Inquest into the death of Brenden Montgomery

CORONERS COURT NEW SOUTH WALES Inquest: Inquest into the death of Brenden Montgomery Hearing dates: 29 August 2022 – 2 September 2022 Date of findings: 12 October 2022 Place of findings: NSW State Coroner’s Court, Lidcombe Findings of: Magistrate C Forbes, Deputy State Coroner Catchwords: CORONIAL LAW- self-inflicted death during the course of a police operation-mandatory inquest-significance of broadcasting threats to kill police on police radio-police contacting triple 0 callers directly-COPS warnings File number: 2020/3733 Representation: Mr W de Mars, Counsel Assisting the Coroner instructed by Mr G Martin, Crown Solicitor’s Office Mr S Fraser instructed by Mr P McManus, Legal Aid, NSW for Ms Pauline Montgomery (Mr Montgomery’s mother) Mr I Fraser instructed by Mr P Hodgetts, Office of General Counsel, for the Commissioner of the NSW Police Force, Senior Constable Alan Thorn and A/Sergeant Mathew Winley (nee Couldrey)

NOTE: PURSUANT TO S 75(5) CORONERS ACT 2009 I PERMIT THE PUBLICATION OF THESE FINDINGS

Findings: Identity The person who died was Brenden Montgomery.

Date of death Mr Montgomery died on 2 January 2020.

Place of death Mr Montgomery died at Liverpool Hospital, NSW.

Cause of death The cause of Mr Montgomery’s s death was Hypoxic Ischaemic Encephalopathy.

Manner of death The manner of Mr Montgomery’s death was self-inflicted.

Non-publication Copies of the non-publication orders made on 28 June 2022 orders: and 12 October 2022

IN THE NSW STATE CORONER’S COURT LIDCOMBE SECTION 81 CORONERS ACT 2009 REASONS FOR DECISION Introduction

1. This is an inquest into the death of Brenden Montgomery who died on 2 January

2020. He was only 36 years of age. Mr Montgomery died at Liverpool Hospital when his life support machine was turned off. Three days before this, on 30 December 2019, he hanged himself in the garage area of his home. At the time, a police operation was underway, and several police officers were present outside his home.

2021. Section 23 of the Coroners Act 2009 (“the Act”) requires a senior coroner to conduct an inquest in cases where a person dies during a police operation. In such cases the community has an expectation that the death will be properly and independently investigated.

2022. The role of a Coroner as set out in s.81 of the Act is to make findings as to: i. the identity of the deceased.

ii. the date and place of the person’s death.

iii. the physical or medical cause of death; and iv. the manner of death, in other words, the circumstances surrounding the death.

4. This Inquest has been a close examination of the circumstances around Mr Montgomery's death and pursuant to s.37 of the Act a summary of the details of this case will be reported to Parliament.

Brenden Montgomery

5. Mr Montgomery had spent much of his adult life living with his parents in their family home. His father had died less than 12 months before, in January 2019. At the time of his death, Mr Montgomery and his mother, Ms Pauline Montgomery, were living

together in the house.

6. His mother stated that Mr Montgomery was a healthy and happy child, although in primary school she wondered whether Mr Montgomery may have had ADHD as he could be erratic and hyper at times, and he wasn’t a great listener.

7. Mr Montgomery finished year 10 at school and then spent 4 years at TAFE where he learnt trade skills in welding and air-conditioning.

8. Ms Montgomery says that in his late teen years, she had the first inkling that Mr Montgomery may have developed issues with his mental health. He would often go through periods when he was very unhappy or depressed.

9. Despite the difficulties that Mr Montgomery had, he appears to have maintained employment throughout most of his adult life. Up until about three months before his death, he worked regularly for a business in Ingleburn that did shop front installations.

10. Ms Montgomery described him as a very kind-hearted person. She explained that he struggled with his mental health more than any of the family realized. She said that she knows how strongly family-oriented he was and just how much his family, his father, his children and everyone he loved meant to him. He was very loved by his family.

Mental Health

11. The brief of evidence contains a considerable volume of material relating to Mr Montgomery’s interactions with police as well as some documents relating to his previous experience of Corrective Services custody, and some brief medical records.

From these records there is evidence that Mr Montgomery had a long-term mental health condition. To the extent there had been any diagnosis, it is described in the records as anxiety and depression.

12. Mr Montgomery had only spent one period in jail of any real substance. This was a period of 7 weeks from late October to mid-December 2018, just over a year before his death.

13. There had been a 3-day period of custody in early November 2008, when case notes

taken at MRRC indicate that during that brief period Mr Montgomery had attempted to cut his wrist with a plastic knife while in court cells and that he told Corrective Services officers that he would harm himself if given the chance, and that he wanted to die. He stated that he had a recent diagnosis of depression, but that he had stopped taking anti-depressant medication that had been prescribed to him.

14. On 5 July 2018, about 18 months before his death, Mr Montgomery was briefly in police custody at Campbelltown Police Station. The Police Custody Management Record from that occasion notes that he had a diagnosis of depression and anxiety for which he took prescription medication daily.

15. Upon his entry into Corrective Services custody on 28 October 2018, his Health Problem Notification Form noted a previous episode of self-harm and a history of depression for which he was on medication. His intake screening questionnaire noted that he currently felt depressed and had depression and anxiety, for which he received medication. When screened by the Justice Health and Forensic Mental Health Network, his history of depression was noted as was the medication he had previously been prescribed.

16. Mr Montgomery’s mother says that Mr Montgomery had a terribly tough time during those weeks in jail in late 2018. Mr Montgomery told her that someone would physically fight him every day, that the experience got to him badly and that he desperately did not want to go back to jail.

17. Corrective Services records also reflect Mr Montgomery being upset that he could not be with his father as his father’s health was declining.

18. Mr Montgomery was released in mid-December 2018 after allegations made against him by his partner (Ms Chloe Staveley) were withdrawn. Soon after this, in January 2019, his father died.

19. In April 2019, Mr Montgomery went to a GP in St Andrews, accompanied by his mother. Records of this visit state that Mr Montgomery had depression on and off for at least 10 years and that he had been on an anti-depressant in the past which he had stopped a few years ago. The doctor noted that in the past Mr Montgomery had thoughts of self-harm and that he had been emotional and teary for a month. He

was said to be stressed, that he found his partner to be difficult, and his father’s death three months earlier was noted. His Kessler 10 score of 36 indicated probable distress. He declined a psychological referral and was prescribed an anti-depressant, Lexapro, to take daily. It was suggested that he come back for review in four weeks.

20. Mr Montgomery returned to the doctor one week later, on 6 May 2019. He reported feeling low, with low motivation, and it appears that he received a letter indicating that he should have some days off work. He indicated that he was taking his medication at that point.

21. Ms Montgomery describes Mr Montgomery becoming very upset in the middle of

2019. He complained that nothing ever went right for him and told his mother that he was going to Kentlyn (a suburb with a large bushland reserve near Campbelltown) to hang himself. Ms Montgomery contacted the police. Police records of this event indicate that Mr Montgomery had told his mother that he believed he would not get bail for a forthcoming court matter. He was visibly upset and told his mother that “I can’t go back to gaol, I have to fight every day, sorry Mummy, I’m going to hang myself.” Police made various efforts to locate Mr Montgomery over the next day, including by triangulating his phone, but to no avail. It appears that by the next day, Mr Montgomery had calmed down as he contacted his mother and told her that he was ok and that he would contact police. Ms Montgomery’s recollection is that when Mr Montgomery later returned home, he told her that the rope had broken when he had tried to hang himself.

2020. A police record dated 27 December 2017 documents an occasion when Mr Montgomery’s father rang police to report that Mr Montgomery was trying to self-harm by taking pills. The matter was categorised by police as a priority 2 matter involving self-harm. An ambulance was informed, and police promptly attended the family home. The police record indicates that Mr Montgomery had become mentally unstable in the context of his relationship issues. He told his parents that when they wake up tomorrow, they would not have a son, and he left the house with two containers of medication. On that occasion police conducted extensive patrols, including the use of PolAir, to locate Mr Montgomery.

2021. Ms Montgomery also recalls that she had been informed that he had a rope hanging from the pergola at the back of the house, which she understood to mean that it was ready if he decided to take his life at any point.

Relationships and domestic violence issues

24. Mr Montgomery had at least two significant relationships as an adult. At the time of his death, he had a 5-year-old daughter from the first of these relationships. He also had two younger children, a girl aged 2 and a half years and a boy aged 18 months from the more recent relationship, with Ms Chloe Staveley.

25. Mr Montgomery and Ms Staveley had what appears to have been a quite tumultuous relationship over a 3-year period leading up to Mr Montgomery’s death. Ms Staveley would often stay with Mr Montgomery at the house in St Andrews. In the period leading up to his death Ms Montgomery says that Mr Montgomery was often staying overnight at Ms Staveley’s place at Claymore. On several occasions during their relationship, they appear to have had arguments, or to have become involved in incidents that were reported to the police as potential domestic violence.

26. Based on police records, the extent to which Mr Montgomery had in fact engaged in any physical violence is not entirely clear. The most serious of his criminal convictions, for which Mr Montgomery received a suspended jail sentence, was an offence of assault occasioning bodily harm that occurred in March 2018, during which it was said that he threw a thong at Ms Staveley while she was sitting up in bed. He does not appear to have had any other convictions for matters involving actual violence. There seems to be little doubt that Mr Montgomery could be volatile and sometimes would engage in angry and verbally abusive arguments that were cause for his conduct to be reported to police.

27. Ms Montgomery describes Mr Montgomery’s relationship with Ms Staveley as toxic.

They would maintain contact despite there being an AVO in place. Ms Montgomery appears to have regarded Ms Stavely as complicit in much of the contact that landed Mr Montgomery in trouble with the police. From Ms Montgomery’s perspective it appears that the motivation for much of Mr Montgomery’s contact with Ms Staveley was his interest in looking after his children. She describes witnessing

Mr Montgomery and Ms Stavely have loud arguments and acknowledges that Mr Montgomery could be intimidating due to his large size. However, she never saw either Mr Montgomery or Ms Stavely engage in physical violence towards each other.

28. Around 26 December 2019, Ms Montgomery went away for a few days to stay with her sister, Felicity Godfrey, in Charlestown near Newcastle. Mr Montgomery drove her to the train station. They had a positive discussion and parted on good terms.

Ms Montgomery did not hear from Mr Montgomery until 30 December, the morning that he hanged himself.

30 December 2019

29. At 9:12 am on 30 December 2019, Ms Staveley made a phone call to Triple 0. In this call she told the operator that Mr Montgomery had been calling her and had said that he would come and “burn the house down if he can’t come see the kids”. She confirmed with the operator that there was an AVO in place that didn’t allow contact.

30. As a result a message was broadcast on the police Computer Assisted Dispatch (CAD) system and two police officers, Senior Constable Alan Thorn and Constable James Mitchell, attended Ms Staveley’s place, arriving at around 10am.

31. Senior Constable Thorn conducted a video recorded interview (DVEC) with Ms Staveley that lasted for about 5 minutes. During the interview, Ms Stavely said:

• She had received two phone calls from Mr Montgomery shortly after 9am that morning followed by a series of 20 further calls, assumed to be from him, that she did not answer.

• During the first of the calls, he asked if he could come and see their kids. She told him “No”. He then rang back and told her that he would come and burn the house down if he couldn’t see the kids. She told him that he couldn’t come.

• A no contact AVO was in place between them.

• Mr Montgomery had also said to her that if she called the police, he would find her and kill her.

32. When Senior Constable Thorn was later interviewed about the nature of any threat

that Ms Staveley told him Mr Montgomery had made, he told investigators that after the DVEC, he had asked Ms Staveley some further questions to clarify what Mr Montgomery had said. At this point, he says that Ms Staveley told him that Mr Montgomery had said, that if she reported the matter to the police, he would “come round and kill you and them”. He said that he took the addition of the words “and them” to be a threat that if she reported the matter to police, he would kill both her and police. He recorded that conversation in his notebook which forms part of the brief of evidence.

33. As a result of taking the complaint from Ms Staveley, Senior Constable Thorn told the police radio operator that: “we’re going to go around to an address in St Andrews to try and hunt this bloke down. I’ve been told that he has threatened to kill police if they turn up and kill her and … the usual kind of stuff”. 1

34. A message was then circulated (on CAD) at 10:31:37-am stating that “HE HAS THREATENED TO KILL POL(Police) IF THEY TURN UP AND THE FM(female)” 2 and asking that another car meet CT22 near the St Andrews residence to cover all entrances and exits.

35. A number of cars acknowledged the request. As a result, between about 10:40am and 10:55am a total of 12 police officers ended up in attendance outside the St Andrews residence.

36. The police were present for about 15 minutes. Two officers entered the backyard and made some observations. Officers also knocked on the front door to try to raise Mr Montgomery. They also tried to open the garage roller door. They thought he may have been home due to; the presence of his car outside the house, hearing Mr Montgomery’s phone ringing from inside the house when they called it, a TV and a fan appeared to be on. However, they were unable to gain contact with Mr Montgomery, and it was decided that they would depart the scene for the timebeing. Senior Constable Thorn says that he intended to try to phone 1 Exhibit 1, Tab 33, audio at 1:19:00.

2 Exhibit 1, Tab 32, page 2.

Mr Montgomery’s mother to assist police in gaining entry. Plain clothes Senior Constable Mears stayed in his car near the address keeping an eye on the house.

37. At 11:26am, about half an hour after the police left, a 000 call was made by Mr Montgomery’s Aunt, Ms Felicity Godfrey who told the operator the following things:

• That she thought that her nephew, Mr Montgomery, was in some trouble, that his mother was with her in Newcastle, and Mr Montgomery had said that “he is tying a noose around his neck in the backyard” at the St Andrews residence.

• That Mr Montgomery was hysterical and was in trouble with his girlfriend and the police. He had said that “he can’t go to gaol and he said he’s got a noose around his neck right now.”

• She clarified that this is what he had told his mother, who was with her.

• In answer to questions of the operator, Ms Godfrey said that he had threatened to kill himself before, and that there were no firearms at the address to her knowledge.

• Ms Godfrey also said that Mr Montgomery had “depression and anxiety and all that stuff so when he thinks somethings going to happen, that’s why he’s gone to this I think.”

38. As a result of the call a CAD message was broadcast and updated in the following terms: “infts nephew Brendan Montgomery has ctcd his mother aa and said he is tieing (sic) noose around neck in backyard”. 3

39. The “job” was broadcast as a concern for welfare matter with a “priority 2” categorisation, which required an immediate response.

40. At about 11:27am plain clothes officer Senior Constable Mears who had remained parked outside the house saw Mr Montgomery outside the front of the house. When he called out to him, Mr Montgomery ran back inside and locked the front door.

3 Exhibit 1, Tab 38, page 5.

41. At this point in time, Senior Constable Thorn was involved in transporting someone from Campbelltown Hospital to Campbelltown Police Station. When he heard this Priority 2 message, at 11.28am he contacted the radio operator and said: “We’re heading back to station one on board from the hospital, can you just remind all those cars of his threat to kill police as well and he’s, obviously he’s wanted”. 4

42. Warnings that referred to him being armed with an edged weapon and threatening with a weapon in the past were broadcast.

43. A message indicating that Mr Montgomery suffered from anxiety and depression, reflecting what Mr Montgomery’s Aunt had told the Triple 0 operator, was also broadcast.

44. The most significant radio message was one sent by Acting Sergeant Matthew Couldrey at 11.33am. By this stage six police officers were on the scene. Acting Sergeant Couldrey was on his way to the scene and said, “Keep everything going, don’t do anything till the dog gets there.” 5 This was a reference to Senior Constable Fairley, a Dog Squad officer who had responded to the priority job indicating that he was 10 minutes away.

45. The Dog Unit officer was the seventeenth and last officer to arrive on scene6 before the entry to the house at 11.42am. Once police did enter, led by the Dog officer, they proceeded to a number of rooms within the main area of the house until an officer spotted Mr Montgomery hanging in the enclosed garage area at 11:43:30am.

46. Mr Montgomery was last known to be alive at the termination of his last phone call to his mother, at about 11:35am. Unfortunately, despite prompt actions by police and the attendance of ambulance officers’ resuscitation was unsuccessful.

Mr Montgomery never regained consciousness before his life support system was turned off three days later at Liverpool Hospital.

47. Phone records indicate that Mr Montgomery had phoned first called his mother at 4 Exhibit 1, Tab 37, audio at 00:01:48.

5 Exhibit 1, Tab 37, audio at 00:06:16.

6 See Exhibit 3.

11:04am, and she returned a further missed call to Mr Montgomery at 11:11am, when they spoke for around 12 minutes. It was evidently the content of this call that led to his aunty, Ms Godfrey’s call to Triple 0 at 11:26am or thereabouts. It was after this call that Mr Montgomery briefly emerged from the house before running back inside after being spotted by Senior Constable Mears. Once back inside the house, the records indicate that Mr Montgomery again phoned his mother, at 11:31am.

It appears that this call ended with Mr Montgomery effectively saying a final farewell to his mother before his voice cut out at 11:35am. This prompted Ms Montgomery to phone her neighbour, Ms Shirley Douglas who took her phone to the police at the scene so that Ms Montgomery could talk directly to them and confirm the urgency of the situation.

ISSUES

48. Unlike in civil or criminal proceedings the issues in an inquest are whether a coroner can make findings and if so whether there are any relevant comments and recommendations that are also to be made. A practice exists where an issues list is prepared before an inquest to provide some structure to the hearing. The issues list neither enlarges, nor constrains the jurisdiction of a coroner.7

49. In this case some of the issues identified at the beginning of the proceedings were no longer of great relevance at the conclusion and evidence emerged during the inquest that gave rise to new issues. I have read and considered all the submissions made by the parties. I am satisfied that the following matters are the relevant issues from this inquest that require comment.

What was the significance of the police radio broadcast that Mr Montgomery had threatened to kill police?

50. Despite the desperate calls to Triple 0, police did not immediately go into Mr Montgomery’s house in attempt to stop him from hanging himself. There were several reasons for this decision. One of the reasons was because a message had 7 For authorities on this point see Inquest into the death of Kumanjayi Walker (Ruling No2) [2022] NTLC 016 pp3-4

been broadcast on police radio that Mr Montgomery had threatened to kill police that morning. That message was broadcast By Senior Constable Thorn who understood that Ms Staveley was referring to police when she told him that Mr Montgomery had threatened to kill her “and them”.

51. A competing, and possible interpretation of the words “and them” is that Mr Montgomery was making a threat against Ms Stavely and the children. This flows from the fact that the words were accompanied by and likely preceded by his threat that he would burn the house down if he could not see the children.

52. Ms Stavely made a statement that she did not say Mr Montgomery was going to kill the police.

53. Senior Constable Thorn gave evidence that a threat to kill police occurred in his estimation in six out of every ten domestic violence jobs that police were involved in. It is possible that this was an incorrect assumption made by Senior Constable Thorn.

54. Whether or not Mr Montgomery made a threat to kill police became of critical significance in this case. Senior Constable Thorn’s subsequent warnings on the police radio influenced the decisions that were made by police.

55. In hindsight, in cases like this, where threats are ambiguous, it is important that police clarify a threat before it is broadcast as a warning. Clearly the warning that was broadcast heightened the perceived risk that the police faced upon entering the St Andrews residence and informed the decision to wait for the Dog Unit to arrive.

Was the first police attendance at the St Andrews residence appropriate?

56. When the officers arrived at the St Andrews residence on the first occasion, they made a concerted effort to try to gain entry to the premises. They were attending at his house to arrest him.

57. They were told by a neighbour that Mr Montgomery slept in the garage area, and they attempted to open the garage door.

58. Two officers climbed into the backyard. They were able to look through a hole in the backdoor which appeared to lead into the garage. There was a padlock and a chain

was bolted from the door down to a cement block or something that was on the ground.

59. The police gave evidence that they were trying the doors and attempting to ascertain if Mr Montgomery was present in the premises and attempting to communicate with him.

60. The officers formed the view that it was highly likely that Mr Montgomery was inside for the following reasons:

• The car he was known to use was parked outside.

• The front latch had been locked from the inside.

• When they called his phone, it could be heard to ring from inside.

• They observed a TV to be on inside and movement of blinds that indicated that a fan was turned on.

61. They were of the opinion that they did not have the requisite belief that he was in the house so that their power to enter his home and arrest him had not been enlivened pursuant to the Law Enforcement (Powers and Responsibilities) Act 2002.

62. Ultimately, the police made the decision to depart and left one plain clothes officer observing the premises. Police Operational Safety Instructor, Sergeant Dadd informed this court that there are greater risks on entering unknown premises in which a person is present, and that it is much safer for police to remain outside of a house with less chance of an escalation of the situation with possible impromptu weapons and surprise attacks. I am satisfied that the police actions were appropriate at this time.

What was the significance of the first Triple 0 Call?

63. At 11:26am a distressed Triple 0 call was made by Mr Montgomery’s auntie. She provided the information that Mr Montgomery had “… a noose around his neck now”. 8

64. The police responded immediately to that concern for welfare.

8 Exhibit 1, Tab 44, page 1.

65. Two minutes after that call, Mr Montgomery was observed coming through his front door by the officer that remained near the St Andrews residence and when Mr Montgomery was confronted by that police officer he ran back inside and locked the door.

66. Other officers who arrived shortly after reported that there was no noose in the backyard and that they could not see Mr Montgomery in the backyard.

67. Because Mr Montgomery had been seen out the front of the property and no noose was seen in the backyard, Acting Sergeant Couldrey believed there was little risk in relation to the self-harm that had been reported.

68. He made a radio call at 11:33:02 and advised “Keep everyone going, don’t do anything until the dog arrives”. 9 This decision was critical to the manner in which the matter ultimately resolved.

69. In hindsight it is apparent that not enough consideration was given to the likelihood that despite Mr Montgomery coming outside there remained a significant ongoing risk that he was going to harm himself. His fear that police would arrest him and place him in custody had in fact now been elevated.

70. Once Acting Sergeant Couldrey made his 11:32:02 call, police waited for a further six and a half minutes for the arrival of the dog and for a further nine minutes till they forced entry. These times were critical. The strap attaching Mr Montgomery's body to the rafter in the garage was cut by police at 11:43am. The termination of his last call to his mother was at 11:35am.

71. Sergeant Dadd, Police Operational Safety Instructor, agreed that if Acting Sergeant Couldrey rang Mr Montgomery’s aunt, who had made the triple 0 call, in order to get direct evidence to assess the degree of risk posed to Mr Montgomery that a different course of action may have occurred. Acting Sergeant Couldrey may not have made the decision to wait for the dog handler to arrive. The telephone number of Mr Montgomery’s auntie was readily available. If he had rung her, Acting Sergeant Couldrey may have had a much clearer appreciation of the urgency of the situation 9 Exhibit 1, Tab 37, audio at 00:06:16.

in relation to the self-harm risk. In hindsight this is one of the lessons that could be learnt from the circumstances surrounding Mr Montgomery’s death.

72. It is notable that at the point of Ms Montgomery’s direct call to police at the scene, via the neighbour Shirley Douglas, that the nature of the self-harm threat was then plainly accepted as overwhelming and dire. Mrs Montgomery was also able to give police permission to enter the premises.

Should police have waited for the Dog Unit to arrive

73. The decision to wait for the dog unit was because;

• Mr Montgomery was wanted for an offence,

• he had locked himself inside the house and

• police believed he had threatened to kill police earlier that day.

74. When the dog handler entered the house, he barked loud commands and the dog was barking. He had not been informed that the person inside was reported to have his head in a noose. In hindsight, it was not appropriate to force entry in this manner into a situation where somebody had threatened immediate self-harm and was suffering with mental health issues.

75. I was pleased to receive information from the Commissioner of NSW Police that when there is no perceived threat against police a dog unit would not usually be required to attend. It was the perceived threat to kill police that resulted in the decision to wait for the dog unit.

Mental Health training of the NSW Police Force

76. It became apparent during the inquest that the level of training in mental health for both Acting Sergeant Couldrey and for the dog unit was limited. Acting Sergeant Couldrey gave evidence that he had one day of mental health training in about 2015.

Officer Fairley of the Dog Unit gave evidence that both he and other officers of the Dog Unit had been trained in mental health. The training consisted of a two-hour online module completed some years ago.

77. In recent inquests, recommendations have been made in relation to mental health

training for the NSW Police Force. This is a large issue and I do not have the appropriate information before me, in this matter, to make further recommendations on the topic. I do however request that the NSW Commissioner for Police consider the scenario and police actions in Mr Montgomery’s death when she is considering the recent recommendations made by coroners in relation to mental health training for the NSW Police Force.

COPS Warnings

78. During the investigation of this matter it became apparent that a warning had been placed on the COPS system in relation Mr Montgomery due to an incident that occurred on the 9th of August 2015. That warning referred to Mr Montgomery being in possession of an edged weapon or blade.

79. As it turned out he had been in possession of a “feeler gauge” which has no blade or edge element to it. Mr Montgomery's family are concerned that this inaccurate warning that was broadcast also had the potential to heighten the perceived risk to police. While it appears from the evidence that no significant weight was placed on this warning by police on 2 January 2020 it is important that police warnings of such a nature are accurate and justified. The Commissioner of NSW Police should consider and review the policies and systems in relation to the creation and storage of warnings on the police system.

CONCLUSION

80. Mr Montgomery suffered a long-term mental illness. He was adamant that he did not want to go back into custody. The presence of the police outside his home and wanting to arrest him was the motive for his decision to take his life.

81. The Police Operational Safety Instructor, Sergeant Dadd, gave evidence that the actions of police on this morning sit within the STOPAR critical thinking mode and I accept the reasons given by police for their actions on the day. However, that does not mean that there are no lessons to be learnt from the circumstances surrounding Mr Montgomery’s death. In particular, the police should, if possible, clarify at the time of receiving any ambiguous threats, before they broadcast them on the police radio. Furthermore, police should consider ringing and speaking to a person making

a triple 0 call of this nature, to assess the urgency and ongoing nature of a threat of self-harm. The benefit of this course of action was born out by what happened in this case.

82. On behalf of the Corners Court of NSW, I offer my sincere and respectful condolences to Mr Montgomery's family. It is evident that his loss is felt most deeply.

Findings: s 81 Coroners Act 2009 Identity The person who died was Brenden Montgomery.

Date of death Mr Montgomery died on 2 January 2020.

Place of death Mr Montgomery died at Liverpool Hospital, NSW.

Cause of death The cause of Mr Montgomery’s s death was Hypoxic Ischaemic Encephalopathy.

Manner of death The manner of Mr Montgomery’s death was self-inflicted.

Magistrate C Forbes Deputy State Coroner 12 October 2022 Coroners Court of New South Wales

Form 16 Coroners Act 2009, Section 74

NON-PUBLICATION ORDER COURT DETAILS Court State Coroner’s Court of NSW Registry 1A Main Avenue, Lidcombe NSW 2141 Case number 2020/3733

PROCEEDINGS Inquest into the death of Brenden MONTGOMERY

TERMS OF ORDER The Court orders:

1. That the following information in the brief of evidence not be published under section 74(1)(b) of the Coroners Act 2009 (NSW): a. Any information in NSW Police Force COPS Events and Intelligence Reports under Tabs 40, 41, 61, 62 and 63 that discloses: i. personal phone numbers, email addresses and addresses of persons other than Brenden Montgomery ii. information (including images) that identifies or tends to identify any children iii. assessments or reports of children or young persons at risk, including the entirety of any Child/Young Person at Risk Incident details and Community Services Report Questions and Responses b. The names and telephone numbers of all persons, other than Pauline, that appear in the photographs of Shirley Douglas’ phone under Tab 31A.

SIGNATURE Signature Name Carmel Forbes Capacity Deputy State Coroner, Magistrate Date 28 June 2022

NON PUBLICATION ORDER COURT DETAILS Court State Coroner’s Court of NSW Registry Lidcombe Case number 2020/3733

TITLE OF PROCEEDINGS Inquest into the death of Brenden Montgomery

TERMS OF ORDER MADE BY THE COURT Pursuant to s. 74(1)(b) of the Coroners Act 2009, the Court orders that:

1. There is to be no publication of the documents titled “COPS warning change info” and “July 2020 Police Monthly article re COPS changes” tendered in this proceeding on 2 September 2022 and marked Exhibit 4.

SIGNATURE Signature: Name Carmel Forbes Capacity Deputy State Coroner, Magistrate Date 12 October 2022