Deceased
Andrew James Chee Quee
Demographics
51y, male
Coroner
Decision ofDeputy State Coroner Grahame
Date of death
2020-04-20
Finding date
2024-11-26
Cause of death
gunshot wound to the chest
AI-generated summary
Andrew Chee Quee, 51, died from a gunshot wound sustained during a police confrontation at Bay Street, Rockdale, on 20 April 2020. He had a longstanding history of depression, substance abuse, and suicidal ideation. On the evening of his death, following an argument with his partner, he made repeated 'final messages' to friends, armed himself with two hammers and knives, and engaged with police over several hours. During the final confrontation, he ran at officers brandishing hammers while shouting for police to shoot him. Officers had deployed Tasers without effect; Probationary Constable Worboys fired a single shot, striking Andrew in the chest. The coroner found Andrew intended to provoke police to cause his death (suicide by police). The shooting was found to be a justified use of force. Key clinical lesson: this case highlights the challenges police face responding to mental health crises, particularly when individuals are at immediate imminent risk and have acute suicidality with intention to provoke lethal confrontation.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Andrew James Chee Quee Hearing dates: 8 October 2024 – 11 October 2024 Date of findings: 26 November 2024 Coroners Court of New South Wales Place of findings: Lidcombe, New South Wales Findings of: Magistrate Harriet Grahame, Deputy State Coroner CORONIAL LAW – death in a police operation; police shooting; self-inflicted death; actions to provoke police to Catchwords: shoot; PACER program; police response to persons experiencing mental health crises File Number: 2020/118749 Jake Harris, Counsel Assisting, instructed by Ashliegh Heritage (Crown Solicitor’s Office) Kim Burke, for the Commissioner of the New South Wales Police Force and the following NSW Police Officers, Acting Representation: Sergeant Jeannie Assaf and Acting Inspector Shane Gemmell, instructed by Stuart Robinson (Office of the General Counsel) Linda Barnes, for Probationary Constable Joshua Worboys, instructed by Warwick Anderson (Anderson Boemi Lawyers)
Non publication orders were made on 20 September 2022. A Non publication orders: copy of the orders can be obtained on application to the Coroners Court registry.
Identity The person who died was Andrew James Chee Quee.
Date of death Andrew died on 20 April 2020.
Place of death Andrew died at St George Hospital, Kogarah, New South Findings Wales.
Cause of death Andrew died from a gunshot wound to the chest.
Manner of death Andrew was shot by police when he confronted them with two hammers, intending to provoke police to shoot him and intending thereby to end his own life.
Table of Contents
Introduction
This inquest concerns the death of Andrew Chee Quee, who died on 20 April 2020 at St George Hospital, Kogarah, New South Wales. Andrew was 51 years of age at the time of his death. On 20 April 2020, Andrew was shot by a NSW Police officer as he ran towards another officer brandishing two weapons, while shouting threats. Earlier in the evening Andrew had made various threats to family members and claimed to have a firearm and a willingness to kill. He had also expressed thoughts of ending his life and sent final messages to friends. Andrew’s death occurred during a period of particularly heightened emotional dysregulation and distress in the context of longstanding mental health issues.
While Andrew had experienced some instability in his adult life, he had close friends, some of whom he had known since childhood. For many years he had been in stable employment and although he had not been able to work during the last years of his life, he had been studying with the hope of working in social or community work. His psychologist saw him in the days before his death and did not have specific concerns. Nevertheless, there were also signs of escalating distress in the months before his death.
Andrew’s death has affected his friends, family and the officers involved in the events of that evening.
The role of the coroner
The role of the coroner is to make findings as to the identity of the nominated person and in relation to the place and date of their death. The coroner is also to address issues concerning the manner and cause of the person’s death.1 A coroner may make recommendations, arising from the evidence, in relation to matters that have the capacity to improve public health and safety in the future.2
This inquest was mandatory pursuant to ss. 23 (1)(c) and 27 (1)(b) of the Coroners Act 2009 (NSW), given that Andrew’s death occurred in a police operation. There are sound public policy reasons why a death of this kind should be investigated publicly and independently.
Nevertheless, it is important to acknowledge and have regard to how proceedings such as these, while necessary, can also be traumatic for those involved in giving evidence in open Court.
1 Section 81, Coroners Act 2009 (NSW).
2 Section 82, Coroners Act 2009 (NSW).
The evidence
The Court took oral evidence over four hearing days. The Court also received extensive documentary material in five volumes. This material included witness statements, medical records, photographs and video footage, as well as policy and procedure documents.
The Court had the benefit of hearing expert evidence from consultant forensic psychiatrist Dr Kerrie Eagle. The Court was also assisted by two police witnesses, both with expertise in their fields, Acting Commander of the Mental Health Command, Capability Performance and Youth Command, Acting Superintendent Kirsty Hales and Senior Sergeant William Watt.3
While I am unable to refer specifically to all the available material in detail in my reasons, it has been comprehensively reviewed and assessed.
The scope and context of the inquest
There were limited factual issues in dispute during these proceedings. The medical cause of death was unambiguous and objective evidence from police records and recordings, assisted in establishing the timeline of events. The Court focussed primarily on the circumstances at the precise time of Andrew’s death, and in understanding whether other options existed for the police officers who were faced with these frightening events as they unfolded.
There is enormous public interest in understanding any situation where NSW Police feel compelled to shoot at a fellow citizen. I note that these proceedings come at a time when the NSW Police Force is grappling with two important issues. Firstly, what is a police officer’s role in dealing with persons experiencing mental health crises and, secondly, whether police officers are well equipped to deal with the mental health situations they routinely face. At the same time, the NSW Police Force is tasked with managing and supporting a workforce under enormous pressure.
The NSW Police Force has recently conducted a review into the role of officers responding to mental health incidents in the community. This Summary Internal Review of the NSW Police Force response to mental health incidents in the community (the Review), dated April 2024, was received into evidence in this inquest and is publicly available. The Review noted that it is not intended to represent NSW Government policy.
The Review recognised that the “prevalence of mental ill-health continues to increase within the NSW community and the demands on health services and community supports are 3 References to the police rank of Kirsty Hales and William Watt are as at the hearing in 2024. Unless otherwise stated, references to involved officer’s ranks were as at the time of the incident.
stretched”.4 This has placed an increased dependence on police as the call of both first and last resort as the primary responders to mental health crises.5 Indeed, in 2022, on average, a mental health incident was attended/recorded by the NSW Police Force every nine minutes.6
A key recommendation from the Review was that the NSW Police Force work with NSW Health to explore models for responding to mental health incidents in New South Wales consistent with the principles of the “Right Care, Right Person” model, centred on a trauma informed response to people suffering emotional distress and mental health crises, with the aim of ensuring that any response to mental health incidents is from the agency which can help the most. The Court was informed that this is a recommendation which requires further consultation with stakeholders, including NSW Health, Ambulance NSW, as well as consumer, peers, carers and non-government organisations involved in mental health service provision.7
The Court heard from the current Acting Commander of the Mental Health Command, Capability Performance and Youth Command, Acting Superintendent Kirsty Hales about work currently being done within the NSW Police Force to grapple with broad questions relating to the intersection between policing and health responses to mental health issues.
While Acting Superintendent Hales did not speak on behalf of the NSW Police Force executive,8 she ably assisted the Court to understand the nature of the review which had taken place. She noted that there may be missed opportunities when police are the first responders for mental health generally. There are instances where there is likely to be a police response required, however, there are also many instances where another agency or response would be more appropriate in the circumstances.9 Many of the issues raised in her evidence were beyond the scope of this inquest, but it was useful to understand the major rethink which is occurring as the backdrop to these proceedings.
Did Andrew intend to provoke police to shoot him, and intend thereby to cause his own death?
Was the negotiation with Andrew undertaken by Acting Sergeant Assaf, by phone in 4 Tab 156, Summary Internal Review of the NSW Police Force response to mental health incidents in the community, April 2024, p. 2.
5 Tab 156, Summary Internal Review of the NSW Police Force response to mental health incidents in the community, April 2024, p. 2.
6 Tab 156, Summary Internal Review of the NSW Police Force response to mental health incidents in the community, April 2024, p. 4.
7 Tab 156, Summary Internal Review of the NSW Police Force response to mental health incidents in the community, April 2024, p. 2.
8 Transcript of 11 October 2024, T272:25-33.
9 Transcript of 11 October 2024, T271:30-38.
accordance with NSW Police Force policy and training? What alternatives were there?
Was the police response planned by Acting Inspector Gemmell in accordance with NSW Police Force policy and appropriate in the circumstances? In particular, was it appropriate to wait for police dog units to attend before approaching Andrew?
Prior to the shooting, what was known about: a. the weapons Andrew had with him?
b. Andrew’s state of mind?
Was the action taken by police in Bay Street when Andrew walked towards them appropriate in the circumstances? What alternatives were considered, and why were these not used?
Was the decision to shoot Andrew a justifiable use of force and in accordance with NSW Police Force policy, and?
Is it likely that other resources or equipment would have affected the outcome, including mental health resources such as those available through the Police, Ambulance and Clinical Early Response (PACER) program?
Is it necessary or desirable to make any recommendations in relation to any matter connected with the death?
Background and brief chronology
In opening, Counsel Assisting set out a summary of many of the events in Andrew’s background and mental health history from the documents which were then tendered. Given the uncontested nature of these events, I have relied heavily upon his summary in recording both the background and chronology of events in my written reasons. I have reviewed the evidence carefully and in all matters the conclusions are my own.
Andrew was born in 1969. His parents, Norman and Alisson, are deceased. Norman was Chinese and Alisson was Scottish. Andrew had two older brothers, Jeffrey and David. When Andrew was growing up, the family owned a fish and chip shop in Waverly, New South Wales.
Andrew was a keen rugby player as a child. He went to Scots College. He got into trouble at school. On one occasion he broke another child’s arm.10 In his 20s, he assaulted a 10 Tab 6, Statement of David Chee Quee, at [5].
girlfriend and also broke her arm.11 He once attacked Jeffrey with a cricket bat and a shovel.12
Although a settlement was reached, this seems to have deepened the divide between the siblings.
Dr Kerri Eagle, consultant forensic psychiatrist, was asked to review Andrew’s medical records and prepare a report for these proceedings. She acknowledged the difficulty in conducting a review without having assessed or treated Andrew, but concluded that it was most likely that Andrew had a major depressive disorder, a substance abuse disorder and a gambling disorder. He may also have had generalised anxiety disorder. He had borderline personality traits, which included a pattern of instability in interpersonal relationships, and marked impulsivity. He was sensitive to perceived rejection or abandonment.16
Dr Eagle was of the view that the records suggested that the mental health treatment and support Andrew received in the last two years of his life was adequate and appropriate.
Briefly, Andrew had been receiving treatment in the community for depression since about
He saw his General Practitioner (GP), Dr Joseph Santos, and also engaged with a psychologist, Ms Shen Lin Koo. In the last two years of his life, he presented to hospital on six occasions, including a two-week voluntary admission to the Kiloh Centre at the Prince of Wales Hospital (POWH) in early 2019. He last presented to St Vincent’s Hospital in December 2019.
11 Tab 5, Statement of Jeffrey Chee Quee, at [11], Tab 6, Statement of David Chee Quee, at [7].
12 Tab 5, Statement of Jeffrey Chee Quee, at [12].
13 See, for example, Tab 139(A), Records of Redfern Station Medical Centre, report of Dr Stephen Allnutt, dated 23 July 2015, p. 39.
14 Tab 10, Statement of George Paltos, at [5]; Statement of Massimiliano Di Pio, at [18]; Tab 18, Statement of Clifton Kenny, at [6].
15 See, for example, Tab 6, Statement of David Chee Quee, at [20]; Tab 15, Statement of Jean Christian Cheung, at [11]; Tab 16, Statement of David Simons, at [8].
16 Tab 151, Report of Dr Kerri Eagle, at [160]-[164].
Many of Andrew’s mental health crises appear to have been related to relationship difficulties. In late 2019 and early 2020, he told friends he was planning to end his life, although on each occasion he appeared to improve.
The records reveal that: a. Andrew took an overdose following the death of his mother in 1994.
b. On 25 December 1999, Andrew took ecstasy and passed out. When his then partner called an ambulance, he became agitated. Police attended and had to force entry and subdue him with Oleoresin Capsicum (OC) spray. He was thought to have experienced a drug-induced psychosis.17 c. From about 2008, he was managed by his GP and a private psychiatrist. He was prescribed antidepressants.
d. On 27 July 2009, Andrew left his then partner a message to say he had taken Valium after losing $10,000 gambling. Police located him via phone triangulation. He was admitted on an involuntary basis to the Kiloh Centre and remained there for 2 months.
e. On 30 Jan 2010, Andrew presented to the Kiloh Centre with suicidal ideation, and was admitted for two weeks. While admitted, he attempted to hang himself on the ward.
f. In 2017, Andrew commenced seeing Ms Shen Lin Koo, a psychologist at the Redfern Station Medical Centre. He continued seeing her until shortly prior to his death.18 g. On 16 September 2018, Andrew presented to POWH with suicidal ideation.
Events of 2019-2020
In the last year or so of his life, Andrew apparently experienced suicidal thoughts on multiple occasions. With hindsight, there appears to have been a clear escalation of his distress.
On 18 January 2019, Andrew again presented to POWH with suicidal ideation, and a plan to gas himself in his car. He then absconded from the hospital. Police were contacted and performed a phone triangulation to locate him. After an extensive search, he was located in the gaming section of the Doncaster Hotel. He was returned to POWH until 31 January 2019.19 17 Tab 124, COPS Event E8668492; Tab 139(A), Records of Redfern Station Medical Centre, report of Dr Stephen Allnutt, dated 23 July 2015, p. 38.
18 Tab 139(A), Records of Redfern Station Medical Centre, pp. 68, 81-119; Tab 139B, Statement of Shen Lin Koo, at [11].
19 Tab 128, COPS Event E70419062; Tab 127, Statement of Constable Dean Hodges, at [4]-[7]; Tab 15, Statement of Jean Christian Cheung, at [14].
On 18 February 2019, Andrew moved into crisis accommodation at Foster House in Surry Hills. He had a caseworker, Will Mataka, who met with him weekly and assisted him with medication.
In about September 2019, Andrew commenced a Social Work course at St George TAFE.
There he met Anya Nefedova, a Russian national who was on the same course. She was divorced and had a 9-year-old son. They became friends. Andrew’s friends understood that Ms Nefedova and Andrew had been seeing each other,20 and he also told Ms Koo they were in a relationship.21 However, Ms Nefedova states they were just good friends, though she knew he had strong feelings for her. She says Andrew cooked and helped her around the house.
On 10 November 2019, Andrew’s caseworker contacted police after he expressed suicidal feelings. Andrew then flagged down an ambulance in the street and was admitted to St Vincent’s Hospital as an involuntary patient. While in the Emergency Department, he threatened to take a police officer’s gun and shoot himself.22
In mid-November 2019, Andrew sent a message to his friend, Matthew Wise, expressing suicidal ideation. He sent a similar message to another friend, George Paltos. Mr Paltos and Mr Wise confronted Andrew about these messages, and Andrew said he had a fight with his girlfriend and felt like killing himself.
On 5 December 2019, Andrew told staff at Foster House he had a plan to kill himself on Boxing Day, being the anniversary of his father’s death. An ambulance was called, but on being told he would be scheduled, Andrew absconded. Police were called and conducted a search. They made contact with Andrew, who said he was going to go to St Vincent’s Hospital. Police later located Andrew, again by phone triangulation. This was the third occasion that phone triangulation had been used.23
In December 2019, Andrew was referred to the Northeastern Alliance for Mentally Ill, who assisted him to find accommodation.
On 26 February 2020, Andrew sent Christian Cheung a message saying he had “hit rock bottom”.24 20 See, for example, Tab 10, Statement of George Paltos, at [11]; Tab 11, Statement of Massimiliano Di Pio, at [40]; Tab 12, Statement of Matthew Wise, at [14]; Tab 14, Statement of Jocelyn Lim, at [20].
21 Tab 139(A), Records of Redfern Station Medical Centre, p. 112.
22 Tab 129, Statement of Constable Paul Rawson, at [8]; Tab 130, COPS Event E75358688; Tab 137, Synopsis of St Vincent’s Hospital medical records, p. 1.
23 Tab 133, COPS Event E74748480; Tab 137, Synopsis of St Vincent’s Hospital medical records, p. 2.
24 Tab 15, Statement of Jean Christian Cheung, at [22].
On 23 March 2020, Andrew signed a lease for a property at 10/96 Maroubra Road, Maroubra.
However, when the COVID-19 lockdown commenced at the end of March 2020, Ms Nefedova offered for Andrew to come at stay in the spare room of her apartment in Kings Road, Brighton-le-Sands. He was going to stay there until lockdown ended, and then move into the Maroubra property.
He saw his GP on 30 March 2020, and told him he was “coping ok” and felt his “mood is stable”.25
On 7 April 2020, Andrew sent messages to Mr Cheung and Mr Paltos, saying he wanted to “end it”.26
Andrew saw his psychologist, Ms Koo, by telehealth the following day, explaining that he had a “massive fight” with his partner. Ms Koo talked about a plan for keeping Andrew safe, which involved him “tak[ing] time-out to walk off his emotions”.27
On 15 April 2020, Andrew sent his friend Massimiliano Di Pio a video from news footage showing a man confronting police with two knives. Mr Di Pio lives in Western Australia. He did not respond and did not understand the significance of it. He spoke to Andrew a few days later, and Andrew appeared fine.28
In the days prior to his death, Andrew’s friends and acquaintances report he appeared normal.29
He finally saw Ms Koo by telehealth on 16 April 2020, three days prior to his death. He told her he had been “much better this week”.30 He gave no indication of any suicidal thoughts.
She planned to review him in three weeks’ time. In a statement to this inquest, Ms Koo says she was surprised to learn of his death, “as things were starting to finally go well for him”.31 Events of 19 April 2020
26 Tab 10, Statement of George Paltos, at [13]; Tab 15, Statement of Jean Christian Cheung, at [24].
27 Tab 139(A), Records of Redfern Station Medical Centre, p. 118.
28 Tab 11, Statement of Massimiliano Di Pio, at [42]-[47].
29 Tab 17, Statement of Blaize Major, at [13]; Tab 12, Statement of Matthew Wise, at [16]; Tab 14, Statement of Jocelyn Lim, at [18].
30 Tab 139B, Statement of Shen Lin Koo, at [51].
31 Tab 139B, Statement of Shen Lin Koo, at [53].
messages available between them, and these reveal that Andrew was annoyed because Ms Nefedova’s son had been playing the Play Station/Xbox.32
Andrew then made calls to some of his friends. At 7:30pm, he called Ronald Francis, from Foster House. He appeared agitated.33
At about 8pm, Andrew became angry and was shouting and swearing. He began complaining about his brothers and also maligning Ms Nefedova’s ex-husband. Ms Nefedova was concerned about the noise, and she sent her son downstairs to their neighbour.34
At one point, Andrew picked up a knife in the kitchen and held the blade towards his stomach. Ms Nefedova managed to take the knife from him and threw it towards the sink.35
Andrew then went onto the balcony and called his brothers. He had not spoken to either of them for many years. At 8:42pm, Andrew called David. He left a voicemail saying, “I will see you all soon. Nice family reunion, can't wait, last supper, you fuckwits”. He left a further abusive message five minutes later.36
At 8:52pm, he called Jeffrey. Jeffrey lives on the mid-North Coast. Andrew said, “I’m going to kill your fuckin brother. I am going to kill the whole family and slice them up. You’ve ruined my fuckin life”.37 He then hung up.
Jeffrey contacted David, who lives in Coogee, via Facetime and told him about the call.
While Jeffrey was speaking to David, Andrew called again. He repeated the threats. Jeffrey recognised it was Andrew this time, and tried to calm him down, asking what was wrong.
During the call, Ms Nefedova asked Jeffrey to stop talking to Andrew, as it was aggravating him. Jeffrey thought she sounded scared and said he would get the police for her. She provided her address to Jeffrey.38
Andrew then put some belongings into two bags. He went into the kitchen and took a large black handled carving knife, a small knife with an orange sheath, and a pink handled hammer. He told Ms Nefedova he was sorry for “creating all this distract[ing]” and said, “I’m sorry for what I have done you won’t see me again” and then left the unit.39 32 Tab 8, Statement of Anya Nefedova, at [13]; Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, p. 1.
33 Tab 142, Statement of Ronald Francis, at [15].
34 Tab 8, Statement of Anya Nefedova, at [15], Tab 9, Statement of Belinda Hoschke, at [8].
35 Tab 8, Statement of Anya Nefedova, at [17].
36 Tab 7A, Transcript of voicemail messages, p. 2; Tab 7B, Recordings of voicemail messages.
37 Tab 5, Statement of Jeffrey Chee Quee, at [23]; see also Tab 6, Statement of David Chee Quee, at [21].
38 Tab 5, Statement of Jeffrey Chee Quee, at [25]; Tab 6, Statement of David Chee Quee, at [21]; Tab 8, Statement of Anya Nefedova, at [22].
39 Tab 8, Statement of Anya Nefedova, at [23].
First 000 call at 9:08pm
There was a total of three calls made to 000 that night. The first call was made by Jeffrey, at 9:08pm. He told the operator he had received a call from Andrew, who had threatened to kill David. He was concerned about Ms Nefedova. A Police Computer Aided Dispatch (CAD) message was created and broadcast over the channel for the St George area.41
The supervisor, Acting Sergeant Jeannie Assaf, who was assigned police vehicle St George 12, asked Constable Sam Wolf and Probationary Constable Sally Probert (St George 17) to respond. They acknowledged the incident at 9:29pm. Constable Wolf called Jeffrey, and on finding out he was in the mid-North Coast, arranged for a local unit to attend his address.
Police at Coffs Harbour, being Senior Constable Peter Risby and Constable Andrew Hilton, attended Jeffrey’s home at about 11:05pm. They also spoke with David by phone. Neither Jeffrey nor David needed police assistance and stated that they were concerned about Andrew’s mental health. This information was broadcast via police radio.42 Andrew’s whereabouts
It is not known exactly where Andrew went after he left Ms Nefedova’s home. During the evening, he called Ms Nefedova and told her he was in a park. The police investigation obtained Closed Circuit Television footage (CCTV) from the local area, but he wasn’t detected until 11:19pm, just over two hours after he left Ms Nefedova’s home. Mr Chee Quee was captured on CCTV walking north on West Botany Street. It is probable he spent the intervening period in the area of Bicentennial Park in Rockdale.43
Andrew made calls or sent messages to his friends during the evening, in which he said he was going to “end it”.44 At 9:50pm, he sent a Facebook message to Ms Nefedova, apologising for his behaviour and saying “it’s time to go”.45 He later sent her a message saying he could “feel my [parents]”. 46 40 Tab 8, Statement of Anya Nefedova, at [25].
41 Tab 75, CAD Incident Log 329927-19042020, p. 1; Tab 36A, Transcript of VKG Broadcast – St George, p.
42 Tab 73, Statement of Senior Constable Peter Risby, at [5]; Tab 74, Statement of Constable Andrew Hilton, at [5]; Tab 75, CAD Incident Log 329927-19042020 p. 5.
43 Tab 94, Mapped summary of movements of Andrew Chee Quee on 19-20 April 2020, p. 1.
44 See, for example, Tab 94A, Compiled summary of messages and calls, p. 10.
45 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, pp. 9-10.
46 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, p. 15.
At 10:06pm, Andrew called his friend Mr Di Pio. He stated he had “hit rock bottom” and was going to “end it”. He refused to say where he was, saying he was “In the rainforest”.47 Second 000 call at 10:16pm
At 10:16pm (Australian Eastern Standard Time), Mr Di Pio phoned 000. He stated he had a friend who is “about to end it all” who had “some mental health issues”.48 He gave Andrew’s last known address at Foster House and said Andrew had been staying with a Russian girl in Botany. He asked police to perform a phone triangulation. At 10:27pm, this incident was broadcast over the channel for Surry Hills Police Area Command, where Foster House is located.49
Police at Surry Hills, being Constable Allan Jenkins, Constable Brooke Temple and Constable Andy Wang, responded to this broadcast at 10:40pm. They spoke to staff at Foster House.50 At 10:47pm, Constable Jenkins obtained an updated address for Andrew in Coogee, and asked local police to attend that address. However, that was not Ms Nefedova’s address, it was the home of one of Andrew’s ex-girlfriends, Ms Lim. Police at Eastern Beaches, being Senior Constable Rhys Gilmour and Constable Fuller attended and spoke with her. They also identified Andrew’s new address in Maroubra. Police attended that address, but found it was unoccupied.
At 11:03pm, Constable Jenkins spoke to Andrew by telephone. That was the first direct contact police had with Andrew. Andrew told him, “I’ve just lost the love of my life” and advised Constable Jenkins that he just wanted to be left alone to sleep, and if he still felt bad in the morning, he would go to the hospital.51 Andrew refused to give his location, and said he was going to throw his phone in the river. Constable Jenkins did not want to aggravate the situation, and so ended the call.
Third 000 call at 10:53pm
Just prior to Constable Jenkins contacting Andrew, there had been the third call to 000, at 10:53pm, this time by Ms Nefedova. She informed the operator that Andrew had taken Valium and Stilnox and had left her home about an hour and 20 minutes earlier. That was broadcast via channel Lima, for the St George area.
The officers who had responded to Jeffrey’s earlier 000 call, Constable Wolf and Probationary Constable Probert, were tasked to respond again. They and Acting Sergeant Assaf went to speak with Ms Nefedova, meeting her near a church near her address.
47 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, pp. 11-12.
48 Tab 71A, Transcript of 000 call, p. 2.
49 Tab 80, CAD Incident Log 330086-19042020, p. 1; Tab 81A, Transcript of VKG Broadcast – Surry Hills, p.
50 Tab 77, Statement of Constable Allan Jenkins, at [7].
51 Tab 77, Statement of Constable Allan Jenkins, at [16].
Ms Nefedova told police that Andrew had taken pills and had taken two knives and a hammer with him. She also said Andrew had struck her to the left temple, although she later denied there had been any violence.52
At 11:09pm, Constable Wolf telephoned Andrew. Andrew said he was in a park, that he just wanted to be left alone, and that he was going to sleep in the open. He said he would throw his phone in the river so he could not be tracked. He also said that he was armed, and if approached by police he would kill them. Constable Wolf took a note of this conversation in his official police notebook. Constable Wolf agreed to end the call, but asked Andrew to pick up if he called back.53
At 11:19pm, Acting Sergeant Assaf contacted her supervisor, the duty officer Acting Inspector Shane Gemmell, to discuss a phone triangulation. At that time, Acting Inspector Gemmell did not think there was enough information to do so as the “procedures with triangulations are quite strict” and requested Acting Sergeant Assaf to speak with Andrew again.54
At 11:27pm, Ms Lim called Andrew. He was not making sense to her and was slurring his words. He stated he had told police that he would be okay, provided they did not come near him. That was the last call between Andrew and any of his friends. At that point, he was in Rockdale, walking north on West Botany Street near the intersection with Bay Street.55
Meanwhile, Acting Sergeant Assaf had found out that Andrew had weapons with him and had made a threat to attack police. She called Acting Inspector Gemmell again, who now agreed to seek a triangulation. Acting Sergeant Assaf made arrangements with the State Coordinator for that to occur.56
Acting Sergeant Assaf then herself spoke with Andrew by telephone. This was a substantial call, initially lasting about five minutes with a further call of up to ten minutes in duration.
She made some notes of the conversation. She attempted to build rapport with Andrew, and to persuade him to tell her where he was. Andrew said to her, “Don’t come near me, I’ll get the cops to kill me anyway, or I’ll get them”.57 52 Tab 29B, Transcript of interview of Constable Sam Wolf, pp. 12-13, at Q64; Tab 21B, Transcript of interview of Acting Sergeant Jeannie Assaf, pp. 7-9, at Q21; Tab 8, Statement of Anya Nefedova, at [18].
53 Tab 29E, Official Police Notebook of Constable Sam Wolf, p. 43; Transcript of 9 October 2024, T81:7-11; 32-35.
54 Transcript of 8 October 2024, T56:42-50; T57:1-2; T58:4-17.
55 Tab 94, Mapped summary of movements of Andrew Chee Quee on 19-20 April 2020, p. 1.
56 Transcript of 8 October 2024, T38:5-27; T60:10-37; Tab 20B, Transcript of interview of Acting Inspector Shane Gemmell, p. 8, at Q24; Tab 21B, Transcript of interview of Acting Sergeant Jeannie Assaf, p. 9 at
57 Tab 21B, Transcript of interview of Acting Sergeant Jeannie Assaf, pp. 10-12, at Q21.
In oral evidence Acting Sergeant Assaf told the Court that she had completed the four-day mental health training that was previously offered by the NSW Police Force.58 She also had extensive experience, both personal and professional, in dealing with people who were experiencing mental health difficulties.59 She gave the Court concrete examples of the kinds of things she raised to keep Andrew talking and to build rapport. She empathised with him about losing a parent and said things like “Look, you know, we can have a smoke, we can sit there and we can think of our loved ones…” and suggested the pair catch up.60 Her aim was to attempt a phone triangulation and for that she wanted to retain contact.
While this was occurring, Constable Wolf obtained a description of Andrew, and at 11:37pm broadcast a request for other units to keep a lookout for him.61
At 11:39pm, the State Coordinator updated CAD with a result from the phone triangulation.
It showed Andrew’s phone was within 500 metres of Bunnings at Rockdale. This location was broadcast, and a number of police units began to attend. Further updates were given about the location during the incident.
Acting Sergeant Assaf began to organise other resources. She sought assistance from PolAir (NSW Police Force Aviation Command), which responded promptly at around midnight, and then asked for a dog unit to attend. Acting Sergeant Assaf also asked radio to arrange for an ambulance to be on standby.
Acting Sergeant Assaf broadcast a warning for other police units, referring to what Andrew had told her:62 “St George 14 just for the information of other vehicles, apparently he does have 2 knives and a hammer. And he is threatening to hurt Police or himself if they come up”.
Acting Sergeant Assaf also broadcast for police to put on ballistic vests.63 She made her way to the location, stopping near the PCYC at Ador Ave, Rockdale.
Andrew is located
59 Transcript of 8 October 2024, T31: 18-26.
60 Transcript of 8 October 2024, T43:12-14.
61 Tab 75, CAD Incident Log 329927-19042020, p. 6.
62 Tab 36A, Transcript of VKG Broadcast – St George, p. 14.
63 Tab 36A, Transcript of VKG Broadcast – St George, p. 16.
South and West Botany Street to the East. The Reserve is bisected by a stormwater canal called Muddy Creek.
After this, the duty officer Acting Inspector Gemmell broadcast over police radio that he was attending the scene. He intended to take over command upon his arrival. He told radio he did not want other crews approaching Andrew until the dog unit was present.64
Constable Wolf and Probationary Constable Probert went to West Botany Street. From a distance, they located Andrew under a tree, beyond the canal. Constable Wolf identified himself as the person Andrew had spoken to on the phone. Andrew told him to go away.
Andrew was observed to throw something into the canal, which may have been his phone, although he then retrieved it. Constable Wolf tried to engage with Andrew, but Andrew said words to the effect:65 “I have a gun … and I have a shit load of ammunition and I’m going to kill all you cops”.
In oral evidence, Constable Wolf recalled Andrew saying: "I've got a firearm, I've got plenty of ammunition, and I'm going to kill all the cops".67
Acting Inspector Gemmell made a broadcast again, asking police to back off 50 to 100 metres and wait for the dog unit.68
Acting Inspector Gemmell told the Court that he was already thinking about what other resources might be needed. He was “looking through [his] mobile phone for the state coordinator’s phone number. My next phone call was to the state coordinator to request tactical operations unit and negotiators”.69
At 12:25am, Constable Cameron Buttress and Probationary Constable Joshua Worboys (St George 38) arrived at West Botany Street. Probationary Constable Worboys had been a police officer for just over five months. Acting Inspector Gemmell asked them to take up a position on Bay Street.
Five other officers also attended at Bay Street, being Leading Senior Constable Darren McDiarmid, Senior Constable Jenna Haywood, Senior Constable Greg Sadowski, Constable Jessica Duncan, and Constable James Radoski. The last four were members of 64 Tab 36A, Transcript of VKG Broadcast – St George, p. 17.
65 Tab 29B, Transcript of interview of Constable Sam Wolf, p. 25, at Q151.
66 Tab 36A, Transcript of VKG Broadcast – St George, p. 20; Tab 29B, Transcript of interview of Constable Sam Wolf, pp. 25-26, at Q152.
67 Transcript of 9 October 2024 T85:43-45 68 Tab 20B, Transcript of interview of Acting Inspector Shane Gemmel, p. 10, at Q24.
69 Transcript of 8 October 2024, T65:43-44.
the Operational Support Group, Operation “Odin”, which was a unit providing operational support on scene.
Three dog units were also enroute to the scene. The first two arrived, being Senior Constable Andrew Devlin and Senior Constable Alexander Cook, and informed Acting Inspector Gemmell that they were waiting for their supervisor, Sergeant Mark Mensforth to arrive, before moving in. While they were waiting, they fitted their dogs with ballistic vests.
An ambulance arrived in the area at 12:35am. It held position some distance away, to await police confirmation that the scene was safe.
While those events were occurring, Andrew had climbed a fence at the PCYC and was making his way southwards, towards Bay Street. PolAir continued to broadcast updates about his position. The officers in Bay Street could hear Andrew shouting from the canal.
He was yelling words to the effect, “I have a gun. I’m gunna shoot the first police officer I see”.70
Andrew then began to walk quickly across the park on a diagonal towards the southwestern corner of the park at Bay Street.
Sergeant Mensforth arrived in West Botany Street just prior to 12:37am, when a broadcast was made by PolAir that Andrew was “making his way south towards Bay Street”.71 There was a short discussion, following which Acting Inspector Gemmell and the other two dog units got in their vehicles to drive to Bay Street, where Andrew was headed.
As Andrew approached Bay Street, Leading Senior Constable McDiarmid saw him, and made the following broadcast:72 “St George 13, can confirm he's armed with a hammer and knife by the look of it, two hammers, it's two hammers”.
However, the message was broadcast by the dispatcher as follows:73 “All cars (RADIO SCREECH NOISE) he is armed with two hammers, a knife, two hammers and a knife”.
70 Tab 24B, Transcript of interview of Senior Constable Greg Sadowski, p. 7 at Q23; Tab 25B, Transcript of interview of Senior Constable Jenna Haywood, p. 7, at Q17.
71 Tab 36A, Transcript of VKG Broadcast – St George, p. 25 72 Tab 36A, Transcript of VKG Broadcast – St George, p. 25.
73 Tab 36A, Transcript of VKG Broadcast – St George, p. 25.
The shooting
As Andrew approached the officers in Bay Street, he was saying, “Who’s going to shoot me … why don’t you just shoot me now?”, Senior Constable Sadowski replied, “we don’t want to do that”.74
Andrew began pacing along the line of a high “Hurricane” chain-link fence at the edge of the park. The police officers “shadowed” him on the other side. Senior Constable Sadowski drew and armed his Taser.
Andrew doubled-back and went to a doorway in the fence. As he did so, the officers fanned out into the road in a horseshoe shape around the exit, with officers Senior Constable Sadowski, Constable Radowski, Constable Buttress and Probationary Constable Worboys on the right side of the cordon looking towards the fence, and Leading Senior Constable McDiarmid at the left side.
Andrew swapped both hammers into one hand and placed his other hand into the pocket of his hoodie, as if to simulate that he had a firearm in his front pocket.75
As Andrew exited through the doorway, he raised the hammers to shoulder height and ran towards police. He was yelling “Come on” aggressively. One of the officers made a broadcast “He’s running at police”.76 The officers moved back away from him.
Senior Constable Sadowski discharged his Taser, but this did not appear to have any effect.
Constable Buttress also discharged his Taser, but it also did not have effect. Each of those Tasers captured some video footage of the incident.
Constable Radoski tried to get his OC spray out, but could not as he was backing away.
Andrew then ran past Constable Radoski, towards Constable Buttress, raising his hammer and swinging at Constable Buttress’s head. Constable Buttress stumbled over as he was moving back, and then turned to run.
Constable Buttress explained to the Court that he “just kept trying to create distance”.77 Constable Buttress stated “I tried to search for another appointment but he was closing the gap too quickly, and then he had the hammers raised above his head, and I was trying to avoid any contact with him”.78 Shortly after this, Constable Buttress realised he was about to be struck with the hammers. Some of the officers later said they considered using their 74 Tab 28B, Transcript of interview of Senior Constable Jenna Haywood, p. 8, at Q17, p. 33, at Q267; see also Tab 27B, Transcript of interview of Constable Jessica Duncan, p. 8, at Q26, p. 16, at Q90; Tab 22B, Transcript of interview of Constable Cameron Buttress, p. 8, at Q20.
75 Tab 22B, Transcript of interview of Constable Cameron Buttress, p. 8, at Q20.
76 Tab 36A, Transcript of VKG Broadcast – St George, p. 25.
77 Transcript of 9 October 2024, T159:36.
78 Transcript of 9 October 2024, T159:27-29.
firearms at this point. However, they each thought that the other officers were too close for this to be safe.
Constable Radoski began follow Andrew. He later said he was going to hit Andrew as hard as he could to try to “weapon-less control” him.79 In oral evidence he explained that he was actively considering taking Andrew to the ground, “tackle him and then secure his arms and then get support on me to secure his arms, take the weapons above him and handcuff him”.80 However before he could try this approach, events moved too quickly.
Probationary Constable Worboys saw Andrew running towards Constable Buttress. He moved in an arc out of his partner’s way. He drew his firearm and raised it. As Andrew ran across his path, about two metres away, he fired a single shot, striking Andrew in the right side of the chest.
When later asked about this decision in an interview shortly after the event, Probationary Constable Worboys said that “I did see that [Andrew] had a weapon … from what I could tell it looked like a knife”.81
Probationary Constable Worboys gave evidence before me. He told the Court that he had heard radio broadcasts earlier and certain words were “imprinted” in his head.82 He had a distinct memory of hearing “I have a gun and loads of ammunition”.83 He was aware of a serious threat emerging. Like other officers, he spoke of Andrew’s aggressive and angry screaming. Probationary Constable Worboys believed he saw a knife and believed Andrew may have had a gun.84
Probationary Constable Worboys candidly told the Court he felt absolutely terrified for himself and his fellow officers.85 He could see “a violent confrontation on the horizon”.86 He watched the situation unfold as two officers fired tasers in quick succession, without effect.
He watched Andrew raise the hammer in a “gearing-up-to-strike sort of motion” in the vicinity of Constable Buttress who was trying to get away.87 He told the Court he saw “an immediate and imminent risk to Cameron Buttress’s life”,88 and having a clear path, he used his gun as he had been taught at the Academy.
79 Tab 25B, Transcript of interview of Constable James Radoski, p. 46, at Q332.
80 Transcript of 9 October 2024, T140:27-29.
81 Tab 19B, Transcript of interview of Probationary Constable Joshua Worboys, p. 11, at Q29.
82 Transcript of 10 October 2024, T183:30.
83 Transcript of 10 October 2024, T183:29.
84 Transcript of 10 October 2024, T183:48-50; T184:1; T189:17-20; T190:46-47; T191:38-41; T193:9-13.
85 Transcript of 10 October 2024, T194:24-25.
86 Transcript of 10 October 2024, T197:20.
87 Transcript of 10 October 2024, T200:13.
88 Transcript of 10 October 2024, T202:8.
It is important to remember that Probationary Constable Worboys was only five months into his police career. He knew he was very junior and for that reason he had “stayed back” to allow those with more experience take the lead.89 It was for this reason he had a chance to shoot, while other officers who may have been closer to Andrew would have been in a “crossfire situation”.90
A broadcast “shots fired” was made at 12:38am. That was around 20 seconds after Andrew had emerged from the gate and run at police.
After he had fired the shot, Probationary Constable Worboys activated his Body Worn Video (BWV). The BWV back-captured 60 seconds of footage, including the moment when Andrew was shot. This video is important as it depicts Andrew’s movement towards police and his apparent rage and unpredictability. A frightening scene is depicted.
Andrew was initially handcuffed, and the two hammers were picked up by Constable Radoski and moved away from him. I accept that the hammers, one of which had a claw, were dangerous weapons.
Acting Inspector Gemmell, Sergeant Mensforth and other police units arrived shortly afterwards. Sergeant Mensforth took control of first aid. The handcuffs were removed, and CPR was commenced.
There was a slight delay in the attendance of the ambulance, which had been at the scene, but which was waiting to be informed that it was safe to approach. Paramedics attended Andrew at 12:45am. Andrew was conveyed to St George Hospital at 1:03am. He had sustained an unsurvivable injury and was declared deceased at 1:44am.
The Investigation Crime scene
Cause of death Autopsy
90 Transcript of 10 October 2024, T202:45.
91 Tab 1A, Autopsy Report by Dr Istvan F Szentmariay.
round defect in Andrew’s hooded jacket. The trajectory of the bullet involved the right atrium of the heart and the liver.
Dr Szentmariay also identified a single taser probe embedded in Andrew’s jacket, around the outer aspect of the right upper arm. He did not identify any evidence of a probe having struck Andrew’s body.
There is no dispute that Andrew’s death was caused by a gunshot wound to the chest.
Toxicology
Other medications were within or below therapeutic levels and would not have had any impact.93 Ballistics
Probationary Constable Worboys’ firearm was examined by ballistics experts. It was confirmed that the spent cartridge found at the scene was fired by his firearm.94
Both Tasers were found to be in working order.95 Given the findings at autopsy, it seems that the reason why the Tasers did not incapacitate Andrew was that they were caught in his clothing and were unable to penetrate the material.
The Issues
93 Tab 152, Report of Forensic Pharmacologist / Toxicologist Pieternel van Nieuwenhuijzen, at [58].
94 Tab 90, Statement of Senior Constable Stephen Hay, at [8]-[9].
95 Tab 91, Statement of Senior Technical Officer Christian Halbmeier, at [138].
vulnerable state in the lead up to these events and may have been “having an increased frequency of suicidal thoughts around that time”.96 b. In the last few days Andrew had shared a video with a friend Mr Di Pio which apparently depicted a man confronting police with two knives, before he was struck by a vehicle. Dr Eagle agreed that for a patient who was already vulnerable, Andrew’s interest in the video may give some insight into what he was thinking at the time.97 I accept that it appears that the video resonated with Andrew and that it may be significant that he chose to send it to his friend, along with messages of distress.
ALWAYS AND FOREVER MY GREATEST LOVE, CHING CHING CHEEK WEEK… XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX”; and “Sorry I came into your life… I’ll be dead soon and at peace…” c. To Mr Paltos, and stated:100 “Hi George, sorry but I’m leaving …Can you organise my will”; “Tried to call you Brother… I’ve hit rock bottom and am going sleep and won’t be here tomorrow”; and “… I’ve hit rock bottom and am going sleep and won’t be here tomorrow…
96 Transcript of 10 October 2024, T223:44.
97 Transcript of 10 October 2024, T223:40-44.
98 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, p. 3.
99 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, pp. 10, 14.
100 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, pp. 10, 13.
d. To Mr Di Pio, and said “…I’ve hit rock bottom…I can’t do it anymore, everything has turned to shit”;101 e. To Ms Lim, and advised that he’s had enough and could not keep doing this anymore;102 and f. To Mr Wise, who stated that Andrew said goodbye.103
Dr Eagle told the Court that although Andrew may have taken these substances to “dampen down” the emotional distress he was feeling, they may have had the opposite effect. Both substances are known to be depressants, but they can also disinhibit and impair judgment. These substances can have the undesired effect of making someone feel more emotionally labile.104
There was specific evidence that Andrew invited police to shoot him. Leading Senior Constable McDiarmid, for example, gave evidence that Andrew yelled “Stab me, shoot me, you cunts, shoot me, you cunts, I’m going to kill you”,105 and he continued these taunts when a number of officers had drawn their weapons.
Andrew’s behaviour at the time of the final confrontation included, continuing to advance in the face of being outnumbered by Police who were clearly armed. This occurred even when Tasers had already been deployed. Leading Senior Constable McDiarmid was of the view that Andrew “didn’t seem to want to swing… he was waiting to be shot”.106
Counsel for the Commissioner of Police supported Counsel Assisting’s submissions on this issue. Counsel for Probationary Constable Worboys made no comment.
I have considered the issue carefully, taking into account that a finding that a death is selfinflicted in these circumstances would require clear and cogent evidence. In my view there is strong evidence that Andrew intended to provoke a confrontation with NSW Police at the time he left the park. He had already made a number of specific communications indicating that he was preparing to die. He armed himself, and well understood the likely consequences of his actions. Andrew would have been able to see that Police had their weapons drawn, yet he continued moving towards police even after the tasers had been deployed. I find his final communications with friends and his requests for Police to shoot him compelling evidence of intention. In my view it is established, on the balance of probabilities, that at the time Andrew raised and commenced to swing the hammer in the 101 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, pp. 11-12.
102 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, p. 15.
103 Tab 94A, Compiled summary of messages and calls made or received by Andrew Chee Quee, p. 21.
104 Transcript of 10 October 2024, T214:14-35.
105 Transcript of 9 October 2024, T101:2-3.
106 Tab 23B, Transcript of interview of Leading Senior Constable Darren McDiarmid, p. 20, at Q84; Transcript of 9 October 2024, T105:17-25.
vicinity of Constable Buttress, he did so with the intention that it would provoke an officer to shoot him.
Counsel Assisting submitted that I would accept that Acting Sergeant Assaf acted in accordance with NSW Police Force policy and training.
The Court heard evidence that given the way the incident unfolded, the opportunity to use trained negotiators had not yet arisen. The telephone call between Acting Sergeant Assaf and Andrew was described by Acting Superintendent Hales as a form of “crisis communication”.107
Acting Sergeant Assaf described her conversation with Andrew in the recorded interview she undertook on the day of Andrew’s death.108 Her goal was to build rapport so that Police would be able to find him.109 She understood he had mental health issues and tried to impress upon Andrew that police were not trying to arrest him, rather that they were trying to help. She used a variety of conversational strategies, such as sharing personal aspects of her life to try and gain Andrew’s trust. I had the benefit of hearing Acting Sergeant Assaf give oral evidence. She spoke in a calm and gentle manner, and it was easy to imagine her efforts to engage Andrew. I note that both Senior Sergeant Watt and Acting Superintendent Hales had no criticism of her approach.
Counsel Assisting submitted that Acting Sergeant Assaf acted appropriately at all times.
Counsel for the Commissioner supported Counsel Assisting’s submissions on this issue.
Counsel for Probationary Constable Worboys did not address me on this issue.
107 Transcript of 11 October 2024, T258:33-40.
108 Tab 21B, Transcript of interview of Acting Sergeant Jeannie Assaf, pp. 11-12, at Q21.
109 Transcript of 11 October 2024, T40:30-37.
Counsel for Probationary Constable Worboys did not address the issue.
In my view it was appropriate to direct officers to maintain space at that time.
In any event, at the time that Acting Inspector Gemmel was informed that Andrew was on the move, he was still actively considering what the appropriate tactical response should be. He was looking for the State Coordinator’s telephone number, but had not yet made contact. Once Acting Inspector Gemmel was given Andrew’s location, he jumped in his vehicle to join other police at Bay Street.
Senior Sergeant Watt presented an alternative view, suggesting that whatever Acting Inspector Gemmel had said, ultimately the officers in close proximity to Andrew were best placed to decide how to respond to the rapidly changing circumstances as they occurred.
The overriding Police strategy was to contain Andrew in the park. I accept that once Andrew got to the fence line and entered the roadway, the circumstances and associated risk levels had materially changed.
particularly now that Tasers do not record. Probationary Constable Worboys was wearing his BWV and the footage assisted me in understanding exactly what had occurred.
The first report of Andrew having weapons came from Ms Nefedova. She spoke to Acting Sergeant Assaf and the two constables at the church near her home. In the course of that conversation Ms Nefedova disclosed that Andrew left her home armed with two hammers and a knife or knives.
Later in the evening various officers saw that Andrew was holding a weapon or weapons that some officers perceived to be a knife,111 or a wood file,112 a screwdriver,113 or what was ultimately described as a meat tenderiser.114 Others realised as he got closer that it was a hammer. As well as what they saw, officers reported hearing specific threats to stab.
Leading Senior Constable McDiarmid told the Court that even when he could not see Andrew clearly, he could hear him screaming “Mate, stay the fuck away from me. I’ll stab the first cunt that will come near me” and similar threats.115 Andrew was said to be agitated, angry, very aggressive and “raging”.116 I accept that there was some uncertainty among officers about whether Andrew had a knife or a hammer. What is clear is that officers correctly assumed he had a weapon and he threatened to use it.
112 Transcript of 9 October 2024, T134:23.
113 Transcript of 9 October 2024, T136:36.
114 Transcript of 8 October 2024, T17:16; Transcript of 9 October 2024, T136:39-41; T137:8-9.
115 Transcript of 9 October 2024, T95:47-48.
116 Transcript of 9 October 2024, T96:11.
117 Tab 29B, Transcript of interview of Constable Sam Wolf, p. 25, at Q151.
118 Tab 29E, Office Police Notebook of Constable Sam Wolf, p. 43; Transcript of 9 October 2024, T80:31-37.
119 Transcript of 9 October 2024, T85:38-45.
120 See, for example, evidence of Senior Constable Greg Sadowski at Transcript of 9 October 2024, T118:3542.
Buttress stated that he just didn’t know whether Andrew may have a firearm or not.121 He also recalled that at one point it seemed that Andrew was trying to simulate that he had a firearm in his pocket.122 b. Andrew’s state of mind?
It is clear that officers attempted various strategies to engage with Andrew. As I have mentioned, Acting Sergeant Assaf tried very hard to engage with Andrew and to develop rapport at an early stage. Later there was an attempt to locate him with a view to watching him and containing him until a more comprehensive plan could be developed. Once Andrew left the park area, officers became concerned about public safety and the immediate risk Andrew posed. Each appears to have considered using their equipment to stop and apprehend him. No officer thought OC spray was likely to be an effective option and it was not deployed. Two officers used their Tasers, without effect. Each officer was of the firm view that Andrew represented a clear danger to the public if he could not be contained quickly. Senior Sergeant Watt gave evidence that given Andrew was armed and threatening violence it was not appropriate for NSW Police to just withdraw from the situation.
Senior Sergeant Watt was asked to review all the options available to officers on the night of the event and to describe any alternative approaches that may have been available. In summary, he noted the following relevant matters:124 a. Officer presence at the time of an event can be enough to make a subject conform without any directions; b. Communication with officers is an essential element to any process and it is the most fundamental form of force that can be utilised; c. Weaponless control may involve the use of the human body to control and restrain a person; 121 Transcript of 9 October 2024, T151:45-47.
122 Transcript of 9 October 2024, T155:45-50; T156:1-5.
123 See, for example, Transcript of 9 October 2024, T36:46-49.
124 Tab 72, Statement of Senior Sergeant William Watt, at [10].
d. A Taser is a less lethal tactical option, which is designed to temporarily incapacitate humans while minimising fatalities and permanent injury; e. OC spray, which uses an airborne delivery system to convey an inflammatory agent to a person’s location to discourage or limit the person’s actions; f. A baton delivers physical force through strikes to the body and is generally used in circumstances where the likelihood of injury exists; g. A firearm, which is only to be discharged when there is no other reasonable course of action, and when there is an immediate risk to a person’s life, or there is an immediate risk of serious injury, and there is no other way of preventing that risk; h. Contain and negotiate is where a perimeter is established and the movement of a person is restricted.It should be utilised where possible i. Tactical disengagement is where officers retreat from a situation and can be considered in relevant circumstances j. In the instances of an active armed offender, whose primary intent is to kill or injure as many persons as possible, police must employ tactics which are different to those suitable for most police work.
d. A moving perimeter is a risky tactic that requires “excellent co-ordination and a high level of skill”. General duties police are typically not taught this response tactic. This tactic also poses a significant trip hazard and is problematic when officers move behind the subject, as this may represent a cross-fire situation; e. OC spray requires officers to be within three metres of the subject for it to be deployed effectively, which is exceptionally close when engaging with an armed subject. The use of OC spray in these circumstances may also have caused secondary contamination, where the spray incapacitates unintended nearby persons and officers.
f. Tactical disengagement was not an option in this situation as there were significant concerns about Andrew’s wellbeing and risks to the safety of the public posed by an individual armed with knives in a suburban area; g. Utilising weaponless control techniques or a baton on an armed subject is fraught with dangers and lethal injuries can be inflicted faster than an officer may be able to react, let alone to be able to take action to prevent the attack; h. The actions of Andrew, when he approached police in the manner that he did, and coupled with the items he had with him which were “more than capable of including serious or fatal injuries” precluded any detailed planning or chance to attempt to negotiated resolution; i. The decision to draw and discharge Tasers was in accordance with policy and training, however, the Tasers were unsuccessful; j. The discharge of a firearm should only occur where there is an immediate threat to the life of the officer or another person, or the risk of serious injury to a person and there is no other way of preventing the risk. Probationary Constable Worboys “clearly indicated that he believed Constable Buttress’ life was at immediate risk given the actions” of Andrew and based on the evidence available to Senior Sergeant Watt, the actions of Probationary Constable Worboys were in accordance with training and policy; k. The decision to initially handcuff Andrew following the discharge of the firearm and search him was in accordance with training; and l. The removal of handcuffs and provision of first aid was consistent with the training and what is expected of police from a policy perspective.
Counsel Assisting took him to three specific issues, the possibility of disengagement, a moving perimeter and weapon-less control.
In relation to the option of disengagement, Senior Sergeant Watt advised it was not an option in this situation as Andrew posed an “ongoing risk to the public… Whether or not he was actually intending on doing anything or indicated that is somewhat irrelevant; he’s still in public, armed with weapons. There’s a risk to his own safety”.126 So, if police were to disengage with Andrew, that would allow him the freedom to commit self-harm.
Counsel Assisting asked Senior Sergeant Watt about establishing and maintaining a moving perimeter, to which he responded:127 “while it's not impossible to manage a moving perimeter, it's extraordinarily difficult, and … I would accept that perhaps the tactical operations unit would be able to do it effectively and safely, but unfortunately I don't think most general duties police would be capable of managing that kind of situation with the level of risk that's there”.
In terms of the difficulty and risks posed by such an option, Senior Sergeant Watt noted that:128 “… arranging for the attendance of specialist police on a moving job is even more difficult than arranging for them to attend a static location. It just becomes incredibly complex to manage. It becomes almost impossible to manage the competing risks, and eventually you may end up in the same situation anyway. You - the ability to maintain that moving cordon is dependent on the subject willing to remain in the middle of that moving cordon… if [the subject is] willing to remain within a contained perimeter, you've got the ability to utilise specialist resources. If they're not, if they're willing to challenge a perimeter or the cordon, then you're going to have a confrontation and it may not be in a particularly advantageous location”.
In evidence, I heard from Senior Constable Sadowski, an officer of the Operations Support Group (OSG), who provided some information relating to the use of police shields within OSG and whether he thought it could have been used during the incident. He advised that in his opinion, officers were not trained for use a shield in such a manner, and even if it were to be used, “there’s still a lot of risk [and]… there’s no training for that shield specifically to take down armed offenders in any way whatsoever”.129
Additionally, Constable Radoski advised that the shield is used generally when the subject is “contained in a room or when they’ve surrendered to be arrested”.130 126 Transcript of 11 October 2024, T249:50; T250:1-6.
127 Transcript of 11 October 2024, T248:7-11.
128 Transcript of 11 October 2024, T249:12-22.
129 Transcript of 9 October 2024, T127:1-4.
130 Transcript of 9 October 2024, T141:42-44.
The issue of weaponless control was also raised in evidence. Constable Radoski gave evidence that as Andrew started coming towards officers, he began to follow Andrew and was contemplating tackling him to the ground. In his words, Constable Radoski was intending to “just jump on top of him and grab him and secure him”, to grab Andrew “from behind, as hard as I could”, “Not… punch him, like , just hit him as in just tackle him and secure him".131
Counsel Assisting took Senior Sergeant Watt to Constable Radoski’s evidence, who advised that he would be “diplomatically critical” of the action, due to the risk involved and “particularly with edged weapons in close quarters on the ground, the dangers are immense”.132
Counsel Assisting submitted that whilst Constable Radoski was not an insubstantially sized officer, his intention to tackle Andrew to the ground would certainly have been a very brave thing to do. I accept that the fact that no officer tried to tackle Andrew as he ran out of the park could not be described as a missed opportunity according to NSW Police Policy.
Overall, Senior Sergeant Watts concluded that the officers present understood their options and made appropriate decisions in difficult circumstances. Having considered the evidence I accept that the police involved considered and used the weapons they had and were trained to use according to NSW Police policies and protocols. There was no clear missed opportunity.
Counsel Assisting, Counsel for the Commissioner and Counsel for Probationary Constable Worboys each submitted that in all the circumstances of this case, the decision of Probationary Constable Worboys to shoot Andrew was both reasonable and in accordance with New South Wales Police Policy.
Probationary Constable Worboys has given a consistent account since the incident in question. He believed Andrew had a hammer and a knife. He was aware that there had been earlier threats to kill. Probationary Constable Worboys perceived that the risk to Constable Buttress was imminent, and Andrew was “going to kill him”.133
Probationary Constable Worboys’ account is consistent with what others present saw.134
I had the opportunity to observe Probationary Constable Worboys give evidence. He 131 Transcript of 9 October 2024, T140:1-16; T141:3-5.
132 Transcript of 11 October 2024, T252:19-21.
133 Transcript of 10 October 2024, T199:46.
134 See, for example, evidence of Senior Constable James Sadowski at Transcript of 9 October 2024, T123:2731; evidence of Constable Cameron Buttress at Transcript of 9 October 2024, T159:26-41; T160:6-8.
impressed me as a witness of truth. I accept without reservation that he had a genuine belief that his partner Constable Buttress was at imminent risk of death or serious harm immediately prior to the time he took his shot. I have also viewed and listened to the Taser and BWV footage and taken into account the evidence of other officers present. I accept that Probationary Constable Worboys’ belief was reasonable in all the circumstances. I accept that he acted in accordance with NSW Police Policy.
I acknowledge the frightening situation he faced and the difficult decision he made.
For this reason, it is not particularly useful to speculate about whether increased police resources may have changed the tragic outcome.
I have carefully considered whether further PACER program funding could have changed the course of events. I was informed that by the time this situation was unfolding, no PACER staff would have been on duty. Under current policies, the high-risk nature of the incident would have precluded a PACER staff member attending. However, it is possible that had a PACER staff member been on duty, they could have offered some assistance in obtaining medial information. However, detailed medical information was not necessarily required in the circumstances police faced with Andrew that evening. They were sufficiently aware that Andrew was experiencing a “mental health episode”.
If NSW Police and NSW Health agencies manage to create new ways of working together in the future, it is possible that there could be other options right at the start of an evening such as this. However, by the time Andrew left the park, it is difficult to see how mental health resources could have been effectively used.
the effectiveness of this approach.
Formal Findings
Date of death Andrew died on 20 April 2020.
Place of death Andrew died at St George Hospital, Kogarah, New South Wales.
Cause of death Andrew died from gunshot wound to the chest.
Manner of death Andrew was shot by police when he confronted them with two hammers, intending to provoke police to shoot him and intending thereby to end his own life.
Conclusion
I offer my sincere thanks to Counsel Assisting Jake Harris and to his instructing solicitor, Ashliegh Heritage for their very great assistance in this matter.
I thank the Officer-In-Charge, Detective Chief Inspector Virginia Gorman for conducting a thorough investigation.
Magistrate Harriet Grahame Deputy State Coroner, Coroner’s Court of New South Wales, Lidcombe 26 November 2024
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