Inquest into the death of Trent Nathan Carter

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Trent Nathan Carter Hearing dates: 11-13 April 2023 Date of findings: 13 April 2023 Place of findings: Lidcombe Findings of: Magistrate Kennedy Deputy State Coroner Catchwords: CORONIAL LAW – Police Operation, motorcycle accident, traffic stop, methylamphetamine effects and contribution File number: 2021/00176671 Representation: Mr Andrew Wong Counsel assisting the Coroner with Ms Edgell, Solicitor instructing CSO Mr Craig Norman Office of General Counsel on behalf of New South Wales Commissioner of Police Mr Garrett Bithell, Trial Advocate ALS with Ms Farahbahkt Solicitor instructing ALS

Findings: The identity of the deceased The deceased person was Trent Nathan Carter Date of death 18 June 2021 Place of death St George Hospital, New South Wales Cause of death Complications of multiple blunt force injuries Manner of death Misadventure (motorcycle accident) Recommendations Nil Non-Publication Orders Non-publication orders prohibiting publication of certain evidence pursuant to the Coroners Act 2009 have been made in this Inquest. A copy of these orders, and corresponding orders pursuant to section 65 of the Act, can be found on the Registry file.

Table of Contents

Introduction:

1. Trent Nathan Carter was aged 30 years at the time of his death. Trent was the beloved son of Wayne Carter and Anne Cooley and the older brother of Chantelle, Liam, and Tyrell. Tragically Trent’s mother passed away only months after his death.

2. Trent died on the afternoon of 18 June 2021 as a result of an accident that occurred at 12:40pm on 7 June 2021. Trent was riding his motorcycle east-bound on the M5 Motorway. As he left the motorway at the King Georges Road exit, he lost control and collided with four other vehicles before coming to rest.

3. Section 23(1)(c) of the Coroners Act 2009 provides that a senior coroner has jurisdiction to hold an inquest if it appears or there is reasonable cause to suspect that a person has died as a result of a police operation. Minutes before the collisions, police officers in a police vehicle had attempted a traffic stop on Trent’s motorcycle believing he had committed various traffic offences.

4. The attempted stop by officers of Trent for the purposes of taking action in respect of suspected offences falls within the definition of a police operation as set out in s. 23(2) of the Coroners Act 2009.

5. As a result, section 27(1)(b) of the Coroners Act 2009 provides that an inquest is required to be held in these circumstances, making this inquest mandatory.

Introductory remarks

6. The coroner’s primary function is set out in s. 81 of the Coroners Act 2009. It is to make findings as to the identity of the person who has died, the date and place of their death and the manner and cause of death. The inquest is not adversarial, but inquisitorial.

The focus is to determine what happened without attributing blame, guilt or making findings of liability.

7. In this case, there is no controversy as to identity or the date and place of death. The manner and cause of death were the subject of the inquest. This included the circumstances directly leading up to when Trent lost control of his motorcycle and collided with other vehicles. The questions for determination traversed the

appropriateness of the decision of officers in to engage in a traffic stop or urgent duty driving, whether a police pursuit occurred at any time and the role that illicit drugs may have played in the collisions. The mechanical condition of Trent’s motorcycle has also been investigated.

The Inquest: A. Reflection on the life of Trent

8. While it appears that Trent died in the context of a police operation and had previous issues with the law, it would be easy to view Trent’s life through the prism of what occurred on 7 June 2021. It should be noted that this inquest really covered mere minutes leading up to Trent’s death. However, it is important to reflect on who Trent was. It is clear that Trent had a rich life prior to his passing and he was very dear to his family and friends and his passing has had a profound impact on his loved ones.

9. Trent was born on 19 July 1990. He was the eldest of four children to his father Wayne Arthur Carter and mother Anne Cooley. He had three younger siblings Chantelle, Liam, and Tyrell. Trent lived at home.

10. Trent grew up in a household where he was exposed to drug use and crime. He also witnessed and was influenced by his father’s previous negative relationship with police. When he reached his teenage years, he started to rebel and found his way into trouble with the criminal justice system and his adulthood was marked by periods in and out of prison.

11. Despite the difficulties Trent had with police, there was always love in the family home. This love was evidenced by the fact that Trent played a very active role looking after his mother who had health issues. In fact, on the day of the collision, Mr Carter recalls going to work in the morning and leaving Trent to care for his mother. Trent was on his bike on his way to help his sister move his grandmother’s belongings when the incident occurred. He was trying to do the right thing by his family. She had tragically passed away only days before the accident, and Trent was in mourning for her.

12. Trent struggled with mental health issues, but in the last three years was trying to turn his life around. There were periods when he worked with his father at the same demolition business and he was beginning to enjoy earning his own money.

13. In a very moving family statement Mr Wayne Carter painted a picture of a fun loving, gregarious young man, who drew others to him with his energetic and infectious personality. He was at the centre of many groups of friends, and people sought out his company. He had been diagnosed with ADHD and was prone to acting fast. His family worked hard to influence him to avoid the criminal element. His father guided him but Trent had been impacted so very young by the criminal justice system that his father had trouble reaching him. In the years leading to his death Trent was showing real progress and improvement and was starting to make a happier life for himself.

14. There can be no doubt that he had a strong and supportive family. His father was still trying to be a guide to Trent. He himself had turned his own life around and was a living example to Trent of how life could be better. The support and participation by Trent’s family at the inquest was profoundly moving, and clear evidence of the love and support that he had received in his life, how important Trent was to each of them.

15. Even in the terrible time of grief, his family made the decision to allow Trent to donate organs, to assist others in the community who were in desperate need and is recognised as a last generous and precious gift by Trent.

Events leading up to 7 June 2021

16. Counsel assisting provided a factual background that was not in contention in this inquest, which I repeat in part below.

17. Mr Wayne Carter and his brother Mr Darren Carter had received some money as part of the Redress reparations scheme. Wayne Carter wanted to help his son and 4 weeks before 7 June 2021, he gave Trent $8,000. Trent’s uncle Mr Darren Carter also gave Trent some money.

18. Trent told his father that he wanted to buy a motorbike. Mr Carter spoke with Trent on 6 June 2021. He said Trent told him he saw a motorbike on Facebook Marketplace and he had attended the seller’s home a few days earlier and had paid for the bike.

19. At the time of the collision, there were a number of factors that may have played a role in what ultimately occurred: a) Trent was an inexperienced rider who had only obtained his motorcycle learners licence recently.

b) The motorcycle he was riding, a Suzuki GSXR 600, was not a learner approved motorcycle.

c) It was a motorcycle that was new to Trent, and he was not experienced riding that particular bike.

d) Wayne Carter noted that in the last few years, Trent had negative experiences with the police and had been involved in such things as police pursuits which sat with his desire to avoid police. As Wayne Carter described the situation, “I know Trent’s reaction to the police car and sirens would unfortunately trigger flight in his reaction”. He also stated that “Trent was a person who did everything at 100 miles an hour, he talked 100 miles an hour, he walked 100 miles an hour, he lived life at 100 miles an hour and he would drive and ride at 100 miles an hour”.

e) Trent had a history of drug use where he had previously used heroin, ice, Xanax, and cannabis.

f) After the collision, police located 6.6g of cannabis in Trent’s jacket pocket and the toxicology report detected the presence of methylamphetamine, its metabolite amphetamine and delta-9-tetrahydrocannabinol and delta-THC-acid.

B. Events of 7 June 2021

20. On the afternoon of the collision at 12:40pm Trent was riding the Suzuki motorcycle.

He entered the M5 Motorway via the Belmore Road on-ramp and headed east-bound.

At the same a fully marked police sedan vehicle, SG38, was also travelling east on the motorway. That police car was being driven by Senior Constable Kyle Ferguson.

Leading Senior Constable Jayd Cunningham was in the front passenger seat, seated behind her was Constable Adam Barham and seated behind the driver was Constable Naomi Joseph.

21. Leading Senior Constable Cunningham saw Trent on the motorway and formed the view he was travelling above the speed limit of 100km/hr and saw the motorcycle weave through traffic. As Trent passed them Leading Senior Constable Cunningham observed Trent travelling in an unsafe manner in the breakdown lane before cutting through traffic back towards the lane they were travelling. Leading Senior Constable Cunningham said, “We can’t ignore that”. Senior Constable Ferguson activated the lights, as he travelled around a utility to get closer to Trent, he then activated the sirens as well. As soon as the sirens were activated, Trent accelerated harshly and cut across lanes and through traffic on the motorway and entered the breakdown lane again.

22. Senior Constable Ferguson stated that he activated the lights and sirens, as he wanted to pull Trent over due to his manner of driving. When the lights and sirens were activated, Trent was 50 to 60 metres in front of the police vehicle, the police accelerated to 115km/hr – 120km/hr to catch up with Trent and Senior Constable Ferguson stated that as he accelerated, he saw Trent look in his direction before harshly accelerating away. It was at this point he decided to deactivate the lights and sirens and drop his speed back down to the speed limit. Senior Constable Ferguson believed that the lights and sirens were probably only on for 5 to 10 seconds.

23. After police activated lights and sirens, Trent took the next exit on the M5 Motorway located at King Georges Road. As he exited the off-ramp he proceeded to undertake a number of vehicles travelling in lane one of four. At this point Trent collided with four near stationary or slow-moving vehicles, namely a Kia Cerrato, Iveco Prime Mover truck, Subaru Forrester, and Mazda 6 sedan.

24. Leading Senior Constable Brett Hobbins from the Metropolitan Crash Investigation Unit attended the scene on the day of the collision at 3:45pm. Based on his expertise and as a result of his observations, he formed the view that: a) While Trent was in the off-ramp towards King Georges Road, at some point while undertaking, he broke harshly and his motorcycle fell to its offside and started to slide along the road surface and side-swiped the nearside of the Kia Cerrato vehicle.

b) The motorcycle then grazed the rear mudflap of the nearside of the Iveco Prime Mover truck. This changed the momentum and direction of the motorcycle causing it to commence sliding towards the concrete kerb on the side of the off-ramp.

c) The motorcycle impacted with the raised concrete kerb, causing the motorcycle to change direction and travel towards the Subaru Forrester in lane one.

d) The motorcycle impacted with the nearside of the Subaru Forrester causing the motorcycle to change direction again towards the concrete gutter. It appears Trent was sliding along the roadway as there was a trail of red fabric on the road matching the jacket he wore.

e) His motorcycle then impacted heavily with the Mazda 6 sedan before coming to rest a few metres in front of the Mazda 6 sedan.

25. Police also took the King Georges Road exit. It was accepted that police were always intending to take that exit in order to return to St George Police Station. The officers noticed members of the public waving their hands and Senior Constable Ferguson pulled over and activated the warning lights.

26. The officers saw Trent lying face down on the road behind the rear bumper of a stationary vehicle. His head was rolled to the left facing under the car and his arms were by his sides. Leading Senior Constable Cunningham reached for his hand and told him they were there to help and asked him to squeeze her hand if he could hear her.

There was no response.

27. Senior Constable Ferguson called for assistance on the police radio and when the ambulance arrived, Trent was treated at the scene before being transported to St George Hospital. While at the hospital, he underwent treatment for a traumatic brain injury, high spinal trauma, spinal cord transection and multiple superficial abrasions.

Trent’s condition did not improve as a result of treatment, which included surgery.

Ultimately a decision was made by his family to withdraw further care and Trent was declared deceased on 18 June 2021 at 12:57pm.

Actions of NSWPF Officers The appropriateness of the decision of the officers to engage in a traffic stop or urgent duty driving in an attempt to stop the Suzuki motorcycle KNL12 and whether Senior Constable Kyle Ferguson, as driver of SG38, engaged in a police pursuit.

28. Officers Ferguson and Cunningham initially decided to engage in a traffic stop. They both turned their mind, independently of each other, that they could not ignore the poor and dangerous driving that they had witnessed. They were on duty, in a marked police car and wanted to protect Trent and all road users from his manner of driving.

It was acknowledged that he was more vulnerable by virtue of the fact that he was riding a motorcycle.

29. The officers did not know Trent, they did not know who was riding the bike. They had been unable to obtain the registration details.

30. In both officers’ evidence there was an element of reluctance to engage in a traffic stop, they both started from a position of “we can’t ignore that driving”, which inferentially supports a finding that they were carefully questioning the need for the stop.

31. Submissions were made, and I accept that it was Senior Constable Ferguson as the driver who was the ultimate decision maker. However, the evidence of Leading Senior Constable Cunningham was supportive and in agreement with his decision making, and this evidence corroborated the decisions made.

32. A question arises as to whether there was a lawful basis for officers in SG38 to engage in a traffic stop. Sergeant Brendan Gregory states that s. 169A of the Road Transport Act 2013 and s. 36A of the Law Enforcement (Powers and Responsibilities) Act 2022 empowered SG38 to attempt a traffic stop.

33. Section 169A(1) of the Road Transport Act 2013 applies to any light vehicle on any road. A light vehicle includes a motorcycle. Section 169A(2) allows an authorised officer (which is defined to include a police officer) to direct a driver of a light vehicle to stop for the purpose of or in connection with exercising other powers under the road transport legislation.

34. Section 36A of the Law Enforcement (Powers and Responsibilities) Act 2022 states that: A police officer may stop a vehicle if the police officer suspects on reasonable grounds that the driver of, or a passenger in or on, the vehicle is a person in respect of whom the police officer has grounds to exercise a power of arrest or detention or a search power under this Act or any other law.

35. Each officer in SG38 formed a view that Trent had committed an offence that would allow them to exercise a power under s. 169A or s.36A. Evidence of suspected offending includes: a) Senior Constable Ferguson gave evidence that he saw Trent travelling above the speed limit in the breakdown lane and overtaking one or two other vehicles.

b) Senior Constable Ferguson also stated that before he activated the lights and sirens he recalls saying “Did you see him undertaking” and Leading Senior Constable Cunningham replied, “Yes he’s driving dangerously”.

c) In his directed interview Senior Constable Ferguson said he intended to pull over the motorcycle due to its manner of riding.

d) Leading Senior Constable Cunningham gave evidence that in her mind, there were a number of offences that had been committed. These included driving in manner dangerous, changing lanes not safely, not using indicator and speeding. She said she considered the driving in a manner dangerous the most serious offence.

e) Leading Senior Constable Cunningham said in her directed interview that as SG38 approached the Belmore Road exit on the M5 Motorway, she saw a motorcycle traveling above the speed limit, weaving through traffic and riding in the breakdown lane in an unsafe manner. As a result, she said to the others, “We can’t ignore that” and SC Ferguson agreed.

f) Constable Barham in his directed interview stated that he saw the motorcyclist travelling over the speed limit and going into the stopping lane and weaving back into traffic.

g) Constable Joseph gave evidence that she believed the motorcyclist was travelling at a greater speed than surrounding traffic. In her directed interview she referred

to the motorcyclist coming down the inside shoulder lane coming down Belmore Road and accelerating on the inside before swerving into lane 2.

36. Ultimately, they considered the need for safety for all road users, including Trent, required them to take action. This risk assessment was a required step by the officers to take to properly give attention and consideration to the Safe Driving Policy 6-4.

They acted in a protective role for both Trent and the community. They approached the task carefully, clearly weighing up the need for the stop as opposed to the consequences of not taking action.

37. There was an evidentiary difference as to whether lights and sirens were on, consistent with the policy requirements. Constable Barham and Joseph could not confirm that lights and siren were on. The senior officers were in the best position to be aware of lights and siren. I accepted the evidence that Senior Constable Ferguson did activate both, corroborated by Leading Senior Constable Cunningham.

38. Equally the two senior officers were of one mind in calling an end to the intended stop.

As soon as reasonably practicable after Trent accelerated away, they ceased following him. The footage watched could be counted in seconds rather than minutes. The lights went on, a utility in front of police moved and they accelerated, putting on the siren.

Trent then accelerated changing lanes and police increased speed up to 115-120 km/hr and also changed lane to position themselves behind him. Trent then moved lanes. Police did not. They deactivated the lights and sirens and pulled back their speed to the speed limit.

39. These officers recognised the danger in engaging further and appropriately altered their actions. As Sergeant Gregory said in his evidence after a thorough review of the matter, they applied the policy, did not engage in a pursuit and dropped off the stop.

He was cross examined about lights and sirens lingering, however he provided evidence that firstly the officer driving would need to keep those in the car and around him safe as he dropped back into normal traffic, before he managed to disengage lights and siren.

40. The evidence supports the fact that Trent fled in haste in response to police activating lights and sirens, that evidence can be found from the following matters:

a) The distance from the Belmore Road on-ramp and King Georges Road off-ramp is about 2 kilometres and there is no exit/entry to the motorway in between. It is unlikely Trent would have entered the M5 Motorway only to exit a short distance later.

b) Once the sirens were activated, Trent accelerated harshly and immediately cut across traffic into the left-hand breakdown lane.

c) Trent looked in the direction of police, likely seeing the marked car with lights and sirens before accelerating harshly away.

d) There is evidence from his father that Trent would ordinarily avoid contact with police.

e) There is evidence that will be explored below that Trent was suffering the effects of illicit substances.

41. That Trent reacted the way he did was a tragedy for him and his family. It highlights the serious implications of lights and sirens in a case such as this, and how seemingly a simple decision of police can ultimately result in such devastating consequences.

42. In this matter the police involved took their powers and the decision to stop Trent very seriously, they applied policy, they questioned the need to take action, however in this case the need to pull over Trent was something that was pressing or demanding prompt action.

43. An ordinary road user observing Trent’s manner of driving would in this case have expected the police would try and prevent careless and unsafe driving.

44. Importantly these officers were not caught up in the need to chase, indeed very quickly using experienced policing instincts they knew Trent had made a poor decision, and for the sake of everyone’s safety they pulled out of the stop, even though they intended to take action for suspected offending. Such suspected offending included speeding, negligent driving or driving furiously, recklessly or in a manner dangerous.

45. On the evidence before me the senior officers acted properly and appropriately in both attempting to stop Trent, and deciding to cease that stop when danger presented itself.

46. Submissions were made appropriately on behalf of the family that the timing of the following of Trent’s vehicle and the application of lights and sirens should be scrutinised carefully. The family raised concerns that the police were following Trent for longer than they believed, after considering the objective CCTV footage. They raise the issue that perhaps if a decision had been made faster to pull back from Trent, that a different outcome may have been a possibility. The reality is that lights and sirens and the presence of a police car prompted Trent to accelerate to avoid police.

47. In hindsight, knowing the events as they unfolded it is not difficult to accept police would possibly make a number of different choices, but in the moment a decision was made based on the information available to them. The family highlights the need for police to always carefully consider their actions knowing that there can be far reaching and serious consequences.

48. Submissions were made that a pursuit can be found on the evidence. I am however satisfied that there was no pursuit. The initial following of Trent was as a result of the intended stop, and was proper police practice with lights and sirens. It was clear that the requirements of 7-1 of the Safe Driving Policy were not satisfied to make a finding of pursuit. There was no determination made to pursue Trent. I accepted the evidence from Senior Constable Ferguson that he made no such determination. In fact the evidence supported a finding to the contrary, a decision was made to cease the traffic stop in the interests of safety.

49. Senior Constable Ferguson specifically said that after he activated the lights and sirens and Trent started to accelerate away, “I said, no, he’s driving way too dangerously. I’m gonna stop. I’m gonna switch, I’m gonna stop following him”. Leading Senior Constable Cunningham spoke about her belief as to what was in Senior Constable Ferguson’s mind at the time. She stated, “SC Ferguson went down and turned off the lights as soon as we realised it was, uh, too dangerous to continue, um, which I agreed with and would have told him to do otherwise”.

50. Constable Joseph gave evidence that her impression was that they were no longer involving themselves with Trent. She gave evidence that Leading Senior Constable Cunningham verbalised her concerns about the action of the rider.

51. I accepted that it was the intention of the officers to use the same exit used by Trent, in fact the police believed Trent would have continued on the M5, rather than turning off. CCTV demonstrates a time gap of a significant number of seconds when police exited the M5 after Trent had already taken the exit and had the collisions, which further supports the finding that police were no longer intentionally following Trent.

52. Leading Senior Constable Cunningham was careful and helpful in her recount of events. She impressed as a serious and committed officer, and was compassionate towards Trent, getting under the car with him, holding his hand, speaking to him and trying to reassure him. She described a devastating scene, with a family with a small baby standing by shocked, covered in glass. She, with the other officers took control of the scene, acted swiftly and appropriately to try and save Trent and maintain safety around them.

53. Senior Constable Ferguson’s evidence was that he was careful in his decision making, both to commence a stop and to disengage as soon as he realised that Trent’s driving had become even more dangerous after initiating the stop. I accepted his careful and considered evidence. I also accept that the process of reasoning requires time, particularly when he was the driver, initiating a stop, in traffic at speed, responsible to other road users and the three officers in his vehicle. He had a large number of tasks to undertake while reasoning through his next action.

54. Constable Joseph and Barham also assisted the inquest in corroborating the events in the police car, and ensuring that the inquest had the benefit of transparency while exploring the decision making process.

55. The police did follow Trent for a period of time to effect the stop, in the 17 seconds or so a decision was made to put on lights to move a car out of the way, change lanes, accelerate and add sirens and then a decision to stop and pull back.

The effect of Methylamphetamine and other drugs on Trent’s driving

56. It is of little comfort to Trent’s family that he was affected by substances as he drove, although it may help to understand why he both acted in the manner he did and lost control of his motorcycle.

57. The toxicology results showed that Trent had a variety of illicit substances detected in his sample of antemortem blood. These illicit substances included: a) methylamphetamine (0.39mg/L); b) its metabolite amphetamine (0.05g/L); c) delta-9-tetrahydrocannabinol (0.001mg/L); and d) delta-THC-acid (0.016mg/L).

58. The inquest was assisted by the evidence of forensic pharmacologist, Alen Lin, who gave evidence that given the level of methylamphetamine detected and Trent’s manner of riding, that it is highly likely methylamphetamine played a contributory role in the collision. His view was based on his expertise on the way in which methylamphetamine impacts upon a person’s perceptions, reaction time, ability to judge time and distance.

59. His evidence was that the level of methylamphetamine was medium to high. He said that the likelihood was that Trent was a regular user of the substance, and he based this on the level present in his system. He said a new or naïve user would be unable to function, likely to be rendered unconscious or even die as a result of those levels. He opined that at that level Trent would be prone to risk taking, travel at high speeds, be unlikely to understand the need to maintain safe distance between vehicles and have increased feelings of confidence.

60. Mr Lin had watched the footage and said that those driving traits demonstrated by Trent were consistent with someone who was affected by methylamphetamine. He also described that one may become hyper focused on one single thing, to the exclusion of other matters, detracting from necessary driving skills and failing to see stopped cars ahead.

61. He was not satisfied that cannabis had any part to play in the accident at the low levels which it was detected. The usual affect on driving would be expected to be very different to that observed in the footage.

62. As a result of this investigation, it appears that methylamphetamine had a part to play in the accident, both in adversely affecting Trent’s decision making ability and his ability to safely drive.

Analysis of the mechanical condition of the Suzuki motorcycle

63. As a matter of completeness, the final issue to be explored relates to the mechanical condition of the motorcycle that Trent was riding. In Mr Wayne Carter’s statement, he said he spoke to Trent on the day before the accident on 6 June 2021. They talked about the motorcycle Trent had recently purchased and Mr Carter recalls Trent said the motorcycle had a problem with the throttle and it had been idling too high and when he went to adjust the screw, he ended up breaking the screw off. Mr Carter said Trent told him that he tried to take the motorcycle to a mechanic a few days before but he was not available. As a result, Mr Carter told Trent not to ride the bike and to take it to the mechanic the next day to get it fixed. Mr Carter said he also saw some new front brake pads which were meant to replace the older ones.

64. As a result of Mr Wayne Carter’s statement and his reference to possible issues with the throttle and brake pads of Trent’s motorcycle, a request was made for Senior Constable Samuel Christanga to provide an additional statement.

65. Senior Constable Christanga had originally prepared a statement dated 22 June 2021.

In that statement he stated that in his expert opinion, that prior to the impact, there were no mechanical defects or faults with the motorcycle that may have been a contributing factor toward the collision.

66. Senior Constable Christanga provided a supplementary statement dated 9 February

67. He was specifically asked to comment on whether there were any issues with the throttle or braking system of KNL12. In his supplementary statement, he confirmed that he had examined both the throttle and the braking system and still maintained the view that there were not any mechanical defects that may have contributed to the collision.

68. I accept that the motorcycle did not have defects which contributed to the accident.

The Autopsy Report:

68. Dr Bailey found that the post-mortem findings supported the cause of death as complications of multiple blunt force injuries consistent with the motorcycle collisions.

Concluding Remarks: As set out earlier, Trent’s death was a result of a tragic accident, a decision made by him in just a few minutes that resulted in four collisions and injuries suffered by him that were not able to be recovered from. The police actions have been carefully scrutinized and considered, and found to be appropriate and reasonable in all the circumstances. The very manoeuvre that Trent was engaging in was the very same that initially drew the police attention, and the very manner of driving that they had sought to try to prevent. The police kindness to Trent was evident when they came across the scene that they had hoped to avoid.

Recommendations There are no recommendations that are required to be made as a result of this inquest.

Acknowledgments

1. To the Officer in Charge for careful preparation of the brief, gathering of relevant evidence and ensuring protocol for critical incidents was followed.

2. To the cooperation of all legal representatives that represented the parties in the proceedings in ensuring the inquest was a useful and productive analysis of the loss of Trent.

3. Importantly to Trent’s family who were active participants in the inquest, who presented a moving reflection of Trent’s life and brought great grace and dignity to the inquest.

4. Finally to the team assisting the Coroner. The level of preparation and commitment to ensuring the best possible review of matters relating to Trent was

commendable. The analysis of the factual background material was of great benefit to me in these findings, and the presentation of the inquest very appropriate.

Findings required by s81(1) As a result of considering all of the documentary evidence and the oral evidence heard at the inquest, I am able to confirm that the death occurred and make the following findings in relation to it.

The identity of the deceased The deceased person was Trent Nathan Carter Date of death 18 June 2021 Place of death St George Hospital, New South Wales Cause of death Complications of multiple blunt force injuries Manner of death Misadventure (motorcycle accident) I again extend my most sincere condolences to Trent’s family and friends especially Wayne his father, his brothers and sister Liam, Tyrell and Chantelle, and his godfather Jason for the loss of such a significant person from their lives.

I close this inquest.

Magistrate E Kennedy

Deputy State Coroner 13 April 2023