Deceased
Gabriella Pamela Thompson; Tafari Walton
Demographics
27y, male
Coroner
Decision ofState Coroner O'Sullivan
Date of death
2019-03-13
Finding date
2021-04-30
Cause of death
Gabriella: Multiple stab wounds; Tafari: Gunshot injuries to the head and abdomen
AI-generated summary
Two deaths in a domestic violence and police operation context. Gabriella Thompson, 27, was fatally stabbed by her partner Tafari Walton in domestic violence circumstances on 13 March 2019. Police received a concern for welfare report from a friend who explicitly expressed fear Tafari would kill Gabriella, but police did not conduct an in-person welfare check after speaking to Gabriella by phone, missing an opportunity to intervene. Critical clinical and system factors in Tafari's case (22 years old, mental health disorder, substance misuse) were inadequately managed: he admitted drug use on parole but was not subjected to mandatory drug testing; mental health treatment referrals were made but not fully engaged; Community Corrections policy lacked guidance on reporting bail breaches related to community risk. Police response to Tafari's death involved a shooting in his mother's yard. Key issues included lack of communication between officers about the family's relocation to a safer address, leading TAG officers to believe occupants were at risk inside. The coroner found Tafari intended to provoke police to shoot him (suicide by police), having expressed multiple prior suicide attempts and stating he would not return to prison.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquests into the deaths of Gabriella Thompson and Tafari Walton Hearing dates: 18-22 January and 22 February 2021 Date of findings: 30 April 2021 Place of findings: State Coroner’s Court, Lidcombe Findings of: State Coroner, Magistrate Teresa O’Sullivan Catchwords: CORONIAL LAW – homicide by a known person in the context of domestic violence – death a result of police operations – provoked shooting – mental health issues – adequacy of care File number: 2019/81714 2019/83697 Representation: (1) Counsel Assisting Mr Jake Harris of counsel, instructed by Ms Ellyse McGee 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 General Counsel, NSW Police Force (3) Commissioner of Corrective Services NSW Mr David Brogan of counsel, instructed by Mr Valentino Musico of the NSW Department of Communities and Justice (4) Pamela Cashman [mother of Gabriella Thompson]
Ms Louise Jardim of counsel, instructed by Mr Martin Vazquez of Legal Aid New South Wales (5) Susan Walton [mother of Tafari Walton] Ms Felicity Graham of counsel, instructed by Mr Drew Hamilton of Hamilton Janke Lawyers Pty Ltd (6) Geoffrey Brady Mr Robert Reitano of counsel, instructed by Mr Dominic Longhurst of McNally Jones Staff (7) Senior Constable Chris Fullick Mr Michael Weightman of counsel, instructed by Mr Tony Cardillo of Cardillo Gray Partners (8) Former Detective Senior Constable Nathan Webb Ms Belinda Epstein of counsel, instructed by Mr Shaun Cockle of Carroll & O’Dea Lawyers Non-publication orders: Orders made 10 December 2020:
officers and offices, Mr Walton’s solicitor, and Mr Walton’s Doctor not available to the public; d) Audio phone recordings of the voice of Mr Walton’s mother;
Further orders made on 10 December 2020
1.1. There shall be no publication of the information contained within the documents described in Schedule A; 1.2 The documents may be disclosed to the State Coroner, those assisting the State Coroner, the Officer in Charge of the coronial investigation, and the legal representatives of the interested parties to the inquest; 1.3 The documents may be disclosed beyond the State Coroner, those assisting the State Coroner, the Officer in Charge of the coronial investigation and the legal representatives of Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
the interested parties to the inquest, provided that the documents have been redacted to remove the paragraphs, annexures or highlighted information that is the subject of this order.
In relation to the documents listed in Schedule A, the relatives (as identified by the State Coroner) of Tafari Walton and Gabriella Thompson may inspect unredacted copies of those documents: 2.1 in the case where the relatives (as identified by the State Coroner) of Tafari Walton and Gabriella Thompson are legally represented, in the presence of their legal representatives; or 2.2 in the case where the relatives (as identified by the State Coroner) of Tafari Walton and Gabriella Thompson not represented, in the presence of those assisting the Coroner.
In the event that the oral evidence, or further documentary evidence tendered during the inquest contains information identified in Annexure A, there be no publication of that evidence.
Subject to Orders 1 and 2, the documents listed in Schedule A are not to be supplied or copied to any person seeking access to the Coroner's file pursuant to s. 65 of the Coroners Act 2009.
To the extent that reference is made to the highlighted portions of the attached copies of the documents in Schedule A during the course of these Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
proceedings, including during the inquest, there be no publication of that information.
Schedule ‘A’
Paragraphs 63-67 inclusive of the statement of Sergeant Paul Scott at Tab 190 of the brief of evidence.
Annexures 6, 10, 11, 12 and 16 to the statement of Sergeant Paul Scott at Tab 190 of the brief of evidence.
The highlighted portions of the NSW Police Force ‘Domestic and Family Violence Standard Operating Procedures 2018’ (Tab 190D) attached to these orders.
Orders made 18 January 2021
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Findings: Pursuant to s. 81(1) of the Coroners Act 2009, the following findings are recorded: Gabriella Thompson The identity of the deceased The person who died was Gabriella Pamela Thompson Date of death Gabriella died on 13 March 2019 Place of death Gabriella died at the John Hunter Hospital, NSW Cause of death Multiple stab wounds Manner of death Homicide by a known person, in the context of domestic violence Tafari Walton The identity of the deceased The person who died was Tafari Walton Date of death Tafari died on 14 March 2019 Place of death Tafari died at Glendale, NSW Cause of death Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Gunshot injuries to the head and abdomen Manner of death Tafari was shot as he moved towards a police officer while armed with a knife, intending to provoke the officer to shoot him. The death was a result of police operations.
Recommendations: Pursuant to s. 82 of the Coroners Act 2009, the following recommendations are made: To the NSW Commissioner of Police (1) Consider amending NSW Police Force policy, including if appropriate the Domestic and Family Violence Standard Operating Procedures and the Code of Practice for the NSW Police Force Response to Domestic and Family, in order to: a. Clarify the requirement to record a CAD message as "Domestic Violence" where the circumstances reported by the informant relate to suspected domestic violence, even where no offence is reported.
b. Clarify that, where a report relates to domestic violence, responding police officers should attend and talk to the alleged victim personally, unless there are exceptional reasons not to do so.
(2) Consider developing further training and guidance for police officers about the risks of, and appropriate responses to, people who are likely to attempt to use police officers to commit self-harm.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
To the Commissioner of Corrective Services NSW (1) Consider amending the Community Corrections Policy and Procedures Manual - Section B1 - Legal Issues at [1.7], to identify the circumstances when a Community Corrections officer should report a suspected breach of bail to police, in particular where the breach relates to an identified risk to the community.
(2) Consider amending the Community Corrections Policy and Procedures Manual - Section E2 - Drug testing, to provide further guidance on the circumstances where drug testing ought to be required of an offender who has admitted drug use.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Table of Contents
Introduction
These are the findings of inquests into the deaths of Gabriella (Gabby) Thompson and Tafari Walton.
On 13 March 2019, Tafari stabbed Gabby multiple times at her home in Glendale.
She died from her injuries soon after at the John Hunter Hospital, in Newcastle, NSW. She was 27.
Following the stabbing, Tafari left the scene in Gabby’s car and police were called. Tafari was not located until the next morning, despite an extensive police search, various incidents involving the public and a brief police pursuit.
On 14 March 2019, police confronted Tafari at his home, in Glendale, NSW. He ran towards officers, holding a knife. Two of the officers fired shots, causing fatal head and abdominal wounds. He died at the scene. He was 22.
The nature of an inquest
An inquest was required to be held into each of these deaths because, in Gabby’s case, it appeared she had died as a result of homicide, and in Tafari’s case, it appeared he had died as a result of police operations (ss. 27(1)(a), and 27(1)(b) and 23(1)(c) of the Coroners Act 2009). As the circumstances of the two deaths were closely connected, these inquests were held concurrently, and evidence in one inquest was admitted in the other.
The primary function of an inquest is to identify the circumstances in which the death occurred. At the conclusion of an inquest, the role of a coroner, as set out in s. 81 of the Coroners Act 2009, is to make findings where possible as to: a. The identity of the deceased person; b. The date and place of the person’s death; and c. The manner and cause of death.
A secondary purpose of an inquest is to consider whether it is necessary or desirable to make recommendations in relation to any matter connected with the death. This involves considering whether any lessons can be learned from the Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
death, and whether anything should or could be done to prevent a death in similar circumstances in the future.
The facts Gabby's background
Gabby was the youngest of three children to Pamela Cashman and George Thompson, with two older sisters, Georgina and Rebecca. Mr Thompson died in 1998. Ms Cashman re-partnered with Kevin Cashman, who died in 2004, and, at the time of these events, Jimmy Yilich.
Gabby was generally healthy. She may have suffered depression in the year or so before her death. She attended a psychologist on one occasion in July 2018 and was prescribed an antidepressant, Efexor. However, her friends and family do not think she suffered from depression or other mental health issues, and there is no evidence of any significant mental health treatment.
Gabby also had limited involvement with police. She had a High Range PCA and a Drive while suspended recorded against her in 2014. She was the victim or witness in other incidents.
Although there is evidence of Gabby drinking and using drugs, her friends and family did not know her to be an abuser of substances. There was methamphetamine in her system at the time of her death, and the possible reasons for that are described below.
At the time of her death, Gabby was living at Glendale, C C with her and Tafari's daughter, who was then aged 3. Tragically, lost both of her parents in these events. She is now cared for by her mother's sister, Rebecca.
Tafari's background
He had Ethiopian Falasha or Beta Jewish heritage through his father. His parents
O A separated when assaulted in 1997. The material Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
D suggests that Tafari and his older brother, suffered abuse when they were very young, and again when Tafari was about 8.
P Q children ( and
Possibly in consequence of his early life trauma, Tafari developed significant behavioural issues. Concerns were noted by Dr Anthony Nicholas, a clinical psychologist, who reviewed Tafari in 1999 when he was 2, and considered him to be a "very damaged child" at high risk who needed ongoing specialist support.
Tafari attended mainstream schools, but his behaviour deteriorated. He was reviewed by a number of other mental health professionals during his childhood, who suggested different diagnoses. In 2009, he was he was diagnosed with Major Depressive Disorder, Conduct Disorder, Oppositional Defiant Disorder and Post Traumatic Stress Disorder. He was at one stage believed to have a learning difficulty, although this was doubted. Tafari was treated for a period with an antidepressant, fluoxetine (Lovan).
In 2010, when aged 13, Tafari started drinking to excess and also used Ice for the first time. He later stated he was using up to 7 points of Ice daily from the age of 15. His substance use probably compounded his mental health issues and his conduct deteriorated further.
Tafari left mainstream schooling and attended behaviour schools. His mother thinks Tafari's experience in education, and later in custody, led to further sadness and disconnection from society. Tafari did have a positive influence in his life, from Chris Teale, the Director of Pipeline Youth Project, who acted as a mentor and with whom Tafari learned to fly aeroplanes.
Tafari had a substantial juvenile and adult criminal record, including acquisitive offending and violence. He also had a large number of bail breaches, though he was later involved in a class action regarding these. Significantly, his record also included knife-related crime. In 2007, when aged 10, he allegedly threatened to stab a neighbour. In 2012, aged 15, he was convicted of possession of a knife twice, and also of reckless wounding, when he stabbed another child.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
He entered detention for this, for the first time, in November 2012, just prior to his 16th birthday, and was released in May 2013. He returned to detention from July 2013 to January 2014, for an aggravated break, enter and steal using an offensive weapon. He returned to custody in February 2015 for two months, for an assault. The following year, then aged 19, he received a 2-year sentence for Assault with intent to rob, relating to robbery of a hotel; he was in custody from 6 May 2015 to 5 May 2016. A month after his release, on 7 June 2016, he returned to custody in circumstances I will shortly describe. He was convicted of firearms offences and received a total effective sentence of 3 years and 9 months. He remained in custody from 7 June 2016 to 23 January 2019, when he was released on parole. In summary, in the six years spanning from his 16th birthday to his death at 22, Tafari spent more than four years in gaol.
Tafari threatened or attempted self-harm a number of times. In July 2011, when he was 14, he attempted to hang himself. In September 2011, he took his mother' car and then tried to hang himself again and was admitted to John Hunter Hospital. The context of that incident was the end of a romantic relationship. In June 2012, following an adverse court outcome, he deliberately walked into traffic. However, while in custody at the end of 2012, he was reviewed by a psychiatric registrar and found to be coping well. There were further acts of threatened self-harm during his relationship with Gabby, which I will describe shortly.
Gabby and Tafari's relationship
his emotions, were features of his personality disorder. These personality traits are likely to have contributed to the problems in the relationship.
It is not possible, or necessary, to itemise and evaluate each incident. However, it is useful to form an impression of the nature of their relationship, drawn from the evidence in the brief and the oral testimony, to provide context for the events that led to Gabby's death.
Having considered all of that evidence, on balance I find that it establishes the following facts: that there was significant, ongoing domestic violence, including physical violence and other forms of controlling behaviour; that Tafari was the primary perpetrator of that violence; and that Gabby was the primary victim of his violence.
It is a feature of this case that few of the violent incidents were ever reported to police or other authorities, by Gabby or others. Gabby did not want to report them, probably because she was afraid of retaliation from Tafari if she did. Some of Gabby’s friends and family were aware of the violence, but were also afraid of Tafari, and perhaps they did not see it as their place to make a report. The exception was Emma Russell, whose report to police on 13 March 2019 will be described below. Counsel assisting submitted that I should not be critical of Gabby’s or Tafari’s friends and family for not doing more. I agree they were in a difficult position, in particular as Gabby was generally reluctant to involve police.
However, the circumstances of Gabby’s death underline the risk that domestic violence posed to Gabby, and the tragic consequences of not taking more action to protect her.
Only a few of the incidents of violence were considered in detail during the evidence. The brief also contains further material relating to other incidents. The salient incidents are described below.
The violence commenced just a few months into the relationship, in about April 2014, when Tafari assaulted Gabby, causing bruises, splitting her lip, and pulling out hair.
Nonetheless, the relationship continued. Gabby fell pregnant and had a termination. A month later, she fell pregnant again and had a further termination.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Tafari believed Gabby had cheated on him. Tafari's pre-occupation that Gabby was cheating on him was a consistent theme in later incidents, including the circumstances which led to her death. Some witnesses say they were both jealous of each other and of possible infidelity. There is material which suggests that Gabby had sex with one person in 2014, and had a brief relationship with another person in early 2017, while Tafari was in custody. Tafari's concerns about this issue appear disproportionate and are probably a function of his personality traits.
On 7 July 2014, Tafari became enraged about Gabby cheating on him, drank excess alcohol and deliberately drove a car into a tree. He also obtained a knife and told his mother he was going to kill Gabby. He was scheduled at John Hunter hospital but released on leave overnight. He was commenced on quetiapine (Seroquel) an anti-psychotic.
On 18 July 2014, police were called for the first time to an argument between A Gabby and Tafari in the front garden of home. The report said a woman was calling for help. No offence was reported, and it was recorded as a verbal argument. Following this, Tafari left and went to a park to hang himself.
He was taken to the Nexus Unit at John Hunter hospital, but not admitted.
In September 2014, an Apprehended Violence Order (AVO) was obtained A against Tafari, protecting and her family, following an incident where B Tafari threatened with a knife. He breached that AVO soon after.
On 18 April 2015, police were called for a second time because Gabby was heard screaming. They told police the argument was about a "jealousy matter". Gabby said she had no fears, and it was again recorded as a verbal argument.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
In July 2015, Gabby approached Nova Women's Association and saw a caseworker, Rebecca Prestwidge. Gabby was primarily looking for help with housing. She reported domestic violence from Tafari. She said she did not have current concerns as he was in custody. She obtained some support for housing and also stayed at a refuge for a period.
In April 2016, while still in custody, Tafari made threats towards Gabby in phone calls made from gaol. These calls were recorded, and the transcripts were in evidence. They provide some insight into the dynamic in this relationship.
On 5 April 2016, Gabby complained to Tafari about an arrangement that his mother had made to pick him up when he was released from custody. She said he was "run[ning] back to his mum" and that they were "supposed to be a family", C referring to Gabby, Tafari and She called him "Mummy's little boy". In response he became angry, and said, "I swear to fucking God I'm going to kill you when I fucking get out" and he also threatened to kill her whole family. He then threatened to cut her tongue out of her mouth.
In a subsequent call, Gabby told Tafari she had been out with two girlfriends. In response, he told her she was a slut, and that he was going to punch her face when he saw her. He then called his mother to complain to her that she had C looked after when Gabby went out but had not told him. He made repeated threats to kill or harm Gabby, her family and friends. His mother counselled him about the relationship and suggested it might not be worth it, and told him what he was saying was not appropriate.
After this, Gabby sought assistance from Ms Prestwidge again. Gabby reported the threats from Tafari in the phone calls. She was very anxious about Tafari's release from custody and wanted to flee the area. She wanted to change the A locks, as had a key and she was concerned Tafari would gain access.
Ms Prestwidge suggested an AVO, although Gabby thought this would probably make Tafari angrier.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
On 9 May 2016, he provided urinalysis which was positive for ‘Ice’ (crystal methamphetamine).
On 10 May 2016, Tafari was taken to hospital for assessment, because he was planning to kill himself. He was assessed and released with a referral for community follow up.
That evening, he attended Gabby's home, reportedly asking for money to gamble C and drink. She refused and he assaulted her, taking from her, and telling her if she made a noise he would kill all of them before anyone came. He then took a knife and demanded Gabby kneel on the ground, saying "you are going to sell your soul to the devil". He calmed down after this, although she remained, and left the home the following day.
On 14 May 2016, Tafari took a large overdose of Seroquel, in the context of further Ice and alcohol use, and he was admitted to hospital again. He was C reportedly found by his brother with a photo of Gabby and on his chest.
On 25 May 2016, Tafari contacted Gabby while he was having contact with C asking for a phone ledger book. He threatened to take in his mother's car and run it off the road. When Gabby attended the home, he accused her of infidelity, and checked through her phone. He then obtained a knife and again threatened to kill Gabby before the police arrived.
On 26 May 2016, Gabby reported this incident, and the one from 10 May, to police, and gave a statement.
On 27 May 2016, Tafari was arrested and charged, and a provisional AVO was imposed. The charges were later withdrawn. He was taken to the Mater hospital for a court-ordered mental health review. However, while there he attacked a nurse, grabbing her by the throat and threatening to kill her if she did not give him the keys. He then escaped and was not located for the following 10 days.
He was later charged for that incident, also.
reported to police, child protection services or mentioned by Gabby to anyone else at any stage. Although the incident as described is highly concerning, the lack of any recorded account from Gabby has the result that no finding can be made that it occurred. Ms Prestwidge was not asked to appear as a witness and no adverse finding will be made regarding her contact with Gabby.
A B partner disarmed Tafari and he surrendered to police.
On arrest, he was found to have five bags containing a total of about a gram of Ice.
Tafari in custody 2016 to 2019
Tafari's access to mental health treatment during his time in custody was an identified issue for the inquest. At the early part of his sentence, a history of auditory hallucinations was noted. His mother also contacted the prison in order to advocate for Tafari to get treatment. He was taking Seroquel (an antipsychotic) and Escitalopram (an anti-depressant).
On 2 August 2016, he reported possible auditory hallucinations, and was talking about the devil, although it was doubted these were true hallucinations. He was assessed by Dr Gordon Elliott for a court report, who considered that Tafari’s diagnosis was in keeping with a personality disorder. Later in August 2016, Tafari stated that his medication was not working, and he refused to take it anymore.
A recommendation was made for correctional officers to monitor him, and a referral to psychology would remain open if he needed it. He was not reviewed by a mental health professional again until September 2018, two years later. He was offered a referral to psychology in July 2017, but he declined this.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Nonetheless, Tafari appeared relatively stable over this time. He engaged in prison programs and remained, for the most part, in mainstream prison discipline.
On 20 May 2018, an incident occurred where Tafari and 2 others were accused of stabbing an inmate with a gaol-made weapon. The victim did not suffer lifethreatening injuries. Tafari was charged with Wounding with intent to cause grievous bodily harm and refused bail.
On 18 September 2018, Tafari was observed looking dazed and confused and was behaving bizarrely, talking to an apple. He seemed distressed, talking about a family issue, and was taken to a nurse for assessment, but he refused to talk.
He was taken back to his POD to talk with another inmate. He was placed in an assessment cell on a Risk Intervention Team protocol and remained there for about 10 days. He admitted he had taken Ice.
On 20 September, he tied his prison greens around his neck in a possible attempt at self-harm and staff had to negotiate with him to remove it. However, he later said he was merely tying his greens in a bow tie "to look like a Freemason".
On 18 October 2018, Tafari was reviewed by psychology staff. He was cooperative, although fidgety and tangential. He wanted advice on how to stay out of gaol. He was seen by psychology staff again on 27 November 2018.
Although he was stressed about a court appearance, he wanted education about conflict resolution and assertiveness.
Tafari’s bail and parole conditions
Tafari's earliest release date to parole was in December 2018. However, he was still bail-refused for the May 2018 wounding offence at this time.
In January 2019, a release application was made. The transcript of the hearing and the subsequent determination is within the brief. In light of the strength of the case, including a letter from the victim stating Tafari was not involved, delays in preparation of a prosecution brief and anticipated delays in a trial at Port Macquarie, the Magistrate granted Tafari strict conditional bail.
Tafari's bail conditions included daily reporting to police, that he reside at his mother's address, and a curfew from midnight to midday, when he could only Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
leave in the company of defined people, including his mother and Gabby. He was also to comply with mental health treatment and abstain from drugs. His next Court appearance would have been on 20 March 2019.
Tafari did report to police as required. However, the evidence shows he was not always residing at his mother's home and spent at least part of his nights at Gabby's home. Although there was an enforcement provision, there are no records showing that his residence was ever checked by police. That said, as he was permitted to be away from his mother's home in Gabby's company, it is unlikely a breach would have been detected, or would have resulted in a breach.
Tafari was also subject to a statutory parole order. The terms of parole are also significant. At the time his sentence was imposed, in October 2017, standard parole conditions included a requirement not to use prohibited drugs. However, an amendment made to the Crimes (Administration of Sentences) Regulation 2014 in February 2018, with the effect that a parolee was required to comply with “all reasonable directions of a community corrections officer”, including (if the officer so directed) to cease drug use and undertake drug testing. It was these new conditions which applied to Tafari at the time he was released from custody.1 Accordingly, and somewhat remarkably, when Tafari was released from gaol, his parole conditions did not require him to cease taking drugs.
Tafari on parole
Tafari reported to his parole officer, Geoffrey Brady, on the day following his release. Mr Brady saw Tafari a total of seven times prior to his death. He assessed Tafari according to a structured risk assessment tool, the Level of Service Inventory, and determined that Tafari had Medium/High needs. That assessment determined the frequency of reporting, among other things. He also prepared a case plan. Given Tafari's history, he identified risks of aggressive behaviour, arising from substance abuse and mental health issues. These issues were to be given priority.
The evidence shows that efforts were made to engage Tafari in mental health treatment. On 5 February, Tafari attended GP Dr Paul Karen and obtained a 1 See parole conditions at Brady 8/237A/A Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
mental health care plan. The same day, he attended psychologist Janelle Pritchard. This was not a useful interview, because he was 50 minutes late for C a one-hour appointment. Gabby and also attended, and Gabby reportedly answered questions on Tafari’s behalf.
The following day, on 6 February 2019, Tafari reported for parole. When asked to do a drug swipe test, he admitted using ecstasy and smoking Ice two days prior, after a friend offered it to him. This was about 10 days into his parole. Mr Brady gave Tafari a verbal direction not to use drugs and also obtained Tafari's consent for a referral to psychoeducation and drug counselling. However, Mr Brady did not take any other action regarding a possible breach of bail and parole, including, for example directing for Tafari to undertake further drug testing. That issue is considered further, below.
There is evidence that Tafari continued to take drugs after this point. On 9 March 2019, Gabby's sister Rebecca saw Gabby and Tafari snorting cocaine. There is also evidence he took drugs for an extended period in the days leading to Gabby's death.
On 11 February 2019, Mr Brady made the first of two home visits. No concerns were noted, with Tafari saying his relationship with his partner was going well.
On 12 February, Tafari missed an appointment with Ms Pritchard, because he was in Sydney with Gabby. He told Mr Brady the next day, and also said he planned to arrange a different counsellor. He then attended a different GP on 15 February 2019 and was referred to Hunter Primary Care for counselling, although that referral did not proceed.
A few days later, on 19 February 2019, Tafari cancelled an appointment with a mental health and substance use service. He attended on 22 February, but declined the service, saying he preferred to attend SMART Recovery sessions.
There is no evidence that he did so.
On 26 February, he attended a third GP, and was referred to Headspace in Newcastle. That referral did not proceed.
Finally, on 27 February, Tafari was referred to a private psychological service, ProCare. He was seen promptly by a clinical psychologist Ms Radojevic on Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
28 February. She considered he suffered from anxiety and possibly ADHD, and proposed a psychiatric review. A further appointment was booked for April. He reported this to Mr Brady on 5 March, and Mr Brady verified this and made enquiries about whether drug counselling could also be provided.
Despite these positive steps, there is other evidence which suggests that things were not going well, at least in relation to Tafari and Gabby.
Gabby had recently moved into a new home in in Glendale. She had changed her phone number, which she told her friends was because she did not want Tafari checking her phone history. She was reportedly apprehensive about his release. However, she also seems to have been keen to continue the C relationship, probably also for to have her father in her life.
says she also noticed Gabby had bruising after Tafari was released from custody. On 25 February 2019, Gabby told a colleague she could not go to work because Tafari had "trashed" her house. Either then or in early March, Tafari put a hole in a wall in Gabby's house, a matter to which I will return. Around this time, Gabby attended her friend Claudine Gordon-Meki's home with a black eye.
A According to Ms Gordon-Meki, a fight had occurred at home, with Tafari trying to strangle Gabby. Neighbours also later told police that they heard shouting in the street, from a man and a woman.
On 11 March 2019, Gabby told her mother that she was scared Tafari was going to kill her. She said she was going to have to quit work, as she couldn't keep turning up with bruises on her. She said her mother could not say anything, as Tafari would hurt her, too.
These matters support a finding that Tafari continued to be physically violent to Gabby, on a number of occasions, after his release to parole. Nobody reported these matters to police or other authorities.
Events of 12 March 2019
monitor her calls. She also called her work, saying she was not going to attend that day and would probably have to quit. She appeared hushed and cautious.
Tafari told Mr Brady Gabby had cheated on him while he was in custody, but said he while he felt jealous, he didn't consider it that serious. Mr Brady did not think Gabby was at immediate risk of harm. Gabby was present at the home that day, although Mr Brady only saw her briefly, and did not observe anything untoward.
According to Mr Meki, Tafari smoked Ice that afternoon.
Gabby's sister Rebecca also saw her that afternoon. She told Rebecca that Tafari was on "day 4" which Rebecca took to mean he had been on drugs for four days.
At 6.40pm, Mr White texted Gabby, saying "Dad is down could I grab those coins?". He later explained he was referring to some coins his dad collected.
That evening, Tafari reported as required to Waratah police station. He then C attended Mrs Cashman’s home with Gabby and It seems probable that Tafari saw the message from Mr White, because at about 11pm he called him, on Gabby's phone, asking him what was going on with Gabby and saying she was "texting heaps of blokes". Mr White denied there was anything going on.
Tafari then sent a further text to Mr White, who called him back and suggested they meet and talk about it the next day.
Tafari began to accuse Gabby of infidelity. Tafari showed Gabby's mother a list of men's names, accusing Gabby of being unfaithful. He then assaulted Gabby A and threatened Mrs Cashman. Mrs Cashman called for assistance, C who attended and took away from the home.
At a little after midnight, Gabby told her mother that there was a knife on the floor of her car. When Mrs Cashman went to locate it, Tafari dragged Gabby out of Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
the house by the hair and they left in the car. They drove to Tafari's brother D house.
Concern for welfare report
Earlier in the evening, Tafari had contacted some of Gabby's other friends, including Emma Russell and Cody Patrick, asking about who Gabby had been sleeping with. Ms Russell was concerned, and she spoke to Ms Gordon-Meki, who had been in touch with Gabby about not going to work. They agreed that they should ask police to do a welfare check.
At 12.40am on 13 March 2019, Ms Russell called Sen Cst Parsons who was undertaking station duties at Belmont police station. She said she had received a strange call from Tafari and was concerned. According to Ms Russell, she also stated she was worried that Tafari would stab and kill Gabby.
At 12.41am, Sen Cst Parsons created a Computer Aided Dispatch (“CAD”) message. It was recorded as a “concern for welfare” rather than a domestic violence incident. It did not mention a concern about Gabby being killed. It stated as follows:
INFT RECEIVED STRANGE PHONE CALL FROM HER Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
They checked information about Tafari that was known to police. It is likely this would have included his criminal history and bail conditions. They then attended at Gabby's home at about 2.43am. At this time it appears Gabby was at her mother's. They knocked, but got no response, and left about 8 minutes later.
Sen Cst Walker then phoned Gabby's phone and also left a message for the informant, Ms Russell.
WALTON has been violent in the past to Thompson and inf is concerned for her safety. Contact inf with result.
***** Info only***** Night shift attended the address early morning of 13/03/2019 and processed the job after being unable to raise anyone at the address. Inf returned a phone call to police 4am this date and elaborated on the concerns for her friend. Due to new information a duplicate job has been created for day shift to attend and attempt to locate Thompson.
B address and spoke to who told them Tafari was out with Gabby or D
This will be explored further below.
Gabby's death
D Nonetheless, Gabby went to house to collect Tafari, arriving after 10.30am.
Tafari told he was going to Gabby's house to collect his things, saying D that he was going to move in with for a while. He appeared calm. He then left with Gabby in her car.
Gabby and Tafari arrived at at 11.02am. At 11.23am, there was a call from Gabby's phone, which police suspect may have been drugrelated; it is unknown who made the call.
B wanted to check on Gabby and Tafari, and was going to repair a hole which Tafari had caused in the wall a week prior. At about 11.30am, they Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
C arrived at and parked in the driveway. They had and also
N D ( son) in the car.
B Tafari broke free and started choking Gabby. said Tafari had a B vacant look. Fearing he might have a weapon, then left, and went A to get whom he thought would be able to talk to Tafari.
saw Gabby at the top of the steps, holding her neck. He rendered first aid, finding a towel to put around her neck, and after this he called 000. He ended that call A and called again, to inform her that Tafari had left, and asking where A the children were. arranged for the children to be moved to a safe B place, and she travelled back to Gabby's house, arriving while was on the phone to the ambulance for a second time.
An ambulance attended within about 10 minutes at 11.47am. Police were also informed of the incident, arriving at 11.49am.
Gabby was conveyed to John Hunter Hospital, but she was pronounced deceased at 12.39pm.
Autopsy - Gabby
stab wounds including a laceration to her throat which severed her internal jugular vein. She also suffered a penetrating injury to her right lung and a fractured nose, as well as multiple other injuries.
The search for Tafari
The police search for Tafari was extensive. It was initially co-ordinated by A/Insp Phillip Cosgriff, and then by Ch Insp David Matthews, who gave evidence to the inquest. A/Insp Paul Laksa coordinated the criminal investigation. Local police from Lake Macquarie and Target Action Group (TAG) officers from Newcastle were also involved, as well as local officers from the Operations Support Group.
The first police to arrive, Sen Csts Austin and Tull, obtained information about Tafari, as well as Gabby's vehicle details and their phone numbers. It was quickly realised that Gabby's phone was still within the house. A phone triangulation was commenced on Tafari's phone to see if he could be located. That appeared to show Tafari was still relatively close by, in an area to the west. There were extensive searches, but Tafari was not located. Police canvassed local houses for information and attended addresses of known associates. A police helicopter, PolAir, was also dispatched from 3pm to assist.
Cardiff
It was later discovered that Tafari had in fact driven Gabby's Mitsubishi straight from to Lovell Street, Cardiff, just a few hundred metres to the east. This was a home previously owned by a person known to him who had moved out in about 2012. He broke into the property and remained there all day, with the Mitsubishi parked in the driveway. The occupier, Kristene Holt, was at work.
At about 5pm, Ms Holt returned to Lovell St, where she found Tafari in her driveway, claiming he had run out of fuel. She told him to leave, and he drove Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
off in the Mitsubishi. She entered her home and found it had been ransacked.
Fingerprints later confirmed Tafari had been inside, and CCTV from the street shows he entered at about 11.38am and left at about 4.54pm. Ms Holt phoned 000.
Elemore Vale
F F Elemore Vale. She is the elder sister of who was a friend of E Tafari, and she was at home with her young children that evening.
later told police that Tafari arrived at about 9pm, but there is some evidence that E he arrived prior to that time. In particular, he made a call to sister,
F E at about 8.45pm, probably using phone.
The search of Tafari’s home
G B , mother, who had moved to a new address that was B not known to Tafari. also declined to give police a key to the home, saying that all doors and windows were locked and Tafari could not get in.
to that effect was issued at 6.17am the following morning. That information does not appear to have been made known to the police officers who encountered Tafari at the address. That issue will be considered further, below.
During police attendance, said to police that she was concerned Tafari would attempt "death by police". She says she was assured that Tafari's safety would be a priority.
While at the Walton family home at police were told that Tafari could F F have attended address. Police attended home at about 10pm, and she told them about the earlier call from Tafari. A/Insp Laksa attempted to get authority from the Duty Operations Inspector to trace the phone that had been used to make the call. This was denied by the Duty Operations Inspector, because he determined that relevant test was not met.2 Reverse call-charge records were sought instead.
If the phone call had been traced, police might have discovered Tafari's contact E with earlier, and also the fact that Tafari was now using the Ford E Falcon. They ultimately attended home at about 4.30am, having by then located the Ford Falcon, and found Gabby's Mitsubishi parked in her driveway.
Whitebridge
H I I contacted another friend, , who attended. and I Tafari then left in Holden Commodore.
2 Section 287 of the Telecommunication Act 1997 (Cth) in effect permits disclosure of such information only when a person believes on reasonable grounds that it is reasonably necessary to prevent or lessen a serious and imminent threat to the life or health of a person Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Police pursuit
H I ' address, with driving.
By this time, about 3am, police were responding to the call about ' home. Sgt Lee Cousins saw the Commodore approach Dudley Road, performed I a U-turn, and commenced a pursuit. According to , Tafari held a knife I to throat and told him to drive off, which he did at high speed. About 8 minutes later, the Commodore entered Warners Bay Road and Sgt Cousins ended the pursuit. He patrolled the area but could not locate Tafari.
At 3.41am, Sgt Cousins spotted the Commodore again, and conducted a second I pursuit, which again ended after a few minutes. According to , he slowed L down at one point and he and decamped, leaving Tafari behind in the vehicle. They later reported the events to police.
Tafari remained in the Commodore, but his whereabouts after these events are not known. It is possible he attended his mother's home and attempted to enter, as the flyscreen in one window had been removed when police attended the following day. He may have spent the night elsewhere.
At 6.51am, CCTV captures the Commodore driving into a reserve to the south of Karen Ave, in Glendale. Local residents saw a male, who was probably Tafari, looking over fences, and an hour later a male was seen walking through the backyard of a property on Bell Street. This sighting was reported to police, who attended.
Bell Street
holding a folded knife. He demanded her keys and told her “I just want to see my mum.” She declined. While Tafari was fiddling with the knife, Ms Harrison ran off and alerted a neighbour. The neighbour then called police at about 8.35am.
Police briefings
At about 8.30am that morning, police involved in the search for Tafari had planned to hold a substantial briefing about the investigation at Belmont Police Station. It would have been expected to provide police information about the status of the search and the events that had occurred overnight, Including the fact that Tafari’s family had not spent the night at their home.
However, when the Bell Street attempted carjacking was reported, police left the station and proceeded to Glendale. The briefing did not take place. As a consequence, information which had been obtained during the search for Tafari overnight was not disseminated to all police units who responded to the Bell Street incident.
Separate to this briefing, there was an informal briefing held at Newcastle Police Station for TAG officers. The TAG officers expected they would become involved in the search for Tafari that day, although they were not yet formally tasked to do so. Those officers included Sgt Piddingon, and Sen Csts Fullick, Scotman and Barnett. Sgt Piddington did not recall all the details of the briefing, although expects he would have reviewed the timeline of criminal activity, locations Tafari had been at and the details of the Commodore he was driving. He had reviewed COPS events relating to Gabby's death and intelligence material. He does not A recall if he was aware of the information about having spent the night at a different address. None of the other officers present recall that information.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Tafari's death
After leaving Bell Street, Tafari returned to the reserve to get the Commodore, and drove the short distance from there to
Acting on the information that Tafari might try to see his mother, the three officers from TAG (Sen Csts Fullick, Scotman and Barnett) had already attended stopping about 60m away from the house. They saw a vehicle parked outside, B and Sen Cst Scotman made enquiries and discovered it belonged to A
The officers had a discussion at this point, and formed a view that and her family might be inside There was concern that Tafari may harm the occupants. As a result, Sen Cst Fullick asked police radio to contact A to see if she was okay, and if Tafari was present.
At 8.57am, Tafari drove into in the Commodore and turned into the driveway of his mother's home. He then exited and appeared to have seen police. Sen Cst Fullick broadcast “He's waving at us. Radio we have the POI.” As a result, several police units began converging on
The next to arrive was Lake Macquarie 102, carrying Detectives Webb, Newton and Symington. En route, they also had a brief discussion about the need to contain Tafari, who they presumed was on foot armed with a knife, and who presented a risk to the public.
After Tafari's arrival, he jumped the gate at motioning to officers to follow him. At 8.58am, the TAG officers broadcast that Tafari had “just run into the house”. Sen Cst Barnett broadcast, “we have two officers out the front, we need more cars here, we're going to try to contain the mother's house.”
Following this broadcast, another police unit (Sen Csts Smith, Robinson and Willemsen), was directed to attend the rear of the premises, in case Tafari absconded through the rear of the property.
The property has a driveway to the right and a passageway to the left, which both lead to an area at the rear. At the rear of the property, there is a pool and a raised, chest-height deck which is bounded by a glass barrier. A set of stairs Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
positioned opposite the rear door, leading down to ground level towards the pool gate. A narrow passageway separates the deck from the pool fence.
Sen Cst Fullick and Det Sen Cst Scotman climbed over the gate and entered the driveway to the right. It appears that Det Sen Cst Scotman asked the three Detectives to go to the left of the property. Sen Cst Barnett remained outside, intending to enter via, or remain at the front door.
At 8.59am, a neighbour, Paris Burton began filming events on her mobile phone.
It shows Det Sen Cst Scotman jumping the gate and going down the side of the house out of view. While it does not show Tafari, there is some audio, including police commands and the gunshots.
As Sen Cst Fullick advanced down the driveway, he yelled out, "Tafari, show us your hands, brother." This can be heard on the mobile phone footage.
The Detectives needed to climb a fence in order to get down the left-hand side passage. Det Sen Cst Webb climbed first, followed by Det Sen Cst Newton. As Det Sen Cst Webb moved along the passage, he dropped his handcuffs, although his colleague Det Sen Cst Newton told him to continue, as he would pick them up.
Det Sen Cst Webb was the first to arrive at the rear of the property. He had his firearm drawn. Det Sen Cst Newton also drew his firearm, but had it in the “sul” position, namely held at chest level with the barrel pointed downwards.
Det Sen Cst Webb continued moving around the side of the deck. He was initially unable to see Tafari. When he arrived near the foot of the stairs, he saw Tafari standing on the deck trying to open the door to the home.
The space where all the officers were standing was cramped. Det Sen Cst Webb was in a vulnerable position, standing close to and beneath Tafari, and with his back to a pool barrier. His colleague Det Sen Cst Newton was approaching behind him, and Det Sen Cst Symington arriving beyond that. Sen Csts Fullick and Scotman were approaching from the opposite side (the right).
Tafari raised his hands, holding a 10-15cm bladed knife in his right hand.
According to the officers, he said, words to the effect “come on fucking shoot Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
me.” Det Sen Cst Webb told Tafari to put the knife down repeatedly. He then drew his OC spray and discharged it, although this had no apparent effect on Tafari.
Tafari took a step back and then moved quickly towards Den Sen Cst Webb, with the knife raised.
At the point when Tafari passed the top step, Det Sen Cst Webb and Sen Cst Fullick each discharged two shots, with two shots hitting Tafari and the others hitting a bike and a chair on the deck. Tafari fell to the ground, landing at the point where Det Sen Cst Webb had been standing. It is estimated that Tafari was less than 2m away from Det Sen Cst Webb when the shots were fired. None of the other officers present were in a position to shoot, as others were standing in their line of fire.
On the mobile phone footage, the time from police starting to shout commands to the shots being fired is approximately 13 seconds.
A radio broadcast about the shooting was made at 8.59am. Following this, many other officers arrived. Police commenced first aid. An ambulance arrived at 9.08am, but Tafari was declared deceased soon after, at 9.17am.
Tafari was found to be carrying 4 plastic bags containing cocaine at the time of his death.
Autopsy - Tafari
A full autopsy was conducted on 19 March 2019. It recorded the cause of death to be gunshot injuries to the head and abdomen. Tafari was struck in the right temple, with the bullet exiting near his left ear. A second shot entered at the right side of his back, damaging Tafari's liver and kidney. Both shots were inevitably fatal.
Toxicology shows that Tafari consumed a large quantity of cocaine and Ice in the period prior to his death. Dr Fu opined that the level of cocaine indicated that Tafari was likely to have consumed more cocaine after about 2.30am when he
I L shared a “last line” with and .
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Expert evidence
A review of the action of the offers present at Tafaris' death was performed by Sgt Paul Scott, an Operational Safety Instructor. He gave evidence to the inquest.
Det Sen Cst Apthorpe provided evidence on testing Det Sen Cst Webb's MK-6 OC spray. This was a small version of the standard issue OC spray, and was intended to be used in plain clothes work. He concludes that the spray used by Sen CSt Webb did not function adequately, only travelling a total horizontal distance of about 1 to 1.5m. He also found that other cannisters were deficient.
This issue is considered, below.
The issues
A list of issues was circulated prior to the inquest, to identify the broad areas of interest which were expected to be the focus of evidence.
In Gabby's case, as well as the formal findings required by s. 81 of the Coroners Act 2009, the issues were as follows: a. Whether the nature and adequacy of supervision provided to Tafari by Community Corrections had any impact on the risk presented to Gabriella at the time of her death.
b. Whether appropriate action was taken by NSW Police Force in response to the concern for welfare reports made by Emma Russell on 13 March 2019, and in particular: i. What information was obtained from Ms Russell and recorded by police?
ii. What information was known to the responding police?
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
iii. What action was taken by responding police, and was other action available?
iv. Was any further action appropriate after Gabriella contacted police at 8.54am on 13 March 2019?
b. Whether adequate supervision was provided to Tafari by Community Corrections, including: i. Steps taken to monitor his adherence with mental health treatment; ii. Illicit substance use, including drug testing.
c. Whether adequate action was taken by NSW Police Force to locate Tafari, following the death of Gabriella Thompson on 13 March 2019.
d. Whether adequate steps were taken by NSW Police Force to disseminate information about the investigation to police officers who were searching for Tafari.
e. Whether appropriate action was taken by the involved officers, in light of information known to them, including: i. The extent to which a plan was discussed prior to approaching ii. The decision to engage Tafari, and other options available; iii. The use of appointments.
Tafari’s mental health and treatment
Dr Danny Sullivan, a consultant forensic psychiatrist, prepared a report for the inquest about Tafari's mental health. He gave the following opinions: Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
While Tafari was a child, several diagnoses were suggested, including oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder, obsessive-compulsive disorder, and major depression. It is likely that most of these were met at various times. Emotional trauma contributed to the development of these conditions.3
By the time of his death, Tafari's primary diagnosis was mixed personality disorder with antisocial and borderline traits.4 Dr Sullivan described this as a severe personality disorder.5 This diagnosis is consistent with the view of Dr Gordon Elliott, who assessed Tafari for a Court report in August 2016. Borderline personality disorder generally comprises four clusters of symptoms: cognitive and perceptual symptoms, including brief hallucinatory experiences and delusions; interpersonal problems, where some relationships are idealised while others are devalued; emotional lability and volubility; and impulsive behaviours, including deliberate self-harm. These symptoms all contributed to Tafari’s behaviour.
Tafari also had a severe substance abuse disorder, including stimulants, cannabis, and alcohol.6
Tafari did at times display psychotic symptoms, and he expressed some unusual beliefs that might be considered delusional. However, these were probably induced or exacerbated by substance use.7 Some paranoid and delusional thoughts could also be explained by his personality disorder.8 There was, in Dr Sullivan's view, no evidence of sustained symptoms, and Tafari was repeatedly assessed as not having a serious mental illness. Additionally, Tafari did not display psychotic symptoms during periods of imprisonment where he did not have access to substances.9 Accordingly, Dr Sullivan did not consider Tafari had a psychotic illness.
3 Sullivan 1/15B [95]-[96] 4 Sullivan 1/15B [101] 5 Sullivan T63.8 6 Sullivan 1/15B [100] 7 Sullivan 1/15B [102] 8 Sullivan T49.30-37 9 Sullivan T50.1-13 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
At the time of his death, Tafari met the criteria for stimulant intoxication.10 It was also likely that he had a methamphetamine-induced psychotic disorder at the time of the events which led to his death.11
Dr Sullivan opined that Tafari received adequate and appropriate treatment while in custody.12 Tafari had been ambivalent about receiving mental health treatment and did not seek further treatment after assessment in August 2016. He came to the attention of mental health services again in the context of substance use.
It may have been the case, as Tafari’s family suggested, that he would have benefitted from further planning, prior to his release from custody, to ensure he received appropriate through-care. However, because Tafari was facing serious new charges, his discharge from custody was uncertain. He was also not consistently involved with mental health professionals in custody, although he did see a psychologist on two occasions to prior to release. In these circumstances, it may have been difficult to organise appropriate assessment and treatment until Tafari was in fact released.
Once in the community, significant efforts were made, by Tafari and his mother, to obtain appropriate mental health care for him. He was connected with psychologists and was also scheduled to commence drug and alcohol counselling. However, treatment did not commence prior to his death.
Unfortunately, Tafari’s condition was going to need long-term treatment, more than that which could be provided on a GP mental health care plan. Nonetheless, the referrals made to GPs were appropriate.13 Dr Sullivan described in evidence the nature of such treatment, involving possibly biological, psychological and environmental elements, and which would have required voluntary engagement with Tafari. Critically, Tafari appears to have commenced using substances on his release from custody. In these circumstances, it is unlikely that any treatment would have been of benefit in any event.14 10 Sullivan 1/15B [106] 11 Sullivan T50.22, T50.43 12 Sullivan 1/15B [110]; T52.35-50 13 Sullivan T60.15 14 See Sullivan T51.24-T52.22; T53.38-44 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Overall, I find that the mental health treatment Tafari received, both in custody and in the community, was appropriate.
Supervision of Tafari by Community Corrections
The supervision Tafari received from Community Corrections was generally good. Mr Brady met Tafari and assessed his needs, correctly identifying areas of high risk as aggressive behaviour, drug use and mental health. Mr Brady met Tafari on seven occasions over the seven-week period of parole, including two home visits. Mr Brady also confirmed Tafari’s progress by making contact with third parties. This was an appropriately high level of supervision.
Although Tafari did not commence mental health treatment prior to his death, Mr Brady explained in evidence that he thought Tafari was doing quite a good job of obtaining referrals himself. Mr Brady did not seek to intervene, because he believed it would be more meaningful if Tafari organised such treatment, as it signalled that he was engaged in the process.15 Given the complexities to Tafari’s presentation, it was going to take time to organise appropriate treatment.
The action taken after Tafari’s admitted drug use on 6 February 2019 is more significant. As noted, following this admission, Mr Brady did not require a drug test, but gave Tafari a direction to cease drug use, and also obtained his consent for a referral for drug counselling.
Corrective Services policy provides that where a parolee is required to undertake drug testing, this must be included in a case plan. The policy identifies situations where drug testing should not be required, including where it is not related to an offender’s risk, and where the test results would not change the supervision response.16
Dr Sullivan opined that there would have been benefits in conducting a rigorous program of urine drug screens, because it may have detected drug use and would also have provided some deterrence against Tafari using drugs. However, he acknowledged that it was speculative to consider the outcome of those tests.
Further, he acknowledged that drug testing is resource-intensive, and can create 15 Brady T159.27-44 16 See Community Corrections Policy and Procedures Manual 12/260, E2 Drug testing at [2.1]-[2.3] Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
a “world of headaches” where parolees do not attend or provide inadequate samples.17
Mr Brady did not update Tafari’s case plan to require drug testing. He accepted in evidence that he had intended to do so, and that this was an oversight.18 It is possible that, had it been included in the case plan, and had Tafari been thereby notified that he would be required to undertake further drug testing, this might have had a deterrent effect and curbed his drug use.19
However, Mr Brady stated that, even if he had included drug testing in Tafari’s case plan, this would not have changed his approach. He did not consider drug testing to be appropriate or necessary during the following weeks. Tafari appeared to be engaging well.20 This is to some extent supported by the fact that Tafari was engaging with a number of health professionals, and that none of them recorded any concerns about drug use. Mr Brady also noted that in his role, he was expected to work with clients regarding drug use, which required the client to be comfortable describing their drug use in order to identify ways to reduce the risk of relapse. Some actions, such as reporting to police, would be counterproductive. There needed to be a balance between managing risk and working with the client.21
While Mr Brady believed there was training provided on this issue, he could not recall specific guidance.22 The policy material provided to the inquest does not give any detailed guidance on how to address this balance, and in particular what circumstances ought to require drug testing in the case of admitted drug use. It would appear desirable that the policy identify circumstances where drug testing will be required. This is so, even though Community Corrections will have what Dr Sullivan described as a “fascinating tightrope to walk between coercion and compliance”, balancing the need to build rapport with a parolee against the need to manage their risk.
17 Sullivan 1/15B [117]; T64.47-T65.16; T65.38-42 18 Brady T168.41-49 19 See Brady T168.30 20 Brady T168.47-T169.3; T166.41-50 21 Brady T165.33-48; T187.10-25 22 Brady T166.2-21 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Tafari’s admitted drug use was potentially a breach of his parole conditions, and an offence, and also a breach of his bail conditions. Guidance issued by Corrective Service provides in effect that an officer must only submit a breach of parole report for drug use where there is a specific direction not to use drugs on the person’s parole. Until 6 February, Tafari did not have such a condition on his parole, and accordingly Mr Brady did not take breach action.23 Policy also provides guidance on what action to take where a parolee has committed a further minor offence, in effect giving discretion to the supervising officer.24
Tafari was also under a specific bail condition not to use drugs. Tafari was subject to strict bail conditions, reflecting his serious charges and the risk he presented. However, Mr Brady did not address his mind to what action, if any, to take in relation to the breach of bail. I am not critical of that, because Community Corrections policy does not currently provide any guidance on this issue. Policy should be amended to provide Community Corrections officers guidance on the circumstances where an officer should report a breach of bail to police, in particular where the breach reflects an identified risk to the community. A recommendation to this effect is made, below.
The evidence clearly establishes that Gabby was at increased risk from Tafari, partly in consequence of his undetected drug use. While I am not critical of Mr Brady, this in an area where policy should be amended to provide further guidance.
Police response to the concern for welfare report
The concern for welfare report made by Emma Russell represented an opportunity take action to protect Gabby. Ms Russell was concerned about Gabby and hoped police would check on Gabby to see if she was safe.25
There were some differences between what Ms Russell believes she reported, and what Sen Cst Parson’s recalls her saying. Ms Russell accepted that her recollection at the time of her statement in August 2019 was likely to have been 23 Brady 8/237A/D Assistant Commissioner’s Memorandum 2018/23 24 Brady 8/237A/C 25 Russell T75.21 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
better than it was during evidence.26 In her statement she recalled telling Sen Cst Parsons that she was concerned about Tafari’s phone call, as he sounded erratic, describing previous violence and that Tafari was “knife-happy”. She recalled saying she was afraid Tafari would stab and potentially kill Gabby.27 It is clear that, regardless of what details Ms Russell gave to police, she was conveying a concern that Gabby had been or would be the victim of domestic violence. Tragically, she was correct; Gabby died within a few hours of her call.
Sen Cst Parsons did not have a recollection of the call, and took no notes, other than the CAD message. The message was brief, and he accepted in hindsight that he could have provided more detail.28 I agree that it would have been appropriate to record more detail in the CAD message. The CAD message was important, because police attending the incident relied on the information.
Sen Cst Parsons also accepted that he understood Ms Russell was concerned about Tafari having physically hurt Gabby again, and that he understood this to be a concern about domestic violence.29 However, he stated that if there had been significant things said to him, he would have recorded these; he specifically denied being told of a concern that Tafari might kill Gabby.30
Sen Cst Walker, who responded to Sen Cst Parson’s CAD message and attended Gabby’s home, also spoke to Ms Russell later in the early hours of 13 March 2019. He similarly denied much of the detail provided by Ms Russell about that call. He accepted that Ms Russell gave more details about her concerns than were recorded in the original CAD message, as is reflected in the more detailed CAD message he created. However, he stated that if something else pertinent had been said, he would have put it in the CAD message.31 Sen Cst Walker also understood Ms Russell’s concern to be about domestic violence.
However, he did not consider that the fact that it was described as a domestic violence incident would have affected his approach to the incident.32 26 Russell T76.46 27 Russell 2/60 [61] 28 Parsons T94.40 29 Parsons T86.19; T87.24 30 Parsons T90.27-28 31 Walker T108.47 32 Walker T106.46; T105.46-T106.1; T111.36-T112.7 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Sen Cst Grime was the officer who eventually spoke with Gabby on the morning of 13 March 2019. He was reluctant to accept the characterisation of the incident as being one involving domestic violence.33 In contrast to Sen Cst Walker, he believed the description of the CAD message did affect his approach to the incident. He understood that an incident described as a domestic violence incident would have engaged the relevant policy, including a requirement that police attend to see the alleged victim.34 He did not do so in Gabby’s case, because when he spoke to her by phone she appeared “chirpy” and answered his questions frankly.
There are sound reasons why all incidents relating to suspected domestic violence should be recorded as such. In addition to ensuring appropriate oversight of all domestic violence incidents, it would be an appropriate way to ensure that police attending domestic violence incidents are aware of their nature. I make a recommendation to this effect, below.
There are also sound reasons why police should, in most cases, attend victims where there is a concern about domestic violence. Seeing a victim may reveal information not available over the phone, including a victim’s physical appearance, location and the other people who are present. There may of course be reasons in particular cases why attending a victim would be unsafe or inappropriate, but absent these exceptional circumstances, police should attend.
In my view, the failure of police to see Gabby following the concern for welfare report represents a missed opportunity to take action to protect her. However, I am not critical of Sen Cst Grime for not seeing Gabby, in circumstances where he did make contact with her by phone, and where Gabby herself indicated that she did not require police assistance.
The NSW Police Force domestic violence policy that was in force at the time of these events was available to the inquest. The policy requires officers to thoroughly investigate domestic violence incidents, and notes that the reluctance of a victim to provide information is not a reason to cease investigating.35 It also 33 Grime T125.30-T126.21 34 Grime T134.38-9 35 Domestic and Family Violence Standard Operating Procedure 2018 7A/190D at p62; Domestic and Family Violence Code of Practice 7A/190C p43 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
requires police to attend an incident, even where a second call is made indicating police are not required.36 However, the policy does not appear to explicitly require police to physically attend all domestic violence incidents. In my view, the policy should be amended to reflect this requirement, other than in exceptional circumstances. A recommendation to this effect is made, below.
Manner of Gabby’s death
She was not asked to give evidence.
A B return to fix the hole. was driving, because could not drive. The two children were in the car as no-one else was available to look after them. B did not have any concerns about Gabby’s safety.37 A Nonetheless, he knew from that Gabby and Tafari had broken up during the previous evening38 and that whatever had occurred between Gabby and Tafari had caused A to go to get C in the middle of the night.39 A
37 B T207.13; T208.40 38 B T197.32 39 B T286.11-46 40 A 1/23 [43]; A 1/24/30 41 B T228.28-35 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
When Gabby called for help, realised that something was amiss, and B she drove away. It is likely that she heard the remarks between and Tafari at the door, rather than what Gabby said, as Gabby was located at the A back of the house and some distance from where was waiting in the car.42 B
then confronted Tafari inside the home. He appears to have wrestled with him in an attempt to protect Gabby. While there were differences between the account he gave in his statement and his account in evidence, they are broadly consistent.43 B
told the Court that he saw Tafari glance to the side, and was concerned he might have a knife, and so left the home to call police. I accept B that is likely to have been concerned for his own safety. The B consequence of leaving the home is that he left Gabby in a very B precarious situation. On account, she was on the floor, with a rope around her legs, had already suffered injuries which required an ambulance,44 B and believed Tafari was armed with a knife. The need to get urgent help would have been obvious.
44 B T219.6-7 45 B T223.40-42 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
He tried to apply pressure to the wound, and then went to wash his hands, before calling triple-zero.46 Again, it is difficult to match those actions with the timing of the calls.
account does not explain why there was blood located along the outside wall of the property by police crime scene officers. It may be that violence B occurred prior to arrival. Nonetheless, when asked about this B blood by police attending the scene, said: Cause he … Cause they ... they were fighting and he's taken her inside, dragged her inside as far as I can tell um and that was when I was in and he didn't want to let me in.47 B
If saw these events, that is inconsistent with the account he gave in B his statement and in evidence. However, in evidence suggested that he might have been speculating when he said this to police. He also said he was “very cranky” at that point with Tafari, possibly suggesting he intended to make things worse for Tafari, although how that could be the case is not clear.48 He was firm in his evidence that he had not observed Gabby and Tafari outside the house.
46 B T239.5-7; T240.1-241.48 47 Body Worn Video transcript, 2/51/3
48 B T252.1-16 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
made after her mother’s death, which suggest she saw something that day,49 B said, “somebody’s said that to her”.50 B
Overall, while there are some troubling aspects to account, I accept that the evidence does not establish any different version of events. The B events of 13 March 2019 would have been traumatic. was not prepared or trained to respond to the highly volatile situation which confronted B him. As a result, may have acted in ways which are now difficult to understand. However, he maintained his account, despite close questioning during the inquest. The matters to which I refer above would leave some doubt as to the circumstances of Gabby’s death. However, on balance, I find that it is B likely that those events occurred substantially as described them.
I find that Tafari assaulted Gabby at her home. He tied her up with a rope, and B A then fatally stabbed her, after had left the home to call and the police. Gabby’s death was a homicide that occurred in the context of domestic violence.
Dissemination of information by police
The efforts made by police to locate Tafari were extensive. While in retrospect other steps might have been taken, I accept that adequate resources were allocated to the search, and that police efforts were appropriate.
One issue during the search which had consequences was the information about Tafari’s family relocating to another address. As I have noted above, following police search of the home on the evening of 13 March, the family decided to spend the night at a different address. The fact that they had relocated was significant, as Tafari might have been expected to attend the home.
A/Insp Laksa directed that this information be disseminated to other officers, and this appears to have been done at the latest by the CAD message sent at 6.17am on 14 March 2019.51 However, that message was only available to officers who had access to the Lake Macquarie CAD system.
49 See e.g. Ryan 1/22 [58]
50 B T255.25 51 CAD message 3/113/349-50; however, see Laksa T314.41-49 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Ch Insp Matthews became aware of the information and relayed it to Det Sen Cst Newton when they spoke about the investigation, in the morning of 14 March 2019.52 He confirm this in an email sent at 7.23am.53 Accordingly, Det Sen Cst Newton was aware of the family’s relocation. He could not recall if he told either of his colleagues, Det Sen Cst Symington or Det Sen Cst Webb; neither of those officers recalled this information.54
It is likely that the police officers attending the briefing scheduled later that morning would have been told about the family’s relocation. However, as mentioned, that briefing did not take place, because police received information that Tafari had attended Bell Street.
The Target Action Group officers from Newcastle were not aware that the family had relocated.55 They were not intended to be part of the briefing, which was for local units only. The CAD message regarding the family relocating had not been sent to them, although it would have been possible for them to obtain it.56 Although not formally assigned to the search for Tafari, the TAG officers understood that they would probably be asked to assist.57 There was an informal briefing between Sgt Piddington and the other officers, during which information relevant to the search for Tafari was discussed. However, the information about the family relocating was not known to Sgt Piddington or the other officers.
As a result, none of the TAG officers knew about the family relocating. Sen Cst Barnet said he believed the family was inside the home.58 Sen Cst Fullick was also concerned that someone was in the house, although he did not know either way.59 As I have mentioned, Sgt Barnett asked Sen Cst Fullick to contact radio to check A location, but this could not occur prior to Tafari’s arrival.60
In contrast, Det Sen Cst Newton was aware that the family had relocated. Det A Sen Cst Webb also had some basis to believe that at least was not 52 Matthews T299.17; Newton T358.12 53 Exhibit 3 54 Newton T377.21-29; cf. Symington T390.18; Webb T449.20 55 See e.g. Barnett T331.41 56 Barnett T332.25-49 57 Barnett T331.46-50 58 Barnett T338.5-10 59 Fullick T428.45 60 Barnet T337.35-44 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
at the home. This was because, while at Glendale, he had received a call from A/Insp Laksa, asking him to return to the station in order to take a statement from
A A As a result, he believed was probably on her way to the police station.61
Surprisingly, neither Det Sen Cst Newton nor Det Sen Cst Webb responded to A the broadcast from Sen Cst Fullick, which was asking about whereabouts, to reveal the information they each knew. They accepted they could have done so.62 However, the time between Sen Cst Fullick’s broadcast and Tafari’s arrival was only about a minute, during which time the radio was A busy. Also, neither officer was in a position to confirm for certain that and her family were not inside the home.63
The evidence shows there was a disconnect between the information known by some police officers about the family’s location, and the officers who attended Tafari’s home in order to apprehend him. This had a possible consequence for the events as they unfolded, as I shall describe below.
Action taken by police at Glendale
While overall I find that police acted appropriately in this incident, there are some aspects of their police conduct which should be highlighted.
Firstly, Tafari clearly presented a high risk to the public, as evidenced by the incidents he had caused following Gabby’s death, including the police pursuit, threats against members of the public and most recently the attempted carjacking in Bell Street.64 There was an urgent need to locate and apprehend Tafari, both to answer for his actions against Gabby and others, and to protect the public from further harm.
Second, as I have noted above, information about the family relocating was not known to the TAG officers. They believed the family could be inside the home and feared that Tafari was going to cause them harm.65 They had tried to confirm 61 Webb T452.22-3 62 Webb T485.5; Newton T363.6-16 63 See for example, Fullick T427.12-13 64 Barnett T335.46- 336.2 65 Barnett T340.7-10 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
A whereabouts by radio, but there was insufficient time to confirm this information. Their belief that the family could be inside the home increased the urgency of their response.66
Conversely, Det Sen Csts Newton and Webb each had an understanding that Tafari’s family were not at the home, although they did not know whether this fact was for certain.67
Third, the six police officers who attended the property had limited knowledge about its layout. Sen Cst Fullick had in fact attended the property at about 2.30pm on 13 March 2019, when the search for Tafari was in its early stages. On that occasion, Sen Cst Fullick walked down the driveway and looked into the back yard, saw the deck and the pool, and also tried to open the garage door, which was locked.68 However, he was not aware that there was a passage on the opposite side of the house which also entered the back yard.69
None of the other officers knew the layout of the property,70 and in particular none knew the cramped nature of the back yard. Their lack of knowledge might have suggested a need to proceed with caution, although this was to be balanced against the competing need for urgency. Had they known the layout of the rear of the property, this might have affected the manner in which they approached it.71
Fourth, although police believed Tafari was going to his home, because he had told Ms Harrison in Bell Street that he wanted to see his mother, Tafari’s arrival by car was sudden and unexpected. Police thought he was going to travel on foot, and the TAG officers locked their car doors in in case Tafari approached their vehicle from behind.72 The suddenness of his arrival contributed to the urgency of the police response to some degree, and also reduced the opportunity for any discussion or planning.
66 Barnett T347.33-36 67 Newton T360.19-32, Webb T449.14-27 68 Fullick T409.8-410.44 69 Fullick T425.5-16 70 See for example, Newton T378.46-7; Barnett T349.27-33 71 Barnett T349.40; Newton T374.10-11 72 Scott T509.47 – 510.4, Barnett T337.9-12 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Fifth, when Sen Cst Fullick saw Tafari enter the driveway, he broadcast to police radio that Tafari had “run into the house”. He intended to convey that Tafari had run onto the property, rather than into the house itself.73 However, on hearing this broadcast, the Detectives Newton, Webb and Symington understood that Tafari had actually entered the house.74 This is despite the fact that Det Sen Cst Webb was also told that Tafari had “gone over the fence”.75 Their belief that Tafari was inside the house affected their approach to the incident, because they believed they were trying to contain Tafari in the house.76 They did not expect to confront Tafari at the rear.
Sixth, there was limited discussion or planning between the six officers about what they were going to do. That said, each team had discussed in broad terms the nature of their task prior to Tafari’s arrival. Sen Cst Barnett had reminded the TAG officers that their aim was to contain and negotiate Tafari at the property.77 He had prior experience as a tactical officer, and he anticipated that tactical police would be involved. Similarly, the Detectives also had a discussion in their vehicle about the situation. They recognised that Tafari being at the home would be a “good opportunity to contain him”.78
However, once Tafari had been seen and police approached the property, the only discussion was to the effect that Sen Cst Fullick asked Detectives to go to the left of the property, while the TAG officers went to the right.79
In light of the urgency of the situation, I am not critical of the fact that there was not more discussion or planning. As Sgt Scott observed, the situation was “very fluid and emerged quickly” and the officers did not have an opportunity for open discussion.80 It was necessary for the officers to locate Tafari, as he was not visible from the street. It was possible, for example, that he had either entered inside the property, but alternatively he might have absconded over the back 73 Fullick T416.23-28; CAD 3/113/3 at 8.58am 74 Symington T401.2-4; Webb T456.33-4, Newton T365.28 75 Webb T464.10-11 76 Newton T 373.12-25 77 Barnett T336.16-47; Barnett 4/121 Q177 78 Newton T365.10-12; Symington T393.29-38 79 Symington T394.11-15 80 Scott T505.33-4 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
fence. It was also necessary to confine Tafari to a known area, in keeping with the guiding principle of “contain and negotiate”.
However, the lack of discussion meant that the information mentioned above was not shared between the officers. There was no discussion about what was known about the family’s whereabouts, or the fact that Tafari had not been seen to enter the house, or what was known about the layout of the property. All these matters conceivably had an impact on the manner in which the officers approached the rear of the property.
In evidence, Sen Cst Fullick denied that, had he known for sure that the family were not present, this would have lessened the immediate risk that Tafari presented.81 Nonetheless, it would appear logical that such information would have lessened the risk. While there may have been people in neighbouring properties, they would have been physically further away, and less at risk. Sgt Scott ultimately agreed with this proposition.82 However, this issue is hypothetical, as none of the officers did know for sure where the family was.
The inquest received evidence about training for planning in such situations, namely NSW Police Force’s STOPAR training. That acronym stands for Stop, Think, Observe, Plan, Act, Review. It is intended to provide a framework for situational awareness and critical thinking, supporting the need for police officers to plan appropriate responses. It has more limited application in high-risk situations, where the “plan” is already pre-determined, namely, that officers should contain and negotiate.83
Of the six officers involved in Tafari’s death, only Sen Cst Scotman had any recollection of STOPAR training.84 However, some elements of the STOPAR model were used by police, at least in the period prior to Tafari’s arrival, in particular by observing and discussing the broad nature of the plan.85 81 Fullick T429.27-30; T439.25-29 82 Scott T500.9-21 83 Scott, T505.7-9 84 Scotman 4/120 Q465; Det Sen Cst Symington was not specifically asked about the training in interview, although each of the others were: see T504.25-30 85 See Scott T509.1-36 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Seventh, the officers proceeded quickly into the rear of the property.86 The Commissioner submits that I should not find the officers moved “too quickly” but that they proceeded appropriately in the circumstances, and had no other option but to locate Tafari as quickly as possible.87 I agree that they acted with the urgency they perceived necessary at the time.
Had there been an opportunity for a discussion about the plan, and had the TAG officers been made aware of the information about the family relocating, this might have affected the speed at which the officers approached the rear of the property.
While Sen Cst Fullick moved quickly towards the rear of the property, I also accept that he did so deliberately and that he was exercising some caution. He considered there was urgency because he believed there were people inside the house.88 He thought Tafari was there to kill his parents.89 On seeing Tafari, he exited his vehicle and ran towards the property, and used a bin to climb over the gate while Sen Cst Scotman covered him. Sen Cst Barnett called out after him, saying, “hold up” or “wait up”.90 While he did not stop, it appears Sen Cst Fullick did slow down, with his firearm drawn and facing partly towards the house, because he was concerned about the possibility that Tafari may “pop out” from under the house.91
Eighth, the fact that the officers moved quickly into the rear of the property had an impact on the way the events unfolded. Det Sen Cst Webb did not see Tafari until he was near the bottom of the stairs that led to the deck. He believes this was because Tafari was partially obscured by the doorway.92
Det Sen Cst Webb’s position at that point was, as I have already noted, very vulnerable. He was located beneath Tafari and close to him, with no physical barrier between them. He could not use the balustrade, because there was 86 See e.g. Webb T463.15-19; 87 See 22 February 2021 T24.13-14 88 Fullick T429.5-7; 89 Fullick 4/119 Q255 90 Fullick 4/119 Q277 91 Fullick 4/119 Q288, Q314-317 92 Webb T462.43-463.6 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
insufficient room for him to hold his firearm in that position.93 The space around Det Sen Cst Webb was cramped, and he was aware that the other officers were approaching from both the left and the right. This in effect meant that he had no exit route.94 Had he proceeded less quickly into that area, he might have stopped at a point which was less vulnerable. However, given his evidence that he was unable to see Tafari prior to the point when he was at the foot of the stairs, it is not possible to conclude that a slower approach would have changed the outcome.
Ninth, Det Sen Cst Webb gave evidence of his attempts to persuade Tafari to drop the knife. He stated that Tafari was holding the knife at chest height, and beckoning with his other hand, repeatedly saying “just shoot me”.95 Tafari was moving towards him on the deck at this point. In response, Det Sen Cst Webb announced himself as a police officer, and told Tafari to drop the knife.96 He said he called Tafari by name, and was using a tone which was “more of a plea”.97 Tafari did not comply. It is therefore clear that Det Sen Cst Webb made efforts to communicate with Tafari and de-escalate the situation before he used his appointments.
Tenth, Det Sen Cst Webb appropriately attempted to discharge his OC spray, transitioning from his firearm to discharge the OC spray with his left hand.98 The OC spray discharged at an insufficient pressure, and did not reach Tafari. A subsequent investigation by police revealed a problem with the particular type of OC spray cannister used. The inquest was told that these have been withdrawn from service, and a replacement is being considered.99 In those circumstances it is unnecessary to take the issue further.
It is not possible to conclude that, if the OC spray had functioned adequately, it would have changed the outcome. OC spray is not always effective in stopping an assailant. However, it is highly regrettable that a less lethal tactical option 93 Webb T469.26-29 94 Scott T494.46 95 Webb T468.8-35 96 Webb T469.16-19 97 Webb T470.24 98 Webb T470.35-39 99 Scott T500.38-T501.14 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
could not be used. It was through no fault of Det Sen Cst Webb, who acted entirely appropriately. Tragically, when the OC spray failed, all tactical options other than a firearm had been exhausted.
Eleventh, I find that Det Sen Cst Webb and Sen Cst Fullick were justified in discharging their firearms.
NSW Police Force policy provides that firearms are only to be discharged when there is no other reasonable course of action available. This occurs when there is an immediate risk to the officer's life or the life of someone else, or there is an immediate risk of serious injury to the officer or someone else and there is no other way of preventing that risk.100 The lawfulness of a decision to discharge a firearm would be determined by the general law, including by operation of s. 230 of the Law Enforcement (Powers and Responsibilities) Act 2002, which permits police officers to use such force as is reasonably necessary to exercise a function under the Act.
Det Sen Cst Webb gave compelling evidence about the moments prior to the shooting. He observed Tafari to take a step back after he had discharged the OC spray, and Tafari then moved quickly towards him.101 He came straight toward Det Sen Cst Webb, with the knife raised above his head and the blade pointing forwards.102 He recalls thinking the “point of no return” was the top stair, and that if Tafari passed that point he would be “either hurt real bad or I’m dead”.103 When Tafari reached that point, Det Sen Cst Webb transitioned back to his firearm, and discharged two rounds.104
Det Sen Cst Webb is unable to recall what happened next. This was due to memory loss, one of the consequences of significant psychological issues that he has suffered following this incident.105 The next thing he recalled was jumping 100 Scott 7/190/10; Police Handbook extract 7/190(17) 101 Webb T472.2-5 102 Webb 472.25-33 103 Webb T473.3-6 104 Webb T472.10-T473.11 105 Webb T443.15-27 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
back and coming into contact with Det Sen Cst Newton.106 This demonstrates how close they were and how limited the space was.
Sen Cst Fullick, who was standing to the other side of the deck, observed Tafari lunging towards Det Sen Cst Webb. He believed Det Sen Cst Webb was in immediate risk of his life.107 He did not consider the use of OC spray, because he did not think it would be effective.108 He therefore also discharged his firearm twice.
By the time these events occurred, there were no other options reasonably available to police. The discharge of firearms was justified in the circumstances.
Manner of Tafari’s death
Dr Sullivan also noted that Tafari’s actions indicated an awareness that he could die, and a potential willingness to die, in that he invited police to shoot him.110 I note that it was not Tafari’s request to shoot him that caused Det Sen Csts Newton and Webb to discharge their firearms, but their concern that Tafari was going to stab and kill Det Sen Cst Newton.
Dr Sullivan noted that Tafari is likely to have realised that he was facing a long prison sentence.111 Tafari had made comments to B to the effect that he would not be returning to gaol.112 This suggests he was resolved not to be apprehended by police.
Tafari would have had an appreciation of the general impact of his behaviour, even though he was intoxicated and possibly psychotic at the time.
106 Webb T473.18-26 107 Fullick T422.9-10 108 Fullick T422.36-40 109 Sullivan T66.33-47 110 Sullivan T66.40-47 111 Sullivan T66.44-47
112 B T289.38-9 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Dr Sullivan’s impression was that Tafari had effected a “suicide by police.”113 I agree that the evidence taken as a whole demonstrates that Tafari intended the consequences of his actions.
While a finding might be recorded that Tafari’s death was “self-inflicted”, this term does not sit easily with a situation where a person provokes a response in others.
Instead, I will make a finding which reflects Tafari’s intentions.
Accordingly, I find that Tafari had sufficient awareness of the consequences of his actions, and that he intended to provoke police to shoot him. I will record a formal finding to that effect.
To the extent that s. 75(5) of the Coroners Act 2009 is engaged by that finding, I will order that these findings may be published, subject to separate nonpublication orders that were made in the course of the inquest.
Sgt Scott helpfully provided some academic research related to the issue of provoked police shootings, which he preferred to describe as “use police to commit self-harm.”114 He noted that police in Victoria have policy or training material specific to this situation, which he had reviewed. NSW Police Force are giving consideration to adopting some of that training in a module of STOPAR training, although that project was “in its infancy”.115
Sgt Scott did not consider it likely that knowledge that a person was intending to provoke police to shoot them would vary the current tactics used by police.116 The Commissioner also opposed a recommendation that police consider discrete policy on the issue. Nonetheless, in my view it is desirable that police officers are given specific guidance on how, if at all, tactics should be varied where a suspect is believed to intend to provoke a police shooting. I make a recommendation to this effect, below.
113 Sullivan T66.28-T67.1; T67.13-41 114 Scott T502.25 115 Scott T502.29 116 Scott T502.12-15 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Findings required by s. 81(1) Gabby
The identity of the deceased The person who died was Gabriella Pamela Thompson.
Date of death Gabriella died on 13 March 2019.
Place of death Gabriella died at the John Hunter Hospital, NSW.
Cause of death Multiple stab wounds.
Manner of death Homicide by a known person, in the context of domestic violence.
Tafari
The identity of the deceased The person who died was Tafari Walton.
Date of death Tafari died on 14 March 2019.
Place of death Tafari died at Glendale, NSW.
Cause of death Gunshot injuries to the head and abdomen.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
Manner of death Tafari was shot as he moved towards a police officer while armed with a knife, intending to provoke the officer to shoot him. The death was a result of police operations.
Recommendations
A number of recommendations have been identified in the course of these reasons.
Tafari’s family proposed a further recommendation, to the effect that the Commissioner should audit compliance with STOPAR training. As I have observed, the involved officers were not generally aware of that training, although they nonetheless demonstrated elements of the process in their approach.
However, as the inquest did not receive evidence generally about the take up of this training, I do not consider a recommendation necessary or desirable.
To the NSW Commissioner of Police: (1) Consider amending NSW Police Force policy, including if appropriate the Domestic and Family Violence Standard Operating Procedures and the Code of Practice for the NSW Police Force Response to Domestic and Family, in order to: a. Clarify the requirement to record a CAD message as "Domestic Violence" where the circumstances reported by the informant relate to suspected domestic violence, even where no offence is reported.
b. Clarify that, where a report relates to domestic violence, responding police officers should attend and talk to the alleged victim personally, unless there are exceptional reasons not to do so.
(2) Consider developing further training and guidance for police officers about the risks of, and appropriate responses to, people who are likely to attempt to use police officers to commit self-harm.
Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
To the Commissioner of Corrective Services NSW (1) Consider amending the Community Corrections Policy and Procedures Manual - Section B1 - Legal Issues at [1.7], to identify the circumstances when a Community Corrections officer should report a suspected breach of bail to police, in particular where the breach relates to an identified risk to the community.
(2) Consider amending the Community Corrections Policy and Procedures Manual - Section E2 - Drug testing, to provide further guidance on the circumstances where drug testing ought to be required of an offender who has admitted drug use.
Conclusion
A referred to the difficulty of dealing with her own grief, and the loss of Gabby, while acknowledging that Tafari had caused Gabby’s death.
Now that findings have been delivered into these deaths, I hope that each family can find some comfort in the fact that the inquest has looked carefully into the circumstances and has identified some areas for future change.
I again express my deepest sympathies for the loss of both Gabby and Tafari.
Finally, I thank my counsel assisting team, Mr Jake Harris and his instructing solicitor from the Crown Solicitor’s Office, Ms Ellyse McGee, for their work in assisting me in this inquest.
T M O’Sullivan NSW State Coroner Lidcombe 30 April 2021 Findings in the Inquests into the deaths of Gabriella Thompson and Tafari Walton
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