Deceased
John Inman Bale
Demographics
60y, male
Coroner
Decision ofDeputy State Coroner Grahame
Date of death
2014-09-29
Finding date
2017-03-30
Cause of death
single gunshot wound to the head, self-inflicted
AI-generated summary
A 60-year-old man with bipolar disorder, depression, and recent bereavement made a 000 call stating suicidal intent with a firearm. A PoliceLink telephonist (Mr Tant) engaged him for 17 minutes in skilled de facto negotiation, establishing rapport and attempting dissuasion. A first-responder sergeant, misinterpreting radio broadcasts (hearing 'will shoot police' rather than 'will shoot self'), directed call termination to establish direct contact. The telephonist was not aware this decision was made and terminated the call abruptly—a critical moment described as 'completion' of the suicide act. Contact was never re-established. The deceased died by gunshot within hours. The coroner found no policy breach but identified a systemic failure: first responders lack training in recognising active suicide interventions, understanding the psychological harm of call termination, and procedures for transferring rather than ending calls with suicidal persons. Key lessons: suicide prevention requires slowing responses, maintaining existing rapport, gathering contextual over evidentiary information, and implementing transfer protocols rather than abrupt disconnection.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of John Inman Bale Hearing dates: 10-12 October 2016 Date of findings: 30 March 2017 Place of findings: State Coroners Court, Glebe Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: Coronial Law, - Death in a police operation, transfer and termination of a 000 call, self-inflicted death File number: 2014/286081 Representation: Ms Emma Sullivan instructed by Ms Carolyn Berry, NSW Crown solicitor’s Office, counsel assisting.
Mr R. Reitano, of counsel instructed by W.G McNally Jones, solicitors for Inspector Nick Seddon.
Mr B. Haverfield of counsel instructed by Walter Madden Jenkins solicitors for Sergeant A Steel.
Mr R. Hood of counsel instructed by McCabes solicitors for he Commissioner of Police.
Findings: The deceased was John Inman Bale.
He died at 36 Arndill Avenue, Baulkham Hills, Sydney.
He died on 29 September 2014.
He died as a result of a single gunshot wound to the head. The wound was intentionally self-inflicted.
Non Publication Orders attached Orders Recommendations The following recommendations are directed to the NSW Commissioner of Police I recommend
That the NSW Police Force seek to implement (with expedition) the proposed amendments to the triple ‘000’ emergency PoliceLink/ROG Telephony and Dispatch SOPs (in the form of Annexure A or similar thereto) providing for telephonists to transfer suicidal callers to nominated police officers at the scene.
That the NSW Police Force give consideration to appropriate training for first responders in dealing with suicidal persons in high risk situations including with respect to the potential implications of terminating existing communication, the possibility of having telephonists transfer calls to the scene, and the need for gathering contextual information.
IN THE STATE CORONER’S COURT GLEBE NSW SECTION 81 CORONERS ACT 2009 REASONS FOR DECISION This inquest concerns the death of John Inman Bale.
Introduction
John Bale was 60 years of age at the time of his death. He was the much loved father of James, Amy and Charlie Bale. He was reported to be a gentle man who loved his children. He attended church regularly.
Mr Bale had recently faced some personal difficulties. He had coronary by-pass surgery in 2010 and was known to suffer from depression and bipolar disorder. He was retrenched from his position at the Shell refinery in 2012 and found coping with retirement challenging.
Throughout 2014 he continued to suffer from mental health difficulties and undertook electroconvulsive therapy. He apparently struggled with suicidal thoughts and was hospitalised from time to time. Matters became more unbearable when his mother died in August 2014. This was devastating for Mr Bale and he suffered greatly with ongoing grief.
Throughout this period he remained in contact with his children and his psychiatrist.
Mr Bale was booked to attend the Northside Clinic for a voluntary admission to commence on Monday 29 September, 2014. However, at 7.15am on that day he rang Premier cabs to cancel a booking to take him hospital. Shortly afterwards he rang “000”. He was transferred to a Policelink customer service representative or telephonist called Mr Jacob Tant. Mr Bale explained that he had a rifle and that he was going to shoot himself. He was polite and calm. Police were notified and they made their way to the vicinity of Mr Bale’s house. The conversation with Mr Tant continued for 17 minutes.
Unfortunately communication was never re-established and Mr Bale was eventually found dead on his bed shortly before 11am. It was immediately clear that he had died of a gunshot wound.
The role of the coroner and the scope of the inquest
The role of the coroner is to make findings as to the identity of the nominated person, and in relation to the date and place of death. The coroner is also to address issues concerning the manner and cause of the person’s death.1 In addition, the coroner may make recommendations in relation to matters that have the capacity to improve public health and safety in the future.2
In this case there is no dispute in relation to the identity of Mr Bale, or to the date and place or medical cause of his death. For this reason the inquest focussed on the manner of Mr Bale’s death, in particular the response of the NSW Police Force to the “000” call that he made on the morning of 29 September 2014.
This is a mandatory inquest, because Mr Bale’s death occurred “during the course of a police operation”. Parliament requires that inquests of this kind are conducted by a senior coroner.3 This statutory position reflects the importance of independence and transparency when it comes to investigating deaths in this category. The circumstances surrounding these deaths should be carefully scrutinised and care must be taken to ensure that all relevant police policies and practices are most carefully reviewed. Any opportunities for improvement should be identified and explored, particularly if they have the capacity to save lives in the future. At the same time it is important to remember that operational policing can be highly unpredictable and stressful. One must always be careful when reviewing decisions made in the field from the relative comfort of the courtroom. The purpose of this inquest is not to lay blame on any individual, but rather to see if it is possible to identify opportunities to reduce the risk of tragedy in situations of this nature.
1 Section 81 Coroners Act 2009 (NSW) 2 Section 82 Coroners Act 2009 (NSW) 3 See sections 23 and 27 Coroners Act NSW 2009
With this firmly in mind the inquest explored NSW Police policies and procedures in relation to the following matters, Whether the applicable NSW Police Force policies and procedures were followed regarding the police response to the ‘000’ call made by John Bale, including with respect to: a) the direction by Sergeant Adam Steel to terminate the ‘000’ call; b) the risk assessment undertaken by Sergeant Steel, in particular the basis for the view that Mr Bale was going to kill police and then himself; and c) the critical incident investigation.
Section 81 (1) of the Coroner’s Act (2009) NSW requires that when an inquest is held, the coroner must record in writing his or her findings in relation to the various aspects of the death. These are my findings in relation to the death of John Bale.
The Evidence
The Court heard oral evidence over three days and received extensive documentary material including witness statements, expert reports, photographs and recordings. At the end of proceedings that material was carefully summarised by counsel assisting the court. Each of the parties present accepted the accuracy of her detailed written account, confirming it as a fair statement of what occurred. I thank those assisting me for completing the hard work of distilling a large volume of evidence and I intend to adopt that factual summary in setting out the background to my formal findings.4
In summary, the evidence established that the central and uncontested events were essentially as follows: a) At 7.22 am Mr Bale telephoned ‘000’ and spoke with Mr Tant, the PoliceLink telephonist, stating that he had taken an overdose, was going to end his life, had a rifle and was going put it in his mouth to kill himself; shortly thereafter, Mr Tant sent a CAD message (which classified the incident as a ‘self harm’ job) stating:5 4 The summary of evidence in these Findings is taken directly from the Submissions document prepared by Counsel assisting in this matter.
The document is authored by Emma Sullivan, Director Inquiries, for Crown Solicitor and is attached to the Court file.
5 CAD Incident Log, 29 September 2014, Tab 38, p 5.
“INFT HAS SAID THAT HE IS GOING TO COMMIT SUICIDE. PREVIOUS HISTORY INCLUDES HIS MUMS DEATH AND LOSING HIS JOB. INFT HAS TAKEN AN OVERDOSE OF MOOD STABILISERS ZIPREXA. INFT HAS BIPOLAR DISORDER. INFTS FRONT DOOR UNLOCKED” (and seconds later) “INFT HAS
RIFLE AND IS GOING TO KILL HIMSELF”; b) At around 7.25 am VKG (police radio) (V1) then broadcast the following message:6 “Available Hills vehicle. Any car in the vicinity of 36 Arndill Avenue at Baulkham Hills cross of Hambledon Avenue. Informant has rang Triple 0 saying that he’s going to commit suicide. Reckons he’s taken an overdose of some sort of tranquiliser. Has bipolar disorder and has armed himself with a rifle. Also claims to have a shotgun.” c) Sometime around 7.27 am - 7.28 am, there was a further exchange on VKG as follows:7 “HILLS 35: Yeah Hills 35 um, did you say something about a shotgun?
VKG (V1): I said something about a rifle and a shotgun. Informant has told the Triple 000 operator that he’s armed with a rifle and a shotgun which he intends to shoot himself with.” d) At 7.27 am, Sgt. Steel (the general duties mobile supervisor) acknowledged the job; he called off on scene at 7.37 am;8 e) At 7.38 am (whilst on scene), Sgt. Steel broadcasted a request (via VKG) for the ‘000’ caller to terminate the call with Mr Bale;9 f) Around 7.39 am, Mr Tant terminated the ‘000’ call with Mr Bale;10 g) Around 7.53 am, Acting Superintendent Dean arrived on scene and assumed control as the forward commander,11 sometime shortly after A/Supt. Dean had a 6 VKG Transcript, 29 September 2014, Tab 36, p 1.
7 Supra, p 2.
8 CAD Incident Log, 29 September 2014, Tab 38, pp 7-8.
9 Supra, p 8.
10 Supra, p 8.
11 Supra, p 1.
conversation with Sgt. Steel who advised that since the ‘000’ call had been terminated, police had been unable to make contact with the male. He also said that “Bale had told the operator that he had a gun between his legs and would shoot anyone including himself if they came in”;12 and h) Around 8.00 am, A/Supt. Dean briefed Mr X (the commander of the Police Negotiation Unit) and Inspector Brett Smith of the Tactical Operations Unit);13
Contact with Mr Bale was never re-established and he completed the foreshadowed suicide (his body being discovered around 10.47 am).
It is acknowledged at the outset that the overall police operation involved a multitude of tasks including establishing a perimeter, organizing telephone triangulation, contacting Mr Bale’s psychiatrist to name only a few.14 The Court acknowledges that these complex and diverse tasks were carried out in a timely and appropriate manner and in accordance with the relevant Police policies. For this reason there is no need to review them in detail. I will focus on the “000” call, Sergeant Steele’s decision to 12 Statement of Chief Inspector Helen Dean dated 5 November 2014, Tab 17, at [6].
13 Statement of Inspector Brett Smith dated 1 October 2014, Tab 13, at [10]-[11].
14The police operation effectively extended from at least the acknowledgment of car crews at 7.27am (Hills 14) to the police radio job (broadcast around 7.22 am) until around the time Mr Bale was declared deceased at 11.06 am (by ambulance personnel).The police operation included the following notable aspects: a. The swift arrival of first responders, with HI35 being on scene by 7.29 am (that is, within seven minutes of Mr Bale’s ‘000’ call), and other units (HI20 and HI14) following closely thereafter; b. Early notification to the NSW Ambulance Service (via the ICEMS system) (this occurring by 7.23 am); c. An early direction by Sgt. Steel to responding officers to don their ballistics vests given the information that the POI was armed with a rifle; d. The establishing of a perimeter to protect police and the public; e. The commencement and preparation of a detailed operations log; f. Around 8.10 am, a request for triangulation of the POI’s mobile phone; g. Police contacting Mr Bale’s treating psychiatrist to obtain information about his medical history and background; h. Police contacting Mr Bale’s son, James Bale, to obtain further background information; i. Police contacting the neighbours to obtain relevant background information; j. Deployment of the TOU and police negotiators; k. Appropriate containment of the premises by TOU operatives; l. Numerous efforts to contact Mr Bale via mobile and landline phones, and subsequent efforts to make contact using a loud-hailer; and m. The use of a camera pole inserted through a breach in the window to scope the situation and ultimately confirm that Mr Bale had completed the suicide.
terminate the call, the effect this had on the first responders work at the scene and on matters related to the investigation of the critical incident.
A High Risk situation
A concept relevant to much of the evidence received at the inquest was that of a “highrisk situation”. It is relevantly defined in the NSW Police Force Training Manual “Responding to High Risk Situations” as follows: “The circumstances and types of situations which may be defined as high risk vary widely. The essential judgment that needs to be exercised is whether the real or impending violence or threat to be countered is such that the degree of force that could be applied by the Police is fully justified. In this context, one or more of the following criteria may be used to define High Risk for the purpose of this document: a) Seriousness of the offence committed by the person; b) Expressed intention by the person(s) to use lethal force; c) Reasonable grounds to believe that the person: i. May use lethal force ii. Has or may cause injury/death d) Has issued threats to kill or injure any person…”.15 The role of first responders in high risk situations
The NSW Police Force strategy in response to high risk situations is primarily one of ‘containment and negotiation’, with force to be used as a last resort. The TOU and Negotiation Unit must be contacted in an emergency high risk situation by contacting the Duty Operations Inspector (“DOI”).16
In terms of the first responder’s role, the key considerations include officer survival, taking command, establishing inner and outer perimeters to contain the situation, 15 Statement of Inspector Nicholas Seddon dated 23 March 2016, Tab 54, NSW Police Force Operations Manual – ‘High Risk/Siege Incidents, p 37.
16 Supra, p 36.
keeping media and the public away, considering evacuating members of the public to a safe place and gathering intelligence (ie stronghold, POI, hostages, weapons, landline).
Further responsibilities include establishing a command post, commencing and maintaining an operations log and maintaining communications with VKG.17 The procedure in relation to 000 calls
PoliceLink Command is a division within the NSW Police Force whose mandate includes the training and operation of ‘000’ telephonists. The main role of the ‘000’ caller is to triage the incoming call and when required, create a CAD message for police attendance at the particular location. Once all relevant information is ascertained, the telephonist generally terminates the call; dispatch procedures then begin.18
In this regard, Senior Sergeant Alexandra Cooney, manager of the Education and Development Unit within PoliceLink Command (which includes training for ‘000’ telephonists),19 noted that there are some circumstances where a telephonist will remain on the telephone until police arrive at a location - whether that occurs is determined by the value of the information the caller has for attending police or other emergency services, and “a call from a person advising they are going to, or have, committed self-harm is likely to fall into this category”.20 In oral evidence, S/Sgt. Cooney explained that around 400 self-harm calls were received per month – it would depend on the triage process, but mostly, police would remain on the phone with a suicidal caller.21 Mr Tant’s receipt of the ‘000’ call
As at 29 September 2014, Mr Tant had been with PoliceLink since 30 June 2014. He thus had around three months experience at the time of the call from Mr Bale and was not yet fully trained.22 Mr Tant understood his role at PoliceLink to be receiving 17 Supra.
18 Statement of S/Sgt. Cooney, dated 22 December 2016, Tab 30A, at [5].
19 Oral evidence of S/Sgt. Cooney, T85.24-27 (11 October 2016).
20 Statement of S/Sgt. Cooney, dated 22 December 2016, Tab 30A, at [5].
21 Oral evidence of S/Sgt. Cooney, T86.36-49 (11 October 2016).
22 Statement of Jacob Tant dated 30 January 2016, Tab 48 at [4], [11].
emergency calls from the public and noting important information while questioning the caller. This information was then forwarded to police radio dispatch officers who could organise a NSW Police Force response.23 Mr Tant described his training at PoliceLink as “extensive”, noted that calls were “regularly audited”,24 and also referred to specific training in relation to dealing with persons with mental health issues referring to committing self-harm.25
The Court had the benefit of a complete transcript of the 17-minute ‘000’ call between Mr Bale and Mr Tant, who was then situated at the Lithgow PoliceLink Centre.26 The call itself was also played in court and I was impressed by the warm tone conveyed by Mr Tant. It was impossible to listen to the call from the relative calm and comfort of the courtroom and not wish that Mr Tant could just continue talking.
The interaction commences with Mr Bale stating: “Yeah, Jacob, mate, I’m in a bad situation, I’ve just taken an overdose of tablets … I’m gunna, I’m gunna end my life”; Mr Bale states he has taken an overdose of mood stabilisers (Zyprexa) and that: “I’ve got a rifle, I’m going to shoot myself”. Mr Tant elicits various information from Mr Bale, including his location, and talks to him about a range of subjects, including his son (a police officer), his rural property, medical history and livestock breeding (amongst other matters). The conversation finally concludes after Mr Tant receives the direction via CAD (as given by Sgt. Steel through VKG) to terminate the call around 7.39 am as follows: “Jacob: ---John, I’m sorry, have to let you go, do you mind if I, just wait a ‘sec, OK and I might call you back soon, OK.
John Bale: Yeah, all right.
Jacob: But yeah, I’ll talk to you later though, OK.
John Bale: Yeah, all right.
Jacob: Righto, so maybe consider that medical stuff, OK maybe put the rifle away or something, all right.
23 Supra, at [5].
24 Supra, at [7].
25 Supra, at [8].
26 Supra, at [6].
John Bale: Yeah, all right.
Jacob: OK. I’ll talk to you later, anyway, all right John.
John Bale: Rightio.
Jacob: OK. Bye.
John Bale: Bye.”27
Firstly, I was trying to stall him long enough that the local Police could work out an initiate a plan of action. Secondly, I was trying to outright change his mind about committing suicide. I was hopeful that by talking to him about the positive aspects of his life that he would put away the gun and safely seek help from the Police who were mobilising outside his house.”28
During the call, Mr Tant continued to send messages to police responders via the CAD system (which messages were then available for broadcast over police radio by dispatch officers).29 Whilst Mr Tant was the primary call-taker, he noted that his supervisor, Mr Geoffrey Waters, was present at the time and regularly checked on his progress throughout the call.30
There is no doubt that Mr Tant should be commended for the compassionate and caring way he handled the call with Mr Bale. He made an impressive and skilled attempt to dissuade Mr Bale from taking his life, particularly given his relative inexperience in the role as a PoliceLink telephonist. In his expert report, Dr Diamond described Mr Tant’s attempts to engage with Mr Bale and encourage him into a dialogue and interrupt the intense suicidal intent he was expressing as “… sensitive, measured and effective”;31 further, Mr Tant’s efforts to “pick up on any possible topic 27 ‘000’ transcript, Tab 49.
28 Supra, at [15].
29 Supra, at [17].
30 Supra, at [13].
31 Report of Dr Michael Diamond dated 25 March 2016, Tab 58, p 6.
for further dialogue [was] impressive”,32 and his interaction was “appropriate and sensible”.33 I accept that assessment of what occurred.
During the call, Mr Tant effectively established rapport with Mr Bale, distracting him with subjects as diverse as the family property, sheep shearing, and cow breeding – in fact, “elongating the process”, in the manner Dr Diamond described. It took significant skill and indeed fast talking from Mr Tant to keep Mr Bale on the line – on a number of occasions, Mr Bale said things such as: “Mate, I appreciate you keeping me talking, while somebody’s to see me, but I, I just wanna hang up now and just go and do it”,34 and “Mate, can I go now?”35 and “Yeah dude, … I don’t wanna talk anymore, I’ve had enough”.36
A poignant reflection of Mr Tant’s performance is the statement of James Bale (Mr Bale’s eldest son), that: “The operator did an exceptional job on the phone with Dad and my family and I will be forever grateful that his last 10 minutes or so of life were spent with someone who cared, someone skilled to do the job”.37 Involvement of Mr Geoffrey Waters – supervisor and site floor manager
For his part, site floor manager Mr Geoffrey Waters states that he was seated near Mr Tant at the time of the call. He “monitored the situation”, and was able to both see and hear Mr Tant from where he was seated.38 Mr Waters stated that as Mr Tant had determined the caller’s location and was “effectively managing the call by keeping the conversation going with the caller there was no need for further supervisory involvement during the call.”39
Mr Waters also stated: “I didn’t offer any advice or prompting as Jacob had built a rapport with the caller and from my point of view was doing a great job 32 Supra.
33 Supra.
34 ‘000’ transcript, Tab 49, p 5.
35 Supra, p 8.
36 Supra, p 11.
37 Statement of James Bale dated 25 March 2016, Tab 60 at [25].
38 Statement of Geoffrey Waters dated 19 February 2016, Tab 30I, at [4].
39 Supra.
talking with him and taking his mind away from what he was considering. I listened to the call for a very short period of time, about 30 seconds, to “get a feel” for the caller, in the event that I would be required to become further involved with the job. I monitored the situation whilst Jacob was still on the call waiting for Police to arrive until the call was terminated at the instruction of attending police, given via PoliceCAD Dispatcher Message.”40
As to the site floor manager’s role where a person is threatening self-harm, Mr Waters states that it can involve advice to the telephonist to assist in determining the location of the caller, COPS searches, requests to telecommunications providers for mobile location information and support, advice and “talking points” to keep the caller on the line pending the arrival of police.41
At 8.10am, Mr Waters sent a ‘serious, unusual or newsworthy’ (SUN) notification email about the incident to relevant staff within PoliceLink Command.42 Mr Waters acted professionally throughout his involvement with the call.
The VKG Broadcast
Around or shortly after 7.25 am VKG (police radio) (V1) broadcast the job in the following terms: “Available Hills vehicle. Any car in the vicinity of 36 Arndill Avenue at Baulkham Hills cross of Hambledon Avenue. Informant has rang Triple 0 saying that he’s going to commit suicide. Reckons he’s taken an overdose of some sort of tranquiliser. Has bipolar disorder and has armed himself with a rifle. Also claims to have a shotgun.”
Subsequently, around 7.27 - 7.28 am, there was a further exchange on VKG as follows: “HILLS 35: Yeah Hills 35 um, did you say something about a shotgun?
40 Supra.
41 Supra, at [5].
42 Supra, at [6]. Notably, the Duty Operations Inspector had been notified of the incident at 7.38am – see CAD report, Tab 37, p 8.
VKG (V1): I said something about a rifle and a shotgun. Informant has told the Triple 000 operator that he’s armed with a rifle and a shotgun which he intends to shoot himself with.”43
Evidence of Sergeant Steel
Sgt. Steel’s account of events was central to the matters explored during the inquest. It is appropriate and necessary to set out his evidence in some detail. The Court has the benefit of Sgt. Steel’s contemporaneous notes in his police notebook,44 his directed interview on the afternoon of 29 September 201445 and his oral evidence at the inquest.46 Sgt Steel’s oral evidence demonstrated how deeply the events had affected him. I accept that he felt greatly saddened about what had happened and attended the inquest to assist as best he could.47
Importantly, for around 16 minutes from 7.37am until 7.53am until he was relieved by A/Superintendent Helen Dean, Sgt. Steel was the most senior officer and thus the forward commander in control of the scene during that time. The responsibility clearly weighed heavily upon him.
Background and experience
44 Extracts from notebook of Sergeant Adam Steel dated 29 September 2014, Tab 8.
45 Directed interview of Sergeant Adam Steel dated 29 September 2014, Tab 8A at p 6; oral evidence of Sgt. Steel, T144.33-44 (12 October 2016).
46 On 12 October 2016.
47 Sgt Steele spoke directly to the family during the inquest expressing his sadness about what had occurred. He said “I truly did everything that what I thought was in my best powers and the decisions that I was making were the best decisions to get your dad out of there safely … I’m not even going to compare my grief to yours. I relive this every day in my head, not because of the decisions that I made, but I will never forget this…. It’s something that I go through every day and I relive it. And you’ll know; you’ll go to jobs you never forget. This is one of them.” Oral evidence of Sgt Steele T146.35-49 48 Oral evidence of Sgt. Steel at T141.5-142.8 (12 October 2016).
Initial response to the job and police radio broadcast
Sgt. Steel commenced the morning shift as the mobile supervisor at Castle Hill Police Station – this involved him monitoring jobs and determining which to attend.49 He was working as an alpha unit.50 Sgt. Steel heard the job on police radio about 36 Arndill Avenue, Baulkham Hills and decided to attend immediately. In this regard, in his directed interview, he stated “On the way to the job, I heard that there was, he had a rifle and that he was gunna kill himself, that he had taken tablets and that he was gunna kill police and then himself, and that he also suffers from bipolar.”51
In oral evidence, Sgt. Steel told the Court that en-route to the job, he was “starting to formulate a plan” in his head as to how to deal with the situation, including the establishment of a command post, as well as considering his options in relation to whether or not to “cancel the triple-000 phone call”.52
Sgt. Steel said that whilst en-route, he believed he heard the VKG operator refer to the POI as being armed with a rifle and shotgun. However, instead of the words “and he intends to shoot himself now”, Sgt. Steel said he “definitely” did not hear those two final words, but was certain he heard the word “police”,53 such that he “honestly heard” a VKG broadcast that the POI intended to shoot police.54 Sgt. Steel said that on receiving the brief a year later, he read the VKG recording and went “Wow”; he did not dispute the VKG recording, and was not sure how the error had come about, whether due to the “mumbling” of the triple-0 operator (who Sgt. Steel said “tripped over some words”)55, radio break-up/drop-out56 or cross-over or interference from the siren.57 Sgt. Steel also explained that because the two words had occurred at the end of the message and 49 Supra, at T.145.40-45.
50 Supra, at T.144.30-31.
51 Directed interview of Sergeant Adam Steel dated 29 September 2014, Tab 8A at p 6; oral evidence of Sgt. Steel, T144.33-44 (12 October 2016).
52 Oral evidence of Sgt. Steel, T144.46-145.11 (12 October 2016).
53 Supra, T182.1-6.
54 Supra, T146.7-20; T147.25-31.
55 Supra, T181.2428-29; T183.20-22.
56 Sgt. Steel’s evidence was that radio drop out/black spots were a very common occurred in the Castle Hill area and that it “occurred all over the place”; CAD would also go down more often in the black spots; he knew the exact spots within the LAC where the CAD would go down: T148-12-149.1.
57 Supra, T147.43-50; 182.1-16.
he thought he had heard “shoot police”, he did not think to question the message (it would have been otherwise, however, had the message been “cut out” in the middle).58
More generally, Sgt. Steel’s evidence was that this was not a standard job – it struck him as being potentially very high risk because of the job description given on VKG, and the direct threat to shoot police.59 Under examination by his own counsel, Sgt. Steel also stated that hearing over police radio that the POI was “armed with a rifle and shotgun”, made it “sound worse that … just a suicide attempt at that stage”.60 Sgt. Steel’s decision to terminate the call
Sgt. Steel gave detailed evidence as to the reasons why he formed the view that, weighing up the pros and cons, he should direct that the ‘000’ call with Mr Bale be terminated. He told the Court that it was an “extremely difficult” decision to make and appeared emotional when explaining his reasoning. In oral evidence, Sgt. Steel amplified the matters raised in his directed interview with respect to his decision to terminate the ‘000’ call. He explained that there were numerous reasons he had terminated the ‘000’ call, having weighed up the pros and cons during the ten minutes whilst travelling to the job. He emphasised that it was not a “split-second decision”.61
Sgt. Steel gave the following reasons for his decision to terminate the ‘000’ call:
• Sgt. Steel considered the “high likelihood” police would be able to get through to Mr Bale because his phone call had been voluntary.62
• He was considering, as forward commander, the worst case scenarios (including that the POI might come out shooting).63
• He stated that he took into account logistical issues, including the timeframe and lag in conveying information through police radio (given it was “probably one of the most dangerous jobs a police officer could possibly attend to”).64 58 Supra, T182.38-44; T183.1; T184.36-41.
59 Supra, T150.7-21.
60 Supra, T184.43-46.
61 Oral evidence of Sgt. Steel, T152.15-24; 46-48; T153.2 (12 October 2016).
62 Supra, T152.29-31.
63 Supra, T153.10-18.
64 Supra, T153.19-154.5 (Sgt. Steel telling the Court that from his experience, there could be a five minute delay in asking a question and having information returned in response); To similar effect, in his directed interview, Sgt. Steel referred to the “long drawn out” and delayed process of trying to establish information in a “third hand” way through police radio: see Tab 8A, p 12 and p 16.
• He was concerned by the possibility of “Chinese whispers or misinformation” with the information going through many sets of hands, and potentially making “life threatening decisions on misinformation that is now five minutes old”, all of which could be alleviated by a “real time telephone call” with the POI at the scene.65
• He said he considered the “syphoning of information”, in that information thought to be important by the triple ‘000’ telephonist and information important to a forward commander leading a siege were “two drastically different things”.66
• He stated that he took into consideration “policy and procedure”. Although there was no policy which specifically applied to first responders dealing with a situation where contact with the triple ‘000’ operator is established, the ‘New South Wales Police Operations Manual’ outlined the responsibilities of police at the scene in high risk situations, which included getting in contact with the person and developing rapport. Sgt. Steel stated he needed to get in contact with the POI to establish certain information. Sgt. Steel also recalled an ‘educational package’, with one slide that “popped up” into his head that it was “essential that first responding police attempt to make contact with the person”.67
• He applied his previous experience running a siege involving a male with a mental illness in possession of a firearm in which the importance of establishing contact with the POI was emphasized.68 He also recalled discussions with TOU commanders and negotiators after incidents.69 65 Supra, T154.7-29.
66 Supra, T154.31-155.1. By way of example, Sgt. Steel noted that police at the scene weren’t provided with the information that Mr Bale’s son was a police officer, information he considered “valuable”.
67 Supra, T155.3-43; Exhibit 7 – Decision making framework - first responding police in relation to high risk incidents’ (which Sgt. Steel located on the police intranet: T157.8) relevantly states: “It is essential that first police on the scene attempt to make contact with the person of interest to obtain as much information as possible”: T156.26-30.
68 Supra, T158.11-27; See also Sgt. Steel’s directed interview of 29 September 2014, Tab 8A, where Sgt. Steel stated that due to the communication of information coming “third hand via police and ambulance radio,” he made the decision to have the phone call terminated (at p 7). This was a decision based on his police training and previous experience in dealing with siege situations. He stated: “With a male threatening to shoot police and kill himself and the danger to the community, I decided that that [passing information third hand] was not the right course of action and that the best course, through my training, was to have, try and make direct radio contact, phone contact with the male POI who made the phone call” (at p 7); See also Sgt. Steel’s directed interview of 29 September 2014, Tab 8A, p 12.
69 Supra, T.159.18-30.
He also told the Court there were numerous checking mechanisms in place - namely A/Supt. Dean, the Duty Operations Inspector (“DOI”) and the triple ‘000’ supervisor - who could “step in” had his decision been incorrect. 70
He stated that he did not view the CAD before making the decision to terminate the call.71 If aware of the CAD message from Mr Tant (the telephonist) which stated: “Attempting to hold off the informant from shooting himself now”, Sgt. Steel said he would have “needed to be in the moment ...”, but any new information would have been taken into consideration; he agreed, however, that that information suggested it was a “pretty tenuous conversation”; he also said he “may have held off at that time … let it extend a little bit longer” to work out what that actually meant, if aware of it.72 Sgt.
Steel believed that any important updates coming through CAD would be broadcast to officers at the scene.73 Had that information (as to holding off the informant from shooting himself) been broadcast by VKG, Sgt. Steel said he would “definitely have delayed the decision” and made inquiries to get in contact with someone to try and work out further information.74
I accept Sgt. Steel’s evidence. I accept that he was a conscientious officer who tried to do his best that day. With the benefit of hindsight, it is clear that the direction to terminate the call with Mr Bale was extremely unfortunate. In the circumstances of trust that had been established it had the effect of abruptly ending an important conversation in which Mr Tant was “attempting to hold off” Mr Bale shooting himself.75
It is acknowledged that Sgt. Steel’s direction for the ‘000’ caller to terminate the call was given pursuant to his understanding of the ‘contain and negotiate’ approach to high risk situations. In fact it was the evidence of Mr X that everything Sgt. Steel did was in accordance with policy. It is difficult to be critical of Sgt. Steel in relation to the decision he made, notwithstanding that it is clear that a different approach ought to be considered should similar circumstances present in the future.
In this respect, it is important to stress that it is impossible to say whether or not Mr Tant might have successfully talked Mr Bale out of taking his own life had the 70 Supra, T160.10-161.16.
71 Supra, T161.39-40.
72 Supra, T161.27-50.
73 Supra, T162.1-12.
74 Supra, T162.25-38.
75 Tab 37, p 6. This matter was not known to Sgt. Steel, however.
conversation continued. However, it was the evidence of Dr Diamond that suicidal intent peaks and wanes; even though people may at one moment be intensely suicidal, the state of ambivalence (which can be detected at some points in the discussion with Mr Tant – for example, where reference is made to whether he might be charged with firearms offences if he survived76) is the key to successful suicide intervention.77 Whilst there may ultimately have been only a slim prospect of dissuading Mr Bale from completing the suicide, “there was just that tiny little bit of ambivalence, that little bit of responding to the humanity of the dialogue.”78
Basis for Sgt. Steel’s understanding that Mr Bale would shoot and kill police
It is important to say something further about Sgt Steele’s understanding that Mr Bale would shoot and kill police, given the pain that the reporting of this information gave members of Mr Bale’s family. It should be stressed that it is patently clear that Mr Bale never made any threat to kill anyone other than himself – so much is irrefutable from the ‘000’ transcript. Nothing said by Mr Bale to Mr Tant could even be thought ambiguous in this regard.
It was Sgt. Steel’s account that the error (which he readily accepted as such given the content of the transcript) may have occurred because of the mumbling of the broadcaster, radio-drop out or break-up or interference from his police siren. That may well be the case, however, it is odd that at no time whilst he was the forward commander did he make any reference to the threat, as he understood it, to shoot and kill police, in any of the numerous VKG broadcasts he made.
He told the Court that initially he was too busy establishing the command post and perimeter to make reference to the threat over VKG, and upon A/Supt. Dean assuming command, he did not broadcast reference to the threat as to do so would be “stepping on her toes”. Further, Sgt. Steel’s evidence, that upon arrival at the command post he referred to the threat to shoot police in briefing the junior crews, was contradicted by the evidence of at least Constables Marks, Haller and Constable Klinar (noting also the 76 Oral evidence of Dr Michael Diamond,T.109.36-T110.29 and T115.47–T116.22 (12 October 2016); ‘000’ transcript, Tab 49, p 13.
77 Oral evidence of Dr Michael Diamond, T105.26-38 (12 October 2016).
78 Oral evidence of Dr Michael Diamond, T110.28-29 (12 October 2016).
evidence of S/Cst. Desira). In this regard, it was Constable Klinar’s evidence that once Sgt. Steel attended the scene, “there was no discussion of threats to kill police or anyone who attempted entry”, although he did comment upon the POI “having a long arm” (referring to his firearm and consequent firepower).79
Briefing with crews on scene at Rowe Place
After arriving on scene at Rowe Place, Sgt. Steel had a “fairly quick briefing”80 with the two crews present (Hills 20 and Hills 35) and told them to put on their ballistic vests due to the radio report that the POI “had a firearm and that he was willing to use it against police”.81
Sgt. Steel determined that the best way to proceed would be to “contain and negotiate” the situation. He told the Court that during this briefing, (then) Constable Christie Desira (an officer in Hills 35) approached him and said something along the lines of: “Did you hear the threat to shoot”. Sgt. Steel said this validated what he believed he had heard on the way there (that is, that there was a threat to shoot police).82 He also gave evidence that at this briefing (and notwithstanding Constable Troy Klinar’s evidence to the contrary),83 he believed that he had referred to the threat to shoot police, considering it important to do so.84
According to Sgt. Steel, the plan was that Constable Troy Klinar (of Hills 20) would use Sgt. Steel’s mobile phone to try and establish contact with Mr Bale, and immediately let him know if this occurred. Sgt. Steel did not want to take over negotiations, however.
That evidence was at odds with Constable Klinar’s evidence, which was to the effect that if contact was established, Sgt. Steel would then undertake negotiations.85 Sgt. Steel ultimately agreed with the proposition that it was undesirable that there be a 79 Statement of Constable Troy Klinar dated 24 March 2016, Tab 59 at [5].
80 Supra, T163.8.
81 Directed interview of Sgt. Steel, 29 September 2014, Tab 8A, p 7.
82 Oral evidence of Sgt. Steel, T151.5-9 (12 October 2016).
83 Statement of Constable Troy Klinar dated 24 March 2016, Tab 59 at [5].
84 Oral evidence of Sgt. Steel, T163.6-24 (12 October 2016).
85 Statement of Constable Troy Klinar dated 24 March 2016, Tab 59 at [7].
misunderstanding as to whom was to conduct the negotiations.86 Sgt. Steel told the Court he had instructed Constable Klinar to keep trying to call Mr Bale until he was in contact, having provided both mobile and land-line numbers for him.87
Sgt. Steel also explained that he had sent Constable Klinar, who had some military training, to “get eyes on the premises”,88 trusting his ability to find a “good safe place”.89 Briefing to A/Superintendent Dean
Following A/Supt. Dean’s arrival on-scene around 7.53 am, Sgt. Steel gave her a briefing at the command post, as she was taking over as the forward commander (given her rank as the local area commander and pursuant to policy).90 During the briefing, Sgt.
Steel spoke about the “points people were on”, the fact he had cancelled the triple ‘000’ call, and “the primary police strategy of contain and negotiate” in play.91 Sgt. Steel accepted that he may have told Superintendent Dean that “Mr Bale had told the operator that he had a gun between his legs and would shoot anyone, including himself, if they came in”.92 He did not accept that there was a relevant difference between that formulation, however, and a threat by Mr Bale to shoot police and then himself, stating: “They’re just the words that I used at the time but I would have said there’s a threat to shoot police. That’s about as dangerous as it gets and it can be interpreted any way you like. I don’t see a massive difference, whether we go in or he comes out. I may have said if we go in and I may have used those words to her. I can’t remember …”.93 Other steps taken by Sgt. Steel (including establishing a perimeter)
87 Supra, T165.29-36.
88 Supra, T165.9-10.
89 Supra, T12-16.
90 Supra, T165.38-49-166.31.
91 Supra, T166.35-42.
92 Supra, T.166-167.28.
93 Supra, T167.47-168.1.
94 Directed interview of Sgt. Steel, 29 September 2014, Tab 8A, at p 8.
the sirens were upsetting the POI and accordingly advised all cars to “kill their sirens on attendance so we could try and keep him not getting too upset”.95
Steel subsequently referred to the “extenuating circumstances” of being busy setting up a perimeter with four police, and that after handing over to A/Supt. Dean, she was advised of the threat and it was up to her to broadcast further information if she saw fit.
This was because he did not want residents walking around the premises; he said he told the officers “to be safe”. He could not remember whether he referred to the threat to shoot police.100
Sgt. Steel took other steps with respect to the operation, including organising a triangulation of the POI’s mobile phone to confirm the location, coordinating Hills 35 to contact persons in the neighbouring property (who advised that the POI suffered bipolar), monitoring the entrance and egress of the property and also the radio, as well as generally assisting A/Supt. Dean.101
After the operation concluded (Mr Bale having been found deceased around 10.47 am), Sgt. Steel returned to the station and, appreciating that he would be interviewed, 95 Supra, pp 8-9.
96 Oral evidence of Sgt. Steel, T171.37-172.39 (12 October 2016).
97 Supra, T176.10-24.
98 Supra, T173.16-19.
99 Supra, T.172.43-173.1.
100 Supra, T174.41-175.24.
101 Supra, pp 9-10.
prepared notes in his notebook to try to jog his notebook memory and “give the best account” of himself in the interview that he could.102 Evidence of Senior Constable Christie Desira
Senior Constable Desira provided two statements regarding her involvement in the matter103 and was called to give oral evidence. She has been an officer of the NSW Police Force for just over six years, and is currently attached to the Hills LAC.104
On 29 September 2016, she (then a Constable) was undertaking general duties in Hills 35 (a marked police car), working with Constable Luke Marks. 105
S/Cst. Desira recalled the briefing with Sgt. Steele upon his arrival at the scene; she explained they were outside their vehicles and parked on the left hand side of the cul de sac (in Rowe Place, the command post). In terms of her understanding of any threat to shoot and kill police, she stated: “I believe I heard that via the police radio on the way to the job. However, it may have been said while we were briefing”.106 S/Cst. Desira could not see reference to that information in the transcript from police radio, but still believed that was when she heard it,107 although accepted the possibility it came from other sources.108 However she received the information, S/Cst. Desira agreed she had a clear recollection that she thought the POI would shoot anyone that came near.109
When questioned by counsel for Sgt. Steel, S/Cst. Desira stated that she did not remember saying to Sgt. Steel during the briefing: “Did you hear the call about shooting”.110
S/Cst. Desira otherwise confirmed that the Hills district has both black spots and radio black-out.111 102 Oral evidence of Sgt. Steel, T146.35-49 (12 October 2016). Sgt. Steel also explained that he had presented to investigators a UBD map on which he noted phone numbers and points of interest where he had established a perimeter. Sgt. Steel explained that the investigators could have taken this map had they wanted, but to the best of his recollection, it was returned to the car: T180.36-181.2 (12 October 2016).
The location of those notes are now unknown.
103 Statement of (then) Constable Christie Desire dated 29 September 2014, Tab 11; Statement of Senior Constable Christie Desire dated 13 January 2016, Tab 30E.
104 Oral evidence of Senior Constable Christie Desira, T23.5-12 (10 October 2016).
105 Supra, T23.3-24.5.
106 Supra, T25.6-9.
107 Supra, T25.27-45.
108 Supra, T26.12-15. In this respect, she could not recall whether she had used COPS to prepare her first statement. Whether she did so would depend on whether she had a clear recollection of the incident: T28.38-43.
109 Supra, T28.47-29.1.
110 Supra, T36.16-37.22; T39.11-16.
111 Supra, T32.33-50.
Evidence of Senior Constable Brigitte Monro
Senior Constable Brigitte Monro provided two statements regarding her involvement,112 and gave evidence at the hearing.113 She has been an officer of the NSW Police Force for almost eight years, and is currently attached to Castle Hill Police Station.114
It was S/Cst. Monro’s evidence that shortly before 7.30 am, she partially heard a selfharm job broadcast at Baulkham Hills; five or ten minutes later, she became aware from another officer, Detective Sergeant Andrew Hamill that the situation had turned into a siege, and they (the detectives) were required to attend.115 Together with D/Sgt.
Hamill and Detective Jedda Thompson, S/Cst. Monro travelled to the command post at Rowe Place in vehicle Hills 102. At this time, she believed they were in phone contact (via personal mobile phones) with another car in which Detectives Davies and Bruce were travelling.116 No one was in contact with the command post, however, whilst they were en-route.117
S/Cst. Monro’s understanding that the situation had become a siege was a “different level of threat” – this was why the detectives had to attend (as compared with the initial broadcast as a self-harm, when they were not required).118
In relation to her statement that: “I believe I heard via the police radio that the male would shoot anyone who came in and shoot himself”,119 S/Cst. Monro said: “… I believed that that’s where I heard that information … I believe I heard it via the police radio but the transcript doesn’t reflect it”.120 She was “absolutely 100 [percent]” convinced that by the time she was in the car, she understood there was a threat to shoot other people.121 As to the source of the information, S/Cst. Monro stated – “I’ve tried to find it and honestly I wasn’t able to find where that information came from”.122 112 Statement of (then) Plain Clothes Senior Constable Brigitte Neggers dated 7 October 2014, Tab 24; Statement of Plain Clothes Senior Constable Brigitte Monro dated 22 December 2015, Tab 30F.
113 On 11 October 2016.
114 Oral evidence of Senior Constable Brigitte Monro, T59.21-28 (11 October 2016).
115 See also statement of (then) Plain Clothes Senior Constable Brigitte Neggers dated 7 October 2014, Tab 24 at [6].
116 Supra, T60.17-61.16.
117 Supra, T60.28-30. From the CAD print-out, it appears that HILLS 102 acknowledged the job at 8.04am: see Tab 38.
118 Supra, T65.11-29.
119 As set out in para [6] of her statement dated 7 October 2014,Tab 24.
120 Oral evidence of Senior Constable Bridget Monro, T63.15-18 (11 October 2016).
121 Supra, T67.5-8.
122 Supra, T68.12-14.
S/Cst. Monro said that upon arriving at the command post, she had a brief conversation with Sgt. Steel about which officers were in cars Hills 20 and Hills 35.123 During this conversation Sgt. Steel did not say that Mr Bale had threatened to shoot police.124 Evidence of Chief Inspector Helen Dean
Chief Inspector Helen Dean provided two statements,125 and also gave oral evidence at the hearing.126 She has been an officer of the NSW Police Force for 22 years.127 During this time, C/Insp. Dean said she had been involved in numerous high risk incidents and particularly those involving firearms (having worked in South West Sydney for 15 years).128
In terms of her relevant involvement in events on 29 September 2014, C/Insp. Dean told the Court that whilst in the duty officer’s room, she first heard Sgt. Steele request that the ‘000’ phone call be terminated so he could initiate contact with Mr Bale; at this time, she had just walked into the building up the stairs and into the office.129
Having arrived on scene at Rowe Place at 7.53 am (after travelling alone, using the call sign ‘Hills 10’),130 C/Insp. Dean (who was then acting as Superintendent or commander of the LAC) assumed control of the scene as forward commander.131 C/Insp. Dean said that Sgt. Steel gave her a briefing which went for a couple of minutes.132 He told her what staff were on the ground, who had what point and that Constable Klinar had his mobile to try and initiate contact with the POI who was inside with firearms.133 She agreed that Sgt. Steel had told her that: “Bale had told the operator he had a gun between his legs and would shoot anyone including himself if they came in”.134 She accepted the accuracy of the information conveyed by Sgt. Steel.135 C/Insp. Dean had no 123 Supra, T66.9-15.
124 Supra, T67.40-50.
125 Statement of (then) Inspector Helen Dean dated 5 November 2014, Tab 17; Statement of Chief Inspector Helen Dean dated 22 December 2015, Tab 30C.
126 On 10 October 2016.
127 Oral evidence of Chief Inspector Helen Dean, T40.9-15 (10 October 2012).
128 Supra, T40.39-48.
129 Supra, T41.40-49.
130 Supra, T42.5-6.
131 Supra, T41.9-16.
132 Supra, T43.48-49 133 Supra, T42.21-44.
134 Supra, T43.6-8.
135 Supra, T43.38-46.
recollection that Sgt. Steele had told her the POI was going to kill police and then himself.136
As to whether it was a significant piece of information that the POI had a gun between his legs and would shoot anyone including himself if they came in, C/Insp. Dean stated: “Not with how I would have run the job, the fact that he was inside with firearms made no difference as to how I would've run that job. It's a person armed with firearms and multiple firearms. How I managed the job and the decisions I made had nothing to do with whether he was only going to shoot himself or whether he was going to shoot anyone else.”137
C/Insp. Dean saw no distinction between a direct threat to kill police and one’s self, relative to a threat being contingent upon someone entering the property. She stated: “One life is important to the other – one life is no more valued than another, whether its police officer’s life or a next door neighbour’s, or anyone that could have – yeah, it makes no difference”.138 C/Insp. Dean explained that her priority was to make sure the perimeter was shut down and get on to experts such as the negotiators.139
Notwithstanding, C/Insp. Dean agreed that once negotiators became involved, real accuracy regarding the nature the threat was important.140 She also agreed that it was important for first responders to appreciate the nature of the (relevant) threat.141 In this instance then, it was important for first responding crew (such as Hills 35 and Hills
138 Supra, T46.40-42.
139 Supra, T44.1-9.
140 Supra, T46.46-47.1.
141 Supra, T47.15-17.
142 Supra, T47.19-25.
143 Supra, T47.31-37.
144 Supra, T47.39-46.
C/Insp. Dean agreed that each high risk situation may involve different levels of threat to police, and that an important role for first responders on scene is to gather as much intelligence about a situation as possible (including as to who the offender is, what he wants, whether he is suicidal and armed, and how the episode began). In this regard, she agreed that with the benefit of hindsight, it would have been possible to have made contact with the ‘000’ telephonist (via VKG).145
C/Insp. Dean said she did not discuss with Sgt. Steel his decision to terminate contact with Mr Bale at the scene.146 As to whether it had been a good call, she stated: “It's difficult to negotiate with somebody especially with a mental health issue through a third party, and also the triple-0 operator isn't always aware of the information we need, such as the questions that were raised. They might ask other things to keep the person calm and keep them on the phone but knowing about whether he grazed cows or sheep doesn't help me at the scene, so by talking to the person myself or having a member of my staff speak to them, there's certain information that the police - that would assist us.”147
In relation to a briefing with Mr ‘X’ (Commander of the Police Negotiation Unit within the State Protection Group) and Inspector Brett Smith (a tactical commander within the Tactical Operations Unit) around 8 am that morning, C/Insp. Dean said she recalled the briefing but not what was said.148 Noting discrepancies between the account of Mr ‘X’ and Inspector Smith, C/Insp. Dean said she had no reason to question the accuracy of the latter’s account.149 She agreed that the information about Mr Bale lying on his bed with a shotgun between his legs and that he would shoot anyone who came in was an important piece of information; it was something the negotiators needed to know, and thus she thought it “likely” she would have conveyed that;150 however, C/Insp. Dean could not recall which account was likely to be more accurate, and told the Court there may have been a number of conversations (with Mr ‘X’ and Inspector Smith).151 145 Supra, T56.14-57.6.
146 Supra, T45.1-6.
147 Supra, T57.28-34.
148 Supra, 48.45-46 149 Inspector Smith’s account referred C/Insp. Dean briefing him in terms of the POI threatening self-harm including lying on the bed with a shotgun between his legs and that he would shoot police and himself: supra, T49.22-28.
150 Supra, T50.17-26.
151 Supra, T50.12-15.
Evidence of Mr ‘X’
Mr X is a Detective Inspector of Police, and the commander of the NSW Police Negotiation Unit, State Protection Group.152 He prepared a statement dated 21 March 2016,153 and also gave evidence at the inquest.154
Mr X was involved in preparing the mandatory continuing police education program regarding responding to high risk situations in 1998; he had had an ongoing role since.
That mandatory package was delivered to all NSW police in the year 2000 and 2011/12.155
153 Statement of Mr X dated 21 March 2016, Tab 56.
154 On 11 October 2016.
155 Supra, T72.6-25.
156 Supra, T72.46-49; T73.26-28.
157 Supra, T73.42-47.
159 Supra, T74.8-45.
160 Supra, T74.50-75.19.
Briefing by A/Supt. Dean and Mr X’s understanding as to the nature of the threat
Mr X confirmed that it was his practice to take contemporaneous notes of all high risk situations or negotiation jobs “every single time”.161 It was necessary for him to satisfy himself as to the involvement and deployment of police negotiators.162
In this particular case, Mr X’s notes recorded an initial call from the DOI (Inspector McCormack) around 8 am; he advised that there was a high risk situation at the Baulkham Hills address involving a male armed with a shotgun and threatening suicide.
There was a request for activation of police negotiators. A/Supt. Dean’s mobile was provided. From his office at the Sydney Police Centre, Mr X then rang A/Supt. Dean together with Inspector Brett Smith around 8.14 am and there was a conversation on speaker phone. During the phone call, Mr X agreed that A/Supt. Dean had advised him that the male involved was believed to be John Bale, aged 60, who lived at the address and suffered bipolar disorder. He was also told that the POI had rung ‘000’ and said he had a shotgun between his legs and would commit suicide. Mr X stated that he did not have an independent recollection of the conversation.163
Mr X said he had no recollection of A/Supt. Dean telling him that John Bale had said he would shoot police – Mr X stating that if that had been said, “I have no doubt in my mind through my … set procedures I would’ve written that down…”.164 Mr X also stated that had he been told that Mr Bale would shoot anyone including himself if they came in, he would have recorded that in his notes, that being important information.165 If told that information, Mr X said he would have told his negotiation team that detail.166
Mr X agreed that it was the role of the negotiation team to seek to obtain intelligence through witnesses; in this regard, he agreed that someone should have made contact with the ‘000’ telephonist.167
Under examination by counsel for Sgt. Steel, Mr X opined that Sgt. Steel had done everything in accordance with policy.168 161 Supra, T75.40-42.
162 Supra, T75.44-76.2.
163 Supra, T76.4-77.11.
164 Supra, T77.20-38.
165 Supra, T78.19-49.
166 Supra, T79.1-3.
167 Supra, T80.46-81-20.
Evidence of Inspector Brett Smith (Tactical Operations Unit)
Inspector Smith provided two statements for the inquest, dated 1 October 2014 and 12 October 2016 respectively,169 and also gave oral evidence.170
Inspector Smith has been a police officer for 26 years, including over 20 years in association with the Tactical Operations Unit (“TOU”). Since 2005, Inspector Smith has been a tactical commander attached to the TOU, which involves the coordination of TOU responses to high risk incidents, liaising with commanders as well as the planning associated with high risk operations.171
In terms of Inspector Smith’s recollection of the briefing with Mr X and A/Supt. Dean on the morning of 29 September 2014, he did not take notes regarding that specific conversation, but subsequently made some notes in his personal diary about the incident generally.172 Inspector Smith had no independent recollection of the conversation with A/Supt. Dean; he recalled Mr X taking notes however.173
As to the apparent discrepancy between Inspector Smith’s first statement (which relevantly referred to Mr Bale calling ‘000’ threatening self-harm, stating he was lying on his bed with a shotgun between his legs and that he would shoot police and himself), and that of A/Supt Dean (to the effect that Mr Bale had said he had a gun between his legs and would shoot anyone, including himself, if they came in), and Mr X’s account (of the man having a shotgun between his legs and stating that he would commit suicide), Inspector Smith could not recall whether he had used the precise wording of what was said on the call, or whether he had “extrapolated the information as it came in” and added it in preparing his statement.174
Inspector Smith agreed with the evidence of Mr X that information to the effect that the person was lying on his bed with the shotgun between his legs and would shoot police and himself was important information, and that it would inform matters relating to the operation.175 He also agreed there was a difference between someone threatening 168 Supra, T83.21-27 (note error in transcript which refers to “police” at L27).
169 Statement of Inspector Brett Smith dated 1 October 2014, Tab 13; Statement of Inspector Brett Smith dated 12 October 2016, Exhibit 5.
170 On 12 October 2016.
171 Oral evidence of Inspector Brett Smith, T120.5-29 (12 October 2016).
172 Oral evidence of Inspector Brett Smith, T121.14-25 (12 October 2016); diary notes of Inspector Smith – Exhibit 6.
173 Supra, T121.5-41.
174 Supra, T122.18-123.18.
175 Supra, T124.24-35.
self-harm compared with an offensive threat against police, but explained that it was not uncommon for people in distressed situations to make aggressive statements towards police. The role of TOU once on the ground was to evaluate that risk and the strategies and tactics to put into place.176 Inspector Smith agreed it was important that first responders understood the nature of an incident, and that an important means for doing so would be VKG (police radio); it would also be important for the forward commander of the first response police to advise junior crews about a threat to kill police.177 That information was also relevant to matters such as setting the perimeter, taking cover and giving instructions about evacuating or locking down premises.178
Inspector Smith agreed that this matter was always a high risk situation,179 although explained that prior to deploying TOU, it was necessary for first responders to verify certain information; there was also a process requiring that permission to deploy TOU from the superintendent in charge be sought (who would then seek permission from the assistant commissioner to use special weapons and tactics).180 The first responder verification process was to avoid wasting resources;181 it would be undesirable to roll out TOU personnel and surround an empty house if the person was actually at another location.182 Inspector Smith also gave evidence that Sgt. Steel had taken the appropriate approach in only activating negotiators after the first responders could not make contact, given that the initial contact might have resolved the situation (for example, the person might have come out and surrendered etc).183 In terms of the verification steps first responders might take, Inspector Smith stated that they could “make reasonable attempts”, including containing the location, making observations and attempting to speak to the person of interest (although it might not ultimately be possible to provide verification).184
In relation to any distinction between a male believed to be in a house threatening to shoot himself compared to a person also threatening to shoot police, Inspector Smith initially said there would be no difference in the response of attending police – the 176 Supra, T125.10-22.
177 Supra, T125.24-50.
178 Supra, T126.1-10.
179 Supra, T126.39-40.
180 Supra, T136.40-137.1.
181 Supra, T140.38-40.
182 Supra, T127.7-40. Inspector Smith otherwise described it as “surrounding a potentially empty house or chasing a ghost around the city
183 Supra, T129.18-44.
184 Supra, T131.44-132.3.
main concern would be the welfare for officers attending, and resolving the situation in line with the policy of containing and negotiating.185 However, I understood him to later suggest that there may be a difference in how risks in each situation were weighed up when police were called upon to approach. 186 The evidence of other police regarding “threats” made by Mr Bale
• Constable Luke Marks was in Hills 35 (with S/Cst. Desira) and heard the VKG job to be the informant threatening to commit suicide;187
• Constables Melissa Haller and Troy Klinar in Hills 20 referred to the job as a broadcast for self-harm (prior to arriving at the location, radio had advised them that the informant had a rifle on his person);188
• Around 8.10am, A/Inspector Andrew Hamill (“A/Insp. Hamill”) referred to attending the command post (together with S/Cst. Monro and Detective Senior Constable Jedda Thompson (“D/S/Cst. Thompson”) in an unmarked police car in response to a male threatening self-harm whilst in possession of a firearm; upon attending he observed Sgt. Steel and A/Supt. Dean and commenced a communications log;189 that document notes the attendance of himself and the others officers regarding a “suicide intervention”, and the information that:
• “POI contacted ‘000’ speaking with an Ambulance operator not police radio operator. During conversation POI stated he was in possession of a shotgun which was between his legs and would shoot anyone including himself”;190
• D/S/Cst. Thompson states that she received a call from A/Inspector Hamill during which he advised of a serious incident “being a concern for welfare and a possible 185 Supra, T138.48-139.22.
186 Supra, T140.3-16.
187 Statement of Constable Luke Marks dated 10 October 2014, Tab 9 at [4]- [5].
188 Statement of Constable Melissa Haller dated 29 September 2014, Tab 11 at [4]- [5]; statement of Constable Troy Klinar dated 29 September 2014, Tab 12 at [4]- [5].
189 Statement of A/Inspector Andrew Hamill dated 8 December 2014, Tab 18 at [7].
190 Supra; Annexed log, Tab 17A, p 1.
siege situation at 36 Arndill Avenue, Baulkham Hills”; together with A/Insp.
Hamill and S/Cst. Monro, they drove an unmarked vehicle to Rowe Place;191 once there, Sgt. Steel stated: “Around 7.22am this morning there was a 000 call from the resident John Bale, who lives by himself at 36 Arndill Avenue, Baulkham Hills. The caller, Mr Bale said to the telephone operator words to the effect of, “I am lying on my bed with a gun between my legs, if anyone comes to try and stop me, I will shoot them and shoot myself”;192
• From the TOU officers: Acting Sergeant Dayne Brown (“A/Sgt. Brown”) was told by A/Supt. Dean that Mr Bale had told the ‘000’ operator that “he was he was lying on his bed with a shot gun between his legs and would shoot at police or anyone who came near his house”;193 Leading Senior Constable Steven Davies was advised by A/Sgt. Brown that Mr Bale had contacted ‘000’ threatening self-harm with a firearm;194 Sergeant Paul Whitehead referred to attending a “possible suicide intervention” at Baulkham Hills where the person had rung ‘000’ threatening to kill himself with a firearm;195
• From the Negotiation Unit officers: Detective Sergeant Mathieu Russell (“D/Sgt. Russell”) (the negotiation team leader), spoke with A/Supt. Dean, who advised him and Inspector Smith (amongst others) that Mr Bale “had earlier contacted ‘000’ and threatened suicide with a firearm”;196 Detective Sergeant Michael Egan received a call from Mr X around 8.00 am notifying him of an incident involving a man possibly armed with a firearm threatening self-harm; upon attending the premises with the team, he and team 191 Statement of Detective Senior Constable Jedda Thompson dated 4 October 2014, Tab 25, at [3] – [5].
192 Supra, at [13] – [14].
193 Statement of Acting Sergeant Dayne Brown dated 6 October 2014, Tab 14 at [6].
194 Statement of Leading Senior Constable Steven Davies dated 7 October 2014, Tab 16 at [7].
195 Statement of Sergeant Paul Whitehead dated 9 October 2014, Tab 15 at [4]-[5].
196 Statement of Detective Sergeant Mathieu Russell dated 7 October 2014, Tab 22 at [5].
members A/Sergeant Thomas and Detective Senior Constable Sasha Pinazza (“D/S/Cst. Pinazza”) were briefed by D/Sgt. Russell as follows: “I was advised that the occupant of 36 Arndill Avenue, Mr John Bale, had made a phone call earlier in the morning during which he had made a threat to take his life with a firearm”;197 D/S/Cst. Pinazza arrived at the command post at 9.10am, and was briefed by A/Sergeant Thomas that the occupant Mr Bale had earlier contacted ‘000’ stating he intended on committing suicide with a firearm.198 Confusion in relation to officers’ understanding of the ‘threat’ posed by Mr Bale
As noted above, during his discussion with Mr Tant, Mr Bale only ever threatened selfharm. So much is beyond doubt. Nevertheless, it is clear from the evidence that there were quite discordant understandings as to the exact threat posed that morning among various officers involved in the operation. Leaving aside the fact that some of these understandings were plainly incorrect, the very fact that they existed simultaneously is cause for concern.
As to the significance of such discrepancies in the threat assessment, there was some evidence from officers such as C/Insp. Dean to the effect that there was no relevant distinction in relation to a job that involved a person threatening self-harm with a firearm, relative to one where the person was actively threatening to shoot and kill police (or others), and then himself. I find that approach hard to understand or accept.
There was also clear evidence to the effect that it was important for first responders to appreciate the nature of any relevant threat, and that accuracy regarding the nature of the threat once negotiators became involved was important. Additionally, adequate intelligence, including as to the offender’s threats, assists with proper decision making and every piece of intelligence available to police negotiators is “extremely important”.
Inspector Smith also gave evidence that it was important that first responders 197 Statement of Detective Sergeant Michael Egan dated 31 October 2014, Tab 21 at [5].
198 Statement of Detective Senior Constable Sasha Pinazza dated 7 October 2014, Tab 23 at [7].
understood the nature of an incident, and agreed there was a difference between someone threatening self-harm as compared with an offensive threat against police.
The Critical Incident Investigation and Inspector Seddon’s involvement
A critical incident is essentially one involving a member of the NSW Police Force which results in the death of a person arising from a police operation.199 The defining feature of a critical incident investigation is that it is constituted by an independent specialist investigative team, whose investigation is in turn reviewed by an independent review officer.200
A critical incident investigation is essentially governed by the Critical Incident Guidelines which were developed to assist officers to manage, investigate and review critical incidents. The preamble to the Guidelines states the NSW Police Force’s commitment to investigating all critical incidents in an “effective, accountable and transparent manner” and notes that if “public credibility is to be maintained, such investigations are most appropriately conducted independently”. The Guidelines are said to be a statement that the community can have full confidence that the facts and 199 Critical Incident Guidelines (August 2012), Tab 52, p 9.
200 Supra.
circumstances of a critical incident will be thoroughly examined and reviewed by the NSW Police Force.201
In conducting a critical incident investigation, the Guidelines state that the critical incident team are to conduct a full investigation of the incident, including relevant events and activities leading up to it, as well as the lawfulness of police action and the extent of police compliance with relevant guidelines, legislation, internal policy and procedures.202 The investigation report from the critical incident investigation should comment on these matters and include reference to any problems that have been identified.203
The primary role of the senior critical incident investigator (“SCII”), who is the leader of the critical incident investigation, is to “ensure critical incidents are rigorously and thoroughly investigated”.204 Inspector Nicholas Seddon, from Ku-ring-gai LAC, who was an Acting Inspector on 29 September 2014, was appointed as the Senior Critical Incident investigator on Strike Force Parabel – the investigation into John Bale’s death.
He provided four statements;205 he also gave oral evidence at the inquest.206 An officer of the NSW Police Force since 2000 (with 16 years of experience), he became an Inspector in November 2015 and is currently attached to Griffith LAC.207
202 Supra, p 28.
203 Supra, p 33.
204 Supra, p 26.
205 Statement of Inspector Nicholas Seddon dated 14 January 2015, Tab 7; Statement of Inspector Nicholas Seddon dated 23 March 2016, Tab 54; Supplementary Statement of Inspector Nicholas Seddon dated 5 May 2016, Tab 64; Statement of Inspector Nicholas Seddon dated 5 October 2016, Tab 69.
206 On 10 October 2016.
207 Supra, T12.15-22.
208 Supra, T15.24-16-4.
209 Supra, T16.9-11.
Inspector Seddon agreed that in relation to a high risk situation it would be important to assess a situation on its merits with particular regard to the specific threats.210 If he heard a threat “that the POI was going to shoot and kill police” and then himself, Inspector Seddon agreed he would definitely tell attending police either during a briefing, or via police radio so that people were “aware of what they are possibly coming into as they arrive at the situation”. If acting as supervisor, Inspector Seddon said he would broadcast the threat on VKG himself, “to ensure that people are aware of what’s going on and also to make sure they’re obviously wearing their ballistic vests and taking appropriate measures in relation to their safety”.211
In terms of Inspector Seddon’s training in investigating critical incidents, he stated that as at September 2014, he had “no direct experience in critical incident investigations,” other than his general experience in policing and investigations”. He also said he had not received any training in relation to conducting critical incident investigations, and was aware of the existence of the Guidelines, but “… not totally conversant with them at the time of the incident”.212 Inspector Seddon subsequently explained that by this, he meant that while he had read the Guidelines, he “could not state categorically every duty and requirement that was expected of the senior investigator or the other people involved in an investigation of this type”.213
In a statement dated 5 October 2016, Inspector Seddon noted that he had become aware that the NSW Police Force conducts a two day ‘senior critical incident investigators workshop’. Inspector Seddon had not completed the course at the time of conducting the investigation into Mr Bale’s death. However, he stated that undertaking critical incident investigation training would have assisted him, and provided further skills, knowledge and understanding of the processes relating to such investigations (although he is no longer in a role where he would undertake such investigations).
Looking back on the matter, Inspector Seddon reflected on a number of things that he would have done differently (including re-interviewing Sgt. Steel as to the origin of his 210 Supra, T18.15-19.
211 Supra, T18.34-19.4; T19.47-50.
212 Statement of Inspector Nicholas Seddon dated 31 May 2016, Tab 64 at [3].
213 Statement of Inspector Nicholas Seddon dated 5 October 2016, Tab 69 at [10].
belief regarding Mr Bale’s threat to harm others and also informing the family of the error surrounding such information in a timelier manner).214
A statement of Detective Inspector Glen Browne (currently attached to the Professional Standards Command) was tendered into evidence during the hearing. That statement outlines the training provided regarding critical incident investigations, including the two day ‘Senior Critical Incident Investigators’ workshop (which was piloted in December 2014), and which has since been conducted on ten separate occasions at various locations around the state.
Inspector Seddon’s reflection as to matters that he would approach differently if he were to undertake another critical incident investigation shows insight and integrity.
Further, Inspector Seddon’s concession that he ought to have explored the discrepancy relating to the evidence and Sgt. Steel’s account of the threat apparently stated by Mr Bale, further attests to these qualities.
Inspector Seddon’s communications with the Bale family
Mr James Bale, an officer of the NSW Police Force, described working at Newtown Police Station when on the morning of 29 September 2014 when he was taken into an office by two senior officers and advised that his dad had made a call to ‘000’ stating that he was armed with a gun and “that he was going to shoot himself and/or anyone that attempted to enter his house.”215 James described this information as the “most shocking and unimaginable information to receive”, as he knew his father well. He could not understand the reported behaviour, given his father had never been violent to others nor had he been known to threaten others.216
Some time around 10 am it appears James Bale was conveyed to the command post setup at Rowe Place.217 Around 11.10 am, James was advised that his father was deceased.218 214 Supra, at [11].
215 Statement of James Bale dated 23 December 2014, Tab 31 at [40].
216 Statement of James Bale dated 25 March 2016, Tab 60 at [4]-[5].
217 Log created by A/Inspector Andrew Hamill, Tab 17A, p 3.
218 Supra, p 5.
Subsequently, longstanding neighbours came to understand that there had been a “siege” and that Mr Bale had said he was going to shoot himself and then others.219
James Bale noted that it was not until 13 November 2015 (in a meeting with officers assisting the Coroner), that there was an indication given that there was no evidence that Mr Bale had threatened to shoot or harm anyone other than himself.220 James stated that believing his father had threatened to shoot and kill others on 29 September 2014 had compounded the family’s grief and loss, and caused great anguish and distress, as well as “almost irretrievably and wrongly” tarnishing his father’s reputation.221
Amy Bale, Mr Bale’s daughter, recalled being told by James on that terrible day in September that the family were lucky Mr Bale “didn’t hurt anyone”.222 Amy stated that she was unsure when police became aware of the “true facts” regarding her father’s death, but stated that other than in conversation with the family’s barrister, she had never been spoken to by police to explain that “there was never any threat by my father to hurt anyone other than himself”.223 She stated that the misinformation had affected her father’s reputation but also “impacted terribly” upon the grief she had struggled with since.224
Inspector Nicholas Seddon interviewed Sgt. Steel on the afternoon of 29 September 2014. At this time, he became aware of the perception of at least that officer that Mr Bale had threatened to shoot and kill police. He subsequently received, reviewed and uploaded onto the Eaglei system contemporaneous information concerning the circumstances leading up to Mr Bale’s death relevantly (namely, a CAD incident (2 October 2014), VKG transcripts (17 October 2014) and the ‘000’ call transcript (6 November 2014)).225 Inspector Seddon stated that after reviewing this information and given his knowledge of matters, it was obvious that Mr Bale never said he intended to harm other persons or police.226 219 Statement of James Bale dated 25 March 2016, Tab 60 at [14].
220 Supra at [21] – [22].
221 Supra, at [18].
222 Statement of Amy Bale dated 27 March 2016, Tab 61 at [7].
223 Supra, at [31].
224 Supra, at [32].
225 Statement of Inspector Nicholas Seddon dated 31 May 2016, at Tab 64 at [4]-[5].
226 Supra, at [8].
By statement dated 5 October 2016, Inspector Seddon acknowledged his mistake and oversight in failing to release information as to the true circumstances of Mr Bale’s death to the family. He explained that he had misconstrued a part of the NSW Police Handbook concerning the release of information to persons without the Coroner’s consent (but noted that in any case he could have sought the Coroner’s consent to seek the release of the information). Inspector Seddon apologised to the family for this error of judgment on his part.227
It is extremely regrettable that the Bale family were inadvertently misled as to the circumstances of their father’s death for over a year. The significant human impact of that misinformation, compounding the family’s grief and in their view, irreparably affecting their father’s reputation, is clear.
To his significant credit, Inspector Seddon accepted responsibility for the break-down in communications with the Bale family and unreservedly apologised to them, and in doing so, has shown himself to be an officer of integrity.
Evidence of Dr Michael Diamond, forensic psychiatrist
The Court obtained two reports from forensic psychiatrist Dr Michael Diamond,228 and also had the benefit of his oral evidence.229 He gave compelling evidence based on his extensive knowledge and experience
Dr Diamond is a specialist psychiatrist. He has been a Fellow of the Royal Australian and New Zealand College of Psychiatrists since 1984 and has been practising as a psychiatrist for 32 years.230 Dr Diamond also has longstanding experience and ongoing involvement as a consultant to the Negotiation Unit of the NSW Police Force.231
In his reports, Dr Diamond noted that an adequate threat assessment could not have been made by Sgt. Steel because he was unaware of critical information about the call 227 Statement of Inspector Nicholas Seddon dated 5 October 2016, Tab 69, at [6].
228 Dr Diamond’s initial report was provided on 25 March 2016, Tab 58; Dr Diamond provide a supplementary report on 2 May 2016, Tab 63.
229 On 12 October 2016.
230 Report of Dr Michael Diamond dated 25 March 2016, Tab 58, p 1; curriculum vitae of Dr Michael Diamond, Tab 58; oral evidence of Dr Michael Diamond, T101.34-41 (12 October 2016).
231 Supra; T103.1-24.
between Mr Bale and Mr Tant.232 Specifically - Sgt. Steel was unaware of the severity of Mr Bale’s suicidal intent, and did not appreciate that Mr Tant was engaged in a tenuous dialogue with Mr Bale that was effectively disrupting Mr Bale’s plan to take his own life.233 In oral evidence, Dr Diamond explained that “what was tenuous was Mr Bale’s connection with ongoing life. This was a man very close to completing a suicide”;234 it was not a suicidal threat or distressed person making suicidal hints, but a “suicide in progress”.235
Additionally, Dr Diamond told the Court that the conversation Mr Tant had developed with Mr Bale was “intensely valuable” and should not have been interrupted,236 (Dr Diamond noting that Mr Tant had a “wealth of information”237 and was engaged in a “process that was so precious, so important”238). He explained that when involved in a dialogue of that nature, “one doesn’t bring anything to completion”, because (in effect), it leads to completion of the act of suicide; ending a phone call is an example of a completion process.239
Dr Diamond’s evidence was that Sgt. Steel’s decision to terminate the call between Mr Bale and Mr Tant was not consistent with the practice preferred by police negotiators.240 The first person to respond to a high risk situation often becomes the “de facto primary negotiator” due to the rapport they build with the subject during their communication. In his (second) report, Dr Diamond explained: “The standard police negotiator procedure is not to interrupt the communication between first responder and subject and to, if necessary, support the de facto primary negotiator with the skills of the assembled negotiation team and to work towards removing the untrained de facto negotiator in due course when the Subject is able to indicate that they accept a transfer of the negotiation to a trained negotiator.”241 232 Report of Dr Michael Diamond dated 25 March 2016, Tab 58, p 9 and p 11; Report of Dr Michael Diamond dated 2 May 2016, p 13, Tab 63.
233 Report of Dr Michael Diamond dated 25 March 2016, Tab 58, pp 9-12.
234 Oral evidence of Dr Michael Diamond, T104.37-38 (12 October 2016).
235 Supra, T116.32-33.
236 Supra, T105.49-T106.2 (although Dr Diamond stressed that he was not pointing “fingers of blame”).
237 Supra, T108.27.
238 Supra, T104.20-21.
239 Supra, T106.4-22.
240 Report of Dr Michael Diamond dated 2 May 2016, p 15.
241 Report of Dr Michael Diamond dated 2 May 2016, p 15.
In oral evidence, Dr Diamond reiterated that police negotiators are “trained to work in that ambivalent space where the will to live and the will to die is equally balanced”; he explained that suicidal intent peaks and wanes, and that although someone might be intensely suicidal at one given moment, by “elongating” the process “the chances of success are much greater”.242 He went on to state: “So one works with that ambivalence and the whole key to it is about meaningful communication, slowing down the intensity, allowing a process of extinguishment of the suicidal drive to come into play and creating safety.”243 What if any are the lessons that can be learnt from these tragic circumstances?
The recommendatory power outlined in s. 82 of the Coroners Act is the distillation of the coroner’s death prevention role, “speaking for the dead to protect the living”.
Lessons can often be learnt from the close examination of a single death, and while it is prudent to acknowledge the limited scope of the inquiry, it is equally important to identify areas of possible improvement as they emerge. In this regard, the inquest proceeded against the background of the NSW Police Force’s insight and proactivity in relation to the circumstances surrounding Mr Bale’s death.
I will deal with each in turn.
Training of Radio Operations Group and Police Link Command staff regarding “mental state” of a caller
243 Oral evidence of Dr Michael Diamond, T105.38-41 (12 October 2016).
“An increase in awareness during triple ‘000’ initial training programs of ROG and PoliceLink in relation to the current SOPs for providing relevant information in real time via CAD relating to the “mental state” of a person. This may include information that will assist police managing the scene, such as information provided in relation to the subject matter of the conversation and any relevant information such as the reasons for a suicide attempt, all of which assist in determining the mental state of a person”.244
S/Sgt. Cooney, relevantly the Manager of the Education and Development unit within the PoliceLink Command (since August 2011), gave oral evidence at the inquest. Her role includes the training of telephonists.245 In oral evidence, S/Sgt. Cooney explained that: “…What we also want to include in our training is … to make sure that they’re [telephonists] aware that other information that may be relevant for the police who are - whether they be trying to build rapport or conduct unplanned negotiations so the information that would go into that may not be on appearances going to assist the police in terms of managing the specific incident, for example firearms, weapons, but it might be information about how a change in their psychological state, might be happy to talk about the football team on the weekend, that might be something that the negotiators or police can use for rapport building, so that might be important information that can go into the CAD, so that's the sort of stuff that we want to expand, about psychological state.”246
S/Sgt. Cooney confirmed that the circumstances of Mr Bale’s death were “heavily involved” in informing this proposed training reform.247
Additionally, in relation to PoliceLink telephonist training material, Dr Diamond commented upon a NSW Police training document, extracted in the statement of S/Sgt.
Cooney.248 In relation to certain material set out under the heading ‘Mental health issues’, Dr Diamond stated that training telephonists as to mental health issues was an 244 Letter from McCabes Lawyers (on behalf of the NSW Police Force) to the Crown Solicitor’s Office dated 29 August 2016, Tab 65, pp 5-6.
245 Oral evidence of S/Sgt. Cooney, T85.5-27 (11 October 2016).
246 Supra, T88.3-13 (11 October 2016).
247 Supra, T88.15-17.
248 Statement of S/Sgt. Cooney, dated 22 December 2016, Tab 30A at [10].
“extraordinarily complex task”.249 However, he had no idea what certain medical disorders referred to in it were (notwithstanding his efforts to find out) – ie. Mitoliaisa disorder;250 further, certain comments within the document were “ignorant and not useful”.251 He suggested it was a good idea for the document to be revisited.252 In response S/Sgt Cooney accepted that the material wasn’t as comprehensive or as up to date as it might be and stated “we can look at that certainly”.253 The Court trusts that this important task can occur with expert advice as soon as practical.
Cooney) in this regard, it is not apparent that any specific recommendation is necessary.
Proposed amendments to NSW Police Force telephony and dispatch training and procedures
250 “Mitoliasa disorder” is referred to in the document extracted at [10] of the Statement of S/Sgt. Cooney, dated 22 December 2016, Tab 30A; Dr Diamond comments on this in his oral evidence, T109.21-23 (12 October 2016).
251 Supra, T109.28.
252 Supra, T108.45-109.32.
253 Oral evidence of S/Sgt Cooney, T92.12-45 (11 October 2016) 254 Supra, T88.19-40; T89.12-18.
Mr X for his part stated that in terms of any learnings to take from Mr Bale’s death, he believed that the “transition from [the ‘000’ call] to people at the scene may have been done in a more positive way”, expanding as follows: “…The transition of that phone call and having spoken to senior members of the communications branch, it is something that could be looked at or will be looked at and trying to put things in place so that that transition will be more positive in the future and it may well be that those sorts of phone calls can transition to police at the scene who have the situational awareness of what's taking place, the information on the ground and then can be introduced and start making phone calls.”255
Inspector Seddon, the critical incident investigator, gave evidence that he agreed with the proposed amendments to the telephony and dispatch procedures of the NSW Police Force.256
In oral evidence, Dr Diamond also confirmed that he had reviewed the proposed amendments to the telephony and dispatch SOPS of the NSW Police Force and agreed the proposals were sensible.257
As to the status of the proposed changes, S/Sgt. Cooney stated that the proposed changes had been agreed to by both commanders of the ROG and PoliceLink, however following review there were some further “small changes” which were necessary.
Otherwise, she anticipated there would not be any issues having the changes approved and put in place.258
256 Supra, T20. 49-50.
257 Supra, T106.29-40.
258 Oral evidence of S/Sgt. Cooney, T90.22-38 (11 October 2016).
259 See T186-187.
unclear – whilst it initially appeared that they were soon to be ratified, it later emerged that a further level of approval is necessary.260
Training of NSW Police Force first responders
could be spread more widely amongst general duties and other first responder police that would be a helpful added knowledge to have.”261
Further, Dr Diamond stated that (by analogy with police negotiators), they would often simply observe what was going on where a first responder had made the initial contact, and “then work out a way to introduce themselves into the dialogue”.262 He subsequently explained that:“… there is a simple message about not all jobs need to be attended to rapidly. Sometimes there is a place for slowing things down and gathering information and it's different information. You know, police information is often based on what is likely to amount to evidence. In this sort of world evidentiary material is not that important, it's contextual material, it's interpretative material and understanding what is occurring at a given time that is far more important and that's counterintuitive to most operational police officers. It's not a criticism, once again, it's just very different from what they are normally tasked with. … So if that idea could just be part of a more generic training for broader groups of first responders; that not every job needs a rapid response.”263
Additionally, Dr Diamond explained that the first responder would be better served by understanding what had occurred in a situation to date;264 information conveyed by CAD only captured a certain aspect of what was occurring (address, age, weapons), but did not give much in the way of interpretive or contextual information. In this instance, transfer of information as to the nature of the incident (being a suicide in progress),265 and ensuring the first responder was aware of it, was important.266
Mr X also agreed that there was a need for first responders to be trained as to the risks inherent in terminating a call with someone as intensely suicidal as Mr Bale.267
For his part, Inspector Seddon also agreed as to the need for training of first responders in high risk situations in terms of the risks of terminating contact with a suicidal caller, 261 Supra, T107.3-15.
262 Supra, T109.33-38.
263 Supra, T113.11-23.
264 Supra, T107.46-47.
265 Supra, T116.33.
266 Supra, T107.50-108.7.
267 Oral evidence of Mr X, T83.11-15 (11 October 2016).
and also regarding operation of the new (proposed) procedures for the transfer of callers by telephonists.268
As set out above, the need for such training was also unequivocally accepted by Mr X and also Inspector Seddon.
Further, such training is the corollary of the proposed amendments to the telephony and dispatch SOPS.
Moreover, training of first responders as to the need to obtain relevant contextual information (beyond pure evidentiary material), as advanced by Dr Diamond, would seem highly desirable. Accordingly, I make the following recommendation to the NSW Commissioner of Police, Recommendation 2: That the NSW Police Force give consideration to appropriate training for first responders in dealing with suicidal persons in high risk situations including with respect to the potential implications of terminating existing communication, the possibility of having telephonists transfer calls to the scene, and the need for gathering contextual information.
268 Supra, T21.1-11.
Formal findings made pursuant to section 81 of the Coroner’s Act 2009 (NSW) On the basis of the evidence before me, on the balance of probabilities, I make the following formal findings Identity of the deceased As to identity, the deceased was Mr John Inman Bale, aged 60.269 Place of death The place where Mr Bale died was his home, 36 Arndill Avenue, Baulkham Hills, Sydney.270 Date of death The date that Mr Bale died was 29 September 2014.271 Cause of death The Court has the benefit of the autopsy report of Dr Kendall Bailey dated 31 March 2015.
Dr Bailey found, in unequivocal terms, that the cause of death was a single gunshot wound to the head. 272 Manner of death From the evidence, it is submitted that the precise manner of Mr Bale’s death is clear. The evidence establishes that sometime between 7.39 am (being the time Mr Bale’s call with the PoliceLink telephonist concludes) and 10.47 am (being the time Mr Bale is first seen deceased on his bed by police) on 29 September 2014, Mr Bale used an unregistered a .22 calibre Lithgow bolt action rifle to shoot himself.273 269 Mr Bale was identified by his son, James Bale on 1 October 2014 – see Tab 2, identification statement dated 1 October 2014.
270 See statement of Acting Sergeant Dayne Brown dated 6 October 2014, Tab 14 at [15]-[16]; Statement of Sergeant Paul Whitehead (TOU) dated 9 October 2014, Tab 15 at [14-[17]; Statement of Leading Senior Constable Steven Davies dated 7 October 2014, Tab 16 at [14]-[15] (together with his notebook entry – Tab 16A); Statement of Senior Constable Liam Edwards (FSG) dated 9 March 1015, Tab 28 at [14].
271 Supra.
272 Autopsy Report of Dr Kendall Bailey dated 31 March 2014, Tab 4, p 2. As noted in counsel assisting’s opening, an expert report of Associate Professor Naren Gunja dated 23 June 2016 (Tab 49) considered Mr Bale’s toxicology tests, which detected olanzapine (or Zyprexa, an anti-psychotic medication used for the treatment of psychotic disorders) at the concentration of 0.4mg/L. Relevantly, A/Professor Gunja opines that this level is above the usual therapeutic range for most individuals, and within the range associated with mild to moderate toxicity. Notwithstanding an overdose of olanzapine, A/Professor Gunja states that the it was “unlikely to have been contributory to the death in any significant manner at the time of Mr Bale’s death.” Other medication was detected at concentrations consistent with therapeutic ingestion.
273 See statement of Acting Sergeant Dayne Brown dated 6 October 2014, Tab 14 at [15]-][16]; Statement of Sergeant Paul Whitehead (TOU) dated 9 October 2014, Tab 15 at [14- [17]; Statement of Leading Senior Constable Steven Davies dated 7 October 2014, Tab 16 at [14]-[15] (together with his notebook entry – Tab 16A); Statement of Senior Constable Liam Edwards (FSG) dated 9 March 1015, Tab 28 at [14].
Mr Bale’s intention It is submitted that the evidence overwhelmingly establishes Mr Bale intended to take his own life.274 Finally, I offer my sincere condolences to the Bale family. I thank them for their active participation in this process. I acknowledge their grief and their enormously gracious approach to these proceedings.
I close this inquest.
Magistrate Harriet Grahame Deputy State Coroner 30 March 2017 274 There was no dispute in relation to this finding. The evidence supporting it is accurately summarised by Counsel assisting in her detailed submissions extracted below
Mr Bale said to the PoliceLink telephonist (Mr Joseph Tant) that he wanted to kill himself during the 17-minute telephone call, stating (amongst other matters): “I don’t wanna live any more, I’ve had enough”, and “… Life’s too hard, I just can’t do it any more”. He also stated that he had a rifle and was going to shoot himself: “I’ve got a bullet in the bridge and the moment and I’m gunna, I’m gunna squeeze the trigger and I’ll put it in the rim of my mouth, and that’s it mate, I don’t want be on this earth anymore”. Mr Bale also said “… I can’t bear to go to another … in hospital, I just can’t do it, I just can’t keep going…”;
Consistent with Mr Bale’s statement to Mr Tant that: “I’m in a bad situation, I’ve just taken an overdose of tablets… I’m gunna end my life…”toxicological screening and expert analysis of the results appear to confirm that he had in fact taken an overdose of olanzapine;
The evidence of Dr Fountain, Mr Bale’s treating psychiatrist, establishes that Mr Bale had a chronic history of bi-polar disorder dating back to 1976, a mood disorder involving prolonged depressive relapses often associated with suicidal thoughts; additionally, such episodes could be triggered by relatively minor life problems
Mr Bale’s son - James Bale - also provides evidence relating to his father’s long standing struggle with depression and bi-polar disorder, his ruminations about not wanting to be alive and also the effect of retrenchment, lack of companionship and the death of his mother a month earlier, on him;
Father Mark Bohr provides a further account of Mr Bale’s struggle with depression and his declining mental state around 20 September 2014;
After Mr Bale’s death, various diaries and letters discovered by his children further confirmed his distress and suicidal ideation.
It is also noted that Senior Constable Edwards, the crime scene officer who attended the scene on 29 September 2014 and examined Mr Bale’s body, found no defensive type injuries or signs of disturbance in the room in which Mr Bale was located.
b. If the decision to terminate the call is confirmed, the telephonist will terminate the call accordingly.
c. If a decision is made to transfer the call: i. prior to conferencing the call with the nominated officer, confirm police at the scene are aware that a suicidal caller will immediately hear the police at the scene on the call from the time the call is answered (this confirmation is coordinated by ROG Dispatcher via CAD); ii. obtain the first name and phone number for the nominated officer receiving the transferred call; iii. advise the caller that the call is to be transferred to (insert transfer first name here) who wants to talk to them, and advise the caller that they will hear a phone ringing. Confirmation to be provided to the caller that the telephonist will remain on the phone too; iv. advise the caller not to hang up; v. telephonist to initiate conference call via “consultant” (ROG: Conference) button vi. (the caller will be placed on hold for a short period hearing TZ recorded message).
275 Per letter from McCabes Lawyers (on behalf of the NSW Police Force) to the Crown Solicitor’s Office dated 29 August 2016, Tab 65, pp 67.
vii. Telephonist dials nominated officer’s phone number, then immediately clicks on the “instant call conference” (ROG: complete conference) button which will take the caller off hold so the caller will hear the ringing tone and then the nominated officer will answer; viii. introduce the caller to the nominated officer – for example “John (caller), I have Sam (police at scene) on the line who wants to continue chatting to you.” ix. introduce the nominated officer to the caller and provide any relevant information that might assist with the communication with the caller – e.g.
“Sam, I have John here who I have been talking to about his current situation, he’s got an appointment at his psychiatrist next week and doesn’t want to go back to hospital, so wants to end his life. John has also told me he’s got four adult children and a family property in Bathurst”; x. once police at the scene have taken over the conversation with the caller, the telephonist is to terminate their line and the officer and the caller will continue on the call.
ii. If decision to terminate the call is confirmed and not to transfer:
advise the telephonist of the request to terminate and not transfer; iii. If decision is made to transfer the call:
advise police on the scene that the caller will immediately hear the police at the scene from the time the call is answered;
record acknowledgement of this information in CAD as the telephonist will not attempt to transfer the call prior to confirming this;
obtain first name and phone number for transfer of call and add to CAD message for the telephonist.
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