Inquest into the death of MB

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of MB Hearing dates: 23 August 2018 Date of findings: 28 August 2018 Place of findings: NSW State Coroner’s Court, Glebe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – self-inflicted death, police operation, The Skillion, police negotiation, consultation with psychiatrist File number: 2016/347726 Representation: Mr C McGorey, Counsel Assisting, instructed by Ms C Skinner, Crown Solicitor’s Office Mr R Coffey for the NSW Commissioner of Police Findings: I find that MB died on 20 November 2016 at Terrigal NSW 2260.

MB died from multiple injuries which were sustained after he jumped from a height. MB died as a consequence of actions taken by him with the intention of ending life.

Non-publication orders: Pursuant to section 75(2)(b) of the Coroners Act 2009, the following material is not to be published:

(a) Any matter, including the publication of any photograph or other pictorial representation, that identifies MB; and

(b) Any matter, including the publication of any photograph or other pictorial representation, that identifies any relative of MB.

Pursuant to section 74(1)(b) of the Coroners Act 2009, the name, physical likeness or any other information that would tend to reveal the identity of the following police officers referred to by pseudonyms is not to be published:

(a) Exhibit 1, Tab 10 – “NEGS 1”;

(b) Exhibit 1, Tab 12 – “NEGS 2”;

(c) Exhibit 1, Tab 14 – “NEGS 3”;

(d) Exhibit 1, Tab 15 – “NEGS 4”;

(e) Exhibit 1, Tab 45 – “NEGS Cmdr”;

(f) “NEGS 5” – as referred to within: Exhibit 1, Tab 10, page 103 at Q42/A42; Tab 15, page 152 at [3]; and Tab 26, page 258 at [16];

(g) “NEGS Coord” – as referred to within: Exhibit 1, Tab 12, page 122 at Q3/A4, Q4/A4 and Q17/A17; Tab 14, page 148 at [26] to [27]; Tab 16, page 159 to 160 at [10]; and Tab 21, page 223 at [7].

Pursuant to section 74(1)(b) of the Coroners Act 2009, the following material is not to be published:

(a) The affidavit of Assistant Commissioner Michael Willing sworn 23 July 2018, including its annexures and confidential exhibits.

Table of Contents

1. Introduction 1.1 Mr MB was a much-loved husband and father of three adult children. During the last 18 months of his life, MB experienced a gradual deterioration in his mental health that made him distant and almost unrecognisable to those that loved him the most.

1.2 On 20 November 2016 MB found himself in crisis and placed his own life in danger. A number of police officers responded to this crisis and attempted to bring MB to safety. Tragically, despite their best efforts, the danger that MB was in could not be averted and he took actions to end his own life.

2. Why was an inquest held?

2.1 Under the Coroners Act 2009 (the Act) a Coroner has the responsibility to investigate all reportable deaths. This investigation is conducted primarily so that a Coroner can fulfil their statutory responsibility to answer questions that they are required to answer pursuant to the Act, namely: the identity of the person who died, when and where they died, and what was the cause and the manner of that person’s death.

2.2 Due to the circumstances surrounding the events of 20 November 2016, MB was regarded as having died in the course of a police operation. This meant that, according to the relevant section of the Act which applied at the time1, it was mandatory to hold an inquest into MB’s death. This does not suggest that there was any action taken by any police officer that should be subject to scrutiny or criticism. In fact, the evidence is to the contrary; it establishes that the police officers who were directly interacting with MB on 20 November 2016 did so in a professional and compassionate manner, with the goal of preserving MB’s life.

3. MB’s life 3.1 Inquests and the coronial process are as much about life as they are about death. A coronial system exists because we, as a community, recognise the fragility of human life and value enormously the preciousness of it. Recognising the impact that a death of a person has, and continues to have, on the family and loved ones of that person can only serve to strengthen the resolve we share as a community to strive to reduce the risk of preventable deaths in the future.

3.2 Understanding the impact that the death of a person has had on their family only comes from knowing something of that person’s life and how the loss of that life has affected those who loved that person the most. Therefore it is extremely important at this point to recognise and acknowledge MB’s life in a brief, but hopefully meaningful, way.

3.3 MB was born in India in 1952 and moved to England with his family when he was around 7 years old. MB later met his first wife, Manisha, and together they had three children: AB, AB, and DB. In 1995, shortly after his mother’s death, MB moved to Australia with his then wife and three children.

1 Coroners Act 2009, section 23(1)(c) (since amended).

3.4 At this time, MB was working as a computer engineer. He continued in this capacity until 2001 when he changed jobs and took on a role in sales for a solar company. At around the same time, MB’s marriage came to an end and he and his wife separated. In 2006 MB began a relationship with his second wife, RB. They later married in 2006 and in 2013 they moved to a home in the Kellyville area. By around this time MB had left his sales role and had become involved in property development.

3.5 By all accounts, MB was an intelligent and articulate man as evidenced by his successful professional careers over many years which earned him the respect of his professional peers. He was also a loving husband and a caring and loyal friend.

3.6 Most importantly, MB was also a devoted father who, when his children were younger, took an active and involved role in their upbringing. No doubt MB’s children have very fond memories of the time spent with their father and the great interest and pride that he took in their sporting, and other, activities. When MB’s children grew older, they left Australia to pursue their own careers and other endeavours overseas. Despite this, MB remained in frequent contact with his children and the distance between them in no way diminished his love and affection for them.

3.7 It is most upsetting to know that the life of such a much-loved and well-respected gentleman has ended prematurely and that he will be greatly missed.

4. MB’s medical history 4.1 According to his wife, RB, MB was in good health up until about 18 months before his death. In June 2015 RB noticed that her husband appeared to be under some stress after returning from a business trip to India. The following month MB and RB travelled to England to attend a wedding but they returned to Australia earlier than planned after MB complained of experiencing shortness of breath whilst overseas. RB also noticed that her husband appeared agitated and unsettled during the trip.

4.2 Upon their return MB went to see a GP for a routine health check where nothing adverse was noted. Despite this, MB’s apparent general malaise persisted and he saw a number of doctors (including a gastroenterologist, and a respiratory and sleep physician) in an attempt to resolve his issues. During this time, MB first began to make references to a belief that features of his home were making him sick. MB spoke of a chemical that was emanating from the floorboards, and the air conditioning system which was circulating fibreglass particles throughout the house, causing him to inhale them. During this period RB also noticed that her husband became socially withdrawn; as an example, where MB would previously go out to play golf, he instead preferred to remain at home.

4.3 At around this time one of MB’s closest friends of many years, Jasbir Hothi, noticed what he described as a real change in his friend. He observed that MB had begun to question his own selfconfidence and decision-making, and that this behaviour was a stark contrast to the strong, confident friend that he had known for many years.

4.4 MB was eventually referred to see Dr Jaspreet Singh, a consultant psychiatrist. Dr Singh first saw MB on 25 November 2015. At the time Dr Singh noted that MB was displaying symptoms of low mood, lack of motivation, poor sleep and appetite, and negative ideas about himself and his future. Dr Singh diagnosed MB as suffering from major depression of moderate severity,

prescribed him with antidepressant medication (mirtazapine) and referred him to a psychologist. Dr Singh noted that some recent financial difficulties that MB had experienced, prolonged grief from the breakdown of his first marriage, and increasing isolation from his family were all stressors contributing to his depressive illness.

4.5 MB saw Dr Singh a further three times between December 2015 and March 2016. On these occasions Dr Singh noted that MB continued to experience low mood whilst feeling unmotivated, and was concerned about issues relating to his physical health and financial situation. On 23 March 2016 Dr Singh ceased the prescription of mirtazapine and trialled a new medication regime consisting of another SSRI (selective serotonin reuptake inhibitor) antidepressant (venlafaxine) and an antipsychotic (quetiapine) in an attempt to treat MB’s symptoms.

4.6 In the period between December 2015 and March 2016 MB attended four counselling sessions with a psychologist. During these sessions MB expressed concern about his financial situation and was reported to be experiencing general negativity at this time.

4.7 An extended period passed before MB’s next appointment with Dr Singh. According to RB this was due to her husband’s preoccupation with renovations needed for their home in order to address MB’s concerns regarding the floorboards and air conditioning, combined with MB’s reluctance to continue the appointments. Eventually, MB saw Dr Singh again on 1 June 2016 where it was noted that MB continued to experience stress and depression related to his home renovations and financial issues, and that the change in medication had had little positive effect.

Dr Singh increased the dose of venlafaxine and scheduled a further appointment in three weeks.

4.8 When MB next saw Dr Singh on 23 June 2016 he reported some improvement in his mood, anxiety level, and sleep. Dr Singh also noted that MB denied any suicidal ideation or intent and that he was motivated to resolve his various issues. Dr Singh increased the dose of venlafaxine and made arrangements to see MB again.

4.9 This occurred next on 21 July 2016 when Dr Singh noted that MB “continued to be poorly motivated and was at a pre-motivational stage in terms of making changes to his lifestyle and implementing suggestions about rehabilitation”.2 Dr Singh encouraged MB to engage with his treatment and provided a second referral to a different psychologist. MB later attended a single appointment with this psychologist on 4 August 2016 when it was noted that MB avoided discussion about his psychological symptoms, preferring to instead concentrate on his physical symptoms related to his perceived living conditions at home.

4.10 MB saw Dr Singh for an eighth and final time on 18 August 2016. During this consultation MB reported improvements in his mood, appetite and sleep, but remained preoccupied with his home and its air conditioning system. Dr Singh discussed the possibility of a voluntary admission to hospital but MB was resistant, indicating that he wanted to continue treatment as an outpatient and to address his physical issues first; however, he agreed to discuss the idea of an admission with his wife. Dr Singh made plans to review MB again in two or three weeks, if he decided not to agree to a hospital admission.

4.11 On 2 November 2016 MB went to see a GP at a local medical centre where he again reported his concerns that the air conditioning system in his home was causing him respiratory issues.

Further, MB expressed the view that fibreglass particles circulated by the air conditioning 2 Exhibit 1, page 418 at [63].

system were causing irritation to his skin, and he expressed the view that he should be seen by a dermatologist.

4.12 Dr Singh noted that during his consultations MB “would occasionally voice a passive ‘wish to die’ on questioning but on further exploration, would deny any clear ideas or intent or suicide or selfharm”.3 Dr Singh also formed the view that MB’s concerns about his physical health “were best conceptualised as ‘hypochondriacal ideas’” as part of his depressive condition.4 In this sense, Dr Singh noted it is common for patients with depression to have concerns about their physical well-being.5

5. Events of early November 2016 5.1 On Thursday, 10 November 2016 RB returned home and saw that there was a rope lying on an internal staircase. When she asked MB about this discovery he said that it was nothing and that he was not going to do anything with the rope. Due to concerns for her husband’s welfare, RB contacted Mr Hothi and asked for his assistance. When Mr Hothi later attended MB’s home he was shocked at MB’s appearance, describing him as almost unrecognisable from the friend that he knew and a shell of his former self. Mr Hothi attempted to elicit from MB what was troubling him and MB again referred to perceived issues relating to the floorboards and air conditioning system in his home.

5.2 After meeting with MB, Mr Hothi later asked his son to contact MB’s son, DB, in order to advise him of his father’s condition and ask that he return home to see him. At the time, DB was living in London and, upon hearing that his father was not well, sought further information from both RB and Mr Hothi. After speaking with them, DB learned that learned that his father seemed to be socially withdrawn and staying at home more often than he had previously.

5.3 Several days after discovering the rope at home, RB found a recorded video message that MB had sent to her in a private Facebook message. The message was about three minutes in duration and in it MB bade farewell to his family, expressed his love for them, asked RB to forgive him, and referred to the house which was damaging his health. MB concluded by saying, “And again I’m very sorry to do this to you, but at the moment I’m just not even surviving, I’m just barely getting up I’m so weak, no energy, and it’s all cause [sic] by the gas from the laminated floorboards”.6 After viewing the message, RB spoke to her husband about it. MB expressed great reluctance in going to what he referred to as an “institution” and assured his wife that he was not going to hurt himself.7 After this conversation, RB decided not to speak to her husband about the message again as he had guaranteed his own safety and because she did not want to upset him.

5.4 DB arrived in Sydney unannounced on Sunday, 13 November 2016 and went to see his father, hoping to surprise him. However, when he saw his father DB noticed that he appeared to be emotionless and described him as being in a “dark place”, with a lifeless expression and appearing to be “empty”.8 Whereas DB had previously known his father to be a decisive person he now seemed hesitant and listless.

3 Exhibit 1, page 415 at [20].

4 Exhibit 1, page 421B at [3].

5 Ibid.

6 Exhibit 1, page 591.

7 Exhibit 1, page 341 at [5].

8 Exhibit 1, page 347 at [12].

5.5 On Tuesday, 16 November 2016 DB contacted Mr Hothi in an attempt to arrange a meeting so that he and MB could catch up and socialise. Despite encouragement from his son, MB was noncommittal and ambivalent. Two days later on Thursday, 18 November 2016 DB spoke to RB about his father’s condition and enquired whether he had been seeing any health care professionals. RB told DB about his father’s past medical appointments and mentioned her discovery of the rope at home a week earlier.

5.6 DB saw his father later that day and again encouraged him to contact to Mr Hothi. Again, MB remained hesitant and non-committal. DB attempted to persuade his father to leave the house more often and offered to take him to an outdoor event which he thought he would enjoy, but his father showed little interest in doing so. DB attempted to engage his father in conversation about his welfare and told his father that he loved him and that his family would never judge him no matter how he was feeling. MB acknowledged this but otherwise was reticent to continue the conversation. Eventually DB managed to persuade his father to accompany him to visit Mr Hothi but during the visit MB appeared to be mentally absent. After the visit DB and his father went to Bondi to go for a walk along the coast but DB noticed again that his father appeared to be “mentally slow” during the walk and afterwards, and that he was “zoning in and out, not really there”.9 On their way home from Bondi DB attempted to ask his father about the rope which RB had found but MB said very little in response and dismissed the incident.

5.7 When DB went to visit his father the following day, Friday, 19 November 2016, MB again referred to the floorboards in the house releasing formaldehyde and that the air conditioning system in the house was not being maintained causing fibreglass particles in the roof to be circulated throughout the house and causing damage to his lungs. DB spoke to his father about seeking professional mental health assistance and noted that there was a referral at his father’s house for Dr Singh, and for another clinic in the Kellyville area.

5.8 DB subsequently called Dr Singh’s office to make an appointment and was advised that his father could not be seen until 15 December 2016. When he called the other clinic he was told that because his father would be a new patient he could not be seen until January 2017. DB conveyed during both phone calls that he believed his father’s condition to be poor and that he needed to be seen earlier than the dates that were being offered. After DB spoke to his father about the results of the enquiries MB eventually made an appointment to see Dr Singh on 15 December 2016.

5.9 DB later took his father out to a hardware store in order to buy some equipment so that his father could engage in some gardening activities. Whilst at the store, MB noticed some floorboards and again made reference to his dissatisfaction with the floorboards in his own home. After they returned home and had lunch, they had a conversation with RB during which MB expressed a desire to move homes because of his unhappiness concerning the floorboards and air conditioning system.

6. What happened on 19 and 20 November 2016?

6.1 On Saturday 19 November 2016 RB suggested to her husband that they should go for a short trip to the Central Coast in order to spend some time away from the house that was causing MB a great deal of anxiety and distress. They left home at about 11:30am intending to drive to The Entrance but stopped at Terrigal along the way. They decided to stay overnight there and 9 Exhibit 1, page 349 at [16-17].

checked into the Crowne Plaza Hotel. After walking around Terrigal, they had dinner and otherwise enjoyed a pleasant evening out. Although she had observed MB to be happy during the evening RB found her husband to be restless later that night. She noticed that he turned the air conditioning off and on in their room, and also took the doona off their bed.

6.2 The following morning, Sunday 20 November 2016, MB and RB went out for breakfast and then returned to the hotel to pack before their departure. They left the hotel and drove to the nearby Skillion, a narrow section of headland near Terrigal beach and well-known local attraction. After sitting on a blanket underneath a tree MB and RB decided to go for lunch at a restaurant close by in the area. Following lunch MB returned to the blanket to lie down in a shaded area whilst RB went for a walk.

6.3 When she returned MB decided that he wanted to go for a walk as well and so they both made their way up a hill to the top of the Skillion where there is fenced lookout area with views out to the ocean, at a height of about 150 metres above sea level. MB and RB remained in the area for a while and RB noticed that her husband was quiet. As the weather was hot, RB decided to walk back down and sat on a bench at the base of the Skillion. After about 10 minutes RB saw MB walking around the lookout area. She called him on his mobile phone but he did not answer, so she began walking back up the hill. As she approached the top of the Skillion RB saw that MB was standing on the incorrect side of the fence surrounding the lookout and near the edge of the cliff.

6.4 RB called out to her husband, asking him what he was doing and to return back to the correct side of the fence. MB asked to be given a minute and RB saw what she described as a “lost look” in his eyes.10 She told MB to come out and that she loved him. He responded by saying, “I know”, and then took his wallet out of his pocket and threw it on the ground. RB asked her husband to pick up the wallet and hand it to her, in an attempt to bring him closer to the fence, but he instead picked it up and threw it towards her. At this time, there were some members of the public in the lookout area who had observed what was occurring. One of the persons asked RB if MB was not well and RB confirmed that was the case. Another person asked RB if she wanted the police to be called, to which RB agreed.

6.5 One of the bystanders called triple zero and a broadcast was made over police radio for any available officers to respond. Senior Constable Bernadette Difford was performing general duties in the nearby area at the time and heard the broadcast at 4.49pm. She acknowledged the job and made her way to the Skillion, arriving at 4.52pm. After making her way to the top of the Skillion Senior Constable Difford saw that MB was still standing on the incorrect side of the fence, about five metres away from it, and still near the cliff edge.

6.6 Senior Constable Difford identified RB and asked her what had caused her husband to be on the incorrect side of the fence. RB explained that she and her husband had been looking at the view from the top of the Skillion, and that she had left and returned a short time later to find her husband on the incorrect side of the fence. Senior Constable Difford moved RB and some other members of the public who were at the scene to one side and introduced herself to MB. Senior Constable Difford asked MB to step back from the ledge and to move closer to the fence so that she could speak with him. MB took a step back and Senior Constable Difford asked if she could do anything for him, and again requested that he move closer to the fence.

10 Exhibit 1, page 339 at [23].

6.7 By this time, other police officers who had acknowledged the radio broadcast had also arrived on scene and were making their way to the top of the Skillion. One of the police officers was Senior Constable Craig Tonks. After RB moved away from the scene Senior Constable Tonks spoke to her. RB indicated that MB had been suffering from depression, had not seen his doctor for several weeks and was not taking his medication. She told Senior Constable Tonks that she and her husband had enjoyed a very pleasant day when they arrived in Terrigal the previous day, but that she had noticed that he had been acting somewhat unusually that day.

6.8 Meanwhile, Senior Constable Difford began to engage MB in conversation and asked him if he was happy to speak with her; MB indicated that he was. After asking MB some introductory questions about where he lived and what sporting teams he followed, Senior Constable Difford asked him why he was there. MB replied, “Because of my health”, and when Senior Constable Difford asked what was wrong with his health, MB replied, “My chest”.11 6.9 Senior Constable Difford continued to engage MB in conversation, asking him questions about his background, his employment and his children. As this was occurring, further police officers arrived at the scene. The activity and movement of people away from the summit appeared to unsettle MB, causing him to move closer to the cliff edge. However, Senior Constable Difford continued to reassure MB by advising him that other first responders and emergency personnel would also be arriving at the scene shortly, so that their appearance would not come as a surprise to him. Senior Constable Difford also continued to ask MB if he could move closer to the fence.

6.10 A short time later Senior Constable Difford was joined by a paramedic who also engaged MB in some introductory conversation. At some stage MB began eating berries from a small tree that was located near a small chicken wire fence close to the cliff edge. Senior Constable Difford asked MB if he could bring her some berries so that he would move closer to the fence surrounding the viewing area that she was standing behind. She also asked MB if he wanted some water and he indicated that he did. Senior Constable Difford obtained a bottle of water from the paramedic and asked MB to approach the fence to collect it. MB asked if Senior Constable Difford could throw the bottle to him but she declined and so MB walked over and Senior Constable Difford handed the bottle to him. Senior Constable Difford asked MB to remain close to the fence and engaged him in further conversation about his children and other members of his family. As this conversation continued Senior Constable Difford saw MB step closer to the edge and each time this occurred Senior Constable Difford asked him to step back, and MB complied.

6.11 At some point in their conversation Senior Constable Difford asked MB if he wanted to hurt himself. When MB said that he did not, Senior Constable Difford asked why he had placed himself in danger. MB replied, “Because I’m in a bit of a jam”.12 When Senior Constable Difford enquired further about this, MB said that the floor boards in his house were toxic. After speaking about some other topics, Senior Constable Difford returned to the topic of MB’s health issues.

She asked MB to tell her about his chest pain and he indicated that he had difficulty with indigestion and heart burn. At one stage MB asked Senior Constable Difford if she had a phone.

Senior Constable Difford asked MB if he wanted a phone and if he wanted to call anyone, and MB answered no on both counts. Senior Constable Difford asked MB if he would like to speak to his 11 Exhibit 1, page 47.

12 Exhibit 1, page 51.

wife and he responded by asking Senior Constable Difford to tell her that he loved her. Senior Constable Difford attempted to reassure MB that he could do so himself and asked him again to move back to the correct side of the fence.

6.12 NEGS 1, an officer from the NSW Police Negotiation Unit, later joined Senior Constable Difford at the lookout area. He had arrived on scene at around 5:50pm after receiving a call at about 5:10pm. Senior Constable Difford introduced NEGS 1 to MB and both officers engaged MB in further conversation about topics that had been discussed previously: MB’s health, his family, his job, and the toxic floorboards. During the conversation NEGS 1 asked MB if he could move away from the edge and stand near the fence. Although MB said that he would, he did not actually do so. NEGS 1 left a short time later to call his supervisor whilst Senior Constable Difford continued to engage MB in conversation, reassuring him that he was not in any trouble, that she was there to help, and that she would not leave until they could walk back down from the top of the Skillion together.

6.13 NEGS 1 returned at around 6:15pm and noticed that MB appeared tired. NEGS 1 asked MB what had upset him and why he was at the location, and MB again referred to the fact that the house he was living in was causing him health problems. During this conversation NEGS 1 continued to ask MB to step away from the edge. Both he and Senior Constable Difford asked MB if he wanted anything to eat or drink but MB said that he did not.

6.14 As he was having some difficulty hearing MB, NEGS 1 positioned himself closer to him, along the fence line and about four metres away. He reassured MB that the police were not going to attempt to approach MB and that he was simply moving so that he could better hear him. At this time further police officers were arriving on the scene, including officers from the Rescue Unit, and NEGS 1 explained to MB who they were and that their task was to ensure the safety of all persons involved.

6.15 At around 6:55pm, NEGS 1 saw that other police negotiators had arrived on the scene. He told MB that he was going to speak with them and asked MB to sit down on the grass near the edge so that he knew that he was safe. After speaking with the negotiators who had arrived NEGS 1 made his way back to the top of the Skillion at around 6:58pm, accompanied by NEGS 2, another officer from the Negotiation Unit. As the officers approached, NEGS 1 saw that MB was no longer sitting down and had stood up near the cliff edge. After returning to his previous position where he had been speaking with MB, NEGS 1 introduced NEGS 2 and told MB that they were there because they were concerned about him.

6.16 As this was occurring arrangements were being made for other police officers, including Senor Constable Difford, and emergency personnel to move away from the top of the Skillion and to a command post at the base of the hill. This was to allow the police negotiators to speak to MB without interruption or distraction. As the police and other personnel moved away, NEGS 1 again asked MB to move away from the edge so that he and NEGS 2 could talk to him about what was troubling him. MB looked in their direction and then turned and jumped off the edge of the cliff.

6.17 Emergency personnel were immediately despatched to the rocks at the base of the cliff where MB was found. They discovered that MB had sustained significant traumatic injuries and showed no signs of life.

7. What was the cause and manner of MB’s death?

7.1 MB was later taken to the Department of Forensic Medicine at Newcastle where a postmortem examination was performed by Dr Brian Beer, forensic pathologist, on 24 November 2016. MB was found to have extensive head injuries, including skull and facial fractures, and extensive fractures of the ribs. Dr Beer concluded in his autopsy report dated 23 December 2016 that MB died from multiple injuries.13 7.2 Given the gravity of a finding that a person has intentionally inflicted their own death it is well established that such a finding cannot be assumed, but must be proved on the available evidence. Taking into account MB’s history of declining mental health in the 18 months preceding his death, the discovery of the rope at his home and his video recorded message to his family, and his witnessed actions on 20 November 2016, I conclude that the evidence is sufficiently clear, cogent and exact14 to allow a finding to be made that MB died as a consequence of actions taken by him with the intention of ending his life.

8. Issues considered by the inquest 8.1 Prior to the inquest, a thorough coronial investigation was performed in order to identify whether there were any factors contributing to MB’s death which warranted specific examination at inquest. No such factors were identified. On this basis it was indicated to MB’s family and to the NSW Commissioner of Police (the only other sufficiently interested party) prior to the inquest that:

(a) An inquest was only required to be held because of the mandatory provision contained in the Act which applied at the time of MB’s death, and not because it was expected that any aspect of MB’s death and the circumstances leading up to it would be the subject of critical comment; and

(b) It was expected that the only issues which the inquest would consider would be the statutory requirements under sections 27(1)(c) and 27(1)(d) of the Act – in other words, MB’s identity, the date and place of his death, and the cause and manner of his death – and that none of these issues were controversial or in dispute.

8.2 However, given the events leading up to MB’s death and the events of 20 November 2016, some comment should be made about two specific matters which are set out below.

Attempts to seek treatment for MB 8.3 The first matter concerns the attempts made by DB on 18 November 2016 to make arrangements to have his father seen by a mental health care professional. As noted above, when this attempt was made with Dr Singh’s office on that day DB was advised that the first available appointment would not be until 15 December 2016. The circumstances surrounding DB’s attempts to seek assistance for his father were considered during the course of the coronial investigation. Although the investigation was unable to identify who DB spoke to, it is likely that it was a secretary who was employed at Dr Singh’s medical practice (but who was no longer so employed by the time of the inquest). It is unclear whether the severity of MB’s condition was 13 Exhibit 1, tab 2.

14 Briginshaw v Briginshaw (1938) 60 CLR 336.

made clear at the time of the call or, if it was, whether it was appreciated by the person who received the call.

8.4 In any event, what is of importance is that the nature of DB’s enquiry was not communicated to Dr Singh. Had this occurred, Dr Singh explained that “it is standard practice for acutely unwell patients to be offered the earliest possible appointment, which is generally the same day if clinically indicated. If this cannot be done secretaries are trained to direct patients to their general practitioner immediately, or to contact emergency services if the situation is really urgent”.15 Dr Singh went on to explain that if he had known of the severity of MB’s condition, he would have made himself available to urgently review MB on 18 November 2016, or made alternative suggestions for treatment if this could not occur.16 8.5 Conclusion: The coronial investigation did not identify any systemic issue associated with the enquiries made by DB with Dr Singh’s practice on 18 November 2016. It appears that the appointment date of 15 December 2016, almost a month later, was offered because the severity of MB’s clinical condition was not fully appreciated at the time. The evidence establishes that relevant procedures and training are in place to ensure that patients referred to the practice in need of acute care are triaged adequately and appropriately. The evidence also establishes that if this had been communicated to Dr Singh it is likely that MB would have been offered a consultation with Dr Singh that same day, or been referred to a more timely consultation with a different mental health care professional.

8.6 Due to several unknown variables, it is of course not possible to know whether a consultation between MB and a mental health care professional on 18 November 2016 might have resulted in a different outcome two days later. By 18 November 2016 MB had not seen Dr Singh for exactly three months and his history of consultations indicated that he was somewhat reticent to engage in treatment. Further, MB was in a more positive mental state by the evening of Saturday 19 November 2016, but his mental state worsened during the course of the following day. The totality of evidence does not establish a causal or contributory link between the events of 18 November 2016 and the events of 20 November 2016.

Conduct of the police operation 8.7 The second issue concerns the actions of the police officers who directly spoke with MB on 20 November 2016. It should be recognised at the outset that Senior Constable Difford dealt with MB in a professional, caring and compassionate manner. It is evident that Senior Constable Difford established a rapport with MB and that her actions kept him safe from harm many times for over two hours. At all times Senior Constable Difford’s ultimate goal was the preservation of MB’s life. For that she ought to be warmly commended.

8.8 Beyond the individual involvement of Senior Constable Difford it is also evident that the overall police response was timely and also focused on achieving the same goal. A number of officers from different units specifically trained to respond to the crisis that MB found himself in, together with local police officers, were deployed in an attempt to bring about a safe resolution of the incident.

15 Exhibit 1, page 420 at [8].

16 Exhibit 1, page 421 at [9].

8.9 The decision to transition Senior Constable Difford out of direct communication with MB was made in order to allow officers from the Negotiation Unit to take on this role. To allow them to do so effectively, and to engage MB in a meaningful way, it was considered necessary to remove any external distractions.17 8.10 There is no NSW Police Force policy that dictates whether a general duties police officer, like Senior Constable Difford, should be substituted by trained negotiators once they arrive at the scene of a suicide intervention incident such as the one involving MB.18 However, the evidence established that it is usually best practice to do so and in MB’s case Senior Constable Difford was replaced by two experienced and highly trained officers from the Negotiation Unit.19 Whilst Senior Constable Difford had successfully managed to keep MB engaged and away from potential harm, the arrival of officers from the Negotiation Unit signalled the need to transition to the next phase of the police operation.

8.11 This phase was directed to understanding why MB had placed himself at risk by commencing a planned and structured conversation with him.20 This in turn would allow for a strategy to be devised, and then executed, in order to bring MB back to a position of safety. This required the use of trained negotiators employing a specific skill set suited to such a task. Such a skill set could not be readily imparted to a general duties officer such as Senior Constable Difford given the pressures of time and the situation itself.21 8.12 Conclusion: Given the need to involve police officers specifically trained to respond to the crisis that MB faced it was both appropriate and necessary to transition Senior Constable Difford away from further continued interaction with MB. Up until this point Senior Constable Difford had empathetically kept MB engaged and, more importantly, safe from harm. There is no evidence to suggest that the transition to the use of trained negotiators to continue a dialogue with MB precipitated, or contributed to, the tragic events that were to follow. At all times, the actions of all the police officers involved on 20 November 2016 were motivated by the goal of preserving MB’s life.

9. Findings 9.1 Before turning to the findings that I am required to make, I would like to thank Mr Chris McGorey, Counsel Assisting, and his instructing solicitor, Ms Clare Skinner of the Crown Solicitor’s Office for their valuable assistance during both the preparation for the inquest, and the inquest itself. The equally valuable contributions of both Ms Emma Sullivan and Ms Elizabeth Wells of the Crown Solicitor’s Office during the coronial investigation and preparation for inquest also need to be acknowledged with gratitude as well. I also thank the Senior Critical Incident Investigator, Detective Sergeant Mark Conroy, for his efforts during the critical incident investigation and for compiling the initial brief of evidence. I am grateful to all of these legal and law enforcement professionals for the sensitivity and empathy that they have shown throughout this matter.

9.2 The findings I make under section 81(1) of the Act are: 17 Exhibit 1, page 331 at [38].

18 Exhibit 1, page 327 at [16].

19 Ibid.

20 Exhibit 1, page 330 at [32].

21 Exhibit 1, page 330 at [33].

Identity The person who died was MB.

Date of death MB died on 20 November 2016.

Place of death MB died at Terrigal NSW 2260.

Cause of death MB died from multiple injuries which were sustained after he jumped from a height.

Manner of death MB died as a consequence of actions taken by him with the intention of ending life.

10. Epilogue 10.1 It is most distressing to know that the caring attempts of his family, and of a number of police officers, were not enough to keep MB safe from harm. The loss of such a well-respected, intelligent, and caring husband and father is truly tragic.

10.2 On behalf of the Coroner’s Court, and the counsel assisting team, I extend my deepest sympathies and offer my respectful condolences to RB; AB, AB, and DB; the rest of MB’s family, and MB’s closest friends for their immeasurable loss.

10.3 I close this inquest.

Magistrate Derek Lee Deputy State Coroner 28 August 2018 NSW State Coroner’s Court, Glebe