Inquest into the death of Geoffrey Richardson

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Geoffrey Richardson Hearing dates: 12 to 14 June 2018 Date of findings: 6 July 2018 Place of findings: NSW State Coroner’s Court, Glebe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – police pursuit, NSW Police Force Safe Driving Policy, termination of pursuit, re-initiation of pursuit, GPS, urgent duty response, coded system of driving, VKG training File number: 2016/72079 Representation: Mr T Hammond, Counsel Assisting, instructed by Ms S Hart, Crown Solicitor’s Office Mr R Hood for the NSW Commissioner of Police Mr P Madden for Mrs Margaret Richardson Mr J Tyler-Stott for Mr Graham Richardson Findings: I find that Sergeant Geoffrey Richardson died on 5 March 2016 at Allandale NSW 2320. Sergeant Richardson died from multiple injuries. Sergeant Richardson suffered the multiple injuries whilst on duty, in the course of a police operation, when the police vehicle that he was driving failed to negotiate a sweeping bend, causing it to leave the road and impact with a tree.

Recommendations: To the NSW Commissioner of Police:

1. I recommend that consideration be given to reviewing the current version of the NSW Police Force Safe Driving Policy to ensure that it provides:

(a) an unequivocal definition of the term “termination” as it relates to pursuits;

(b) clear indication as to whether, and in what circumstances, amounts to termination of a pursuit; and

(c) for consistency in language and instructions to police officers in relation to when a pursuit is terminated.

2. I recommend that consideration be given to the establishment of a standard VKG broadcast at the termination of a pursuit to:

(a) confirm the termination of the pursuit;

(b) direct involved police officers to cease pursuing and stop following a pursued vehicle, and to return to driving at the legal speed limit; and

(c) remind involved police officers of the requirement for approval to be given before a pursuit is re-initiated.

I further recommend that the establishment of such a standard VKG broadcast to be incorporated into relevant training packages provided to both VKG Shift Coordinators and VKG dispatchers.

Table of Contents

Introduction

1. On the evening of 5 March 2016 Sergeant Geoffrey Richardson was on duty at Raymond Terrace police station when he responded to a request for assistance that was broadcast over police radio. The request related to events which were at that time taking place in the central Hunter region where a number of police vehicles were taking part in the pursuit of another vehicle. In the course of responding to the request, Sergeant Richardson was involved in a collision which resulted in him suffering fatal injuries.

Why was an inquest held?

2. 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 answer questions that they are required to be answered 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.

3. Due to the circumstances of Sergeant Richardson’s1 death on 5 March 2016, he 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 time2, an inquest into Sergeant Richardson’s death was mandatory. In most cases of deaths which occur in the course of a police operation the person who died is not a police officer. Inquests are mandatory for these types of deaths to ensure that there is an independent and transparent investigation of the circumstances of the death, and the relevant conduct of any of involved police officers. Even though the death of Sergeant Richardson involves the death of a serving police officer, these same principles still apply.

4. Inquests have a forward-thinking, preventative focus. At the end of many inquests Coroners often exercise a power, provided for by section 82 of the Act, to make recommendations. These recommendations are made, usually, to government and non-government organisations, in order to seek to address systemic issues that are highlighted and examined during the course of an inquest. Recommendations in relation to any matter connected with a person’s death may be made if a Coroner considers them to be necessary or desirable.

5. The coronial investigation into the death of a person is one that, by its very nature, occasions grief and trauma to that person’s family. The emotional toll that such an investigation, and any resulting inquest, places on the family of a deceased person is enormous. A coronial investigation seeks to identify whether there have been any shortcomings, whether by an individual or an organisation, with respect to any matter connected with a person’s death. It seeks to identify shortcomings not for the purpose of assigning blame or fault but, rather, so that lessons can be learnt from such shortcomings and so that, hopefully, these shortcomings are not repeated in the future. If families must re-live painful and distressing memories that an inquest brings with it then, where possible, there should be hope for some positive outcome. The recommendations made by Coroners are made with the hope that they will lead to some positive outcome by improving general public health and safety.

1 At the request of Sergeant Richardson’s wife, Sergeant Richardson was referred to by his rank and professional name during the course of the inquest. I will do the same in these findings.

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

Sergeant Richardson’s life

6. 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.

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 to recognise and acknowledge Sergeant Richardson’s life.

7. Sergeant Richardson had completed almost 18 years of dedicated service as a highly-regarded police officer. He commenced training at the police academy in Goulburn in November 1997 and attested from the academy in May 1998. After commencing initial duties at Campbelltown police station in Sydney, Sergeant Richardson later transferred to Cobar police station, before eventually moving to the Central Hunter Local Area Command (LAC) in 2010. Within a short time he was promoted to the rank of Sergeant and later became a supervisor within the Lake Macquarie LAC. In July 2015 Sergeant Richardson transferred to the Port Stephens LAC and became a general duties supervisor at Raymond Terrace police station. Sergeant Richardson brought his considerable policing skills to bear throughout the course of his career. These skills earned Sergeant Richardson the respect and admiration of his colleagues and meant that this career was a decorated and distinguished one.

8. Despite his many professional achievements, Sergeant Richardson’s greatest and proudest achievements were most clearly demonstrated within his loving, young family, and in particular his oldest son, Patrick. Sergeant Richardson’s wife, Margaret, described her husband as an amazing and doting father, someone who loved and guided Patrick in every aspect of his life, and who was Patrick’s best friend. The time they spent together created many lifelong memories, in particular four wheel driving on Stockton beach, which was Patrick’s favourite activity. Sergeant Richardson’s devotion to his younger son, Aiden, was no less. Sergeant Richardson had planned to take time off from work so that he could spend time with Aiden, to nurture him, and bond with him, just as he had when Patrick was of a similar age. It is therefore most distressing to know that Patrick’s time with such a wonderful father was so brief, and that Aiden will never even have the brief time with his father that Patrick had.

9. At the conclusion of the evidence in the inquest, Sergeant Richardson’s wife spoke of how she had lost her life partner, best friend, and deepest love. Sergeant Richardson’s father, Graham, also spoke of his beloved son and best mate, and the enormous pain caused by the separation from his son. The dignity and strength that they showed in sharing their treasured memories was truly admirable.

What happened on 3 March 2016?

10. At about 4:00pm on Thursday, 3 March 2016, a white Ford Falcon was seen by police to be travelling at excessive speed on the New England Highway in Lochinvar, heading towards Rutherford. Checks revealed that the vehicle of interest (VOI) was bearing registration plates that had been reported as being stolen from a vehicle in Bingleburra, sometime around 14 February 2016. The VOI was directed to stop by a police vehicle, and failed to do so. As a result,

the police vehicle commenced pursuing the VOI. During the pursuit the VOI was seen to overtake several vehicles at speed and almost collide with a vehicle at a roundabout in Rutherford.

the police vehicle disengaged and terminated the pursuit.

11. Following this, information concerning the last direction that the VOI was seen travelling was broadcast over police radio, also known as VKG. Acting Sergeant Anthony Blythe was patrolling the New England Highway at Rutherford at the time in a police vehicle with call sign Central Hunter 14 (CEH14). In response to the broadcast, Acting Sergeant Blythe began patrolling the streets of Rutherford in an attempt to locate or intercept the VOI.

12. At about 4:05pm, Acting Sergeant Blythe saw the VOI travelling in his direction. He noticed that the VOI had three holes in its windscreen which appeared to resemble bullet holes. Acting Sergeant Blythe performed a U-turn and activated the warning lights and sirens of his vehicle.

The VOI did not stop and instead accelerated away at speed. Acting Sergeant Blythe commenced pursuing the VOI and saw it drive in excess of the designated 50km/hour speed limit, cross to the incorrect side of the road, and drive over a median strip near other vehicles and a pedestrian. the pursuit was terminated after about two minutes. Instructions were subsequently broadcast over police radio not to re-engage in a pursuit with the VOI.

What happened on 5 March 2016?

13. Just before 11:00pm on Saturday, 5 March 2016 Acting Sergeant Blythe was again driving CEH14 along the New England Highway, Rutherford. He saw the VOI approaching him from the opposite direction, recognising it from the three holes in its windscreen. Acting Sergeant Blythe also noticed that the VOI was bearing different registration plates to when he had last seen it two days earlier. Checks revealed that the plates had been reported as stolen from a vehicle parked in East Maitland sometime between about 11:00am and 10:50pm that day.

14. Acting Sergeant Blythe turned and followed the VOI into Maitland where he activated the warning devices on his vehicle intending to stop the VOI. The VOI did not stop and a pursuit commenced. The initial stages of the pursuit took place in the streets of Maitland. At 11:03pm another police vehicle with call sign North 240 (NTH240) advised that they were on their way from Maitland police station to assist. At about 11:04pm, whilst in Louth Park, the VOI slowed and reversed towards Acting Sergeant Blythe’s vehicle resulting in some minor damage to the front bumper of CEH14.

15. The pursuit continued into East Maitland. By this time, NTH240 had travelled to the intersection of Mount Vincent Road and Chisholm Road, East Maitland with the intention of deploying a tyre deflation device (commonly referred to as road spikes) to stop the VOI. However, before this could occur, the VOI drove through the intersection. As a consequence of being unable to deploy the road spikes, NTH240 joined the pursuit, following after the VOI and CEH14. A short time later, Acting Sergeant Blythe requested that NTH240 take over the role of primary pursuit vehicle due to the fact that there were two police officers in NTH240 (whereas he was driving alone), and because NTH240 was fitted with in-car video recording equipment. As a result of NTH240 taking over as primary pursuit vehicle, it was no longer capable of being used to deploy road spikes. Therefore, a request was broadcast over VKG for any other vehicles in the neighbouring commands of Newcastle or Lake Macquarie that may be equipped with road spikes and able to assist.

16. At this time Sergeant Richardson was on duty at Raymond Terrace Police Station and heard the request for assistance. He informed his superior officer, Inspector Alan Jansen that he had road spikes in his car, call sign Port Stephens 12 (PTS12), and was able to assist the pursuit.

Inspector Jansen told Sergeant Richardson to travel the “back way”, meaning travelling to East Maitland via Raymond Terrace Road and through Millers Forrest. Inspector Jansen suggested this route, believing that it would increase Sergeant Richardson’s chances of intercepting the pursuit.

17. At 11:09pm Sergeant Richardson left Raymond Terrace police station in PTS12. He broadcast over VKG that he had road spikes in his vehicle and could travel to East Maitland. Between 11:10pm and 11:21pm the pursuit continued through a number of streets in the Maitland area.

At around 11:14pm another police vehicle with call sign NTH248, advised VKG that they were equipped with spikes and were travelling from Muswellbrook to assist.

18. At about 11:21pm the VOI drove into Rebecca Close, Rutherford, a no through road. At this time NTH240 was still the primary pursuit vehicle with CEH14 following as the secondary pursuit vehicle. Two other vehicles, with call signs CEH186 and CEH102, and which had been following the pursuit at a distance to assist if necessary, also followed the VOI into Rebecca Close. The VOI performed a U-turn at the end of the street and drove past the police vehicles back towards the New England Highway. At this time, CEH14 took over as the primary pursuit vehicle again with NTH240 becoming the secondary vehicle. Another police vehicle with call sign CEH35, which had responded from Maitland Police Station, also followed the other police vehicles out of Rutherford Close. By this time the pursuit had been running for approximately 20 minutes.

19. At 11:22pm police vehicle with call sign NTH268 advised VKG that they were on their way from Heatherbrae to assist with deploying road spikes. Three minutes later at 11:25pm NTH240 once again took over as primary pursuit vehicle with CEH14 as secondary pursuit vehicle.

20. At 11:28pm the pursuit entered Majors Lane at Sawyers Gully before travelling onto Mears Lane at Keinbah, and then onto Barnard Road. These last two roads are dirt roads which lead into the Werakata National Park in Lovedale. By 11:32pm NTH240 was unable to follow the VOI any further due to the poor condition of the road. CEH14 continued along the road but it could no longer see the VOI and was only following its dust trail. The pursuit was terminated, after it had been running for about 32 minutes. VKG advised that the road where the VOI was last seen travelling would exit at Gibsons Road, Lovedale and requested that a car attend that location.

21. At this time Sergeant Richardson advised VKG that he would not able to travel to the location where the VOI was last seen in time. Sergeant Richardson drove past another police vehicle (with call sign CEH38) which was parked by the side of the road on Mears Lane, performed a Uturn, and drove back in the opposite direction towards Majors Lane.

22. At 11:33pm Sergeant Richardson made a broadcast over Police radio requesting assistance as to whether he was to turn left or right onto Lovedale Road from Majors Lane. Sergeant Richardson was told to turn left and he later advised VKG that he was travelling along Wine Country Drive at Lovedale. Subsequently, there followed a discussion over VKG amongst a number of the police vehicles as to where the VOI might be next sighted.

23. At 11:35pm a police vehicle fitted with a mobile automated number plate recognition (MANPR) system identified Sergeant Richardson’s car at the intersection of Lovedale Road and Brickmans Lane. Two other police vehicles (CEH38 and CEH186) drove past moments later and also sighted Sergeant Richardson’s vehicle stopped at the intersection. Other MANPR records later confirmed that at 11:39pm Sergeant Richardson was travelling south on Lovedale Road.

24. At around this time the VOI was sighted travelling west on Lomas Lane, Nulkaba, with its headlights turned off, and then seen to turn right onto Wine Country Drive, heading north. This sighting was broadcast on VKG which in turn led to an enquiry being made with Sergeant Richardson as to whether he was in the vicinity of the sighting. There was no audible response over VKG from Sergeant Richardson.

25. At 11:40pm the VOI drove past CEH38 and CEH186 which were stopped at the intersection of Lovedale Road and Wine Country Drive. CEH38 followed the VOI along Wine Country Drive, activating its lights and sirens. The VOI did not stop and second pursuit began. CEH38 became the primary pursuit vehicle with CEH186 acting as the secondary pursuit vehicle.

26. At around this time NTH240 was setting up at a location along Lovedale Road, north of Green Lane, with the intention of deploying road spikes. However, NTH240 soon learnt that the pursuit had already passed Lovedale Road and was continuing on Wine Country Drive.

27. A request was broadcast over VKG for any vehicles with road spikes in the vicinity of Wine Country Drive. Sergeant Richardson responded and indicated that he was setting up road spikes on Wine Country Drive south of Brickmans Lane. However, by this time CEH38 broadcast that the pursuit was continuing north and had passed the intersection of Broke Road and Wine Country Drive. It became evident that Sergeant Richardson was confused about his location because the location that he described does not exist.

28. At 11:41pm the pursuit continued north on Wine Country Drive past the intersection of Palmers Lane. When the pursuit reached the intersection of Wilderness Road, VKG told Sergeant Richardson that they could not see where Brickmans Lane was and enquired whether he was ahead of the pursuit. CEH38 broadcast that Brickmans Lane was far behind the pursuit leading VKG to indicate that there was no point in Sergeant Richardson setting up spikes; instead what was required was a car that was ahead of CEH38 on Wine Country Drive.

29. At 11:45pm the pursuit turned east from Wine Country Drive onto Tuckers Lane, North Rothbury heading towards Greta. , CEH186 disengaged from the pursuit as secondary vehicle . At this time it is believed that Sergeant Richardson’s vehicle was sighted by civilians travelling north on Lovedale Road, near the intersection of Wilderness Road.

30. At 11:46pm police vehicle call sign CEH102 was driving along Lovedale Road in a northeast direction towards the New England Highway. CEH102 stopped at a roundabout on Lovedale Road in Allandale, about 80 metres east of the Hunter Expressway. At this time the police officers in CEH102 saw Sergeant Richardson drive past with warning devices activated and heading in a north east direction on Lovedale Road. Shortly afterwards, Sergeant Richardson drove past a civilian vehicle travelling on Lovedale Road. The vehicle was travelling at about 80km/hour and the vehicle’s occupants described Sergeant Richardson’s vehicle as pulling away from them.

31. At 11:47pm CEH38 broadcast that they were still on Tuckers Lane at Greta in pursuit of the VOI.

At the same time NTH238 advised that they were on Camp Road, setting up road spikes under the Hunter Expressway.

32. At the same time, Sergeant Richardson was traveling along a straight downhill section of Lovedale Road leading to a sweeping left hand bend. Whilst driving through the bend at speed, Sergeant Richardson failed to negotiate it, causing his vehicle to leave the road and collide with a medium sized tree. About 30 seconds later, CEH102 drove through the bend and sighted Sergeant Richardson’s vehicle. The police officers inside CEH102 immediately stopped and went to check on Sergeant Richardson’s welfare and call for assistance. Tragically, it was discovered that Sergeant Richardson had suffered catastrophic injuries and was showing no signs of life.

33. Initial attending paramedics arrived at the collision scene at 12:08am on 6 March 2016. They found that Sergeant Richardson was unresponsive and when defibrillator leads were attached to him there was no sign of any electrical activity in the heart. The paramedics also could find no pulse or respirations, and saw that Sergeant Richardson’s pupils were dilated, leading to the conclusion that Sergeant Richardson was deceased.

34. Meanwhile, at 11:48pm, the pursuit was occurring in Greta. It continued onto the New England Highway headed towards Branxton. The VOI was seen with its headlights turned off and overtaking three cars over double unbroken lines.

NTH240 ceased pursuing, but other police vehicles (NTH248 and CEH186) continued to follow the VOI.

35. The pursuit continued towards East Branxton. At this time CEH38 sustained damage to its tyres and ceased pursuing. At 11:51pm NTH248 lost sight of the VOI in East Branxton and also ceased pursuing. This resulted in the end of the pursuit.

What was the cause and manner of Sergeant Richardson’s death?

36. Sergeant Richardson was later taken to the Department of Forensic Medicine in Newcastle where Dr Leah Clifton performed a postmortem examination on 8 March 2016. Dr Clifton found that Sergeant Richardson had sustained multiple injuries to the chest, head and limbs which alone or in combination could have resulted in death.3 She noted that the pattern of injuries was in keeping with those sustained in the blunt force trauma of a motor vehicle collision.

37. Dr Clifton also noted that there was evidence of ischaemic heart disease with moderately severe coronary artery atherosclerosis in three of the major coronary vessels. However, Dr Clifton found no evidence of an acute cardiac event to suggest that a natural episode was the cause of the collision, noting that this cannot always be demonstrated at autopsy.4

38. Conclusion: The obvious evidence of the collision, the observations of Sergeant Stace at the collision site, and the clinical findings from the postmortem examination all establish that Sergeant Richardson died from multiple injuries as a result of a collision involving a single motor vehicle impacting with a tree.

3 Exhibit 1, tab 5, page 11.

4 Ibid.

What were the results of the collision investigation?

39. Sergeant Peter Stace, an investigator from the Traffic and Highway Control Command, Crash Investigation Unit attended the collision scene at about 2:45am on 6 March 2016 to examine it.

Sergeant Stace also undertook a further scene examination on 23 March 2016. In a report dated 18 April 2016 Sergeant Stace concluded that as Sergeant Richardson travelled along a straight and downhill section of Lovedale Road leading to a sweeping left hand bend he was travelling at a speed between 136 and 151 kilometres per hour. This section of Lovedale Road has a designated speed limit of 80 kilometres per hour with advisory signage warning drivers approaching the left hand bend to reduce their speed to 35 kilometres per hour.

40. Sergeant Stace concluded that Sergeant Richardson, in an attempt to negotiate the bend, began his braking and reaction at a point with insufficient time to stop his vehicle and tyre markings on the road indicate that harsh ABS braking was applied. The inability to brake or negotiate the bend resulted in Sergeant Richardson’s vehicle leaving the road and impacting with a post and wire fence before the front driver’s side of the vehicle impacted heavily with a medium sized tree causing significant intrusion into the driver’s compartment of the vehicle. The vehicle then rotated clockwise, disengaging from the tree, before the passenger side of vehicle impacted with another wooden post before coming to rest. Ultimately, Sergeant Stace expressed the belief that excessive speed was the major contributing factor to the collision.5 Sergeant Stace explicitly excluded alcohol, drugs, road, traffic, weather and vehicle conditions as contributing factors.

41. On 11 March 2016 Senior Constable Ben Wilson, a forensic examiner with the Engineering Investigation Unit examined Sergeant Richardson’s vehicle, a Toyota Camry sedan. Senior Constable Wilson concluded that there was no mechanical defect or component failure which may have contributed to the collision occurring.6

42. Conclusion: The mechanical and scene examinations performed following the collision establish that excessive speed was the sole contributing factor to it. The evidence demonstrates that Sergeant Richardson’s vehicle was travelling well in excess of the speed limit at a speed which meant that the sweeping left bend could not be negotiated in a safe manner. This resulted in Sergeant Richardson’s vehicle leaving the road and caused the consequent high-speed, fatal impact.

What issues did the inquest examine?

43. As is apparent from the above, the brief of evidence prepared as part of the investigation into the circumstances of Sergeant Richardson’s death contained sufficient evidence to establish both the cause and manner of death. However, in reviewing the brief of evidence it became apparent that there were aspects of the two pursuits which took place on 5 March 2016 which were connected with Sergeant Richardson’s death.

44. Many of these aspects were identified in a report dated 11 August 2016 prepared by Sergeant Kris Cooper of the Traffic Policy Section, Traffic & Highway Patrol Command. The report followed a review of: 5 Exhibit 1, page 391.

6 Exhibit 1, page 460.

(a) the first pursuit on 5 March 2016 which began with Acting Sergeant Blythe’s sighting of the VOI at around 11:00pm and ended at about 11:32pm when police vehicles were no longer able to see or follow the VOI along dirt roads in the Werakata National Park (the first pursuit); and

(b) the second pursuit which began at about 11:40pm when the VOI was seen by CEH38 at the intersection of Lovedale Road and Wine Country Road, Lovedale and ended at about 11:51pm in East Branxton when NTH248 lost sight of the VOI (the second pursuit).

45. The review was conducted in order to examine the conduct of the police involved and, in particular, whether the NSW Police Force Safe Driving Policy (SDP) had been complied with.

Part 67 of the SDP specifically governs pursuits. The review and Sergeant Cooper’s report established that there were a number of breaches of the SDP, which are relevantly summarised in general terms below:

(a) Firstly, the evidence established that a number of police vehicles were involved in both pursuits without seeking authorisation to do so, and without advising VKG of their involvement. This was a breach of Part 6 of the SDP which provides that

(b) Secondly, the involvement of these vehicles . Again, such a practice is contrary to part 6 of the SDP which provides that unless authorised.

(c) Thirdly, the involvement of vehicles in the pursuit without authorisation also created instances where the vehicles were behind the VOI. Again, such a practice is a breach of Part 6 of the SDP unless authorisation has been given.

46. The breaches are relevant because they raised questions as to:

(a) whether either the first pursuit or the second pursuit should have been terminated at earlier points in time than what in fact occurred;

(b) whether the pursuits were managed appropriately by those with authority to do so; and

(c) whether management of the pursuits could be improved in any way.

47. It should be pointed out that the evidence established that the above issues did not directly cause or contribute to the fatal collision that Sergeant Richardson was involved in, and his subsequent death. As noted above, the sole contributing factor was the excessive speed that Sergeant Richardson’s vehicle was travelling at. However, the issues are relevant and connected to Sergeant Richardson’s death as they provide a basis to understand the reason why Sergeant Richardson was driving at a high speed, and whether earlier termination of the pursuits might have meant that Sergeant Richardson was no longer required to be involved in them.

7 Of version 7.2 of the SDP in force as at March 2016.

Pursuits generally

48. Once a pursuit is reported, or “called”, by a police officer over VKG, that communication over police radio is acknowledged, logged and coordinated by a NSW police communications officer, known as a dispatcher, working in a radio operations centre. A VKG Shift Coordinator on duty in the centre is alerted to the pursuit and attends the terminal where the dispatcher is working in order to monitor and assess the pursuit, and assume overriding control of the pursuit. For pursuits that last longer than five minutes the Duty Operations Inspector (DOI) is required to be notified so as to provide an additional level of oversight and monitoring of the pursuit.

49. For both pursuits on 5 March 2016, Ms Trudy Taylor was the dispatcher, Sergeant David Stevens was the VKG Shift Coordinator, and Inspector Darren Gregor was the DOI.

How many police vehicles were involved in the pursuits?

50. The evidence established that at least five police vehicles were involved in the first pursuit and at least three police vehicles were involved in the second pursuit. Other additional police vehicles were also involved in both pursuits although they could not subsequently be identified upon review. Apart from the primary and secondary pursuing vehicles in each pursuit, no other vehicle was authorised to take part in the pursuit. The involvement of the additional unauthorised vehicles .

51. It is clear from the evidence that Ms Taylor, Sergeant Stevens and Inspector Gregor were all unaware of the involvement of the unauthorised police vehicles. This is because the police vehicles did not broadcast over VKG that they had joined the pursuit, or seek authorisation to do so. This issue is important because the evidence indicates that if those in supervisory role were aware of it, consideration would have been given to earlier termination of the pursuits.

52. Sergeant Stevens said that he was unaware that there were four or five police vehicles following the VOI. In evidence he said that if he had been aware of this fact he probably would have terminated the first pursuit, particularly if the vehicles were not forthcoming with information and if authorisation had not been given to them. Similarly, Inspector Gregor said in evidence that if he had been aware that he almost certainly would have terminated the pursuits.

53. Sergeant Cooper was asked about these instances of unauthorised involvement in evidence. He explained that, in general, it was not unusual for unauthorised vehicles to become involved in a pursuit. He acknowledged that there is often a clear difference between understanding the terms of a policy document such as the SDP, and compliance with it. However, Sergeant Cooper explained in evidence that his Command has observed a cultural change to pursuits in general over time so as to reduce instances of unauthorised involvement. Further, Sergeant Cooper explained that the advent of in-car video, revisions to the SDP and panels constituted to review driving incidents have allowed for increased compliance.

54. Conclusion: The SDP clearly sets out the terms under which police vehicles can become involved in pursuits and what type of driving is prohibited unless authorisation is given.

Individual non-compliance with these terms led to a situation on 5 March 2016 where the VKG Shift Coordinator and DOI were unaware of the number of vehicles involved in both pursuits.

This lack of awareness resulted in further breaches of the SDP by way of

. Had these breaches been made known to those in supervisory role it is probable that both pursuits would have been terminated. Whilst it appears that such noncompliance is not unusual, generally speaking, the evidence established that there has been a reduction in the overall extent of non-compliance.

When did the first pursuit terminate?

55. During the course of the inquest it became apparent that there was an issue in relation to precisely when the first pursuit terminated. Once the first pursuit entered the dirt roads of Werakata National Park, both CEH102 and CEH186 ceased their involvement in the pursuit.

However, both CEH14 and NTH240 continued to pursue the VOI for a short distance until NTH240 also was forced to stop pursuing due to . At this time the following broadcast was made over VKG: NTH240: North 240 we have terminated we cannot go any further, radio.

Dispatcher: Copy, terminated. Last seen on this dirt track, possibly comes out at Gibsons Road at Lovedale for cars that might head in that direction.

NTH240: North 240, Central Hunter 14 has managed its way around so it may be able to pick up that vehicle.

Dispatcher: Copy that, Central Hunter 14 to advise.

CEH14: Yeah, radio, still on Mears Lane, just following dust at the moment, still no sight of the vehicle.

Dispatcher: Copy.

56. The above broadcast by NTH240 seems to suggest that they had terminated their individual involvement in the pursuit. However, the broadcast by NTH240 seems to have been regarded by the VKG dispatcher as a termination of the pursuit as a whole. This is supported by the fact that the VKG dispatcher subsequently broadcasted the direction that the VOI was last seen heading.

This type of broadcast as to last known direction of travel of a VOI is consistent with training provided to VKG dispatchers as to what to broadcast upon termination of a pursuit.

57. The VKG broadcasts also indicate that, despite the termination by NTH240, CEH14 continued to follow the dust trail left behind by the VOI. This itself suggests that the pursuit had not terminated and was still continuing, and appears to be consistent with Part 6 of the SDP which provides: “A pursuit is deemed to continue if you FOLLOW the offending vehicle or continue to attempt to remain in contact with the offending vehicle, whether or not your police vehicle is displaying warning lights or sounding a siren”.

58. A short time later, the VKG dispatcher requested an update from CEH14. The following exchange took place between Acting Sergeant Blythe and the VKG dispatcher: CEH14: Yeah, radio at this stage no, there’s a lot of different tracks in here at the moment, um yeah no longer sight [sic] of the vehicle, or dust.

Dispatcher: We’ve lost all sight of the vehicle and we are not even following dust any more for those cars.

59. The reference to CEH14 no longer being able to follow the dust trail of the VOI also seems to indicate that the pursuit had been terminated at that point. This is because elsewhere in Part 6 of the SDP a list of factors (such as when danger to the pursuing police or public outweighs the need for immediate apprehension) is set out which will result in the termination of a pursuit.

One of the factors noted is when:

60. It should also be noted that Part 6 of the SDP also contains the following definition in relation to pursuits: TERMINATION: “All vehicles cease to pursue, stop following and return to the legal speed limit. Turn off all warning devices as soon as possible and when safe”.

61. Acting Sergeant Blythe said in evidence that whilst following the dust trail of the VOI he still considered that he was in pursuit of the VOI under the terms of the SDP. He said that at the same time he was also attempting to find a route out of the National Park. When asked at what point he considered the pursuit to be terminated, Acting Sergeant Blythe indicated it to be at the point that he lost sight of the VOI. He agreed that he did not specifically use the word “terminate” in his VKG broadcast although he said this would be his general practice (having previously taken part in between 10 and 12 pursuits). He also said that he assumed that by telling VKG that he had lost sight of the VOI they would understand that he had terminated the pursuit.

62. Ms Taylor was asked whether she considered Acting Sergeant Blythe to still be in pursuit when he was following the dust trail. She indicated that she did not believe that he was still in pursuit, although according the SDP he was, technically, still in pursuit. Ms Taylor was further asked how she knew that the first pursuit had been terminated. She indicated that when Acting Sergeant Blythe informed VKG that he had lost sight of the VOI it meant that the pursuit was over. Ms Taylor was asked whether, in most circumstances, it was her experience that pursuing officers use the word “terminate” to indicate the termination of a pursuit. Ms Taylor said that in most instances officers will say that they have terminated a pursuit, although it is not unusual for an officer to indicate that they have lost sight of a vehicle. She went on to say that when this is said it is understood that a pursuit has been terminated and that occasionally confirmation will be sought by a dispatcher.

63. Sergeant Stevens said that he assumed that Acting Sergeant Blythe was still pursuing the VOI, including when he was only following the dust trail, until he lost sight of the VOI. He said that a pursuing officer does not always use the word “terminate” and that sometimes it is simply indicated by a pursuing officer that they have lost sight of a VOI, which is by definition a termination of the pursuit.

64. Conclusion: A review of the VKG recording from 5 March 2106, the relevant terms of the SDP and the evidence given during the course of the inquest gives rise to a degree of ambiguity as to when the first pursuit terminated. The broadcast made by NTH240 terminating its own involvement in the pursuit seems to have been regarded as a termination of the pursuit as a whole, given the subsequent broadcast as to the last known direction of travel of the VOI.

65. However, the evidence of Acting Sergeant Blythe, Ms Taylor and Sergeant Stevens is that the pursuit had not terminated due to the mere fact of Acting Sergeant Blythe’s actions in following the dust trail left by the VOI. This understanding appears to be in accordance with the SDP which regards a pursuing vehicle attempting to remain in contact with a pursued vehicle as continuation of the pursuit. However, the evidence from Ms Taylor establishes that even though Acting Sergeant Blythe’s actions met the strict definition contained in the SDP, she did not believe the pursuit to be continuing past the point that NTH240 indicated its own disengagement from the pursuit. Again, this is supported by the broadcast made by Ms Taylor as to the last known direction that the VOI was seen to travel.

66. Further, the SDP itself does not appear to provide a clear and precise definition as to when a pursuit ends. The “definition” of termination referred to above is more akin to an instruction given by a VKG dispatcher, following the termination of a pursuit, for all vehicles to return to driving at the legal speed limit. Interestingly, the evidence established that despite the appearance of this apparent instruction, it is not standard practice for such an instruction to be given by a VKG dispatcher at the termination of a pursuit.

67. Instead of providing a precise definition of termination, the SDP instead sets out a list of factors that may result in the termination of a pursuit. Even though Acting Sergeant Blythe, Ms Taylor and Sergeant Stevens all referred to the loss of the VOI from sight as amounting to termination of the pursuit, losing sight of a VOI is not set out anywhere in the SDP as amounting to termination of a pursuit. Instead, it may be inferred that loss of sight of a pursued vehicle means that the distance away from it is so great that further pursuit is futile. This is one of the factors referred to in the SDP.

68. Having regard to all of the above, it is evidence that some degree of ambiguity surrounds precisely when a pursuit is terminated, and that there is an absence of an unequivocal definition of the term termination as it relates to pursuits. It should be noted that the current version of the SDP is in the same terms as the version which applied as at March 2016. For these reasons it is desirable that the following recommendation be made:

69. Recommendation 1: I recommend to the NSW Commissioner of Police that consideration be given to reviewing the current version of the NSW Police Force Safe Driving Policy to ensure that it provides (a) an unequivocal definition of the term “termination” as it relates to pursuits; (b) clear indication as to whether, and in what circumstances, losing sight of a pursued vehicle amounts to termination of a pursuit; and (c) for consistency in language and instructions to police officers in relation to when a pursuit is terminated.

What issues were identified in relation to the beginning of the second pursuit?

70. At 11:38pm CEH21 made a broadcast of a possible sighting of the VOI leaving the National Park from Lomas Lane, Nukulba onto Wine Country Drive. CEH38 was positioned at the intersection of Wine Country Drive and Lovedale Road. When the VOI passed CEH38 it activated all warning devices but the VOI did not stop and CEH38 broadcast at 11:39pm that it was in pursuit. CEH38 commenced pursuing the VOI, along with NTH248, NTH240 and CEH186.

71. A period of one minute and 25 seconds elapsed between the first pursuit and the second pursuit.

Part 6 of the SDP provides that:

”.

72. Neither of the police officers in CEH38 sought or obtained permission to re-initiate the pursuit; rather a broadcast was simply made by CEH38 in the following terms: “Central Hunter 38 in pursuit”. Ms Taylor said in evidence that she regarded the broadcast by CEH38 as amounting to the commencement of a second pursuit. However, Ms Taylor agreed that at this time she did not follow standard practice by broadcasting the start of pursuit. This standard practice, taught during training, requires a dispatcher to make the following broadcast: “All cars standby unless urgent. [Call sign] is in pursuit. [Call sign] only go ahead, and keep your locations coming”.

73. Sergeant Stevens agreed that CEH38 did not seek permission to re-initiate the pursuit. In evidence he was asked how he would normally approve the re-initiation of a pursuit. He explained that it would be his practice to ask a VKG dispatcher to broadcast that no police vehicle is to re-initiate a pursuit without first seeking authority, in accordance with the terms of the SDP. Sergeant Stevens went on to explain that this was a practice he had observed other VKG Shift Coordinators follow and had adopted it as part of his usual practice since the events of 5 March 2016. Sergeant Stevens concluded by indicating that he was unaware if other VKG Shift Coordinators were also following this practice.

74. Senior Sergeant Bernard Sloane, the State Coordinator for the Radio Operations Group (whose responsibilities include management the Radio Operations Training Unit), was asked about this issue in evidence. He explained that when a pursuing vehicle terminates a pursuit, VKG dispatchers are taught to acknowledge the termination. Further, he confirmed that unlike the standard broadcast made by a VKG operator at the start of pursuit, there is no equivalent standard broadcast which VKG operators are trained to make at the conclusion of a pursuit. On this basis Senior Sergeant Sloane was asked whether he thought it would be beneficial for such a standard broadcast to be made so as to ensure that there was no ambiguity as to the circumstances in which a pursuit could be re-initiated. Senior Sergeant Sloane said that as part of training provided to VKG Shift Coordinators it is recommended that such a standard broadcast be utilised; however, such a recommendation does not form part of any training provided to VKG dispatchers. Senior Sergeant Sloane acknowledged in evidence that such training would be beneficial.

75. Conclusion: The commencement of the second pursuit did not comply with the terms of the SDP . It is clear that on 5 March 2016 there was no broadcast made on VKG reminding the involved police officers of this requirement. It seems that the adoption of such a practice since 5 March 2016 has been the result of a combination of initiative taken by individual VKG Shift Coordinators and recommendations made to such Coordinators during relevant training. The adoption of such a practice does not form part of any equivalent training provided to VKG dispatchers. The evidence given by Senior Sergeant Sloane supports a conclusion that such training would be of benefit to VKG dispatchers and to the operation and management of pursuits in general.

76. Consideration of the above issues relating to clearly defining when a pursuit is terminated and what is required before a pursuit can be re-initiated is directly relevant to the manner of Sergeant Richardson’s death. This is because if on 5 March 2016 it had been clearly established over VKG that the first pursuit had ended, and if there had been consideration at that time as to whether approval ought to have been given for the re-initiation of the pursuit, it may have led to the second pursuit not commencing at all. If this had occurred, it means that it is likely that Sergeant Richardson may not have considered it necessary to drive in excess of the designated speed limit in order to reach a point in the pursuit where he was able to usefully deploy road spikes.

77. Of course, it impossible to know whether this would have been the case or not. The point to be made is not that if the above actions had been taken on 5 March 2016 it would have altered the eventual outcome. Rather, the point is that given that vehicles responding to requests for assistance in relation to pursuits will usually be doing so under urgent duty response (see further below), any approval for the re-initiation of a pursuit should be only be given following an opportunity for careful consideration of all relevant factors. Having regard to all of the above, it is desirable that the following recommendation be made.

78. Recommendation 2: I recommend to the NSW Commissioner of Police that consideration be given to the establishment of a standard VKG broadcast at the termination of a pursuit to: (a) confirm the termination of the pursuit; (b) direct involved police officers to cease pursuing and stop following a pursued vehicle, and to return to driving at the legal speed limit; and (c) remind involved police officers of the requirement for approval to be given before a pursuit is reinitiated. I further recommend that the establishment of such a standard VKG broadcast to be incorporated into relevant training packages provided to both VKG Shift Coordinators and VKG dispatchers.

What issues were identified with the management of the pursuits?

79. The evidence establishes that Sergeant Richardson only had limited familiarity with the geographical area where the pursuits were taking place. At certain points it appears that this led to confusion on his part, and on the parts of the VKG Shift Coordinator and the VKG dispatcher, as to his exact location and how to best utilise him as a resource to assist the pursuit. In this regard the inquest considered issues relating to in police vehicles, the distance that Sergeant Richardson had to travel in response to the request for assistance, and the management of the pursuit in general.

80. PTS12 was fitted with the mobile Computer Aided Dispatch (CAD) system.

. However, the evidence revealed that the CAD in PTS12 was not activated on 5 March 2016.

of tracking the movements of PTS12 was via radio transmissions, sightings by other police vehicles, and images captured by MANPR systems.

81. The evidence established that applicable NSW Police Force standard operating procedures requires police officers to log in to the CAD when using vehicles fitted with the system. Ms Taylor said that in her experience general duties and highway patrol officers generally complied with these procedures, although this was not universally the case. The evidence suggested that there was a general degree of non-compliance with these procedures although the extent of non14

compliance could not be determined. However, it appears that non-compliance may be due to a number of factors, with the urgency of response to a situation often proving to be a limiting factor. It is not possible to determine the reason why Sergeant Richardson did not log into the CAD within PTS12, although it is likely that the urgency of his travel from Raymond Terrace contributed to it.

82. Ms Taylor said that it would be greatly beneficial to use both radio communication to monitor the movement of police vehicles during a pursuit. However she explained that she would not rely solely on . This means that radio communication is still required to confirm the location of a police vehicle. Nonetheless, evidence given at the inquest by Senior Sergeant Terrence Brombey, the Systems Coordinator of the CAD Business Support Unit, established that there is an anticipated future roll out of up to 2,000 CAD units with GPS functionality.

83. Clause 2-3-2 of the Standard Operating Procedures for the Deployment of Tyre Deflation Devices (the SOP) provides that deployment officers are to “ensure that they are able to deploy the Tyre Deflation Device without lateral catch-up, or by travelling lengthy distances, or by overtaking the pursuit. Advise VKG communications operator of approximate time and distance from pursuit/deployment site”. Further, the SOP requires that VKG will “ascertain the location of the authorised vehicle and the distance that is required to be travelled to deploy the Tyre Deflation Devices”.

84. The evidence established that there was some dispute as to whether the distance that Sergeant Richardson had to travel from Raymond Terrace amounted to a lengthy distance. Sergeant Stevens said that he did not consider the distance that Sergeant Richardson had to travel to be excessive. He explained that this was because the pursuit kept changing directions and that it did not follow one fixed direction. Similarly Inspector Gregor expressed the view that a vehicle travelling from a neighbouring command in a rural area would not be considered to be a lengthy distance.

85. However Sergeant Cooper said in evidence that the pursuit was fluid and moving in unknown directions and had doubled back on itself. He said that the pursuit was moving away from Sergeant Richardson and that he had not broadcast on VKG that he was providing an urgent duty response. This suggested to Sergeant Cooper that the distance was a lengthy one.

86. Part 6 of the SDP defines urgent duty response as “duty which has become pressing or demanding prompt action”. Relevantly, it is noted that police officers providing urgent duty response “must consider high-speed urgent duty driving as a last resort (refer to the ‘Coded System of Driving’ page 34). It will only be engaged when the gravity and seriousness of the circumstances require such action and there are no other immediate means of responding”.

87. The Coded System of Driving (CSD) prescribes actions required of drivers engaging in urgent duty. An urgent duty response under the CSD is a “code red” response. It requires that officers must advise VKG of the response code and give an estimated time of arrival. It notes that “by advising VKG of the response an officer is also informing other car crews, duty officer and

supervisors of the capacity to respond. This will assist in managing the overall police response to an incident”.

88. The evidence established that Sergeant Richardson did not provide VKG with his response code or estimated time and distance from a possible road spikes deployment site. Similarly, Ms Taylor said that she did not ask where Sergeant Richardson was nor seek any information as to the distance he was to travel. She said that she believed that she had not received training by March 2016 (the version of the SOP applicable at the time was published in February 2016, although the requirement had been in the SOP since its inception in 2010) and so she was unaware of this requirement at the time. Similarly, Sergeant Stevens said that at the time he was also unaware of these requirements in the SOP.

89. In his report, Sergeant Cooper reached the following conclusion: “Had all the involved officers complied with their requirements it would have become readily apparent to Sergeant Stevens as the VKG Shift Coordinator, and possibly Inspector Gregor as the Duty Operations Inspector, that the response to the pursuit, rather than the pursuit itself, was becoming unmanageable and corrective action could have been taken. This in turn may have influenced the decision making processes surrounding the pursuit itself”.

90. This was something that Sergeant Stevens was asked about in evidence. He explained that he felt that he had a good grasp of where the pursuit was going, but possibly not as a good grasp in relation to monitoring vehicles other than the primary and secondary pursuit vehicles, and their surroundings. Sergeant Stevens said that he particularly would have liked to have known where vehicles capable of deploying road spikes were travelling from. Despite this, Sergeant Stevens said that he did not find management of the pursuits of 5 March 2016 to be any more difficult than other pursuits, and did not consider the pursuits themselves to be unmanageable.

91. Conclusion: As the CAD in Sergeant Richardson’s vehicle had not been activated on 5 March 2016, to communication officers monitoring the pursuits on screen. Further, the lack of information, both requested and provided, as to how far away Sergeant Richardson was (both in time and distance) from the pursuit was contrary to applicable procedures at the time. This was due in part to the lack of awareness within the radio operations centre of these procedures.

92. However, the evidence established that there is now an increased understanding of the requirements of these procedures by those to whom they apply. Further, it also appears that since the events of March 2016, improvements have allowed for of police vehicles. Despite this, to monitor police resources is not a feasible option, and that the technology works best in conjunction with radio communication.

93. It was acknowledged in evidence that greater awareness of vehicles involved in the pursuits and their precise locations, other than the primary and secondary pursuit vehicles, would have been of general assistance to those monitoring and managing the pursuits. However, it is not possible to determine to what degree such assistance might have improved management of the pursuits, nor whether such assistance might have affected Sergeant Richardson’s involvement in the pursuit in a material way. This is because even without this assistance, those monitoring the pursuits had an understanding of where Sergeant Richardson was about six minutes before the

collision, and information was provided that he was behind the direction of travel of the second pursuit.

94. However, one important matter relating to these considerations emerged during the course of Sergeant Cooper’s evidence. He was asked about the training provided to police officers regarding the SDP, and whether such training included testimonials from families of police officers who had died during pursuits. Including such testimonials would serve as a powerful reminder of the risks involved in a pursuit, and that, in accordance with the SDP, high speed urgent duty driving should only be used as a last resort.

95. Sergeant Cooper referred to similar testimonials being used as part of a conference relating to police officer safety that he had attended in the United States, and expressed an intention to draw on that material in the future. Given this expressed intention, a recommendation in this regard does not appear to be necessary or desirable. To the extent that such testimonials would assist in mitigating the risk to the lives of police officers performing duties in service of the NSW community, such an intention is to be strongly endorsed and commended.

Findings

96. Before turning to the findings that I am required to make, I would like to acknowledge, and express my gratitude to, Mr Timothy Hammond, Counsel Assisting, and his instructing solicitor, Ms Sylvia Hart of the Crown Solicitor’s Office. Their assistance during both the preparation for inquest, and during the inquest itself, has been invaluable. I also thank Detective Sergeant Scott Wheeler, the Senior Critical Incident Investigator, for compiling a comprehensive brief of evidence and for his assistance during the course of the coronial investigation.

97. The findings I make under section 81(1) of the Act are: Identity The person who died was Sergeant Geoffrey Richardson.

Date of death Sergeant Richardson died on 5 March 2016.

Place of death Sergeant Richardson died at Allandale NSW 2320.

Cause of death Sergeant Richardson died from multiple injuries.

Manner of death Sergeant Richardson suffered the multiple injuries whilst on duty, in the course of a police operation, when the police vehicle that he was driving failed to negotiate a sweeping bend, causing it to leave the road and impact with a tree.

Epilogue

98. In the words of his father, Sergeant Richardson died doing what he loved. The NSW community should be grateful for Sergeant Richardson’s service and it is hoped that that gratitude will in

some small measure ease the enormous pain and loss that Sergeant Richardson’s family have experienced, and continue to experience.

99. On behalf of the Coroner’s Court, and the counsel assisting team, I extend my deepest sympathy and offer my respectful condolences to Sergeant Richardson’s wife, Margaret; his sons, Patrick and Aiden; his parents, and the rest of his family for their truly heartbreaking loss.

100. I close this inquest.

Magistrate Derek Lee Deputy State Coroner 6 July 2018 NSW State Coroner’s Court, Glebe