Inquest into the death of Paul Lambert

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Paul Lambert Hearing dates: 5 to 9 November 2018 Date of findings: 15 February 2019 Place of findings: Coffs Harbour Local Court Findings of: Acting State Coroner, Magistrate Teresa O’Sullivan Catchwords: CORONIAL LAW – Cause and manner of death – police shooting – mental health – history of intimate partner violence and stalking – suggestion of consideration of non-lethal tactics by NSW Police Force File number: 2016/329687 Representation: (1) Counsel Assisting Ms Kirsten Edwards of counsel, instructed by Ms Alana McCarthy and Ms Clare Skinner of the NSW Crown Solicitor’s Office (2) NSW Commissioner of Police Mr Michael Spartalis of counsel, instructed by Mr Stuart Robinson of the Office of the General Counsel, NSW Police Force (3) Senior Constables Damien Buckley, Craig Myles and Richard Osborne Mr Ray Hood of counsel, instructed by Mr Kenneth Madden of Walter Madden Jenkins (4) Next of kin Mr David Evenden, instructed by Ms Helen Cooper of Legal Aid NSW

Non publication order: Pursuant to ss. 74 and 65 of the Coroners Act 2009 there shall be no publication of and no access to:

1. Paragraphs 97-102 inclusive and annexures 5-8 inclusive of the statements of Sergeant Jonathan Healy dated 31 October 2018;

2. NSW Police Force Safe Driving policies;

3. NSW Police Force tyre deflation device standard operating procedures;

4. Paragraph 116 of the statement of Detective Sergeant Luke Scott dated 18 May 2018;

5. Paragraph 177 of the statement of Detective Chief Inspector Mark Henney dated 3 November 2018;

6. Transcript of the VKG broadcast of 3 November 2016 between time markings 08:20 and 11:30 and the corresponding in-car video footage;

7. The Taser footage of 3 November 2016;

8. The audio recording of the conversation between Paul Lambert and Detective Senior Constable Shaun Durbridge on 3 November 2016;

9. The identity of persons known as Negotiator 2, Negotiator 3 and Negotiator 4; and

10. Items 25, 26, 35, 36 and 37 of Exhibit 10.

Findings: The Coroners Act 2009 in s. 81 (1) 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 death of Paul Lambert.

Identity of deceased: The deceased person was Paul Lambert Date of death: Mr Lambert died on 3 November 2016 Place of death: Mr Lambert died on the Pacific Highway, near Bonville in

NSW Manner of death: Mr Lambert was shot multiple times by an officer or officers of the NSW Police Force in circumstances where he was advancing towards a police officer with a raised knife. The shooting followed an attack by Mr Lambert on the same day on his former girlfriend and a subsequent police pursuit and stand-off with police on the Pacific Highway.

Cause of death: The medical cause of death was the combined effect of gunshot wounds to the chest and abdomen.

Recommendations: To the Commissioner of the NSW Police Force:

1. That the NSW Police Force continue to review other tactical options of a non-lethal nature for dealing with offenders armed with a knife, including the use of shields, in order to minimise the likelihood of serious harm in the event of a police response that requires an offender to be disarmed.

2. That the NSW Police Force consider the implementation of an opt-in information sharing system to allow licensed weapons dealers to check if a person attempting to buy a knife has an outstanding apprehended violence order or apprehended domestic violence order.

Table of Contents Were there alternatives to lethal force available to the officers who discharged With the benefit of hindsight and reflection, could any steps have been taken by the police officers on the Pacific Highway that may have led to a different and With the benefit of hindsight and reflection, was there any particular form of intervention with Mr Lambert in the two weeks prior to his death that had a

The Coroners Act 2009 in s. 81 (1) 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 death of Paul Lambert.

Introduction

1. Paul Lambert was born on 10 August 1980 in Queensland. He was 36 years old when he died on 3 November 2016. The shooting was a culmination of a series of dramatic and tragic events that day. Mr Lambert died after he attacked and stabbed Dr Angela Jay in Port Macquarie, was involved in a police pursuit and stand-off on the Pacific Highway, and was ultimately shot multiple times by officers of the NSW Police Force at approximately 9:38pm on 3 November 2016.

At the time he was shot, he was advancing on a number of police officers with a raised knife. He received gunshot wounds to the upper body and died at the scene.

2. As Mr Lambert died in the course of a police operation, an inquest is required to be held pursuant to ss. 23(c) and 27(1)(b) of the Coroners Act 2009 (“the Act”).1 The nature of an inquest

3. The role of a Coroner, as set out in s. 81 of the Act, is to make findings as to: a. the identity of the deceased; b. the date and place of the person’s death; c. the physical or medical cause of death; and d. the manner of death, in other words, the circumstances surrounding the death.

4. There is no controversy about Mr Lambert’s identity, or about the date and place of his death. As to the cause of death, the available medical evidence suggests that the cause was three gunshot wounds to the chest and abdomen which, according to forensic pathologist Dr Lyons, would have “rapidly and inevitably 1 Note that Mr Lambert’s death occurred prior to the amendment of s. 23 of the Coroners Act 2009 on 1 July 2017, pursuant to Sch. 6.5 cl. 1 of the Law Enforcement Conduct Commission Act 2016.

lead to death”.2 Accordingly, the focus of the inquest was on the manner of Mr Lambert’s death, both in the two weeks leading up to the shooting and the shooting itself. The inquest examined if the death was preventable.

5. A secondary purpose of an inquest is to determine whether it is necessary or desirable to make any recommendations in relation to any matter connected with the death, including in relation to matters of public health and safety.3 The Facts Background Personal circumstances

6. Mr Lambert (nee Scales) was born in Queensland and was 36 years old when he died. His mother and father separated in 1986, when he was four years old. He had an older sister, who is married with a family. Mr Lambert’s father had two boys in a subsequent relationship and two daughters from a previous relationship.

7. Mr Lambert graduated from St James Practical School in 1998 and completed a tertiary degree in business and finance at Queensland University of Technology/Southern Queensland. Mr Lambert worked in a finance position at a motorcycle dealer in Hervey Bay and when he moved to NSW he found a job in finance at a motorcycle dealer in Kogarah.

8. Mr Lambert’s family attended every day of the inquest hearing, which is a testament to the love they held for him. Through their advocate Mr Evenden, they asked intelligent and reasonable questions of the individual police officers and showed considerable compassion and respect towards them. On the final day of the hearing they read a beautiful statement which illuminated a kinder, gentler and more complex person than the evidence had revealed. I thank them for their presence and contribution.

2 Autopsy Report for the Coroner, 3 March 2017, p. 3.

3 Section 82 Coroners Act 2009.

Mr Lambert’s criminal history

9. Mr Lambert had a history of intimate partner violence. It appears that Mr Lambert engaged in criminal conduct towards many of his previous girlfriends and, between March 2003 and October 2016, he was the subject of 10 interim or full apprehended domestic violence orders (“ADVOs”) in respect to five women (including Dr Jay). On three occasions, he was charged and convicted in relation to breach of an ADVO.

10. The evidence indicates that Mr Lambert repeatedly engaged in controlling, intimidating and sometimes physically violent behaviour towards his partners. He had a pattern of engaging in dramatic behaviour when women tried to end relationships with him. This included threatening to kill himself, inventing elaborate lies about family members dying or claiming that he had cancer or had been sexually abused as a child. Sometimes he would contact family members of romantic partners and make threats of harm or created false identities to stalk partners. He would claim diagnoses of various psychological disorders to excuse his behaviour, implying that he suffered from a dissociative or multiple personality disorder (referring to “bad Paul” or “evil Paul”). At one stage, Mr Lambert claimed to have nine personalities.

11. On 2 February 2014, Mr Lambert married a woman he had known since 2008.

The relationship quickly became troubled but they travelled to the US for holidays and renewed their vows in Orlando, Florida in September 2014. Mr Lambert returned to Florida in 2014, while he was still married, and began a relationship with a television reporter, Ms Brittany Keil, after meeting her via a dating application. His marriage broke down and he moved to Florida to be with Ms Keil in around March 2015.

12. Like his past relationships, whenever Ms Keil tried to end the relationship Mr Lambert would invent a major life trauma, for example the death of his father, a history of sexual abuse or diagnoses of a brain tumour and she felt pressured to stay. When Ms Keil finally terminated the relationship, Mr Lambert harassed her and threatened to release private information about her to her employer and other news stations. Ms Keil reported the conduct to police and Mr Lambert was arrested on 11 May 2015 and charged with stalking and extortion. He was

deported on 23 June 2015, after spending approximately a month in immigration detention. It appears that Mr Lambert changed his name from Paul Scales to Paul Lambert after he was deported from the US.

13. When Mr Lambert’s wife found out that he had been deported for offences against a woman she went to police in Hervey Bay in Queensland and told them that Mr Lambert had also stalked and intimidated her. She was granted a protection order but Mr Lambert breached it on a number of occasions and, on 22 February 2016, he attacked her while they were travelling to a Justice of the Peace to sign divorce documents. During the car ride, Mr Lambert verbally abused his wife, made comments that “he may as well crash the car”, accelerated the vehicle, then grabbed her neck and punched her in the face. She escaped and Mr Lambert was charged with a number of offences including assault occasioning actual bodily harm.

14. On 19 July 2016, Mr Lambert was convicted of assault occasioning actual bodily harm and sentenced to nine months’ imprisonment with immediate release to parole. Convictions were also recorded for driving offences and contravention of the protection order, for which he was sentenced to 12 months’ probation and disqualified from driving for two years.

15. In around May 2016 Mr Lambert had moved into a boarding house in Kogarah and commenced work nearby at a motorcycle dealer. He stayed living and working in NSW in breach of his parole and probation orders.

Mr Lambert’s parole

16. It is a condition of every Queensland parole and probation order that offenders cannot leave Queensland (or live or work in another State) without the permission of the Queensland Probation and Parole Service. Breach of parole orders can lead to a suspension of parole by the Probation and Parole Service (depending on the circumstances and the outcome of a risk assessment) and the matter is referred to the Parole Board of Queensland to determine the action to be taken.

17. Mr Lambert was supervised by a Probation and Parole Service Senior Case Manager, Ms Raewyn Sanson. At his initial risk assessment on 19 July 2016, Mr Lambert requested that the orders be transferred to NSW so that he could live

and work there. He expressed surprise that he was not able to live in Sydney or travel as he pleased and said he was not aware of these conditions of his sentence. His application to transfer his orders to NSW was declined on 27 July

2016. Mr Lambert was told he could return to NSW to collect his belongings from 17-22 August 2016. A further application to transfer his orders was declined on 19 September 2016.

2017. However, Mr Lambert did not return to Queensland and he started actively deceiving his Case Manager, flying back to Brisbane from Sydney for their meetings. On 9 August 2016, Mr Lambert falsely told his Case Manager that he was living on the Sunshine Coast for a few days’ work at a motorcycle company, staying with his sister, and that he spent the rest of the time in Brisbane residing with his parents. On 20 September 2016, he reported that he was working fulltime. It appears that no collateral checks were made with his mother, sister or his employer to verify where he was living and working.

2018. Mr Lambert was directed on 23 August 2016 to attend the Responsible Men program (a program aimed at preventing domestic violence) but he requested to do the program through his own psychologist. Mr Lambert had not undertaken the course by the time of his death. It appears he was not actually seeing a psychologist at the time and no check was made. Mr Lambert called in sick when he was required to report to his Case Manager on 31 October 2016 and did not report on his next scheduled meeting on 3 November 2016, the day he died.

2019. Ms Sanson states that if information was received that Mr Lambert was living and working in NSW it is highly likely that action would have been taken to suspend his parole order and a warrant would have been issued for his arrest. However, Mr Lambert’s breach of parole had not been discovered by the time of his death.

Psychological and psychiatric issues and treatment

21. It does not appear that Mr Lambert was being treated for any mental health issues at the time of his death. An anti-depressant/mood stabiliser, Olanzapine (Zyprexa), was found with his belongings after his death but the drug was not detected in his post-mortem blood. Mr Lambert told his mother and sister and

others that a psychologist had diagnosed him with a borderline personality disorder whilst in immigration custody in the US.

22. Dr John Aloizos started seeing Mr Lambert when he was seven or eight years old and described him as “always [having] had behavioural issues”. He referred Mr Lambert for psychological treatment at around the age of 10. Dr Aloizos saw Mr Lambert on seven occasions between 2015 and 2016. He initially prescribed Mr Lambert with the anxiety medication Ativan but Mr Lambert told Dr Aloizos that he had been diagnosed with borderline personality disorder in the US and Dr Aloizios issued a mental health plan for Mr Lambert to see clinical psychologist Joey Tai. On 6 August 2015, Dr Aloizos prescribed Mr Lambert with antidepressants but on 3 November 2015 Mr Lambert indicated that Mr Tai had diagnosed him with bipolar disorder and Dr Aloizos issued a prescription for Olanzapine. Dr Aloizos urged Mr Lambert to see a psychiatrist to no avail.

23. On 22 July 2015, Mr Lambert had attended psychiatrist Dr Simone Becker.

Dr Becker considered that Mr Lambert was suffering from symptoms suggestive of a manic episode with psychotic features and advised him that he required immediate in-patient treatment. Mr Lambert presented himself to the Emergency Department (“ED”) at Royal Brisbane Women’s Hospital and was assessed by mental health clinicians who determined that he did not require inpatient care. Dr Becker subsequently contacted the ED psychiatrist to express her concerns and referred Mr Lambert to the Mental Health Acute Care Team.

24. On 7 December 2015, Mr Lambert informed Dr Aloizos that he had stopped taking Olanzapine. Dr Aloizos said in his statement that “it was obvious to me that Paul had a personality disorder”. On 5 October 2016, Dr Aloizos received a message from his administrative staff that Mr Lambert had requested an extension of his mental health plan. Dr Aloizos completed the extension and gave it to Mr Lambert’s mother. He did not see Mr Lambert on this occasion.

25. On 4 August 2015, Mr Lambert started seeing Mr Tai. He had 17 sessions in total, the last being on 3 May 2016. On the first occasion they met, Mr Lambert provided Mr Tai with a 17 page document outlining his life and mental health issues. Mr Tai diagnosed Mr Lambert with borderline personality disorder and secondary depression, and recommended ongoing psychological intervention.

26. According to his contemporaneous clinical notes, Mr Tai repeatedly warned Mr Lambert not to contact him outside sessions and told him that he would not respond to any non-administrative message. Mr Lambert would often threaten suicide to gain attention but he also told Mr Tai that he would not have the courage and that he made the threats to manipulate people. Mr Tai told Mr Lambert that he would not respond to suicide threats and that if he felt suicidal he should contact emergency services.

27. During Mr Lambert’s last session with Mr Tai on 3 May 2016, Mr Lambert said he was moving to Sydney. On 27 October 2016, Mr Lambert sent a message to Mr Tai that read: “Hi joey if you have anyone cancel today could you please call me for a phone appointment. I’ve fallen off the rails again. Been very suicidal and not functioning properly”

28. On the same day Mr Lambert made an appointment to see Mr Tai on 3 November 2016. Mr Tai recorded in his notes that he did not respond to Mr Lambert’s text message because he had made an appointment and due his policy of not responding to Paul Lambert’s regular threats of suicide.

29. Forensic psychiatrist Dr Kerri Eagle was retained during the coronial investigation to provide a retrospective diagnosis of Mr Lambert (sometimes called a psychiatric autopsy). She opined that Mr Lambert most likely had Bipolar 1 disorder and severe personality disorder with borderline and narcissistic personality traits. Dr Eagle considered that the disorder was longstanding and that it affected had Mr Lambert’s relationships from late adolescence/early adulthood. Dr Eagle’s report states that, while Mr Lambert would have benefitted from assessment and ongoing treatment by a psychiatrist, there are no real options for the treatment of entrenched stalking behaviour and legal frameworks have so far proved ineffective.

Relationship with Dr Angela Jay

30. At the time that she met Mr Lambert, Dr Jay was living in Port Macquarie and doing a rotation at Port Macquarie Hospital as a trainee obstetrician and gynaecologist.

31. Dr Jay met Mr Lambert via a dating application in around August 2016. The long distance relationship lasted for approximately two months. It was normal and happy at first, with the pair travelling to see each other on weekends, but soured after Dr Jay started to feel overwhelmed and Mr Lambert began engaging in controlling and possessive behaviour.

32. Towards the end of the relationship, Mr Lambert used the techniques he had used in previous relationships to emotionally manipulate Dr Jay and make her feel unable to reject him, including threatening self-harm and suicide, claiming to have various mental illnesses, lying about deaths in his family, manufacturing crises and stating that he needed help. Mr Lambert also invented a friend called “Dan” and registered a different phone number to text Dr Jay as “Dan” to tell her that “Paul” had attempted suicide . “Dan” used Dr Jay’s caring nature and sense of responsibility against her. He told her that she had a duty to look after Paul because she was a doctor and pressured her to reconcile with him, telling her she was heartless and the only person who could keep Paul alive. Dr Jay was aware through her work of the risk of suicide in people with borderline personality disorder.

33. The techniques of manipulation may seem obvious in retrospect but they were subtle and insidious at the time, involving layers of escalating emotional abuse. It led to an erosion of Dr Jay’s confidence and self-worth and to her doubting her own judgment and her own behaviour.

34. On Saturday 29 October 2016, Dr Jay agreed to allow Mr Lambert to accompany her, strictly as a friend, to a school reunion function at the Crowne Plaza in Terrigal. During the night Dr Jay became emotional and confided to a friend that she felt scared of Mr Lambert and that he was emotionally blackmailing her into resuming the relationship. Mr Lambert left the function with Dr Jay’s bag, phone and keys and her friends retrieved them for her. Dr Jay told the inquest that the concerned reaction of her friends helped her to see the relationship in a new light.

35. Dr Jay stayed the night at her sister’s house that night and Mr Lambert appeared unannounced a couple of times through the night. He also sent Dr Jay approximately 50 threatening messages and phone calls. Dr Jay’s sister urged Dr Jay to go to the police.

The week of 30 October 2016 Dr Jay goes to the police - Gosford Police Station 30 October 2016

36. On the morning of 30 October 2016, Dr Jay attended Gosford Police Station with her sister. She told Senior Constable (“SC”) Bradley Clarkson that she was scared of Mr Lambert and felt that he was emotionally blackmailing her with threats of self-harm. SC Clarkson checked the National Suspects and Offenders System and found what he described as “an extensive history of mental health and officer safety issues”. SC Clarkson did not tell Dr Jay what was in the records (and had no power to do so) but suggested to Dr Jay that the information “was more pertinent to self-harm and officer safety”. Dr Jay told the inquest that SC Clarkson was kind and made her feel validated. He encouraged her to call police if there were more threats of self-harm or concerns for her safety.

37. The National Suspects and Offenders System entry for Paul Lambert included warnings about the risk of self-harm and violence towards police, details relating to three expired protection orders relating to past partners, an active protection order in relation to his former wife and Mr Lambert’s convictions for attacking his wife in the car. There was nothing on the system which would have alerted SC Clarkson to the fact that Mr Lambert was in breach of his parole (or of the content of his parole and probation conditions).

38. The COPS entry prepared by SC Clarkson in respect to Dr Jay’s visit to Gosford Police Station records that Dr Jay said she did not want to report an offence but wanted to make sure it was reported in case the situation escalated. The matter was recorded as “domestic violence – no offence”. Gosford senior officers reviewed the file and ultimately there was a decision to attend Mr Lambert’s house in Kogarah and make a welfare check.

Paul Lambert stalks Dr Jay in Port Macquarie and is pulled over by police

39. On the same day Mr Lambert took leave from work telling his employer he was having issues with his girlfriend. He flew to Port Macquarie and rented a white Corolla hatchback from 1st Class Rentals at the airport telling manager Lee Scott that he was trying to make amends with his girlfriend. Mr Lambert was

disqualified from driving but Mr Scott had no access to any system which would have identified his license status. I address a recommendation proposed by Mr Scott below.

40. At 2:17pm on 30 October 2016, Mr Lambert went to Bunnings at Port Macquarie and bought a utility knife, a hatchet (an axe) and two 30 metre rolls of duct tape.

41. At 4:20pm on 30 October 2016, Mr Lambert was pulled over by SC Justin Cordell for driving 71km in a 50km/h zone. He was found to be disqualified and appropriately issued a Court Attendance Notice (“CAN”). Mr Lambert persuaded SC Cordell that he was unaware that his license was disqualified and SC Cordell noted that he had a good traffic record. Mr Lambert told SC Cordell that he would ask his girlfriend (whom he said was a doctor) to collect the car and return it to the rental company. He walked away but then returned and sat in the gutter until SC Cordell and his fellow officer left the location. Presumably, Mr Lambert then drove away.

42. As Counsel Assisting noted in her opening, at the time Mr Lambert was pulled over by Port Macquarie police he was disqualified from driving, in breach of his Queensland parole, had been subject to a complaint by Dr Jay for frightening her (but not an ADVO) and had purchased weapons suggesting violent intentions towards Dr Jay. The weapons may well have been in the car when SC Cordell was speaking to Mr Lambert. The officer in charge Detective Chief Inspector (“DCI”) Mark Henney informed the inquest that police have no power to confiscate keys from disqualified drivers. This is a matter outside the scope of this inquest.

43. Later that night on 30 October 2016 Dr Jay drove back from Gosford to Port Macquarie. Mr Lambert was waiting at her house when she arrived. Dr Jay returned his bags without allowing him into the house. During the conversation, Mr Lambert told her that “Dan” was not a real person and he was just trying to get her attention. He also stated that he was “the good Paul” but he could feel “the bad Paul” taking over. Dr Jay was frightened and called Port Macquarie police.

44. About 6:00 or 7:00pm on 30 October 2016 Mr Lambert texted Dr Jay and Dr Jay again called the police. At 7:07pm she sent a message to Mr Lambert:

“Don’t ever contact me again”.

45. At 7:30pm she received a message which read: “Angela you need to call the police right now. Get them there. When they are there ring me and I will tell you and them why. I need you to understand that this is my good side right now. That good side wont last long. Especially being rejected Call the police when they are they ring me and put me on speaker Text ok back that you understand I care about your safety”.

46. At 8.13pm she received a message which read: “Are they there yet? Go to a neighbours house until they do. Im not near by atm I need you to fully understand this is the good side still. I cant keep it long and need positive reinforcement for it to stay for long periods. I know you’re scared right now and rightfully so but please know Im doing this for you. OK?”

47. At 8.16pm she received a further message: “Ang I need you to be positive with me ok. Encourgae [sic] the good. I know it sounds wacky but its how it happens in me. Your not safe in that house. I have some of the house keys”.

48. Dr Jay called the police four times between 7:08pm and 8:16pm as she became increasingly concerned about the messages and, after the last message, went to her neighbour’s house. While Dr Jay was waiting she received more messages from Mr Lambert stating he had keys to her house and she realised that some of her keys were in fact missing.

49. SC Mick Gentle and SC Styles arrived around 9:00pm and took Dr Jay to Port Macquarie Police Station. An interim ADVO was made on her behalf. While Dr Jay was at the station, Mr Lambert called and SC Gentle answered the phone. Mr Lambert hung up but called again. Dr Jay said she overheard Mr Lambert’s voice on the phone saying he could not trust “the other Paul” as he didn’t know what he was capable of. SC Gentle told Mr Lambert that his conduct was terrifying Dr Jay and that he needed to stop. He also told Mr Lambert and that he was taking out an ADVO so he had to stop calling and messaging.

50. Dr Jay told SC Gentle that Mr Lambert was flying to Brisbane for a parole hearing the next day in order to assist him to serve the ADVO.

51. In an ideal world, this was an opportunity for NSW authorities to contact Queensland authorities and discover that Mr Lambert was in breach of his parole.

However, DCI Henney informed the inquest that the NSW Police Force have no way of knowing the parole conditions of interstate offenders by way of computer inquiry. DCI Henney stated the only way for a police officer to discover an interstate offender’s conditions was to contact the Queensland Probation and Parole Service Case Manager directly (an option not available to SC Gentle that night).

52. In any event, while it is possible that an interstate communication between police and Queensland parole would have led to a warrant being issued for Mr Lambert, it is speculative to find that this necessarily would have occurred before the events of 3 November 2016. I do direct that this finding be provided to Queensland Probation and Parole Service and the Commissioner for the NSW Police Force so that further reflection can take place about how information systems between States could operate more effectively.

53. After her contact with Port Macquarie police Dr Jay took a number of steps to protect her own safety, some based on the suggestions of SC Gentle and SC Clarkson. She also kept working 24 hour shifts at the Hospital delivering babies and caring for patients. Dr Jay was unable to change her phone number because of its importance to her job.

31 October 2016

54. The next morning at about 6:30am Mr Lambert sent a text to his mother: Mr Lambert: “Mum I’m in trouble again. I tried to talk to joey [former psychologist Joey Tai] last week but he wasn’t available. Could I talk to you jacalyn or Nathan. I almost hurt angela but had enough strength not to. I told her to call the police and she did ive lost the plot and im on the run. Im a mess”.

Mum: “What can I say … I’m sorry but u need help we can’t help u And u knew the outcome and being on the run isn’t the answer” Mr Lambert: “I’m psychopath I really am. Could you or Jacalyn call me later when boys have gone to school. I’ve lost the plot again. Please don’t leave me alone”.

55. Mr Lambert was required to report at the Queensland Probation and Parole Service but called his Case Manager and said he was sick with a head cold. She thought he sounded unwell and said he could report on 3 November 2016.

56. On the same day, Dr Jay’s mother travelled to Port Macquarie to stay with Dr Jay at her house. Dr Jay worked out what keys had been stolen from her keyring by Mr Lambert and removed the locking mechanism from those doors. She also removed a door handle from the downstairs bedroom. She asked her real estate agent to change the locks. She also hid knives in locations around the house. Dr Jay said police called her and told her they were trying to serve the ADVO. She did not hear from Mr Lambert.

57. The ADVO was never served. Port Macquarie police attempted to serve the ADVO by attending Port Macquarie airport on 31 October 2016 when Mr Lambert was expected to be flying from Port Macquarie to Brisbane for his parole meeting.

The ground staff would not tell the police if Mr Lambert was on the plane and told them to contact head office. The two officers informed their supervisor.

31 October 2016

58. At 10:08am on 31 October 2016 Mr Lambert went to PL Firearms in Port Macquarie and attempted to obtain a gun. The owners Mr Peter Long and Ms Cheryl Long spoke to Mr Lambert. When Mr Lambert was told he needed a license for a gun, he asked for a Taser or capsicum spray (which he was also unable to buy as he was told that Tasers were illegal). He said he wanted protection for a friend who was scared of her ex-boyfriend. Mr Long encouraged him to buy a personal alarm from Jayco and even gave him directions to the Jayco store. Mr Lambert left the store and then returned at about midday and bought a knife, despite Mr Long trying to persuade him to buy a torch instead (these conversations were captured on CCTV footage and extracts were viewed

during the inquest). According to DCI Henney, it has not been determined whether the knife bought by Mr Lambert was used in the attack on Dr Jay.

59. Mr and Mrs Long provided statements to the inquest suggesting a coronial recommendation that weapons sellers be able to opt-in or have voluntary access to an online system that would notify them if anyone seeking to buy a knife has an outstanding ADVO. I have made such a recommendation below.

60. I note here that Mr and Mrs Long behaved as extremely responsible business owners and citizens. They had no reason to think Mr Lambert was a danger to Dr Jay but they did all they could to encourage him not to buy weapons as it could endanger his safety.

61. Meanwhile, Mr Lambert continued to stalk Dr Jay. At 11:04am on 31 October 2016 Mr Lambert rented a room at the Rotary Lodge at the Port Macquarie Base Hospital under a false name (Brady Jackson), claiming his wife was staying in the hospital. It appears he spent much of the week using the Lodge as a base to stalk Dr Jay. He told other guests at the Lodge that his wife had a premature baby and spoke about how his wife’s doctor was being stalked by a former boyfriend. Ms Patricia Darcy remembered thinking it was odd that “Toby” (as he introduced himself) was more concerned about his wife’s doctor than his own wife and baby. She said that “Toby” seemed agitated and was chain smoking.

62. That night a man matching Mr Lambert’s description started chatting to a woman outside Port Macquarie Base Hospital. He told the woman that his wife was in labour inside and persuaded her to let him drive her home to Wauchope. During the drive he put his hand on her knee. She told him that she had a boyfriend and asked him to drop her in the main street.

1 November 2016

63. The next day – 1 November 2016 – Mr Lambert was seen on CCTV footage at 3:26pm buying and filling a five litre can of petrol when refuelling his car. Earlier that day he had exchanged his white Corolla for a larger X6 Tarago and appeared interested in the luggage area of the Tarago. He returned the Tarago shortly after and reverted to the hatchback stating that the new car was too big (the car was so dirty and full of litter the car rental manager thought he had been

sleeping in it). At 11:23am, Mr Lambert sent a text to his sister and brother in law in law stating: “You can call the police this isn’t a joke. I wont call again. I have to do this before I change and someone gets hurt. You need to stay away from me im not safe mum too”.

64. There was no reply to this message. I would like to make very clear that Mr Lambert had a long history of using threats of self-harm and manufactured crises to seek attention. His family had sought professional advice about this on a number of occasions and had been told to ignore these messages. Their actions were entirely appropriate and consistent with their desire to do everything possible to help Mr Lambert.

2 November 2016

65. On 2 November 2016, Mr Lambert went back to Bunnings and bought a club hammer and a crow bar.

66. That evening two officer of the NSW Police Force attended Mr Lambert’s home in Kogarah. The officers were told that Mr Lambert had not been seen for several days and that he may have been visiting his girlfriend in Port Macquarie. No contact was made with Mr Lambert’s family or with Dr Jay and Mr Lambert’s Case Manager in Queensland was not aware of the home visit by the police.

Events of 3 November 2016 The attack on Dr Jay

67. On the morning of 3 November 2016 Dr Jay went to work at the hospital. At about 3:15pm, a neighbour saw a man without a shirt on in Dr Jay’s kitchen through the kitchen window. The neighbour saw the same man some time later smoking a cigarette on the back porch of Dr Jay’s house.

68. At about 5:00pm, Dr Jay came home from work. She turned on the TV and reheated some spaghetti bolognese her mother had for made her in the microwave. At around 6:00pm, she went to her bedroom to pack some clothes to

stay overnight with her cousin. Mr Lambert emerged from the bedroom walk-in wardrobe and put his hand over her mouth. He was barefoot and bare-chested.

He had a knife in his pocket and told her he had taken the knives out of her bedroom drawer (Dr Jay had been keeping a kitchen knife in her bedside table in case Mr Lambert returned). Dr Jay spoke to him briefly and asked to go to the toilet. Mr Lambert let her go but watched her.

69. After a brief conversation, Dr Jay decided she needed to escape. She ran towards the door but Mr Lambert grabbed her wrist and started stabbing her.

Dr Jay received 11 stab wounds to the chest, arms and legs. Mr Lambert also poured petrol over her. This made Dr Jay slippery and she was able to evade Mr Lambert’s grasp and run to the neighbours screaming for help.

70. Dr Jay’s neighbours ran to help her and were confronted with a horrific scene. Dr Jay retained consciousness and was able to direct her neighbours to treat her injuries and instruct them about what to tell emergency services. I note that at this time no one knew Mr Lambert had fled the scene and there was some fear the attacker remained nearby. The combination of Dr Jay’s medical skills and her neighbours’ bravery saved her life.

71. The neighbours have asked not to be named or otherwise involved in this inquest. I respect their wishes but I commend their bravery and thank them for their efforts. Bystanders play a critical role in preventing deaths from the domestic violence.

72. An ambulance was called at around 6:27pm and a number of police including Detective Senior Constable (“DSC”) Shaun Durbridge attended and canvassed the area for the attacker while Dr Jay was rushed to hospital.

73. Subsequent crime scene investigations suggested that Mr Lambert had planned the scene for some hours and had items stored in Dr Jay’s bedside drawers including duct tape, cable ties and knives. He had also showered and written “I love Paul” in condensation on the mirror and stored a fire extinguisher in the bedroom wardrobe.

74. Dr Eagle states that the attack on Dr Jay was the culmination of a sustained period of stalking and likely prompted by anger and revenge following Dr Jay’s

rejection. She also states that Mr Lambert may have been in a manic or hypomanic state at the time of the attack which would have impaired his judgment and self-control and increased his propensity for aggressive behaviour.

75. Dr Jay gave evidence at the inquest and I thank her for her powerful and moving testimony. She was an extraordinary witness and it was a privilege to hear her account. Dr Jay has used her traumatic experience to help others and has become a prominent advocate against domestic violence and she also has assisted patients escaping or enduring violent relationships. Dr Jay said she has been invited to speak about her experiences to police officers undertaking domestic violence training. I commend the Commissioner of NSW Police and the relevant officers for this action. I cannot think of anyone who would not benefit from hearing Dr Jay speak and police officers, in particular, would gain great insight into how to detect the more subtle signs of emotional abuse and the potentially devastating consequences of failing to appreciate those signs.

Events after the attack

76. After Mr Lambert fled the scene he made a number of communications (presumably from his car): a. At around 7:05pm, he called Dr Jay’s phone. Her neighbour answered the phone and then handed it to an ambulance officer.

According to the ambulance officer, Mr Lambert said “how is she” and “I didn’t mean to do it. I want to talk to her. You know an AVO is not going to stop me. I know where to find her”.

b. At 7:17pm he sent text messages to his mother: Mum: “so whats next Paul” Mr Lambert: “I’m sorry mum I’m taking my life” Mum: “And how ru doing that” Mr Lambert: “Truck or building” Mr Lambert: “I’m sorry”

c. At 7:34pm Dr Jay’s mother received messages from Mr Lambert on Facebook Messenger, which included screen shots of messages sent to Dr Jay: “I told the Police to do more. I told them they wouldn’t listen. Now he’s hurt someone I care about deeply. I hope she is ok. I’m going to kill myself and I’m sure you welcome it. Tell Angela I’m sorry I wasn’t strong enough to stop him. He tried to stab her and light her on Fire” “he’s fighting his way out and I can only hold on so long. I’m not dominant” “an AVO isn’t enough tell them to do more” “I’m sorry you’re scared. I’m saying this to protect you”.

d. At 7:35pm, Mr Lambert contacted a Sydney police station and told an officer that he had stabbed his girlfriend and set her alight and was planning to throw himself under a truck on the highway.

e. At 7:39pm Mr Lambert called his sister. He told her the police were chasing him and he was sick of hurting everyone. She told him to seek help from the police or a hospital but he ended the call saying “goodbye Jacalyn”.

f. At 7:44pm Mr Lambert called the Port Macquarie Police Station and informed an officer “I just tried to kill my girlfriend”. He said he was on a highway and wanted to jump in front of a truck.

g. At 7:53pm Mr Lambert spoke to DSC Durbridge who called his mobile phone. Mr Lambert told him to put police guards at the hospital and at Dr Jay’s mother and sister’s house and during the call he said “I watched it in my head and I wasn’t strong enough to stop it”. Lambert terminated the call.

h. DSC Durbridge spoke to Inspector Fuller about engaging police negotiators and Inspector Fuller requested their assistance at 8:00pm.

i. At 8:02pm DSC Durbridge called Mr Lambert on his mobile phone.

Mr Lambert described stalking Dr Jay over a few days, knocking the locks out of the rear door to enter the house and waiting for an hour and half for Dr Jay to come home. He talked about himself in the third person. Mr Lambert told DSC Durbridge that “he” was going to force sex on Dr Jay, tie her up, strangle her, pour petrol on her and kill her.

DSC Durbridge tried to get Lambert to meet with him to no avail.

j. At 8:10pm the on-call negotiator declined to assist because of the perceived risk of erratic behaviour while talking to Mr Lambert on a mobile phone whilst driving at high speed.

k. At 8:17pm, Mr Lambert tried unsuccessfully to call his former psychologist Mr Tai. It appears the call went to voicemail.

l. At 8:18pm and 8:20pm, Mr Lambert he called his estranged wife.

This call was recorded by her sister in order to prove that Mr Lambert was in breach of a protection order. During the call, he told his wife that he had stabbed someone and set them on fire and told her to get her mother and sister and keep them safe.

The Pursuit

77. At 7:05pm it was identified that Mr Lambert had been stopped in Port Macquarie four days earlier and a description of the vehicle was broadcast over the police radio known as VKG. A series of broadcasts followed including that Mr Lambert was wanted for a stabbing and attempted murder, that he was “armed and dangerous” and should be treated with “extreme caution” and that he had previous warning for firearms, suicide and self-harm.

78. Police located Mr Lambert driving north on the Pacific Highway at around 8:00pm after triangulating his phone. A police pursuit started at about 9:00pm when Mr Lambert failed to stop for Highway Patrol officers SC Craig Myles and SC Logan O’Donahue (in vehicle North 296).

79. The pursuit was appropriately terminated at 9:14pm but recommenced soon afterwards with SC Damien Buckley as the lead driver in an unmarked police car.

During the pursuit Mr Lambert engaged in extremely dangerous driving that put himself, police and other road users at serious risk.

80. The pursuit ended at around 9:30pm after road spikes were successfully deployed near Bonville by SC Gio Zugajev and SC Rodney Peters. An earlier attempt to use road spikes by Acting Sergeant Wallace Brooks and SC Vicky Bamford had failed after dangerous driving by Mr Lambert.

The stand-off on the Pacific Highway

81. Mr Lambert exited the car; he was bare-foot and wearing shorts and a jumper. Incar video (“ICV”) footage shows him facing the officers and raising the knife above his head before turning and running away towards the median strip.

82. SC Myles and SC O’Donohue can be seen on the ICV footage running after Mr Lambert and vaulting over a concrete barrier on the median strip. SC Buckley followed.

83. Other officers engaged in the highway pursuit arrived soon after. Some searched the bushland west of the car, partly as a result of an erroneous broadcast on VKG that Mr Lambert had run towards the west. The responding police vehicles parked on the highway effectively blocked traffic on the northbound side of the highway within five minutes of their arrival.

84. Meanwhile SC Myles, SC O’Donahue and SC Buckley engaged in a chase north up the southbound side of the highway (in other words they ran on the road towards the oncoming traffic). The lighting was poor and cars narrowly missed the group including two large B-double trucks. I attended the scene at night as part of the inquest and can only imagine how frightening it must have been for those officers to run towards an armed and dangerous man while trucks roared towards them in the darkness.

85. As they ran, the officers, particularly SC Buckley, urged Mr Lambert to get off the road and to put down his weapon. At one point Mr Lambert yelled “I’ve got a knife” and SC Myles replied “I’ve got a gun, put the knife down”.

86. After about 300-400 metres Mr Lambert stopped and stood facing the officers on the southbound part of the highway. Mr Lambert held the knife and waved it in

front of his body. SC Myles and SC Buckley had their guns drawn. SC O’Donahue shone a torch at Mr Lambert’s eyes (to blind him and hamper any attempt to attack the officers) and kept his gun in its holster. He also made radio transmissions from the scene.

87. SC O’Donahue said he radioed for the highway to be closed. This transmission is not recorded on the VKG radio. It is not possible to say whether SC O’Donahue is mistaken about the broadcast, if the broadcast is not audible on the recording, or if the recording did not transmit because the button was not pressed at the right time. I accept SC O’Donaghue’s evidence that he believed he had made the broadcast and, in any event, I would not be critical of him given the stress of the difficult and dangerous situation he was in and the real difficulty of making broadcasts while running down a live highway.

88. SC Buckley, SC Myles and SC O’Donahue continued to call for Mr Lambert to drop the knife and SC Buckley tried to engage him in conversation. SC Buckley tried to steer Mr Lambert off the road and onto the median strip.

89. All the officers gave evidence at the inquest and their evidence was honest and thoughtful. They answered questions openly and without any defensiveness. SC Buckley was a particularly impressive witness. SC Buckley detailed the various techniques he had used to try and gain rapport with Mr Lambert and to try and de-escalate the situation. For example, SC Buckley described the following interactions with Mr Lambert: “I kept talking to him. I was just saying words to the effect of, ‘I don't want to do that brother. I don't, I don't want this to happen. Talk to me.’ You know, I said, I asked him, I said, ‘What's your name? I'm Damien. What's your name brother? Talk to me. Please talk to me. I'm happy to sort anything out but you've got to put that knife down.’"

90. At times SC Buckley seemed to be getting through to Mr Lambert and he became convinced he could get Mr Lambert to surrender. At one key point he was able to persuade Mr Lambert to move off the southbound highway and onto the grass verge in the middle. As this occurred, more officers were arriving on the scene.

91. A number of police officers present on the highway gave evidence that, during the encounter, Mr Lambert was continually saying words to the effect of “what do I have to do to make you shoot me” and “I want you to kill me”.

92. Mr Lambert crossed the grass verge and brifen wire onto the northbound part of the highway. By this stage the road was blocked by the vehicles of police officers.

Mr Lambert walked backwards away from the police. At various times, and as more officers arrived, he demanded that no officer moved behind him. This was an issue of obvious sensitivity to him and SC Buckley said it was the first time he saw Mr Lambert “flare up” and show signs of aggression.

93. The stand-off continued with SC Buckley repeatedly trying to engage with Mr Lambert and other officers calling on him to drop the knife. SC Buckley still believes he could have connected with Mr Lambert and ended the stand-off. He said in evidence, believably, that he was prepared to talk all night.

94. Sergeant Rory McDonnell called for a Taser trained officer when he arrived at the scene. Most of the officers’ present at the scene were Highway Patrol Officers and accordingly did not have Tasers. Some of the officers including the Sergeant had Tasers but had left them at the station in their eagerness to reach the scene.

95. SC Richard Osborne (with SC Tajinder Singh in Coffs Harbour 14) was the only officer who responded to the Taser call.

SC Richard Osborne arrives

96. SC Richard Osborne arrived with the Taser and saw Mr Lambert holding a knife and the other officers facing him with their weapons drawn. He heard Mr Lambert saying that he only wanted to talk to SC Buckley but did not know that SC Buckley had established a rapport with Mr Lambert. SC Osborne approached Mr Lambert from behind. SC Osborne was not aware that Mr Lambert had an issue with people moving behind him. His plan was to surprise Mr Lambert by firing the Taser at his back. SC Osborne had been trained that the back was a preferred “Taser area or body mass” and that the element of surprise can be an effective method of gaining control and disarming an offender. Unfortunately, this action precipitated the final fatal confrontation.

97. As SC Osborne approached, SC Myles said “mate you are going to get Tasered”.

In evidence, SC Myles said this comment was partly to focus Mr Lambert’s attention on him and partly to give Mr Lambert an opportunity to surrender. Mr Lambert turned and saw SC Osborne. SC Osborne fired the Taser around the same time. The Taser footage depicts Mr Lambert turning and then raising the knife and coming very close to SC Osborne. Many of the officers at the scene thought SC Osborne was about to be stabbed.

98. The Taser was working properly but was not effective when it was deployed, possibly because the barbs connected with clothing rather than skin (a barb was found in Mr Lambert’s jumper and shorts).

99. Mr Lambert can be seen on the Taser footage to turn to his left, raise the knife over his head and move forward. At that point, the footage goes dark as SC Osborne reloads and a loud bang is audible followed by a cry of pain. It is possible this records the first gun shot. Some of the witnesses, including SC Myles and SC Buckley, state that Mr Lambert buckled or stopped after the first shot but then continued to move forward with the knife towards SC Myles and a number of shots were fired.

100. Many of the witnesses say that after the Taser was deployed something profound changed in Mr Lambert’s demeanour, he stiffened and acted like he was enraged. In a statement prepared for the inquest, Mr Lambert’s family stated that this change was something they were familiar with.

101. The VKG log records “shots fired, shots fired” and a request for an ambulance at 9:37pm. There are many different versions of how many shots were heard, what sequence they were in and where pauses may have been. Similarly, there are many different accounts of where each officer was standing. It is not possible nor necessary to resolve each version.

102. It is tolerably clear that SC Myles discharged his firearm first and there was a pause before Mr Lambert came at him again and he and SC Buckley fired again.

A number of officers reported a delay between the first shot and subsequent shots.

103. SC Andrew Harris was standing next to SC Myles. He said Mr Lambert lunged towards him and SC Myles with his arm extended. He stated that Mr Lambert was less than a couple of metres away and he feared for his life, but he did not fire his weapon because he feared SC Osborne was in his line of fire. He heard one shot, saw Mr Lambert stumble and then fall after three to four more shots.

104. SC Judd Rowsell was facing the officers. He had not drawn his weapon due to fear of cross-fire. He saw Mr Lambert lunge towards SC Myles and heard three to four shots. It took him a moment to compose himself before realising he had not been shot.

105. Only SC Buckley and SC Myles state that they discharged their weapons. The magazines of the remaining officers were not checked but there is no evidence that any other officer discharged a weapon.

106. SC Buckley said he fired twice. SC Myles said he fired four times. When the weapons were checked, SC Buckley had 13 bullets left in his magazine and SC Myles had 11 bullets (a magazine contains 15 bullets). NSW Police Force ballistics expert, Matthew Bolton, matched four cartridges to SC Myles’ pistol and one to SC Buckley’s pistol. DCI Henney said in his evidence that cartridges commonly go missing from busy scenes which are attended by multiple officers and emergency services.

107. Mr Lambert had one entry shot in his back with an upward trajectory. SC Buckley said in evidence that he believes he fired this shot as Mr Lambert moved quickly past him towards SC Myles. On the available forensic and ballistic evidence this seems like the only explanation for the entry wound in Mr Lambert’s back.

Response to the shooting

108. Several police called for an ambulance immediately after shots were fired (VKG suggests this was at 9:37pm). SC Buckley handcuffed Mr Lambert from behind as a safety measure. Shortly afterwards, the handcuffs were removed and a number of officers commenced CPR. SC Rowsell secured the knife and the handcuffs. He also had the presence of mind to take some photos of the scene and some notes on his phone.

109. Inspector Brendan Gorman (who was the duty officer on scene) states that he identified SC Myles, SC Buckley and SC Osborne as involved officers (for the purposes of the critical incident investigation) and instructed them not to discuss the matter. He instructed Sergeant Rory McDonnell to get the three involved officers to the station.

110. SC Bamford states she saw SC Myles cradling the offender. SC Myles confirmed he shot Mr Lambert and SC Buckley said “so did I”. SC Bamford states she took SC Myles away and asked another officer to support SC Myles.

111. SC Singh drove SC Osborne back to the station almost immediately after the incident. Sergeant McDonnell transported SC Myles and Buckley back to Coffs Harbour police station some time later.

Critical Incident Procedures

112. A critical incident was declared and it was decided that SC Myles, SC Buckley and SC Osborne were “involved officers”. Those officers had their appointments seized, were subject to breath tests and drug tests (after a slight delay) and subject to a verbal direction by Superintendent Holohan not to discuss their evidence. SC Buckley and SC Osborne were interviewed on 9 November 2016 and SC Myles on 10 November 2016.

Note discovered post death

113. A search of Mr Lambert’s rental car revealed Mr Lambert’s passport, driver's license, traffic infringements, disqualified driver CAN and cash. Mobile phones were also located with a backpack and an amount of clothing. An undated note signed by Mr Lambert was located in the backpack. The note provided for his funeral and stated: “Free of what I do cause and subject people too. I'm toxic and not worth shit. I try and do the right thing, try to be a good person but that person is not enough for some and too much for others … Your all now at peace and free to live happy lives without me fucking it up and being a toxic blight on this world and to you all".

Issues explored at the inquest

114. A list of issues was circulated to the interested parties, outlining the broad areas of interest for the inquest as follows: a. the manner and cause of Mr Lambert’s death on 3 November 2016; b. were there alternatives to lethal force available to the officers who discharged their firearms; c. to what extent was Mr Lambert motivated by suicidal intent in his interactions with police on the Pacific Highway; d. with the benefit of hindsight and reflection, could any steps have been taken by the police officers on the Pacific Highway that may have led to a different and better outcome for Mr Lambert; and e. with the benefit of hindsight and reflection, was there any particular form of intervention with Mr Lambert in the two weeks prior to his death that had a realistic prospect of changing the tragic course of events.

115. I will deal with these issues in turn.

Were there alternatives to lethal force available to the officers who discharged their firearms?

116. I do not consider that there was any available alternative to lethal force when Mr Lambert was shot. When the first shot was fired, Mr Lambert was moving towards SC Myles with a raised knife, having previously threatened SC Osborne and, of course, having earlier almost killed Dr Jay. An attempt to disarm him with a Taser (ie non-lethal force) had failed. Mr Lambert had refused repeated directions from the police to surrender and put down the knife. He had also shown a reckless disregard for his own safety with extremely dangerous driving and requests to be shot. It is unecessary to say exactly how close Mr Lambert was to SC Myles or how fast he was moving when shots were fired as perceptions are inevitably different and affected by stress and the speed of the unfolding and dynamic situation.

117. I accept without reservation that SC Myles had an honest and reasonable belief that his life was in danger and that SC Buckley had an honest and reasonable belief that SC Myles’ life was in danger when they discharged their firearms. Both officers were honest witnesses who clearly remain deeply affected by the death. SC Myles was completely overcome with emotion when he recounted the moment at which he discharged his firearm. SC Buckley said he reflects on the death every day and desperately wishes that there could have been a different outcome and that he could have “sent Paul home” to his family.

He even said he wishes he could have “swapped spots” with Mr Lambert. Firing shots was clearly a last resort.

118. I further do not consider that steps could have been taken at an earlier time to de-escalate the stand-off and prevent the death. All the officers, but SC Buckley in particular, did everything they could to negotiate with and to disarm Mr Lambert without resorting to force. I accept Dr Eagle’s conclusion that there was nothing else the officers could have reasonably done, in the circumstances, to avoid the outcome.

To what extent was Mr Lambert motivated by suicidal intent?

119. Somewhat unusually, in this inquest the family have asked me to find that Mr Lambert had homicidal intent (or at least violent intent) when he was killed. The representatives for the Commissioner of Police, NSW Police Force and the individual officers have submitted that I should find that Mr Lambert was suicidal.

120. It is not necessary for me to make a finding about Mr Lambert’s motivation and, on reflection, I do not consider that I have sufficient evidence to do so. It is certainly the case that Mr Lambert had made repeated threats of suicide in texts and phone calls during the pursuit, his behaviour at the scene suggested he wanted to be killed, either by dangerous driving during the pursuit or by police at the scene, and the undated note found in his car indicates some suicidal intent.

121. I also consider it is significant that Mr Lambert was “provoked” by SC Osborne moving behind him, given his repeated demands to police to keep in front, and that the Taser shot led to a loss of control, a circumstance that seemed to enrage Mr Lambert like it had when Dr Jay attempted to flee. At that point, witnesses

describe a change in demeanour more like homicidal or violent rage than suicidal intent.

122. Mr Lambert’s psyche was clearly extremely complex. Dr Eagle was unavailable to give oral evidence at the inquest and she was not aware of the family’s insights into Mr Lambert’s behaviour so I do not have the benefit of her opinion with all the available evidence. In the circumstances, I decline to make a finding about Mr Lambert’s motivation in charging at SC Myles.

With the benefit of hindsight and reflection, could any steps have been taken by the police officers on the Pacific Highway that may have led to a different and better outcome for Mr Lambert?

123. This question is inherently speculative but it is designed to be constructive so that lessons can be learned for future application in dangerous situations where life is at risk. Fatal police shootings have a devastating impact. The loss of life in such circumstances is harrowing for the family of the deceased. The trauma to the police is also intense and enduring and was very noticeable in this case. Mr Evenden for the family made detailed and compelling submissions about a number of aspects of the police operation and how the death may have been prevented. He also persuasively argued that the NSW Police Force need to be proactive in exploring different mechanisms to defuse situations with armed offenders including investigating the use of shields and methods used in different Australian States and overseas.

124. Counsel Assisting submitted that it was unfair, even in hindsight, to apply a counsel of perfection to the officers’ conduct. I accept this submission and will endeavour to be realistic when assessing the conduct of police in what was described as “a dark, dynamic and dangerous situation”.

125. I agree with Counsel Assisting and Mr Evenden that, ideally, the Pacific Highway would have been closed sooner and that more officers on the scene should have been armed with Tasers. The live highway posed considerable danger to Mr Lambert, the police and the public as road users. It also no doubt spiked the adrenaline of those involved and hampered the ability for calm judgment. However, I do not accept Mr Evenden’s submission that the pursuing

police needed to close the highway (or request it be done) before they gave chase on foot. It was appropriate in the specific circumstances of this case, indeed very brave, of the officers to give immediate chase in order to apprehend an armed and extremely dangerous offender. This is not a case where there is ambiguity about the potential danger of Mr Lambert to the public; he attacked Dr Jay three hours earlier and, in fact, had made further threats to Dr Jay and his wife during the pursuit. In any event, the northbound highway was blocked within five minutes by responding police cars.

126. Inspector Gorman, the senior officer on the scene, very responsibly accepted that his first step on arrival should have been to take steps to close the highway but said in effect he was distracted by the stand-off and his desire to take more immediate action at the scene. I am not critical of Inspector Gorman for this and no doubt this experience will inform his practice in the future.

127. Inspector Gorman said that his plan on arrival was to establish a secure inner and outer perimeter and to contact specialist services including negotiators. As he walked to his car to make these calls he heard the first shot fired. If Inspector Gorman had been able to complete his plan, the situation may, possibly, have had a better outcome. Similarly, if SC Buckley had more time to keep talking to Mr Lambert, it is certainly possible that he may have persuaded him to surrender.

With the benefit of hindsight, Inspector Gorman said he would have facilitated continued negotiation by SC Buckley and not used a Taser operator.

128. I understand fully why Mr Lambert’s family feel that the use of the Taser precipitated the tragic outcome and accordingly why they submit this should not have occurred. But I also find that SC Osborne acted in a manner entirely consistent with his training. He understood that he was being called out to use the Taser and made an assessment that immediate action was necessary when he arrived on the scene and saw Mr Lambert (wanted for the attack on Dr Jay) facing armed police and refusing directions to put his knife down. He did not know that Inspector Gorman was on the north side of the highway. SC Osborne acted quickly and put his own life in danger trying to immobilize Mr Lambert and to preserve Mr Lambert’s life.

129. Even with the benefit of hindsight, it cannot be said with any confidence that a better outcome would have occurred if SC Osborne had reported to Inspector Gorman and a prolonged negotiation had occurred instead. The outcome may still have been Mr Lambert lunging towards police, and possibly causing injuries to those officers. SC Buckley gave evidence that he was planning to crash tackle Mr Lambert if the opportunity presented and stated, “I would have been laying in a box right now had I done that”.

130. On the other hand, if the Taser had worked, Mr Lambert’s life would have been spared and the officers would have avoided the trauma of his death.

131. I do not consider that the use of trained negotiators during the highway pursuit or at the scene was likely to make a difference. Dr Eagle reviewed the tapes of DSC Durbridge’s calls to Mr Lambert and the statements of the individual officers.

She commended the use of techniques by the officers to create rapport, provide hope and offer options. Dr Eagle was unable to suggest anything else that could have been attempted that might have led to a better outcome.

132. There may well be lessons from an operational perspective that can be drawn from this incident particularly relating to command and co-ordination of a dynamic, fast-moving scene, establishing a proper perimeter and communications between officers in person and over radio. Further, the risk of cross-fire was acute in the ultimate confrontation, some officers didn’t fire for fear of wounding another officer and Mr Lambert was shot in the back. On the evidence, however, it appeared that risk was unavoidable.

133. Sergeant Jonathan Healy, Operational Safety Instructor, from the Weapons, Tactics, Policy and Review Unit attended each day of the inquest and said he was not aware of anything that could have been improved with the benefit of hindsight. I make no recommendation but would urge the Weapons, Tactics, Policy and Review Unit to reflect on the lessons that may be drawn, and on the family’s submissions in particular, and consider if this incident could be effectively integrated in some way into training exercises.

With the benefit of hindsight and reflection, was there any particular form of intervention with Mr Lambert in the two weeks prior to his death that had a realistic prospect of changing the tragic course of events?

134. Sadly, the inquest has not identified any possible intervention in the final two weeks of Mr Lambert’s life that could have prevented the tragic outcome. The only realistic way of preventing the attack on Dr Jay and the ensuing events on the Pacific Highway was for Mr Lambert to choose desist or to be arrested or otherwise contained.

135. Dr Eagle considered Mr Lambert’s disorder capable of treatment but only with motivation to change, compliance with appropriate mood stabilising medication and regular sessions with an engaged and skilled psychiatrist. None of these factors were present in November 2016.

136. An ADVO would not have stopped Mr Lambert. The evidence suggests that he thought an order was in place at the time.

137. Dr Jay had no responsibility to protect herself but she took every conceivable step to protect her own safety including staying with relatives, alerting her neighbours, changing locks, repeatedly seeking police assistance and completely disengaging with Mr Lambert.

138. The best possible prospect of intervention was detection of Mr Lambert’s breach of parole by living in NSW from July 2016 to November 2016. If a warrant had been issued for Mr Lambert’s arrest it is highly likely that his encounters with the NSW Police Force in October and November 2016 would have led to his arrest and, possibly, psychiatric treatment. An examination of the Queensland parole system is not suitable for this inquiry but I direct that a copy of the transcript of the inquest and of these findings be forwarded to the Queensland Probation and Parole.

Is it necessary or desirable to make a recommendation?

139. During the inquest, Mr Evenden asked a number of police witnesses about evidence given by Police Commissioner Fuller to Portfolio Committee No. 4,

Legal Affairs, NSW Parliament Budget Estimates 2018-2019 the week before the inquest on 31 October 2018, which is publically available on Hansard: Mr FULLER: Assistant Commissioner Mark Walton, who is the commander of the Central Metropolitan Region, is our spokesperson for mental health. I talk to him regularly about these issues. There is a new tactical model in North America-I think it is Chicago. You would have heard us talk before, Mr Shoebridge, around contain, negotiate-which is very much based on a bricksand-mortar approach that you have someone in a room, in a house or in a building and you can contain, negotiate with them in there and then you safely negotiate a better outcome. If the topic matter is out in the open, it obviously makes it much, much more challenging to contain, negotiate.

They have trialled and-I believe successfully-put in place some different tactics around using different types of shields to better contain, negotiate people in open environments. I have asked Mr Walton to progress--quickly, expeditiously-if this is something we could use in New South Wales. The answer is ‘yes’ and that is one example.”

140. Sergeant Healy of the Weapons, Tactics, Policy and Review Unit gave evidence but he was not aware of the trials of different tactical initiatives or different types of shields. No further information was provided by the NSW Police Force on request but the representatives for the Commissioner of the NSW Police Force have indicated that there is support for the following recommendation: “That NSW Police Force continue to review other tactical options of a nonlethal nature for dealing with offenders armed with a knife, including the use of shields, in order to minimise the likelihood of serious harm in the event of a police response that requires an offender to be disarmed."

141. I am very grateful for two suggested recommendations from two Port Macquarie business owners.

142. Mr and Mrs Long have asked that licensed weapons dealers be able to check if a person buying a knife has an outstanding apprehended violence order (“AVO”) or ADVO as is currently the situation in respect of firearms. AVO and

ADVO defendants are not able to purchase firearms. I think the recommendation is desirable. I understand, as DCI Henney observed in his evidence, that knives are sold in supermarkets, fishing shops and Bunnings and that this recommendation will not prevent a determined killer. However, any information sharing that takes place between police and weapons dealers about attempts to buy lethal weapons by AVO and ADVO defendants is desirable for public safety.

Privacy issues are less fraught because the facility already exists for licensed dealers with respect to firearms. I recommend that the suggestion be considered by the Commissioner of the NSW Police Force.

143. Mr Scott of First Class Rentals gave evidence that his rental company was not notified by police that Mr Lambert had been detected speeding and driving while disqualified and stated that, if alerted, he would have cancelled the hire contract and placed an alert on the company computer system. Mr Scott also said that he fears that rental cars are often used to commit crimes such a drug running by disqualified drivers. Mr Scott suggested that rental companies be able to check the license status of drivers as they are apparently able to do in Western Australia.

144. Roads and Maritime Services (“RMS”) were notified prior to the inquest of the matters raised by Mr Scott and were invited to make submissions as to a possible recommendation that the Minister of Transport for NSW consider implementing a system similar to the Western Australian system in NSW.

145. RMS have advised that there are initiatives presently being undertaken at RMS, including the Digital Driver License system whereby an electronic version of a NSW license is available via an application (as in a web “app”). Once implemented, this system will allow rental car companies to identify whether a NSW license is active, expired or suspended (including out of state disqualifications which lead to NSW licence cancellation if properly notified to the RMS). In the circumstances, I do not consider that a recommendation as proposed by Mr Scott is necessary. I should note that I am very grateful to Mr Scott for his evidence to the inquest and commend him on his highly responsible conduct of his business.

146. I note one final matter. SC Buckley gave evidence that he was instructed to take notes as part of his critical incident direction but he did not do so on legal advice. He was not interviewed until six days after the shooting despite making himself available and cancelling prepaid travel arrangements so that he could be available. He clearly experienced some stress waiting for the interview. DCI Henney was asked about the timing of the interview but could not recall the reason for it. It would have been desirable for the interview with SC Buckley to have been done sooner, both for an account of the events closer to the time and for his own healing. There may be many sound reasons why this did not occur but they were not available to the inquest. One useful approach might be for critical incident investigation teams to record why officers are interviewed on a relevant date and what measures were undertaken to ensure the witnesses did not discuss the matter with other officers in the interim. This is not formal recommendation but I trust the NSW Police Force representatives will bring my comments to the attention of relevant parties.

Concluding remarks

147. The evidence of Dr Jay and SC Buckley was so compelling and important. I consider that their insights and wisdom would be an enormous benefit to the continuing education of police and, if they are willing, I encourage the Commissioner of Police to involve them in training.

148. I would like to thank my team. I have had the great benefit of being assisted by Kirsten Edwards, my Counsel Assisting and Alana McCarthy and Clare Skinner from the Crown Solicitor’s Office. They have worked so carefully and thoughtfully in the months leading up to this inquest and the months following the hearing. I am most grateful.

149. I would like to thanks the Critical Investigation Team for their assistance.

150. Finally, I offer my condolences to Paul’s family who have attended this inquest every day. I thank them for showing such courage and dignity.

Findings required by s. 81(1) Pursuant to s. 81 of the Coroners Act 2009, I make the following findings: Paul Lambert died on 3 November 2016 on the Pacific Highway, near Bonville in NSW. Mr Lambert was shot multiple times by an officer or officers of the NSW Police Force in circumstances where he was advancing towards a police officer with a raised knife. The shooting followed an attack by Mr Lambert on the same day on his former girlfriend and a subsequent police pursuit and stand-off with police on the Pacific Highway. The medical cause of death was the combined effect of gunshot wounds to the chest and abdomen.

Recommendations Pursuant to s. 82 of the Coroners Act 2009, Coroners may make recommendations connected with a death.

I make the following recommendations: To the Commissioner of NSW Police Force:

1. That the NSW Police Force continue to review other tactical options of a non-lethal nature for dealing with offenders armed with a knife, including the use of shields, in order to minimise the likelihood of serious harm in the event of a police response that requires an offender to be disarmed.

2. That the NSW Police Force consider the implementation of an information sharing system to allow licensed weapons dealers to check if a person buying a knife has an outstanding apprehended violence order or apprehended domestic violence order.

I close this inquest.

Teresa O’Sullivan Acting State Coroner Coffs Harbour Date: 15 February 2019