Inquest into the death of Dennis Brooks

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Dennis Brooks Hearing date: 29 and 30 July 2019 Date of findings: 30 July 2019 Place of findings: NSW Coroner Court - Lidcombe Findings of: Magistrate Elizabeth Ryan, Deputy State Coroner Catchwords: CORONIAL LAW – disappearance and death of a person in the Blue Mountains region – can cause and manner of death be established – should the coordinated land search have commenced earlier – question of recommendations.

File number: 2016/174220 Representation: Counsel Assisting the inquest: J Harris of Counsel i/b Crown Solicitor’s Office.

NSW Commissioner of Police: K Burke of Counsel i/b Makinson d’Apice Inquest into the death of Dennis Brooks

Findings: Identity The person who died is Dennis Brooks.

Date of death Dennis Brooks died between 2 May 2016 and 6 June 2016.

Place of death Dennis Brooks died at Katoomba NSW in the area of Minnehaha Falls.

Manner of death The manner of Dennis Brooks’s death is unknown.

Cause of death The cause of Dennis Brooks’ death is unknown.

Section 81(1) of the Coroners Act 2009 (NSW) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death.

These are the findings of an inquest into the disappearance and death of Dennis Brooks.

The Inquest

1. An inquest is different to other types of hearings. It is neither criminal nor civil in nature. It does not determine whether a person is guilty of an offence and does not make determinations and orders that are binding on parties.

2. A Coroner is required to confirm that a particular death occurred and make findings as to the identity of the person who died, the date and place of death, and the cause and manner of the death. Sometimes the evidence is not sufficient to answer all these questions.

3. In addition under section 82 of the Act a Coroner may make recommendations that are necessary or desirable in relation to any matter connected with the death, including health and safety.

Introduction

4. Dennis Brooks was 35 years old when his sister Monica Brooks reported his disappearance to police on 4 May 2016. Five weeks later his body was found at the base of a small waterfall in dense bushland near Katoomba, in NSW’s Blue Mountains.

5. Dennis Brooks was born on 20 November 1980. His parents Maria and Christopher Brooks were both teachers. In 1988 they moved to Leura in the Inquest into the death of Dennis Brooks

Blue Mountains where they raised Dennis and his sister Monica. After his school years Dennis studied environmental sciences, wrote poetry and worked as a landscaper and arborist. However during his twenties he was badly affected by the sudden deaths of people close to him, including his best friend and then his father. He became withdrawn and in 2008 began to suffer psychotic episodes with auditory hallucinations and persecutory delusions.

Then in 2013 Dennis and Monica learnt that their mother had developed ovarian cancer. She died the following year.

6. Dennis’ mental health difficulties were quite severe but it is important to note that he was generally motivated to get better. In August 2010 he formed a relationship with Jeanie Nicholson and they moved together to a property on Minnehaha Rd, Katoomba. This was where Dennis was living at the time of his death. In 2013 Jeanie and Dennis became parents to a much loved son.

The couple later separated but maintained a good relationship, and Dennis was in regular contact with his son.

7. At the close of the evidence Jeanie spoke to the court of how much Dennis was loved and valued by herself and by others in his Blue Mountains community. Dennis’ sister Monica also wrote a letter which in accordance with her wishes was not read out in court. Her letter was very moving in its expression of whole-hearted love and deep sadness for the loss of her brother, whom she described as having great intellect and heart.

Dennis’ mental health history

8. Dennis’ mental history was of some relevance to the inquest, due to evidence he was becoming unwell again around the time of his disappearance.

9. Following his first episode of psychosis in 2008 Dennis was diagnosed with paranoid schizophrenia. Although he was generally compliant with his treatment regime he suffered regular relapses which became more intense over time. Under the influence of command hallucinations his behaviour was occasionally violent. On at least three occasions while unwell between 2012 and 2014 he went missing from his home.

10. Dennis’ most recent hospital admission was in mid-2015. He was discharged into the care of the Katoomba Community Mental Health Team and he had regular contact with his case worker Mr Michael Clarke. He also had regular medication reviews with his psychiatrist Dr Raphael Fraser.

11. A month before he went missing Dennis told Dr Fraser he had been experiencing breakthrough symptoms of psychosis. He had otherwise been relatively stable for some months. Mr Clarke learned afterwards from Jeanie Brooks that he had been complaining to her of sleep disturbance. He had not mentioned this feature to his clinicians. This would have been important for them to know, due to its known association with relapse of psychosis.

12. Those close to Dennis also noticed signs of unwellness around this time.

Jeanie found him to be unusually quiet and disengaged when he visited Inquest into the death of Dennis Brooks

herself and their son on 24 April. Four days later Monica visited her brother and thought he seemed anxious. In phone conversations with Jeanie and Monica he complained of sleep disturbance and of not feeling well. On the evening of 1 May Jeanie spoke to Dennis on the phone and suggested a bushwalk might help his anxiety. Dennis said he might take one then and there, but Jeanie advised him to wait until the morning.

13. At about 6pm on 2 May both Monica and Jeanie sent Dennis text messages, to which he didn’t reply. Soon afterwards that evening he went to a hotel in Katoomba and was observed to be drinking beer and shouting to himself. He left there at about 9pm. This was the last known sighting of him.

The events of 4 May

14. On the morning of 4 May Jeanie drove past Dennis’ home and noticed the doors were open. She assumed he had a visitor. A neighbour informed Monica that the doors had been left open and Monica drove there from her home in Arncliffe. Dennis was not home but the doors were still open and the lights were on inside the house. Dennis’ mobile phone was also there, with unread messages from herself and Jeanie.

15. Monica informed Michael Clarke of these events but given Dennis’ past history of temporary disappearances, he was confident Dennis would turn up soon.

16. However Monica went to Katoomba Police Station that afternoon and reported Dennis missing. She spoke with Senior Constable Erica Drzewiecki, telling her that her brother was schizophrenic, was taking medication, had seemed unwell recently, and had not been seen since the night of 2 May at Katoomba’s Gearins Hotel.

17. At the inquest SC Drzewiecki was certain Monica had not told her that she had found Dennis’ doors left open and the lights on. I note that this important detail is missing from the COPS report which SC Drzewiecki prepared that evening.

18. In response to Monica’s report SC Drzewiecki did the following:  obtained from Monica a photo of Dennis to upload onto a police Facebook site  tasked police officers to attend Dennis’ home and canvass neighbours.

 checked with hospitals and mental health services to see if he had been admitted  completed a mandatory Risk Assessment, assessing Dennis’ risk as ‘High’ on the basis of his mental state, need for medication, and history of previous disappearances  briefed a criminal investigator, Detective Senior Constable Colleen Hayden, the following morning.

19. On 5 May SC Drzewiecki spoke to the licensee of Gearins Hotel, who told her that on the night of 2 May Dennis had been acting strangely and had been abusive towards staff and patrons. He had left in the direction of the train Inquest into the death of Dennis Brooks

station. SC Drzewiecki also spoke with Michael Clarke who expressed concern that in an unwell state Dennis might harm himself or others.

20. On 7 May Monica attended the police station and told officers she had a ‘hunch’ that Dennis had gone bushwalking in the area of Minnehaha Falls, not far from his home. The next day SC Drzewiecki sent an email to Detective Sergeant Dallas Atkinson, who is the supervising sergeant for Blue Mountains Search and Rescue. SC Drzewiecki wanted to know whether there was sufficient basis to commence a land search for Dennis. She commented in her email that the only information suggesting he had gone to the area of Minnehaha Falls was that he lived on the road leading to the Falls track, and that he had walked there on previous occasions.

The events of 9 – 11 May

21. For the next few days SC Drzewiecki was not on duty. Her colleague Sergeant Peter Beszant pursued various enquiries related to the case, including a number of alleged sightings which turned out to be false.

22. On the morning of 9 May Sgt Beszant had a discussion with Jeanie Brooks who had come to the police station. She told him she strongly believed Dennis was in the bush. She also told him that on 4 May the doors had been left open at his home and the lights had been left on. Sgt Beszant completed a COPS entry the next day which included this information. I note that this is the first time this information appears in police records, although it appears to have been known to Monica and Jeanie, and also to Michael Clarke who had included it in a letter to the police on 8 May.

23. On 10 May foot searches with police rescue officers and cadaver dogs were made to the area north of where Dennis lived. The next day two police officers searched Dennis’ home and spoke again to neighbours. In addition PolAir conducted an aerial search of the Minnehaha Falls area. The area of their search incorporated the location where Dennis’ body was discovered four weeks later, in a pool at the base of the Falls. However the only object of significance noted in the PolAir search was a hat which was spotted on the other side of this pool. When the hat was retrieved the following day it was found not to be related to Dennis.

The consideration of a land search operation

24. Detective Sergeant Dallas Atkinson has been qualified as a Land Search and Rescue Coordinator since 2009. In 2014 he was appointed as the Blue Mountains Police Rescue Squad Supervising Sergeant. Over the years he has been involved in and has coordinated hundreds of search and rescue operations.

25. DS Atkinson first became involved in this investigation when he received SC Drzewiecki’s email, referred to in paragraph 20 above. He then reviewed the COPS event report and spoke with Sgt Beszant on the afternoon of 9 May.

He concluded that at this stage it was not feasible to perform a coordinated Inquest into the death of Dennis Brooks

land search. He communicated this decision in an email to SC Drzewiecki and suggested that priority be given to having Dennis’ phone examined, as any content on it in the period between 2 and 4 May could help to identify a plausible start point for a land search.

26. At the inquest DS Atkinson was questioned about this assessment. He acknowledged that he had been aware of the family’s belief that Dennis had gone missing in bushland. This information if accurate would ordinarily result in a coordinated land search. However in Sgt Atkinson’s view, based on what he knew on 9 May, there was insufficient evidence to suggest where, if at all, Dennis had gone into a bush environment. He could not confidently ascertain his last known position, taking into account a report from a member of the public (later found to be false) that Dennis had been seen outside another Katoomba hotel, the Harp and Fiddle, at about 3pm on 3 May. If accurate, this report represented the last known sighting of Dennis.

27. Regarding DS Atkinsons’ assessment of the unfeasibility of a coordinated land search, there are two important things to note. These are:  the alleged sighting of Dennis on the afternoon of 3 May turned out to have been incorrect, but this fact was not confirmed until 14 May. Until then it continued to present the possibility that Dennis’ last known location was within the Katoomba central area.

 until 13 May Sgt Atkinson was unaware of the information that on 4 May Dennis’ house had been found with the doors open and lights on. I have noted that Jeanie advised Sgt Beszant of this on the morning of 9 May.

Although Sgt Beszant and Sgt Atkinson discussed the case that afternoon, DS Atkinson was adamant that Sgt Beszant had not mentioned it. He told the inquest that had he done so, this would have altered his approach to the matter as it raised the distinct possibility that Dennis had gone missing from his home. This would have provided the search operation with a focus from which to search.

28. I should note that in his evidence Sgt Beszant believed he would have advised DS Atkinson of it.

Events on 13 and 14 May

29. On 13 May two very important features came to Sgt Atkinson’s attention. The first was the information about the state of Dennis’ house referred to above.

This was conveyed to him by Monica, when he went to Dennis’ house that afternoon to conduct his own search of it.

30. The second was that while he was at Dennis’ house Sgt Atkinson was shown a hat. He immediately recognised it as the same as that worn by Dennis when he was Gearins Hotel on the night of 2 May. Sgt Atkinson had viewed the relevant CCTV footage that same morning. This link confirmed that Dennis had returned to his home after having been at Gearins Hotel, and made it increasingly plausible that he had gone missing from his home.

Inquest into the death of Dennis Brooks

31. DS Atkinson now determined that it would be appropriate to conduct a coordinated land search. He made arrangements for this to commence the following morning.

32. The search on 14 May comprised almost fifty people from NSW Police, Rural Fire Service, SES, and Bushwalker rescue volunteers. They searched the area from Dennis’ home northwards into the Minnehaha Reserve, including along Yosemite Creek which leads to the Falls. There was also a further canvass of neighbours. No trace of Dennis was found.

The discovery of Dennis’ body

33. Non-urgent searches continued over the following days. These included searches by cadaver dogs on 31 May and 1 June, taking a route close to Minnehaha Falls.

34. Heavy rain fell over the Katoomba area in the weekend of 3-5 June. Then on Monday 6 June a member of the public who was visiting the Minnehaha Falls Lookout spotted a body in the pool down at the base of the Falls. She immediately alerted police. When the body was retrieved, fingerprints identified the person as Dennis.

The post mortem report

35. An autopsy was conducted by forensic pathologist Dr Rebecca Irvine on 10 June. Unfortunately due to the state of decomposition it was not possible to identify the cause of Dennis’ death. Nor was it possible to determine whether his death was the direct result of drowning. He had suffered some injuries including fractures to the ribs and right elbow, but Dr Irvine could not determine whether these had occurred prior to, at the time of, or after death.

36. During the autopsy a sample of algae was taken from Dennis’ body. This was analysed in an attempt to estimate the length of time his body had been in the water. Unfortunately this did not yield concrete results, beyond the conclusion that the condition of the algae was consistent with what would be expected if he had entered the water on or about 2 May and remained submerged in or near water until he was discovered on 6 June.

37. The available medical evidence is therefore unable to provide a cause and manner of Dennis’ death. The inquest explored the remaining evidence to determine whether it could shed any further light on the circumstances of his death.

How did Dennis’ body come to be at the base of the Minnehaha Falls?

38. In his evidence at the inquest DS Atkinson was strongly of the view that Dennis’ body had not been positioned at the location where it was eventually found for a period of more than a few days. His reasons for this were as follows: Inquest into the death of Dennis Brooks

 the PolAir search on 11 May did not detect Dennis’ body in the pool at the base of the Minnehaha Falls. Had it been there on 11 May DS Atkinson was adamant his body would have been visible from the air. He noted that from the helicopter the PolAir searchers were able to spot a hat located on the other side of the pool, about twenty metres from where Dennis’ body was later found.

 The Lookout from which Dennis’ body was spotted on 6 June is a frequently visited site, from which the pool twenty metres below is clearly visible. DS Atkinson had himself been there on 12 May in the course of the search effort and had not seen Dennis’ body in the pool. That the pool is clearly visible from the Lookout was established in footage shown in court which DS Atkinson had captured by means of a camera mounted on a drone, after the retrieval of Dennis’ body. From the height of the Lookout the footage clearly showed the pool below, in which a person swimming was able to be seen.

39. DS Atkinson further considered whether Dennis’ body may have been concealed for a period of time below the surface of the pool in which it was found. He acknowledged he was not an expert in such matters, but on the basis of his experience with search operations he thought this was unlikely.

He considered it would be unusual for a body to lie submerged for more than a few days, before becoming buoyant and moving to the surface.

40. For the above reasons DS Atkinson strongly believed that within a few days of its discovery Dennis’ body had travelled to its resting place from another location. As to how this had happened, he noted the strong rains that had fallen in the two days before the discovery, causing a significant rise in the water levels of Yosemite Creek which feeds into the Falls. DS Atkinson considered the increased water level would have been sufficient to wash out a body which may have become lodged upstream of the Falls or in vegetation close by the creek.

41. In my view the above evidence sufficiently establishes, on the balance of probabilities, that prior to 6 June Dennis’ body had not been at its discovered location for more than a few days at most. The evidence indicates that his body entered Yosemite Creek at some point upstream of the Falls and remained there until washed down over the Falls.

42. Unfortunately the evidence cannot establish precisely where or when Dennis’ body entered the water and most importantly for Dennis’ family, what caused this to happen. When he entered Yosemite Creek had he perhaps suffered an injury which had already caused his death or had severely incapacitated him?

And what had been happening to him in the period before this time, after his entry into bushland presumably soon after the night of 2 May? Sadly for Dennis’ family, there is insufficient evidence to provide answers to these questions.

43. The possibility that Dennis remained alive for a period of time after going into the bushland was acknowledged by DS Atkinson. I accept that this possibility, Inquest into the death of Dennis Brooks

naturally very distressing for Dennis’ family members, cannot be discounted on the evidence.

Should the coordinated land search have been commenced at an earlier stage?

44. As has been described above, it was not until the afternoon of 13 May that DS Atkinson considered there was sufficient basis to commence a coordinated land search. It was on this date he became aware of information strongly indicating that Dennis had gone missing from his home and not from some other location. This was the information about the state of Dennis’ home as observed by Jeanie and Monica on 4 May, and the realisation that the hat he saw in Dennis’ home on 13 May was the same hat he had been wearing on the night of 2 May.

45. I accept that it was not feasible for NSW Police to commence a coordinated land search until they had sufficient evidence of a last known position, so as to focus the search on a particular area. As described, Sgt Atkinson did not reach this state of awareness until 13 May. But could this awareness have crystalised earlier?

46. I have noted above that according to SC Drzewiecki, Monica did not inform her on 4 May that the doors of Dennis’ home had been left open. However this information was made known to police on 9 May, when Jeanie conveyed it to Sgt Beszant. Despite this DS Atkinson was unaware of it for a further four days. He acknowledged it would have been relevant to his assessment at that stage of whether a coordinated land search ought to be commenced. He acknowledged further that this gap in his information represented a breakdown in police communication.

47. It appears therefore that had the information about Dennis’ home been available to DS Atkinson, the land search operation could have commenced up to four days earlier than it did.

48. The Blue Mountains Local Area Command has Standard Operating Procedures to guide police in cases of missing persons. DS Atkinson described some changes he had made to the Operating Procedures since Dennis’ death, which were designed to improve communication between investigating police and Rescue Team Leaders such as himself. The revised Procedures set out the circumstances in which the investigating officer is to apprise a Rescue Team Leader of the missing person; and contain a brief section on the responsibilities of Rescue Team Leaders.

49. In Dennis’ case the investigating officer SC Drzewiecki did apprise DS Atkinson of his disappearance. It appears however that DS Atkinson was not fully apprised of further information when it became known to the investigating police. I note that the changes to the Operating Procedures do not specifically address this scenario.

Inquest into the death of Dennis Brooks

50. I have considered whether it is necessary or desirable to make a recommendation that the Procedures regarding missing persons include a formal process for updating the Rescue Team Leader in cases such as this.

However I did not hear evidence or submissions on this point. Furthermore I acknowledge the practical reality that it is not feasible in all cases to make provision against human error. For these reasons I do not consider it would be appropriate to make this the subject of any recommendation.

Could an earlier coordinated land search have altered the outcome?

51. It is not possible to make a finding as to whether Dennis’ death might have been prevented if a land search operation had commenced earlier. This is because there is no clarity as precisely where Dennis was between 2 May and the time when he entered the waters of Yosemite Creek; nor whether during this period he remained alive.

52. In submissions Counsel Assisting noted DS Atkinson’s opinion that it was unlikely Dennis had remained alive for long once he had entered the bushland surrounding his home. This was because in his view, Dennis would have been noticed due to the area being much frequented by bushwalkers. I accept the submission of Counsel Assisting that while this theory is plausible, there is insufficient evidence to make it the subject of a positive finding.

53. Due to the absence of available evidence as to when and how Dennis died, it is not possible to find that an earlier coordinated land search would have altered this very sad outcome.

54. It is important to state however that there is no evidence that Dennis’ death was the result of a deliberate act to end his life. He loved his little son very much. Although when he was unwell the conditions of his life could be very difficult, he had never expressed suicidal thoughts or intentions to his therapists or to his loved ones.

Conclusion

55. It is sometimes the case that inquests are not able to establish how a person has died. This uncertainty only adds to the distress families feel at the loss of their loved one. In Dennis’ case it is not possible to determine the cause and manner of his death. Nor can the precise date of his death be established due to the difficulty of determining when, between the period of his last known sighting and the discovery of his body, his death actually took place.

56. For the sake of Dennis’ family I regret that this inquest has not been able to answer many of their questions about what happened to him. They have lost a beloved person and will feel his loss for the rest of their lives. I hope they will accept the sincere sympathy of us all at the Coroners Court.

57. I thank those who have assisted this inquest, including Counsel Assisting, the Crown Solicitor’s Office, and Counsel for the NSW Commissioner for Police. I Inquest into the death of Dennis Brooks

also acknowledge the work of the Officer in Charge SC Colleen Hayden in preparing the coronial brief and assisting the inquest Findings required by s81(1) of the Coroners Act 2009 As a result of considering all of the documentary evidence and the oral evidence heard at the inquest, I am able to confirm that the death occurred and make the following findings in relation to it.

Date of death Dennis Brooks died between 2 May 2016 and 6 June 2016.

Place of death Dennis Brooks died at Katoomba NSW in the area of Minnehaha Falls.

Manner of death The manner of Dennis Brooks’s death is unknown.

Cause of death The cause of Dennis Brooks’ death is unknown.

I close this inquest.

E Ryan Deputy State Coroner Lidcombe 12 August 2019 Inquest into the death of Dennis Brooks