Inquest into the death of Sandra Deacon

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Sandra Deacon Hearing dates: 16 November 2017 Date of findings: 16 November 2017 Place of findings: NSW State Coroner’s Court, Glebe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – homicide, mandatory inquest, blunt force trauma File numbers: 2014/288219 Representation: Mr B Hart, Coronial Advocate assisting the Coroner Findings: I find that Sandra Deacon died on either 30 September 2014 or 1 October 2014 at Budgewoi NSW. Ms Deacon died from blunt force head trauma. These fatal injuries were inflicted when Ms Deacon was struck multiple times to the head by an axe wielded by Garry Weigand. The manner of Ms Deacon’s death is therefore homicide.

Table of Contents

Introduction

1. Sandra Deacon died in 2014 at the age of 59. Due to a debilitating neurological condition from birth, Sandra faced many challenges and hardships. Sadly, Sandra’s life was not always a happy one, despite the best efforts of her family to love her and care for her. Tragically, Sandra’s life was cut short in 2014 due to a terrible and violent act.

Why was an inquest held?

2. All violent and unnatural deaths must be reported to a Coroner. A Coroner has an obligation to make findings about the identity of the person who died, when and where they died, and what the cause and the manner of their death was. The manner of a person’s death means the circumstances in which that person died. If it appears to a Coroner that a person died, or might have died, as a result of homicide, then section 27(1)(a) of the Coroners Act 2009 (the Act) requires that an inquest must be held.

3. In Sandra’s case, because the evidence that has been gathered about her death indicates that she died as a result of homicide, the law requires that an inquest must be held into her death.

Regrettably, the mandatory requirements of the Act bring with it the distressing memories associated with Sandra’s death.

Sandra’s life

4. Before going on to set out the findings from the inquest it is appropriate at this point to recognise, and say a few brief words about, Sandra’s life. Cases involving deaths due to homicide are often most concerned with gathering evidence which may result in the apprehension and conviction of the person or persons responsible for the homicide. That evidence rarely tells us much about the person who died, their life, and the way in which their death has impacted their family and friends. Therefore it is important to recognise the life of that person in some small, but hopefully meaningful, way.

5. Sandra was born in Bankstown in 1955 to Shirley Parkes and Bertie Deacon. Tragically, Sandra suffered from encephalitis at birth, resulting in brain damage and mild intellectual impairment.

Several years after Sandra’s birth her brother, Grahame, was born.

6. Sandra began her education at Bankstown primary school but because of her intellectual impairment she found the structured school environment to be difficult. As a result Sandra’s parents made the decision to school Sandra at home.

7. As Sandra grew from childhood to adulthood she remained unable to look after her daily living needs. This meant that she was heavily reliant on her parents, especially her mother, to care for her. Grahame recalls that Sandra’s mother was devoted to caring for Sandra and that Sandra continued to live with her parents well into adulthood.

8. In the late 1970s Sandra and her parents moved from Sydney to the Budgewoi area in the Central Coast. Sadly, Sandra’s mother passed away several years later. Sandra’s father continued to care for Sandra although he found this to be challenging. Over time, Sandra developed enough basic living skills to be able to live independently.

9. Some years later Sandra’s father also passed away. As Sandra was comfortable in her parents’ house she continued living there for about 2 years. However, Grahame (who had remained in Sydney after the family moved to Budgewoi) later discovered that Sandra was struggling to look after herself.

10. Eventually Grahame decided to sell his parents’ house as it was becoming difficult for Sandra to manage it. Although Sandra was initially upset at having to move out of the house, Grahame subsequently found another house for Sandra to rent that was also in Budgewoi. Sandra also received some money from the sale of her parents’ house. Unfortunately Sandra was unable to manage her financial affairs and this led Grahame to apply for a guardianship order. In December 2001 the Office of the Protective Commissioner (as it then was) was appointed pursuant to a guardianship order to manage Sandra’s financial affairs.

11. With the assistance of the Office of the Protective Commissioner, Sandra later purchased a mobile home and began living at a caravan park in Hamlyn Terrace. By all accounts Sandra enjoyed her life on the Central Coast and was proud of being able to live independently.

Sandra’s relationship with Garry Weigand

12. Sometime in early 2013 Sandra met Garry Weigand at a social event organised by a not-forprofit organisation that engaged with people in the community with intellectual impairment.

They formed a relationship shortly afterwards. Sadly, it appears that the relationship between Sandra and Mr Weigand was a volatile one and was an on and off type relationship. There was a suggestion at various times that Mr Weigand was taking money from Sandra, and that there may have been domestic violence within the relationship.1 However no report of domestic violence was ever made to the police.

13. When Mr Weigand was 5 or 6 years old he was involved in an incident where he was struck by a motor vehicle whilst crossing the road. Mr Weigand suffered a number of injuries and it was later discovered that he had sustained damage to his brain leading to impairment of his intellectual functioning. As an adult Mr Weigand was informed by his treating physicians that his injury would lead to gradual decline of his intellectual functioning.

14. Sometime in March 2014 Mr Weigand began behaving erratically. He made a number of public accusations against Sandra, including that she was using illicit drugs. This erratic behaviour continued into April 2014. In late April 2014 Greg Boulton, one of Mr Weigand’s friends, told Mr Weigand’s sister, Maria Doolan, that Mr Weigand was not well. Ms Doolan went to see Mr Weigand and discovered that he appeared to be terrified and repeatedly said that some unnamed people were going to harm him. Mr Weigand also said that he believed that listening devices had been placed in his home and that his phone calls were being monitored.

15. Ms Doolan thought that her brother was suffering from some mental health issues and so she took Mr Weigand to Wyong Hospital on 27 April 2014 for treatment. Mr Weigand was diagnosed as suffering from paranoid ideations and it was noted that he had been abusing alcohol. He was prescribed anti-psychotic medication.

1 Exhibit 2, page 188.

16. After being discharged from hospital, Ms Doolan and her husband stayed with Mr Weigand for several days to make sure that he was well. During this period of time they noticed that Mr Weigand’s mental well-being appeared to improve. It was also during this time that Mr Weigand told Ms Doolan that he had been seeing Ms Deacon regularly and described her as a “bad influence”.2 Mr Weigand also said that he did not want to see Sandra anymore. According to Ms Doolan, Mr Weigand seemed to be somewhat scared of Sandra. Exactly why Mr Weigand made these comments, and the reason for this attitude towards Ms Deacon, is unclear on the available evidence. However, it appears that Mr Weigand’s deteriorating mental condition was likely a contributory factor.

What happened in September 2014?

17. In the 6 weeks before Sandra’s death she increasingly spent time with Mr Weigand, often visiting him at his house at 15 Sonoma Road, Budgewoi. About 3 weeks before her death Sandra left the caravan park in Hamlyn Terrace where she had been living. She told the manager of the park that she would be away for a few days, staying with Mr Weigand.

18. In the 2 weeks before Sandra’s death, some of Mr Weigand’s neighbours and acquaintances noticed that he was behaving strangely, often mumbling incoherent words to himself. On 27 September 2014 Mr Weigand went to a local bottle shop and bought some beer. Leanne Sellers, the employee who served Mr Weigand (and who also happened to be Mr Weigand’s neighbour) noticed that his eyes were glazed and he was mumbling. Ms Sellers observed that Mr Weigand was acting erratically in general, much as he had in March and April 2014.

What happened on 30 September 2014 and 1 October 2014?

19. Peter Soltan, one of Mr Weigand’s neighbours, saw Mr Weigand on the morning of 30 September 2014 and describes Mr Weigand as acting strangely.

20. At 8:11am on 30 September 2014 a call was made from Mr Weigand’s home phone number to

21. The caller did not speak and, due to the high number of nuisance calls made to 000, as part of routine protocol the call was not transferred to the NSW Police, NSW Fire & Rescue or NSW Ambulance.

22. Another phone call was made to 000 at 6:05pm. During that call Mr Weigand identified himself as a lifesaver at the Lakes Surf Club and said, “Um, a Westpac helicopter to [indecipherable] around the world. Need it here now at 15 Sonoma Road, Budgewoi”. The call was transferred to the police but the call was terminated by Mr Weigand before it could be answered. As a result of the call an incident was created on the police computer aided despatch to attend Mr Weigand’s address. The job was acknowledged at 6:32pm by local police officers. However, due to other workload commitments, no police officers attended Mr Weigand’s address at that time.

23. Between about 7:15pm and 10:00pm several neighbours noticed that the external lights at the back of Mr Weigand’s house were on. After being turned off briefly for about 30 minutes, the lights were turned on again at 10:30pm and remained on. Mr Weigand’s neighbours noticed that it was unusual for the lights to remain on for this length of time during the night.

2 Exhibit 1, page 335.

23. Between about 8:30pm and 9:30pm one of Mr Weigand’s neighbours, Brooke Vidler, saw Mr Weigand at the rear of his house. Ms Vidler saw Mr Weigand walk down the side of his garage (which was located at the rear of his house) towards his back fence, and then walk back to the house.

24. At about 11:20pm on 30 September 2014, the residents of 152 Scenic Drive, Budgewoi saw Mr Weigand in the front yard of their neighbouring house. This house is approximately 500 metres from Mr Weigand’s address. The residents saw that Mr Weigand was dressed only in his underpants and was behaving erratically. The residents contacted the police.

25. Two police officers arrived on the scene at about 11:34pm. They saw that Mr Weigand was still in the front yard of the house. They also saw that Mr Weigand had what appeared to be blood on his hands and feet. Arrangements were made for an ambulance to take Mr Weigand to Wyong Hospital for an assessment, accompanied by one of the police officers.

26. At about 12:10am on 1 October 2014 police officers went to Mr Weigand’s address. They found the front door open and most of the lights on inside the house. The rear door was also open. At the back of the house the police officers found Ms Deacon, unresponsive, lying at the bottom of a set of steps, with her head resting on the bottom step. It was immediately obvious to the police officers that Sandra was deceased and that she had suffered a number of serious injuries to her head. Paramedics were called. They arrived at the scene at 12:20am and confirmed that Sandra was deceased.

27. The police officers searched the area surrounding the garage at the rear of the house. They found a large amount of blood on a concrete path behind the garage, along with blood splatter patterns on a fence and garden wall near the garage. Drag marks and a blood trail indicated that Sandra had been dragged from the concrete path behind the garage, to the front of the garage, and then to the set of steps at the back of the house. A large yellow-handled axe covered with blood was later found leaning against the garage. Forensic examination later identified Sandra’s DNA on samples taken from the blood trail and the axe.

28. After Sandra’s body was discovered the police officer who was in the ambulance accompanying Mr Weigand to hospital was alerted. The police officer placed Mr Weigand under arrest, whilst in the ambulance, and made arrangements for him to be transferred to a police vehicle. Mr Weigand was taken to Wyong police station, charged with Sandra’s murder, and placed into custody.

29. During a recorded phone call on 10 October 2014, which took place after Mr Weigand entered custody, Mr Weigand said, “I know I have done the wrong thing. I had to do it because she wouldn’t leave”.

What was the cause of Sandra’s death?

30. Sandra was later taken to the Department of Forensic Medicine at Newcastle. Professor Tim Lyons performed the post-mortem examination on 2 October 2014. From the autopsy Professor Lyons made the following clinical findings:

(a) Sandra had at least 8 complex stellate3 wounds to her scalp. The shape of these wounds was consistent with having been caused by the corner of the axe found at the scene which had 3 edges, similar to the stellate pattern of the wounds.

(b) The wounds were consistent with the application of severe combined blunt and sharp force trauma. Professor Lyons noted that the moderately sharp edge of the axe could have accounted for the lacerated (blunt force) and incised (sharp force) wounds which Sandra suffered.

(c) There was a complex fracture of the skull and associated closed head injury.

(d) There were wounds to the hands and forearms consistent with being defence-type injuries due to fending off several blows from the axe.

(e) There was a parchment-like abrasion over the right upper arm which was consistent with a drag mark caused by moving Sandra’s body.

31. Ultimately, in the autopsy report dated 22 January 2015, Professor Lyons concluded that the cause of Sandra’s death was blunt force head trauma.

What was the manner of Sandra’s death?

32. The forensic evidence and clinical findings from the autopsy establish that Sandra died from wounds she suffered as a result of being struck multiple times by the axe located in the garage area at the rear of Mr Weigand’s house.

33. CONCLUSION: Having regard to the location of Sandra at the rear of Mr Weigand’s house, the forensic evidence, and Mr Weigand’s location a short distance away I conclude that Mr Weigand wielded the axe and used it to strike Sandra to the head multiple times. The manner of death is, therefore, homicide.

34. The circumstances which gave rise to these actions are much less clear on the available evidence. Certainly, the evidence establishes that Mr Weigand was behaving erratically in the months leading up to Sandra’s death. Although it appears that this behaviour subsided following Mr Weigand’s hospitalisation and treatment, the evidence indicates that it returned in the weeks before Sandra’s death and was obvious to Mr Weigand’s neighbours on 30 September 2014.

There is also evidence that Mr Weigand had purchased alcohol in the days before Sandra’s death.

His consumption of it may have contributed to his actions.

35. The evidence also indicates that Mr Weigand was exhibiting delusional and paranoid behaviour in the period before Sandra’s death. Mr Weigand told his sister that Sandra was a bad influence on him and that he did not want to see her any more. It is unclear whether a particular incident or some relationship issue between Sandra and Mr Weigand might have led to these comments being made, whether they were a result of Mr Weigand’s deteriorating mental health, or whether they were due to a combination of these (and possibly other) factors.

36. The available evidence does not allow for a conclusion to be reached as to what caused or precipitated Mr Weigand’s actions on 30 September 2014. However it is probable that Mr 3 Arranged in a radiating pattern, like that of a star.

Weigand’s progressively deteriorating mental condition, possibly exacerbated by excessive alcohol intake and non-compliance with prescribed medication, was a strong contributing factor which caused Mr Weigand to act in the manner that he did.

Domestic violence issues

37. As noted already, due to her challenges with living independently, Sandra was receiving support for personal and domestic assistance from Home Care NSW from November 2006. The case management support for this assistance was provided by Aging, Disability Support Services Inc.

(ADSII), a non-government service provider. Sharon Townsend was the community options case manager for ADSII and had regular contact with Sandra from November 2009 onwards.

38. As part of the services provided by ADSII, Sandra was also allocated a social worker, Patricia Gumulak, and she was given assistance with her personal care, household work, and shopping.

Ms Gumulak also helped Sandra with her independent living skills and arranged for regular health checks via medical appointments.

39. In early 2012 Ms Gumulak noticed that Sandra had a number of minor injuries on her body. Ms Gumulak also saw that in August 2014 Sandra had some other injuries (a black eye and lump on her forehead). When asked about these injuries Sandra said that they were due to a fall and would not provide any further details.

40. From about mid-2013 to mid-2014, Ms Townsend noticed that Sandra was decreasing her engagement with Ms Gumulak and ADSII. Sandra appeared more resistant to assistance and began to cancel services and medical appointments. After learning that Sandra had formed a relationship with Mr Weigand, Ms Townsend eventually formed the belief that Mr Weigand was controlling Sandra and contributing to her disengagement from support services.4

41. On 22 September 2014 Ms Townsend called Lauren Hirst, the Senior Guardian at the Gosford office of the Public Guardian. Ms Hirst was familiar with Sandra and her history as she had previously been involved in guardianship proceedings relating to Sandra. During the phone call Ms Townsend said that she held concerns that Mr Weigand had taken control of Sandra and that he would kill her.5 In a statement provided to the police, Ms Hirst gave a different account of the conversation with Ms Townsend. Ms Hirst stated that Ms Townsend told her that she (Ms Townsend) was concerned about Sandra’s welfare and what Mr Weigand might do to her.6 Ms Townsend’s statement to the police is consistent with a contemporaneous note which she made on 22 September 2014 regarding the conversation.7

42. In the 14 pages of Ms Townsend’s statement there is no indication of what specific factors, if any, led to her apparently telling Ms Hirst that she (Ms Townsend) believed that Mr Weigand would kill Sandra. It appears that this comment (if made) was based on the following factors: (a) Ms Townsend’s awareness that Sandra’s disengagement from support services coincided with the period that she began seeing Mr Weigand; (b) Ms Townsend’s belief that Mr Weigand was a negative and controlling influence over Sandra; and (c) the suspicion that Sandra had been subjected to domestic violence by Mr Weigand. Taking into the account the evidence contained 4 Exhibit 2, page 203.

5 Exhibit 2, page 205.

6 Exhibit 1, tab 8.

7 Ibid.

in Ms Townsend’s statement I accept that Ms Townsend was justified in reaching these conclusions.

43. What is less clear is whether Ms Townsend expressly said to Ms Hirst on 22 September 2014 that she (Ms Townsend) believed that Mr Weigand would kill Sandra. The accounts of the conversation given by Ms Townsend and Ms Hirst are obviously inconsistent with each other.

However, I consider the contemporaneous note of the conversation made by Ms Hirst to be ultimately persuasive. That is, I conclude that Ms Townsend only expressed concern regarding what Mr Weigand might do to Sandra, without making specific mention of thinking that Mr Weigand would kill Sandra. It is possible, if one were to surmise, that when Ms Townsend made her statement to police after Sandra’s death Ms Townsend’s recollection was affected by hindsight bias.

44. The issue is then whether intervening action (such as making a report to police) should have been taken after the 22 September 2014 conversation. I have accepted that, in accordance with Ms Hirst’s filenote, Ms Townsend only told Ms Hirst that she was “concerned for Sandra’s welfare and [was] worried about [what Mr Weigand] would be doing to her”. 8

45. CONCLUSION: The content of the conversation between Ms Hirst and Ms Townsend on 22 September 2014 was non-specific and did not extend beyond a general concern by Ms Townsend for Sandra’s welfare. Whilst the available evidence indicates that Ms Townsend was justified in holding such general concerns, what was actually expressed on 22 September 2014 did not indicate that Sandra was at immediate risk of harm. There was also nothing about the content of the 22 September 2014 conversation which indicated that the matter should be reported to the police to investigate.

46. As part of the coronial investigation further information was sought from the Department of Family and Community Services (FACS). Evidence9 was obtained from FACS which establishes that there are appropriate policies and procedures in place which govern the reporting of suspected abuse to case managers and superiors, as well as law enforcement authorities. These policies and procedures apply to all Aging, Disability and Home Care operated and funded nongovernment support services, such as those provided by ADSII to Sandra.

47. CONCLUSION: Appropriate policies and procedures exist to ensure that the suspected abuse of persons who are provided with support services by ADSII are escalated to case managers and superiors, as well as to law enforcement authorities.

Findings

48. Before turning to the findings that I am required to make, I would like to thank Mr Peter Bain and Mr Ben Hart, Coronial Advocates, for their assistance with the preparation and conduct of this inquest. I would also like to thank Detective Senior Constable Bradley Milton, the officer-incharge of the police investigation.

49. The findings that I make under section 81(1) of the Act are 8 Exhibit 1, tab 8.

9 Exhibit 1, tabs 9-12.

Identity The person who died was Sandra Deacon.

Date of death Sandra died on 30 September 2014 or 1 October 2014.

Place of death Sandra died at Budgewoi, NSW.

Cause of death Sandra died from blunt force head trauma.

Manner of death Sandra died when she was struck multiple times to the head by an axe wielded by Garry Weigand, and therefore the manner of her death was homicide.

Epilogue

50. From birth, Sandra faced many challenges in life. With the support of family members who loved her, services provided in the community, and her own resolve, Sandra was able to overcome most of these challenges. This makes Sandra’s death in 2014 that much more tragic. On behalf of the Coroner’s Court I extend my condolences to Sandra’s family and loved ones for their loss.

51. I close this inquest.

Magistrate Derek Lee Deputy State Coroner 16 November 2017 NSW State Coroner’s Court, Glebe