Inquest into three deaths in the Northern Beaches Local Government Area

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into three deaths in the Northern Beaches Local Government Area Hearing dates: 4-5 June 2018 Date of findings: 31 July 2018 Place of findings: NSW State Coroner’s Court, Glebe Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – self-inflicted death, death by jumping from height, preventative strategies to minimise future risk File numbers: A (2016/00147533)

B (2016/00273179) C (2017/00108066) Representation: Advocate Assisting Mr A Creagh (Sergeant, NSWPF) National Parks and Wildlife Service (NPWS) Ms G Furness SC, instructed by Ms J Hackett of Crown Solicitor’s Office Catholic Archdiocese of Sydney Mr Pintos-Lopez, instructed by Campbell of Allens Northern Beaches Council (NBC) Mr Down, solicitor Mills Oakley

Findings: As a result of reviewing the documentary and oral evidence presented in this matter, I make the following findings pursuant to section 81(1) of the Coroners Act 2009 (NSW) Identity 1 The persons who died was A Date of death He died on 12 May 2016 Place of death He died at Shelly Beach, Manly, NSW.

Cause of death He died from multiple injuries consistent with a fall from height.

Manner of death A’s death was intentionally self-inflicted. He died after jumping from a cliff.

Identity 2 The persons who died was B Date of death He died between 9 September 2016 and 10 September 2016 Place of death He died adjacent to the Fairfax Walking Trail on North Head, NSW Cause of death He died from multiple injuries consistent with a fall from height.

Manner of death B’s death was intentionally self-inflicted. He died after jumping from a cliff.

Identity 3 The persons who died was C Date of death He died between 30 March 2017 and 7 April 2017 Place of death He died adjacent to Blue Fish Point, North Head

NSW Cause of death He died from multiple injuries consistent with a fall from height Manner of death C’s death was intentionally self-inflicted. He died after jumping from a cliff.

Recommendations Pursuant to section 82 Coroners Act 2009, I make the following recommendations NSW Police

1. That the NSW Police Force works to develop a short training course focused on the skills required for de-escalating situations where a person is threatening self-harm by jumping from a height. The course should be designed for, and offered to, first-response officers in those commands with the highest incidence of suicide by jumping from heights.

2. That the NSW Police Force continue to engage with the telecommunication industry to improve the access of police to technology that will allow reliable and real time tracking of people thought to be threatening self-harm on North Head at Manly.

National Parks and Wildlife

3. That the National Parks and Wildlife Service consult with appropriate experts to ensure that suicide prevention strategies are incorporated into the North Head Landscape Concept Plan before the plan is finalised and implementation begins. Suicide prevention strategies considered should include the following: a. Restricting access to potential jumping sites through use of appropriate barriers or structural design, b. Encouraging help-seeking. For example, through the use of signs with numbers for support services, the installation of phones that link directly to support services, or the use of Near-Field Technology,

c. Increasing the likelihood of intervention by third parties. For example, by increasing the likelihood that other people will be present, or the installation of CCTV cameras at likely jump sites. Consideration should also be given to numbering signs around the park so that if a by-stander is reporting a person that appears to be considering self-harm they can easily communicate their location within the park.

Northern Beaches Council

4. That the Northern Beaches Council, Community Safety Committee, support and assist the Northern Beaches Police Local Area Command in lobbying Telstra, Optus and other relevant telecommunications companies to install a telephone tower or other appropriate technology on the North Head to improve the ability to track the mobile phones of people threatening self-harm on the North Head.

5. That the Northern Beaches Council continue to auspice and support the Community Safety Committee.

6. That the Northern Beaches Council, Community Safety Committee work with all relevant stakeholders, including the NPWS, Police Local Area Command and Lifeline to determine suitable places on the North Head to trial Near Field Technology.

Catholic Archdiocese of Sydney

7. That the Catholic Archdiocese of Sydney, consider the implementation of suicide prevention strategies around the cliff tops at Shelly Beach. The Catholic Archdiocese should be guided by the Northern Beaches Council, Community Safety Committee. Strategies considered should include: a. Restricting access to potential jumping sites through use of appropriate barriers or structural design, b. Encouraging help-seeking. For example, through the use of signs with numbers for support services, the installation of phones that link directly to support services, or the use of Near-Field Technology, c. Increasing the likelihood of intervention by third parties. For example, by increasing the likelihood that other people will be present, or the installation of CCTV cameras at likely jump sites.

Non Publication Order The detailed reasons for these findings are subject to a non-publication order pursuant to section 75 of the Coroners Act 2009 NSW.

Magistrate Harriet Grahame Deputy State Coroner 31 July 2018 NSW State Coroner’s Court, Glebe