind the door to the right.

From your left to your right?Yes, that's correct.

Okay. And what angle to the ground was the knife?From what I can remember, it was parallel to the knife and about stomach height. Parallel to the

HIS WORSHIP: The ground you mean? ground, sorry.

MR BUDDIN: And about stomach level?Yes, that's correct.

And we can assume that Constable Sheehan is of normal height?Yes, pretty well.

Did it go completely across the front of him?From what I can remember, it was - it seemed to be waving around in the stomach region, I don't whether it actually crossed to the wall or that it stopped in around his stomach but I can remember the knife in the stomach region, crossing the front of his body.

And at what speed?Very quickly.

Now, you then saw a portion of a male person, I mean, there's no mystery about this, this is Warren we are talking about?Yes.

That his face was facing towards the front door, lunge forward, is that right?Yes.

What angle to the ground was his body at the time?The portion I could - I could only see the hair and the face and the top of his shoulders, the portion of the top of his shoulders just seemed to be going at the same parallel to the knife, going towards the wall. His body seemed to be going across at stomach height to Constable Sheehan.

So, relative to the height of the door knob, where would his - where would Warren's face have been?At the height of the door knob.

The position of the knife and actions of Warren I'Anson were confirmed by Constable Walls. Constable Sheehan said that as Warren lunged, he could see Warren's face - Warren was coming at him and trying to kill him. He fired his pistol.

"And then you heard the two shots in rapid succession?Yes, I did, yes.

And was there some time lapse between your observations of the knife and ?From the time the door opened

the shots?From the time the door opened I'd estimate probably three seconds from the time that the door popped open to the time that he went through the door until the time that the shot was fired - the shots were fired, two to three seconds maximum.

For the totality of the incident?Yes.

How far did the door open?I'm not very good at centimetres, millimetres, probably about a foot and a half, maybe two feet.

And was Constable Sheehan actually inside the flat when the shots ?Yes, he was.

Completely inside?Basically, yes, he got - he pushed the door, the door seemed to be jammed or whatever and we were just pushing the door, pushing the door all in one movement, there was myself

So, all three of you were pushing the door?Yes, Constable Sheehan went through the door, I was on the left hand side probably pushing the door myself and Sergeant Sly was on my right as we were going through, Constable Sheehan got halfway through or three quarters of the weight of his body through the door when the knife appeared and he sort of twisted away from the door and the knife across his stomach from there and then the two shots were fired."

Sergeant Sly when questioned by Mr Bradfield - representing the police officers - confirmed that as Constable Sheehan entered the flat, his police revolver was visibly in its holster. "I can only assume that he drew his firearm as he turned and entered".

"As you went through the door, how far were you from Constable Sheehan?Approximately a foot.

Where was Sergeant Sly in relation to you?On - at my right shoulder but slightly ahead of me.

So, how far was he in that position away from Constable Sheehan?The other side.

How big is the area that we're talking about, in totality from open door to whatever was on the other side? What was on the other side, a wall, I suppose?I don't know, I didn't go inside the flat.

But presumably there was a wall, when the door opened there was a wall on the right hand side?Yes, there was, yes.

And I think you indicated it was 18 inches open originally?Yes, 18 inches to two feet.

And when the force of the three of you was exerted against the door, how far did it open?Probably about a third of its full arc.

Okay, well, can you tell us how far that is, roughly?Probably two feet, two and a half feet, something like that.

From your experiences and your observation of the circumstances in which you found yourself that evening, is it your view that Constable Sheehan had any opportunity to retreat?No.

Did he have an opportunity to retreat in terms of time?No.

I'm talking about the arm with the knife coming towards him?Yes - no. What about in terms of space?No, definitely not.

Was there any other avenue available to Constable Sheehan in those circumstances for a retreat?None.

Or to move anywhere else?No.

And if he had endeavoured to, what in your view may have happened?I missed the first part of your question, sorry.

If he had endeavoured to move forward - I withdraw that. I take it he couldn't move sideways?No.

Either side?No.

He couldn't move back?No.

Why is that?Because we were there.

If he'd endeavoured to move forward what, in your view, might have happened?He would have been - well, I can't really say what would happen, I would say he would have been injured.

How?He would have been cut with the knife."

In both his statement and his evidence Sergeant Sly gave it as his opinion that Constable Sheehan "acted correctly and positively, and the only way possible in the circumstances, and that his action saved further injury or worse to himself and other persons in the immediate vicinity and once (Constable Sheehan) entered Warren was the agressor. He - Constable Sheehan - had no time to retreat and nowhere to retreat to". The incident - from the time of the forcible entry to Warren I'Anson being shot - was approximately 3 seconds.

"Now, during the time that you were there, can you say something about the atmosphere and more particularly can you say whether or not the atmosphere remained the same throughout or changed?Changed.

First of all, when did it change?It obviously changed when - after Constable Walls and I had gone upstairs and spoken to - or Constable Walls attempted to speak to Mr I'Anson through the door. Having seen the condition Mr I'Anson was in, we felt that this was going to be a different situation than a normal going getting a person out of a house, that there was some strong element of danger there and that the whole atmosphere changed from that point.

And how did it change?It made matters more urgent, we knew that we had to react straight away, we couldn't leave it until the next day or hours later on that evening or whatever, we felt that whatever had to be done had to be done almost immediately for the sake of Mr I'Anson. We felt if we didn't go in and get him or he wouldn't come out, he was going to do something to himself.

Was that a primary concern?Yes, it was.

And how would you describe the atmosphere as at about 8 o'clock when the forcible entry was effected and the decision was made to effect it?Well, we all knew what we had to do, I mean, most of us have been in that situation before, we just didn't expect it to - the outcome to happen, we didn't expect this to happen. So, the atmosphere, although urgent, we felt very

confident that we could do the job with the least amount of fuss and with little or no injuries. That didn't occur."

In answer to a question put by the Community Advocate in relation to their knowledge of a mattress being put up against the front door, both Sergeant Sly and Constable Muir stated that the only time they knew that there was a mattress there was when the door was pushed open and the mattress was on the floor.

Sergeant Sly was asked by me the following:

"HIS WORSHIP: I take it that prior to this incident occuring, Sergeant Sly, you had no information or no knowledge that the deceased ahd forecast he would be shot by police but would not suicide? You had no knowledge of anything ...? --- No knowledge whatsoever.

And the question of suicide by proxy or any phrase like that had never been mentioned by anyone at the scene, you had no knowledge, on your part? --- No.

Had you had that knowledge would that have made any difference to how you would have dealt with the situation? --- As I said, very difficult to say. I would have had to have weighed it up. Policing is a risky business. I eman, we had a duty of care. It was a matter of enter at the least possible risk time.

You would have still done the same thing anyway? --- I think so.

You do not believe you had any other options? --- No. There was an order which said he needed immediate treatment, urgent treatment, he was in acute mental torment, they feared that he would suicide, that that was imminent and I think, in the long run, that would have been what we would have done, any way."

Similarly it was Constable Walls' opinion that due to the state that Warren I'Anson was in at the time of the forced entry, the options of a negotiator or the SOT would have "been useless", bearing in mind the time delay factor and that the Crisis Team had wanted Warren I'Anson out of the flat as quickly as possible.

Constable Finck summoned an ambulance. EXHIBITS

Several items were found in Warren's flat:

• Exhibit 6 - A red-handled knife used by the deceased in his attack on Constable Sheehan.

• Exhibit 15 - A photocopy of a map of the Gungahlin cemetery, located in the pocket of the jeans of the deceased.

• Exhibit 16 - a handwritten note addressed to "Danny" - located on the coffee table in the flat.

• Brian I'Anson identified the handwriting on the note as being Warren's, but was unable to identify the addressee - "Danny" - other than to suggest that it may refer to Danny Kindermann (a police officer) who had spoken with Warren when Sue had died. Nor was Mr I'Anson able to identify the person "Rod - a writer" other than to suggest that it may refer to a person who was a patient at Watson Hostel.

• Exhibit 17 - Redicard with phone numbers and a message reading "Could I get buried with Sue" (written with a purple felt tipped pen), and pen - also located on the coffee table by Constable Kindermann.

Brian I'Anson identified the handwriting as being Warren's, but was unable to identify any familiarity with the phone numbers.

PROPOSITION OF WARREN I'ANSON'S INTENTION

In further oral evidence given by Brian I'Anson he was unable to recall any suggestion of having been contacted by the Crisis Team at approximately 10 minutes to 10, although he confirmed that he had been in the house at that time.

Police attended at Brian I'Anson's home at about midnight and spoke to him about Warren's death. Mr I'Anson outlined his son's history of schizophrenia which first became apparent in 1977. He further explained the effect the death of his son's wife had upon his son, and the fact that this was then closely followed by the suicide of a close friend. These deaths occurred during May 1995.

Mr I'Anson stated that in his opinion his son's condition gradually deteriorated from the time of these events to the present, and that they culminated to the events which have lead to the death of his son. He supported this belief by describing his son's recent unusual and out of character behaviour. This included a telephone conversation made by the deceased to him approximately half an hour before his son's death.

Mr I'Anson gave it as his belief that Warren deliberately provoked the situation which resulted in his death, and that it was Warren's intention to commit suicide by proxy. In clarification of his use of the term "suicide by proxy", Mr I'Anson said that given all the information that he had, he formed the view that Warren had deliberately sought to end his life by provoking a policeman to shoot him.

Regardless of what Mr I'Anson's feelings may have been about Warren's intention as to provocation he changed his view "considerably" when factual information and evidence came out in the inquiry. The question remains as to what Mr I'Anson's opinion, or view, was at the time of the shooting. At pages 61 and 62 of the transcript of evidence, the following appears:

"HIS WORSHIP: ... there are two aspects to it. There is first of all the question of what his opinion was about his son's intention, and the second part is, as to whether he provoked it and the actual incident itself. I am directing my concentration purely to what his view was about his intentions.

...

HIS WORSHIP: And that is what I meant to do. So, do you understand? --- Yes, well, at the time, when I thought I was talking to Warren, after he'd said he wouldn't be committing suicide, that he would be shot, I asked him to take account of the situation of the person who would do the shooting, that this was a very violent act and the person would have to live with that for the rest of their lives. So, clearly, in my mind, I anticipated that, if what he was predicting was going to happen, that it would involve someone else shooting him."

...

MR BUDDIN: Back to exhibit 17, particularly the words, "Could I get buried with Sue", you can remember the words, can you not? --- I think so, yes.

How does that fit in with your view as to Warren's intentions or state of mind before he died?

--- I think it anticipates his death and I think that that's why he rang me, because he anticipated dying.

And how? --- I can't say. All I can say is that what he said to me was that he wasn't going to commit suicide, that he would be shot. In what way he got that premonition, I don't know."

It is in the nature of human affairs that on occasions important information is not transmitted. We do not live in a perfect world and I would wish to attach no blame to anyone in the circumstances in respect of this issue - least of all Brian I'Anson, who was the subject at the relevant time of an incredible level of pressure and emotional stress.

THE ROLE OF THE POLICE

The role of the police became an issue raised both by the Community Advocate in her Issues Paper Analysing and Raising Systems Issues and during the hearing of the evidence.

During cross-examination by Mr Horler on behalf of Mr Brian I'Anson - the father of the deceased - Detective Sergeant Tietz stated that he was unaware as to whether members of the Australian Federal Police generally were trained or instructed as to the procedure to be used when confronted by a mentally disturbed person - certainly he, himself, had not received any such training or instruction. He was aware, however, that members of the Special Operation Team (SOT) - of which Constable Sheehan was a member - undergo training concerning mentally disturbed persons. He agreed with Mr Horler that the expandable baton - an accessory on Constable Sheehan's accoutrements belt, which had been introduced in the last two to three years would have been "most useful" in disarming someone who had a weapon in his hand, as had Warren I'Anson. He further agreed with Mr Horler that there was no suggestion in the record of interview conducted with Constable Sheehan, or from any police investigation, that Constable Sheehan used any item from his police accoutrements belt other than his service pistol in attempting to subdue Warren I'Anson. Sergeant Tietz, however, was unaware as to the existence of disabling sprays being available to members of the Australian Federal Police.

The extract entitled "Protective body armour" at page 28 of Exhibit 31 is as follows:

"The issue of the wearing of soft body armour by our members is one which has not been adequately addressed. Procedures and guidelines for training, storage and operational carriage of soft body armour vary markedly from region to region with the only consistency

being that the majority of bullet resistant vests, which are available to our members, are no longer guaranteed by the manufacturer since their shelf life has expired. Decisions need to be made with regard to the need for our members to wear bullet resistant vests. If such a need is identified then the vest chosen must be appropriate, the members must be adequately trained in their usage, limitations, etcetera.

"Certainly for members performing duties within the Australian Capital Territory it would seem that the wearing of vests may well be appropriate due to the highly unpredictable nature of the situations to which our members respond. Indeed, for all of our members it would appear nonsensical t carry a firearm to save our lives yet not wear a vest for the same self defence. The situation, at present, with regard to our uniform members within the ACT is that a total of 30 vests have been distributed amongst the four stations. These vests were originally purchased for the Haiti peace keeping contingent and are now carried in the boot of supervisor's vehicles and in the limited number of patrol vehicles where they are available. This approach is cosmetic by its nature and limited in its value because:

"(a) those vests are designed for use in an anti-terrorist or military environment where they may be required to defeat consistent hits by high calibre weaponry. For this reason they are bulky, black, extremely heavy and cumbersome to wear. It is not appropriate body armour for general duties members who will not often face that form of threat. A more realistic approach would be to select the lighter bullet resistant vest, although it should be heavy enough to defeat our own standard issue round.

"(b) there is a trade-off between ballistic protection and user wearability. Most instances wherein police officers are shot do not involve them being given prior warning of that likelihood. We need only look to the Walsh Street murders, job allocated as "Abandoned vehicle, possibly stolen" or to the more recent Kempsey murders (members attended at the home of a man who allegedly made a threatening telephone call to his former girlfriend). A vest in the boot of a patrol car or the boot of a supervisor's care will not save the officer standing on the front porch facing an armed offender.

"Modern day body armour is available in forms which are concealable, lightweight, comfortable and easy to wear. Such body armour can be worn unnoticeably under a shirt for the duration of a shift. In addition, whilst such body armour is obviously designed to protect the wearer from an assault by a firearm overseas experience has also shown the soft body armour has prevented serious injuries in assaults with clubs, edged weapons (although soft body armour can be penetrated by direct strikes with sharp long blades). It has even enhanced protection of officers involved in motor vehicle accidents. Soft body armour is not inexpensive and its need must be carefully evaluated. If however a need is identified then we must address the problem in a realistic and consistent manner."

Federal Agent McDevitt produced a supplementary statement in which he commented upon specific issues in relation to the death of Warren I'Anson raised by Ms Heather McGregor - the Community Advocate - in her Issues Paper Analysing and Raising Systems Issues dated 23 May 1996. Those issues and Federal Agent McDevitt's comments are as follows:

"Police use of plastic shields

"In paragraph 89 of Ms McGregor's Issues Paper she refers to the absence of any explanation being given as to why a plastic shield was not used. Plastic shields are

completely defensive tools and their use in the AFP is confined to crowd control situations involving the possibility of injury through flying projectiles. Whilst there may be a place for the greater use of plastic shields in related situations, I do not favour their use in a one-on- one encounter against a knife wielding assailant. In such a situation, a plastic shield would not afford sufficient protection and indeed could be more of a hindrance than a help (because the requirement to hold the shield could expose a Police Officer to increased risk of injury/death by limited use of the Officer's hands and/or by limiting freedom of body movement)."

"Use of Police baton

"In paragraph 89 of Ms McGregor's Issues Paper she queries the limitations on effective baton use posed by confined spaces on the basis that, in the situation confronting Constable Sheehan, 'the baton could have been extended outside the door before forcing entry'. In this regard I am of the opinion that a confined space makes effective baton use difficult even if the baton can be fully extended before entry into a confined space. This is because a confined space imposes limitations on the freedom and flexibility with which a fully extended baton can be wielded."

"Type of firearm used by Constable Sheehan

"In paragraph 84 of Ms McGregor's Issues Paper she notes that Constable Sheehan was using 'a powerful self loading pistol, discharging two shots in immediate succession, as distinct from the firearms carried by regular police'. The particular firearm used by Constable Sheehan was a Glock 9mm semi-automatic pistol. Most AFP members carry a Smith and Wesson model 10, .38 special. The ammunition used by each of these firearms is of a similar type, namely hollow point. The .38 ammunition is slightly lighter in weight, but it is, in effect, just as lethal. The projectiles fired by a Glock 9mm and a .38 are fired at similar speeds, and two shots can be fired almost as quickly from a .38 revolver as from the Glock.

The main points of distinction between the two types of weapon are: first the .38 revolver is limited to 6 shots before re-loading whereas the Glock 9mm can accommodate a magazine of 17 shots (to this extent, a Glock 9mm pistol has greater fire power); secondly the Glock pistol has faster reloading; and thirdly, it is relatively easier to pass a full magazine to a downed member using a Glock 9mm pistol than it is to assist re-loading of a .38 revolver used by a downed member. For these reasons, both the Australian Federal Police and the New South Wales Police are currently considering changing to the Glock pistol as the standard issue firearm. However, in the case of two shots fired at close range it is extraordinarily unlikely that a person, if killed by Glock fired projectiles, would not also have been killed by .38 revolver fired projectiles. The critical factor with respect to lethality is shot placement rather than the small difference in projectile size/speed."

"The possibility of Constable Sheehan stepping further into the room to his right to get out of reach.

"In paragraph 88 of Ms McGregor's Issues Paper she refers to the fact that Constable Sheehan could have gone further into the room, to his right, to get out of Mr I'Anson's reach. Ms McGregor also notes that Mr I'Anson 'was lunging parallel to the floor and therefore not very mobile, and there were two extra Police Officers to overpower him'. Given that Constable Sheehan was apparently attacked at close quarters, almost immediately upon entering the room, in my view it was not viable for him to step to the right as a realistic

alternative to the use of his firearm. I accept that it is important, wherever possible, for a Police Officer to try and use 'distance' to his/her advantage. However, in my view, it is not viable for a Police Officer to rely upon stepping aside when under attack, at close quarters, by an assailant wielding a knife in the hope of avoiding injury/death or in the expectation that other members will be able to intervene. In my view, the opportunity to create effective distance is lost, or never arises, in the case of an attack at close quarters. Whilst opinions might differ as to the minimum effective safe distance from a knife wielder within arms reach as an alternative to the use of a firearm. To demonstrate this, I have been involved in many training exercises with recruits involving a particular trainee wearing a white t-shirt and a holstered firearm and a role-playing assailant 'armed' with a red texta. The assailant is asked to stand some 20 feet away from the trainee. The trainee is instructed to try to draw his/her firearm to defend an attack. The firearm is, of course, loaded with blank rounds. In every exercise I have been involved in the mock assailant has been able, from an initial distance of 20 feet, to leave several red texta marks on the t-shirt worn by the trainee before that trainee has been able to draw his/her firearm and aim it accurately. In my opinion, it was proper police practice for Constable Sheehan to draw his firearm as he entered Mr I'Anson's premises and to use that firearm as a means of defending himself against a close quarters knife attack.

"Moreover, members are taught, when effecting forcible entry, to enter premises only so far as is necessary to clear the doorway and to take up a stable and defensive vantage point. Had Constable Sheehan rushed too far into the room he may not have been able to maximise his defensive position in sufficient time, and may also have exposed the members following him (who may have had less line of vision) to attack."

"The question of cross-fire.

"In paragraph 91 of Ms McGregor's Issues Paper she indicates that cross fire may not have been an issue as Mr I'Anson did not have a gun. In my view, the fact that Mr I'Anson did not have a gun is no answer to the possible problems posed by cross fire consequent upon a multiple entry strategy. Given that Mr I'Anson was armed with a lethal weapon which might have occasioned simultaneous use of firearms by Police members, acting defensively, there is a real risk of injury or death inherent in a multiple entry scenario."

THE USE OF QUALIFIED NEGOTIATORS

During cross-examination by Mr Horler, Detective Constable Barnicoat acknowledged that she was a qualified negotiator and had been a member of the police hostage negotiation team since 1986.

Mr Horler directed his questioning to Detective Constable Barnicoat's training as a police negotiator. During the period 1986 to 1995 she had participated in a number of courses, the duration of those courses ranging from a two-day course to a course lasting two weeks. Those courses related to basic training (2), police hostage courses - some held in the A.C.T. and some interstate - a suicide prevention course with the New South Wales Police Academy at Goulburn lasting two days, as well as a number of courses in relation to anti-terrorism. On enquiry by Mr Horler, Detective Barnicoat said that she was aware of 'schizophrenia', had been instructed as to how to recognise possible symptoms of the disorder, and dealing with the situation of possible threats of suicide, while recognising that each incident had to be considered on an individual basis. As to her experience in hostage negotiation, Detective

Constable Barnicoat gave evidence that she had never been 'called out' where there had been a threatened suicide, but had been 'called upon' to attend a criminal siege, where an offender was said to have barricaded him- or her- self into premises. During 1995 she believed that she had been called upon twice. She had had some part in the formulation of ACT Regional Instruction 19/91. ACT Regional Instruction 19/91 reads as follows:

"ACT REGION

REGIONAL INSTRUCTION 19/91

POLICE HOSTAGE NEGOTIATION TEAM CALL-OUT PROCEDURES

1. Members of the Australian Federal Police (AFP) who are trained as police hostage negotiators will respond to all criminal sieges, barricaded offenders, threatened suicides or other similar situations occurring within the Australian Capital Territory (ACT), where a police negotiator may be of assistance.

ON-CALL LIST

2. A current list of on-call members of the Police Hostage Negotiation Team is maintained by the Communications/Operations Branch, City District Police Station.

RESPONSIBILITY FOR CALL-OUT

3. During normal hours District OIC's are responsible for calling out the Hostage Negotiation Team, outside normal hours the Duty Superintendent has this responsibility. Irrespective of who initiates the call-out, the Commanders of the Crime and Operations Divisions are to be advised.

ASSEMBLY POINT

4. The officer authorising the call-out out is to arrange a suitable assembly point and assume responsibility for the initial briefing of the Hostage Negotiation Team, where-ever possible, not less than two members of the Hostage Negotiation Team are to attend the initial call out.

INITIAL CONTACT

5. It is recognised that some situations may require other members to make initial contact with an offender or hostage and begin preliminary negotiations. Should this occur that member will be required to fully brief the Hostage Negotiation Team on their arrival. Once the Hostage Negotiation Team is in position, the use of untrained personnel in the negotiation process is a matter for the Hostage Negotiation Team Leader.

COMMAND AND CONTROL

6. At the incident scene, the Hostage Negotiation Team Leader will place himself or herself under the command and control of the Officer in Charge of the Incident.

(BRIAN C. BATES)

Assistant Commissioner ACT Region

8 April 1991"

Constable Barnicoat was aware that in relation to that Regional Instruction, the discretion as to calling a negotiator is with the supervisor that is on the scene of the incident, following his assessment of the circumstances of that situation. She agreed with the proposition that "at times the circumstances and the pressing nature of the certain situation may lead to the fact that there is not time to call a negotiator".

As to the night of the incident of the death of Warren I'Anson, she was unable to give evidence as to how many qualified negotiators may have been on duty at the time. She was aware of the existence of the mental health crisis team, but had had limited, if no, dealings with them, and was not aware of their experience in suicide or threatened suicide situations.

Detective Constable Kindermann, when cross-examined by Mr Horler, was personally aware of, and was able to name a number of police officers who are members of, the negotiating team, but was unable to state why a member was not "called out". As a result of this incident

- the death of Warren I'Anson - Sergeant Sly had told him that he did not call out the negotiating team because "time was of the essence" and that he was utilising the services and the experience of the Mental Health Crisis Team.

The issue of the use of trained negotiators in crisis intervention situations involving persons suffering from mental illness is discussed in my recommendations below.

THE COMMUNICATIONS BRANCH

Constable John McDonald gave as his reason for not sending police direct to the location - as requested by Witness 'S' - was that in his experience, as an officer of the Police Communications Branch, police are not normally sent straight to these types of incidents and normally support the Mental Health Crisis Team and not the reverse. Police will respond directly when the person complained of has a current Emergency Order in place and/or the person is an immediate danger to themselves and others. Such an Emergency Order was not in effect at that time.

The performance of the AFP Communications Branch in this incident is discussed at length below.

THE ROLE OF MENTAL HEALTH SERVICES

Witness 'S' spoke with Witness 'A', a member of the Crisis Team. Witness 'A' decided that the situation sounded serious, but she advised (Witness) 'S' that the Crisis Team was currently admitting a patient and could not respond immediately. She suggested that (Witness) 'S' call the police.

In her evidence, Witness 'S' admitted that she had forgotten to mention to the Crisis Team that Warren talked about placing the mattress against the door and about police 'blasting through the door'.

As an adjunct to the 'Role of Mental Health Services' Witness 'J' was asked questions in regard to the relationship between treating psychiatrists, the Psychiatric Rehabilitation Service and Mental Health Services particularly relating to psychiatrists attending crises, as follows:

"There were some questions relating to psychiatrists attending and there was a reference them not attending in the circumstances that present themselves in this case and that was because - and I think the word that you used was "policy", of PRS. It might have been policy, it might have been practice - was it policy? --- I don't think it would be policy. I don't think I would have used the word policy in that, or if I did - its not a practice that psychiatrists attend crises.

"And why is that? --- I beleve that the role of the Crisis Team is to assess the person and assist them in going to a safe and contained environment in which a treating psychiatrist or a psychiatrist on duty can further assess and administer treatment as required.

"So if a psychiatrist was involved in the process, it would be at the hospital? --- That's right. "After the person had been brought in? --- That's correct.

"And, in your experience, have you ever heard of a situation in which a psychiatrist has been taken to the point at which the crisis has arisen for the p;urpose of talking a person down? --- No. I've heard of systems that have a registrar as part of a crisis team just in process, but not specifically to one crisis or a particular client."

In answer to a question put to him by the Community Advocate as to why treating psychiatrists either were not requested or did not attend crises with the Crisis Team, Patrick Fleming gave it as "his understanding that it would not take place because of a scarcity of resources and psychiatrists that simply wouldn't have been available."

ROLE OF THE MENTAL HEALTH FOUNDATION, IT'S SUPPORT WORKERS

Witness 'S's occupation was stated as a 'support worker'. As such she has been working with the Mental Health Foundation, Focus and Respite Care. Commencing some five years previously initially with Focus, she had been working in that capacity, followed by the Mental Health Foundation and then also with Respite Care. As result of her employment with the Foundation she came into contact with Warren I'Anson, who was a fellow support worker at the time.

Mr Horler questioned Witness 'S' as to her training to fit her for her work with the Mental Health Foundation. She replied:

"Specifically training in psychiatric disability work, none. I have worked with people who have disabilities for a number of years, but continuously for the last six years, and some few years back in the 1970s when I was a rehabilitation counsellor."

And when asked by Mr Horler to describe briefly the nature of the work she was doing for the Foundation, she replied:

"... helping people probably access services, initiating some sort of social network for people, perhaps assisting people where they're getting a raw deal through a service and sort of helping them put through a complaint ....."

Witness 'S' agreed that on the day prior to Warren's death, he was 'agreeable' to her contacting Mental Health Services, although she did not do so. She knew Warren's psychiatrist - Dr Drew - but on the day of Warren's death she did not contact the psychiatrist, nor was she aware of any efforts by any person to contact him. She was aware, in hindsight, that she ought to have done so.

Witness 'S' did not go with Warren I'Anson to any hospital in the Territory in the 48 hours before his death, nor was she aware of any other person having gone with him.

She was aware, however, that Warren had been previously admitted voluntarily to the Woden Valley Hospital, as he had not only told her, but she had attended with him on one occasion.

It was her belief that there is, or could be, a stigma attached to being admitted involuntarily rather that voluntarily:

"I think if a person admits themselves voluntarily, they're in control of the treatment that's going on and to then - for subsequently a decision to be made by someone else that they really need to be transferred and become involuntary, there could be a lot of stigma attached to that in terms of losing control of your own treatment."

However, Witness 'S' also agreed with the proposition that there was also a stigma in a 'voluntary admission' - a person is in the community, living independently and a voluntary admission represents some inability to cope.

She admitted that Warren had previously said to her on 16 November that he did not want to be admitted as an involuntary patient - she had had her recollection prompted by Pat Daniels, a member of the Mental Health Foundation.

She further admitted that she is unable to 'assess people on a formal basis' but noticed in the time that she was at the flat that the 'place was in a bit of disarray and that Warren had obviously been drinking'.

In her evidence, Witness 'S' admitted that she had forgotten to mention to the Crisis Team that Warren spoke about placing the mattress against the door and about police 'blasting through the door'. She noted that:

"Discussion re symptoms; possible admission. Rang crisis team, Witness 'K'. Suggested I take American Express Card. Warren agreed."

(Witness) 'S' agreed with the proposition that Warren required more than than what could be provided in visits by a support worker. She was, however,unaware that Warren had been visited by a psychiatrist for approximately an hour and a half on Friday. If she had been aware, her approach would have been different.

In her conversations with Brian I'Anson on Friday prior to Warren's death, Brian I'anson told her that he had had:

"two strange phone calls from Warren, but he didn't elaborate what they were and I didn't ask and then I relayed what my impressions of what happened on Thursday night with the crisis team and basically Brian's approach was that if there is a crisis then beds can be made available, and that something can be done if admission is warranted and I said that I would try and contact Warren and the crisis team again."

She acknowledged that it was at approximately 4.36 pm when she phoned the Crisis Team and spoke with Witness 'K'. She felt that the situation was not as serious as she had thought, but that she still had 'concerns' and that it was inappropriate to wait until there was a 'risk of immediate harm' for an admission to be made. She further admitted that had she thought that there was 'a risk of immediate harm' to Warren, she would have told the crisis team.

Issues arising from the position of support workers at the Mental Health Foundation are discussed below. Warren I'Anson expressed concerns to Witness 'J' and to Patrick Fleming - his case worker - as to the potential conflict of interest between his role as a support worker and a client of the Mental Health Foundation.

ROLE OF OTHER SUPPORT GROUPS

Witness 'S' admitted being aware of some persons suggested to her, but she was unaware of their position or their role in other organisations such as the Canberra Schizophrenic Fellowship and the Psychiatric Rehabilitation Services. Warren had not spoken to her in relation to whether he had been consulting or had been receiving support from any other organisations. She agreed with the proposition that it would be 'ideal' for a person providing support to a patient to be aware of the support being provided or available from other support groups.

SUBMISSIONS IN RELATION TO FINDING AN INDICTABLE OFFENCE HAS BEEN COMMITTED

Counsel Assisting - Mr Buddin SC - submitted as follows:

"During the evening of 17 November 1995, Warren I'Anson was shot and killed in his Red Hill flat. On 15 December 1995 your Worship, sitting as the Coroner, formally opened an inquest as a result of Mr I'Anson's tragic death. Since then the inquest has occupied 16 hearing days. It has received evidence from 40 witnesses and over 70 exhibits have been tendered. Apart from myself acting as Counsel Assisting your Worship, there have been five other interested parties who have been represented, including the family of Warren I'Anson and the Community Advocate who has appeared in person. There has been extensive canvassing by all parties of the relevant issues upon which your Worship is required to make a determination.

"Moreover, the proceedings have been conducted in a public forum. Various media interests have been present throughout and there has been widespread coverage of the proceedings.

With the exception of a suppression order in relation to the identities of the mental health workers, and another concerning certain confidential material affecting Mr I'Anson's privacy, all evidence before the inquest has entered the public domain. It is not an issue that Mr I'Anson died as a result of having been shot by Constable Chris Sheehan of the Australian Federal Police. The critical question which arises at this stage is whether your Worship is, pursuant to section 59 of the Coroners Act 1956, of the opinion, and I quote (in part):

"Having regard to all the evidence given at the inquest or inquiry, that the evidence is capable of satisfying a jury beyond reasonable doubt that a person has committed an indictable offence ......"

"In the ordinary course of events, an in-depth assessment of the evidence given at the inquest would now be undertaken. Realistically, the only person in relation to whom the provisions of section 59 could possibly apply is Constable Sheehan. Perhaps it should be mentioned that Constable Sheehan gave a fulsome account to investigators of his involvement in the shooting in questioning within a few hours of it having occurred. In that record of conversation he made it very clear that he had acted in self defence. He gave sworn evidence before your Worship in accordance with that version of events.

"Nothing emerged in cross-examination which cast any doubt upon his credibility. It is highly significant that none of the parties whose interests are represented here have made any submissions in respect of the possible criminal liability of constable Sheehan or of any other person, for that matter. The reason for the attitude adopted by my colleagues is readily apparent. The totality of the evidence, with the exception of certain very weak inferences which could possibly be drawn from the evidence of Glen Chapman, were it to be accepted, is completely consistent with Constable Sheehan's account. Your Worship would, in my submission, have little difficulty in rejecting the evidence of Mr Chapman as being entirely unacceptable for reasons that scarcely need to be canvassed.

"In my submission, in all the circumstances, and particularly since Constable Sheehan has waited nearly six months to hear your Worship's findings, it is unnecessary to delay those orders until a full review of the evidence has been completed. Having listened to all the evidence and seen all the witnesses, I would respectfully submit that there is no evidence before you that fits the description contemplated by section 59. It is my submission, upon the evidence which is before you, and consistently with the relevant legal principles established by the High Court in Zecevic v. DPP (Victoria), that it is quite apparent that Constable Sheehan acted in self defence when he shot and killed Warren I'Anson.

"At the very least it could not be said that the Crown would be able to eliminate any reasonable possibility that he was acting in self defence, and be able to do so beyond reasonable doubt. If your Worship was to accede to that submission and make a finding to that effect, or alternatively, to not make a finding within the meaning of section 59, then the finger of suspicion would be, as it should be, removed from Constable Sheehan. Although that would be an important legal finding, it would not, of course, erase the events of that evening from the minds of any of the participants. It is apparent from the evidence which has been given at this inquest that each of the participants in this tragedy are likely to carry scars of it for a very long time, and in some cases no doubt forever.

"All that having been said, it would be quite wrong for anyone to think that the task facing your Worship was now complete. No one needs any reminder in the present climate of the tragic consequences of the use of firearms. It is a rarity in this Territory, fortunately, for citizens to die at the hands of police officers acting in the course of their duties. You Worship is, of course, also empowered, pursuant to section 58 of the Coroners Act 1956 to, and I quote in part:

"Make recommendations to the Attorney-General on any matter connected with an inquest or inquiry, including matters relating to public health or safety, or the administration of justice."

"It is crucial that the circumstances which lead to Warren I'Anson's death be analysed in an endeavour to understand what it was that caused the systemic failure, and more importantly to use the lessons thus learned to implement such procedures as are necessary to prevent such a tragedy from being repeated. That much is owed to Warren I'Anson, his family and friends, and the community at large. May it please your Worship."

The submissions were adopted by Mr Bayliss on behalf of the ACT Health and Community Care Service and the Department of Health and Community Care.

Mr Bradfield on behalf of Sergeant Sly and Constables Sheehan, Walls, Muir and Finck, also submitted that there should not be a finding of culpability against any of the police officers and, in particular, Constable Sheehan. The submissions, in part, are as follows:

"At approximately 7:30pm Constable Walls was on mobile patrol on the Monaro Highway when he received a request on the police radio to attend at 39 Cygnet Crescent, Red Hill in order to assist the Mental Health Crisis Team to effect an Emergency Order. A caged vehicle was requested for conveyance to the Psychiatric Ward at Woden Valley. Constable Walls responded on the police radio and indicated that he would attend.

"Constable Walls was advised on his arrival by members of the Mental Health Crisis Team that:

1. A person by the name of Warren I'Anson rented the flat.

2. Warren I'Anson suffered from Schizophrenia.

3. He was not taking his medication.

4. Approximately 7 - 8 weeks prior his wife had past away after an accident.

5. He was consuming a large amount of alcohol.

6. He had refused to open the door upon the request of the Mental Health Crisis Team.

7. They wanted him transferred to the Psychiatric Ward at the Woden Valley Hospital.

"Shortly after this conversation Constables Muir and Finck arrived and during a further conversation with the Mental Health Crisis Team (being Witness 'K' and Witness 'A') it was confirmed that Warren I'Anson had possession of a large orange handled knife, had made threats through the balcony window to Witness 'K' and refused to come out of the flat.

"Subsequently, Constable Walls stepped onto the balcony and for approximately five minutes attempted to talk Warren I'Anson into putting the knife down in order for him to access the flat and speak to him. Constable Walls checked the door was locked and observed the windows were closed. Warren I'Anson refused to unlock the door and, in the view of Constable Walls, was psychologically unstable.

"After Warren I'Anson's refusal to co-operate, Constable Walls proceeded down stairs and had a conversation with Constables Muir and Finck. It was decided that their supervisor, Sergeant Sly, would be called by police radio from City Police Station to attend.

"Sergeant Sly was advised by Constable Muir prior to attending that Warren I'Anson had refused to come out of the flat, was aggressive to police and was holding a large knife. He was also advised that the Mental Health Crisis Team had concerns about his safety and condition and that they had requested him to be taken to the Woden Valley Hospital Psychiatric Centre, pursuant to an Emergency Order which was being prepared.

"Sergeant Sly was debriefed by Constable Walls, Constable Finck and Constable Muir on his arrival of the situation together with the following facts by Witness 'A' and Witness 'K' , the Mental Health Crisis Team members:

1. Warren I'Anson's father, Brian I'Anson, had attended somewhere between 6:00pm and 6:30pm and was told to leave by Warren and not allowed entry.

2. His wife had died recently in an accident.

3. A close male friend had recently committed suicide.

4. They were concerned about his alcohol consumption.

6. They had diagnosed acute mental torment and a suicidal condition.

7. They feared that he may endanger the health and safety of nearby residents.

8. Witness 'K' advised that he had known Warren I'Anson for a long period of time and could always reason with him before.

9. Witness 'A' conveyed particular concern that, as his condition appeared to be deteriorating rapidly, he could harm himself and other residents.

10. There were fears he would commit suicide or do himself a serious injury either by consuming drugs, with the knife that he had in his possession or by taking other poisons that were inside the house.

11. He needed urgent and immediate medical attention and an Emergency Order had been completed as he had refused treatment and needed to be taken to Woden Valley Hospital where it could be administered.

"After receiving this information, Sergeant Sly attempted to contact Warren I'Anson through the door for approximately five minutes. There was general conversation but no response apart from a muffled voice and music.

"Sergeant Sly then spoke to a neighbour "Bill" who confirmed the information provided by Witness 'A' and Witness 'K' and in particular the following:

1. That his condition had been deteriorating over a number of days.

2. He had been drinking while taking medication.

3. He was becoming more depressed.

4. He had made the comment that: "It had been going on for years and had to end."

5. His wife had died and he could not handle it.

"At the completion of the conversation with the neighbour "Bill", Constable Sheehan arrived. He was Constable Walls' partner and had also heard the police radio call to which Constable Walls had responded.

"The Mental Health Crisis Team confirmed their view that they were not leaving without Warren I'Anson as the situation required immediate action and that it was imperative that he be taken to the Woden Valley Hospital for psychiatric treatment pursuant to the Emergency Order.

"Sergeant Sly discounted further negotiation on the basis of the matters referred to and particularly:

1. His deteriorating condition and need for treatment.

2. His father's earlier attempt at contact had failed.]

3. Witness 'K' a Mental Health Officer and friend of some 12 years had failed to make contact and had been threatened with the knife.

4. Constable Walls' attempts at contact had failed and he had also been threatened with the knife.

5. Contact by Sergeant Sly himself had failed.

6. Contact by "Bill" the neighbour and friend had failed.

7. The contact subsequently made with Warren I'Ansons's father to attend had been declined.

"Pursuant to the Mental Health Act Sergeant Sly decided that the only method of transferring Warren I'Anson to the Woden Valley Hospital for psychiatric treatment as required by the Emergency Order was forcible entry. The avenues of entry were locked and proceeding through the glass windows on the balcony would have been inherently dangerous and taken away the element of surprise.

"Due to Constable Sheehan's Special Operations Team training, it was decided that he would obtain entry through the front door. Prior to gaining entry, Constable Sheehan checked the opposite unit's door for construction and ease of access. Constable Sheehan was positioned at

the door with Sergeant Sly and Constable Muir directly behind him. Constable Walls positioned himself so he could observe Warren I'Anson through the balcony window.

"When Constable Walls advised that Warren I'Anson was sitting down and had put the knife down, entry was obtained by Constable Sheehan kicking the door once solidly when facing it and then subsequently turning his back and kicking backwards. Constable Sheehan's momentum carried him through the door. As he entered he twisted his body and drew his police service revolver as was standard practice with an armed person in a confined space.

"When in the process of turning Constable Sheehan became wedged between the door and the wall. Warren I'Anson lunged at Constable Sheehan with the knife striking once in the arm and a second time on the police belt. Constable Sheehan warned:

"Police! Put it down!"

"Constable Sheehan then fired two shots as Warren I'Anson was about to strike him a third time.

"Warren I'Anson was positioned low to the ground in a lunging motion supporting his weight on one arm which led to the two shots which were fired striking him in the upper part of the back of his body.

"Sergeant Sly in making the decision to enter had used the information available from the Mental Health Crisis Team and approximately 30 years experience in dealing with hundreds of domestic violence matters and approximately 50 mental health matters.

"Based upon the information provided, it is submitted that the actions taken by Sergeant Sly and Constable Walls, Sheehan, Finck and Muir were in accordance with the training, practice and procedure of the Australian Federal Police.

"It is no criticism of Brian I'Anson in that he did not convey the conversation with his son advising that the police were in attendance and that he was providing his will over the telephone as he was going to commit suicide by proxy.

"Brian I'Anson had assumed that this meant that he was going to attempt to have the police take his life and commit suicide. Due to this information he was not surprised when he was advised by police of his son's death.

"Another important factor which was not known by Sergeant Sly (or the other police officers when forcing entry) was that a mattress had been placed against the inside of the door to the unit. This delay impeded the access of Constable Sheehan and allowed time for Warren I'Anson to grab the knife and stab Constable Sheehan as he gained entry. The mattress was not able to be viewed during assessment of the flat due to the lack of light in the unit and a portion of the wall obscuring it from view."

Mr Bradfield then addressed specific comments made by the Community Advocate in her Issues Paper Analysing and Raising Systems Issues which specifically address the issue of culpability.

"A) Paragraph 84 on page 28:

"The problem I have with this decision is that Constable Sheehan was too rushed, had not been thoroughly briefed and was not in any position to even think carefully about his own safety or about Warren's safety.

"Again Constable Sheehan was very ready to agree with this decision, given his SOT training, but the problem I have is that Constable Sheehan's willingness to force entry was dependent upon his ability to draw his firearm."

"From the evidence of Constable Sheehan, Sergeant Sly, Constable Muir and Constable Finck as well as the mental health workers in attendance, it is clear that there was as very carefully considered decision made by Sergeant Sly based on all the available information provided by both the Mental Health Crisis Team and neighbours. The decision that forced entry at the time was required took into account all possible alternatives for entry and considered the safety of Mr I'Anson as well as neighbours.

"Constable Sheehan was the appropriate member given his SOT training. The only problem was the unknown factor to any of the participants and also the mattress impeding entry through the door already referred to.

B) Paragraph 88 at page 29 of the Issues Paper states:

"Constable Sheehan gave evidence that he had no where to go as his back was against the wall and he had (Sergeant) Sly and (Constable) Muir pressing in on him from his left. The problem here is that what is obvious, in hindsight, is that Constable Sheehan could have gone further into the room to his right to get out of Warren's reach, Warren was lunging parallel to the floor and therefore not very mobile and there were two extra police officers there to overpower him".

"This statement is incorrect as the evidence is that Constable Sheehan could not have moved to his right as he was partly wedged between the dor and the back wall during entry and that Warren I'Anson was already on top of him. As Constable Sheehan could not have moved anywhere, the two extra police officers behind had no access to the room in order to overpower Warren I'Anson and assist.

"Evidence was provided that the force used subsequently by Constable Sheehan was proportionate and in accordance with training.

C) Paragraph 90, page 30 of the Issues Paper:

"The problem was that Constable Sheehan entered with a firearm in his hand and of course he was going to use it if attacked. This use, I would think, would be instinctive and spontaneous, happening before any decision occurred to make it happen."

"From the evidence of Constable Sheehan it is clear that use of the firearm was the last available option, and has already been accepted by the Coroner in finding no case against Constable Sheehan or any other police officer."

Mr Refshauge as counsel for the Community Advocate made no submission in relation to specific members of the Australian Federal Police being held liable for the death of Warren I'Anson.

Mr Howe appearing for the Commissioner made no submission in reation to the culpability of members of the Australian Federal Police.

FINDINGS IN RELATION TO THE DEATH OF WARREN I'ANSON

On the evidence the following findings, pursuant to section 56 of the Coroners Act 1956, can be made:

The deceased, Warren I'Anson, died just after 8 pm on Friday, 17 November 1995. He died at [redacted], Red Hill. The cause of his death - and I think I should be specific about this - there were two shots fired but the precise cause of death is transaction of the aorta with exsanguination - which means bleeding - caused by bullet injury through the mid-back region of his body. I also make the finding that two wounds were fired from a pistol by Constable Chris Sheehan at that time. Death occurred shortly after the bullet wounds.

Those are the formal findings that I make under the Act.

WHETHER AN INDICTABLE OFFENCE HAS BEEN COMMITTED

I now move to the consideration of section 59 of the Coroners Act 1956 which deals with the issue of whether or not the evidence is capable of satisfying a jury beyond reasonable doubt that a person has committed an indictable offence. The section reads as follows:

59. (1) If a Coroner is of opinion, having regard to all the evidence given at an inquest or inquiry, that the evidence is capable of satisfying a jury beyond reasonable doubt that a person has committed an indictable offence, the Coroner shall -

(a) ...

(b) ... (2) ... (3) ...

4) When the person who has been arrested is brought before a Coroner, the Coroner shall proceed in the same manner as the Magistrates Court proceeds under the Bail Act 1992 or Part VI of the Magistrates Court Act 1930 when it is satisfied that the evidence before it is capable of satisfying a jury beyond reasonable doubt that an accused person has committed an indictable offence.

5) The provisions of the Bail Act 1992 and Part VI of the Magistrates Court Act 1930 apply, mutatis mutandis, to and in relation to a person against whom a Coroner has found that the evidence before the Coroner is capable of satisfying a jury beyond reasonable doubt that the person has committed an indictable offence.

6) In this section, "jury" means a reasonable jury properly instructed.

In this case, of course, the indictable offence would be either murder of manslaughter. In respect of that task, it requires me to make an assessment of the evidence and look at the capability of satisfying a jury, not a formal finding of beyond reasonable doubt, but the

capability of the status of the evidence as it now is of being capable of satisfying a jury beyond reasonable doubt that those offences have been committed.

In this particular case, the only issue really that would be remaining for a jury is the question of whether or not self defence was applicable or otherwise. Referring to the case, the High Court decision, and there have been others, but the fundamental decision on this area of the law remains Zecevic v. DPP (Victoria), which has been mentioned by Mr Buddin. The law is now clear that once self defence is raised, it does not even become a defence. Once self defence is, in fact, raised the prosecution at any trial would have to rebut it beyond reasonable doubt.

In this particular case, self defence is clearly raised so the onus upon the Crown at any trial would be to convince a jury beyond reasonable doubt that it has not been rebutted. In this particular case, an account has been given by Constable Sheehan of what he saw acted and what he did. That account has been basically verified by other witnesses, particularly police witnesses, who gave limited versions of what they were able to see and experience at that particular time. The evidence of Dr Jain poses questions in relation to angles of entry and associated issues. The evidence of Mr Barnes, in my view, is very powerful in supporting the basic thrust of the evidence given by Constable Sheehan.

The Evidence of Glenn Chapman

The only piece of evidence, and this has been referred to by Mr Buddin, that might cause some doubt upon the sequence, timing and course of events indicated and sworn to by Constable Sheehan and other persons, is the evidence of Mr Chapman that indicates somewhat vaguely that words may have been said by the deceased just prior to his death. That may be inconsistent with the version given by others and also be quite inconsistent with the quick sequence of events that was described. Mr Chapman was, in fact, closely examined and cross-examined by Mr Buddin, but he certainly was put to the test because that was important and it was done on my instructions.

It needed to be done because Mr Chapman stood out as a witness, and the only witness, that caused any doubt about the version of events given. I believe having listened carefully to that evidence, listened to the evidence about Mr Chapman's motivation, Mr Chapman's vagueness, uncertainty and unreliability, I find Mr Chapman a witness totally undeserving of any belief whatsoever and I believe, not only would a jury have reasonable doubts about his evidence, they would discount it completely. So, in my view, the evidence of Mr Chapman should be discounted from this matter as being totally unreliable.

I believe that he leaves the court as a completely discredited witness. No doubt his motivation probably was assisted by the attitude taken by the Canberra Times reporter Andrew Kazar.

That particular reporter, and obviously his editor, still see no dangers in the fact that witnesses might be encouraged to embellish evidence if they are rewarded by money, particularly in an important factual and emotional situation as is this incident. I believe the dangers of that are well exemplified by what has occurred in this particular case. I propose to say nor more about it except that I hope people would learn the lesson from that in future cases.

In short, I am not of the opinion that the evidence here is capable of satisfying a jury beyond reasonable doubt that Constable Sheehan or any other person has committed any indictable

offence in this matter, in particular the offences of murder or manslaughter which would be applicable offences that are involved and, therefore, I take no action whatsoever for the reasons I indicated under section 59 of the Coroners Act 1956.

INQUEST INTO THE DEATH OF WARREN I'ANSON PART II

Introduction and Process

The inquest commenced on 15 December 1995, a month after the death on 17 November 1995. Sixteen days of evidence was heard from 40 witnesses. Seventy exhibits were tendered. On 10 May 1996, I recorded my formal findings as to the death and also ruled that no person had committed any indictable offence within the meaning of section 59 of the Coroners Act and thus no committal for trial was made in respect of any person.

Although it is unclear whether the death was a "death in custody" within section 24 of the

Coroners Act, the procedural safeguards surrounding the death were nonetheless observed.

It was resolved that the inquest would be in two parts. The second part of the inquest which involved an examination of systems, best practice and issues concerning deaths of persons suffering mental illness in circumstances such as these, was embarked upon on 11 June 1996. Prior to the commencement of that part, the Office of the Community Advocate represented by Mr Richard Refshauge, provided an extensive Issues Paper that served the excellent role of a catalyst for the development of further issues and the calling of evidence from persons able to provide assistance to the Coroner in the examination of systemic issues arising from this death. I express my gratitude to the Community Advocate and her representatives for this decisive and important role which enabled the focusing of the examination of relevant issues in the inquest.

The Issues Paper became exhibit 88A and was distributed to the parties on 23 May 1996. The Community Advocate made it clear that her intention was and always had been to examine the events, subject of the inquest, from a systems perspective and only to seek that the Coroner make any relevant recommendations about systems, procedures and processes of agencies that might be reviewed and improved. The Community Advocate made it clear that she did not intend and never intended to question any finding made by the Coroner, alleging any misconduct on the part of any individual police officer or to seek adverse finding against any individual from any of the agencies concerned. The process adopted by the Community Advocate was a constructive one.

In part two of the inquest, a further ten days of evidence was heard and a further sixty four exhibits were tendered and eight additional witnesses gave evidence. Many lengthy reports were considered resulting in lengthy submission by all parties concerned.

Context of the Inquest

The inquest has canvassed in Part II a very wide net involving examination of the Australian Federal Police (AFP) and Mental Health Services as agencies. A wide consideration has also taken place of the role of non government agencies in the community and their relationship with Mental Health Services and the AFP. The focus of the inquest remains the role of the

AFP and Mental Health Services (in particular the Crisis Team) dealing with persons with mental illness and the use of force in circumstances such as this. The inquest must never be seen as an inquiry into Mental Health Services or the AFP in general.

The tragedy occurred on 17 November 1995 and submissions at the inquest were completed in May 1997. In November 1995, the Mental Health Crisis Team and AFP policy concerning the use of force had commenced the process of review and change. The tragedy and the resultant inquest gave impetus to the relevant agencies to be accountable in assessing the tragedy and responding in the public forum of the inquest to institute change as appropriate in an endeavour to prevent a reoccurrence of this tragedy. As a result, significant changes had taken place and were continuing as the process of the inquest occurred. Since the conclusion of the inquest, further change has also taken place. The role of the inquest is not only related to the recommendations that I may make, but perhaps more importantly, being a strong encouragement to the agencies concerned toreview, make decisions as to what has to be done and to implement the appropriate change.

In conjunction with the officer assisting me in the inquest, Mr Terry Buddin, SC (ACT DPP), a deliberate decision was taken to ensure that the process of this inquest was a proactive one. Pressure was applied to various agencies to respond and come up with answers, proposals and suggestions. This may have meant that the process of the inquest has been labouriously lengthened. Nevertheless, the success of the changes so far achieved and promised in the future has made that approach a worthwhile task.

The Process

The object of the exercise was that parties would respond by evidence and submission to the catalyst provided by the Issues Paper presented by the Office of the Community Advocate. The paper follows:

INQUEST

INTO THE DEATH BY POLICE SHOOTING OF MR WARREN I'ANSON on 17.11.95

Issues paper analysing and raising systems issues

prepared by Heather McGregor

Community Advocate 23.5.96

1. Pursuant to my functions under the Community Advocate Act 1991 including the promotion and protection of the rights and best interests of people with mental illness, I sought and was granted leave to participate in this inquest so that I would be in a position to

2. try to ensure that we all learn from this tragedy. In response to the death by police shooting of Warren I'Anson, I consider that I have a statutory obligation to conduct a thorough examination of the relevant systems, legislation, policies and procedures and to provide an analysis of how it is that this tragedy occurred and how to minimise the possibility of such a tragedyoccurring in the future.

3. Following the Coroner's formal findings in relation to the time, date, place and cause of death, the Coroner Mr Ron Cahill directed that there should be a coronial investigation into the systems issues raised by the incident. Thus, the second stage process requires a much broader definition of cause to be applied to an analysis of the events leading up to and including the death. I submit this issues paper to this second stage process anticipating that it will provoke constructive and nondefensive debate among the people at the bar table. This debate I trust will be helpful to the Coroner in making his formal findings about systems issues or failings which may have contributed to the outcome.

4. As this is a matter of serious public concern and as the inquest has been an open and public process, copies of this issues paper will be available to any member of the public who is interested.

5. I start from the position that this death should not have occurred. I do not accept that it was unavoidable in the circumstances. I do not accept that there was no alternative. No aspect of the events is exempt from this scrutiny, which could possibly have the consequence of discomfort, pain or anger for some of the people involved. If we are to look to preventing such a tragedy in the future, the examination of this matter should be made critically, with an open mind and without defensiveness.

6. At this stage of the inquest, there is little evidence of any progress at all towards the learning of lessons which would give the public confidence that a repeat occurrence would not occur. Indeed, each one of the witnesses who was at the scene has given evidence that they would not have done anything differently, even with the benefit of hindsight.

7. Although there seems to have been a general view that the death should not have occurred, there has been little suggestion of ideas, resolutions, afterthoughts or decisions, going towards the necessary change to restore public confidence in police responses to people with mental illness. The police have a very significant role to play under the legislation which relates to people with mental illness and it is crucial that this role is carried out with diligence, competence and respect. Following the spate of police shootings during 1995 of people with mental illness in Victoria and other states and this incident in the ACT, it is important that a realistic, and balanced examination of police practice in relation to people with mental illness occurs immediately, if it has not already been done.

8. A lack of wisdom in hindsight is expected of course from the process of the inquest as the primary concern has been about individual culpability and the establishment of facts. There has been a great deal of concordant evidence about the sequence of events leading up to the shooting and in the main, there is nothing of great significance to examine in this regard. There are some minor exceptions of conflicting evidence which I shall deal with later. However in terms of the police and the crisis team members at the scene, in my view their evidence is entirely credible and consistent.

9. . There is an urgent need for reform of the systems currently in place. It is my purpose therefore, to examine the process and make comment or ask questions about what might have been done differently so that the outcome could be different. I am in a position to maximise the benefit of hindsight, hopefully to its best advantage. The one thing we all should be demanding from an event such as this is that change occurs. I must point out at this stage however, that it is unlikely that enough energy will be applied to this reform process, without some degree of accountability being imposed on the relevant agencies and their systems.

8. . I do this exercise with absolute compassion for the police and crisis team members involved at the scene, for Warren's friends and support people, all of whom are probably left wondering whether they could have done more, and for Warren's father who has had more than the usual parental agonies to endure. It is with respect for all of the difficulties faced by these people that I carry out this task. I hope what I say can be received and understood as constructive criticism which is aimed at improving the performance of the relevant systems and procedures. I reiterate that this analysis is aimed at the goal of preventing such a tragdy in the future. I guess it would be a comfort to all these people if they thought that something good might come out of Warren's death.

10. My background experience has involved working collaboratively with the police in attending crisis situations and of working professionally with disturbed people who were suicidal. I am also not unaware of the physical dangers and mental stress that such work entails, including being personally under threat and unsafe.

11. By way of methodology, I have traced the events leading up to the shooting and at each significant stage (see chronology attached) I have put systems and procedures under scrutiny. I have done this from the perspective of the best interests of people with mental illness. This paper poses questions, arising from my analysis, to the various agencies involved, as distinct from the individuals. My formal submission to the Coroner will follow the hearing about systems issues scheduled for 11 and 12 June 1996.

Role of Mental Health Service

12. It is clearly established that Warren I'Anson was a client of the Mental Health Service (MHS) and received a great deal of medical, practical and therapeutic support. From the time of the deaths of his wife and friend, Warren's psychiatrists and other MHS practitioners were making an effort to assist and support him.

13. On 14.11.95 Warren's psychologist with Community Mental Health (CMH), noticed a marked increase in agitation in Warren. This was preceded by a disturbing change in Warren's manner from 7.11.95. Warren mentioned to him that he had jumped off the high tower at the swimming pool as 'practice', this being connected to his friend's method of suicide. The psychologist did not have serious concerns about Warren being seriously suicidal at that time and did not explore the possibility of suicide with him.

14. On 15 November 1995, this psychologist heard from a psychologist working with Psychiatric Rehabilitation Service (PRS),that she believed Warren was becoming thought disordered. The two resolved to closely monitor him. The PRS psychologist on the same day expressed her concerns to the Crisis Team that Warren was not well. The CMH psychologist called Warren unsuccessfully on 16.11.95 however he had appointments to see him on two occasions in the following week.

15. The PRS psychologist had extensive involvement with Warren in the two weeks before his death on 17.11.95. She followed up her concerns by attempting to phone him on the morning of 17 November and with mounting concern, attended his flat at about 2pm that day and spent over an hour with him.

16. It is my opinion that this level of support, involvement, case planning, coordination and follow up is of a high standard and could have only been improved by the appointment of a casemanager, given the network of people involved with him, or with the injection of vastly increased resources to the Mental Health Service. There is a great deal of evidence of sound communication occurring among the different internal units of the MHS, involving quite a large number of people, which was clearly motivated out of professional concern for Warren. There is no doubt in my mind that Warren was receiving intensive therapeutic support from the MHS.

17. The PRS psychologist gave well substantiated professional evidence that in her assessment, he was not seriously suicidal; Warren talked about future plans with her, exhibited no premeditated intent and was accepting of a support plan. She found him to be depressed and distressed, which she attributed to his grieving process. She found him to be coherent with no evidence of psychotic symptoms such as delusions, hallucinations, thought disorder or other strange behaviour.

18. As the PRS psychologist was a person who had personal contact with Warren on the day he was shot, I consider her involvement in the process to be significant. She gave expert evidence that a deterioration in Warren's condition as apparently occurred on 17.11.95 between 3.15pm and 6.45pm when the Crisis Team arrived, could be explained by the use of alcohol and/or drugs, by conflict, by disturbing information or by other environmental factors. She was worried about Warren when she left him on 17.11.95 but was satisfied with the crisis support plan in place. It seems that she did not however, advise the Crisis Team of her visit or assessment.

19. This raises for me the question of whether, the MHS needs a policy which requires all its practitioners to update the Crisis Team of all contacts with a person immediately thereafter, when a person is known to be in a crisis or seriously suicidal.

1. Should the MHS have a policy of providing updated reports to the Crisis Team when a person is known to be in a crisis?

20. It is clear that from the time of the deaths of Warren's wife and friend, professionals taking responsibility for Warren's care were considering the risk of Warren suiciding. This would be expected, given the extreme circumstances of his loss and the statistical fact that people with mental illness suicide at a disproportionately high rate.

21. This factor is of relevance, not only because of the response to him of those at the scene, which I address later, but also because if he had been assessed as seriously suicidal by the MHS professionals, then presumably he would have been hospitalised, against his wishes if necessary.

22. The general MHS assessment made of Warren's condition by was that he was not at immediate risk of suicide, that he knew how to access support and that he was not in a seriously psychotic state. In my view, there is no evidence to suggest that this is an unreasonable or incredible conclusion. It seems reasonable also, because there was an appointment for Warren to see his psychiatrist on Monday 20.11.95.

23. Nevertheless, the question which arises in my mind here is, given the very problematic clinical distinction between a person being suicidal and a person actually committing suicide, should suicidal indicators in people with mental illness always be takensu seriously? That is, should a professional therapist always take a client through a thorough exploration of any vaguely expressed suicidal ideas, regardless of the clinical assessment of risk? My comment here is that nobody seems to have done this with Warren. It seems that nobody explored with him what method of suicide he might use, which may have provided useful data to the Crisis Team on 17.11.96. When Warren talked about his jumping from the tower and referred to this as practice, this was heard by a number of people with a great deal of worry, but it was not fully explored.

24. My point is that, if the focus is limited to whether a person will or will not go through with a suicide threat, the professional is rather stymied. If on the other hand the professional sees this as an expression of despair to be worked with and to be used as a tool to gain clinical insight, then the suicidal person is forced into a serious and rational consideration of suicide as a real possibility. The clinician is then in a better position to make a judgement about risk by assessing the person's intentions and reactions in discussions about, for example, the process and possibilities of overdosing, stabbing, jumping from a building or running in front of a truck. This judgement cannot be made by merely asking the person if they are serious about suicide or not.

25. This is a matter of theoretical debate and different schools of thought will disagree. I ask these question of the MHS.

1. How regularly do clinical staff review their skills in relation to suicidal ideation when accompanied by mental illness?

2. Is there a MHS policy which guides responses to suicidal ideas or are all practitioners governed by their own professional backgrounds and training?

3. Does the MHS accept that it is a best practice initiative to respond to all suicidal ideas expressed by people with mental illness, by taking the person through a thorough exploration of the process of

4. suicide, the steps leading up to the act, a detailed description of the method, the discovery of the death and the impact on others?

5. Are there clinical issues to be addressed when a person has a mental illness and is regarded as unwell and needing treatment for the illness, and at the same time expressing suicidal ideas? Is there

an issue about which matter needs to be focussed on as a priority? Can the combination of presenting concerns be confusing clinically? Is there a risk that this may possibly lead to a less decisive response?

6. When a person has multiple needs and is being supported by a number of people including a community agency, does the MHS consider appointing a case manager so that one person is in

a position to assimilate all information?

7. Do counsellors and therapists working with MHS have access to regular supervision?

Role of Mental Health Foundation

26. A matter which has not been explored during the inquest is the apparent conflict between the Mental Health Foundation(MHF) and the MHS. Clearly this was, of great concern to Warren and seems to have contributed significantly to his high level of disturbance and agitation in the hours before his death. The conflict was also apparent from Mr Brian I'Anson's evidence and so far as the inquest is concerned, the conflict remains something of a disturbing mystery. It is not uncommon for community agencies to be critical of the related bureaucracy and vice versa. I point out that this conflict is present and powerful and would want to make the point to both agencies that such conflict is counter productive and usually compromises service delivery.

1. What protocols exist between the MHS and the

2. MHF when both agencies are involved with the same person and do they need to be revisited?

27. A support worker with MHF, had quite extensive involvement with Warren including the period during the first two weeks of November. On 16 November when Warren failed to keep an appointment with her, she attended Warren's flat at about 6.10pm, gained entry via an unlocked verandah door and woke him up, according to an arrangement which he had made with her. While the subject of Warren's giving away his car was raised, along with Warren's overspending, Warren also talked about future plans he had. She was concerned however. She proposed hospitalisation and he agreed. She contacted the Crisis Team at 6.35pm, expressed her concerns and then a Crisis Team member spoke to Warren. Subsequently, she was advised that Warren was not in immediate danger and therefore hospital admission was not justified.

28. Although there is some discrepancy in the evidence here, I believe that the discrepancy arises from misunderstanding of terms and procedures. I believe that the MHF support worker heard that a bed was not available, whereas I believe that the Crisis Team member intended to communicate to her that hospitalisation was not justified because Warren's condition was not serious enough. (I note that the evidence here was inconsistent and may have given rise to quite different views.) In any event, it seems that the confusion about beds and admissions was transmitted to Mr BrianI'Anson.

29. The obvious issue which arises here is one of available resources and the connection with clinical judgement. The community needs to be assured that if somebody needs to be hospitalised as a matter of life and death, a bed will be available no matter what. The community also needs to understand that it is not desirable to have a system which admits people to a hospital bed just because a person is willing to be admitted to a hospital bed. There needs to be a medical or psychiatric assessment done before a voluntary admission would be arranged.

30. In an ideal world, clinical assessment and judgement should be uninfluenced by resource constraints. There are questions emerging from the confusion about criteria for admission which the MHS may wish to address.

1. Does any lack of resources, the pressure of work or any lack of clinical expertise have an influence on

the judgement that a person is not at immediate risk and does not need to be hospitalised?

2. If there are issues about beds, what arrangements exist with Calvary Hospital?

31. The MHF support worker followed up her visit with phone calls the next morning on 17.11.95, having also been contacted by Mr Brian I'Anson. Again this is a conscientious and high level of support which is being offered by a support worker.

32. To her credit, she recontacted the Crisis Team to express her concerns at 4.36pm.

33. These questions arise.

1. What alternatives to hospital services are available to people with mental illness who clearly need 24

hour or in house support but who are not serious enough for hospital admission?

2. Is the MHS operating from a rationale that it is better to keep people in the community and in their own homes and to provide the support in situ?

3. Would it be ideal to have a range of options available, including community respite care?

34. The MHF support worker gave evidence that she persisted with phoning Warren on

17.11.95 and eventually he answered. She gave evidence that this call was shortly after her 4.36pm call to the Crisis Team. (The evidence is conflicting about the timing of calls). During this conversation, her alarm increased, because Warren accounted his activities at the cemetery that day, visiting the graves of his wife and friend, and his empathic reference to his friend's suicide. He also told her that he had placed a mattress across the front door to stop police blazing their guns through the door. If this call was made shortly after her 4.36pm call to the Crisis Team, then it is hard to reconcile that she did not then call the Crisis Team to make a report about this conversation until 5.55pm (which is the record in the Crisis Team log). The MHF support worker gave evidence that she started work at 6pm that night and believed the call to be much earlier, however her call to the police is recorded as being about 6pm. (This makes the 5.55pm time more probable).

35. To a professional who is trained in crisis intervention work, the reference to the mattress stopping police from coming through the door with guns blazing is a significant matter for Warren to raise and crisis intervention theory would require that this statement be fully explored and tested and reported immediately to the appropriate people, particularly the police. Presumably the MHF support worker heard the statement as unusual and she may have attributed it to Warren possibly being delusional. In any event, her handling of it was consistent with that of a support worker.

36. The MHF support worker, having contacted the Crisis Team again at 5.55pm (the time recorded in the Crisis Team log),received acknowledgement that the situation was serious but was advised that they were busy on another job and that in the meantime she should call the police and the Crisis Team would attend when possible.

37. The MHF support worker had a conversation with an officer in police operations which I shall discuss later. In the main she was told that the police would not attend without the Crisis

38. Team. She advised the Crisis Team of this immediately, at 6pm. This is significant because had the police responded immediately at 6pm, the outcome may have been different because they could have arrived an hour earlier than they did.

39. The MHF support worker then also advised Mr Brian I'Anson by message on his answering machine, that Warren's situation was serious, that the Crisis Team would respond and that the police would be involved. One has the impression of a very concerned and conscientious support worker actively trying very hard to get somebody to take the situation seriously.

40. My comments here are that it was apparent from the evidence that the MHF support worker was not certain that police are in a position to take emergency action under the Mental Health(Treatment & Care) Act 1994 without the involvement of the CrisisTeam. While I acknowledge that support workers are just that, people who give support, given the MHF involvement in the lives of people with mental illness, it would seem wise for their workers to have sound information about the law, which would only add to their sense of competence.

In no way is this support worker

responsible for the police officer's response to her, but I must mention this interaction because had she been confident about what the police can do when somebody is suicidal, the outcome of the interaction may have been different. I deal with the police response later.

41. The other matter which I return to here is that the MHF support worker did not advise either the police officer or the Crisis Team about Warren's having told her that he had placed a mattress at the door to stop police coming in with guns blazing. To her credit, she telephoned the Crisis Team to ensure that they knew that Warren left his verandah door unlocked. If the advice had been given to the police and the Crisis Team, the outcome may have been different.

42. This MHF support worker was involved with a person with mental illness in a crisis situation and she was doing crisis intervention work somewhat by default. This is work of a very serious and demanding kind. While emphasising her considerable

efforts to get a response to Warren and her own acknowledgement that she was not the right person to be making an assessment of his condition, I must put her intervention under the same scrutiny.

43. This raises the following questions.

1. What training do MHF support workers receive?

2. What clear and plain english information is available to them about the law as it relates to people with mental illness?

3. Is crisis intervention addressed as a specialised form of support to be dealt with by the support

4. worker?

5. If not, what guidelines are in place for support workers who get caught up in a crisis to make appropriate and detailed referrals?

6. What support and debriefing is available to support workers?

44. The role of Mr Brian I'Anson in the inquest has been two fold. I presume he sought to be a party to the proceedings as the father of the deceased, certainly this has been the emphasis of his counsel, however it is difficult to separate his being Warren's father from his role as President of the MHF in the context of the inquest.

45. In most organisations providing counselling, therapeutic support or other responses to people with mental illness, it would be considered unwise and even unethical for a person to have professional or employment related involvement with a family member. As a member of the MHF; Mr Brian I'Anson was responsible for employing a support worker to provide support to clients including his own adult son. Warren was a client of the MHF and somebody who had also worked as a support worker for the MHF I propose that this arrangement is fraught and would be avoided in most agencies or organisations for this reason.

46. I would also argue that it is very difficult, if not impossible, to professionally and objectively weigh up clinical matters of the kind involved in both suicide and mental illness when there is a familial connection. The role of a parent or family member is quite different to that of a service provider and they require two quite

different sets of value judgements.

47. This raises the following questions.

1. Is there a philosophical or other basis which guides the MHF in their nonprofessional support work?

2. What standards does the MHF have to guide its role as a community agency providing non professional support to people with mental illness?

3. Does the MHF need to review its policies in this regard and to develop very careful guidelines about the very real value, appropriateness but also the

4. limitations of support work?

5. Does the MHF see a need for professional expertise in providing supervision, guidance and clinical judgement for its support workers?

48. Mr Brian I'Anson was very worried about Warren, cutting short his time at the coast and on his return he made considerable efforts to reach him but was turned away. He also contacted the Crisis Team to express his concern at 4.51pm on 17.11.95, as well as visiting Warren's flat at some time around 6pm prior to Warren's death at 8pm. The MHF support worker left a message on his answering machine at about the same time that the Crisis Team would respond and that this would probably involve the police. It is unclear whether this call was from a support worker to her

employer, advising him of a serious situation with a client, or whether the worker was calling Mr I'Anson as the father of Warren. Mr Brian I'Anson returned home after being at Warren's flat.

49. It is estimated by Mr Brian I'Anson that somewhere between 7.15pm and 7.30pm Warren rang asking him to record his living will. There are discrepancies in the evidence here and it is hard to be sure about the sequence and timing of events. (See chronology for estimates - Walls on balcony at about 7.25pm - CT and Walls on balcony 7.35pm) The Crisis Team rang Mr Brian I'Anson from Warren's address to ask him could he help at about 7.40pm. Mr Brian I'Anson did not think he could achieve anything, given Warren's refusal to let him in when he was there around 6pm.

Mr Brian I'Anson puts the sequence of the calls as follows - 4.51pm Brian I'Anson's call to Crisis Team

6pm Brian I'Anson's visit to flat (there about 10 minutes)

7.40pm Brian I'Anson receives a call from CT asking him to attend to assist

? Brian I'Anson receives call from Warren re living will and saying he would not suicide but would be shot

? Brian I'Anson phones Warren back, no answer, leaves message encouraging Warren to accept

help of CT and police.

50. It is therefore more probable that Warren rang Mr Brian I'Anson at about 7.45pm to record his living will. Mr Brian I'Anson gives evidence that during this conversation, Warren indicated that he would not suicide but that he would be shot. Mr Brian I'Anson wanted to ask Warren to consider the feelings of the person doing the shooting but believes Warren hung up and did not hear this. He rang Warren back to encourage him to accept help from the Crisis Team and the police, this message being left on the answering machine.

51. Mr I'Anson gave evidence that he believed Warren to be quite genuine in his claims, however he did not contact the police or the Crisis Team to advise them that Warren had said he would not suicide but he would be shot and that he had rung to make a living will. Had this information been conveyed it may have had an impact on the decisions made by both the Crisis Team and the police which may have resulted in a different outcome. As a parent, Mr Brian I'Anson has a right to privacy and to make his own decisions. However, the systems issue i§ that had the President of the MHF failed to warn police that another client had said these things, then the community would have reason to be critical.

Role of Crisis Team

52. The Crisis Team was advised of Warren's vulnerability on 15.11.95 at 5.10pm by the PRS psychologist who said that he may end up in hospital. Later that same day at 9.45pm Warren rang sounding elevated and delusional and very worried about the possibility that he might have a serious medical condition. He was encouraged to contact the Crisis Team whenever he needed to. So far, this is consistent with concerns about Warren's depression and mental illness, as distinct from his being suicidal.

53. On 16.11.95 at 6.35pm, the MHF worker phoned the CrisisTeam expressing her concerns and she gave evidence that he said he was prepared to be admitted to hospital voluntarily. The CrisisTeam member gave evidence that he spoke to Warren and concluded that he was not in a crisis. He gave evidence that he advised the MHF worker that it would be easier to facilitate a voluntary admission for Warren the next day, 17.11.95, (because more Registrars are employed during the day) that the Crisis Team would respond if needed and advised that Warren should go to the WVH emergency department. (Again, the accuracy of this interaction is unclear from the evidence).

54. This response is consistent with crisis intervention work in that if a person is able to present themself to the emergency department, then the Crisis Team does not need to be involved. The interaction between the Crisis Team member and the MHF support worker is of concern. Firstly it is clear that it resulted in confusion. The communication between the two was not crystal clear, which is essential in a crisis. Secondly, it highlights the need for the MHS to have realistic expectations of the MHF's role. The questions which arise from the evidence are

1. In a situation like this, would the MHS think it a good idea to be proactive in their service response and put in a review plan to phone or visit the

2. person in 30 minutes?

3. Is there a pressure of work issue which results in the Crisis Team members putting too much reliance on support workers' reports?

4. Should a one to one assessment be made at a stage like this?

5. One member gave evidence that he did not receive any specialist training when joining the CT. Does

the MHS consider that training in crisis intervention work is distinct from other psychiatric nurse training?

6. Are the after hours procedures for necessary admissions easy and streamlined to facilitate or are they cumbersome?

7. What service is available after hours to a person with a major mental illness who is obviously unstable but who is not in a serious enough crisis to be admitted?

8. Does the focus on the crisis, or the definition of the term crisis, actually interfere with a service

response to a person with a major mental illness?

55. The Crisis Team received another call from the MHF worker on 17.11.96 at 4.36pm expressing concerns about Warren's mental state, his drinking, spending and so on. The Crisis Team member gave assurance that they would respond either by phone or visit and also advised that Warren should present to the emergency department for assessment.

56. At 4.51pm on 17-11.95, Mr Brian I'Anson rang the Crisis Team expressing the belief that Warren needed admission, mentioned his overspending and the discussion he had had with Warren about his "practice" jump off the top diving board.

57. At 5.21pm the Crisis Team member telephoned Warren and left a message on his answering machine as he did not answer.

58. At 5.55pm the MHF worker phoned the Crisis Team again advising them that Warren had mentioned his friend's suicide as the way to go. She was advised that the team was assessing someone so she should call the police. It is clear at this stage that the Crisis Team was considering the risk of Warren's suiciding to be very serious. This raises questions of resources.

1. Is the work load on the Crisis Team realistically manageable or is it seriously underresourced?

2. Given the existence of protocols between the Crisis Team and the police, and given the apparent

recognition by the Crisis Team that the situation was now an emergency, should such a call to the police be made by the Crisis Team rather than by support agencies?

59. At 6pm the MHF worker advised the Crisis Team that the police would not attend without them.

60. At 6.05 and 6.10pm, the Crisis Team tried to contact Warren by phone.

61. At 6.30pm the MHF worker rang to advise the CrisisTeam that Warren leaves his balcony door unlocked.

62. At 6.45pm, two members of the Crisis Team arrived at Warren's address and they attempted to have him open the door so that they could speak to him face to face. He was hostile and unreceptive to their endeavours. It was their conclusion that they needed to get Warren to hospital to be assessed. They were already holding fears that he was a serious suicide risk and on top of this they found him to be inaccessible.

63. It is apparent that in situations like this, it is common for the Crisis Team to contact the police and it is common for the police to force entry if necessary which emphasises the importance of there being an established code of practice. This is discussed more fully under the police section of this report.

64. The Crisis Team were faced with a further complication however, in that after attempting to connect with Warren, they held fears that he may have ingested dangerous substances and that this was a possible explanation for the serious deterioration in his condition, as evidenced by his not recognising one member he knew well and his elevated hostility. I believe that at this point the Crisis Team's assessment was that Warren needed urgent medical attention, not

65. a psychiatric assessment. I believe also that the evidence supports their conclusion that there was little hope that a therapeutic response could be made in response to his reported

suicidal ideation. In other words, it seemed pointless to try further attempts at negotiation.

66. Thus their conclusion was that they needed to get him to hospital and there was nothing that could be achieved at the scene. It is critical to understand this conclusion I would argue, for it was very influential in what followed. It is critical to understand that Warren's mental illness was not the immediate concern, rather it was his medical condition, given the nature of his behaviour when the Crisis Team attempted to engage him at the door. Their assessment was that he may have already ingested a dangerous amount of alcohol, other drugs or household substances and may die as a result. This makes sense of their conclusion that they had to get him to hospital urgently. Concerns about his mental illness ordinarily would not have been so urgent. Concerns that he might inflict harm to himself with the knife would also not have been resolved sensibly by a conclusion that he had to get to hospital to be assessed urgently. If somebody is about to jump off a building, you do not consider an assessment at hospital. First you have to try and talk them down.

67. The question I have about the conclusion that Warren needed an assessment at hospital relates to my previous questions, at paragraph 25, about the combination of a major mental illness and a suicide threat.

1. Does the Crisis Team have guidelines about why and when people need to be taken to hospital as distinct from their doing an assessment in the

home?

2. Is the conclusion that somebody needs to be taken to hospital for an assessment about the need for a psychiatric assessment?

3. Does the Crisis Team have guidelines about criteria for asking the police to force entry?

68. At 6.58 pm the Crisis Team requested police assistance and the first officer arrived at 7.20pm with two others arriving soon after. The Crisis Team advised Constables Walls, Muir and Finck that time was of the essence, that Warren needed to be taken to hospital and they also briefed them on his background. Sgt Sly was similarly briefed when he arrived at 7.50pm although it is apparent that the Crisis Team did not speak to Constable Sheehan.

69. It is around this section of the evidence that confusion and mistaken beliefs about emergency detentions under the Mental Health (Treatment & Care) Act 1994 are rife. Section 38 makes it possible for a police officer or a mental health officer to use reasonable force to take a person to a treatment facility, if certain grounds are established. In evidence, there

70. were many references to an "order" having been signed- or sighted. It seems that police were influenced to force entry urgently by the presence of an "order" and some seemed to believe that the presence of the "order" gave them authority to force entry. There was even a sense that the "order" compelled the police to force entry and that the "order" meant that it was the Crisis Team's decision. Sgt Sly gave evidence that when he arrived an "emergency order" had been completed.

71. This so called "order" was not a warrant, nor was it an order issued by a court. It was a statement of emergency action, required by section 39 to be completed as soon as practicable after an emergency detention under section 37 has been made and the person has been taken to a health facility. The police do not need any authority (or order) from the Crisis Team and vice versa. No order needs to be completed before the emergency detention is made. The so called "order" was not in fact an order of any sort. Police or mental health officers are authorised to make this judgement themselves. This matter poses very serious questions to the Coroner about how procedures relate to the legislation and crucial questions about the serious consequences resulting from these mistaken beliefs.

1. From a MHS point of view, is there an urgent need to review procedures relating to emergency

detentions?

2. Does the MHS consider that it would be a better practice for the Crisis Team to complete their Section 39 form after they have taken a person to hospital?

3. From a police point of view, is there a clear enough distinction drawn between, say, a warrant to bring somebody before the court, and an emergency

detention under mental health law?

4. Is there a perception in the minds of the Crisis Team or the police that this "order" relates to forced entry being legitimated?

72. It is apparent that prior to the arrival of Sgt Sly, the five people at the scene talked together as a team and discussed what options were available. It is also apparent that they all had a realistic view of the danger of going into Warren's flat, given their direct experiences of his lunging at the glass door with a knife. The one option that may not have been considered however was for the MHF worker to be asked to attend. Clearly she had a good rapport with

73. him given he had invited her to enter his flat via the balcony door if he did not answer her knocks. Had this occurred, she may well have provided people with the vital information that Warren said he had placed a mattress at the door in case police came in with guns blazing.

1. Would the MHS consider it a good idea for the crisis team to have available summary information giving them the name of all people involved with a client, to act as a check list in a crisis?

2. If so, would a case manager provide this information?

74. After Sgt Sly arrived, he was the obvious decision maker, given his senior rank. It is apparent, however that while the Crisis Team had come to the conclusion that Warren needed to be taken to hospital, it was a decision made by Sgt Sly to force entry and my impression from the evidence was that he believed his duty of care

gave him no choice. Sgt Sly was influenced by the Crisis Team's advice that time was of the essence and that they were not leaving without Warren.

75. However forcing entry when a person is passed out on the floor is one thing, forcing entry when a person has been brandishing a knife is another. Yet in both situations the Crisis Team could conclude that the person needed to be taken to hospital. In other words, I am emphasising that a decision that somebody needs to be

taken to hospital is not the same as a decision to force entry. It is at this point that I am most convinced something different should have happened and that more time should have been taken to think and plan. This does not take away from the fact that in order to plan and think properly, all the relevant information needs to be

assimilated. I raise the following issues.

1. Is it problematic in terms of decision making that the Crisis Team members decide that somebody needs to be taken to hospital when it is the police

who decide to force entry to facilitate this?

2. Is it the position of the MHS that the Crisis Team should be consulted by police on whether they

should force entry and what effect this would have

on the inaccessible person?

3. Is it the MHS position that there is an important distinction to be drawn between the decision that somebody needs to be taken to hospital for assessment and a decision to force entry, especially when there are safety issues involved?

4. Would the police and the MHS agree that when somebody has been threatening with a knife that

the issue of safety ought to be paramount? Even more important that the possibility of a person suiciding?

76. It seems that no questions were asked of the Crisis Team about the likelihood of a person suiciding using a knife. Because Warren had a knife it was regarded as a serious possibility that he would use it on himself, even though observations through the glass door revealed Warren's use of the knife to threaten others. In any case, the position at this point had two worst possible outcomes. The first was that Warren might die from whatever he might have ingested. This possibility is balanced with the fact that there was only evidence of alcohol consumption. The second was that Warren might use the knife on himself in some way. This possibility is balanced by the fact that people rarely kill themselves by stabbing or cutting wrists, and in any event, Warren could have been observed through the glass door, with torches after it got dark if necessary. (This kind of judgement may have been helped, had his

ideas about suicide been more fully explored as suggested earlier at paragraph 24.)

77. There were all kinds of fears in people's minds but it seems that these were not fully expressed, discussed or tested for likelihood. For example, fear was expressed that Warren might hurt somebody else and this is quite a sensible conclusion given his attacks on the glass door. However this was not going to happen whilever he was inside the flat and everyone else was outside and if he came out, there were five police officers there.

1. Does the MHS consider that it would be a good idea to do reality testing of worst case scenarios at this point, using check list decision making procedures including the careful examination of all possibilities?

2. Counsel for Mr Brian I'Anson made much of the fact that Warren's psychiatrist was not contacted and asked to attend to try to communicate with Warren. I make a different point and it is that given the disturbing nature of events for the Crisis Team members, it would have been wise for them to seek supervision from a psychiatrist or another supervisor, not to attend but to have the process and decision reviewed and challenged by a skilled outsider. One member at least was visibly shaken by his experience on the balcony. It is clear that the situation was extremely tense and frightening and this would have been a good time to get an objective review of decision making. Psychiatric nurses know only too well how fear and panic can blur sound judgement.

3. Does the MHS facilitate the availability of after hours supervision for the Crisis Team?

78. My conclusion is that the decision to force entry was not a fully explored one and I reiterate that the decision that Warren needed to be taken to hospital is a quite different decision to one that entry needed to be forced. It is apparent from the evidence that the police did not go to the Crisis Team and advise them that, because Warren had a knife, Constable Sheehan would have to force entry with his firearm in his hand. Had the Crisis Team known this they would have been in a position to raise the possibility of Warren lunging with the knife as he had done twice, already and to challenge the efficacy of forcing entry under such risky circumstances. Whilever there is a firearm in a hand there isa likelihood that it will be used.

1. If police are required to force entry, should it be the police who make this decision based on their own

police criteria?

2. Should it be the police who act as authorised officers under the Mental Health Act when a conclusion has been reached to force entry?

3. Should there be more joint collaboration and consultation about matters such as whether forced entry is to take place, that is, is there a problem with the police assuming the decision making role?

4. Would it be wise, practical or more sensible for the Crisis Team and the police to both take

responsibility for a decision that entry be forced in a

matter involving a person with mental illness?

Role of Police

79. The police were phoned by the MHF support worker at about 6pm on 17.11.95 after the Crisis Team had suggested she do this because they were busy on another matter. She has an interaction with Operations Supervisor who has a number of misgivings about her request that police attend Warren's flat. With only very sketchy information, he advises the MHF support worker effectively that police cannot knock on people's doors and drag them off to hospital; police can be sued and lose their houses for wrongful arrest; a man's house is his castle and police should not intrude; police cannot take away people's liberty; these situations are a minefield for police. He advises the MHF worker that the police will attend ff the Crisis Team contact them. He also expresses frustration that the Crisis Team often does not turn up when police want them. If I understand his evidence correctly, in expressing all these misgivings he was attempting to push the MHF worker to try to judge just how serious the situation was.

80. There are a number of issues to raise here, not the least of which is the fact that had police made a thorough assessment of the situation at this time, they may have been at Warren's flat one hour earlier, which may have made a difference.

81. As well, the transcript of this interaction reveals an example of commonly held disrespectful attitudes to people with mental illness. I have not repeated the derogatory remark here for obvious reasons. Also, I would not want to single out this police officer and not many of us are unfortunate enough to have our conversations recorded and transcribed for public scrutiny, however it is an important matter for me to raise. Unfortunately, poor attitudes, disrespect, ignorance and patronage, were all present at times during the course of this inquest.

1. Is the training adequate which police receive about mental health law, dealing with people with mental illness and/or who are suicidal, and working with

the Crisis Team?

2. Are Operations police trained in information gathering, risk assessment, priority determination?

3. Do Operations police have guidelines about responding to a report that somebody is suicidal or is there a checklist of questions that they might ask to determine urgency?

4. Do Operations police have guidelines about doing

5. firearm checks when police attend people's houses? How is this information given to the patrol police?

6. To what extent is the Crisis Team unable to provide assistance to police when requested?

7. How real is the basis for the fear that an officer might lose his house for false arrest?

8. Is there any component of training that police receive which would make clear the distinction between arresting an alleged offender (and the risk of false arrest) and attending to assist with somebody who has mental illness who is not an alleged offender?

9. Is there any component of police training which ensures that police know their powers in relation to the emergency detention of a person with mental dysfunction who has not committed an offence?

10. Does police training address the issue of attitudes to people with mental illness?

82. The police were phoned by the Crisis Team at 6.58pm, one hour after the MHF support worker's call. At 7.05pm they were advised that all cars were busy, at 7.09pm that a car would be there soon and at 7.20pm Constable Walls arrived, closely followed by Constables Muir and Finck.

1. Do police consider that 20 minutes is a reasonable and prompt response or are police underresourced?

83. In a briefing from the Crisis Team, police were advised of a fear for Warren's safety, about his grief over the deaths of his wife and friend, about his alcohol consumption, his not having taken his medication, his possible abuse of drugs or other substances, that he had given away his motor vehicle and their failure to engage with him. After the five proceeded up to Warren's door and failed to communicate with him, Constable Finck stayed downstairs

84. with the Crisis Team and Constable Walls went upstairs and for 5-10 minutes attempted to communicate with Warren, with Constable Muir nearby. Constable Walls got onto the balcony and tried, commendably, to engage Warren through the glass door, which he found to be locked. By all assessments, this police officer used an entirely appropriate manner, was painstaking in his efforts and demonstrated respect for Warren and good judgement of the situation.

85. Constables Finck and Muir also demonstrated a great deal of compassion and insight and all three police were aware that their presence was in fact causing Warren to become more agitated. They discussed ways to defuse the situation and in this regard, held a conference out of Warren's line of vision. They accompanied a Crisis Team member who had known Warren for twelve years up onto the balcony to make a further attempt to communicate with him, when Warren again lunged at the glass with his knife.

86. Constables Muir and Walls decided that it was too dangerous to go in to Warren's flat. The situation had become extremely tense and all five people present were worried and disturbed by Warren's lunging at the glass with the knife. They discussed with the Crisis Team other possibilities, including doing nothing and leaving, the use of a negotiator, plastic shields, batons, asking somebody who knows Warren well, to assist. The Crisis Team advised that they were not leaving without Warren and stressed the urgency of the situation. It seems that at this point, there are two disparate goals. One goal is safety. The other goal is to get Warren to hospital. At this point, there are three police officers who have come to the conclusion that it is reasonably foreseeable that forced entry would be unsafe. They anticipated that Warren would be highly likely to lunge at them with his knife if they entered his flat. They are very certain of this.. On the other hand, there is a pressing need to get Warren to hospital.

87. It was this assessment of the situation that provoked Constable Muir to ring his supervisor Sgt Sly at 7.35pm. Sgt Sly said he would attend. The Crisis Team also rang Mr Brian I'Anson at about this time. Sgt Sly arrived at the address at 7.50pm, having been contacted en route by Constable Sheen who had noticed from the computer screen that his partner was at a job at Warren's address. Constable Sheehan was wanting a lift but Sgt Sly advised him to attend in his own car. On arrival at 7.50pm, Sgt Sly was briefed by the five people there, no doubt picking up from them their level of tension. While by necessity there can only be estimates of the timing of the following events, it is reasonable to state that to the point of the forced entry being executed, less than ten minutes was used for briefing, decision making, planning and execution.

88. Evidence given did not produce any clarity about there being a code of practice for forced entry and this lack of detail in the system appears to me to be problematic. I understand that police now have, for example, very strict guidelines about police car chases and about conducting police interviews. These very specific

procedures result from a number of unsatisfactory outcomes. I propose that in a similar way, forced entry is another aspect of police work needing close examination.

1. Should police develop strict guidelines to be followed when making a decision to force entry and

2. a code of practice regarding forced entry?

3. Should procedures relating to forced entry involving criminal activity be different from procedures relating to forced entry to provide assistance to somebody who is suicidal?

4. Should there be a step in these procedures that the people already at the scene be thoroughly

questioned because they have the best knowledge of the situation?

5. When it is reasonably foreseeable that an entry will be dangerous, is it reasonable to proceed?

6. When it is reasonably foreseeable that a firearm will have to be used, is it reasonable to proceed when the person is not a danger to anybody else given their confinement?

89. At about 7.53pm Sgt Sly proceeded upstairs with Constables Walls and Muir. He attempted to talk to Warren through the door. At about 7.55pm a neighbour offered to try to talk to him, without success. Constable Sheehan arrived at the door at about the same time it seems, so I am estimating that Constable Sheehan arrived at about 7.55pm, although from his evidence it is apparent that he thought he was there a lot longer. This estimation means that at the most, Constable Sheehan had five minutes to be briefed on the situation and to plan and execute the entry. Constable Sheehan's role was confined to effecting a forced entry and Sgt Sly decided that he would be the best person to do this because of his SOT training. . Apparently Constable Sheehan's SOT training gave him skills and knowledge in forced entry. The problem I have with this decision is that Constable Sheehan was too rushed, had not been thoroughly briefed and was not in any position to even think carefully about his own safety or about Warren's safety. Again Constable Sheehan was very ready to agree with this decision, given his SOT training, but the problem I have here is that Constable Sheehan's willingness to force entry was dependent upon his ability to draw his firearm. Further, because of his SOT training his firearm was a powerful self loading pistol, discharging two shots in immediate succession, as distinct from the firearms carried by regular police. My guess would be that had he not been armed, he would not have been prepared, to force entry.

1. Is it reasonable to expect an officer to carry out such

2. a dangerous task without having time to himself become fully cognizant of the context in which he is making this forced entry?

3. Does SOT training include training in making judgements about- safety and weighing up consequences before forcing entry?

90. Constable Sheehan held a discussion with Sgt Sly and went to the balcony railing and looked into the flat. A discussion was held with the neighbour about what would be the best way to do kick in the door and the neighbour's door was examined. Constable Walls was positioned at the balcony railing, as Sgt Sly was worried that Warren might come out via the balcony door. Constable Muir and Sgt Sly were to push in behind Constable Sheehan.

91. Constable Sheehan first kicked the door using a forward kick but this did not open the door. This was immediately followed by Constable Sheehan turning his back to the door and kicking the door again. This time the door opened. Constable Sheehan, removing his pistol from his belt with his right hand, turned to face the opening and forced his body through the doorway. Sgt Sly and Constable Muir were pressing close behind him. The timing of the first kick was influenced by the advice from Constable Walls that Warren had put down the knife.

92. However the first kick, being unsuccessful, obviously gave Warren time to pick up the knife and he was therefore ready to lunge when the second kick opened the door. A problem raised in evidence with using the glass door to gain entry was that Warren would have seen them coming. The problem with needing to use two kicks was that Warren heard them coming.. This raises again the need for strict guidelines about forced entry. Clearly if the first attempt is unsuccessful, the situation has immediately changed andthe new situation therefore needs to be reassessed.

93. The door was obstructed by a mattress and did not open cleanly. Warren lunged at Constable Sheehan with the knife, first striking him on his belt and then on his left inner elbow. Constable Sheehan fired two shots from his self loading pistol in self defence, believing that he was going to die. Constable Sheehan gave evidence that he had nowhere to go as his back was against the wall and he had Sly and Muir pressing in on him from his left. The problem here is that what is obvious, in hindsight, is that Constable Sheehan could have gone further into the room to his right to get out of Warren's reach, Warren was lunging parallel to the floor and therefore not very mobile, and there were two extra police officers right there to overpower him.

94. There was evidence provided by a police trainer about other methods of dealing with the fact that Warren had a knife and various police also gave evidence about these suggestions from the witness box. Police vests apparently do not provide protection from a knife but no explanation was given as to why a plastic shield was not used. It seems that batons are not regarded as sufficiently superior to a knife, as knife attacks can be as lethal as a firearm. Another negative aspect of the baton was that they cannot be extended in a confined space, however this did not make a lot of sense to me as surely the baton could have been extended

95. outside the door before forcing entry. Ironically, the evidence given against the use of police dogs or OC spray is that these methods can cause harm or serious injury, which makes it not a very compelling argument considering the lethal impact of the use of a firearm! In any case, it seems that it is accepted wisdom nationally that police should protect themselves against a knife attack with a firearm.

1. Does the AFP consider it necessary to review these guidelines in light of this shooting?

96. I would speculate that if the officer forcing the entry had not held a firearm, he would have had to resort to some quick thinking to physically overpower the attacker or to get out of the way of the knife attack, having already been wounded. The problem was that Constable Sheehan entered with the firearm in his hand and of course he was going to use it if attacked. This use, I would think, would be instinctive and spontaneous, happening before any decision occurred to make it happen. In any event, evidence was given that police are trained to shoot at the "centre of the seen mass" when in a life threatening situation and are not trained to shoot to wound.

97. If firearms were not available for use in these situations, probably a lot more possibilities would have emerged. For example, once the door was kicked in, the police officers could have stood back, waiting for Warren to come out and overpowering him with numbers., If he did not come out, the officer on the balcony was in a position to provide advice to those at the door about what he was doing. Everybody knew he did not have a gun. The glass door gave the advantage of vision. So the officer near the balcony could have made himself even' more obvious on the balcony to perhaps encourage Warren to come towards the glass door again, thus providing extra space and time for the forced entry via the wooden door to be executed more successfully. The recommendation against the use of multiple entries in a situation like this was that they need to be carefully planned and there is a danger of cross fire. I do not think cross fire was an issue as Warren did not have a gun. I would also argue that there was more time available for planning, given Warren could be observed from the balcony.

1. Have police considered the efficacy of the use of firearms on jobs where they are to provide

assistance to somebody who is suicidal and/or mentally ill?

2. Would the police agree that safety is the paramount issue and the drawing of a firearm immediately compromises safety?

3. Would the police agree that if a firearm has to be used to protect the safety of a police officer, no

4. forced entry would be a better decision?

5. Would the police agree that it would be better for officers not to be asked to take risks such as was involved in this forced entry, even when the consequence might be that somebody dies as a result of their own actions?

98. The outcome has been very unsatisfactory from a police point of view as not one of the officers at the scene that night is going to live without anguish about the outcome. Indeed it was evident when they gave evidence that the incident has had a profoundly detrimental effect on them with Constable Sheehan bearing the biggest burden.

99. One of the matters which this systems inquiry must consider is accountability. I would argue theoretically that change in any system is unlikely to occur without the prospect of some person or agency being held accountable.

100. It seems from the evidence given that the AFP does not have an adequate code of practice (or set of guidelines or protocols)for police in relation to how and when it is appropriate to force entry. Nor is it apparent that there is any adequate code of practice for dealing with people who are suicidal or with mental illness.

101. As mentioned previously, there were a number of cases in Victoria and other states in recent years where police have shot dead mentally ill people. It was therefore quite foreseeable that similar circumstances may eventually arise in the ACT. It is further arguable that a code of practice concerning police responses to people with mental illness, including forced entry, would have prevented the harm which occurred and it would have been practicable for the AFP to devise such a code. In short, it could be argued that the death which occurred was foreseeable, preventable and reasonably practicable to prevent.

1. Does it follow from this that the AFP, as an Organisation, has failed in its duty of care to Warren as a member of the public; and can be said to have been negligent in failing to develop a code of practice for responding to people with mental illness who need assistance; and for the handling of forced entry situations involving people with mental illness who are not offenders?

2. Where does accountability lie for the fact that police did not have sound knowledge of the law and their powers relating to emergency detentions and for

the resulting confusion about the "emergency order"?

102. Several of the police involved in the incident have suffered great psychological damage from which they may never recover. It is not my responsibility to raise issues about this matter and these police have been legally represented at the inquest. Nevertheless, I must point out that a code of practice of the type to which I have alluded above would have protected these police from the harm which they have suffered as a result of the incident. Under occupational health and safety legislation the AFP has a duty to provide a safe workplace for its employees, so far as is reasonably practicable. Developing and following suitable codes of practice is a standard way for employers to show that they have done what is reasonably practicable in this respect.

1. Is there a duty of care issue for the AFP in relation to its own employees?

After the shooting

96. I was aware during the inquest especially when neighbours were giving evidence that the shooting and death of Warren I'Anson had a disturbing effect on many people and as well, there were children in the block of flats and in buildings adjacent to the premises. I understand from information not given in evidence that the MHS initiated an emergency recovery plan in response to the disaster according to established protocols. I understand that that this occurred on 19.11.96 but stress that I have not fully investigated this matter.

96.1 Was the emergency response to this incident timely and should such an initiative come immediately

from the police?

SUMMARY CHRONOLOGY

* a best guess or discrepancy in evidence

14.11.95 WI keeps his appointment with CMH psychologist who notices increased agitation and has been concerned since 7.11.95. WI mentions jumping of high board at pool

15.11.95 5.10pm CT receives a call from PRS psychologist; Warren not well and may end up in hospital

15.11.95 9.45pm CT receives a call from WI who sounds elevated and delusional and is worried about

a serious medical condition - he is advised to contact CT "prn"

16.11.95 6.10pm MHF support worker visits WI

16.11.95 6.35pm CT receives a call from MHF worker, CT member speaks to WI - does not appear to be

in crisis - discussion about voluntary admission and attendance at emergency department

17.11.95 *am BI phones MHF worker saying he's had two strange calls from Warren - she will ring

Warren and CT again - she tries WI several times

17.11.95 2pm PRS psychologist visits WI - did not advise CT

17.11.95 4.36pm CT called by MHF worker, worried about WI expressing concerns about his needing

admission

17.11.95 4.51pm BI phones CT very worried

17.11.95 5.21pm CT leaves message on Wl's answering machine

17.11.95 *5.45pm MHF worker phones WI - WI talks about

visit to cemetery, being refused access to NAC, spending more money, knew how friend felt when suicided, mattress at door, guns blazing

17.11.95 5.55pm CT phoned by MHF worker very worried,

WI says friend's suicide the way to go advised to contact AFP as CT busy

17.11.95 *5.58pm MHF worker phones AFP, won't attend without CT

17.11.95 6pm MHF worker phones CT advises this

17.11.95 *6.02pm MHF worker phones BI to advise CT will attend when possible and will involve police

- message left on answering machine\

17.11.95 6-6.30pm BI visits WI but refuses to open door - there about 10 minutes

17.11.95 6.05pm CT phones WI, engaged

6.10pm CT phones WI, leaves message on machine

17.11.95 6.30pm CT phoned by MHF worker, WI leaves balcony door unlocked

17.11.95 6.45pm CT arrives at WI address, both members attempt to talk to him through the door, WI

angry and abusive, incoherent (about 15 minutes) - decide that WI needs to be taken to hospital to be assessed

17.11.95 6.58pm CT phones AFP requesting assistance

17.11.95 7.05pm AFP advises CT all cars busy

17.11.95 7.09pm AFP advises CT car there soon

17.11.95 7.20pm Constable Walls arrives and is briefed by CT

17.11.95 7.22pm Constables Muir and Finck arrive - Finck stays downstairs with CT - Walls and Muir

go upstairs

17.11.95 *7.25pm Walls tries to talk to WI from balcony, Muir watching, WI lunges at glass with knife

17.11.95 *7.28pm Three police and two CT discuss situation, query is there anybody who could get

through to WI

17.11.95 7.30pm CT member decides to try to talk to WI on. balcony with Walls and Muir watching, WI

lunged at glass with knife - three go back downstairs

17.11.95 7.35pm Walls and Muir agree that it is too dangerous to go in - Constable Muir rings Supervisor for assistance

17.11.95 7.40pm BI receives call from CT asking to assist, BI says he's been there and can't help

17.11.95 7.40pm Constable Sheehan notices job on computer indicating his partner is at Warren's address

17.11.95 7.42pm Constable Sheehan contacts Sgt Sly who is on his way to Warren's address

17.11.95 *7.45pm BI receives call from WI re living will, saying

he will not suicide but would be shot

17.11.95 *7.50pm BI phones WI back, no answer, leaves message on machine to accept help from CT

and police

17.11.95 7.50pm Sgt Sly arrives at WI's address, talks to CT and goes to WI's door with Muir and Walls

17.11.95 *7.53pm Sgt Sly attempts to talk to WI 7.54pm Sgt Sly and neighbour at Wl's door trying to talk to WI

17.11.95 *7.55pm Constable Sheehan arrives at Wl's address and goes upstairs to Sly

*7.56pm Sheehan looks over balcony railing.

*7.57pm Sly positions Walls near railing of balcony

*7.58pm Sheehan and Sly examine neighbour's door to determine best way to forcibly open

17.11.95 8pm front door kicked in by Sheehan with Sly and Muir pressing behind him

8.0lpm WI lunged at Sheehan twice with knife, WI shot

17.11.95 8.05pm BI advised WI dead

17.11.95 8.17pm ambulance arrives

17.11.95 8.35pm Kinderman and Tietz, investigating police arrive

STATEMENT

Counsel for certain police officers who have given evidence in this Inquest has taken objection to some passages in the Issues Paper dated 23 May 1996 and prepared by Ms Heather McGregor, the CommunityAdvocate.

The Paper is, and should be seen to be, a submission by a party who was granted leave to appear at the Inquest and is, as such, not evidence.

The Paper is directed to assisting the Coroner to identify issues on which he may care to report in accordance with Section 58 of the Coroners Act 1956. In this Inquest, this has been called "Part 2 of the Inquest"(Transcript 1 0 May 1996 p 20).The Paper was prepared following a specific request by Mr Bayliss appearing for the ACT Department of Health that "people get in contact... with a list of questions that they would have and which they would want some response to ... either in evidentiary or documentary form."(Transcript 10 May 1996 p 21). It was also clear at p 22 that Ms McGregor was requested by the Coroner to take on a slightly wider brief and also raise issues from the perspective of "the interests of the forensic mentally ill patients" in addition to her formal role.

The objection raised to certain passages in the Paper is that inferences are drawn in the paper about matters that might be said to be critical of those police officers or some of them when those criticisms were not, it is said, put to the police officers in a way that would comply with the technical rule of evidence in Browne v Dunn (1 894) 6 R 67.

Without conceding that the rule applies to these proceedings or has been breached, Ms McGregor states that:

1) her intention is and always was to examine the events the subject of the Inquest from a systems perspective and only to seek that

the Coroner make any relevant recommendations about systems, procedures and processes of agencies that might be reviewed and improved; and

2) that she does not intend and never intended to question any finding already made by the Coroner, allege any misconduct on

the part of any individual police officer or seek any adverse finding against any individual.

I enclose an outline of issues raised in that Issues Paper.

OUTLINE AND SUMMARY OF MATTERS TO BE DISCUSSED IN RESPECT OF SYSTEMS ISSUES RAISED BY THE DEATH OF MR. WARREN I'ANSON

Generally, the following areas need to be analysed in respect of the particular fact situation of the death of Warren I'Anson:

Role of the Police:

i) The AFP policy (the approach and rationale) for dealing with mentally ill persons in emergency situations including the impact of interstate and overseas policies on those in place in the ACT; and liaison with other police agencies;

ii) training of AFP officers in respect of mentally ill persons addressing what training which was available prior to the incident; any training which is envisaged; and training which is presently occurring;

iii) protocols governing the AFP's interaction with other agencies dealing with mentally ill persons.

Role of the Mental Health Services:

i) The policy from which mental health services are provided;

ii) the available resources;

iii) the training provided, in particular, in the cases of emergencies, life and death situations and sieges involving mentally ill persons in the community;

iv) the determination of procedures and protocols which govern interaction with other agencies;

v) to what extent would the Mental Health Services benefit from a psychiatrist;

vi) policies in respect of mentally ill persons detained, assessed and rejected when they wish to enter hospital.

I have also briefly outlined the 'systems issues' raised by Ms. Heather MacGregor (Community Advocate) in the Issues Paper dated 23rd May 1995 which I am of the view are a useful starting point. The following issues have been raised within a preventative

context.

Role of the Mental Health Service ('MHS')

1) Should the MHS have a policy of providing updated reports to the Crisis Team when a person is known to be in crisis?

2) In respect of suicidal ideation the following issues can be raised with the MHS:

a) How regularly do clinical staff review their skills in relation to suicidal ideation when accompanied by mental illness?

b) Is there a MHS policy which guides responses to suicidal ideas or are all practitioners governed by their own professional backgrounds and training?

c) Does the MHS accept that it is a best practice initiative to respond to all suicidal ideas expressed by people with mental illness, by taking the person through a thorough exploration of the process of suicide , the steps leading up to the act, a detailed description of the method, the discovery of the death and the impact on others?

d) Are there clinical issues to be addressed when a person has a mental illness and is regarded as unwell and needing treatment for the illness, and at the same time expressing suicidal ideas? Is there an issue about which matter needs to be focussed on as a priority? Can the combination of presenting concerns be confusing clinically? Is there a risk that this may possibly lead to a less decisive response?

e) When a person has multiple needs and is being supported by a number of people including a community agency, does the MHS consider appointing a case manager so that one person is in a position to assimilate all information?

f) Do counsellors and therapists working with MHS have access to regular supervision?

3) Alternatives to hospital services available:

a) What alternatives to hospital services are available to people with mental illness who clearly need 24 hour or in house support, but who are not serious enough for hospital admission?

b) Is the MHS operating from a rationale that it is better to keep people in the community and in their own homes and to provide the support in situ?

c) Would it be ideal to have a range of options available , including community respite care?

Role of the Mental Health Foundation ('MHF')

1) What protocols exist between the MHS and the MHF when both agencies are involved with the same person and do they need to be revised?

2) Resource implications:

a) Does any lack of resources, the pressure of work or any lack of clinical expertise have an influence on the judgement that a person is not at immediate risk and does not need to be hospitalised?

b) If there are issues about the availability of beds, what arrangements exist with Calvary Hospital?

3) Training and guidelines available:

a) What training do MHF support workers receive?

b) What clear and plain English information is available to them about the law as it relates to people with mental illness?

c) Is crisis intervention addressed as a specialised form of support to be dealt with by the support worker? If not, what guidelines are in place for support workers who are involved in a crisis to make appropriate and detailed referrals?

d) What support and debriefing is available to support workers?

4) Policies and philosophical basis of the MHF:

a) Is there a philosophical basis or other basis which guides the MHF in their non professional support work?

b) What standards does the MHF have to guide its role as a community agency providing non professional support to people with mental illness?

c) Does the MHF need to review its policies and develop careful guidelines about the value of, appropriateness and limitations of support work?

d) Does the MHF see a need for professional expertise in providing supervision, guidance and clinical judgement for its support workers?

Role of the Crisis Team:

1) Interaction between the Crisis Team member and the MHF support worker:

a) Should the MHS be proactive in their service response and put in a review plan to phone or visit the person in 30 minutes?

b) Is there a pressure of work issue which results in the Crisis

Team member s placing too much reliance on support worker's reports? Should a one to one assessment be made?

2) Training and Services:

a) Does the MHS consider that training in crisis intervention work is distinct from other psychiatric nurse training?

b) Are the after hours procedures for necessary admissions easy and streamlined to facilitate or are they cumbersome?

c) What service is available after hours to a person with a mental illness who is obviously unstable but who is not in a serious enough crisis to be admitted?

d) Does the focus on the crisis, or the definition of the term

crisis actually interfere with a service response to a person with a major mental illness?

3) Resources:

a) Is the workload on the Crisis Team realistically manageable or is it seriously under resourced?

b) Given the existence of protocols between the Crisis Team and the police, and given the apparent recognition by the Crisis Team that the situation was now an emergency, should a call to the police be made by the Crisis Team rather than by support agencies?

4) Guidelines:

a) Does the Crisis Team have guidelines about why and when people need to be taken to hospital as distinct from their doing an assessment in the home?

b) Is the conclusion that a person needs to be taken to hospital for an assessment in respect of a psychiatric assessment?

c) Does the Crisis Team have guidelines about a criteria for asking the police to force entry?

5) Emergency detention procedures under the Mental Health (Treatment and Care) Act 1994:

a) From a MHS point of view, is there a need to review procedures relating to emergency detentions?

b) Does the MHS consider that it would be better practice for the Crisis Team to complete the requisite form pursuant to S. 39 of the Act after they have taken a person to hospital?

c) From a police point of view, is there a clear enough distinction between a warrant to bring somebody before the court, and an emergency detention under mental health law?

d) Is there a perception amongst members of the Crisis Team or the police that an emergency detention order legitimises forced entry?

6) Availability of further information:

Would the MHS consider it a good idea for the Crisis Team to have available summary information giving them the names of all persons involved with a client , to act as a check list in a crisis? If so could a case manager provide this information?

7) Interaction with the police:

a) Is it problematic in terms of decision making that the Crisis Team members decide that somebody needs to be taken to hospital, when it is the police who decide to force entry to facilitate this?

b) Is it the position of the MHS that the Crisis Team should be consulted by police on whether they should force entry and what

effect this will have on the inaccessible person?

c) Is there an important distinction to be drawn between the

decision that somebody needs to be taken to hospital for assessment and a decision to force entry, especially where there are safety issues involved?

d) Do the police and the MHS agree that when a person has threatened with a knife that the issue of safety should be paramount? More so than the possibility of a person committing suicide?

e) If police are required to force entry, should it be the police who make this decision based on their own police criteria?

f) Should it be the police who act as authorised officers under the Mental Health Act when a conclusion has been reached to force entry?

g) Should there be more joint collaboration and consultation about matters such as whether forced entry is to take place, that is, is there a problem with the police assuming the decision making role?

h) Would it be practical or more sensible for the Crisis Team and the police to both take responsibility for a decision that entry be forced in a matter involving a person with mental illness?

8) Reality testing of worst case scenarios:

In making a decision does the MHS consider that it would be a good idea to do reality testing of worst case scenarios using check list decision making procedures including the careful examination of all possibilities?

9) After hours supervision:

Does the MHS facilitate the availability of after hours supervision for the Crisis Team?

Role of the Police:

10) Training:

a) Is the training which police receive about mental health law, dealing with people with mental illness and/or who are suicidal, and about the Crisis Team, adequate?

b) Are Operations police trained in information gathering, risk assessment, priority determination?

c) Do Operations police have guidelines about responding to a report that somebody is suicidal or is there a checklist of questions that they might ask to determine urgency?

d) Do Operations police have guidelines about doing firearm checks when police attend people's houses? How is this information given to

e) the patrol police?

f) To what extent is the Crisis Team unable to provide assistance to police when requested?

g) How real is the basis for the fear that an officer might lose his house for false arrest?

h) Is there any component of training that police receive which would make clear the distinction between arresting an alleged offender (and the risk of false arrest) and attending to assist with somebody who has mental illness who is not an alleged offender?

i) Is there any component of police training which ensures that police know their powers in relation to the emergency detention of a person with mental dysfunction who has not committed an offence?

11) Police procedures and guidelines:

a) Do police consider that 20 minutes is a reasonable and prompt response? Are police under resourced?

b) Should police develop strict guidelines to be followed when making a decision to force entry, and a code of practice regarding forced entry?

c) Should procedures relating to forced entry involving criminal activity be different from procedures relating to forced entry to provide assistance to somebody who is suicidal?

d) Should there be a step in these procedures that the people already at the scene be thoroughly questioned because they have the best knowledge of the situation?

e) When is it reasonable to proceed with a forced entry?

f) When is it reasonably foreseeable that a firearm will have to be used? Is it reasonable to proceed when the person is not a danger to

any body else?

i) Is it reasonable to expect an officer to carry out a forced entry without having time to himself to become fully cognizant of the context in which he is making this forced entry?

j) Does SOT training include training in making judgements about safety and weighing up consequences before forcing entry?

k) Does the AFP consider it necessary to review these guidelines in light of this shooting?

12) Use of firearms:

a) Have the police considered the efficacy of the use of firearms on jobs where they are to provide assistance to somebody who is suicidal and/or mentally ill?

b) Would the police agree that safety is the paramount issue and the drawing of a firearm immediately compromises safety?

c) Would the police agree that if a firearm has to be used to protect safety of a police officer, no forced entry would be a better decision?

d) Would the police agree that it would be better for officers not to be asked to take risks such as was involved in this forced entry, even when the consequence might be that somebody dies as a result of their own actions?

13) Accountability:

a) Has the AFP, as an organisation, failed in its duty of care to Warren as a member of the public? Was the AFP negligent in failing to

develop a code of practice for responding to people with mental

illness who need assistance; and for the handling of forced entry situations involving people with mental illness who are not offenders?

b) Where does accountability lie for the fact that police did not have sound knowledge of the law and their powers relating to

emergency detentions and for the resulting confusion about the "emergency order"?

c) Is there a duty of care issue for the AFP in relation to its own employees?

14) Was the emergency response to this incident timely and should such an initiative come immediately from the police?

A response was sought from the various stakeholder agencies to the Issues Paper of the Community Advocate.

Witnesses were called from the various stakeholder agencies as follows: Australian Federal Police: Assistant Commissioner Bill Stoll

Sergeant Brendon McDevitt

Department of Health and Community Care - Mental Health Services: Pru Wilson, Helen Briggs, David Butt, Richard Clarke

The Mental Health Foundation and the Non Government Mental Health Sector: Brian I'Anson, Libby Steeper

The statements submitted by the various witnesses are attached as Annexure A.

Comments on the evidence of Special Agent Brendon Joseph McDevitt (AFP)

This officer gave long and extensive evidence before me on 11 and 12 June 1996. He submitted two lengthy statements and numerous documents.

His function in short is to develop policy and implement training for the Australian Federal Police (AFP) on the use of force. He was in the process of reviewing changes and the implementation of new policies on the use of force when this tragedy occurred.

The witness indicated that he held a general view that training in this area needs to have more focus on the negotiation aspect of conflict. The increased use of scenario type training for skills in this area was supported.

He created the central policy document "Asses and Reasses - A Conflict De-Escalation Model", exhibit 71B. Whilst the physical training skills are important in "use of force" training, there must be a greater emphasis upon the alternative conflict management strategies. Negotiation and discussion should be emphasised in intial and refresher training. Members of the AFP should be assessed accross the board on their performance in "use of force" issues. The testing should go beyond physical skills such as use of firearms and batons and include a testing of negotiation and communication capability. The implrementation of his review in these areas effectively commenced in February 1996.

Decisions on the use of "forced entry " were based on the experience of the officer and training, particularly scenario training. Special Agent McDevitt conceded in evidence the desirability of developing a protocol or police document setting out the principles involved in a decision to make a forced entry. He regarded the decision to make a forced entry in this case as pivital. He indicated this is often the case in a "use of force" situation. He further supported the development and use of police negotiators in this type of situtation.

He referred to exhibit 72D - the national police research unit report - alternatives to lethal force.

He conceded options to the use of firearms such as oc/cs sprays, police dogs, body armour, sheilds etc were either unavailable or not in use to general duties officers in the ACT. Some of these matters may have been available to the Special Operations Team in certain circumstances. Research continues into the use of OC sprays and national and world police forces are developing approaches and policies for the increasing ue of OC sprays in appropriate circumstances. It should be noted that in recent times (1997/98) there have been a number of instances of the use of OC sprays and police dogs (notably in Victoria).

Special Agent McDevitt conceded the central relevance of the work done in Victoria on Operation Beacon. That process and reform followed a spate of police shootings in that State. That experience has been used by him in the development of AFP policies.

The witness appreciated the value of increased training and knowledge concerning mentally ill people in violent situations. This training should include expert knowledge and practical demonstrations of the use of the relevant legislation. Such training should go beyond the Special Operations Team and include the onstreet ACT police officer.

He emphasised that the decision to make a forced entry was a separate but important decision from the ultimate decision to use a firearm in a given situation. These are two separate steps which, if time permitted, would enable the officer to assess and re-assess the situation between the two decisions made. He conceded that the use of distraction and forced entry was important. The element of surprise was also important. The delay occasioned by the difficulty in breaking down the door and the obstruction provided by the mattress jammed against it, were significant in this case.

This tragedy occurred at a time when the AFP were assessing their policy on the question of the use of force. The lessons to be learned from this tragedy have been implemented in the development of that policy. At the time of giving evidence, no policy or protocol was available on the principles guiding officers in making a decision to embark upon a forced entry. Special Agent McDevitt appreciated that such a task was a desirable one. He also saw the need to emphasise the role of communication and negotiation prior to and even at the time of a forced entry.

Near the end of his evidence on 12 June 1996, Special Agent McDevitt was requested to assess the importance of information that the deceased had demonstrated an intention "to suicide by cop".

For reasons already indicated at the inquest, I would appreciate that the phrase "suicide by cop" not be used. The situation could be described as "an intention to be shot by police".

His answers to questions on this subject are significant and are set out at page 44 of the transcript of 12 June 1995 as follows:

MR HOWE: You will recall that Mr Buddin asked you whether or not the scenario involving Mr I'anson might provide the basis for a useful training exercise and you agreed with that?Yes.

Can you tell his Worship whether you are familiar with the concept of suicide by cop?Yes, I am.

And do you think that there is a place in AFP training for a scenario involving a suicide by cop motivation on the part of a person?Yes, and we've conducted scenarios relating to suicide by cop on a number of occasions.

HIS WORSHIP: Just stopping. That would, of course, presuppose that the persons involved in the operation had knowledge that the person intended to suicide by proxy?Yes.

Which is not the case here, on the evidence?That's correct, your Worship. MR HOWE: Yes, I was going to ask him that, yes.

You have told his Worship that you have a broad understanding of the events which preceded the forcible entry and the shooting of Mr I'anson?Yes, that's correct.

I want you to accept from me that his Worship has heard evidence to the effect that Mr I'anson had, a short time prior to the events in question, indicated to his father that he would not kill himself but would be shot by the police. Accepting that, if you were one of the police

in attendance on the police. Accepting that, if you were one of the police in attendance on the night in question, would that information, had you been aware of it, influenced the decision by you as to whether to effect forcible entry?That would have immense influence upon me. I would not allow a forcible entry to take place if I was aware of that information.

And why is that?Because I believe that that is a clear indicator that perhaps a suicide by cop situation maybe imminent.

And you can also accept from me that his Worship has heard evidence from some of the members in attendance, that even if they had been aware of that information, they may nonetheless have still effected a forcible entry. Does that indicate to you a possible need at least for some training of AFP members on the topic of suicide by cop?I believe that demonstrates a very real need for training in that area.

HIS WORSHIP: Well, the real question that I wish to ask you following that, and it does not need to be the particular facts of this case - and I did indicate that on the evidence before me no such information was available to the police unfortunately or to the Mental Health Team, unfortunately - but what would you have done in that situation with no forcible entry, what do you revert to?Your Worship, I would have sought to maintain an inner cordon on the premises and I would play the waiting game and I would seek to continue negotiations if possible. If negotiations were failing and there was no communication going on, well so be it, I would just wait.

But I suppose, if I can inject another ingredient, that already you had been pushed by the Mental Health Team of the necessity to get this person to hospital, and you had been told of a very high suicide risk. It makes it a very difficult decision, does it not?That is a factor which would weigh heavily in the mind of the decision maker at the time, your Worship, along with a number of other factors.

MR HOWE: Yes.

HIW WORSHIP: And so that is just a discretionary matter you would have to judge? There is no - what I am stressing in that, given all of those facts plus the fact that the Mental Health Team had requested you get the person to hospital, that he was in desperate need of treatment and there was a perceptive high suicide risk, you just have to make a decision on a discretionary basis as to whether you take the risk or not?That's correct, your Worship.

There is not any magic matter you can derive from your document that is going to solve that problem for the police officer concerned making the decision?No, your Worship, there's no magical solution.

MR HOWE: And I think in giving the answer you did to my question about the significance of this information imparted by Mr I'anson to his father, you would agree that you are not entirely familiar with exactly the sort of information imparted by the Mental Health Crisis Team to the individual members in attendance?No, I'm not.

And the significance of that information might, in particular circumstances, be outweighed by other considerations, is that possible?Certainly.

For instance, if the occupant of the premises were observed to consume some unidentified pills or to commence harming himself or herself with a knife, one might, in those circumstances, effect a forcible entry?Yes, that's correct.

Even in the light of the information that indicates a potential for suicide by cop?It may do, yes.

And indeed, if the police in attendance had received information to the effect that the occupant may already be in the grips of a medical emergency on the basis that they may have consumed drugs, tablets or other dangerous substances, that would be a factor that would have to be taken into account and decided whether to effect a forcible entry?Yes, that's correct.

And I think in response to his Worship's question, if all of those things that I have put to you were part of a scenario, including the information that suggested a possibility of suicide by cop, it would be an extraordinarily difficult decision on the part of police officers as to whether to effect a forcible entry. Would you agree with that?It would be a difficult decision to make, yes.

....

MR BUDDIN: First is, in relation to this question of suicide by cop, is it the case that that would be a pivotal piece of information for the decision maker to have before deciding whether or not to effect forcible entry?Yes.

And what effect would it have on the notional decision maker?If I was the decision maker and I was told information such as that, there would be - an overwhelming thought in my mind would be not to grant the wish of a person who wanted to commit suicide by cop.

And therefore what would you do or not do?Depending on other variables, my primary inclination would be not to effect a forcible entry.

Flowing from that, is it the case that in the light of all the information that you have available to yourself, and putting yourself in the role of a notional decision maker and of course with the benefit of hindsight, is it the situation that you would not have effected a forcible entry in the circumstances facing the police on the evening of 17 November 1995?

MR HOWE: Your Worship, I only rise to object to that question because the witness has already indicated, in response to a question from me, that he in fact is not across all of the information that was imparted by the Mental Health Crisis Team to the police in attendance, and I think he has indicated that he only has a broad or a rough understanding of the particular information that prompted the decision to effect a forcible entry.

MR BUDDIN: I am not suggesting that it is going to be a perfect answer, your Worship, but it might be of some assistance to you.

HIS WORSHIP: Well, it can be asked on the basis of the information that he has, which he has described in general terms to the cross-examination of Mr Horler. I will allow the question on that basis.

THE WITNESS: Your Worship, with the benefit of hindsight, obviously I would say not to effect a forcible entry. It is a very difficult question to answer because I wasn't the decision maker who was at the scene, I wasn't the person who was told certain things by members of the Mental Health Crisis Team and I don't know exactly what those things were, that they would bring considerable pressure to bear upon the decision maker even though the decision would be one which I believe would be made by the police not by the Mental Health Crisis Team. I also am not privy to what was said by members of the family or neighbours or anyone else who was at the scene and those things too would weigh in on any decision, as would whatever may have been coming across in the way of competing demands for resources or other jobs occurring through the police radio and so on. I find it a very difficult question to answer. The factor of information regarding a suicide by cop would be another primary thing that would really weigh on my mind in any decision that I was to make."

The evidence of Special Agent McDevitt has been signifcant to the inquest and has enabled all parties to test AFP policies and practices in this are of use by force. I am conficent that the experience of this inquest has left Special Agent McDevitt with new insights for reform and reconsideration of practices.

Additional Comments by Assistant Commissioner William James Stoll AFP

Mr Stoll gave evidence before me for most of three days (31 July, 2 and 19 August 1996). He is an Assistant Commissioner with the Australian Federal Police (AFP) and is the police regional commander for the ACT and is the Chief Police Officer of the ACT.

He indicated the fundamental guiding performance of Project Beacon from Victoria. The document developed by Special Agent McDevitt "Asses and Reassess - A Conflict De- Escalation Model", exhibit 71B, has been adopted by the AFP ACT region of the Australian Federal Police. The document has been renamed "Safety Principles". Mr Stoll gave a report on the progress towards adoption of the various recommendations for the operation of policing within the ACT. He discussed the development and adaptation of new extendable batons. He was recommending a special project team continue the investigation concerning the use of OC sprays and their safety before any trial project concerning their use would be adopted.

The draft Memorandum of Understanding between the AFP (ACT region) and Mental Health Services (exhibit 79) was the subject of continuing development. He welcomed input from any interested stakeholder. At the time of delivering this decision, the Memorandum of Understanding has been adopted and in its current form was released in December 1998.

Mr Stoll indicated and produced a number of documents relative to police knowledge and operational experience involving persons with a mental illness including:

• Police Practice Training Syllabus (exhibit 80)

• Lesson Plan (re persons with a mental illness) Local Procedures Course (exhibit 73)

• Seminar for Operational Trainers (provided by a Victorian psychiatrist Dr Simon Brown-Greaves)

• Standard Operating Procedure - Police Negotiating Team (exhibit 82)

• Refinement of Special Operation Team - Deployment Procedures (exhibit 83)

He indicated that a safety procedures training group under the chairmanship of Detective Constable Rath had been formed. It was anticipated there would be input from Mental Health Services, the OCA and persons from the Project Beacon team in development of training an implementation.

• Training of officers in Communications Branch concerning mental health issues and appropriate language

• Interaction with the Mental Health Crisis Team

• The development of a new General Order 10 (exhibit 72B[2])

• Regional Instruction 2293: "Mental Health Patients and Forensic Patients" (setting out detailed procedures to cover the operation of the Memorandum of Understanding)

He supported the recommendation from Project Beacon (exhibit 77) concerning a "use of force" register. This would ensure positive and sustainable change through to communication. He favoured debriefing and interviews with members who had successfully used the ten safety principles. Other methods of ensuring sustainable change included focus group discussions and surveying operational members. Further, members of the community may also be surveyed to measure their satisfaction with police operations involving persons with mental illness. This would provide valuable feedback and would identify any gaps in service by police or mental health agencies.

Mr Stoll also set out his views on the police negotiation team and referred to relevant qualities for selection and training objectives at page 11 of the transcript of 2 August 1996 as follows:

"Can I ask you some questions in relation to membership of the Police Negotiation Team?--- Yes.

What process of selection for membership of that team is undertaken?---Expressions of interest are called on a reasonable basis from experienced officers, both male and female. They then go through reasonably the same process as the selection for the special operations team, initial selection procedures and then psychological testing and assessment based on their police experience and their suitability for negotiation duties.

And what are the minimum qualities that are required for selection?---The ability to take command of situations. Operational experience. The ability to interact and communicate, of course it being the primary responsibility in negotiations to open communications and to maintain those communications in accordance with parameters set through their negotiator training to apply the policy of negotiation in a balanced and fair consistent way.

I think you said that both men and women are members of the team, is that right?---Yes, that is right.

Are you able to say off the top of your head how many women negotiators there are?---We have, I think it is a cadre of 15 total negotiators. There are 9 who have undertaken a higher

level of negotiator training under the antiterrorist plan, national standards. There is one female team leader who is also a Detective Constable and - - -

Who is that?---Therese Barnicoat. There are three or four other, maybe five other female members out of a total of 15.

Is there anything else you wanted to say about qualities or selection processes?---It is rigorous, of course. We have interstate trainers from other jurisdictions attend who are nationally recognised negotiator trainers under the SACPAV arrangements. They are responsible for providing the training. They are also responsible for maintaining and providing some objective advice to myself and other jurisdictions as to the suitability of the members. There is a fair, as with the SOT training, there is a fair drop out rate during the initial period. That is used as part of the selection criteria as well and the ongoing interest and retraining is also fairly rigorous and required part of the selection."

Local procedures training will currently be reviewed to include communication and dealing with persons with a mental illness as well as increased training on statutory and other procedures in the relevant area. This can take place in conjunction with the ongoing development of the Memorandum of Understanding. Mr Stoll at page 17 of the transcript of 2 August 1996, encapsulated the changes that have occurred or in the process of occurring as a result of this tragedy and the result of the following inquest:

1. Change in training programmes to increase awareness of those suffering mental illness and disorders.

1. Revision of regional instructions concerning standard operation procedures affecting police negotiation.

1. Enhancement of procedures governing the activities of the SOCT team.

1. Adoption of a central practice of a philosophical approach to the question of the use of force by the adoption of 10 safety principles (formally "Asses and Reassess - A Conflict De-Escalation Model").

1. A review of practices in the Regional Co-ordination Centre/Communications Branch.

1. A general review of practice procedure and philosophy for dealing with persons with mental illness within ACT region.

1. A continuing process to review and apply the Memorandum of Understanding AFP/Mental Health Services (inclusive of other stakeholders such as the OCA, Mental Health Foundation and other persons).

Mr Stoll was requested to detail how a change in police culture effecting policemen at the coalface will be introduced and maintained. He indicated at page 18 as follows:

".... If a member of the community were to put this proposition to you, Assistant Commissioner Stoll, the theory and the rhetoric sounds terrific and they might even be prepared to go so far as to say everything that you have done personally in your own appearance here indicates significantly progressive leadership in the Australian Federal

Police. All I am concerned about is will it change police culture? And more particularly, how will this affect people who work every day at the coal face? How would you respond to that type of challenge?---I think that we have been very reflective in our reaction to this tragedy. I must say that by virtue of the evidence given by McDevitt and the others and the production of the model, it should be clear that prior to November there was already work under way to enhance the model that was applied in our training procedures which is part of the ongoing objectives of the AFP. To answer your question more particularly, the results from my own personal point of view will be the outcome of a review, say at the end of twelve months when we embark upon the new way with training. It will be reflected in the attitude that the community then holds as a result of what we have done. A lot of the things we have been speaking about, of course, are yet to be put in place. They are under way as far as the concept. I can publish ten safety principles. I can have the agenda, teaching aids, program, but the real test is the attitude and the application of those principles on the streets of Canberra. We will know that at the end of probably twelve months or a reasonable period of evaluation. I think we have demonstrated the commitment is there from the management level and we need to now ensure that that translates into operations policing. And I should say that too, that we are coming off a fairly firm base in my view. We do have a high standard of training. We have got a high standard of accountability and in some respects we are already in advance of some of the other jurisdictions and have been for a number of years. It does not mean to say we cannot improve."

In cross examination by Mr Refshauge, a lengthy discussion of police understanding of the significance of their powers, particularly arising under section 37 of the Mental Health (Treatment and Care) Act ensued. This perhaps gives rise to a greater concentration on these issues in police training.

Commanders in each of the ACT regions liaise with Mental Health Services. This is valuable feedback for both parties. The interaction between Mental Health Crisis teams and police negotiation teams should be encouraged at a higher level in the future.

In cross examination by Mr Refshauge, Mr Stoll indicated that the contact between communications and the Mental Health Foundation worker prior to the incident, lacked direction and a professional approach on behalf of police communications. The use of inappropriate language, inappropriate responses and discussion of a threat of legal action against the police was not appropriate. Steps have been taken to remedy this situation.

In cross examination, Mr Stoll favoured a record of contact between AFP and Mental Health Services concerning crisis of persons with a mental illness be kept. A record of the attendance of either AFP or Mental Health should be recorded and the response also recorded. This could form a discussion basis for a cultural change in the attitudes of police towards persons suffering a mental illness. An examination of responses and debriefing would play a large role in that.

Recertification and refresher training on the safety principles has been introduced for all operational police in the ACT. An offer of help from the Mental Health Foundation in assisting police training from their perspective, would be gratefully recieved. Mr Stoll commented on the rationale for creating the 10 Safety Principles at page 64 of his evidence of 2 August 1996:

".... The safety principles, avoiding confrontation, force is the last resort, opportunity for negotiation, opportunity for communication and once again it depends on the specific incident. Opportunity for a whole range of things that are determined by the situation that is confronted at that particular time including a whole range of things. I said there was a whole range of that sort of range of issues that come into play."

He discussed the publication of the Safety Principles and its effect in the enhancement of the Memorandum of Understanding at pages 64 and 65 in his evidence of 19 August 1996 as follows:

"Can I ask you this question. Why did you see a necessity to create such a document?---Well it seemed that the project Beacon experience had proven the benefits of having the principles in place. The key to the document is its brevity, its conciseness, and the fact that it can be used as a ready reckoner, a check list, something that hopefully stands in the forefront of the minds of the police dealing with crisis situations. I think that's its real value, it is not meant to be a package, part of the curriculum, it is meant to be a practical guide, and I think it is a worthwhile initiative, we have adjusted that to our own needs.

What improvements in practice are you hoping will be achieved through its introduction?---I think better practices emerge and it is very much staying at the forefront of them, giving the people the right tools to react positively and properly in a professional way and I think the safety principles themselves, the concept that underpins them is important in that ongoing enhancement of all that we do.

It would appear that considerable time has been invested in enhancing the memorandum of understanding?---That is correct.

Why has that time been invested?---For the very reason I think has been demonstrated during my own cross-examination and the matters that have come out. I think there is always a better way to do things, there are always different points of view, there is always a professional approach that can be enhanced. I think it has taken the time that it has, because we have been very painstakingly engaged in finding a better way to do things in this area.

And what improvement in practices do you anticipate will flow from that exercise?---I think the people will have a clearer understanding of their responsibilities. They should be focussed. They should be made aware that there has been a new development, that there have been changes. There has been a better process developed and they will be encouraged to apply that and in fact in some areas they will have to apply it. I think it points to - it points at a better way of doing things.

And have you received any feedback from your own officers in relation to the draft memorandum?---The officers involved in it are quite enthusiastic and confident that most of the issues have been covered and addressed. I have spoken at my own regional command meetings to senior executives and others and advised them that this is an ongoing process. They are all enthusiastic about it, they have all contributed to it, they see it as a primary responsibility that they have all got to make sure that we have such a thing in place, and I think it has been a very positive exercise.

And can I ask you the same question in relation to the safety principles. What if any feedback have you received from your officers about that document?---That was distributed widely,

once again at the operational meetings and at the executive meetings that I hold and take part in. There has been feedback that that is seen as a positive step by all members.

Is there anything more particular you have been told?---I think it is regarded and accepted as being - providing a focus for the way in which management, myself particularly, anticipates and requires that members will apply to resolving operational incidents, that is very positive.

Have you received any feedback from the broader community about either the safety principles or memorandum of understanding?---Well, it is a question of awareness, only in regard to having given evidence previously and the publicity that was generated as a result of that, the media comments and I have spoken to a range - some people at least who have been very supportive.

Some people, sorry?---Some people have been very supportive of the concept that not only police of course, but mental health services and others are addressing some of the issues."

He further commented on the importance of tackling police culture issues at page 69.9:

"Is that the sort of sensitivity that you were talking about?---Yes, yes.

And is it the same sorts of sensitivity which would suggest that it is inappropriate to talk about a person in Warren I'Anson's situation as being a schizophrenic?---Yes, my understanding of the term and the concept is it would be.

I think you have already indicated that you have disavowed at least one expression that was used by Constable McDonald, in referring to a person with mental illness as being, bananas?---That is correct.

And that indicates concern about a prevailing police culture, does it not?---Indeed, and I think police in that regard are reflective unfortunately at the wider community.

Can I ask you this? There is a package of reforms and enhancements that you have highlighted during the course of your evidence, is that right?---Yes.

And no doubt that has been in part designed to change police culture?---That is correct.

And certainly as it concerns dealing with people who may have some form of mental illness?-

--Yes.

What confidence have you that the package of reforms will in fact have the desired effect, namely of changing police culture, so far as dealings with the people that have a mental illness is concerned?---Well I am optimistic of course, much of the initiative was under way prior to November of last year. In fact a lot of the work had been prepared and a lot of the issues were in fact part of the AFPs agenda for change and I think the change in culture is evolving in ever present need, and I am reasonably optimistic that through this program, not only in relation to dealing with this but other issues, those negative sides of the culture can be adjusted, of course there are many positive signs as well, negative signs can be adjusted and dealt with.

Now, your Worship, Mr I'Anson was not in court on the last occasion and I am going to ask Assistant Commissioner Stoll to go through the check list of matters that constitute that reform package, that is the purpose for doing so.

HIS WORSHIP: Yes.

MR BUDDIN: As I understand the situation that the package of initiatives includes, the making of significant changes to training programs?---Yes.

And particularly to create an awareness amongst police of those persons who are suffering from some sort of mental disorder?---That is correct.

It includes a revision of the regional instructions concerning the standard operating procedures so far as police negotiators are concerned?---That is correct.

It involves enhancing the procedures for the SOT team?---Yes.

And adoption of the conflict the escalation model of assess and reassess?---Yes.

And adoption of the 10 safety principles as a code of practice for police in circumstances where the safety of the public and people suffering from some form of mental illness is concerned?---Yes.

The improvement in practices in the regional coordination centre or the communications branch?---Yes.

And improving relationships with mental health services, by way of significantly enhancing the memorandum of understanding with that agency?

---That is correct.

Now is there anything else that you wish to add to that list as representing the package of initiatives that are being either instigated or have been ongoing since before 17 November 1995?---No, I am satisfied that that is the range of procedures."

Mr Stoll indicated that information that Warren I'Anson had earlier in the day indicated that he would be shot by police was a significant and influential factor mitigating against a decision to make a "forcible entry". Such a situation would necessitate an approach directed towards negotiation and containment to avoid a tragedy.

I express my gratitude for the Chief Police of the ACT who has come before this inquest and been prepared to lay bare all the issues as far as the AFP are concerned in the ACT. This surely is an issue of appropriate and searching accountability in respect of this tragedy.

Comments on the Evidence of Libby Steeper

For in excess of 12 years Libby Steeper has had extensive community and quasi government matters involving mental health issues in the ACT. At about the time of this tragedy, she was chair of the ACT Mental Health Council and held positions on numerous community mental

health bodies in the Territory. Her statement to the inquest is endorsed by the ACT Mental Health Council as a whole.

Shortly after the tragedy, a forum was sponsored by the ACT Mental Health Council to discuss and allay fears arising from the tragedy. All stakeholders and others involved in the mental health scene attended and discussed a wide range of important issues.

The report is contained as an attachment to exhibit 95 and also appears as exhibit 100J. The report focused on a number of recommendations as follows:

• improvement to staffing of Mental Health Services;

• further training of police and Crisis Team, particularly to listen to patients and families;

• admission to psychiatric wards to be made easier for known sufferers by-passing hospital accident and emergency section;

• attention to the needs of voluntary patients who have not reached a crisis point or severe psychotic symptoms with the intent to prevent crisis;

• a policy of early intervention to be instituted in the ACT with appropriate services to implement;

• an urgent improvement to the support offered to people with mental illnesses living in the community and resourcing of the relapse prevention programme.

It was recommended that a multi disciplinary approach be taken to employing people in the Mental Health Service with a variety of qualifications and experience. The Counsel endorsed the Memorandum of Understanding and its contents. A need to involve other jurisdictions in training and in part experience for the operation of the Crisis Team was emphasised. The question of the difficulty of families gaining admission for persons suffering mental illness to hospital was ventilated. The problem of a person presenting at hospital and failing to gain admission and then returning home and their condition severely deteriorating was far to common. Ms Steeper indicated that the ACT mental health system was a system under stress

Ms Steeper advocated the adoption of a policy of early intervention for persons suffering from a mental illness. This does not occur only in relation to hospitalization but in the community context. She particularly identified the need for action in the area of youth and adolescent mental illness. The question of social and employment intervention and the creation of community activity for those suffering mental illness, was also discussed. The application of the principle of "front end resourcing" will pay dividends for the efficiency of the service and the benefit of the mentally ill in the community.

Ms Steeper emphasised the need of the Mental Health Services to respond in respect of these matters. She is particularly concerned that the Gianfresco Report be implemented and the ACT Mental Health Council completely supports its recommendations. The report, when implemented, will result in a fundamental change to the Crisis Team and will result in a change of philosophy and nature of its work. The emphasis needs to be on a more pro-active approach to assist persons suffering mental illness in the community by was of home visits

and community involvement etc. Intensive home care and visit activity has resulted, in the NSW experience, in a reduction of 50% of hospital admissions. The aim is to provide actual support to people in their living that keeps them in control of their lives and allows them to manage their illness so much better than they can when they are alone, living in inappropriate circumstances and without the requisite community support. The relapse prevention programme is philosophically aligned to this approach. The ACT Mental Health Council first developed this approach in its response to the Purdon Report which dealt with accommodation needs for people with psychiatric disabilities. Ms Steeper also produced a position paper by the Schizophrenia Australia Foundation on police shootings and people with a mental illness.

A discussion took place on the recommendations of the Gianfresco Report. The generic crisis intervention role of the Crisis Team was discussed. It involves looking after people with a mental illness or a psychiatric crisis and also involves concern for other people in crisis situations such as domestic violence or a drug or alcohol incident. The team would go to that crisis, deal with it and if needed, refer to another appropriate service as appropriate. The Crisis Team would be the first point of contact. The report provided an assessment of the Crisis Team's relationship with mental health programmes and other service providers and also questioned the adequacy of the existing guidelines for service provisions and cost effectiveness. The report revealed that staff spent 75% of their activity in assessment and only 25% with face to face contact with clients. The team itself felt they had limited opportunity for training and supervision. Questions of access and availability of the Crisis Team was also questioned. The Crisis Team was the first point of contact in a multifaceted problem involving other issues such as domestic violence, drugs and alcohol. There is a generic approach to the problems of the person rather than a concentration on individual characterization of those problems. The need to bring in other services where required.

Ms Steeper endorsed the Gianfresco Report recommendations for means of improvement of the operation of the Crisis Team, including - increased home visits, better means of contacting communication, better provision of alternatives to psychiatric admission and less police involvement (this may be questioned). She indicated the operation of a Memorandum of Understanding is extremely important.

Ms Steeper indicated in relation to Warren I'Anson's death an increased level of service by Mental Health Service and the Crisis Team may have prevented the outcome of the case, particularly in relation to visiting Warren during the previous week and introduction of other treatment options and a more intensive visiting programme for him over the period of his deterioration. The build up of a good therapeutic relationship would have added confidence to him in dealing with crisis. She concedes these things are fine with hindsight.

At page 34 of her evidence on 26 September 1996, Ms Steeper expands on her views concerning the relationship between government and non government services and the need for a standard protocol in the are of supportive accommodation as follows:

"Under the next heading, which is entitled "Relationship between Non-Government and Government Services", you talk about the need, in your view, for a standard protocol for Mental Health Services and non-government organisations providing supportive accommodation, who do you think should take the initiative in developing such a protocol?--- Well, I think Mental Health Services because they are actually at the centre of all these other services and they are the ones who are providing the service that the other organisations

require. So, it would show good leadership if the Mental Health Service actually did offer such a protocol or at least increased understanding of what they've got to offer and how available it is to all those groups that need it. I think if you get in first like that, you increase the cooperation between organisations and cut down on unrealistic expectations. It also serves an educative purpose to other organisations. I do know, quite often, in some areas, they call Mental Health because they have struck a person who is very difficult, obviously in great distress and they don't know what to do with them, so they think it must be a Mental Health problem, they know everything and they call Mental Health who understandably at times resist being called in because they in fact don't have a solution for such a person. At this stage, in Canberra, there's nobody who can help that person, as far as I know. It's a very difficult area, but because they haven't been able to help the other agencies, then form a poor impression of Mental Health Services and assume its because they are very unwilling. Having said that too, sometimes they are unwilling because they are difficult and they are requiring a great deal of time and energy such - these more awkward cases and I think, being stretched already to their own service limits, they are unwilling to become involved."

Ms Steeper dealt with time limits of response once a serious mental health situation has arisen. There will be occasions when the Crisis Team cannot attend there needs to be flexible alternative forms of arrangements for an ambulance or the police to attend where the Crisis Team is stretched. Delay of even half and hour to an hour could be fatal.

Ms Steeper also raised the need for increased training for support workers in non government organizations to handle emerging and more difficult problems as days pass. Accreditation and minimum training standards need to be introduced.

Ms Steeper, on behalf of the ACT Mental Health Council, supports the concept and appropriateness of the Memorandum of Understanding. She emphasises the need to monitor its use and constant updating and in particular, as providing the opportunity for joint training between police and mental health service workers.

The question of the involvement of the Mental Health Crisis Team with the responsibility of the writing of psychiatric assessments of persons in police custody on remand or serving a custodial sentence or at the Belconnen Remand Centre. That issue needs to be addressed, although it is not directly the subject matter of this inquest.

Ms Steeper supports the increased use of the police negotiation team even in low risk situations. This would serve to the various stakeholders becoming more comfortable with the idea of working together and constructively in dealing with people with mental illness. She emphasised that negotiation skills per se are insufficient, there needs to be specialist training in negotiation with people with mental illness. It is a separate art form. The ACT Mental Health Council would wish to stay involved in the planning for the implementation of the Gianfresco Report. Some concern is expressed in that the generic roles suggested for the Crisis Team has been rejected on the funding basis. Other issues concerning implementation were discussed.

The need to update information concerning patients and their progress in the community needs to be assured. The question of response to suicidal ideation and skills and approaches to that problem needs to be constantly reinforced. The resources and alternatives for dealing with such issues need always to be available. The need for the co-ordinating role of a case manager as distinct from a case worker in Mental Health Services, was emphasised. The need

to ensure community support accommodation both in a centralized sense and in a community housing sense was noted. The ACT Mental Health Council submitted a brief response to the Chief Minister to Gianfresco Report. That report particularly focused on the recommendation that the Mental Health Service should, through the Crisis Team, provide rapid assessment and treatment to people in the ACT when and where it is required. The locus of care emphasis for the Crisis Team should be placed on home visiting rather than requiring people to attend a site such as the Emergency Department of the Psychiatric Unit. The Mental Health Service should, through the Crisis Team, focus heavily on providing the people of the ACT with options in regard to acute psychiatric care and treatment. All admissions to the Canberra Hospital Psychiatric Unit should be assessed by the Crisis Team prior to arrival at hospital with the to the provision of community based acute psychiatric treatment. The Crisis Team should develop a capacity to provide an intensive home visiting through a course of a crisis and or episode of acute mental disorder.

Those were the issues of the Gianfresco Report that Ms Steeper felt were critically important for provision of better mental health services in the ACT.

Comments on the Evidence of Brian I'Anson

Mr Brian I'Anson, father of Warren I'Anson, was called separately in Part II of the inquest. He gave evidence extensively before me on 19 and 22 August 1996. This evidence related to his role as president of the Mental Health Foundation and his involvement with a number of other non government community activities in the mental health field over a long period.

He indicated that the operations of the Mental Health Foundation were based on a social support or psycho social model. This model differs from the medical model approach to mental health in that it seeks to prevent the person who may have problems with psychiatric disability from having to go into hospital, the reason being that they normally come out less competent than they went in and that situation may be possible to be turned around if the support workers who are with that person (from the community perspective) seek to reduce stress in those persons lives by ensuring they have the necessary support to maintain adequate security of accommodation, finances and personal matters. The aim is to get access to regaining some of the skills that they have lost through the medical process.

The Mental Health Foundations to main purposes are to first of all identify the gaps in services that need to be provided and met, which people with the disability should be able to expect to get promptly and adequately. Secondly, to involve consumers in all aspects of the planning, provision of treatment and other services including evaluation. This is an aspect upon which the Mental Health Foundation differs from other organizations which traditionally take the view that people who are consumers, users, survivors of psychiatric services do not know enough to contribute effectively in the process. The Mental Health Foundation is seeking to redress that by ensuring that people who are consumers are survivors who have the skills to play a part in providing necessary advice and support. In this connection, the Mental Health Foundation skills and information programme provides that consumers participate and present mental illness in a way which is not frightening and will assist in the destygmatising of mental illness and reduce the apathy of young people who will come to know that help is available if they need it. The Mental Health Foundation seeks to redress the erroneous public perceptions of mental illness and to improve media treatment on the topic.

The plight of the mentally ill in the forensic system is also a concern and the availability of treatment is an issue. The accommodation issue in the ACT is also a concern and was redressed in the Purdon Report. The Mental Health Foundation is concerned to ensure that there are "community beds" for those suffering from mental illness which will lead to a better recover than the hospitalization approach.

The Mental Health Foundation seeks tor redress the existing power structure in mental health matters and for the provision of a greater input from consumers of mental health services and their families and supporters.

On 12 December 1996, Mr Brian I'Anson was recalled in his capacity as the father of Warren I'Anson and also as the founder and head of the Mental Health Foundation. He was asked to comment on the current situation and in particular, the reaction of police and Mental Health Services to the inquest and changes in the process of being implemented.

He indicated that in terms of any systems failure at the AFP end of the spectrum, that he believed that the AFP are doing everything they can to improve the system to ensure that the attitude and training of police were addressed. He further reiterated that he wished to reserve judgment on the question of changes to the Mental Health Service.

He commented on his views at this stage concerning the inquest and its effect as follows:

"Now, is there anything further you want to say in relation to the Australian Federal Police at this stage, bearing in mind the answers I have just indicated that were recorded on a previous occasion?---Well, only that discussions with the AFP have been proceeding with the foundation into their training processes, and we are encouraged in the foundation that the help that we can give through our schools education program and our suicide prevention program, both of which have got training elements in them, are being appropriately adopted by the police, so we are happy about that.

So you made that overture and the police have positively responded and taken you up on that suggestion?---Yes, they have.

All right. Can I now ask you to turn your attention to the mental health service. You sat in the body of the court for the last two days and heard evidence from David Butt and Richard Clarke, and you are aware of their respective positions?---Yes.

Just in global terms first, I think I asked you a question in relation to the police. Are you heartened by - perhaps I will ask it in the same terms. Are you heartened by what you have seen and heard in regard to what they have said here in the last two days?---Very much so because this has been our focus in the last 12 years to seek to achieve a lot of the changes that have now been announced. So we are very pleased indeed on that basis.

Feel free to indicate some of the things that you feel that have been an element of indication in relation to?---Sure. Well, so far as the restructuring of the branch and the policy changes that are being proposed, we are very very hopeful that they will be achieved and that the ACT citizens will therefore have a more responsive mental health service and one which will achieve its aims with much less danger to the people involved. I should mention that not everything I have advocated in the inquest earlier have yet been achieved. For instance we have not yet achieved the clinical access for our respite facility. The house has been provided

and now funding has been provided recently. But we do not, as I understand it, yet have access to clinical resources which would help in the provision of that service. I should mention too that Libby Steeper who spoke on behalf of the mental health council has indicated that respite is possible of a number of interpretations and I would mention that particularly because I do believe that the first interpretation which that council had, which was essentially one of a clinical service, is not the service that the foundation was seeking to provide, which was rather respite for people in the same way that everyone needs a break, a vacation, help at times, rather than specific clinical services. And in her submission to the inquest I think Libby indicated that respite is capable of a number of interpretations. And it is very important when we use the word to make sure that we are specific as to the sort of respite that we are referring to. The other evidence that Libby gave was in support of the psycho-social model which has been demonstrated conclusively as reducing the need for clinical services. That is, and I refer you specifically to David Plant's paper which was a mental health and psychiatric disability community service development project and in the project outline he refers to the McCauley community which I referred to earlier and one of the people who gave evidence to his inquiry, a Mr McDonald, is the I think chief officer of that project and it has demonstrated that the recidivism into clinical services for people in an appropriate community can be reduced by up to 80 per cent. And that is an enormous benefit to the community but also to the individuals concerned because, and I would refer particularly to the Community Advocate, I think it is important for her to be aware that the community involves a whole healing process quite outside of hospitals and professionals that if we can create an appropriate community in the ACT we can reduce the incidence of mental illness and reduce the severity of mental illness because it has been recognised that people come out of hospital after crisis with less competencies, less skills, than they went in with.

They might have their psychosis fixed but the skills loss is an enormous loss to the community. If we can turn around the process so that when people are identified as heading into crisis so that they don't actually get to the crisis stage, then we will be saving the community enormous cost and for the individual, for people with a psychiatric disability, they are saved an enormous cost too. They can actually get their lives together so much more easily if they don't actually have a crisis.

You are aware that David Butt gave evidence yesterday that he basically accepted the tenor of Libby Steeper's statement, do you recall that part of the evidence?---Yes, yes, I do.

Were you heartened by that?---I am very heartened by it because that accepts a lot of the propositions that David Plant has put in his paper.

You will recall, of course, the exercise that we went through this morning whereby Richard Clarke indicated seriatim his response to the implementation of the Gianfresco report?---Yes.

Any comments upon that process?---I am very heartened indeed that we will have a crisis team that will do the sort of work that they learn to expect in other places in Australia.

Is there anything else?---Yes. I think that the warnings were there from Gianfresco and from Purdon and from Plant and the statements at the highest level of government in the ACT that they are going to turn around the processes in order to ensure that the majority of those recommendations will be taken up is great. And could I refer you specifically to David Plant's paper, that I don't think has actually been introduced into evidence, but which I think has some important messages and unfortunately - well, fortunately I will just refer to the three

pages of the project outline which I think on the, let me see, one, two, three, fourth page he says:

Across Australia it is often small poorly funded non-government organisations and consumer groups which provide the specialist community supports which are not provided and perhaps not able to be directly provided by government mental health services. The established links which these organisations have with the government mental health services are not altogether respectful, helpful or strong. In summary persons with mental illness and people with psychiatric disabilities claim frustration on all sides. They feel that the public mental health system treats them as incompetent and regards their opinions about the treatment and quality of services as unimportant, and for the most part their access to services is limited to assist them which is mandated to respond with an actual or threatened aspect of coercion attached.

I would like to digress a little bit from that point to say that his main point there is that it is not always the government mental health services who are better placed to provide management, case management and I think it is important perhaps to look at that because the government mental health services are necessarily involved in the coercion process:

The psycho-social needs receive little attention and few supports exist to assist their full participation in community life. Linkages between services frequently break down. If they seek assistance in the non-government sector they find that specialists and knowledgeable services are few, underresourced and often in consequence poorly staffed, organised and managed. If they seek assistance from generic services or disability services which are not experienced in dealing with psychiatric disability, they find it difficult to access appropriate or even any service. They are often in these circumstances the victims of stigmatisation and a failure to understand how to respond. Few if any services exist which seek to understand and activate their personal support networks. Thus a primary aspect of community integration is essentially ignored.

I would certainly hope and I look forward to the community advocate's summary of paper on the second part and I certainly hope she would take account of a number of the points that are mentioned in that paper. In addition I would just like to say that so far as the death of my son is concerned, I regard the mental health foundation support worker as the hero in this whole exercise. I think that she had acted completely in accordance with the sort of - and sought to get the sort of help that we expected Warren would need at that time. And unfortunately the system as it existed then did not achieve that result and I am hopeful that in future we will not have this sort of outcome.

MR BUDDIN: Can I ask you this, so far as that last matter is concerned, you greater reason for optimism as of today than you did on 18 November 1995?---Yes, yes. Greater optimism today than I had two months ago.

And can I ask you what factors have contributed to that greater optimism than you had two months ago?---I think the acceptance at the political level that the system wasn't well serving the citizens of Canberra. And the changes that have been brought about have obviously come by recognition, both in the police and the mental health branch of the inadequacy of the existing service.

And do you think that the death of Warren and the process that has followed, particularly the inquest, and the way in which the inquest has unfolded has contributed to that process?---I think it has, in retrospect. I was a bit impatient to start with, but I think that the way it's unfolded has in fact brought about change in perhaps a more acceptable way.

And in that sense has it done what it can in the circumstances to provide some satisfaction for you, I mean insofar as you could ever be satisfied with what has occurred?---Yes, well there are I think some gaps which - and the forensic services is one that I'd like to identify as an area that still needs to be addressed. I think the services that we've been promised hopefully is only a start, because I know that well $150,000 for housing and that these days isn't a great deal and I just - I think there are more than 20 people in need of the sort of housing and support needs in the ACT community.

So you would have very much greater faith in the system sitting there today than would have been the case even a week ago, is that right?---Yes. Well, the watershed was when the government made its announcement. First of all the budget announcement and then the subsequent changes to the whole structure.

Can I ask you at a very personal level, is that the way in which those matters have unfolded, the entire process itself, including the inquest, did that assist you at all in the healing process? If you do not feel like answering that, don't?---I think we have got to look for the best outcome for the people with psychiatric disability. And certainly it seems to have leapt forward in people's minds and actions.

I'm sorry, did you say leapt forward?---Leapt forward. I think there has been a huge leap forward, yes."

Mr I'nson discussed extensively attempts by the Mental Health Foundation, under his guidance, to gain additional funding for additional housing enterprises as well as unsuccessful attempts to resolve a protocol of operation between the Mental Health Foundation and ACT Mental Health Services. This protocol issue related to the availability, contact and support of Mental Health Foundation clients by the ACT Mental Health Crisis Team. The Mental Health Foundation was seeking greater access to clinical expertise for their operations.

Mr I'Anson also discussed at length the desirability of developing a standard protocol for Mental Health Services with non government organizations providing mental health services and accommodation. The Mental Health Foundation has rather found itself in a role of providing information to the Mental Health Crisis Team rather than acting in the framework of dealing with mental health crisis intervention. That was seen as the role of Mental Health Services and the Crisis Team.

Mr I'Anson raised issues concerning involvement of community organizations such as the Mental Health Foundation in improved training for the Australian Federal Police and particularly saw a role in humanizing and destygmatizing the issue of mental illness and making people more aware of the need to be of assistance to mental clients rather than being judgmental about them. He is concerned that the progress made since Warren I'Anson's death in the Australian Federal Police response continue and the effect upon the AFP as an organization be permanently in place.

He saw the Crisis Team as providing an assessment and support service to the staff and clients of the Mental Health Foundation.

He indicated that staff of the Mental Health Foundation who perform as support workers have no specific training and need the clinical and expert support of bodies such as the Crisis Team.

The role of the support worker is to understand the intricacies of mental illness and assist people to cope with their mental illness by providing support in their social, financial and accommodation needs. The support worker reduces the stress which enables the person to more easily handle the stress of their mental illness. The scope of the training provided for Mental Health Foundation support workers was discussed at length and a need to provide greater training and honing of skills was identified.

Mr I'Anson indicated he had not hear of the Gianfresco Report until it was raised within evidence on 22 August 1996.

In cross examination by Mr Refshauge, Mr I'Anson discussed at length the skills, qualities, experience and training needs of a support worker. He agreed to support the notion of better trained people in the support services generally but said that the approach of the Mental Health Foundation was in a support role rather than a clinical medical role. He indicated he supported the idea of accreditation of workers provided the training can take a formal clinical or experience in the job approach. At this stage, accreditation has not occurred. The operations of the Mental Health Foundation and its support workers are largely on a voluntary basis.

The role of the support worker is not to provide clinical services or assist in taking of medication. That is seen as a clinical matter beyond the area of involvement of a support worker. Crisis intervention, assessment and diagnosis is also outside the role of a support worker. Nevertheless, a support worker may call upon help for a person they observe to be in crisis and this is precisely what Ms Sue Harkness did on 17 November 1995. She formed a view that Warren I'Anson was becoming suicidal and needed urgent help and hospital admission.

The role of support workers in contacting Mental Health Services and even the police where a crisis, risk of suicide or other event occurs was discussed at length. A debate occurred as to whether Sue Harkness, by contacting the police and ultimately involving the Crisis Team, was really involved in crisis intervention. Mr I'Anson insisted that that was a support role rather than a crisis intervention role. The support worker role was to contact and access assessment and service to deal with the crisis rather than intervene in the crisis personally.

In re examination by Mr Buddin, Mr I'Anson said he would welcome the opportunity for enhancement of training for his support workers. They should be made aware of Crisis Team procedures, the behaviour they should noting or reporting to the Crisis Team to assist in assessment, they should attend seminars and other activities to make them more aware of the needs and options open for people suffering mental illness. There is a gap in training provided to support workers due to lack of funding. Funding requests to ACT and Commonwealth Governments have proved unsuccessful in this regard. Specific funding had been sought to provide a Administrator/Manager for the Foundations operations.

Applications for funding had also been made pursuant to the national plan and strategy for

mental health where funding should be available for community organizations such as the Mental Health Foundation. Until funding is available, the Mental Health Foundation will still continue to rely heavily on volunteers.

Mr Howe raised the issue of the gap in knowledge by Ms Sue Harkness concerning emergency detention, police and mental health procedures. She nevertheless acted in accordance with the assumption she made that the police were entitled to attend and act. The lack of training should be seen in no way as a personal criticism of Ms Harkness. She had been told with her first contact with the Mental Health Crisis Team that the police could attend without the Crisis Team. She acted on that assumption by phoning the police and in any event, those issues did not have any significant effect on the outcome of this particular tragedy.

Comments on the evidence of Pru Wilson

Pru Wilson gave extensive evidence before me on 6 September and 12 December 1996. She was Programme Director of Community Mental Health Services. In a lengthy statement tendered as exhibits 98A and 98B, she addressed, on behalf of Mental Health Services, questions raised by the Community Advocate on the management and care of the late Warren I'Anson by the Mental Health Service.

She raised issues about the impact of poor media reporting on such incidents as this one. She mentioned the danger of "copy cat" reactions to situations and headlines such as "Suicide by Cop" and describing people as "schizophrenics". Research by Professor Hassan in the Australia and New Zetland Journal of Psychiatry in late 1995, demonstrated that the daily average rate of suicide in Australia increased significantly after the publication and publicity arising from suicide stories. She referred to the manner of reporting this case in the Canberra Times as representing a danger in light of that research (see extracts from the Canberra Times on 21 and 22 November 1995; exhibits 99A and 99B). The issue was addressed in November 1995 by the Mental Health Advisory Council following a forum that was convened on the incident. Ms Wilson suggested that the working party on prevention and management of youth suicide should meet with journalists and everyone in the community to ventilate these issues of reporting of suicides and destygmatization of mental illness. She spoke of incidents involving a "copy cat syndrome" that followed Warren I'Anson's death where some persons attempted to provoke police and the Crisis Team and said they were attempting to set up a similar situation and to be shot by police. She advocated the abandonment of use of phrases such "suicide by cop".

Ms Wilson indicated that this incident plus the subsequent publicity led to a general loss of confidence in the Crisis Team and an undue reliance on calling in police where otherwise it might not have been necessary. The adverse publicity concerning the Crisis Team also spread to clients who in some cases appeared to have lost confidence in the efficacy of the Crisis Team to assist them.

Ms Wilson indicated that her line of responsibility directly involved the Crisis Team but she in turn was responsible to the Acting Executive Director of Mental Health Services, Dr Stephen Rosenmann.

In response to a request by me as Chief Coroner, a number of documents were produced concerning the structure, operation and procedural manuals of the Mental Health Crisis

Team, both at the time of the incident and presently in operation at the time whilst the inquest was being conducted. The tender also included some national documents proposing change and reporting on the progress of mental health activities throughout the country and also some reports for future structuring and financing in Mental Health Services.

In cross examination, Mr Refshauge raised the issue of the availability of the information of previous assessments and activities by other staff members to the Crisis Team dealing with Warren I'Anson on the night of the tragedy. Ms Wilson agreed that information transfer in this respect could be improved and it is important for the purposes of making accurate assessments.

Increased training and emphasis upon assessments of suicide risk are being held throughout Mental Health Services, in particular with the Crisis Team. A critical debrief of this incident was held for all the Mental Health Services in May 1996 in an effort to enhance skills and give direction to future activity.

The issue of the safety of the client and others is a balancing of risk against the risk of suicide. These issues have been discussed and examined since the incident and it is hoped that Crisis Team members will be better equipped. The need for increased crisis intervention training as a specific topic was also discussed. The access to resources and information already available to the Service about the client was vital to the increased performance of the crisis team. The need of "on the job" support and a supervision reference point was also appreciated.

Warren I'Anson, at the time of his death, had a case worker, Patrick Flemming, a psychiatrist, Dr Les Drew and a psychologist, Witness 'J' (from Psychiatric Rehabilitation Services) all based at City Mental Health Services. The question of the emergence of a concept of a case manager to oversee and deal with general liaison and information issues about Mr I'Anson was discussed.

Ms Wilson conceded there was no formal protocol in general terms between Mental Health Services and the Mental Health Foundation. There was obvious liaison and some degree of information exchange between the two agencies on a client to client basis. It was conceded that a general protocol between a community organization such as the Mental Health Foundation and the ACT Mental Health Services was desirable to ensure the clarity of the respective roles of the organization and to ensure more effective communications of issues concerns and information between the two bodies. A case manager at Mental Health Services would heighten the efficiency of that process.

The issue of the training and experience of members of the Mental Health Crisis Team was canvassed. The issue of multi skilling and expansion of individual skills was supported, particularly in the area of crisis intervention. The issue of communication between the Mental Health Foundation worker, the Crisis Team and the police in this case was the subject of examination. A clearer procedure for contact and co-operartion between the Mental Health Foundation worker, the Crisis Team involved and the calling in of the police needs further clarification. The relationship of individuals belonging to the three agencies needs improvement and a more efficient procedure may have led to a quicker response by all concerned. The need to examine this relationship in the light of the development of the Memorandum of Understanding between police and Mental Health Services, needs consideration. It occurs to me that the involvement of community agencies in the operation of

the Memorandum of Understanding also needs clarification. The involvement of a third party namely the community organization, where the Crisis Team or the police are not available, needs to be further developed.

The recommendation of the Gianfresco Report that the Crisis Team ought to have more face to face assessments with clients and less telephone assessments was discussed. That recommendation has been accepted. The question of response time and target response time for the Crisis Team to emergency or critical situations was discussed. The importance of information from support workers, family members and other persons involved was critical to the role of the Crisis Team. A clinical decisions to be made whether a face to face assessment of the client or a telephone assessment of the client needs to occur. The response time is a phone contact within 10 minutes of being notified of the emergency and if necessary, a visit within 30 minutes. This was not the response time that occurred in respect of this incident.

The suicidal nature of Warren I'Anson's condition required a highly urgent response and a decision was reached that he needed to be hospitalized for further psychiatric assessment. The issue of access by the Crisis Team to a supervisor, namely herself, or a psychiatric registrar or a psychiatric consultant on duty, was appreciated as being required in critical situations.

Mr Buddin, SC, raised with Ms Wilson the issue as to why the inquest and the parties thereto were not advised of the existence of the Gianfresco Report until a later point of time. Ms Wilson replied that it was an inhouse document and in early stages they did not see its relevance to the inquiry.

Comments on the evidence of Richard Clarke - Executive Director of Mental Health Services

Mr Clarke gave evidence before the inquest on 11 and 12 December 1996 at a time when he had only been recently appointed to his new position.

Mr Clarke observed the need to create necessary mechanisms to ensure there is continuity of care or treatment between one service or another. The system needs to be redesigned to ensure that it works as a system, not as a number of functional components of a system.

Bureaucratic barriers between parts of the system need to be eliminated so it operates as a cohesive whole. Mr Clarke heralded his plans to make fundamental change in the way the ACT Mental Health Services operate. The process of change involves consultation with consumers, carerers and the non government sector. The staff of the organization need to examine and define the services they provide and the manner in which they will be provided. Process will start with a draft strategic plan and then a plan for the implementation of the change. The question will not be solved by reviews but by implementation of appropriate views.

Mr Clarke referred to the implementation of the "Oscar" system which will involve the development of computerized patient information systems. This will ensure that information is readily available to people in crisis situations and could have direct bearing on the sort of situation as that which arose in this tragedy. The central feature of such a system is centralized available information from all sources in possession of the mental health services. In the absence of such a process, it is almost impossible to gain a clear and complete picture of a particular client when information is required. Privacy and access issues obviously need consideration. The system needs to focus and function upon the requirements of service providers in dealing with their clients. The access to up to date information is a key to a

responsive service. The information system may need to include valuable information from sources outside ACT Mental Health Services such as non government, community mental health agencies as well as other sources.

Mr Clarke has had some experience with the regional mental health services in Bendigo, Victoria. He hopes to use information and resources from that service to assist the development of ACT Mental Health Services. The Bendigo experience of cross training and cross cultures between mental health services and police may be valuable in the ACT context.

The Memorandum of Understanding (MOU) between police and Mental Health Services has now been signed. A review process involving Assistant Commissioner Stoll on the police side, and Richard Clarke on the mental health side will be put in place. Staff in mental health and the police service will also be made familiar with the significance of the MOU on a day to day operational basis. Mr Clarke emphasised the need for development of a specific skills in crisis intervention techniques for mental health staff. Training of Crisis Team members in crisis intervention techniques will be given top priority. Such training needs to be on a continuing basis.

He indicated that a number of the recommendations of the Gianfresco Report are very sensible, logical and will be implemented.

Mr Clarke made the following general comments concerning the Gianfresco Report and its implementation commencing at page 6.5 of his evidence on 12 December 1994:

"All right. Now, is there something that you'd like to say by way of opening remark about the general thrust of the Gianfresco Report, bearing of course that there's already been a commitment at the government level to the philosophical thrust of the report?---Yes. Just a couple of - I suppose three or four points I'd like to make. One, the implementation, as I mentioned yesterday, will be in the context of trying to change the organisation and the organisational culture. I therefore need to go through a process of probably debating some of these issues through with staff that are going to be affected by change. There are some industrial implications. Secondly, the - Peter Gianfresco has come from a service in Sydney that I'm, in fact, very familiar with and have previously worked with his superior in helping to change the service that I work in so I'm familiar with where he is coming from and, in fact, I was scheduled to do a review of their service last week so I am quite familiar with Peter's work and how he operates. I would also like to say that in the executive summary Peter refers to - and it seems - the way the report is written it seems somewhat almost paradoxical or contradictory but he makes a point that there is a trend in Australia to moving away from it. Having a stand-alone crisis into crisis team. In fact, in the fourth paragraph - fifth paragraph this review of the ACT Mental Health Service crisis team occurred at a time when crisis teams in New South Wales are increasingly embracing the generic crisis intervention role through integration with other adult mental health programs.

Yes?---Now, I do not want to confuse the court but basically what he is getting at is that there are two - what's traditionally happened is that a service sets up a stand-alone crisis intervention team that is highly mobile and is involved in treatment and all the things that he is recommending and then has evolved on to a service which is incorporated - a crisis function is incorporated into a community mental health service and the way that operates is that you have all staff being rostered to a crisis roster; all staff being skilled up in being able to deal with those crisis and community based treatment capacities but also all those people

aren't, if you like, a bit like the fire brigade sitting around polishing the brass waiting for crisis to happen. There are some downsides with going with a stand-alone service so Peter makes reference to this but still suggests that we go ahead with a standalone service. My experience is that I've set up two from scratch - two crisis community based services and then changed them to incorporate what Peter's talking about which, I believe is probably the state of the art in terms of a mental health service. I'm still - - -

So it's a sort of a hybrid in a way?---Yes.

Right?---You still get the same functions but it's a much more effective utilisation of staff and you get a broader skill base into your team and it gives you greater flexibility. Now, I'm still in two minds about whether we proceed in terms of skilling up the existing stand-alone crisis team or we move straight ahead to saying, look we want this type of service in place as soon as possible which is really the state of the art service.

Can you just repeat what it is that you mean by the state of the art service?---What I would see as a state of the art service is an amalgamation of a number of functions in a community based mental health service, that is that they do, in fact, have a crisis function. They are, in fact, very mobile. They use case management and they provide assertive outreach treatment and support in the community and at each day, for example, you would have two people who would be rostered to a - to be the crisis - provide that crisis service for that day or that shift but tomorrow they may be, in fact, case managing a number of people that they have as on- going case management so that you don't just have people only doing the crisis work. You rotate that through - my experience is you get a better utilisation of staff; you get all staff skilled up and so it's a question we have to debate throughout the next few weeks about - - -

Now, the latter proposal is what you talked about as state of the art?---Yes.

Do I take it from that that in your mind that represents the optimum?---Yes and Peter has actually referred to that in his report saying there's an increasing trend towards this in New South Wales. There's also an increasing trend in Victoria and it's a debate we have to go through about whether we go through stage 1 or jump to - - -

All right. Is it the situation that come what may you would try and move, at some stage, to the optimum model?---Exactly.

All right. Now, do I take it from what you're saying that you're simply not sufficiently familiar with the local operation, the personnel, the structures and the culture to know whether or not it's appropriate to move straight to stage 2 rather than go through stage 1 and ultimately get to stage 2?---Basically."

Mr Clarke indicated he will be reviewing the operation of the Mental Health Crisis Team in the light of the detailed of the detailed examination and recommendations in the Gianfresco Report. He sees the role of the Crisis Team as a process that evolves and is need of constant review to meet increasing and changing circumstances. He generally favoured a rotational crisis services to ensure the pressure of crisis intervention and out of hours work is not thrust upon a limited few. Mr Clarke detailed his early response (due to his recent appointment) to the various recommendations of the Gianfresco Report.

He emphasises the need for an assessment by a community mental health service prior to anyone being admitted to hospital and that is the proper process. He favours the establishment of a "triage" system to enable an adequate assessment of priorities for response. Such a process would need to be underpinned by significant training. Mr Clarke explained his views on that matter at page 18.3 in his evidence of 12 December 1996:

"Right. Please go on, you were going to say?---Well, basically you have a triage capacity where some body whose role is to answer a phone and you have a system to divert phone calls if some body is tied up on a phone call. But basically there are four categories you can broadly put if you get a call from a carer, consumer, GP or whoever about a client or a potential client. And what we call category one is really an emergency, where some body needs to go to hospital and needs admission and that's very clear that they are a danger to themselves and the community and that - those arrangements need to happen quickly, so that is a category one response. Category two, what we call a category two is a - where there is a clear psychiatric crisis or appears to be a crisis and you want some body there as soon as possible and we would develop bench marks in terms of those response rates. For example, within the southern tablelands 80 per cent of that geographic area we can respond to within one hour. In Canberra I would expect it to come under that. Then you go, for example, they work on a response time to a crisis of about 20 minutes, so that is category two. It is not all that common but when it happens you need to get there fairly quickly. Category three, is really saying that this person clearly needs an assessment, but it is not urgent, but can be done within the next 24 hours. And category four is saying this person appears not to require an assessment from us because it is clear something that doesn't fall within our business, if you like, and what is the appropriate person to refer them on to. So that's, I suppose a category two and three is really sending in the people to do the assessment and to determine what is the best course of action. It's about building responsiveness into the system."

Mr Clarke favours a much more expanded role in terms of more intensive community based treatment prior to any attempt at hospitalization. That will involve increased training and enhancement of skills on the part of members in those community teams. There is a spectrum in the terms of the level of severity of illness or dysfunction and the need for levels of management of acute mental illness or dysfunction. One end it represents the need for hospitalization, at the other end a person has a mental health problem but can live within the community with support. People can manage the acute phase of their illness in the community if they are given adequate resources and support. That may include a psychiatrist going with the Crisis Service to assess and visit a person, sometimes on many occasions per day, if that is necessary to avert an admission to hospital. It is a case of using the same skills but moving them into a more community based setting.

The greater emphasis upon a community based operation has industrial implications. It also involves changing professional work practices and changing the roles of professionals in the relevant areas. This requires significant training, discussion and planning. It also gives to consumers a greater input into a larger number of options to receive necessary treatment in the community rather than being admitted to hospital. It is an important extension for appropriate crisis intervention.

In cross examination by Richard Refshauge, Mr Clarke emphasised the need for a centrally based holistic information system which is constantly updated at the least on a 24 hour basis with the hope that it could be wound back to a 12 hourly update. This may have assisted in the present case to enable the police and Mental Health Crisis Team workers had total and

updated information concerning Warren I'Anson, his history and condition particularly in relation to the views of Witness 'J' the psychologist who visited shortly before the death. Issues were also raised in relation to discharge liaison for people who have recovered sufficiently from the mental illness to be discharged from hospital but still need to be community follow up. Co-ordination of discharge treatment for patients needs to be dealt with appropriately.

Mr Clarke emphasised the importance of development of a case management system of operation. Training and multi skilling should mean that adequate and appropriate case managers can be drawn from a variety of mental health related backgrounds - social workers, nurses, psychologists, occupational therapists etc.

With the development of the "purchaser provider" model the need for standards of accountability of outcomes involving both government and non government/community agencies in necessary. The provision by the non government sector of accommodation for persons suffering mental illness was discussed.

The question of clarification and co-operation between police and mental health workers in taking emergency action was to be discussed. The question of decision making on emergency action needs cross training and development. The education of police officers and mental health officers has occurred extensively in Victoria and in the Bendigo area where Mr Clarke has had some experience. That can perhaps be drawn upon to assist developments in the ACT.

The clinical practice and procedures concerning risk assessment for suicide need development, dissemination and training. The availability of information and modern and new approaches to this difficult area, need to be discussed and disseminated amongst mental health workers.

In cross examination by Mr Bayliss, Mr Clarke discussed extensively minimum and optimum levels of training experience for Crisis Team members. That issue will be further developed.

Comments on the Evidence of Helen Briggs

Helen Briggs gave evidence before me at the inquest on 8 November 1996. Her evidence and the statement made by her tendered as exhibit 119B were as a result of a letter from me to Mr Russell Bayliss of the ACT Government Solicitor's Office, representing health interests. That letter requested certain material be provided to the inquest from Mental Health Services perspective. The letter from me is exhibit 119A.

Helen Briggs is a senior policy adviser with the Mental Health Policy Team in the Health Outcomes Policy and Planning area of the Department of Health and Community Care. She gave evidence as to imminent changes in the structure, organization and performance of health services including mental health services within the ACT. She indicated mental health issues will canvass a number of areas outside departmental structures such as Calvary Hospital, general practitioners, Richmond Fellowship, Ainslie Village and other agencies and groups in the community involved in the provision of mental health services. She indicated that following the Gianfresco Report and other reform moves, a basic issue in reform was the underpinning philosophy of what role the Mental Health Crisis Team should take. The question of the Mental Health Crisis Team being a mobile treatment team or a mobile

assessment team or a combination of both is a matter of policy debate which is at present unresolved. Mental health services at present in the ACT operate very much on a medical or clinical model and not in a wider community based model as occurs in other places in Australia.

She foreshadowed that the Chief Minister and Minister for Health is about to make a significant policy statement concerning restructuring of health services including mental health and a movement to deal with mental health clients within the community. The number of persons using the Psychiatric Unit or living in mental health facilities such as Watson or Hennessy House are comparatively small in respect of the client requirements of mental health services. The smallest number of people are actually at the acute end of the service provision whereas the bulk of people with mental health problems live at home.

There is a need for a well qualified responsive group of people who are highly mobile who can respond to persons with mental health problems and crisis in the community. The real attention is to whether they simply respond and assess or whether they respond, assess and provide treatment in situ.

She indicated there was general support from her and others in positions of influence for the recommendations of the Gianfresco Report. The issues involved in providing community based mental health care go beyond the operation of the Crisis Team. The issue of discharge planning from the Psychiatric Unit is equally important. Face to face operations of the Mental Health Crisis Team are a matter of some significance.

Ms Briggs discussed the issue of putting the draft Memorandum of Understanding (MOU) into full operation. She indicated the final adoption of the MOU between Mental Health Services and the AFP was immanent. She made general comments concerning community directions and the ensuring of a more responsive response to the individual needs of clients in the community as being a basic direction of the Chief Minister's proposed policy statement.

That policy statement has been the subject of discussion at later days of evidence in the inquest.

In response to cross examination by Mr Refshauge, Ms Briggs indicated that the focus of the form would be to direct mental health services towards a community focused service. On the basis that there is an acknowledgment that people live in the community with mental health problems and services should be provided where they need them rather than necessarily using medical model of service to give the level of support they need. A closer relationship with GPs and other community workers is vital in this community focus. The idea that the Mental Health Crisis Team would have a greater emphasis upon treatment operations rather than mere assessment was foreshadowed.

General Comments:

The Community Advocate submits the need to make a finding of organizational culpability and a finding that the death was avoidable.

I reject the need legally, philosophically or logically to make any such finding. Although there may be cases where such a finding is appropriate.

Further, I do not find it justified on the facts that I make such a finding. That is not to say that in hindsight there were not steps that could have been taken to improve performance and perhaps even prevented the death occurring.

A more constructive approach consistent with my powers under the Act, is to examine in detail what occurred and make recommendations as to improvements and best practice for all agencies involved in the challenge of dealing with such crisis in the future.

There are three immediate important factors in this case that were most significant in a direct sense in defeating the aim of the plan formulated by AFP officers in conjunction with Mental Health Crisis Team members at the scene in both gaining entry and safely removing Warren I'Anson to hospital for treatment.

Those factors are:

• The delay in breaking through the door by Constable Sheehan. He needed two decisive kicks. He had "practiced" on a similar door in a nearby flat to assist his judgment in this area. Had he been able to gain a quicker entry, the element of surprise may have meant that Warren I'Anson could have been safely subdued without the tragedy occurring.

• The lack of precise knowledge of the position and situation of Warren I'Anson just prior to the entry. He was not sitting perhaps asleep on the couch as thought. He had jammed a mattress against the door unbeknown to the "entry team".

• The fact that Warren I'Anson had indicated a prediction to his father and the Mental Health Foundation worker, that he may suicide and be shot by the police. Although the police involved in the case indicated this last factor may not have changed their tactics, both Assistant Commissioner Stoll and Federal Agent McDevitt indicated that it would be significant knowledge for them and would give rise to a reluctance to adopt a decision to make a forcible entry.

The Community Advocate focuses upon six systemic causal factors as follows:

1. Inadequate training and policies to guide police operation responses.

The performance of Sergeant John McDonald in communications area in his contact with Sue Harkness from the Mental Health Foundation, was complete inadequate in both eliciting the relevant information, dealing out adequately and appropriately with the caller and ensuring a response co-ordination between police and the Mental Health Crisis Service. Those criticisms as to the professionalism of Sergeant McDonald's approach and his insensitive dealing with mental health issues are accepted by Assistant Commission Stoll. I support this aspect.

Nevertheless, I cannot say that it would have made a high level of difference in the ultimate outcome of this tragedy.

2. Inadequate knowledge and training about current mental health law and the police role and powers under it. There appears to be a lack of detailed knowledge of the exact extent of powers and discretions by police acting under emergency powers under the Mental Health (Treatment and Care) Act. The lack of a precise and clear understanding of the various powers and decisions to be made under the Act is present. I cannot be satisfied that any

3. misunderstanding changed the action to be taken. It is clear that a decision jointly was made by police and Mental Health Services that the appropriate course of conduct was to intervene even if it involved the use of force and forcing entry and removing Warren I'Anson to hospital for treatment and assessment.

4. The absence of a viable or updated Memorandum of Understanding between the AFP and Mental Health Services. This matter was under discussion and has developed and operated with appropriate amendments up to the present time.

5. The absence of a policy to assess the efficacy of forced entry and an absence of safety principles.

Developments in this area and the introduction of safety principles have since occurred and will assist to rectify the criticism under this head.

6. The policy of the Mental Health Services that the Mental Health Crisis Service have an assessment role rather than a proactive crisis intervention role.

The new "community based and focus" approach may have meant that earlier community assessment and treatment may have prevented the resultant deterioration in Warren I'Anson's condition.

7. The failure of the Mental Health Foundation to provide adequate training and support to its support workers. Better training and relevant experience may have meant that the worker, Witness 'S', may have passed on important information that Warren I'Anson had discussed the issue of him being "shot by police". This is meant as no personal criticism of Witness 'S' and the comment is made in hindsight.

Many of the issues raised by the Community Advocate above are dealt with in the recommendations and the discussion relating to them below.

Pru Wilson of the Mental Health Services raised issues concerning the impact of media reporting on incidents such as this. She mentioned the danger of "copycat" reactions to situations in headlines such as "Suicide by Cop" and describing people as "schizophrenics". She mentioned research published in 1995 that demonstrated the daily average rate of suicide in Australia increased significantly after the publication and publicity from such stories. I would support the recommendation that a working party on prevention and management of suicide and particular, youth suicide, meet with journalists and other relevant persons in the community to ventilate these issues and look at strategies to minimising the effect of media reporting. The object is to invoke the assistance of the media to reduce impact on suicide levels and also generally, to aid the destigmatization of mental illness in the community.

The evidence given by a witness, Glenn Chapman, to this inquest has been completely discounted as unreliable and misleading. Mr Chapman approached a Canberra Times reporter at the scene and requested the payment of a fee for the provision of information to the effect that he had heard a voice say "Do not shoot" or words to that effect just prior to hearing shots. That version of events was supported by no other witness. The media, including the Canberra Times, has a responsibility and duty to report in the public interest evidence surrounding such interests. I implore that care be taken to ensure that persons are not encouraged to seek money for the circulation of false and misleading information.

At my request, the editor of the Canberra Times, Mr Jack Waterford, submitted a draft statement to the inquest and explained the position of the Canberra Times in respect of these issues. his statement, exhibit 130A. I set out that explanation below:

Draft Statement of John Edward O'Brien Waterford, journalist, of 64 Elimatta Street, Braddon, 2601 in the ACT.

Prepared for the Warren I'Anson inquest

1. I am and have been since April; 1994 the Editor of The Canberra Times and responsible generally for editorial matter appearing in that newspaper.

2. I was on duty on November 17 last year and I became aware of the I'Anson death,

in mid-evening, Friday night is a peak production night at The Canberra Times, with the first edition generally going to press at about 10.30pm, and, while dispatching reporters and photographers to the scene, I took some care to organise (and ended up myself writing) the brief first edition report.

3. Soon after, I myself went to the scene. By then, much of the area had been roped off by police and it was difficult to obtain any near access the site or to interview witnesses.

4. I spoke there to one of my reporters, Andrew Kazar, who told me that he had been approached by a person who had said he was a near neighbour of the dead man and who was offering, for a fee, to tell what happened.

5. It is unusual for such a fee to be paid,- particularly by The Canberra Times, though it is not unknown. (It is far more common with other newspapers, and very common in Britain.)

6. In deciding to authorise the fee, which I did before any interview took place, I took into account the following considerations:

a) The matter was a matter of high public interest, and it was difficult, particularly because of time constraints, to get a lot of information. Although

police had already provided some bare-bones information, their information was limited and not incapable of being interested,

b) The person was a mere witness of events, and was in no way involved in any criminal enterprise.

c) There was no incentive placed upon him to gild the story, nor, on

the information which was available to me was there any reason to believe that he would do so, Our agreement to pay was not conditional on his giving us material of any particular sort.

d) Had we not made a payment it is unlikely that we would have been able, particularly within the production time-frame, to get any information

other than that which was officially supplied.

e) the sum asked for was quite trivial - I think $30 and unlikely to influence him in anything he said.

8. The conversation was recorded by the reporter.

9. Several days later, I was asked by investigating police whether I would give the name of the witness and a copy of any notes in relation to him. After consideration (focussed on whether we had given him any explicit or implicit promises of confidence I decided we had not) I had the person's name and a tape of the conversation supplied to police.

I do no more than warn of the danger to investigation and resolution of matters in such a practice. I do not specifically criticise the practice but merely emphasise the need for care.

There is no doubt that the misleading evidence of Mr Glenn Chapman deflected the investigation in this matter, causing the waste of resources and time and involved publicity that was misleading to the general thrust of the coronial investigation.

The process of joint consultation between Mental Health Services and the AFP has continued since the completion of the inquest. The current operating Memorandum of Understanding is attached as Annexure C.

The Gianfresco Report has proved the foundational document for change in respect of the operations and structure of the ACT Mental Health Crisis Team. A summary of the recommendations of that report are attached as Annexure D.

RECOMMENDATIONS

I am gratified by the positive attitude of the Australian Federal Police and the Mental Health Services during the period of this inquest. Substantial action has been taken to reform and change by the agencies separately and jointly as the inquest proceeded until May 1997.

Progress and achievement has been significant and has been detailed, to some extent, in these reasons.

The inquest has provided, in a sense, an impetus to the proactive process. What has occurred has been a tribute to the leadership of the heads and senior staff of both agencies.

Accordingly, many of the recommendations I make here may have been considered and been fully or partially implemented already. The recommendations must be considered in that light and be evaluated and considered accordingly. I have taken the approach that the identification of best practice and means of importance are a much more positive approach than attributing blame in this case. That is not to say that that should always be the approach of a Coroner. In this case, I believe that to be the correct and constructive approach. The recommendations can be considered as a check of the accountability of all relevant stakeholders in tackling the vexed issue of crisis intervention involving persons with a mental illness. A consideration of

the appropriate approach of negotiation, the use of force and the use of other alternatives in dealing with these situations must be under continuous review and consideration.

I now detail my recommendations as follows:

1. The availability of the best intelligence gathering methods and equipment at the scene of a crisis. Surveillance equipment of both an audio and visual type would provide the decision makers with the current activities, intentions and statements of the person in crisis. If a decision on forced entry is to be made, it should be made on the best accurate, current knowledge of the position, activities and capabilities of the person concerned. Such equipment should be readily available to police and crisis workers.

2. An emphasis should be made in the training of mental health crisis workers and AFP officers on specific issues involved in crisis intervention. Such training could involve exercises and scenarios from actual cases followed by joint discussion on the question of decision making, techniques and the development of best practice and successful approaches. Approaches to risk assessment and joint decision making by police mental health personnel at the scene should be developed. It is important that such training be encourage a joint and cross/exchange basis between the two agencies.

3. A full and continuing evaluation of other means of subduing and safely controlling a person in a dangerous mental health crisis situation. Other alternatives need to be available and developed other than the use of lethal force by firearm. Such alternatives as OC and CS sprays, nets, police dogs, batons and body armour should be considered and evaluated against the safety principles currently in force and practice in the AFP. New techniques and approaches are constantly emerging. The AFP must keep abreast of all developments and evaluate them. Every incident is different and safely evaluated techniques should be available to officers and considered, appropriate or otherwise, in a crisis intervention situation. Such measures must clearly be involved with negotiation and consideration of action.

4. Mental Health Services should liaise with media and journalistic representatives concerning the development of an increased level of understanding of the effect of media reporting on suicide rates and those persons in the community suffering mental illness. Sensitive reporting approaches should be encouraged in respect of issues involving crisis intervention with the mentally ill. The aim should be the decrease in stigmatization of mental illness and a change in the community culture and attitude towards mental illness.

5. The development in Mental Health Services of an information system that is updated and complete concerning the clients of the Service. Such a system will enable full and up to date information for Mental Health Crisis workers at the scenes of incidents requiring crisis intervention.

6. The maintenance of an increased emphasis in AFP training on issues involving the mentally ill. The focus should be upon communication with persons and the response to mental health issues. A continuing evaluation and monitoring of AFP performance in this area should follow.

7. A full register/record of crisis interventions where the AFP and mental health community crisis teams have been called in to act jointly should be kept. This should include incidents

8. that have been satisfactorily resolved by negotiation and should not be restricted to cases forcible entry by police has been required.

9. The register should collect such information and publish it on a regular basis. The information should be separately evaluated by each agency in respect of its future planning and also some joint consideration be given by both agencies.

10. A monitoring group should be formalized concerning the register of crisis intervention. That group should report and evaluate progress. I believe the Office of the Community Advocate, in the best interest of clients with a mental illness would play a significant role and interact well with agency representatives. The aim is to keep the process of change and review active and continuing to strive towards achieving best practice.

11. The establishment of joint training ventures involving AFP officers and Mental Health Crisis Team workers. The aim of such training would be to build up a team approach to decision making and action in dealing with crisis intervention situations. The need is to expose each agency to the operations, culture and attitudes of the other. An experiment in Bendigo, Victoria, of having the members of one agency accompany a team from the other agency on a work shift, has proved beneficial. This would develop a greater understanding and respect for the work and skills of each agency and the role perfumed in crisis intervention.

12. Mental Health Services should encourage workers and staff of non government community agencies to be exposed to training on crisis intervention. Such persons are at the coal face when an emergency crisis emerges. They need to be trained in identifying emerging crisis for persons suffering mental illness as well as being aware of the procedures for contact and dealing with the Mental Health Crisis Team and the AFP. Procedures for community workers in this area should be drafted, disseminated and training programmes developed. Mental Health Services should ensure that clear protocols are available to Mental Health Crisis Teams at the scene of crisis intervention for available admissions to a psychiatric unit if that is required. Mental Health Services should ensure that clear advice is at hand from a supervisor and also expert clinical advice from a psychiatrist, psychologist or case manager concerning the particular individual involved. Attendance at the scene should be a viable option for such persons if the crisis indicates it appropriate. A Mental Health Crisis worker at the scene of a crisis should have up to date information about any contact or reports from Mental Health Services as whole concerning contact with the client.

13. The formation and maintenance of an Interdepartmental Standing Committee on Mental Health that meets on a regular basis. This would provide a forum for government and related stakeholder agencies to take a holistic approach to mental health issues, procedures, and reforms.

14. The AFP liaise with the local media and emphasise the possible dangers to investigations and resolution of crisis intervention situations involved in the offering of a reward to potential witnesses for an exclusive story. No universal statement against such a practice should be made but, a greater appreciation of possible consequences needs to be ventilated.

15. Using Project Beacon as an approach and relevant experience and developments with other relevant police forces in crisis intervention, the AFP should regularly review its approach, training, culture and attitude towards crisis intervention. The AFP needs to ensure

16. the reinforcement of the 10 Safety Principles. The use of debriefing on crisis intervention incidents is a means of reinforcing their safety principles and encouraging a culture of reinforcement of successful interventions without injury, danger to the public or fatal results. The 10 Safety Principles for the AFP in the ACT are attached as Annexure E.

17. The development of appropriate strategies in dealing with persons that have indicated a disturbed intention to be "shot by police". This situation necessitates a greater emphasis on the negotiation and containment but consistent with safety to the person, relevant police and other members of the public involved.

18. Media pubilicity that persons in a mental health crisis may indicate an intention to be "shot by police" should be given sensitive and non sensational treatment. This is so in the light of research experience that demonstrates a "copy cat" approach by other disturbed persons with the resultant increase in suicide generally (see the research by Professor Hassan in the Australian and New Zealand Psychiatric Journal, 1995).

19. The use in crisis intervention situations of trained police negotiators. The need exists to give such police negotiators special training in mental health issues and assistance in the need for a distinct approach for persons in mental health crisis. There is value in involving some mental health crisis workers in exposure to negotiation techniques in their dealings. The present focus of police negotiation upon terrorist type situations involves different skills and approaches to those required when dealing with mental health crisis. Skills, training and accreditation for negotiators in mental health crisis interventions, should be encouraged. The availability of such negotiators at an early point of time in a siege mental health crisis situation is highly recommended.

20. Both Mental Health Services and the AFP need to ensure that both police and Crisis Team members have an accurate and functional knowledge of the powers and procedures involved in the emergency detention of a person in mental health crisis. This issue should be ventilated in the Memorandum of Understanding and also in agency training, (both separately and jointly).

21. Mental Health Services should ensure that there is a standardized protocol regulating the operation, co-operation and procedures of non government community agencies that provide important community based care for persons with a mental illness in the community. The scope of such agencies in the community includes support and care as well as accommodation services. Both Mental Health Services and the community agencies need to have a clearly understood protocol regulating their relationships.

22. Mental Health Services should provide funding for the adequate training of community workers working for non government community agencies providing services for the mentally ill.

23. In consultation with community agencies, Mental Health Services should develop adequate accreditation, training and experience standards for persons to perform tasks for the mentally ill in the community. Information and knowledge concerning available services and interaction with police and the Crisis Team are particularly significant in the context of this inquest.

24. As community agencies provide a great percentage of the day to day support, care and accommodation for the mentally ill in the community, the recognition of their role must be emphasised and adequate funding be made available. Should this not occur, the earlier development and increase of mental health crisis will exacerbate.

25. The formation by Mental Health Services of a working party with representative of all relevant non government community agencies to oversee and ensure issues involving protocols of operation, training and accreditation, adequate management and accountability of community agencies to the community, their clients and Mental Health Services. I see this group as a forum for the development of approaches to non government community care. One of the issues involved is the role of non government agencies and their workers in the reduction of crisis in mental health matters and the assurance that adequate procedures and processes are available to deal with an involved appropriate agency should a crisis exacerbate.

26. Appropriate levels of funding for non government community agencies providing mental health care and accommodations to person in the community is a vital consideration. If such groups are not appropriately funded, mental health crisis will increase and exacerbate and the need for mental health crisis intervention will become greater.

27. The AFP to ensure that available written guidance is to be given to officers to assist them in the decision to exercise their discretion to make a forcible entry in a mental health crisis situation. Emphasis needs to be given to an approach that the decision to make a forcible entry does not automatically involve the decision to use lethal force by firearm. Consideration should be given to the use of other methods beyond the use of a firearm to safely secure a person in a mental health crisis situation. The decision making process in this respect to be integrated both with an adequate consideration of the safety principles and the availability of alternative methods of securing persons in a mental health crisis beyond the use of a firearm. Emphasis should also be placed upon negotiation and containment as a first line priority with adequate consideration of the safety principles. These issues are best achieved by debriefing and scenario training.

28. Consistent with the approach and the development of the recommendations of the Gianfresco Report, the role of the Mental Health Crisis Team should be clearly defined. Early intervention should be encouraged. The team should be community based in both in assessment and "on the spot treatment" role. The aim should be to ensure that hospitalization is restricted to a situation of last resort where it is absolutely necessary consistent with the safety of the patient and others.

29. Membership of the Mental Health Crisis Team be comprised of multi skilled persons across the range of relevant mental health professionals. A turnover of mental health professionals from other parts of the mental health service would achieve a well balanced and greater understanding across the board in mental health services of the role and importance of Mental Health Crisis Teams.

CONCLUSION

I have made the above recommedations constructively in an attempt to provide guidance to the relevant agencies in continuing the proactive process of change and review that began

while the inquest was running its course. I restate, that many changes have already occurred at the time of my delivering this decision.

I thank Mr Terry Buddin, SC, (the ACT DPP) who gave me great assistance and support during this long inquest. I congratulate the other parties and their representatives for the constructive way in which they approached their tasks. I single out Mr Richard Refshauge and the Community Advocate, Ms Heather McGregor, for the pivotal role they played in the development and progress of Part II of the inquest involving a consideration of system issue.

Finally, I express my personal sympathy to Mr Brian I'Anson and his family. I record my appreciation of his immense personal contribution in the community to assist the plight of persons with mental illness and crisis. We have all learnt lessons from this tragedy and my fervent hope remains that the results of those lessons may mean that the death of Warren I'Anson has not been entirely in vain.

R.J. CAHILL Chief Coroner

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