Deceased
CPL Ian Turner
Demographics
35y, male
Coroner
Decision ofDeputy State Coroner Grahame
Date of death
2017-07-15
Finding date
2024-12-19
Cause of death
multi-drug toxicity
AI-generated summary
CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, disciplinary proceedings, and failed mental health management. Critical failures included: deployment approval despite known PTSD despite initial refusal, lack of coordinated psychiatric care, failure to escalate severe mental health deterioration, inadequate support during disciplinary proceedings, inappropriate company transfer removing support networks, and insufficient supervision while experiencing suicidal ideation. The coroner found the ADF's response to his declining mental health was grossly inadequate. Key preventable factors included poor communication between treating clinicians, lack of systematic mental health monitoring, and prioritisation of operational capability over individual welfare.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of CPL Ian Turner Hearing dates: 19-23 October 2020; 2-6 August 2021; 10-13 August 2021; 29 August 2022; 1, 6 and 9 September 2022; 1, 3, 6, 7, 8 and 9 February 2023 Date of findings: 19 December 2024 Place of findings: NSW Coroners Court, Lidcombe NSW Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – intentional self-harm – multi-drug toxicity – Post Traumatic Stress Disorder (PTSD) – combat-related PTSD – mental health supports for ADF member whilst on deployment and while at home – risks of deployment to ADF member with PTSD – medical clearances and command waivers – history of domestic violence and alcohol abuse – effect of disciplinary proceedings, reduction in rank, transfer to another company, and rejection of study plans File number: 2017/216798 Representation: Counsel Assisting: Ms Kristina Stern SC, Ms Madeleine Ellicott, and Ms Naomi Wootton instructed by Mr Paul Armstrong of the Crown Solicitor’s Office Counsel for Ms Joanna Turner: Mr Bruce Levet OA Counsel for Mrs Patricia Turner and Mr Mike Turner: Mr Jonathan Hyde, instructed by Mr Greg Isolani of KCI Lawyers Counsel for the Commonwealth: Ms Jennifer Single SC and Mr Joe Edwards, instructed by Ms Karina Harvey of the Australian Government Solicitor Counsel for Dr Sujaya Sringeri: Ms Kim Burke, instructed by Ms Lauren Rickersey of Barry Nilsson Lawyers Counsel for Dr Muhammad Malik: Mr Ryan Coffey, instructed by Ms Marie Panuccio of Makinson d'Apice Lawyers Counsel for Dr Brendan Hale: Mr Geoffrey Gemmell, instructed by Ms Kerrie Chambers of HWL Ebsworth
Counsel for CAPT MH: Mr Joshua Nottle Counsel for Group Captain James Ross: Ms Laura Johnston Counsel for CAPT BJ: Ms Catherine Gleeson Counsel for CPL TJ: Mr Luke Chapman Protective orders: Pseudonym orders protecting the identities of a number of serving members of the Australian Defence Force have been made in this Inquest.
Non-disclosure orders and non-publication orders have also been made. A copy of these orders can be found on the Registry file.
Publication order: In accordance with s 75(5) of the Coroners Act 2009 (NSW), I make an order permitting the publication of a report of the proceedings as I consider that it is desirable in the public interest to permit a report of the proceedings of the inquest to be published.
s 61 certificates None issued issued: Findings: Identity The person who died was Ian Turner.
Date of death He died between 14 and 15 July 2017.
Place of death He died at 206/18 Amelia Street, Waterloo, NSW.
Cause of death He died of multi-drug toxicity. The antecedent cause was combatrelated Post Traumatic Stress Disorder (PTSD).
Manner of death His death was intentionally self-inflicted in the context of combatrelated PTSD.
Recommendations: To the Chief of the Defence Force, I recommend that consideration be given to:
Introducing a systematic process for mapping the history of an ADF member’s deployments, their RtAPS and POPS screens data, and other reported psychiatric diagnoses and treatment, that forms part of the member’s health record and including systems to record and action such notifications and to ensure that they are taken into account in decisions relating to deployment.
Including a mandatory annual training for all Special Forces members in recognising and destigmatising the symptoms of and managing PTSD, which appropriately includes simulations of real-life scenarios and recommendations about methods of decision-making.
Establishing a system by which psychological distress in the home environment can be communicated to an ADF member’s unit by family members including systems to record and action such notifications and to ensure that they are taken into account in decisions relating to deployment.
Providing opportunities for ADF families to be notified of and involved in treatment programs provided to ADF members for PTSD and other combat-related psychological conditions.
Making it a requirement that the impact upon mental health be taken into account in decisions relating to deployment, change of company, or support of members’ study plans or transitional plans to non-combat roles within the ADF or employment roles outside the ADF.
Implementing a requirement for psychological screening and support to be automatically offered to ADF members who are undergoing disciplinary proceedings.
Providing psychological screening and support whilst on deployment to ADF members who have previously been diagnosed with PTSD.
Employing enlisted ADF psychiatrists with: a. specialist training in military and veterans’ psychiatry; and b. security clearances at a level consistent with the clearances of the ADF members who are being treated by them.
Ensuring that enlisted psychologists and contracted psychologists have security clearances at a level consistent with the clearances of the ADF members who are being treated by them.
Establishing systems and a culture of transition from Special Forces, including providing adequate support for transitions: a. to non-combat roles within the ADF; and b. to employment roles outside the ADF.
Undertaking an evidence-based review as to whether and how the ADF should limit the number of combat deployments upon which an ADF member can deploy during their career before being required to transition to non-combat roles.
Reviewing the ADF policy framework with respect to the making of deployment decisions for ADF members who have or have had a diagnosis of PTSD or another similar mental health condition, with a view to developing clear guidelines and procedures about: a. How such decisions should be made (including whether and how they can be “appealed”); b. The roles and responsibilities of operational personnel, medical personnel and any external health practitioners in the making of such decisions; c. The information to which operational personnel, medical personnel and any external health practitioners may and may not have access in making such decisions; and d. In the event that a decision to deploy is made, the development and implementation of risk mitigation strategies (a plan of action should also be formulated as part of the mitigation plan/strategy in the event the condition for which the ADF member received a clearance or waiver begins to deteriorate).
Where an RtAPS or POPS reveals severe PTSD symptoms and permission to advise the Chain of Command is not forthcoming, that the Chain of Command is promptly notified by issuing a simple alert.
Implementing training programs for ADF members in command roles in relation to PTSD, including the identification of PTSD symptoms and the appropriate management of soldiers experiencing PTSD.
Reviewing the management of soldiers suffering from mental health conditions in 2CDO in consideration of: a. best clinical practice; b. longitudinal management of conditions and treatments; and
c. the appointment of a single point of coordination and responsibility for the overall treatment of the individual.
Reviewing the role of the padre in relation to the identification, treatment, and management of soldiers with mental health conditions in 2CDO.
Implementing a system whereby the ADF formally track the time members deploy by establishing a system for mapping the history of an ADF members leave entitlements, the leave taken, and lapsing/lapsed leave and to ensure that they are considered in decisions relating to deployments.
Undertaking a study of the effects of repeated deployments on a member’s home and family life.
Conducting greater research and analysis on the correlation between incidents of domestic violence and PTSD and considering the impact of vicarious trauma on intimate partners and children of ADF members and, in turn, their ability to support the ADF member, which could include undertaking a study that investigates the decompensation of members with PTSD on or around the dates of the traumas experienced by the members.
Requiring all ADF psychologists conducting the RtAPS and POPS to: a. consider previous psychological screening results to ensure that they have a complete picture when carrying out individual assessments; b. be trained to ensure they understand and appreciate the importance of their role in identifying and responding appropriately to combat trauma; and c. undertake the assessment in an environment that allows the member to fully participate in the assessment.
Providing better education regarding subsyndromal PTSD and undertaking an independent review of health files and a policy developed to guide future reviews in similar situations.
That where ADF members are discharging on medical grounds for combat-acquired PTSD, it should be seen as a red flag for others within the unit and should trigger suitable interventions where necessary.
Reviewing ADF policies and practices in managing complex psychiatric cases, including clarity on where additional support and when referral to alternative service providers can be requested and ensuring that there is specialised clinical oversight in managing and making decisions regarding the
suitability of activities, duties, and clinical intervention for members in CPL Turner’s situation.
Amending the ADF’s policy, Army Standing Instruction (Personnel) Part 8 Chapter 8: Delivery of Support to Wounded, Injured and Ill Members in the Australian Army (ASI(P) Part 8 Chapter 8) dated November 2021, by including the following: a. If the member is physically unable to attend the welfare board meeting, the policy is to stipulate who is responsible for providing the member with details of the proceeding and the outcome; b. A process of referral in circumstances where the welfare board is not witnessing an expected trajectory of improvement in the member’s condition, the Chain of Command can escalate the matter for additional resource support, including additional clinical input for a higher level of care; c. Implementing recommendation (d) arising from a Joint After-Action Review conducted by Special Operations Command and Joint Health Command 195 that Director Garrison Operations be included in quarterly Commander Special Forces Welfare Board to ensure that complex cases have the adequate resources at the unit level to deliver appropriate care; and d. Coordination of services.
Clearly delineating the difference between a medical clearance and a command waiver and ensuring that all documentation including policies and forms used in the process reflect that delineation.
Undertaking research regarding the value of a transition period between a member being on operations and returning to a domestic environment and the time required to make such a transition.
Providing education for units, in particular male dominated units, regarding the ethical and moral treatment of women and placing greater emphasis on “[p]rotecting the family unit” for a member suffering from ill mental health.
A copy of these Findings is to be provided to the Chief of the Defence Force and the Minister for Defence.
Contents
INTRODUCTION 1 THE ROLE OF THE CORONER AND THE SCOPE OF THE INQUEST 1 THE EVIDENCE 2 BACKGROUND FACTS 3 RELEVANT EVENTS OF 2013 6 RELEVANT EVENTS OF 2014 8 (A) SERVICE IN THE ADF 8 (B) 2014 DOMESTIC VIOLENCE CHARGES 9 (C) ADMISSION TO SYDNEY SOUTHWEST PRIVATE HOSPITAL IN 2014 12 (D) JOANNA TURNER’S ATTEMPTS TO ASSIST CPL TURNER THROUGH THE ADF 13 (E) TREATMENT DURING THE PERIOD OF CONDITIONAL RELEASE 14 RELEVANT EVENTS OF 2015 16 (A) SERVICE IN THE ADF 16 (B) RELATIONSHIP WITH JOANNA TURNER 22 RELEVANT EVENTS OF 2016 23 (A) RELATIONSHIP WITH JOANNA TURNER 23 (B) MENTAL HEALTH 23 (C) MANAGEMENT OF PTSD 23 (D) DEPLOYMENT ON OP OKRA 26 (E) THE MEDICAL CLEARANCE / “WAIVER” 30 (F) DR SRINGERI’S LETTER 46 (G) GPCAPT ROSS’ DECISION 48 (H) DEPLOYMENT TO IRAQ ON OP OKRA IN 2016 57 (I) DISCIPLINARY PROCEEDINGS AND REDUCTION IN RANK 57 (J) CARE OF CPL TURNER’S MENTAL HEALTH IN IRAQ 61 (K) THE NOTICE TO SHOW CAUSE (NTSC) 63 (L) DETERIORATING MENTAL HEALTH IN IRAQ AND AVAILABLE SUPPORTS 63 (M) AVAILABILITY OF ALCOHOL IN IRAQ 70 (N) THE BODY RECOVERY 71 (O) RELATIONSHIP WITH CPL TJ 74 (P) STEROID USE 75 (Q) END OF THE IRAQ DEPLOYMENT AND RETURN TO AUSTRALIA 75 RELEVANT EVENTS OF JANUARY TO JULY 2017 78 (A) TRANSFER FROM BRAVO TO CHARLIE COMPANY 78 (B) EFFECT OF THE COMPANY MOVE ON CPL TURNER’S MENTAL HEALTH 81 (C) RELATIONSHIP WITH JOANNA TURNER AND THE CHILDREN 82 (D) MENTAL HEALTH IN EARLY 2017 83 (E) THE PHD PROPOSAL 85 (F) FIRST SUICIDE ATTEMPT AND MARCH 2017 ADMISSION 86 (G) SECOND SUICIDE ATTEMPT AND APRIL 2017 ADMISSION 88 (H) THE REHABILITATION PLAN 94 (I) JUNE TO JULY 2017 94
12 TO 15 JULY 2017 99 OTHER FACTUAL ISSUES 101 EXPERT EVIDENCE 109 PRELIMINARY MATTERS 138 PROCEDURAL FAIRNESS 138 HINDSIGHT BIAS 142 CONCLUSIONS OF OTHER INQUIRIES AND FORESEEABILITY 145 ISSUES FOR CONSIDERATION 146 ISSUE 1 – THE CAUSE OF CPL TURNER’S DEATH 148 ISSUE 2 - THE IMPACT OF CPL TURNER’S SERVICE IN THE ADF UPON HIS MENTAL HEALTH AND HIS DEATH IN THE CONTEXT OF HIS PERSONALITY TYPE AND INTERPERSONAL RELATIONSHIPS 149 ISSUE 3 – THE ADEQUACY OF THE ADF’S RESPONSE TO CPL TURNER’S MENTAL HEALTH ISSUES IN PARTICULAR FROM 2014 TO JULY 2017 AND WHETHER CPL TURNER’S DECLINING MENTAL HEALTH WAS APPROPRIATELY MANAGED BY THE ADF IN GENERAL AND IN PARTICULAR BY THE HUMAN PERFORMANCE WING AT HOLSWORTHY 153 ADEQUACY OF ADF’S RESPONSE PRIOR TO 2014 153 ADEQUACY OF ADF’S RESPONSE IN 2014 159 ADEQUACY OF ADF’S RESPONSE IN 2015 173 ADEQUACY OF ADF’S RESPONSE IN 2016 179 ADEQUACY OF ADF’S RESPONSE IN 2017 (UP UNTIL 15 JULY 2017) 209 ADEQUACY OF THE ADF’S RESPONSE IN THE PERIOD FROM 15 TO 17 JULY 2017 227 OTHER MATTERS RAISED IN CONNECTION WITH ISSUE 3 228 ISSUE 4 – WHETHER THERE WAS ANY DISINCENTIVE TO CPL TURNER RAISING MENTAL HEALTH ISSUES OR SEEKING MENTAL HEALTH TREATMENT BY REASON OF ADF POLICIES OR PROCEDURES 240 ISSUE 5 – THE EXTENT TO WHICH THE INVESTIGATION AND LAYING OF CHARGES ARISING FROM AN INCIDENT INVOLVING A PORNOGRAPHIC PLAYING CARD AFFECTED CPL TURNER’S MENTAL HEALTH, THE EXTENT TO WHICH CPL TURNER’S MENTAL HEALTH HISTORY WAS TAKEN INTO ACCOUNT IN THIS PROCESS AND WHETHER ADEQUATE SUPPORT WAS PROVIDED IN THESE CIRCUMSTANCES. 244 ISSUE 6 – THE MOVE FROM B COMPANY TO C COMPANY 253 ISSUE 7 – LACK OF COMMUNICATION AND/OR COOPERATION BETWEEN PRESCRIBING DOCTORS ISSUE 8 - THE CIRCUMSTANCES BY WHICH CPL TURNER CAME TO HAVE SIGNIFICANT SUPPLIES OF MEDICATION AVAILABLE TO HIM AT THE TIME OF HIS DEATH. 260 ISSUE 9 – THE REMOVAL OF ITEMS FROM CPL TURNER’S PREMISES AFTER HIS DEATH (SANITISATION) 265
ISSUE 10 – ALLEGATIONS MADE IN LATE JUNE 2017 REPORTED TO ADF AND NSWPF 272 ISSUE 11 – WHETHER ANY OTHER FACTORS ARISING DURING CPL TURNER’S SERVICE CONTRIBUTED TO HIS DEATH 272 FINAL ISSUE: THE PRODUCTION OF DOCUMENTS BY THE ADF 275 RECOMMENDATIONS 277 COUNSEL ASSISTING’S PROPOSED RECOMMENDATIONS 278 MR AND MRS TURNER’S PROPOSED RECOMMENDATIONS 300 RECOMMENDATIONS PROPOSED BY JOANNA TURNER 315 RECOMMENDATIONS PROPOSED BY GPCAPT ROSS 319 RECOMMENDATIONS PROPOSED BY CAPT MH 320 RECOMMENDATIONS PROPOSED BY CPL TJ 321 FINDINGS 322 IDENTITY 322 DATE OF DEATH 322 PLACE OF DEATH 322 CAUSE OF DEATH 322 MANNER OF DEATH 322 RECOMMENDATIONS 322 CONCLUSION 327
This Inquest concerns the death of CPL Ian Turner who was found deceased in his unit at Waterloo NSW on 15 July 2017.
CPL Turner was 35 years old when he died.1 He had a history of post-traumatic stress disorder (PTSD) and substance abuse. Except for a short period when he worked for a private security company in Iraq, CPL Turner had been a member of the Australian Defence Force (ADF) since 2000 and had been deployed multiple times to East Timor, Iraq, and Afghanistan. CPL Turner gave much of his life to serving his country through the ADF.
It was clear during these proceedings that CPL Turner’s death has profoundly affected many. He was greatly loved by his family and fellow soldiers. Tragically, however, the intensity of his journey with PTSD complicated and damaged some of his relationships with those around him and theirs with each other. At the outset I acknowledge the pain and grief of Joanna Turner, Pat and Mike Turner and their family, and all of those who served with or loved CPL Ian Turner. I am acutely aware that the trauma that surrounds his death continues.
The role of the coroner is to make findings as to the identity of the deceased 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.2 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.3
It is important to acknowledge that this Inquest occurred during a period when there was broad community concern about the prevalence of defence and veteran suicides.
Prior to these proceedings commencing, the Commonwealth Government had announced the establishment of a new National Commissioner for Defence and Veteran Suicide Prevention and the terms of reference for the Independent Review of Past Defence and Veteran Suicides. This important inquiry was resourced to examine broad systemic issues. In contrast, these coronial proceedings focussed on the death of a single soldier and the specific issues he faced. Nevertheless, the close 1 Tab 1 (P79A Report of Death to the Coroner).
2 Coroners Act 2009 (NSW) s 81.
3 Coroners Act 2009 (NSW) s 82.
examination of CPL Turner’s death brought into focus important issues that have a wider significance.
The Court took evidence over 24 hearing days and received documentary material comprising an 11-volume brief of evidence (Exhibit 1) and 66 further exhibits. In total, more than 14,400 pages of evidence were tendered. This material included witness statements, medical records, ADF service records, ADF policies and procedures, and expert reports. The Court heard oral evidence from many witnesses including CPL Turner’s fellow soldiers, his treating medical practitioners, ADF officers, his family and friends, and five expert psychiatrists.
Notwithstanding the volume of evidence, certain evidentiary gaps were identified by the parties. For example, the Commonwealth submits that it could be inferred that not all messages were recovered from CPL Turner’s phone,4 which “has consequences”5 for the findings, comments, and recommendations that can now be made. Separately, Counsel Assisting submits that I could not be confident the ADF produced all documents falling within the scope of subpoenas issued in 2019 and 2021. While accepting there was an initial mistaken non-compliance with the 2019 subpoena, the Commonwealth submits in reply that the ADF was not required to produce “all” material within scope, but only make “reasonable searches” and “reasonable enquiries” to find such documents.6 This issue is explored in further detail at [130]-[134] and [1039]- [1047] below.
I have taken into account the extensive evidence before me. The parties also provided very extensive submissions. While I have not been able to refer to every point raised, each has been considered carefully.
It is acknowledged that delay has also impacted these proceedings. Difficulties in obtaining relevant material, the effect of COVID 19 on court listings, and various other factors have all played a role. The Court acknowledges the additional stress this has placed on CPL Turner’s loved ones and on witnesses awaiting the conclusion of these proceedings.
4 Submissions of the Commonwealth dated 7 June 2024 at [34]-[37].
5 Submissions of the Commonwealth dated 7 June 2024 at [37].
6 Submissions of the Commonwealth dated 7 June 2024 at [38]-[46].
BACKGROUND FACTS Childhood, Early Life, Family
CPL Turner was born on 13 November 1981. CPL Turner’s father, Mike Turner, was a reservist in the Army. His mother, Patricia Turner, was a schoolteacher. He also has three sisters (Christine, Karen, and Lisa), and had a brother (Steven) who sadly passed away not long after the close of oral evidence in the Inquest.
CPL Turner met his wife, Joanna Turner, in 1994, as they attended the same high school. They commenced a relationship in 2002 and were married in 2006.7 Joanna Turner had a son from a previous relationship (XS), who was born on 26 September 2002.8 CPL Turner and Joanna Turner subsequently had a daughter (ET), born on 2 January 2005.9 CPL Turner’s Early Service in the ADF and Events Prior to 2013
On 4 April 2000, CPL Turner enlisted in the Australian Regular Army (ARA).10 He served with the 2nd Battalion, The Royal Australian Regiment (RAR), until October
During this time, he deployed to East Timor on OP TANAGER (2001), from 28 October 2001 to 11 December 2001, and again from 20 December 2001 to 30 April 2002.11 It appears that during his second deployment, he was convicted of a DUI offence, but did not show any signs of subsequent alcohol dependence and a liver function test showed normal function.12 Following successful completion of Commando Training and Selection, CPL Turner was posted to the 4th Battalion, RAR (Commando)
CPL Turner transferred to the Army Reserve on 5 April 2004 and was posted as a rifleman to 12/40th Battalion, The Royal Tasmanian Regiment. He undertook security contract work in Iraq, prior to re-joining the ARA on 1 November 2006 as a 4 RAR (CDO) reinforcement.13 On 19 June 2009, 4 RAR (CDO) was renamed the 2nd Commando Regiment, or 2CDO.14
CPL Turner deployed on Operation SLIPPER (Afghanistan) in 2007, 2009, 2011/2012 and 2013, and Operation OKRA (Iraq) (OP OKRA) in 2015 and 2016. He also 7 Tab 6 (Statement of Joanna Turner) at [3].
8 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 4.
9 Tab 6 (Statement of Joanna Turner) at [3].
10 Tab 13 (IGADF Report) at [3].
11 Tab 43 (ADF Personnel File) at 18.
12 Tab 49 (ADF Medical Records – Unit copy) at 279.
13 Tab 13 (IGADF Report) at [3].
14 Tab 13 (IGADF Report) at [3].
completed other deployments which did not involve active combat or deployment to a warzone.
CPL Turner deployed to Afghanistan in 2007 (2007 Afghanistan Deployment) and was deployed there on Operation SLIPPER from approximately 24 August 2007 to 4 January 2008.15 During this deployment, CPL Turner’s close friend, PTE Luke Worsley, died during a building clearance operation.16 Joanna Turner’s evidence was to the effect that PTE Worsley’s death had a negative impact on CPL Turner, and his alcohol consumption increased noticeably following this deployment. CPL Turner reported (to Dr Sringeri, sometime in 2014) “experiencing symptoms of post-traumatic stress disorder like … frequent flashbacks, intrusive memories of nightmares and panic attacks”, and “swings and irritability”.17 He reported using alcohol to cope with his PTSD symptoms.18
CPL Turner deployed again to Afghanistan in 2009 (2009 Afghanistan Deployment), and was deployed there on Operation SLIPPER from approximately 6 March 2009 to 10 July 2009.19 During this deployment, he applied first aid to PTE Damien Thomlinson, who lost both of his legs when his vehicle was struck by an IED.20 CAPT MH stated that CPL Turner, in his view, seemed to speak about this incident more than others, talking about being hit with Damien’s foot, “the mess, the sound of Damien like in incredible pain”.21
CPL Turner completed a Return to Australia Psychological Screening (RtAPS) on 1 July 2009 in which he reported traumatic experiences including one colleague who was killed and another wounded. He reported that an event involving a young child had occurred on this deployment, who was severely injured and that this caused him “some distress” and that he “tries not to think about these events”. It was reported that his symptom levels met “PTSD criteria, with high re-experiencing symptoms, a tendency to avoid discussing events and increased hyper-vigilance”, and that other people had noted his “jumpiness”. The recommendation made was a follow up in two months, and CAPT KH (the psychologist at 2CDO) was contacted and asked to follow up with CPL Turner.22 15 Tab 43 (ADF Personnel File) at 18.
16 Tab 13 (IGADF Report) at [7].
17 Tab 105 (Letter from Dr Sringeri to Meehans Solicitors dated 12 May 2014) at 15.
18 Tab 105 (Letter from Dr Sringeri to Meehans Solicitors dated 12 May 2014) at 15. See also Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 8.
19 Tab 43 (ADF Personnel File) at 18.
20 Tab 13 (IGADF Report) at [7].
21 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 24. See also Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 13.
22 Tab 48 (ADF medical records psyche file) at 41-42. See also Tab 49 (ADF Medical records – unit copy) at 592- 596.
CPL Turner reported (to Dr Sringeri, sometime in 2014) that he experienced an exacerbation of his PTSD symptoms after he returned from the 2009 Afghanistan Deployment, including reliving symptoms (recurrent flashbacks, intrusive memories and nightmares) in a more severe fashion, having “more frequent panic attacks and more intense mood swings”, being “increasingly angry for trivial reasons”, consuming “excessive alcohol to cope with PTSD symptoms”, and alcohol dependence symptoms like tolerance and craving.23
A Post-Operational Psychological Screening (POPS) was conducted with CPL Turner on 22 September 2009 as a result of the RtAPS referral. He recalled during that session the traumatic experiences he had during the 2009 deployment. He reported “no concerns at home”. He further reported low psychological distress, but restlessness and an inability to sit still. The conclusion in the POPS was that there were no “immediate concerns” and no reason to recall him for another session/follow up, and that he had “impressed as coping well thus far”.24 CPL Turner deployed again to Afghanistan in 2011-2012 (2011-2012 Afghanistan Deployment) and was deployed there on Operation SLIPPER from approximately 27 July 2011 to 1 February 2012.25 CPL Turner reported (to Dr Sringeri, sometime in 2014), that he experienced “more traumas of his friends getting injured”, and continued to have symptoms of PTSD and consume alcohol excessively.26
CPL Turner underwent an RtAPS on 31 January 2012. During that session, he reported that he had significant exposure to potentially traumatic events but that this was “not an issue for him” and that he would seek support if issues arose. CPL Turner reported that for his “coping skills” he utilises “Beer” as well as “kids missus fitness and watching movies”.27 On 5 July 2012, CPL Turner was seen by a plastic surgeon in relation to lacerations sustained from punching a television screen.28
CPL Turner underwent a POPS on 28 August 2012. During that screening he reported being restless, difficulty concentrating, hyper-alertness, and jumpiness but stated these were “typical / normal for him”.29 He reported re-experiencing symptoms in relation to him having provided first aid to Damien Thomlinson, stating that the “visual intensity of this scene still intrudes today with vivid images” and “monthly disturbing weird dreams”, as well as drinking “4–6 stubbies of beer most nights”. The 23 Tab 105 (Letter from Dr Sringeri to Meehans Solicitors dated 12 May 2014) at 15.
24 Tab 48 (ADF medical records) at 35-36.
25 Tab 43 (ADF Personnel File) at 18.
26 Tab 105 (Letter from Dr Sringeri to Meehans Solicitors dated 12 May 2014) at 16.
27 Tab 48 (ADF medical records – unit copy) at 27.
28 Tab 47 (ADF Medical Records – Central Part 2) at 323.
29 Tab 48 (ADF medical records – unit copy) at 21.
recommendation noted was that the member would benefit from follow up support, but had refused support, and that it therefore seemed “unlikely the member would appropriately engage in therapy or the ADF RESET program”, so “no further action is planned”.30
Joanna Turner gave evidence that the first time CPL Turner was violent to her was a few weeks after their daughter was born in 2005. Joanna also gave evidence that excessive alcohol use was a long-term problem for CPL Turner that she started noticing before 2013.31 Relevant Events of 2013
CPL Turner deployed again to Afghanistan in 2013 (2013 Afghanistan Deployment) and was deployed there on Operation SLIPPER from approximately 31 January 2013 to 17 July 2013.32 He reported (to Dr Sringeri, sometime in 2014) that he experienced “witnessing multiple traumatic experiences like 4 of his friends were shot and 5 blowups”.33 Joanna Turner reported that following this deployment, she saw “the most significantly dangerous change in Ian … he was spiralling quick”.34
CPL Cameron Baird lost his life during this deployment. CAPT MH stated that CPL Turner and CPL Baird were “very close mates, and he often talked about Cam … He often said he wished he could change places with Cam”.35 CPL JW stated in his record of interview (ROI) that the death of CPL Baird was “a pretty hard one for everyone to take” and that CPL Turner was “blaming himself, but he was really grieving the loss.”36
CPL Turner underwent an RtAPS on 10 July 2013. He reported high psychological distress and reported his alcohol dependence which the psychologist interviewing him attributed to “traumatic grief”, seemingly related to the death of CPL Baird. The notes also recorded that CPL Turner had admitted to consuming significant volumes of alcohol, drinking in the workplace, and hiding this behaviour in 2012 but stated that he now had the ability to “stop after 2 drinks.”37
Joanna Turner’s evidence was to the effect that when CPL Turner returned from the 2013 Afghanistan Deployment, he was “highly withdrawn”, there was an increase in 30 Tab 48 (ADF medical records – psyche file) at 21-22.
31 19/10/2020 T52.26-30 and T53.20-35.
32 Tab 43 (ADF Personnel File) at 18.
33 Tab 105 (Letter from Dr Sringeri to Meehans Solicitors dated 12 May 2014) at 16.
34 Tab 32 (IGADF ROI with Joanna Turner) at 16.
35 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 25. See also Tab 20 (IGADF ROI with CPL JW on 5 June 2018) at 7.
36 Tab 20 (IGADF ROI with CPL JW) on 5 June 2018 at 7-8.
37 Tab 48 (ADF medical records – psych file) at 11-19.
“Army talk” at home and his “pain compliance” towards Joanna and the children increased, as well as his anger towards XS who he would make “do drills”.38 Joanna Turner reported an increase in what I will describe as “ coercively controlling” behaviour around this time, whereby she was not allowed to have male friends on Facebook, CPL Turner would check her phone every day, she had to give him a rundown of who she had spoken to, and if he wanted to know at any time where she was, he would send her a message and she would have to take a photo “to prove where I was”. If she did not comply, he would choke her, or hold her in pain compliance until she did what CPL Turner asked.39
Joanna Turner’s evidence in her ROI was that “everyone at work knew what was happening” but “no one talks about it”.40 Joanna Turner stated that she spoke to Selena Clancy and the padre (who was then Padre M about the issues in her home around 2013.41
Joanna Turner’s evidence was that CPL Turner had told her about things he had done on deployment, including stabbing a man to death, executing someone who he made get on their knees “to see what it was like”, that an officer he was with used to “chop hands off” in order to identify a deceased person instead of following proper biometric identification procedures, and that he had “shot a child” and on another incident a “baby had been killed by mistake” which bothered CPL Turner greatly.42
Padre MP considered that CPL Turner had “moral injury from killing too many people… he was a sniper, so I think he killed a lot of people”. Padre MP stated that he had a “big argument” one day with CPL Turner, as he had a “shimar” on his TV, which CPL Turner had taken from his 100th kill. Padre MP stated that he said “that’s a trophy, I said you’ve got to be careful and we got into an argument about having trophies of killing people”.43 Dr Malik reported that in 2017, when CPL Turner was being treated 38 Tab 7 (Statement of Joanna Turner) at 2 [11]. See also Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 20.
39 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 21.
40 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 26.
41 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 27-28. See also 19/10/20 at T53-54.
42 Tab 7 (Statement of Joanna Turner) at 6 [32].
43 Tab 19 (IGADF ROI with Padre MP on 18 September 2018). It should be noted that Padre MP’s evidence to the Inquest was that he was on significant pain medication at the time of his IGADF interview, and that as a result his interview was very “fractured”:
at St John of God Hospital (SJoGH), he stated “I have killed so many people and I cannot live with myself. I have killed innocents”.44
On 16 October 2013, CPL Turner underwent a POPS screening, at which he presented with a high degree of “psychomotor agitation (wringing hands, tapping feet and eye twitch)” and a flat affect. He denied any significant reintegration issues within the domestic, social, or work context. The psychologist, however, noted that he described several symptoms which would suggest some level of functional impairment, including constant restlessness, visual images of deployment scenes, dreams, psychical anxiety, avoidance of crowded places, low frustration tolerance, and feeling hyperalert, as well as alcohol consumption of 2 beers on weeknights and 6-8 on Friday and Saturday nights. The psychologist reported concern about his reported symptoms and encouraged a review, but CPL Turner “flatly denied the existence of any difficulties” and reported that if things worsened he would “deal with it”. The POPS concluded that no further action was stipulated because of CPL Turner’s resistance to engage and denial of any current difficulties.45
On 9 December 2013, the POPS was discussed between medical practitioners and it was noted that CPL Turner was then presenting to a unit welfare board (UWB) by reason of physical injuries, and that he would be called in early 2014 to be offered further support. On 5 February 2014, CPL Turner was called and offered further support, and he refused further engagement with psychological support, stating “not trying to be rude, but I don’t really like to talk”. He was advised that his POPS would be closed off and he would not be contacted but was informed that he could always self-refer.46 Relevant events of 2014
(a) Service in the ADF
45 Tab 48 (ADF Medical psych file) at 5-6.
46 Tab 48 (ADF Medical records) at 5-6.
47 The evidence in the Inquest was to the effect that “deployed” can have different meanings. It appears that the term was used to describe when a member was sent to another location for an extended period of time, whether that was to a conflict zone or not. In some circumstances, it was only used to describe deployment to a conflict zone, such as the MEAO: see, e.g., 21/10/20
48 Tab 43 (ADF Personnel File) at 18.
(b) 2014 Domestic Violence Charges
On 7 April 2014, CPL Turner was charged with stalking or intimidation with intent to cause fear of physical or mental harm, use of a carriage service to threaten to kill, and common assault.
The documentary evidence indicates that Joanna Turner reported the domestic violence on 30 March 2014,49 and then attended Liverpool Police Station on 1 April 2014 to provide an updated statement in relation to the offences. CPL Turner attended Liverpool Police Station at 10am on 7 April 2014 with a support person, Ben Treloar (who was a member of the ADF), and at that time was charged.50
A provisional domestic violence order was issued by the NSW Police on 1 April 2014 for the protection of Joanna Turner.51 This was known to the ADF: on 1 April 2014, a copy of the Provisional AVO was emailed from the Adjutant of 2CDO and it was noted that the CSM, WO2 NW, was in location where CPL Turner was then doing a course, to serve the provisional AVO on him.52 The Adjutant noted that the CSM intended to “seek any required provisions with the NSW Police” in order to allow CPL Turner to complete the course he was doing, with respect to “weapons use”.53
CPL JW noted that while CPL Turner was on course in Singleton, he was getting calls from unit members stating “look, he’s drinking a considerable amount”. He stated that he and CPL SM were concerned about his wellbeing and went to discuss the issue with the unit psychologist. They were told that if he was to be pulled out of the course, that would be “more detrimental” to his state at that time.54
On 3 June 2014, the charges were conditionally discharged pursuant to s 32 of the Mental Health (Forensic Provisions) Act 1990 (NSW) (MH(FP) Act) (with the Commonwealth offence similarly discharged under s 20BQ of the Crimes Act 1914 (Cth) (Crimes Act)).55
The order made under the MH(FP) Act was in the following terms:56 “The charge is dismissed and the accused person is discharged Subject to the following conditions: 49 Tab 32 (IGADF Investigation, Evidence of Joanna Turner) at 113.
50 Tab 105 (Police Facts Sheet) at 29.
51 Exhibit 31 (Tranche 1) at 300.
52 Exhibit 31 (Tranche 1) at 299.
53 Exhibit 31 (Tranche 1) at 299. See also Tab 47 (ADF Medical Records Central Part 2) at 48.
54 Tab 20 (IGADF ROI with CPL JW) on 5 June 2018 at 13.
55 Tab 105 (Local Cour File – New South Wales Police Force Bail Report) at 36.
56 Tab 105 (Local Court File) at 12.
TAKE PRESCRIBED MEDICATION/ATTEND COUNSELLING TREATMENT IN ACCORDANCE WITH MEDICAL ADVICE/NOMINATED PSYCHIATRIST/PSYCHOLOGIST CAPTAIN [SG] & Dr. SUJAYA SRINGERI INCLUDING TREATMENT PLAN
TAKE PRESCRIBED MEDICATION/ATTEND COUNSELLING TREATMENT IN ACCORDANCE WITH MEDICAL ADVICE/NOMINATED PSYCHIATRIST/PSYCHOLOGIST DR. SUJAYA SRINGERI & CAPTAIN [SG] INCLUDING TREATMENT PLAN SET OUT ON PAGE 8 OF DR. SRINGERI’S REPORT.
Additionally, a final Apprehended Violence Order (AVO) was made for a period of 6 months which contained an order not to assault, molest, harass, threaten or otherwise interfere with, intimidate, or stalk Joanna Turner or a person with whom Joanna Turner had a domestic relationship. It also provided that CPL Turner was not to approach Joanna Turner or any such premises within which she resided or worked within 6 hours of consuming alcohol or illicit drugs.58
The facts on which CPL Turner was sentenced record that “over the past few years” CPL Turner had begun to consume large amounts of alcohol on a daily basis, which made him aggressive and hostile towards Joanna Turner, and that he had been both verbally and physically violent towards her. The facts record that CPL Turner had begun to ostracise and control Joanna by taking control of her bank account and disconnecting her phone when she “upset” CPL Turner, and that he had become paranoid about her “trying to find a new boyfriend”.59
The facts sheet recorded an event in November 2013, where CPL Turner had attended a Remembrance Day unveiling for a friend at the Australian War Memorial. Upon returning home, CPL Turner became aggressive and caused a large kitchen window to smash and pulled at Joanna Turner’s clothing until it ripped. The facts record further abusive and controlling behaviour over text messages, CPL Turner requiring that 57 Tab 105 (Local Court File) at 13.
58 Tab 60 (DVA Medical Records) at 75.
59 Tab 105 (Police Facts Sheet) at 25.
Joanna Turner delete her Facebook account under threat of “a world of hurt” and “grave trouble”, and later threatening to cut off her mobile phone and then doing so. It recorded that CPL Turner later made threats that he would, in relation to another individual, “break his jaw, set him on fire and burn my name into his forehead with a hot knife”.60
The facts record that on 21 March 2014, CPL Turner stated that he had tried to “slit” his wrists but that his “shit fucking knife was too blunt to do the job”.61 On 27 March 2014, CPL Turner travelled with Joanna and their children to Wollongong to watch the football. CPL Turner became aggressive and ordered Joanna to drive home, and later told her he did not think he could cope with the amount of people at the football.62 The facts further record aggressive behaviour on 28 March and 29 March 2014.63
Character references were supplied to the Court by members of 2CDO. The first, written by WO2 NW (the CSM of B Company, 2CDO) was written on the letterhead of 2CDO. It is not apparent from the terms of that letter whether WO2 NW was informed of the substance of the charges against CPL Turner. Nonetheless, it is apparent that he was writing a letter of reference in circumstances where CPL Turner required some mitigation in his favour, noting the letter refers to the writer hoping “you take this [CPL Turner’s service to the Australian Army] into account during this tough period of his life”.64 The second, written by MAJ JP, was written on the letterhead of the Australian Army. Again, it is not apparent from the terms of this letter whether MAJ JP was informed of the substance of the charges against CPL Turner.65 Joanna Turner also wrote a letter for reference, noting that CPL Turner’s deployments overseas had had an effect on his mental health, caused “problems for both him and our family”, and made him “unable to rationally respond to events that occurred in the home”.66 Joanna noted that it was essential that CPL Turner “be provided with necessary mental health care and the opportunity to be rehabilitated”.67
Joanna Turner also gave evidence that at the time of the November 2013 incident, one of his friends got CPL Turner and took him to Holsworthy to sleep at base, and that his “work mates in Bravo company knew what he had done”.68 CAPT MH stated in his ROI that on a “platoon sergeant’s course” in 2014, CPL Turner approached him for advice 60 Tab 105 (Police Facts Sheet) at 27-28.
61 Tab 105 (Police Facts Sheet) at 28.
62 Tab 105 (Police Facts Sheet) at 28.
63 Tab 105 (Police Facts Sheet) at 28.
64 Tab 105 (Letter of Reference for CPL Turner from WO2 NW dated 29 May 2014) at 33.
65 Tab 105 (Letter of Reference for CPL Turner from MAJ JP dated 30 May 2014 at 34.
66 Tab 105 (Letter of Reference for CPL Turner from Joanna Turner dated 29 May 2014) at 35.
67 Tab 105 (Letter of Reference for CPL Turner from Joanna Turner dated 29 May 2014) at 35.
68 Tab 7 (Statement of Joanna Turner) at 3 [15].
about an AVO, and relayed to him that he was having “significant issues” with his wife.69
BRIG Langford (at that time, COL Langford and also referred to in the material as “COL IL”), who was the CO of 2CDO at this time, could not recall being made aware of the AVO other than when Joanna Turner brought it to his attention by way of a letter on 11 June 2014.70
As noted above, the charges were dismissed on condition that CPL Turner was to take medication and attend counselling/treatment in accordance with medical advice from CAPT SG (the unit psychologist) and Dr Sringeri, including the treatment plan set out on page 8 of the report of Dr Sringeri dated 12 May 2014, for a period of 12 months.71 That treatment plan was as follows:72
(c) Admission to Sydney Southwest Private Hospital in 2014
71 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 16.
73 Tab 53 (The Southwest Clinic Discharge Summary dated 14 May 2014) at 2.
74 Tab 111 (Statement of Dr Sringeri) at 76-77.
twice a week commencing on 19 May 2014,75 and it appears from the records that he attended therapy with CAPT SG regularly until at least July 2014.76 He attended a psychiatric review with Dr Sringeri on 27 May 2014, at which time CPL Turner reported he was doing well.77 He was seen again by Dr Sringeri on 26 June 2014, at which time he reported that he was doing well and that his symptoms were under control.78 CPL Turner went on exercise for a period of three weeks around August 2014, and subsequently met again with CAPT SG on 8 September 2014.79
(d) Joanna Turner’s attempts to assist CPL Turner through the ADF
Joanna Turner’s evidence was to the effect that “during his plan” (that is, the 12-month period of conditional release), CPL Turner began to “drink immediately” and blamed her for ruining his career.80 She stated that she contacted CAPT SG, the psychologist at 2CDO, but that he stated “what [Joanna] explained wasn’t the case” and Joanna felt that “he was just doing what Ian wished him to do”.81
On 11 June 2014, Joanna Turner penned a letter to the then-CO of 2CDO, BRIG Langford, which was emailed to BRIG Langford on 12 June 2014.82 In that letter, Joanna raised concerns as to the support which had been provided to her, her family, and to CPL Turner by the ADF throughout his deteriorating mental health and in the events which led to her report to the NSW Police. At the conclusion of that letter, Joanna stated that: “all I want is for you to make sure Ian is offered every opportunity to heal and move forward in his career, and I expect that the mental health care offered is of the highest possible standard. I want reassurance that he will be cared for and given the respect he deserves as a person who has committed his life to serve to the unit [sic] to a high standard.”83
Joanna Turner gave oral evidence about this letter to the effect that she had raised her concerns and nothing would happen and when she got the AVO she was “harshly criticised and shamed”, and instead of “anyone providing my family with any level of 75 Tab 47 (ADF Medical Records Central Part 2) at 32.
76 See Tab 47 (ADF Medical Records Central Part 2) at 37-44, 81, 90, 92, 102-103; Tab 48 (ADF Medical Records – Unit Copy) at 65.
77 Tab 47 (ADF Medical Records Central Part 2) at 87.
78 Tab 47 (ADF Medical Records Central Part 2) at 93-94.
79 Tab 49 (ADF Medical Records) at 521.
80 Tab 7 (Statement of Joanna Turner) at 3-4 [18].
81 Tab 7 (Statement of Joanna Turner) at 4 [19]. See also Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 38.
82 Tab 7 (Statement of Joanna Turner) at 14.
83 Tab 7 (Supplementary Statement of Joanna Turner) at 17.
support, pretty much I was just cut off, not told anything and then I was blamed. I was left feeling like I was crazy or I was making up lies to get Ian in trouble”.84
(e) Treatment during the period of conditional release
CPL Turner attended on CAPT SG at Tobruk Clinic on 3 July 2014 and reported that he had “no further significant alcohol related issues” but “is still consuming alcohol socially with his wife over dinner”, and that he “has slowly taken himself off antidepressant medication over the past 3 weeks with no residual affect”.87
Subsequently, on 24 July 2014, Dr Sringeri penned a letter to Dr Matilda Metledge of Tobruk Clinic, stating that he saw CPL Turner on 17 July 2014 for psychiatric review.
It reported that CPL Turner had stopped his anti-depressants (Escitalopram) about 6 weeks prior, “which is earlier than our plan to stop medication”.88 It reported that CPL Turner had “consumed alcohol” on one occasion in the prior 4 weeks and reported “having control and he stopped after 2 drinks”, and that he and his wife had “been working on improving their relationship”.89
It reported “no foreseeable risk” and concluded that “Ian continues to stabilise and no longer meets PTSD criteria”, that a “significant factor in his recovery has been the reduction in alcohol” and that he “responded well to treatment and remains engaged and medication free”.90
85 Tab 7 (Statement of Joanna Turner) at 4 [20]. See also 19/10/20 at T58.30-38.
87 Tab 47 (ADF Medical Records) at 37.
88 Tab 47 (ADF Central Medical Records) at 36.
89 Tab 47 (ADF Central Medical Records) at 36.
90 Tab 47 (ADF Central Medical Records) at 34.
that CPL Turner reported he remains “abstinent from alcohol” and that his “marital relationship is good”. Dr Sringeri provided the following recommendation: “Psychoeducation In my opinion Ian is well and stable.
In my opinion Ian is cleared to attend all duties from a psychiatric point. He does not require any psychiatric follow up for next 6 to 12 months.”
CPL Turner was conditionally released by the Local Court of NSW on the understanding that he would be following a treatment plan under the care of Dr Sringeri for a period of 12 months. Dr Sringeri was asked about this during his evidence at the hearing and he stated that “usually” with section 32 matters he would “follow for six months”, and he did not know why he had originally written “12 months” in the treatment plan he provided to the Local Court. He stated that in his view, he had complied with the order for conditional release because he “followed him for six months” and then he was discharged back to the GP and Dr Sringeri had said he was happy to see him if required, although he acknowledged it was “a breach in some sense”.91
It appears that the 16 October 2014 report from Dr Sringeri was sought in the context of a waiver being sought for CPL Turner to participate in Operation PARAPET, the G20 related “deployment” to Brisbane. A “mental health/psychological report” dated 24 October 2014 for “G20 Waiver” was prepared which stated that CPL Turner “has not been on medication or restriction for over three months and thus is psychologically suitable to deploy on G20”.92 On 4 December 2014, CPL Turner was medically reclassified by the ADF as MEC J23.93 This classification is explained in a policy document produced by the ADF as follows: “MEC J23 – Restricted Deployment – Defined Limitations and/or Required Material Support and/or Access to Health Support up to Medical Officer support – reviewed at Unit Medical Employment Classification Review (UMECR) at least every two years”.94
Joanna Turner’s evidence was that prior to CPL Turner’s 2015 Deployment, he was “really, really dangerous”, his behaviour was “erratic”, he had assaulted Joanna significantly during a family holiday to Thredbo, and he was growing in size from the use of steroids. He was also using alcohol excessively, on a daily basis.95
93 Operation PARAPET was the ADF’s contribution to supporting the G20 Summit in Brisbane.
94 Tab 50 (ADF Medical Records) at 133.
95 Tab 43 (ADF Personnel File) at 18.
(a) Service in the ADF
CPL Turner deployed to Iraq on OP OKRA from approximately 18 February 2015 to 17 June 2015.98
WO1 EL, who was the Regimental Sergeant Major on SOTG 632 in Iraq in 2015, stated in his ROI that CPL Turner had left the operational area early, he was “sent home” because he had a “marital/domestic impasse or problems with home, with his then wife, Jo Turner”.99
CPL Turner’s RtAPS, which was conducted on 16 June 2015, reported that he had a “predominantly frustrating deployment”, that he had a medium level of psychological distress “attributed to his current home front problems”, and “marital discord and conflict and problems within his family of origin”. He declined an offer for a further referral but stated that he would seek further psych support if his situation worsened.100
CPL Turner was contacted for a follow up on 23 June 2015 by psychologist CAPT KH, who enquired about his well-being. It was reported that CPL Turner “answered the call and engaged well” and that “no follow up” was required at that stage, but a POPS was booked for 3 months’ time.101 A further note from that interaction reported “domestic distress” and that his “wife was threatening self-harm, she keeps denying it”. It reported that he had PTSD in 2014. It was noted that they discussed using strategies which 96 Tab 41 (Career Guidance and related records) at 25.
97 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 42.
98 Tab 43 (ADF Personnel File) at 18.
99 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 6.
100 Tab 50 (Medical records) at 160-168.
101 Tab 50 (Medical Records) at 57.
CPL Turner had learned in therapy, that he was “very insightful” and was “likely to reengage [in support] if required”.102
Joanna Turner stated in her ROI that CPL Turner told work he had to come home because of her mental health, but that “wasn’t true”, and she “got really scared when he was coming home” and contacted the police.103 Joanna Turner reported that when CPL Turner returned from deployment in 2015, the “violence and alcohol intake increased dramatically”.104
On 21 June 2015, an incident occurred in CPL Turner and Joanna Turner’s home whereby they commenced arguing, Joanna Turner pushed food on the floor, and CPL Turner called police and stated that Joanna Turner was threatening self-harm. Joanna Turner denied this.105 It appears that around 29 June 2015, police applied for an AVO against CPL Turner by reason of the concerns they had for Joanna Turner’s welfare.106 This was reported to the ADF.107
On 10 July 2015, CPL Turner underwent a mental health assessment. He was referred for assessment after service of the 2015 AVO. He was assessed as being at a “low risk of harming self or others”, but an AUDIT assessment indicated a score of 15, which was noted to be “in the harmful use range” and CPL Turner was given “education regarding alcohol and interventions for reducing it as a coping mechanism”.108
On 16 July 2015, CPL Turner attended on Dr Sringeri because “he was feeling stressed and worried from his relationship issues”. He reported to Dr Sringeri that Joanna Turner had threatened self-harm with a kitchen knife, that he had called the police and that the police had “charged him with domestic violence”. He denied experiencing any current symptoms of PTSD and a response to a PTSD checklist showed a score of 20, “suggestive of him having no or minimum symptoms of PTSD”.109 He was diagnosed by Dr Sringeri as having “Post Traumatic Stress Disorder in remission”.110
On 25 August 2015, an AVO was issued in final terms with the “standard orders” that CPL Turner not assault, intimidate, or stalk Joanna Turner.111 102 Tab 50 (ADF medical records) at 169-170.
103 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 44.
104 Tab 6 (Statement of Joanna Turner) at 2 [7].
105 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 122-125.
106 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 126.
107 See Tab 42 (Conduct & Disciplinary Records) at 100.
108 Tab 50 (Medical Records) at 171.
109 Tab 111 (Statement of Dr Sringeri) at [13].
110 Tab 111 (Letter from Dr Sringeri to Senior Medical Officer, Tobruk Clinic (20 August 2015) at 87.
111 Tab 60 (DVA Medical Records for TI) (Terms of Final Order) at 72.
On 20 August 2015, CPL Turner made a claim for permanent impairment compensation from the Department of Veterans’ Affairs (DVA) under the Military Rehabilitation and Compensation Act 2004 (Cth).112 The listed injuries were “emotional condition” and “alcohol abuse/dependence”.113
On 3 September 2015, CPL Turner underwent the POPS to which CPL Turner was referred following his RtAPS on return from the 2015 Deployment.114 A mental health progress note was made by a clinical psychologist in the ADF which noted that CPL Turner had an “anxious affect”, reported that his moods were “up and down”, and noted “some evidence of emotional dysregulation when in domestic conflicts at home that leads to some impulsive, aggressive acts which places him at a low risk of harm to others”. It appears the catalyst for CPL Turner seeing the clinical psychologist was a “significant argument” with Joanna Turner the previous evening.115 The note concludes that the psychologist “will consider referral to an external MHP if internal support cannot adequately address issues without the member being concerned about medical downgrade”.116
CPL Turner reported that he was drinking only two to four times a month during this period, and only had six or more drinks on one occasion “monthly”.117 Joanna Turner’s evidence was that he was in fact drinking six or more drinks on a daily basis during this period.118 She also gave evidence that friends of CPL Turner raised concerns with her that he was drinking at work during the day.119
On 9 September 2015, CPL Turner sought a medical waiver (signed by the unit Medical Officer, MAJ AM) for deployment on Ex Night Tiger in Malaysia from 4 to 20 October 2015. At the time, CPL Turner was “J22” with restrictions which included “4-5 Fit for deployment with ML2 MO”. The waiver stated that CPL Turner had been “unmedicated for almost over 12 months over which time he has deployed on OP Parapet and OP OKRA, neither events required any health intervention”.120
On 18 September 2015, CAPT KH (clinical psychologist) and MAJ SC (then the acting CO of 2CDO) had a teleconference where they discussed that CPL Turner’s situation was deteriorating, and he was living in his office when he could not be at home. CAPT 112 See Tab 58 (DVA Client File) at 242.
113 Tab 58 (DVA Client File) at 246.
114 Tab 50 (ADF Medical records) at 117, 192.
115 Tab 50 (ADF Medical Records) at 190.
116 Tab 50 (ADF Medical Records) at 190.
117 Tab 50 (ADF Medical records) at 196.
118 19/10/20 at 64.1-14.
119 19/10/20 at T71.4-16.
120 Tab 49 (ADF Medical Records) at 337.
KH also reported “possible drinking alcohol at work” and that he needed a room at the Mess. This was organised, and CAPT KH left a message on CPL Turner’s mobile that afternoon indicating that keys had been left for him “at the bar”. There were “possible reports” that Joanna Turner had been harmed the previous evening and Selena Clancy, the Welfare Officer, advised that members of the unit indicated Joanna Turner wanted CAPT KH to call her, but CAPT KH “didn’t consider this appropriate based on my professional relationship with Ian and reports of her animosity towards me”.121
Joanna Turner’s evidence was that she was “curious” about this comment from CAPT KH, because she did not at the time even “really know” who CAPT KH was, or that she was providing CPL Turner with support. She attributed it to CPL Turner telling CAPT KH a mistruth and noted that “no one thought to fact check that with me”, and that she did not have any direct contact with CAPT KH at that time.122
It appears that on that same day (the notes made by CAPT KH state that CPL Turner was called in on “Fri 21 Sep to come in for a consult” in relation to “reports a domestic argument occurred between Ian and his wife last night at their home”; however, it appears the date is intended to be Friday 18 September 2015, noting that is also the date indicated on the notes),123 CPL Turner was asked to see CAPT KH and he reported to her that Joanna Turner had accused him of cheating earlier in the week, that on Thursday he learned of the death of a friend by suicide and drank alcohol, and that Joanna Turner had “questioned him” about drinking alcohol. He denied hitting Joanna Turner but agreed he had yelled at his daughter, ET.124
On 19 September 2015, Selena Clancy and CAPT KH spoke and Selena advised that Joanna Turner had reported she had been harmed on the Thursday night (i.e., 17 September 2015) but did not want to call the police because CPL Turner would be in breach of an AVO.125 Joanna Turner stated in her oral evidence that she was not forthcoming with the extent of the domestic violence she was suffering during this period because she was afraid that CPL Turner would lose his career. She stated that CPL Turner’s job was both a barrier to him actually getting well, but also was “potentially keeping my family safe”.126 Selena Clancy’s evidence confirmed this in that 121 Tab 50 (ADF Medical Records) at 212-213.
123 Tab 50 (ADF Medical Records) at 210.
124 Tab 50 (ADF Medical Records) at 21.
125 Tab 50 (ADF Medical Records) at 213.
she was hearing from Joanna Turner that there were events of “attempted assaults, throwing things at her, psychological bulling”.127
On 28 October 2015, CPL Turner attended on Dr Sringeri.128 Dr Sringeri subsequently wrote a report to the Senior Medical Officer at Tobruk Clinic on 30 October 2015, noting that CPL Turner had denied experiencing any symptoms of PTSD, reported he was functioning well and enjoying work, and that he was consuming alcohol occasionally, only on social occasions and not using illicit substances. The diagnosis was listed as “PTSD in remission”.129 Dr Sringeri’s evidence was that PTSD may relapse with future trauma and it is “episodic”.130 Dr Sringeri accepted that there were discrepancies between what CPL Turner was reporting to Selena Clancy and reporting to him, and that “maybe he was under reporting some of his symptoms”.131
In late September 2015, CPL Turner was referred for counselling with the Veterans and Veterans’ Families Counselling Service (VVCS). The referral noted that it was to assist CPL Turner to “manage any residual anxiety, alcohol use and impulse control issues”.132
Notes of CPL Turner’s session with VVCS on 4 November 2015 demonstrate that CPL Turner presented to that psychologist with concerning mental health symptoms.
In particular, the presenting issues were listed as: “Disrupted sleep, difficulties relaxing and muscle tension, periods of depression (no present suicidal ideation indicated), anxiety, fatigue and agitation, avoidance reactions and isolation, withdrawal from significant others, anger outbursts, relationship issues of trust and intimacy, significant alcohol consumption to help him ‘relax and cope’, adjustment issues to home circumstances and work pressures/challenges, feeling trapped, frustrated and unsupported at work, trauma reaction from deployment and other events, as well as difficulties with personal interpersonal communication and emotional expression”.133
128 Tab 111 (Statement of Dr Sringeri) at [13].
129 Tab 111 (Statement of Dr Sringeri) at 88.
132 Tab 50 (ADF Medical Records) at 223.
133 Tab 50 (ADF Medical Records) at 227-228.
134 Tab 50 (ADF Medical Records) at 227-232.
recorded in the VVCS note were consistent with what she was experiencing with CPL Turner in the 2015 period.135
CPL Turner again reported that he had concerns in relation to Joanna Turner’s mental health.136
In a note made in late 2015, psychologist CAPT KH recorded that CPL Turner was “guarded about the prospect of being medically downgraded based on his reported ‘hard work’ he put in to being upgraded in 2014 post his PTSD diagnosis and inpatient alcohol management”. It reported that CPL Turner’s symptoms as reported via RtAPS and POPS for OP OKRA were “variable”. It also reported that there was an ongoing referral to a psychologist with VVCS for assisting to cope with stress in his relationship, however, “he has chosen not to continue”. The report notes that “relationship with wife is a source of volatility leading to change in risk status over the months I’ve seen Ian, which leads to alcohol use”. The purpose of the note was to handover to CAPT KV, the incoming 2CDO psychologist.137
WO1 EL, the RSM of B Company during 2015, stated that he had “heard rumours at the back end of 2015 that Ian did have previous alcohol issues” but that he “was still performing at work”.138 Minutes of a Welfare Board meeting conducted on 4 September 2015 indicated that the update from CPL Turner was that “things are tracking well … still have ongoing marital issues that we are working through” and that the CO’s comments were to “seek legal assistance where require[d], keep COC informed, and unit will provide what assistance it can”.139
SGT NA’s evidence was to the effect that CPL Turner was a highly functioning alcoholic, like “just one of those alcoholics who could just work no matter what”.140 When asked if CPL Turner was coping in his job, CPL JW stated: “Yes. Like Ian was extremely intelligent and capable at the job and I guess – and he was probably known for being like that high functioning alcoholic”.141 CPL JW stated that there was no issue
136 Tab 50 (ADF Medical Records) at 226.
138 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 8.
139 Tab 38 (Welfare Board Minutes) at 14.
140 Tab 14 (IGADF ROI with SGT NA on 14 August 2018) at 10.
141 Tab 20 (IGADF ROI with CPL JW) on 5 June 2018 at 16.
with performance of his work, but “the thing in the back of everyone’s minds was where – what effect that had on his personal health and that sort of thing”.142
(b) Relationship with Joanna Turner
Joanna Turner stated in her ROI that from at least mid-2015 she was experiencing worsening domestic violence at the hands of CPL Turner, who was drinking more and not taking medication.143 Her children also suffered the effects of domestic violence by witnessing acts of violence and being forced to intervene to protect Joanna Turner from CPL Turner.144 Joanna Turner stated in her oral evidence that CPL Turner would have nights where he did not sleep very well, have bad nightmares and would sweat a lot, and he would then consume alcohol immediately in the morning. He would also drink when he had a difficult time at work where traumatic memories were relived, and that when he was under the influence of alcohol he would “just rant about his memories, trauma memories”.145
Around the end of 2015, Joanna Turner moved out to a friend’s house.146
Joanna Turner stated in her ROI that until CPL Turner was deployed in mid-2016, she was under the impression that they were still in a relationship, and that they would spend weekends together and she would stay at the Sergeants’ Mess with him when he was living there. She reported that CPL Turner assaulted her in his room at the Sergeants’ Mess around two days before he deployed.147
Joanna Turner stated in her ROI in respect of the 2015 period that she felt the unit “protected [CPL Turner] by blaming things on me and by looking at me as if I was crazy … this is how I thought I was treated, like I didn’t even mater. No one ever contacted me. No one ever checked on me. No one ever provided my children with any level of, you know, concern or care”.148
Joanna Turner clarified in her oral evidence that she considered Selena Clancy was doing the best she could, but that she would have liked more consideration for her family and collateral information to be provided about his welfare. She thought that the ADF was not “looking outside of the service for information about his welfare”.149 142 Tab 20 (IGADF ROI with CPL JW) on 5 June 2018 at 16.
143 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 48-49.
144 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 50.
146 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 50. See also 20/10/20 T73.27-29.
147 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 52-53.
148 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 48. See also 20/10/20 at T72.43-48.
Relevant events of 2016
(a) Relationship with Joanna Turner
(b) Mental health
(c) Management of PTSD
CAPT KV gave evidence to the effect that when he took over from CAPT KH, he reviewed the VVCS case closure report, the defence electronic health record, and agreed with CPL Turner to close his case. He was asked if he had concerns having regard to what CPL Turner had reported to the VVCS psychologist and not getting any follow-up, and he said “the member was saying he was coping okay, that he could selfmanage and that he’ll self-refer in the future if required. So that in itself was reassurance that the member would self-refer if required in the future”.155
Minutes of welfare boards conducted in relation to CPL Turner on 3 March 2016, 7 June 2016, and 6 September 2016 were provided to the Inquest. The 3 March 2016 welfare board indicated that the “COC” had “put in waiver to deploy. No response” and that CPL Turner reported he was “going good. no issues”.156 150 Tab 6 (Statement of Joanna Turner) at 2 [8].
151 Tab 6 (Statement of Joanna Turner) at 2 [10].
156 Tab 38 (Welfare board Minutes) at 5-9.
The minutes of the 7 June 2016 welfare board indicate that the focus of that board was the “waiver” which CPL Turner had sought to deploy to Iraq, and that CPL Turner reported he was “doing well, no issues”.157
CAPT KV gave evidence that he was not the “clinical case coordinator” for CPL Turner at this time despite sitting on the welfare board, and that he did not recall providing an update to the Board about CPL Turner’s presentation. He was asked in his evidence whether he should have told the UWB that CPL Turner had been recommended for further psychological follow-up and had declined. He stated there was “no requirement to provide any information on, about what he decided to do” and that he “respected his confidentiality”. CAPT KV returned to the theme of confidentiality in his evidence on multiple occasions,158 and ultimately stated unequivocally that he did not have consent to release CPL Turner’s information to the UWB.159 This is difficult to then square with his own evidence that his role at the UWB was to “help command make decisions with regards to what information was presented at the unit welfare board with regards to the management of personnel’s welfare and health”.160 For at least the 6 September 2016 and the 7 July 2017 UWBs, the notes of the welfare board indicate in the “Medical Consent Given” box, “Yes”.161 Submissions
Counsel Assisting submits162 that what emerges from CAPT KV’s evidence about this period is this: i. By the end of 2015, there was clear information available to the ADF that CPL Turner was experiencing symptoms of PTSD and was not willing to engage in further psychological treatment. That information was known to CAPT KH and was part of the information which CAPT KV said he read when he took over CAPT KH’s role.163 ii. CAPT KV had one conversation with CPL Turner in early 2016, in which CPL Turner declined further psychiatric or psychological support.164 iii. CAPT KV then attended welfare boards and, apparently in reliance on CPL Turner’s assurances, did not raise with the UWB any of the information which 157 Tab 38 (Welfare Board Minutes) at 10-11.
158 See, e.g., 10/08/21 T65-66.
161 Tab 38 (Welfare Board Minutes) at 1, 15.
162 Submissions of Counsel Assisting dated 2 November 2023 at [95].
was known to him about CPL Turner’s symptoms at the end of 2015 and lack of engagement in any further treatment since that time.
iv. Either CAPT KV did not consider (incorrectly, it appears) that he had “consent” to release information to the UWB (which is objectively unlikely given the point of his presence at the UWB was to provide Command with information to make decisions based on personnel’s health and welfare) or CAPT KV did have consent and simply chose not to provide this information to the UWB so it could inform CPL Turner’s ongoing management.
If the former is correct, Counsel Assisting considers that plainly enough there is a systemic issue in the functioning of UWBs: namely, if the person present at a UWB for the purpose of providing information to Command feels unable to do so because the medical professionals present perceive they have a lack of consent to release health information. If the latter is correct, it demonstrates a failure by CAPT KV to perform the function that he was attending UWBs to perform: to provide Command with information about personnel welfare and health.
It is not apparent, in any event, that CAPT KV could have provided the UWBs with relevant and updated information because he did not consider he had any responsibility to continue staying in touch with CPL Turner, as he was no longer in treatment.165 Nor is it apparent that even if CAPT KV had relevant and updated information, he would have felt it necessary to share that with the UWB: his evidence was to the effect he could not recall whether Padre MP had raised concerns with him about CPL Turner’s health in 2016, but even if he had, he would have simply told the Padre to encourage CPL Turner to self-refer and that he would not have told the UWB about those concerns.166 He was unable to answer what the point in him being at the UWB was in those circumstances, beyond repeating that it was “to help command make decisions … with regards the management of personnel’s welfare and health”.167 It is difficult to discern what real substantive purpose the welfare boards in this period had for CPL Turner’s welfare: the evidence tends to suggest that these boards were treated as little more than tick-a-box exercises.
The Commonwealth submits that the second alternative above at [98] is “not open” on the evidence.168 In support of its submission in favour of Counsel Assisting’s first
168 Submissions of the Commonwealth dated 7 June 2024 at [294].
alternative, the Commonwealth refers169 to (i) the minutes of the unit welfare board indicating CPL Turner had not given the necessary consent170 and (ii) the fact that, when considered in the context of ADF policy,171 it is entirely possible that CAPT KV did not have the necessary consent.
In reply submissions, Counsel Assisting notes that, in relation to the second alternative, if it is accepted that CAPT KV did consider he had consent, then it is difficult to conceive of what other inference can be drawn about his failure to disclose other than “he chose not to do so”. While the Commonwealth submits such a finding would be “serious”,172 it does not proffer an alternative explanation on the hypothesis that CAPT KV did have such a state of mind. In any event, despite the extensive submissions the Commonwealth makes about the seriousness of such a finding, Counsel Assisting does not seek a finding one way or another as to CAPT KV’s state of mind. The finding that is sought is that, on any hypothesis, it was difficult to discern what real substantive purpose the welfare boards had for CPL Turner’s welfare in 2016.173 Consideration
Having considered all the available evidence on this issue, I have concluded that the UWB process was of no discernible benefit to CPL Turner throughout 2016. While it appears that CAPT KV had little or no useful information to add to any discussions about CPL Turner’s health or wellbeing, the fact that CPL Turner had declined further involvement with psychological or psychiatric services was relevant and should have been shared. CAPT KV had reviewed CPL Turner’s file and was well aware that he had experienced symptoms of PTSD but refused further psychological engagement.
That should have been a red flag. CAPT KV cited “confidentiality” or a lack of consent as the barrier to sharing this information. Whatever the reason, the effect was to render nugatory the value of CAPT KV’s participation in the welfare board process.
(d) Deployment on OP OKRA
170 Tab 38 at 6.
171 Tab 66 at [9]; Tab 63 at [8.8(b)], [8.9(c)] and [8.10(e)(1)].
172 Submissions of the Commonwealth dated 7 June 2024 at [285].
173 Submissions in reply of Counsel Assisting dated 22 August 2024 at [209].
174 Tab 43 (ADF Personnel File) at 18.
bases, and Australian soldiers were not authorised “at any point to leave a designated area”.175
Medical clearances and command waivers
b. Being MEC J23, CPL Turner did not need a “command waiver” to deploy. A “command waiver”, would ordinarily be considered in respect of an ADF member who is “mission-critical”. The granting of a command waiver rests with the Deputy Chief of Joint Operations. It is a Command decision, although ADF medical officers would have input into the decision-making process.
c. The policies in place for OP OKRA in 2016 required that all ADF members with a MEC J23 classification or a 4-4 Employment/Deployment restriction obtain a medical clearance from J07 HQJOC (the Director Health, Joint Operations Headquarters). A medical clearance, by contrast to a command waiver, is a medical decision. The ADF indicated to the Inquest that the “chain of command may have input into the decision-making process”. It was not clear from the evidence in the Inquest what that “input” was supposed to be directed to (i.e.
whether the “medical” decision was nevertheless intended to be influenced by Command needs, or whether Command was intended to provide medical information to inform the medical decision, or something else). There is an ability to appeal a decision not to grant a medical clearance by presenting J07 HQJOC with additional material.
176 Tab 116 (Letter from AGS re medical waiver granted to TI in 2016).
witnesses who gave evidence about it tended to refer to it in this way). There was a significant degree of confusion in the evidence given by relevant witnesses as to the nature of a “medical clearance”, the appropriateness of Command input or “influence” on that decision, and the distinction between a medical clearance and a command waiver.
The risks of the deployment to Iraq on OP OKRA in 2016
The deployment to Iraq involved the potential exposure to traumatic events. BRIG Langford, for example, accepted that even if the primary purpose of the deployment was to train Iraqi soldiers, deployment to a conflict zone was “inherently potentially traumatic”.177 COL MF similarly accepted that the nature of the deployment was inherently potentially traumatic.178 However, he stated his view was that there was “little to no risk that any personnel would be exposed to a personal combat trauma incident”.179 MAJ AF maintained in his oral evidence that the deployment was the “lowest risk of trauma of any of his deployments”, commenting that “you can find trauma in Sydney”.180 MAJ AM accepted the potential for trauma, noting that on his own rotation into Iraq he had experienced the rocketing of the compound in which he was located, and seeing wounded individuals.181
What emerged as a whole from the oral evidence of those involved in the medical clearance (except GPCAPT Ross) was that they all accepted there was the potential for exposure to traumatic events but viewed that potential risk by reference to the trauma to which CPL Turner had already been exposed on his many deployments to Afghanistan, thus diminishing the significance of the risk. GPCAPT Ross, by contrast, accepted with no hesitation that the deployment was on OP OKRA was inherently potentially traumatic.182
This accorded with the view of the expert witnesses, who generally agreed that there was a probability of events in Iraq triggering a recurrence of PTSD.183 The initial discussions around CPL Turner’s deployment on OP OKRA in 2016
In relation to the original decision made within 2CDO for CPL Turner to deploy on OP OKRA, MAJ AF gave evidence that “it went to the board, to the unit welfare
179 Exhibit 11 at 1 [8].
183 See 08/02/23 T47-48.
board”.184 He stated that he went and saw the CO, and that “my outlook was that I wanted to deploy him. My decision was made because I saw him remaining back home whilst the company was deployed as being more detrimental for his mental health than deploying”.185 He additionally stated that CPL Turner had come to see him and said “Look, I want to deploy” and they had talked about it on numerous occasions.186 He stated that “I saw him deploying and that being the moment (1) he could get some money to come back from his separation, but (2) I think it was going to be the break he needed, separating from, I don’t know, life at home … So I made the decision for him to deploy”, and “Went to the board, the board agreed, psych agreed, everybody agreed”.187 (It is noted that this evidence relates to the decision initially to put CPL Turner forward for deployment, and not the subsequent decision to seek a reconsideration of the decision of GPCAPT Ross about his clearance given no “board” was conducted between the time GPCAPT Ross made his initial decision and when he ultimately reversed that decision and granted the clearance).
In his ROI, WO2 DP stated that initially, when he was coming up with the manning, he “actually suggested that we probably shouldn’t take Ian”, which Ian “didn’t like”, so he “enlisted some – because he’s quite influential, he then enlisted support from some of the platoon commanders within the company” and that the “OC” (who was MAJ AF) was initially on WO2 DP’s side, but then the decision “was turned around and he ended up on the trip”.188
CAPT BJ was involved in preparing the paperwork around CPL Turner’s medical clearance to deploy. His evidence was that he supported CPL Turner’s deployment and that he did not observe any significant mental health concerns in CPL Turner’s presentation in late 2015 and early 2016. He accepted, with the benefit of hindsight, that CPL Turner was not presenting an accurate description of his mental health to him at the time.189
On 2 June 2016, CPL Turner underwent a pre-deployment health screen. He was assessed as fit to deploy, but as noted above, because CPL Turner was MEC J23, he required a medical clearance from J07 HQJOC to deploy.190 On or around 8 July 2016, 184 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 6.
185 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 13.
186 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 13-14.
187 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 14.
188 Tab 24 (IGADF ROI with WO2 DP on 5 July 2018) at 11.
190 Tab 49 (ADF medical records) at 325-329; Tab 50 (ADF Medical Records) at 108-111, 264-268.
J07 HQJOC (which position was then filled by GPCAPT Ross) refused to grant CPL Turner a medical clearance to deploy.191
(e) The medical clearance / “waiver”
MAJ AM, who was the unit RMO, stated in his statement to the Inquest that he was informed on 8 July 2016 that the J07 HQJOC had refused to grant a medical clearance to CPL Turner. He stated that he had a conversation with MAJ AF, who he knew would be concerned about the decision, because CPL Turner had a “pivotal role in MAJ AF’s company for the imminent deployment”. MAJ AM’s evidence was that MAJ AF was “intensely keen for the situation to be ‘fixed’” and he was “adamant that [CPL Turner] had to deploy”. MAJ AF wanted to know how the decision could be influenced and in fact overturned. He stated that MAJ AF said “What the fuck? [CPL Turner] …. must deploy with us. No one can replace him or his knowledge of the team this close to deployment”.192 MAJ AM’s evidence was to the effect that MAJ AF had made it explicit to him, “in no uncertain terms” that “there was a significant mission risk if Ian was unable to deploy”.193
This evidence was put to MAJ AF, who stated that he considered the “tone” was aggressive and suggests that he was more invested in CPL Turner’s deployment than he actually was, and he did not believe that the words MAJ AM attributed to him were his words.194 Submissions on the conversation between MAJ AM and MAJ AF
It is submitted by Counsel Assisting that I would accept MAJ AM’s version of what MAJ AF said.195 First, MAJ AF admitted that he was concerned about CPL Turner not being deployed, because he wanted to “firm up” the personnel who were deploying.196 Second, MAJ AF admitted that he formed the view that GPCAPT Ross’ decision was the “wrong decision” without having seen the terms of the decision that were made nor having any idea what had or had not been taken into account by GPCAPT Ross.197 Third, there was no apparent motive for MAJ AM to exaggerate the terms of his discussion with MAJ AF in his evidence. Fourth, the evidence which ultimately emerged from MAJ AF over the course of a number of years was that he was unshaken (and remained unshaken) in his view that it was preferable for CPL Turner to deploy 191 Tab 50 (ADF Medical records) at 108.
192 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 3-4.
195 Note also that MAJ AM maintained this version under cross-examination: see 05/08/21 T56-57.
to Iraq in 2016. He stated that he “believed and still believe[s] it was in Ian’s best interest to deploy” and that he was seeking a review hoping the decision would be changed.198 It is submitted that this firm view sits comfortably with the version of the conversation which MAJ AM gave. MAJ AF’s professed indifference in his oral evidence to whether CPL Turner deployed or not, as he sought to downplay this conversation with MAJ AM, sits uncomfortably with the balance of his evidence in this regard, which was largely to the effect that he wanted CPL Turner to deploy.199 Consideration
Further, I have no trouble accepting MAJ AM’s description of the intensity of MAJ AF’s desire to have the situation “fixed”. I accept Counsel Assisting’s submission that there was no reason for him to exaggerate MAJ AF’s response to the news that CPL Turner’s medical clearance had been refused.
I had the opportunity of watching MAJ AF give evidence. In my view, he appeared defensive and tried to downplay his displeasure with what had occurred and recast his reaction as measured and focussed only on ensuring that the decision was reconsidered with all the available material. This is particularly implausible given the steps later taken by MAJ AM and his contemporaneous email that stated “My CoC, to CO level, is VERY keen to have this decision reviewed”.200 I do not accept MAJ AF’s evidence on this issue.
Returning to the evidence, MAJ AM spoke to COL MF, who was supportive of preparing additional information to submit to the J07 HQJOC for consideration. MAJ AM subsequently called GPCAPT Ross, outlined the “intent of MAJ AF and [COL MF]”, and MAJ AM outlined verbally why he thought that MAJ AF’s “arguments had merit”.
GPCAPT Ross agreed to review a written submission from MAJ AM.201
200 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 49.
201 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 5.
Document).202 That document assumed some significance in the Inquest. It is extracted below in full.
202 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 45-47.
comprehensive review”, and he accepted that he instead prepared a document “selling the idea that CPL Turner was sufficiently fit to deploy”.203
MAJ AM stated that he considered that GPCAPT Ross would review all of the medical records in making a decision, so it was not necessary for him to include material indicative of the risks to CPL Turner’s health.204 MAJ AM did not consult with CPL Turner in putting together the document, but rather conducted it “on the basis of a medical record review.”205
MAJ AM accepted, having been taken through a number of medical records in the period between June and December 2016, that those records would have changed what he wrote in his summary document.206 He considered that his role involved advocating for “defence” and “his commanders wanted to deploy him” which he tried to balance with his “responsibility to protect” his patients.207 He accepted that Command’s requirements were a significant factor in considering the appropriateness of CPL Turner’s deployment.208 He ultimately described the clearance process as a “command-driven process informed by the medical system”, that he understood the CO’s “intent”, and that he enacted the CO’s “intent” in “doing what I did”.209
MAJ AM’s evidence in relation to the nature of the decision to be made by GPCAPT Ross was to the effect that, in his view, it was part of the J07’s role to consider CPL Turner’s importance to the “mission” in deciding whether he should make a different decision about deployment.210 MAJ AF accepted that the request he made was a clinical summary emphasising the points he considered had been “overlooked”, and that MAJ AM’s document was “well written and it achieved its aim”.211
The Clinical Perspective Document was sent by MAJ AM to MAJ2 LK212 and MAJ AF, with MAJ AM noting that he had “compiled a clinical summary emphasising the points I think were overlooked by the JOC J07 when considering” CPL Turner’s deployment.213 It was then sent from MAJ AM to LTCOL NB, who was working with CPCAPT Ross at the time.214 The email noted that “My CoC, to CO level is VERY keen
212 Who was the acting CO of 2CDO at the time: see 05/08/21 T78.14-17.
213 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 50.
to have this decision reviewed”.215 The email further noted that “The soldier in question, in my opinion, is LESS risk to himself deployed than he will be if he is left behind at this point. Paradoxical, I know, and deployment shouldn’t be a therapy, but it is what it is”.216
MAJ AM’s evidence about his comment commencing with “Paradoxical” in the email was that CPL Turner was “very functionable in the deployed environment”, that he had “some psychosocial welfare issues whilst he’d been in barracks”, and that if he was “rejected from a deployment” it was “probably not something that he would, would like to face”.217 This opinion was reflected in the substance of the Clinical Perspective Document, which similarly stated:218 “Importantly, his treating clinicians note that while he was task-focussed on deployments, away from the social stress of his deteriorating relationship and easy alcohol availability, he was the most stable/functional and least anxious/stressed. This may seem paradoxical in a soldier previously suffering PTSD/Depression consequent to deployment experiences, but the observation highlights the lack of relevance of his prior diagnoses to risk.”
MAJ AM’s oral evidence was that he could not recall which treating clinicians he consulted in order to inform the above comment but he accepted he did not speak to any psychologist before preparing that document.219
Subsequent to MAJ AM’s oral evidence, a further document was produced by the ADF which included an email from MAJ AM to LTCOL NB stating “I was holding off sending this until I had the specialist report, but last night the CoC was getting anxious”.220 The “this” referred to in that email was the Clinical Perspective Document.221 MAJ AM was asked to put on a statement in relation to this document. He stated he could not recall to whom in the Chain of Command he was referring to when he typed “getting anxious”, and all he could recall was that the “general feel from the chain of command was that they needed to know, one way or another, whether CPL Turner was waivered to deploy”.222 In his oral evidence, MAJ AM stated he could not recall who in the Chain of Command was “anxious”, that he had an “impression” about what the anxiety of “all the stakeholders in the unit was about that situation”, but that he could not say conclusively what they were anxious about.223 MAJ AF’s evidence was that it was 215 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 49.
216 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 49.
218 Tab 115 (Statement of MAJ AM dated 2 October 2020) at 46.
220 Exhibit 45 (Further Statement of MAJ AM dated 31 August 2022) at 4.
221 Exhibit 45 (Further Statement of MAJ AM dated 31 August 2022) at 2.
222 Exhibit 45 (Further Statement of MAJ AM dated 31 August 2022) at 2.
highly likely that it was he (MAJ AF) who was being referred to in this email, because he “definitely wanted to get this moving”.224
His evidence ultimately tended to suggest that he did likely have access to the email but that his legal representatives decided it should not be included in his first statement and that is why it would not have been attached.226 He was asked whether he should have reviewed the emails himself to ensure that a “full and complete picture of events as represented in those emails was included”. He answered that “I wouldn’t have known that it was my duty to ensure it was full and complete … I was prepared to trust my legal counsel to determine what was and what was not relevant”.227 Submissions on the email from MAJ AM to LTCOL NB Submissions of Counsel Assisting
(b) a decision was made on behalf of MAJ AM not to include an email in his evidence which plainly enough is relevant to how the medical clearance decision was made.
Submissions of the Commonwealth
228 Submissions of the Commonwealth dated 7 June 2024 at [343]-[346].
229 Submissions of the Commonwealth dated 7 June 2024 at [347]-[353].
searched until September 2021, which was after the finalisation of the first statement of MAJ AM’s statement in October 2020. Following discussions between the ADF and those assisting in January-February 2022, searches were done on various ADF email databases and in April 2022 the email from MAJ AM was produced. Accordingly, the Commonwealth submits that the email was located after MAJ AM’s statement was finalised and so could not have been included in his first statement and was, therefore, not “deliberately excluded” from the statement.230 It was further submitted no adverse finding could now be made without affording the ADF the opportunity to seek further evidence be admitted to rebut the proposed finding.231 Submissions in reply of Counsel Assisting
MAJ AM’s evidence on this point made the submission above available, and that proposed finding was put to the parties in Counsel Assisting’s submission as a matter of fairness.234
231 Submissions of the Commonwealth dated 7 June 2024 at [361]-[362].
233 Exhibit 45 at [9].
234 Submissions in reply of Counsel Assisting dated 22 August 2024 at [216].
235 Submissions in reply of Counsel Assisting dated 22 August 2024 at [217].
Consideration
I was greatly troubled by MAJ AM’s evidence on this issue. I accept Counsel Assisting’s submission that he did not give a cogent explanation for the exclusion of this email. In circumstances where every other email in the chain was produced in his original statement, any purported confusion about the terms of the subpoena seems unlikely to be relevant to his initial decision. On balance, I find that a decision was made to exclude it, and I accept that it is most likely to have been excluded to avoid disclosing the extent of the Chain of Command’s attempt to influence the medical decision. MAJ AM’s evidence was particularly concerning because it was an example of an occasion where an ADF member appeared to see his loyalty to the organisation as more compelling than his duty to provide the Court with a full and frank account. I was deeply troubled that he did not see that it was his duty to provide “a full and complete” account.236 I make no finding in relation to the legal advice he received.
Returning to the evidence, MAJ AF accepted in his oral evidence that he did not in fact have an accurate understanding of the extent of CPL Turner’s alcohol use, or “domestic difficulties”, in mid-2016 when he made the decision to have him deploy.237 He further accepted that he did not have any of the detail of CPL Turner’s medical history or his medical notes.238 However, he accepted that he knew that CPL Turner had ongoing symptoms of PTSD as at June 2016 and still thought it was in his best interests to deploy.239 His view was that CPL Turner had a “fractured and compartmentalised personal life and problems with alcohol” and that the deployment would give him a “break” with his “support network around him that the Company provided while deployed”.240
COL MF did not have specific training in PTSD.241 COL MF’s view was that the deployment would give CPL Turner “time and space” from his marital difficulties to focus on work. He did not recall taking any psychiatric or psychological advice as to whether deployment would be good or bad for CPL Turner’s mental health.242
In his ROI, COL MF stated that his recollection of why a medical clearance or waiver was required, was “related to medication that he was taking” (which was not the case) and that he supported the waiver, “based off the fact that he was performing, all
reports, well in his role” and that “clinically, the recommendation was that he was fine to support”.243 He stated he had “no reservations about recommending him to go back, based off what I’d observed” but ultimately recognised he had only seen CPL Turner a “few times”.244 He went on to explain:245 “And, to be honest, at that point, he was almost a good news story with regard to members that had seen a lot of action as a result of that service… So from a regiment’s perspective and my viewpoint, it was really quite positive for him personally to be able to continue to soldier on … organisationally as well, to display that just because you did put your hand up and say you had an issue, it wasn’t a one-way ticket to medical discharge.”
COL MF stated that he was aware of CPL Turner’s alcohol issues and that, as a result, CPL Turner was “on the radar” but that in his view “he had sort of turned that around”.246 COL MF indicated that he did not consider there was a real risk that in 2016 CPL Turner was not fully disclosing his mental health conditions because of a concern that it would reduce deployability, because of the “trust that goes with being a senior NCO” and because he had “received treatment beforehand”.247 He could not recall speaking to any psychologist prior to making the decision about whether CPL Turner should deploy in 2016.248
COL MF stated that the decision to deploy CPL Turner did not rest with him because he required a medical clearance to deploy.249 However, he ultimately accepted that within the Chain of Command, he had the ultimate responsibility for the recommendation that CPL Turner be deployed.250
WO1 EL, the RSM of B Company at this time, stated that “to be honest … [he] appeared to be, for [want of] a better word, a good news story for a member that had previous alcohol issues, you know, ongoing trauma he had seen on operations in Afghanistan … and he’d come out at the other side”.251
Subsequent to MAJ AF’s first evidence in relation to this matter, a document was produced by the ADF which was a minute prepared by MAJ AF for the CO, to ultimately be provided to the J07 (GPCAPT Ross).252 The document was amended before it was provided to GPCAPT Ross. In its draft form, it was as follows: 243 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 8-9.
244 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 10.
245 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 9.
246 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 12.
251 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 10.
252 Exhibit 31 (Tranche 7) at 25.
The document stated that the RMO (MAJ AM) had been consulted in its drafting. MAJ AM’s evidence was that he was not verbally consulted although he may have had a “brief discussion” with MAJ AF about CPL Turner.253 MAJ AF accepted that it was likely that he had drafted this document.254
MAJ AF did not accept that he ought not to have drafted the brief which ultimately came to be provided to the CO, amended, and then provided to GPCAPT Ross. He was asked whether he “should never have drafted this document because you should never have sought to interfere with the decision-making process of the JO7”.255 He responded that “that’s incorrect. The role of the Chain of Command is purposely separated from the medical decision making process” and concluded that if “CPL Turner wasn’t medically or psychologically cleared to deploy, then he wouldn’t have”, but “[t]his is a mechanism for the army to – to communicate with decision makers”256 (“this”, being the draft of the Brief for the CO which was ultimately sent to the J07 albeit with amendments).
The brief which he prepared strikes me as a piece of written advocacy aimed at achieving a specific outcome: the deployment of CPL Turner, and to seek to demonstrate that his deployment would be “beneficial” to his rehabilitation (which is quintessentially, a medical question and not a command one). It stated expressly the CO’s apparent view that CPL Turner’s “rehabilitation will be best managed by maintaining the level of operational readiness associated with his position” and sought to provide an assurance that CPL Turner would have access to medical support and his team members as a “mitigation measure”.257
I accept Counsel Assisting’s submission that this is not a document which conveys information to a medical professional for that medical professional to make an independent-minded decision. Rather, it is a document designed to persuade and, therefore, seeks to present a particular view about CPL Turner’s mental state. MAJ AF did not accept this characterisation of the document and, in my view, this affected the integrity of his evidence as a whole. It was another example where I had reason to doubt the veracity of MAJ AF’s account of the events in question.
253 Exhibit 31 (Tranche 7) at 25.
257 Exhibit 31 (Tranche 7) at 25.
An amended version of this document was then sent on to GPCAPT Ross, under the hand of COL MF, in the following form:258 258 Exhibit 31, Tranche 1 at 4-5. See also Exhibit 35 (Statement of Brig MF dated 26 August 2022) at 4.
COL MF’s evidence was that he recalled reading this brief and the two enclosures, that he did not have an actual recollection of signing and dating the brief but is confident that he would have done so.259 COL MF’s evidence in relation to this document was that he was “providing additional context that GP CAPT Ross did not have previously about the decision”.260 He accepted, however, that he did not actually know what information GPCAPT Ross had available to him when he made his initial decision.261 259 Exhibit 35 (Statement of COL MF dated 26 August 2022) at 5.
This makes it difficult to understand how he could have formed the view that he was only providing additional information which GPCAPT Ross did not have to begin with.
COL MF accepted that he was relying on the information provided to him that CPL Turner’s domestic circumstances had stabilised. He did not make any investigations himself as to CPL Turner’s personal situation and he did not accept he should have made any inquiries or investigations himself (including of Joanna Turner).262
Although the document stated that the personnel best able to monitor, assess, and manage CPL Turner’s mental health were his team members, he accepted he did not check which of CPL Turner’s team members had training in PTSD.263 He expressed confidence that his team members would know the symptoms of PTSD because he thought that was how CPL Turner’s first incidence of severe PTSD in 2014 had been identified. He was not aware it was in fact Joanna Turner who reported his symptoms to the ADF in 2014.264 It is also not apparent why he assumed that those team members who had identified it in 2014 were necessarily the same members who would be deploying with him on this deployment.
COL MF accepted that based on what in fact subsequently happened, it was not the case that the personnel best able to monitor, assess and manage CPL Turner’s mental health were his regular team members in Iraq.265
COL MF accepted that he intended this brief to influence GPCAPT Ross in his reconsideration of whether or not CPL Turner should be granted a clearance. He accepted that it would be given weight by GPCAPT Ross. He did not accept that doing so was inappropriate.266 COL MF specifically rejected the proposition that his Brief constituted “intervention by the chain of command”. He stated “what the chain of command did was provide additional supplementary information that was not provided in the initial form which was pushed forward” and there was “no chain of command leaning in on anybody to seek to get them to change their decision”.267 He stated that the purpose of the document, and by him signing off as CO, was to provide assurance that the “issue was significant enough to be raised” and to show “we had done the background behind it to get to a point where we were seeking to get the decisions sort of changed”.268 It appeared that COL MF made a distinction between “influencing” and
leaning on or pressuring GPCAPT Ross. He accepted he was trying to do the former and he rejected that he was doing the latter.269
(f) Dr Sringeri’s letter
Enclosed within COL MF’s brief to the J07 was a letter from Dr Sringeri (listed under “Enclosures” and titled “Psychiatrist Recommendation”). The background to that letter is as follows.
On 11 July 2016, a referral request was penned by Dr Aftab Ahmed to Dr Sringeri.270 It stated that: “Member has history PTSD and alcohol dependence in 2014 and that time CPL Turner was admitted to Sydney Southwest Private Hospital for substance abuse control and PTSD treatment for over 5 weeks. He was diagnosed with PTSD and Alcohol use Disorder - He was seen by the psychologist your self. Memebr [sic] is stable now. He no longer requires psychological treatment for PTSD. His symptoms are in remission.
Recently member was up graded to MEC J23. I need your opinion about his deployment is member is fit to Deploy? Regards . Dr Aftab Ahmed”.271
Dr Sringeri penned a letter on 13 July 2016 to MAJ AM, the RMO. In that letter, Dr Sringeri stated (emphasis in original):272 “Diagnosis: Post Traumatic Stress Disorder in remission Alcohol Dependence Syndrome in remission I saw Ian 13th July 2016 for her [sic] psychiatric review. Ian remains symptom free and denied having any symptoms of PTSD. Ian is not on any medication since 28th August
He has attended 2 operational deployments and 2 international engagements successfully. He denied experiencing any anxiety symptoms or PTSD symptoms during stressful situations.
He consumes alcohol only on the weekends and special occasions and monitors his alcohol intake. He was proud and positive about his progress.
On examination he was found to be pleasant cooperative and relaxed. His psychomotor activity was normal. His speech was normal. He described his mood as fine and his affect was reactive. He was found to be positive and hopeful. He denied having any ideas of self-harm or experiencing any psychotic symptoms. He had good insight.
Impression: In my opinion Mr Turner is free of symptoms of anxiety and PTSD.
In my opinion his chances of recurrence of his PTSD symptoms are very low.
His risk of self and harm to others also very low.
Recommendation: Psychoeducation In my opinion Mr Turner is well and stable.
In my opinion Ian is cleared to attend all duties from a psychiatric point.
He does not require any psychiatric follow up. However, I am happy to review him if required.
270 Tab 116 (Letter from AGS re medical waiver) at 12.
271 Tab 50 (ADF Medical Records) at 9.
272 Exhibit 26.
If you need any further information please do not hesitate to contact me”
Dr Sringeri’s contemporaneous note from that consult recorded that “Ian wanted to go for a deployment to Iraq and needed psychiatric clearance”.273
Dr Sringeri’s (and GPCAPT Ross’) oral evidence was taken without the benefit of this letter, which was belatedly produced by the ADF to the Inquest (an issue which is dealt with below at [1039]-[1047]). However, Dr Sringeri later answered questions via letter from his solicitors in relation to this letter. He stated that he did consider the risks associated with deployment to Iraq when he penned the letter and discussed those during the consultation. He stated in response to the question “whether he considered Sgt Turner should be cleared for deployment” that “[t]he clearance for deployment was not a matter for me, it was a matter for the ADF medical board and the chains of command”.274
In his ROI, COL MF stated that after CPL Turner’s first suicide attempt, he revealed that he had previously told the Chain of Command, and also the “specialist” (which would be inferred to mean Dr Sringeri), “whatever they wanted to hear” to enable him to do what he wanted to do next, two deployments was one of those”.275 Joanna Turner gave similar evidence, to the effect that CPL Turner had said openly to her that he could “manipulate” Dr Sringeri.276 Joanna Turner gave evidence that she had been present in conversations where CPL Turner would speak with colleagues who would share or compare notes on how to “get Sringeri to do” certain things,277 and that CPL Turner had “implied” to her that his understanding with Dr Sringeri was that CPL Turner would be open and honest, but not at the risk of damaging his career, and that he could “get the result that he wanted, like on paper” from Dr Sringeri.278 Dr Sringeri denied this in his oral evidence. 279
COL MF’s evidence in relation to the letter from Dr Sringeri was that he made no decision about CPL Turner’s deployment prior to getting Dr Sringeri’s report, although he had a brief prepared before he received that report because it “started getting tight with regard to timelines”.280 He stated that he relied in particular on Dr Sringeri’s opinion that CPL Turner’s chances of recurrence of his PTSD symptoms were very low.281 COL MF recalled reading Dr Sringeri’s opinion that CPL Turner was “cleared to 273 Tab 11 (Statement of Dr Sringeri) at 90.
274 Exhibit 19.
275 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 24.
276 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 33.
attend all duties from a psychiatric point” and that he took it to mean that CPL Turner was fit psychiatrically to be deployed on OP OKRA.282 He did not think to question whether Dr Sringeri intended to state that CPL Turner was fit for active deployment with the Special Forces in Iraq because he assumed that the letter had been procured for a specific purpose, namely, the response to go back to the J07.283 COL MF did not consider at the time the possibility that CPL Turner might have had symptoms of PTSD which he did not disclose to Dr Sringeri.284
His view was that external psychiatrists “don’t necessarily have a background” for “specific military contextual advice”.285 He stated that he would not expect a consultant psychiatrist who is not military to make an assessment about deployment.286 This sits at odds with the fact that Dr Ahmed, a medical officer working at Tobruk Clinic, asked Dr Sringeri “I need your opinion about his deployment…is member fit to Deploy?”.287
(g) GPCAPT Ross’ decision
On 8 June 2016, GPCAPT Ross refused CPL Turner’s medical clearance to deploy on OP OKRA. The reasons for the refusal were recorded as follows: 288 “Pre-deployment medical reviewed by HQJOC J07 – member has been deemed unfit to deploy based on medical history. Extensive psychological and alcohol dependence history, ongoing stressors, and failure to continue psych support as recommended places member at high risk of deterioration whilst deployed. Tobruk Lines Health Centre notified, and member is to be recalled to receive feedback from MO”.
GPCAPT Ross gave a statement to the Inquest289 and gave oral evidence during the second tranche of hearings. While he stated that he could not remember the precise reasoning behind his refusal to grant a clearance to CPL Turner in the first place, having regard to the notes available in the brief of evidence, he stated that his particular concern was that CPL Turner had been recommended for ongoing psychological support (but had unilaterally discontinued treatment) and GPCAPT Ross considered
287 Tab 50 (ADF Medical Records) at 9.
288 Tab 50 (ADF Medical Records) at 108.
289 Tab 114A (Statement of CPCAPT James Ross dated 28 September 2020).
that this suggested CPL Turner had poor insight into his situation.290 The notes which were available to GPCAPT Ross from which he refreshed his memory were as follows:291 “History of significant mental health issues from 2013/14, with further problems identified in late 2015. Recommendation of continuing psych support was not taken up by member. Issues around stress/agitation, interpersonal relationships, alcohol use. Member at high risk of deterioration if deploys to Middle East.”
In GPCAPT Ross’ oral evidence, he accepted that there were three matters which led to his original refusal decision: (1) the history of significant mental health issues from 2013/2014 with further problems identified in late 2015; (2) the recommendation of continuing psychological support which was not taken up; and (3) issues around stress/agitation, interpersonal relationships, and alcohol use.292
When asked as to whether CPL Turner might have been seeking to avoid detection of his symptoms, CPCAPT Ross gave evidence that:293 “That was the concern that I had. It was either that he was well aware of his poor psychological health and was trying to hide it or he had poor insight and that he, although he was unwell, he was in denial and was avoiding because he didn’t think there was anything wrong so they were the two options but there’s the same outcome essentially. That I was concerned that ongoing symptoms were not being adequately dealt with.”
On 20 July 2016, GPCAPT Ross reversed his original decision. GPCAPT Ross’ evidence was that he relied on the Clinical Perspective Document in making his decision. He stated the level of involvement demonstrated in that document from an RMO was unusual and he expected that was a “large part of why I reversed my original decision” and that he expected (though he could not actually recall) that he considered that document contained “adequate justification for [CPL Turner’s] deployment on operation from a medical officer who had direct clinical knowledge of him.”294
In his oral evidence, GPCAPT Ross stated that to the best of his recollection the Clinical Perspective Document was the one document he considered before he reversed his decision.295 290 Tab 114A (Statement of GPCAPT James Ross dated 28 September 2020) at 6-7.
291 Exhibit 3 (Letter from AGS re additional medical waiver issue documents) at 5.
294 Tab 114A (Statement of GPCAPT James Ross dated 28 September 2020) at 7.
GPCAPT Ross later suggested that his revised decision would have “been based on all of the documentation available” and that he “would have re-familiarised” himself with the other documentation, being the documentation he had originally looked at when making the decision not to grant a clearance (although he could not, at the time of giving evidence, recall what documentation that was).296 Submissions on GPCAPT Ross’ evidence regarding the reversal/review decision Submissions of Counsel Assisting
Counsel Assisting submits that, plainly enough, there is an inconsistency between these two versions and that there would be cogent reasons to prefer GPCAPT Ross’ first version of events, namely, that he only considered the Clinical Perspective Document.
First, that was his first answer given in evidence in an apparently forthright and honest response to questioning. His second answer, by contrast, emerged after an objection was taken by Senior Counsel for the ADF who suggested, as part of that objection, that GPCAPT Ross had not given the evidence he did in fact give (that the Clinical Perspective Document was the only document he considered in his reconsideration).297
Second, when GPCAPT Ross was taken through the medical records, he accepted there was an inconsistency between the medical records and what was being presented in the Clinical Perspective Document.298 It is exceedingly unlikely that a doctor of GPCAPT Ross’ experience and rank would have read the medical records again contemporaneously and not have noticed this inconsistency at the time.
Third, GPCAPT Ross’ evidence was that he considered an RMO would have direct knowledge of the members in the regiment,299 and his statement indicated that he considered the level of involvement of an RMO in the Clinic Perspective Document was “unusual to the point of being unique”, that it “addressed the issues mentioned in the record of my original decision, including [CPL Turner]’s discontinuation of psychological treatment”, and that, in GPCAPT Ross’ view, it contained “adequate justification for [CPL Turner’s] deployment on operation from a medical officer who had direct clinical knowledge of [CPL Turner]”. That is, GPCAPT Ross viewed the Clinical Perspective Document as an important document which had been written by someone
with medical qualifications who he considered would have an awareness of CPL Turner’s clinical history.
Finally, the written reasons which were provided by HQJOC in relation to the decision stated that “Based on new evidence sent to the J07 by MAJ AM this Member has been cleared to deploy on Okra by the J07 HQJOC”.300 That is, the contemporaneous reasons given for the change in GP CAPT Ross’ decision identified MAJ AM’s document as the reason for the change in decision.
On the other hand, if it is to be accepted that GPCAPT Ross did reconsider all of the medical records he had considered in the first place, and assuming he followed his usual practice and considered the documents which are contained in Exhibit 3 (which included the VVCS case closure summary), it is unclear how GPCAPT Ross did not identify the glaring inconsistency between the medical records and what was being put forward in the Clinical Perspective Document, and take some step to investigate this issue before overturning his original decision. That is, if GPCAPT Ross did not consider any further medical records, he should have done so. That is what, on his own evidence, he would ordinarily have done. If he did consider the medical records, his evidence offered no cogent explanation for why he made the clearance decision he did.
That is because his evidence, ultimately, was that having regard to the medical records which were available to him, none of the three concerns which he had raised in his original decision had in fact been alleviated or addressed,301 and in fact, CPL Turner was still experiencing three issues that he had relied on in his original clearance decision, when he had reached the conclusion that deployment presented an unacceptable risk of deterioration.302 GPCAPT Ross further accepted that if he had picked up on the inconsistency between the Clinical Perspective Document and the medical records at the time, he would have “done more about it”303 and that his reliance on the Clinical Perspective Document led him to the view that CPL Turner had a sufficiently low risk to be able to deploy but, in retrospect, the “risk profile was higher”.304 300 Tab 49 (ADF Medical Records) at 330.
GPCAPT Ross accepted that he could have granted a clearance that was subject to a condition that there be regular psychological reviews of CPL Turner,305 although he considered that this would have been an unusual thing to do.306
GPCAPT Ross’ evidence revealed similar confusion to MAJ AM’s evidence in terms of what he was supposed to be considering as part of his decision-making process. At one point, GPCAPT Ross stated that the medical clearance process is “intended to be a medical decision” because there is a “command process” (the command waiver process), which could be implemented if the Chain of Command was not satisfied with the outcome of the clearance process.307 However, at another point in his evidence, he stated that he had to “walk a tightrope” where “there’s the interests of the individual, the interests of the organisation, the interests of the operation, are considered on balance”.308 Again, by contrast, he later considered that it was “no part” of his consideration to consider what the operational significance of the particular individual was to the deployment.309
GPCAPT Ross’ evidence was that he had “no reason” to think that the Chain of Command had been involved in the process of preparation of the Clinical Perspective Document.310 However, he accepted that it was clear from the face of the Clinical Perspective Document that CPL Turner’s Chain of Command wanted to have the decision reversed: it stated in terms that it was “aligned to his OC and CO’s intent”.
GPCAPT Ross suggested in evidence he might not have taken particular note of this at the time of making his reconsideration decision.311 This is again difficult to reconcile with the fact that the Clinical Perspective Document was provided to GPCAPT Ross under cover of a brief under the hand of the CO, COL MF.
Submissions of the Commonwealth
312 Submissions of the Commonwealth dated 7 June 2024 at [316]-[317], [386].
Submissions of GPCAPT Ross
First, GPCAPT Ross disagrees with the contention that he was suffering from any confusion as to his role as J07 HQJOC. He submits that his evidence was clear about: when Command seeks that an individual deploy because it suits an organisational imperative, yet that person is not medically cleared to deploy, the appropriate process is a command waiver; at all times he understood the difference between medical clearances and command waivers; the role of an occupational physician; and the matters that an occupational physician might permissibly consider in the medical clearance process. He maintains that: the medical clearance decision involved only medical considerations; those medical issues have impacts on the individual and on the organisation; an occupational physician can validly take into account both of those perspectives; and the appropriate course for the Chain of Command to influence a decision is through the command waiver process. 313
Second, GPCAPT Ross disagrees with Counsel Assisting’s contention that he only had regard to the Clinical Perspective Document when making the “reversal decision” and submits that he also considered the report of Dr Sringeri, which was enclosed in the brief to GPCAPT Ross containing the Clinical Perspective Document.314 In support of this submission, GPCAPT Ross refers to: his evidence of having a “very limited recollection”315 of CPL Turner’s case generally (which was understandable considering the passage of time and volume of cases GPCAPT Ross reviewed as J07 HQJOC); he had not indicated in his written statement that he only had regard to the Clinical Perspective Document;316 his oral evidence suggested that he reviewed other documents in making his appeal decision;317 and the evidence of Professor Hopwood.318 GPCAPT Ross considers that a finding ought to be made that he did consider all of the material before him in first refusing and then granting the clearance.
In submissions in reply, Counsel Assisting accepts GPCAPT Ross’ submission on this point.319 313 Submissions of GPCAPT Ross dated 5 June 2024 at [100]-[103]; Submissions in reply of GPCAPT Ross dated 22 July 2024 at [9]-[12] 314 Submissions of GPCAPT Ross dated 5 June 2024 at [36]-[44].
315 Exhibit 114 at [18]; 06.08.21 T35.47-48 and T41.36-37.
316 Exhibit 114 at [25].
319 Submissions in reply of Counsel Assisting dated 22 August 2024 at [177].
GPCAPT Ross submits that the Clinical Perspective Document addressed his concerns as to CPL Turner’s history of mental illness, his alcohol consumption, and his interpersonal relationships, and why CPL Turner had discontinued his psychological treatment, which were the matters in CPL Turner’s health record that had caused GPCAPT Ross to make his initial decision. However, he also submits that on the basis that the Clinical Perspective Document was not the only new evidence available to him at the time of making the reversal decision, the question of whether that document answered every concern he had expressed at the time of the initial decision to refuse the clearance “becomes much less significant”.320
In relation to Counsel Assisting’s submission that the Clinical Perspective Document led GPCAPT Ross to the view that CPL Turner had a sufficiently low risk to be able to deploy but in retrospect “the risk profile was higher”, GPCAPT Ross submits that this was evidence given prior to the production of Dr Sringeri’s letter (which independently addresses CPL Turner’s risk profile and expressly states that CPL Turner was at low risk of a recurrence of PTSD).321
GPCAPT Ross also considers that the fact that a document such as the Clinical Perspective Document advocates a position which its author is convinced does not necessarily mean that it is unbalanced or that it does not accurately reflect the true position and, accordingly, GPCAPT Ross was entitled to approach the document on the basis that MAJ AM’s conviction was based on the medical information known to
321 Submissions of GPCAPT Ross dated 5 June 2024 at [57].
322 Submissions of GPCAPT Ross dated 5 June 2024 at [59].
AM to make clear any matter that might have affected the veracity or reliability of the opinions he expressed in the document.323
GPCAPT Ross submits that while he approached the document with his usual caution, he ought not to have been expected to have approached a document from a professional colleague holding the senior role of RMO with scepticism or suspicion, nor to second-guess the information it contained.324
GPCAPT Ross also rejects any contention that his “second version” of events (referred to at [166] above) was influenced by the content of Senior Counsel for the Commonwealth’s objection and was not true.325
Third, GPCAPT Ross submits that a finding ought to be made that he “had no reason” to interrogate the medical records to test what was being put to him in the Clinical Perspective Document. It is further submitted that GPCAPT Ross was “likely to have done so”.326
On this point, Counsel Assisting submits that it is difficult to reconcile GP CAPT Ross’ submission that he had no reason to interrogate the records with the further submission that he was likely to have done so. Counsel Assisting maintains that it is open to make a finding that GPCAPT Ross did not subsequently interrogate the medical records which had led him to make his first refusal decision.327
Fourth, GPCAPT Ross submits that on the premise that Dr Sringeri’s letter was before him, that letter provides an independent answer to the concerns that he held as to CPL Turner’s fitness to deploy.328
Fifth, in relation to the contention that the reference to “new evidence” was the basis for appeal/reversal decision (referred to at [171] above), GPCAPT Ross submits that there is no cogent reason to read this narrowly as a reference to the Clinical Perspective Document given that it has become clear that GPCAPT Ross most likely also had the benefit of Dr Sringeri’s letter at the time of the appeal/reversal decision.
For similar reasons, GPCAPT Ross rejects Counsel Assisting’s submission above at [172] that there is “no cogent reason” why GPCAPT Ross could have made the appeal 323 Submissions of GPCAPT Ross dated 5 June 2024 at [60]-[62].
324 Submission of GPCAPT Ross dated 5 June 2024 at [66].
325 Submissions of GPCAPT Ross dated 5 June 2024 at [42].
326 Submissions of GPCAPT Ross dated 5 June 2024 at [88(b)].
327 Submissions in reply of Counsel Assisting dated 22 August 2024 at [177].
328 Submissions of GPCAPT Ross dated 5 June 2024 at [96]-[97].
decision if he had taken into account the medical records (given that Dr Sringeri’s letter addressed his concerns as to CPL Turner’s fitness to deploy). 329 Consideration
At the conclusion of all the evidence I was not persuaded that GCAPT Ross’ “reversal” decision was not infected by some confusion in relation to his understanding of his role as J07 HQJOC. While he may have understood the theoretical difference between a medical clearance and a command waiver, his evidence demonstrated he was affected by competing concerns. He spoke of “walking a tightrope” where he had to balance the interests of the individual, the organisation, and the operation. While he appeared to see that balancing task as part of his role as an occupational physician, it demonstrated to me the extent to which Chain of Command interests weighed upon him. It is important to note that GPCAPT Ross was not alone in this confusion and it is an issue to which I will return.
I was persuaded that GPCAPT Ross placed great emphasis on the Clinical Perspective Document in coming to his second decision. He accepted that there were significant inconsistencies between the medical records and the Clinical Perspective Document. In my view, this was compelling evidence which demonstrated that it was most unlikely that he reviewed the medical records again at the time of his second decision. While he originally gave evidence that to the best of his recollection the Clinical Perspective Document was the only document he relied upon, I accept that it is now clear he may well have had the Dr Sringeri report. I have some sympathy for the submission that he was entitled to give significant weight to Dr Sringeri’s opinion that CPL Turner was at “low risk” for a recurrence of PTSD. However, he was not entitled to accept that opinion without placing it in context and having regard to all the material available to him. He was not entitled to substitute Dr Sringeri’s opinion for his own.
I also have some sympathy for GPCAPT Ross’ contention that he was entitled to place reliance on the Clinical Perspective Document. It had been prepared by a RMO and made expansive claims about CPL Turner’s wellbeing. GPCAPT Ross believed MAJ AM had a clinical role in CPL Turner’s care, which added to the weight he gave the document. Nevertheless, GPCAPT Ross was not entitled to abrogate his own decision to the opinion of MAJ AM. Even a cursory re-examination of the medical records would 329 Submissions of GPCAPT Ross dated 5 June 2024 at [94]-[95].
have alerted GPCAPT Ross to areas of concern and caused him to question the accuracy of the Clinical Perspective Document.
There is another issue which should have alerted GPCAPT Ross to the need for caution when asked to re-consider his original decision. Given that GPCAPT Ross considered the level of involvement of an RMO in the Clinical Perspective Document as “unusual to the point of being unique”, one wonders why he did not at least consider whether he was being pressured to change his decision. GPCAPT Ross’ original decision makes it clear that he was aware of CPL Turner’s extensive psychological and alcohol dependence history, his failure to continue psychological support as recommended, and his risk of deterioration whilst deployed. In my view, on receipt of new information he was obliged to reconsider the original material, particularly where the new material conflicted with matters set out in his original written decision. There was real need for curiosity.
In my view, there were significant deficits in the second decision.
(h) Deployment to Iraq on OP OKRA in 2016
(i) Disciplinary proceedings and reduction in rank
The incident which became known in the Inquest as the “cock-carding” incident occurred on 30 July 2016. At this time, CPL Turner was on a Royal New Zealand Airforce aircraft, travelling into Iraq. He placed a pornographic playing card displaying a photograph of a naked male on a cargo pallet, which was scheduled for offload at Al Assad Air Base. The card was discovered by a member of the aircrew and when discovered, the flight was briefed on the cargo inspection processes used by Iraqi customs officers and the possible consequences if the card had been found by Iraqi officials.330
It is not the role of a coroner to review the decision to charge CPL Turner, the severity of his punishment, or the outcome of his ultimate petition for review. The disciplinary proceedings were the subject of an investigation by the IGADF, the report of which was tendered in evidence in the Inquest.331 Rather, the relevance of the disciplinary proceedings to the issues in the Inquest are as follows: 330 Tab 40 (Military Charge Papers) at 12.
331 Tab 125 (IGADF Report of investigation into disciplinary proceedings).
(a) first, the causal link (if any) between CPL Turner’s mental state and his participation in the cock-carding incident;
(b) second, the ADF’s management of CPL Turner’s mental health throughout the disciplinary proceedings and their aftermath; and
(c) third, the effect of the disciplinary proceedings on CPL Turner’s mental health during the Iraq deployment and subsequently.
MAJ AF’s evidence was to the effect that the incident became “bigger than Ben Hur”, and that one of the “key things that all come out when we talk about his charge, he was charged for an international incident that never took place”.332 He gave evidence that prior to the charge the vibe was “it’s not a big deal, let us know who these people are”, and that his impression was “I’ll charge a couple of diggers and move on”.333 However, it became an “integrity issue” for the Commander of Joint Task Force (JTF) 633.
CAPT MH stated in his ROI that “at the time we were told that there would be no further action with regards to what had occurred, they simply wanted to get the names of the individuals who were responsible so they could pass those on to 633, and that would be it”. This came to be described as the promise of an “amnesty”. He stated that CPL Turner put his hand up and said “I’m responsible for the one that was found in the package”.334 He stated that shortly thereafter, CPL Turner was told he would likely be facing disciplinary action and CAPT MH was told he would be the Defending Officer.335 CPL TJ stated that the amnesty was given by LTCOL NJ, that the group who had been on the flight was brought in together (with those who were not in Baghdad on a video conference) and that they were told you “have amnesty”.336
WO2 DP stated that it “really put a rocket through the company”, because his view was that they were told that if people came forward, nothing would happen, and the “next thing they see is a sergeant is getting charged after putting his hand up”.337
The summary hearing in relation to the cock-carding incident occurred on 16 August 2016.
332 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 19.
333 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 19.
334 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 7-8.
335 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 5.
336 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 7.
337 Tab 24 (IGADF ROI with WO2 DP on 5 July 2018) at 15.
CPL Turner was charged with prejudicial conduct contrary to s 60(1) of the Defence Force Discipline Act 1982 (Cth),338 pleaded guilty, and was sentenced to a reduction in rank (from SGT) to CPL.339 The reasons for judgment stated that the officer trying the charge assessed CPL Turner’s judgment as “incredibly poor” but noted that he did not believe that his intent was to cause damage.340 It also noted that the behaviour of concern was “your inability to understand or foresee the potential outcome of your behaviour and how poor this decision was in the circumstances in which you chose to perform the act”.341
It is notable that the reasons do not record any consideration being given to CPL Turner’s diagnosis with PTSD or mental health in the sentencing consideration. That being said, neither CPL Turner’s mitigation statement, which was prepared with the assistance of CAPT MH, nor the character references supplied in support of his plea in mitigation, referenced these issues.342
LTCOL SW, who wrote a letter of reference for CPL Turner, stated that (subjectively speaking) he was surprised at the severity of the punishment, and that his statement did not appear to be “actually given any credence”.343 WO2 DP stated that he considered it to be a “very harsh punishment” for something that was “not an actual incident”.344
MAJ AF’s evidence was that he was worried about the “guys who were going back” to Al Minhad Air Base (AMAB), because “AMAB is cancerous … its institutionalised fraud”.345 His evidence was that he was “quite worried about them”, they were “treated like lepers”, and that “we tried to look after them as much as we can”.346 MAJ AF’s evidence was to the effect that it was then decided that CPL Turner “would be in Baghdad” after the charge and the decision to allow him to stay in country.347 It is not clear that this in fact was the case. Following his return from AMAB after the charge process was complete, CPL Turner remained in BDSC for around 6 days before returning to TQ for over 6 weeks (as set out in Annexure C).348 338 Tab 40 (Military charge papers) at 35.
339 Tab 40 (Military charge papers) at 39.
340 Tab 40 (Military charge papers) at 38.
341 Tab 40 (Military charge papers) at 38.
342 See Tab 40 (Military charge papers) at 69-77.
343 Tab 22 (IGADF ROI with LTCOL SW on 11 December 2018) at 10-11.
344 Tab 24 (IGADF ROI with WO2 DP dated 5 July 2018) at 22.
345 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 20.
346 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 20.
347 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 21.
348 Exhibit 67 (Agreed Fact: CPL Turner’s movements during the 2016 Iraq Deployment).
A further issue which arose in relation to the disciplinary proceedings related to an incident involving COL L, who was standing near the front gate of the accommodation on the morning of the disciplinary proceedings. WO2 DP’s evidence was that it was strange that he was there at the time, early in the morning and in full uniform. He stopped CPL Turner to talk, and WO2 DP stated that CPL Turner later said to him (WO2 DP) that COL L had said “Hey, I heard you’re getting charged today. Good luck with that, mate”. Neither WO2 DP nor CAPT MH, who were with CPL Turner, were in fact privy to the conversation. CPL Turner then told WO2 DP that he had a sexual relationship with COL L’s wife, and COL L was aware that had happened.349 CPL TJ stated in her ROI that CPL Turner considered there was a person who was “out to get him" involved in the disciplinary proceedings. CPL TJ’s evidence was that CPL Turner considered that this person “took the opportunity to seek maximum damage on Ian. So he kind of had that mindset that everything was just turning against him”.350
Joanna Turner similarly stated that CPL Turner believed that a woman who he had been sexually involved with had a father who was somehow involved in the disciplinary proceedings and was out to get him. Joanna Turner indicated she did not know if this was true and said “to be honest, CPL Turner was that paranoid that you couldn’t believe – I couldn’t believe a word that he said”.351
This issue was canvassed in the IGADF investigation into the disciplinary proceedings, which found no evidence to substantiate the allegations.352 The issue was not dealt with in any significant detail in oral evidence in the Inquest. The relevance of it is simply to understand CPL Turner’s response to the disciplinary proceedings. That is, it is evident that CPL Turner had a sense of grievance about the disciplinary proceedings.
One way in which this manifested was in his belief that there had been collusion and/or bias involved in his disciplinary proceedings, which had affected their outcome.
350 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 8.
351 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 53.
352 Tab 125 (IGADF Report of investigation into disciplinary proceedings) at 6.
his written answers to questions posed to him, CAPT MH said that he was aware of cock-carding being a widespread practice in the unit when he joined in 2015; that he had had cock cards placed on and in his equipment; that he had placed cock cards on others and their equipment; and that he was aware that the OC (MAJ AF) had been cock-carded in the lead-up to the deployment to Iraq in August 2016. CAPT MH also said he had taken no action to curtail the practice of cock-carding and justified this by saying he did not think it was a problem and understood the practice to be an accepted one within the unit, including up to the OC, and in the international special forces community.355 Although CAPT MH said he did not have any concerns for CPL Turner’s mental health after the outcome of the disciplinary proceedings were known, he did observe him to be “angry, frustrated and disillusioned”.356
(j) Care of CPL Turner’s mental health in Iraq
COL MF was asked if he took any step upon CPL Turner being charged to provide him with psychological support. He stated he did not because “him being deemed fit to deployment in the context of the mission that they were going to deploy on, I took to mean that he was physically and mentally in a position to cope with the activities with that mission… I did not see that as a red flag”.357 However, he also stated that because CPL Turner was “force assigned” to a different Chain of Command, “we are very conscious that once the members are force assigned we sort of stay out of it”.358
CAPT MH described CPL Turner’s mental state during the time they were in AMAB as “angry”, “devastated”, and “disillusioned”.359 CAPT MH stated that following the return from AMAB into Iraq, CPL Turner’s work performance “never suffered” but it was evident from the conversations he was having with him that he was “angry, and he was getting more angry…and he was getting more frustrated and disillusioned”.360
LTCOL SW had been asked by CPL Turner to provide a reference for him in his disciplinary proceedings. He stated in his ROI that CPL Turner had written to him after the outcome of the proceedings and expressed “dismay” at the lack of support the organisation had shown him, saying that the army had been a “fair-weather friend” to him, and that he was going to look for a job with an employer that would value him.
LTCOL SW said he wrote back and said he was sorry it had turned out that way but 355 Exhibit 66 at 2 [3].
356 Exhibit 66 at 6 [15].
358 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 13.
359 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 9.
360 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 11.
not to rush to any conclusions about his future and that “command needed people like him”.361
LTCOL SW also stated in his ROI that he had a discussion with BRIG GD (who was, at that time, Commander Special Forces) and stated that as CPL Turner was clearly upset, he might appreciate an email from him (BRIG GD) stating something like “Listen I know you’ve done the wrong thing, but I know you’ve owned up to it”, and “we still value you … you’re going to bounce back and you’ll get your rank back”. LTCOL SW stated he was “pretty sure” he even drafted an email and sent it to BRIG GD to consider, just in case he wanted to do it. No such email was produced to the Inquest (noting it would have fallen well within the scope of the subpoenas issued to the ADF), and LTCOL SW stated in his ROI that he had looked for it and could not find it.362 BRIG GD’s evidence to the Inquest was that he could not recall receiving this, but he did not deny that it took place and, in any event, he would have thought it was “not the right thing to do” because the investigation was happening overseas and the punishment was being awarded overseas.363
On 18 August 2016, CPL Turner lodged a petition for review of the conviction. The decision made at first instance was upheld.364 The petition which was submitted by CPL Turner did not refer to his history of mental health issues as a potentially mitigating factor.365
CAPT MH was unavailable to give evidence to the Inquest but provided a number of written statements at the request of Counsel Assisting. He was asked why CPL Turner’s mental health was not raised during the summary authority hearing. In a letter dated 31 July 2021, CAPT MH stated that this was because “it was not raised by Ian Turner with me and it was not something that I was aware of at the time”. He further stated that “nothing was raised by Ian in the course of preparing for the hearing that indicated his mental health was a relevant matter”, and that he was not instructed by CPL Turner to raise any issues regarding his mental health.366 He clarified in a later letter responding to further questions that “at the time” meant at the time of the summary proceedings.367 361 Tab 22 (IGADF ROI with LTCOL SW on 11 December 2018) at 9.
362 Tab 22 (IGADF ROI with LTCOL SW on 11 December 2018) at 22.
364 Tab 40 (Military Charge Papers) at 9.
365 Tab 40 (Military Charge Papers) at 20-24.
366 Exhibit 13.
367 Exhibit 66 at 5-6.
(k) The Notice to Show Cause (NTSC)
Following the disciplinary action, on 17 August 2016, CPL Turner was issued with a Notice to Show Cause (NTSC) as to why he should not be returned to Australia.368 The NTSC required a response within 2 days. CAPT MH assisted CPL Turner with responding to the NTSC.369 The response to the NTSC referred to CPL Turner’s PTSD diagnosis, stating as follows:370
It appears that there was a policy in the ADF that a NTSC as to why a member should not be returned to Australia followed the institution of any disciplinary proceedings on deployment. MAJ AF’s evidence in relation to the NTSC was that he put CPL Turner under administrative action himself because then “I have done it”, and not some “random deputy commander”. He did not personally agree with the policy that administrative action should automatically follow DFDA Action,371 and his view was “He’s mine, and I’ll decide whether he goes home or not”.372
(l) Deteriorating mental health in Iraq and available supports
369 Exhibit 66 (Response to Questions posed to CAPT MH) at 5.
370 Exhibit 31, Tranche 8 at 42.
371 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 25.
372 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 24.
further below).373 At this juncture, however, it is useful to consider the available mental health supports in Iraq for CPL Turner.
The brief sent from the CO of 2CDO to the J07 specifically stated that “the following management strategies and mitigations have been developed by SGT Turner’s chain of command, in consultation with rehabilitation staff and psychologists [in order to] ensure SGT Turner’s welfare is managed appropriately and successfully whilst deployed”, and then stated: “a. The personnel best able to monitor, asses [sic] and manage his mental health are his regular team members, who he will be deployed with; b. During the deployment, SGT Turner will have ready access to coalition medical support, including… psychologists;”
MAJ AF’s oral evidence was that there was no specific mental health plan designed for CPL Turner once he had deployed. The only steps he took to determine if there was a deterioration in his mental health condition was “routine engagement by the chain of command”.374 This would have been CAPT MH whilst CPL Turner was in TQ, and then later MAJ AF when CPL Turner returned to BDSC.375 WO2 DP stated in his ROI that because CPL Turner was “such a high performer, we put him into a position where it’s fairly isolated” (talking about TQ).376 The evidence revealed that CPL Turner himself felt lonely and isolated whilst he was in TQ.377 (Set out in Annexure C to these findings is a timeline which constituted an agreed fact of CPL Turner’s movements in Iraq).
COL MF’s evidence was that once CPL Turner was deemed “fit to deploy”, no “caveats” were put on that deployment, and he therefore did not take any steps to reduce the risk of any relapse by CPL Turner of his PTSD.378 His view was that “his being deemed medically fit to deploy meant that he was capable of, you know, completing the physical and psychological taskings that he was going to encounter”.379 His understanding of PTSD was that, essentially, he could “rule a line” underneath it, he was “better”, and his PTSD was not something that needed to be monitored unless he was informed by a doctor that something had changed.380 COL MF did not, in 2016, hold an understanding that when someone has had PTSD the risk of further ongoing 373 See, e.g., Exhibit 57 (WhatsApp and SMS messages) at 257-258.
376 Tab 24 (IGADF ROI with WO2 DP on 5 July 2018) at 11.
377 See, e.g., Exhibit 57 (WhatsApp and SMS Messages) at 739, 1051, 1289.
exposure carries a substantial risk of relapse.381 He was not aware that alcohol abuse can manifest as a form of self-medication in individuals with PTSD, or can be a symptom of PTSD.382 At the time of recommending that CPL Turner be deployed, he did not think he was at risk of recurrence of PTSD in Iraq, even if exposed to traumatic events.383
MAJ BJ’s evidence was that he could not recall seeing the 2CDO CO’s brief to the J07 (notwithstanding he sent it to CAPT MH for his awareness because CPL Turner was deploying with CAPT MH as his immediate superior).384 His evidence was later that although he forwarded it (because he thought it was important that CAPT MH have the information in the brief), he could not in fact recall whether he had read it, skimmed it, or forwarded it – he just did not recall having “read it in detail”.385 He stated that he did not “feel at that stage that Ian was under a rehabilitation, yeah, management plan” and that “we felt that him going on that deployment was in his best interests, being around his teammates…and not being at home by himself”.386 He could not recall if a psychologist was available at BSDC.387 He could not recall whether either of the two mitigation strategies extracted above at [221] were put into place but stated the “decision making around that would have been through administrative lines, so I’m not sure”.388 CAPT BJ’s evidence was that he was aware of the disciplinary proceedings concerning CPL Turner but did not raise any concern with the Chain of Command about CPL Turner’s mental health going through that process.389 His explanation for not having done so was that CPL Turner was not his direct reporting line at this stage, and other people in the Company were aware of his mental health difficulties and that he had been granted a “waiver” to deploy.390
MAJ BJ received an email from CPL Turner on around 14 October 2016, in which CPL Turner noted that he was experiencing a “minor relapse at the minute” from “that body recovery thing”, “not as in the drinking piece, but the other stuff”. CPL Turner stated “[n]ot sure why, but it has just had a bit of an impact on me” and it was impacting his sleep and his decision-making processes.391 MAJ BJ stated that he did not really track
391 Exhibit 31, Tranche 9 at 55.
this issue or try to understand what had occurred and he did not think it warranted any further lines of enquiry.392
MAJ BJ’s evidence highlighted that his deployment on OP OKRA was turbulent in an operational sense and he had a lot of responsibilities. He was also remotely located around 350km away from where CPL Turner was located.393
CAPT MH was CPL Turner’s immediate supervisor. He was responsible for the “west of Iraq” during 2016, including TQ.394 CAPT MH was excused from giving oral evidence in the Inquest but he gave a statement answering some questions in relation to disclosures that CPL Turner made to him about his declining mental health in Iraq via text and WhatsApp messages.395 CAPT MH’s answer given in writing to the Inquest explained that he did not have a good recollection of the events of 2016 but that he did not recall doing anything formal in respect of the disclosures which CPL Turner made about his relapse. He stated:396 “Having reviewed the messages, I note that when CPL Turner did disclose to me that he had had a relapse of his PTSD, he also said to me: “I’m being honest with you so you are aware. Don’t use it against me please.” to which I replied “I would never use it against you mate. You know you can trust me.” I also note that the messages reveal amongst the frequent communications I had with CPL Turner, interspersed with messages about work, I checked on his welfare and tried to give him moral support.
By way of illustration, (at DEF.2002.0024.0141) I said to him “More importantly, what’s going on with your sleep or lack of it! I’m out on a work party til lunch but let’s talk this arvo.” I also recall having a conversation with MAJ AF about CPL Turner being relocated from where he was to BDSC. I felt BDSC would be better place for him because CPL TJ and I would be there with him and the facilities, including the gym, were much better.”
394 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 5.
395 See Exhibit 57 at 346.
396 Exhibit 66 (Response to questions posed to MAJ MH) at 11.
MAJ AF’s evidence was that he never discussed with CPL Turner the opportunity for CPL Turner to put his hands up about his declining mental health, but that he “was aware in the community that was the company at the time that there was people he could reach out to, and one of them was me”.400 He accepted that he could not recall asking any particular person to look out for CPL Turner’s mental health and any relapse in PTSD whilst he was deployed in Iraq.401 He accepted he did not task any person in TQ to monitor CPL Turner personally.402 He accepted he did not know what CPL Turner’s process of continued psychological support was during the Iraq deployment and that he did not require him to have any sort of program of psychiatric or psychological support.403 He accepted, with the benefit of hindsight, that CPL Turner was not open with his Chain of Command as to his psychiatric or psychological difficulties in Iraq.404
MAJ AF accepted that there was evidence that each of CPL TJ, MAJ BJ, and CAPT MH knew about CPL Turner’s relapse and none of those individuals reported it to him.
He refused to accept that he could not therefore rely on those who are serving with a soldier to report to the Chain of Command whether those soldiers have suffered from relapses of mental health conditions. It is useful to extract his entire answer: “Q. And does that suggest to you now that you cannot rely upon those who are serving with soldiers to report to you whether those soldiers have suffered from relapses of mental health conditions?
No. I don’t want to speak for the decision process that MH and BJ or TJ went through.
They have been nothing but reliable for me in the past. They have made a decision here. I’m sure they went through a process.” Submissions on MAJ AF’s evidence regarding reliance on soldiers to report relapses of mental health conditions of other soldiers Submissions of Counsel Assisting
superiors to report a decline in their psychological well-being to the Chain of Command.
Submissions of the Commonwealth
Rather, it submits that it is an obvious conclusion that “it is not sufficient for the chain of command to rely on a soldier’s peers” to monitor their well-being. The basis for the objection on this point is that it purportedly seeks to “universalise from one case”.405 Submissions of CAPT MH
Submissions in reply of Counsel Assisting
In reply submissions, Counsel Assisting submits that the focus in this respect is on the deficiencies in CPL Turner’s case, and the Commonwealth accepts that “the system of reporting matters up the chain of command did not work in this case”. But that is not to say the matter is irrelevant for the broader practice of ensuring appropriate monitoring of the well-being of ADF members, in circumstances where a medical clearance for deployment has been obtained.407
Counsel Assisting submits that the assertion of CAPT MH that he was more “vulnerable” to being influenced by CPL Turner lacks a strong evidentiary foundation.
405 Submissions of the Commonwealth dated 7 June 2024 at [444].
406 Submissions of CAPT MH dated 7 June 2024 at [31]-[45].
407 Submissions in reply of Counsel Assisting dated 22 August 2024 at [220].
Nevertheless, Counsel Assisting does not seek any particular adverse finding against CAPT MH for his conduct; rather, Counsel Assisting submits that CAPT MH was inadequately trained to deal with CPL Turner’s mental health issues and provide an appropriate response. It is emphasised that there was no system put in place at this time to monitor CPL Turner’s condition notwithstanding the knowledge of his medical history.408 Consideration
It is clear that the Chain of Command cannot rely solely on a soldier’s peers or immediate superiors to monitor their mental health. CPL Turner’s case shows how a variety of factors including misplaced loyalty, lack of knowledge and skills in mental health, and a reluctance to get involved in a “private” matter can influence a decision to feed information up the line.
I make no adverse finding in relation to CAPT MH who was inadequately trained to assist CPL Turner. CAPT MH was in a difficult position and I understand the pressures on him to “keep information confidential.”
To gain insight from examining CPL Turner’s case is not to “universalise” impermissibly. The evidence shows that CPL Turner’s peers were not able to meaningfully monitor his mental health. His relationship with CAPT MH is a case in point. No matter how well meaning CAPT MH was, his desire to help was impacted by the rank disparity and the need not to appear to “use information against” CPL Turner.
Returning to the evidence, the welfare board minutes for 6 September 2016409 indicate that very little was discussed at the meeting, with most entries listed “N/A” because CPL Turner was deployed.
On 17 September 2016, CPL Turner contacted the health facility at BDSC. He reported continued sleep deprivation. He was prescribed temazepam.410 MAJ AF’s evidence was that he was not aware of this, and it was something that he would have liked to have been made aware of. He did not ask CPL Turner to report to him if he had sleeplessness or anxiety.411
CPL TJ stated in her ROI that during CPL Turner’s time in Iraq, he was “extremely frustrated” and he “would go through waves”. There would be “a day where he would 408 Submissions in reply of Counsel Assisting dated 22 August 2024 at [141].
409 Tab 38 (Welfare Board Minutes) at 1-4.
410 Tab 49 (ADF Medical Records – unit copy) at 56.
be okay, this is it, I just cop it on the chin” and “there would be days where he was just inconsolable and just angry and become very volatile towards just being around the rank, the chain of command”. She stated that there was a day she did not see CPL Turner at breakfast and she found him in his room shaving down a bullet, and he said that he was going to drive himself to HRT (where he was working at the time), lock himself in the armoured car, and pull the trigger with one of his shaved down rounds.412
(m) Availability of alcohol in Iraq
A major factor in MAJ AF’s reasoning that it was “better” for CPL Turner to deploy to Iraq than remain in Australia in mid-2016 was that Australian soldiers were not permitted to drink alcohol during the Iraq deployment and, thus, deployment would give CPL Turner a break from alcohol. Counsel Assisting considers that that opinion was (at best) naïve, and at worst, wilfully blind to the true nature of alcohol consumption by Australian soldiers in Iraq. I accept that submission.
CPL TJ’s evidence in her ROI was that “even on deployment like he would find a way of getting alcohol to have alcohol on deployment”.413 She stated the Chain of Command was not aware of his alcohol consumption on deployment but “they were definitely aware prior to him going on this trip”.414 Her evidence was that CPL Turner obtained alcohol from the pizza shop, and that at least two of the nights that CPL TJ was with him a week (which was about four nights a week), he would have alcohol.415 Notwithstanding this, CPL TJ gave evidence that “I believe it was effective because you [could] only get a limited amount of alcohol…[I]t was an effective measure because it did reduce the amount and when he was drinking”.416
The messages to and from CPL Turner demonstrated that CPL Turner was regularly accessing alcohol in Iraq and that other soldiers he was deployed with were also doing so, both in BDSC and in TQ.417 412 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 13.
413 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 30.
414 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 30.
417 Exhibit 57 (WhatsApp and SMS messages) at 544 “That's the only thing I miss about not being in BDSC. Is the easy access to alcohol and the parties"; 878 "Just cracked a bottle of piss that we scored today"; 1108 “then after an hour or so, his guys came in and they had alcohol with them”; 1530 “I have drinks and we can order pizza”; 1543: "I scored alcohol and Valium and took a little too much”; 1567 "I'll have a beer; 1571 "Just having a beer”; 1572 “Ill drop you a beer off”; 1627 “drinking wine alone; 1566 "I just dropped into the pizza shop for a sneaky beer”; 1635 [picture of a bottle of vodka]; 1638: "I'm drunk still"; 1729 "I'm going to go to the bottle shop”; 1758 "I'm about to drink more and knock myself out"; 1815 "I might try a thing I heard about called beer"
MAJ AF indicated in a statement dated 2 August 2021 in relation to this issue that “[t]here was to be no alcohol consumed on this deployment” and that he was “not aware of any person consuming alcohol while deployed within this rotation/deployment”.418 However, he acknowledged later in his oral evidence that alcohol was available in BDSC it was simply that Australian soldiers were not permitted to drink alcohol on the deployment.419 MAJ AF was subsequently recalled to give evidence in circumstances where he had reviewed the text and WhatsApp messages on CPL Turner’s phone during the Iraq deployment in 2016. He accepted that, having regard to those messages, it was not possible to simply rely on orders restricting access to alcohol being complied with.420 Overall, I found his evidence on the issue of the availability and use of alcohol less than convincing. I was not persuaded that he was trying to assist the Court by providing a full and honest account. The only alternative, given that he was “not aware of any person consuming alcohol”, is that he was completely out of touch with daily life in BDSC.
MAJ AM’s evidence was that he was aware alcohol was not permitted to be used by Australian soldiers on OP OKRA and that alcohol was available for purchase, and when asked whether alcohol was used by Australian soldiers he responded that “Australian soldiers have an uncanny way of finding alcohol wherever they are”.421 He stated that his “experience in multiple theatres with the Australian Army is that soldiers manage to find alcohol somehow in every environment”, so he would not be surprised if they found alcohol in Iraq on OP OKRA (although he did not see evidence of that himself).422 He accepted that he knew that CPL Turner would be able to access alcohol in Iraq when he prepared the Clinical Perspective Document.423
(n) The body recovery
stuff which caused a bit of stress for him because it just triggered some PTSD”.424 The evidence was to the effect that this incident occurred on 31 September 2016.425
During the first tranche of the hearings of the Inquest, Senior Counsel for the ADF cross-examined Dr Sringeri as to whether it was possible that the body recovery only happened in “CPL Turner’s mind”. Senior Counsel indicated that the ADF could not say that “it did not happen” but would be submitting “it would be very unlikely that it did happen”, seemingly because if the event had happened, CPL Turner would have had to have “gone outside the wire” and he had no authority to do so.426 Senior Counsel for the ADF subsequently asked Dr Sringeri whether “people can have quite detailed memories where they give you detail about something that’s quite distinct and it didn’t happen”.427
As became apparent throughout the Inquest, the body recovery did happen, and CPL Turner was involved in it. It is regrettable that court time was wasted in proving that this event did occur, having regard to what must always have been known to the ADF about the incident and the possibility that CPL Turner could have been involved in it whilst remaining inside the wire at TQ.
It is also regrettable that MAJ AF’s evidence originally suggested to the Court that CPL Turner had not participated in the body recovery mission. His evidence did this by suggesting that CPL Turner was not permitted to go outside the wire.428 As became apparent, whether or not CPL Turner was permitted to go outside the wire was irrelevant to the likelihood that he had participated in the mission. There was an attempt to explain that evidence in re-examination by asking MAJ AF whether the information he was “permitted to disclose” in the proceedings changed between a statement he made on 2 August 2021 and a statement he made on 12 August 2021 and that he had understood when he wrote his 2 August 2021 statement that he was not allowed to disclose that the mission had occurred inside the wire.429 That was similarly what emerged from his cross-examination by then Senior Counsel Assisting: that “the context behind that answer was in regards to the fallacy that this activity took place outside the wire”.430 424 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 12.
428 See, e.g., Exhibit 11 (Statement of MAJ AF dated 2 August 2021) at [15]. See also 05/08/21 T45.
That fallacy was again one which was within the capacity of the ADF to correct and it is not to the point that MAJ AF had been apparently “instructed” not to reveal the whole truth because of some nebulous and ill-defined concept of the “public interest”. In that regard, it ought to be noted that the interests of the Commonwealth in public interest immunity were amply protected by the presence of senior counsel, including on occasion by separate senior counsel (Mr Berger KC), and the questioning proceeded by asking MAJ AF to pause before answering questions so that the Commonwealth had a proper opportunity to consider whether an objection on the basis of public interest immunity would be taken. It is not for a witness to withhold evidence on the basis of public interest immunity: it is for the Commonwealth to take an appropriate objection. Witnesses are under an obligation, by the oath or affirmation which they take at the commencement of their evidence, to simply tell the truth.
Counsel Assisting submits that there are two matters which should not have occurred in relation to MAJ AF’s evidence about the body recovery. The first is that MAJ AF ought not to have provided a statement and answered questions in a way which suggested to the Court that it was unlikely CPL Turner participated in the body recovery because he did not have permission to go outside the wire. The second is that MAJ AF ought not to have been instructed that there were matters he was not permitted to disclose in his evidence: that was a matter for a claim for public interest immunity. MAJ AF was under an obligation to tell the whole truth. An obligation, in my view, that he did not appear to understand or take seriously.
I was deeply troubled by the evidence of MAJ AF in relation to this issue. He should not have provided a statement which was designed to suggest that CPL Turner did not participate in a body recovery because he was not allowed outside the wire. It was misleading and eventually caused me to treat all his evidence in this Inquest with extreme caution. If there were matters which warranted a public interest immunity claim, it should have been made. I was particularly disturbed by his evidence that he had been told he was not permitted to disclose information to these coronial proceedings.
The associated line of questioning to Dr Sringeri about the possibility of CPL Turner’s mind inventing the body recovery is also concerning. It was either highly inappropriate or occurred because the Commonwealth’s own counsel was kept in the dark about this issue for a considerable time.
The messages recovered from CPL Turner’s phone appear to unequivocally demonstrate that CPL Turner suffered a serious decline in his mental health which he attributed to that incident and the bagpipes and ramp ceremony which followed it.431
CPL TJ’s evidence was that CPL Turner suffered a mental health episode after the body recovery. She said that CPL Turner stated to her that he had helped put the body onto a helicopter, that he was disturbed by seeing the body, and that he was distressed by the incident.432 CPL TJ stated he was just “quite nervous and couldn’t sit still. He kept sitting down, standing back up. He kept putting his head in his hands. He was just talking a lot about it … And then he was just getting real worked up”.433 She stated that CPL Turner was saying “it kind of brought up memories that he had from Afghanistan”.434
Professor McFarlane was asked about the body recovery in his oral evidence. He stated that “simply seeing another ramp ceremony is likely to be a very significant trigger to his distress” about the death of colleagues in the past.435
It is apparent that CPL Turner suffered a serious decline in his mental health consequent on that incident. He reported to each of CPL TJ,436 CAPT MH437 and MAJ BJ438 that he had relapsed, the major symptoms of which appeared to be drinking, anxiety, and insomnia.
(o) Relationship with CPL TJ
CPL TJ’s evidence was that it was just a few days prior to their deployment on OP OKRA.439 Her evidence was that their relationship was kept private for a while and after some time, people began to realise they were in a relationship.440
436 Exhibit 57 (WhatsApp and SMS messages) at 1318.
437 Exhibit 57 (WhatsApp and SMS messages) at 346.
438 Exhibit 31, Tranche 9 at 55.
Turner became increasingly jealous, suspicious, and agitated at CPL TJ. As is apparent from the expert evidence (discussed below), these behaviours can be associated with PTSD and coincided with the decline in CPL Turner’s mental health following his return to Australia at the end of 2016.
(p) Steroid use
The issue of steroid use by CPL Turner was raised by Joanna Turner in evidence, who stated that CPL Turner had “taken steroids to gain size”, which the “ADF was aware of”. She stated that he had begun taking steroids in 2015 following a shoulder reconstruction in order to regain strength.441 Joanna Turner’s evidence was to the effect that CPL Turner had said to her that the Commandos were “informed of when drug tests would happen and to stop taking what they were taking for a clean sample”.442
Joanna Turner’s evidence in relation to CPL Turner’s steroid use was borne out by the evidence in CPL Turner’s messages, which demonstrated CPL Turner had used steroids prior to the OP OKRA deployment444 and used it throughout that deployment.445 It also appears that he was able to access it in Iraq through his interpreter in Iraq whom he identified as “Big Hassan”.446
Joanna Turner’s evidence in relation to commandos having advance notice of when drug tests would occur was also borne out by the evidence, which demonstrated that on at least three occasions in 2016, CPL Turner had advance notice of a drug test.447
The evidence concerned me and I hope it is carefully reviewed by the Chain of Command.
(q) End of the Iraq deployment and return to Australia
442 Tab 6 (Statement of Joanna Turner) at 2 [9].
444 Exhibit 57 (WhatsApp and SMS messages) at 951.
445 Exhibit 57 (WhatsApp and SMS messages) at 952, 1904.
446 Exhibit 31, Tranche 1 at 262, 267.
447 Exhibit 57 (WhatsApp and SMS messages) at 951 (20 September 2016); 1792 (30 November 2016); 1856 (11 December 2016).
448 Tab 50 (ADF medical records) at 267-283.
for the deceased triggered disturbing memories of past trauma. He said he had a relapse of PTSD symptoms (previously treated for PTSD) and has since had greater difficulties with sleep because of nightmares of previous trauma. He reported no critical incidents on this deployment.”
Assessment by MO at TLHC to provide medical support if required. POPs with Psych at 3 months.”
CAPT KV’s notes of that RtAPS indicate that CPL Turner had reported he had planned to suicide during Iraq but denied current suicidal ideation.449 COL MF’s evidence was that this was not reported to him as CPL Turner’s commanding officer and that he should have been made aware of it.450
CAPT KV’s evidence was that it was not a “requirement” to pass this information on, he repeated the need for “individual confidentiality”, and stated that his recommendation was to have CPL Turner assessed upon his return to Australia, to “go through a comprehensive risk assessment” and “then make recommendations with regards to any command involvement”.451 CAPT KV’s evidence in this regard repeatedly sought to justify his actions by reference to the “policy” and “procedure” and the need for “comprehensive assessment”.452 He was adamant it was not necessary to report CPL Turner’s previous suicidal ideation because it was not a current ideation.453 CAPT KV was not able to identify the particular policy he was relying on in this regard. Nor was he able to cogently articulate why he did not report this back to the command structure beyond that he thought he had not done a “full assessment”.454
On 16 December 2016, CPL Turner was called for an RtAPS follow up, and it was noted that he declined a referral for ongoing psychological support, felt he could selfmanage, and that past psychological support was not helpful, he declined information on a PTSD treatment trial, and declined being on the RAP monitoring service.455
In late December 2016, CPL Turner moved to Waterloo into an apartment on his own.
449 Tab 50 (ADF medical records) at 273-274.
455 Tab 50 (ADF medical records) at 107. See also Tab 50A at 156-163.
Submissions regarding CAPT KV’s decision not to pass on information about CPL Turner’s disclosure of suicidal ideations while deployed Submissions of Counsel Assisting
Submissions of the Commonwealth
The Commonwealth notes456 that Counsel Assisting’s submission on this point should be rejected as the report “did not cross the threshold for non-consensual mandatory reporting”. This appears to be a reference to the Defence Health Manual (DHM) which permits disclosure of health information to “prevent a serious threat to life, health or safety or any individual.”457 This was a topic raised by the Commonwealth as an introductory matter in its submissions where it was noted that the ADF’s privacy policies attempted to strike a balance between a member’s right to privacy/confidentiality in respect of his or her health information and the needs of the Chain of Command to be aware of information relevant to “employability/deployability” of a member.458
As for criticism of CAPT KV’s role for the period between January and June 2016, the Commonwealth submits that CAPT KV, relying on CPL Turner’s clinical records, could not compel CPL Turner to have treatment and encouraged him to self-refer – the suggestion that the fact that he did not do so was itself a “red flag” is submitted to be “a clear manifestation of hindsight bias”.459 Submissions in reply of Counsel Assisting
In reply submissions,460 Counsel Assisting notes that an account to CAPT KV was given on 9 December 2016 and a note was made that CPL Turner “planned to suicide on his birthday last month after his daughter did not send him a birthday message” but that he denied current suicidal ideation.461 If CAPT KV had in mind the confidentiality 456 Submissions of the Commonwealth dated 7 June 2024 at [461].
457 Tab 50 at 96.
458 Submissions of the Commonwealth dated 7 June 2024 at [63]-[73].
459 Submissions of the Commonwealth dated 7 June 2024 at [295]-[299].
460 Submissions in reply of Counsel Assisting dated 22 August 2024 at [210]-[211].
461 Tab 50 at 273.
restrictions at this time, then a report of suicidal ideation within the previous month (along with the reports to CAPT KV of a relapse of PTSD as a result of trauma, and that CPL Turner was “unsure if he will experience reintegration difficulties”) would arguably meet the definition of “serious threat” in the DHM. Counsel Assisting accepts that CAPT KV’s evidence was that he did not consider he could disclose this ideation due to ADF policy and that it is a reasonable inference that he was referring to, but could not recall, that part of the DHM to which the Commonwealth refers to. Counsel Assisting notes that COL MF’s evidence was that he should have been made aware of the ideation.
Consideration
Once again, there is a distinct lack of curiosity in the care CPL Turner received.
Relevant events of January to July 2017
(a) Transfer from Bravo to Charlie Company
In around January 2017, CPL Turner was transferred from Bravo Company (B Company) to Charlie Company (C Company).
SGT NA’s evidence was that the posting out of B Company “angered him”. His view, however, was that CPL Turner had an “autocratic leadership style” and that “it just wouldn’t have worked” for him to stay in B Company, to have a “junior corporal” told to “Go tell Turns, you know he’s your 2IC now … Turns would tear him apart. It wouldn’t work”.462
MAJ AF’s evidence was that there was a “variety” of reasons for the move from B Company to C Company, including that there were too many NCOs in B Company and not enough in C Company and that it was considered that CPL Turner would undermine the senior NCOs and Chain of Command in B Company when he returned 462 Tab 14 (IGADF ROI with SGT NA on 14 August 2018) at 114.
(as a Corporal) because he was “so influential”.463 MAJ AF’s evidence was that he did not want CPL Turner moved, but it was the CO’s decision along with the RSM, and in hindsight, he agreed it was a good decision.464
COL MF (i.e., the CO) stated in his ROI in response to being asked to explain his reasons for moving CPL Turner from B Company (where his support network was) to C Company, “as the CO I have to look at – I have obligations to the individuals. I also have obligations to the organisation, and also very much to the capabilities that I am mandated to maintain”.465 COL MF also considered that it was “untenable” that CPL Turner, who was considered an “extremely influential member of that [B] Company”, to then be reduced in rank and have a sergeant, “in effect, command him”, being a sergeant who would have previously been more junior than CPL Turner.466 Additionally, COL MF considered that B Company was “going to go back onto war roles” (a “very demanding component of their cycle”) whereas C Company was going to be in “supporting courses” and other supporting roles.467 COL MF considered that this would “give [CPL Turner] a bit more time to sort himself out”.468 COL MF stated in his ROI that he stood by his decision: “every decision that I made with regard to Turner along the way, and I’ve had plenty of time to think about. My responsibility is not only [sic] to the balancing act between the individual and organisation ... I did everything I could in both sense for him, particularly a decision to move him out of that company”.469 He noted that towards the end of the year there were “positive reflections through the Chain of Command about what his move had actually done”, allowing “capability to advance”.470
COL MF’s oral evidence to the Inquest was substantially aligned with his statements to the IGADF. What emerged from the lengthy oral evidence was that the decision to move CPL Turner from B Company to C Company was based solely on the “effective delivery of capability”.471
It is difficult to discern from COL MF’s oral evidence that any particular consideration was given to CPL Turner’s mental health history, the experiences he had in Iraq and the potential impact of those experiences on his mental health, and the potential impact on his mental health of the move from B Company to C Company. There was no 463 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 28.
464 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 29.
465 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 14.
466 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 17.
467 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 18.
468 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 18.
469 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 33.
470 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 33.
evidence that COL MF had inquired about CPL Turner’s mental health subsequent to the disciplinary proceedings, either with CPL Turner directly or with anyone deployed with him. COL MF admitted that he did not even turn his mind to whether the decision would have an adverse impact on CPL Turner’s mental health.472 At base, the decision was made with “capability” at the front of mind, not the interests of CPL Turner.
WO1 EL gave a slightly different explanation of the process of moving CPL Turner from B Company to C Company. He stated that he worked “as a command team” with COL MF, and that COL MF was: 473 “obviously very distressed about the reputation damage that had been caused not only to B Company but 2 Commando Regiment, Special Operations Command and the whole of army. It was not a good look. COL MF questioned whether now CPL Turner had been protected within B Company …. And whether it would be best for him to be moved to another Company for a fresh set of eyes, some supervision and to be honest the CO, COL MF, was also concerned that perhaps Ian had a stifling effect on the other NCOs within Bravo.”
He concluded, however, that it was “very complicated” and that was “the decision we came to and I backed the commanding officer a hundred per cent, as is my job”.474 He did not recall any other NCOs being moved at the same time.475
WO2 DP stated that he spoke to WO1 EL at the time the decision was being made and said that this will be seen as “another punishment”, and that the RSM “initially sort of agreed with me” that CPL Turner should not be moved from B Company. The decision was ultimately made to move CPL Turner. WO2 DP stated that he believed the “CO and RSM had the best intentions …and wanted to remove Ian from Bravo Company to try and alleviate some of that influence he had on us because now – Ian was very jaded at this point about the whole process and his dealings”.476
Mr Nick Hill, who had previously served alongside CPL Turner (but subsequently discharged) stated that, in his view, “moving one person from a company to another, is one of the worst things you can do to them” because when you “get moved to another company, it’s like you’re taken away from your home”.477 He explained:478 “Guys like [CPL Turner] who did four or five tours overseas and deployments, who trained as private soldier and worked his way up to a sergeant, you know, in the one company that’s a long time, and then if you take them away from that it doesn’t do them any good, especially if they have things going on, because they need to be part of their home and the company is their home, because that’s where they feel the
473 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 16.
474 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 17.
475 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 17.
476 Tab 24 (IGADF ROI with WO2 DP dated 5 July 2018) at 27.
477 Tab 28 (IGADF ROI with Nick Hill dated 18 September 2018) at 19.
478 Tab 28 (IGADF ROI with Nick Hill dated 18 September 2018) at 20.
safest. You know, you’re talking about guys who have done some pretty horrific things in their time and taking them away from that, they’ve got nothing. They might know guys in that company that they go to, but they don't have the same experience.”
Hannah Steele described the effect of the move on CPL Turner as “[d]emotivating, definitely made him more and more depressed; his self-worth was destroyed”. She said CPL Turner said that he felt he was being punished by the ADF.479
The decision to move CPL Turner was made while he was posted overseas. It was notified to him via his Chain of Command whilst he was overseas.480 MAJ AF’s evidence was that he had the conversation about the transfer and that he gave CPL Turner the “context as to why it was taking place, reaffirming with him that it was not a continuation of a punishment, it was a cultural and organisation decision being made by the regimental leadership about how we manage NCOs across the regiment, and that it wasn’t about him in particular”. 481
CPL TJ’s evidence was that CPL Turner very much connected the move from B Company to C Company to the charge, and that he believed it was “part of the unit’s reaction to the charge”.482
(b) Effect of the company move on CPL Turner’s mental health
It is readily apparent that CPL Turner viewed the movement from B Company to C Company as a form of further punishment for the cock-carding incident. For example, LCPL DL stated in his ROI that “I think he thought it was a continuation of punishment…he went downhill pretty quick after this charge and I think he was disillusioned and probably a bit upset with an organisation he’d given his youth to and he’d worked so hard to be a leader in, all of a sudden he’s a subordinate to people who are nowhere on his level as an operator, as a commander”.483
LTCOL SW, who visited CPL Turner after his second suicide attempt, stated that CPL Turner talked about the night that Damien Thomlinson lost his legs, his loss of rank, and the fact he had been moved companies when he returned back to Australia.484
CPL JW gave evidence in his ROI that it appeared that “once he got sort of taken away from that support system [B Company] and what he knows he started to decline”.485 479 19/10/20 at T34.4-10.
483 Tab 21 (IGADF ROI with LCPL DL on 14 August 2018) at 9-10.
484 Tab 22 (IGADF ROI with LTCOL SW on 11 December 2018) at 14.
485 Tab 20 (IGADF ROI with CPL JW on 5 June 2018) at 16.
CPL TJ stated that CPL Turner “didn’t appreciate the no warning about this move and it just trifled with his emotions again…he just was conspiring against this ultimate meltdown of the hierarchy because they didn’t give him any respect, to tell him…he felt he was getting double-tapped not only from what happened with 633 [i.e. the disciplinary proceedings] but also back here in Australia at the unit and that just broke him, it broke him”.486 CPL TJ stated CPL Turner did not get any “forewarning that the change was going to happen, not from his CO or his OC who had made the decision”.487
COL MF’s evidence was to the effect that if he had been made aware of the resumption of symptoms in CPL Turner in December 2016, and January 2017, it would not have impacted on his decision to move CPL Turner from B Company to C Company.
However, he would have provided more “mental health scaffolding around him”.488
(c) Relationship with Joanna Turner and the children
487 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 17.
489 Exhibit 31, Tranche 9 at 23.
490 Exhibit 66 (Response to questions posed to MAJ MH) at 7.
491 Exhibit 31, Tranche 9 at 37.
492 Exhibit 31, Tranche 9 at 50.
493 Exhibit 57 (WhatsApp and SMS messages) at 136.
him. CPL Turner blamed Joanna Turner for that and attempted to see ET at school.
ET was frightened and the family moved to the Sutherland Shire and ET changed schools in the hope that CPL Turner would be unable to find them.495
(d) Mental health in early 2017
On 9 January 2017, CPL Turner was called by Ms Sullivan from Tobruk Clinic for a telephone review. He reported a difficult Christmas with no access to his daughter, anger at the SOCOMD 2CDO hierarchy’s treatment of him, that he planned to undertake a PhD in Canberra and have respite from SOCOMD and deployments, that he had “continuing fleeting thoughts of suicide” mostly when he had arguments with his ex-wife but had “no intent or plan”, and that he requested a referral to Dr Sringeri.496
COL MF stated in his ROI that when CPL Turner returned from Iraq just before Christmas, although he was tracking “the disciplinary issues”, he was not “tracking mental health issues at that point”, because CPL Turner had “got a waiver to deploy and there’d been no sort of significant red flags”.497
CAPT MH stated that he had developed a “close relationship” with CPL Turner from 2014 and that he “knew that he wasn’t coping with what had occurred in Iraq”. He stated that CPL Turner was viewing everything that happened after the disciplinary proceedings as punishment.498
On 23 January 2017, CPL Turner was contacted again by Ms Sullivan from Tobruk Clinic for a telephone review. CPL Turner reported that he had been to Canberra for a PhD interview at ANU and had been offered a spot, but he needed to discuss study approval with his Chain of Command. He stated that he had booked psychiatric review with Dr Sringeri and that the earliest appointment was 4 May but he was on the cancellation list. CPL Turner stated that he did not want to engage in psychological counselling at the time and that he felt he was “well enough”.499
Christine Turner stated that CPL Turner sent her a message on 18 February 2017 stating:500 “It just hurts that my lifelong dream and my dream job was the very thing that destroyed me. I tried to take on too much pain and protect my guys too much. I should’ve shared the pain more but with my PTSD, anxiety, depression and alcohol 495 Tab 32 (IGADF ROI with Joanna Turner dated 15 August 2018) at 55-56. See also 20/10/20 at T84.
496 Tab 50 (ADF Medical records) at 107.
497 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 18.
498 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 13.
499 Tab 50 (ADF Medical records) at 106.
500 Tab 34 (IGADF ROI with Christine Turner on 21 August 2018) at 13.
dependency I’ve just had enough. I spent seven years of my life overseas fighting cunts. I’ve had enough.”
CPL TJ’s evidence was that she was never contacted about that meeting by either the CO or RSM.501
CPL Turner attended on Dr Sringeri on 22 February 2017 for an urgent review with an apparent relapse of PTSD symptoms.502 On 27 February 2017, Dr Hale saw CPL Turner and recorded that CPL Turner would require close supervision and crosschecking for tasks requiring high focus such as parachute packing. A letter from Dr Sringeri to Dr Hale at Tobruk Clinic reported significant and serious PTSD symptoms.503
On 2 March 2017, CPL Turner attended a follow-up review by Dr Hale, and admitted to suicidal thoughts over a long period of time. He was prescribed diazepam and Dr Hale reported putting in place “crisis counselling” which involved calling the padre or going to St Vincent’s Hospital. A psychiatrist appointment was booked for the following day.504
On 3 March 2017, Dr Hale saw the letter from Dr Sringeri dated 24 February 2017.505 On that day, Dr Reppas emailed Ms Cantwell, recommending that CPL Turner be downgraded to MEC J31 and stating he assumed the unit will conduct daily welfare checks.506
A medical note made by CAPT KV on 3 March 2017 indicated that the COC would be informed of the change in CPL Turner’s risk status.507 COL MF gave evidence that he was not informed on that day of any change in CPL Turner’s risk.508 The evidence was ultimately that the information was passed on to the acting OC at the time and he did not pass it on to COL MF because there was a UWB on the following Tuesday. The acting OC was issued with a NTSC in relation to this incident. COL MF’s evidence was therefore that the lack of communication has been “identified by the ADF and dealt with”.509
502 Tab 111 (Statement of Dr Sringeri dated 25 September 2020) at 10.
503 Tab 111 (Statement of Dr Sringeri dated 25 September 2020) at 92-93.
504 Tab 50 (ADF Medical records) at 103.
505 Tab 50 (ADF Medical records) at 304.
506 Tab 50 (ADF Medical records) at 102.
507 Tab 50 (ADF Medical records) at 102.
(e) The PhD proposal
The Inquest heard evidence in relation to a proposal by CPL Turner to undertake a PhD, along with a placement at a government Department. Hannah Steele gave evidence that the PhD proposal was “the one thing” that CPL Turner got excited about and that CPL Turner had planned to do the PhD out of a university in Canberra.511
Hannah Steele gave evidence that the PhD proposal was raised at a “welfare meeting”, which she later described as a welfare board,512 at which the CO, Matthew Cardinaels, Carmel Poulter, the RSM, and CAPT KC as well as some doctors were present. She described the CO as “scoffing” at the PhD proposal and that it was “mentioned and it was just – whether he said, yeah, we’ll think about it, we’ll talk about it later, it was given no air time”.513
MAJ JP spoke to the IGADF and confirmed that he was involved in a proposal for CPL Turner to undertake a PhD. He stated he had discussions with CPL Turner regarding a PhD at the end of 2016 to “give him something to look into for his future and give him options”. MAJ JP arranged for CPL Turner to speak with a potential supervisor and discussed the matter with CPL Turner’s Chain of Command. He stated his understanding was that the proposal was not supported by 2CDO.514 CPL TJ confirmed in her ROI that MAJ JP had been in touch with CPL Turner, that they took the proposal to Mr Cardinaels who supported it, but then the “CO turned around and said no, because of his admin infraction that he wasn’t going to support it”.515 CPL TJ indicated that the CO “shut it down” and then CPL Turner pretty much gave up on it.516
COL MF stated in his ROI that he could not recall how the issue of CPL Turner wanting to study had come to him, but he “was aware of his intention to conduct study” early in
COL MF stated that he did not support the PhD proposal “by virtue of the disciplinary issues that were associated with Turner” and he was concerned about “reputation damage for army” because the proposal came up as part of an out510 22/10/20 T25-30.
514 Tab 25 (IGADF ROI with MAJ JP on 17 December 2018) at 1.
515 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 21.
516 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 21-22.
placement with another government agency.517 He also maintained it was not a “formal” proposal to do study and it was the “out-placement component” which he was not supportive of which was “pitched as part of the concept”.518 He accepted he did not make any inquires as to CPL Turner’s mental state or psychiatric well-being at the time he made this decision.519 He placed this decision as being made before CPL Turner’s first suicide attempt.520 There was no evidence to suggest that COL MF had indicated to CPL Turner that he was supportive of the PhD proposal on its own (just not the outplacement). CPL TJ’s evidence was that if CPL MF had done so, that would have been something they could have worked towards.521
(f) First suicide attempt and March 2017 admission
On 6 March 2017, CPL Turner was reviewed by psychologist Andrea Cantwell following a psychiatric consultation on 2 March 2017.523 He denied thoughts of suicide and declined hospital admission.524
It is apparent from the text messages between CPL Turner and CPL TJ that he was in a heightened emotional state and took this out in various ways on CPL TJ throughout the course of the evening by way of text messages which were aggressive, manipulative, and demeaning of her. Towards the conclusion of a long series of messages between CPL Turner and CPL TJ, he stated “I’m going to be unconscious very Soon. Hopefully I don’t wake us [sic] I wish you had called Goodbye”.525 CPL TJ was outside his house at the time trying the buzzer and, ultimately, he let her up into the apartment.526
CPL Turner had attempted suicide by consuming a large amount of alcohol and overdosing on prescription medication. He was admitted to St Vincent’s Hospital.527 517 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 30.
518 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 31.
522 10/08/21 T71.33-34. See also 11/08/21 T8.39-40.
523 Tab 50 (ADF Medical records) at 101-102.
524 Tab 50 (ADF Medical Records) at 102.
525 Exhibit 57 (WhatsApp and SMS messages) at 2443.
526 Exhibit 57 (WhatsApp and SMS messages) at 2444.
527 Tab 50 (ADF Medical Records) at 45.
CPL Turner tested positive for cocaine in his system after this overdose.528 WO1 EL stated that he was made aware that toxicology had been taken of CPL Turner’s bloods and it indicated there was a prohibited substance there and that a decision was to hold any future administrative action until CPL Turner was mentally stable because he was not “going to dump that on him as well”.529
On 7 March 2017, CPL Turner was discharged from St Vincent’s Hospital to Holsworthy Health Centre.
On 8 March 2017, CAPT KV prepared a “Comprehensive Assessment and Management Plan”, recording that CPL Turner had thoughts of suicide. In a section entitled “estimation of risk”, CAPT KV assessed CPL Turner as “low risk”.
On 8 March 2017, CPL Turner was transferred to the inpatient mental health unit at SSPH. Dr Sringeri’s notes in relation to the admission record that CPL Turner’s PTSD was “rekindled about 18 months ago” and that he had been drinking excessively to manage PTSD and depressive symptoms. His “current issues” were listed as “PTSD - reliving experiences, mood swings, irritability and anger, panic attacks”.
On 15 March 2017, CPL Turner absconded from SSPH. He messaged CPL TJ and informed her he was drunk. She told him to go back to the hospital. It appears she and the Padre subsequently located CPL Turner and took him back to SSPH.530
In late March 2017, CPL Turner made a claim to DVA for compensation. He listed his injuries which included “major depression” and “suicidal behaviour” and identified that his symptoms were first suffered in 2009.531
On 29 March 2017, CPL Turner was discharged from SSPH. A copy of the discharge summary prepared by Dr Sringeri was sent to Dr Hale. The discharge summary notes (inter alia):532 “[CPL Turner] was transferred from St Vincent's Hospital Sydney, where he was admitted with the history of taking an overdose of multiple prescription medications under the influence of alcohol.
[He] reported witnessing a significant trauma during his deployment to Iraq in relation to finding human remains of an US Marine. The above said trauma has rekindled the memories of the traumas he has experienced during his previous deployments. He also reported experiencing a setback in his study of that (sic) he was demoted interrelation (sic) to a minor mistake and he with (sic) extremely disappointed for the 528 Tab 50 (ADF Medical records) at 94.
529 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 32.
530 Exhibit 57 (WhatsApp and SMS messages) at 2512-2514; Tab 50 (ADF Medical Records) at 96.
531 Tab 60 (DVA Medical Records) at 45ff.
532 Tab 54 (Sydney SW Hospital - March 2017 admission) at 3-5.
same. He reported experiencing significant distress in relation to divorce proceedings and child custody issues.
He reported experiencing intrusive memories, flashbacks and nightmares of trauma.
He reported experiencing intrusive and recurrent flashbacks and memories of decomposed human remains and the smell of decomposed human body. He reported experiencing mood swings, irritability and anger. He described episodes of panic attacks related to reliving experiences of PTSD. He reported experiencing persistent anxiety, agitation and tremulousness. His sleep was disturbed due to nightmares. He also reported having frequent arguments with his girlfriend.
….
On 19 March 2017 he was found to be extremely angry, irritable and physically aggressive in relation to constant phone calls and message from his ex-wife (sic) legal team.”
Under the heading “state on discharge” it was stated that CPL Turner had achieved considerable improvement in his depressive symptoms and moderate improvement in his PTSD symptoms. The discharge summary noted that Dr Sringeri would review him on 13 April 2017.533 On the day of discharge, CPL Turner was reviewed by Dr Hale.
In early April 2017, CPL Turner returned to work and was placed under the daily supervision of the 2CDO Human Performance Wing (HPW) and Mr Cardinaels, who was the leader of that wing.534
CAPT MH stated in his ROI that at this stage, C Company was deployed and, in his view, “[CPL Turner] was just running his own show, from what I could see”.535
(g) Second suicide attempt and April 2017 admission
On 1 April 2017, CPL Turner failed to attend a medical appointment which had been scheduled for that day. When contacted, he advised that he was well and there was a problem with his base access pass.
CPL Turner continued to engage in what can be described as controlling behaviour of CPL TJ through this time. On 11 April 2017, he engaged in a long series of messages accusing CPL TJ of having been unfaithful and lying to him. CPL TJ asked CPL Turner to bring her house key downstairs to her. He responded with a claim that she had been dishonest and then ceased messaging her.536 He subsequently attempted suicide by overdosing on prescription medication. He was admitted to St Vincent’s Hospital.
533 Tab 54 (Sydney SW Hospital - March 2017 admission) at 5.
534 Tab 15 (IGADF ROI with SGT MC on 5 June 2018) at 3-4.
535 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 20-21.
536 Exhibit 57 (WhatsApp and SMS messages) at 2698.
On 21 April 2017, CPL Turner was transferred to SSPH. Later that day, he absconded from the hospital.537
Hannah Steele’s evidence was to the effect that CPL Turner was at his apartment with police. Hannah Steele stated that she, Steven Turner, LCPL DL, and CPL Turner’s family had decided on a plan involving staying with CPL Turner all weekend, with CPL Turner to return to work on Monday. Hannah Steele’s evidence was that she heard a phone call in which CAPT KV called CPL Turner and was abusive to him.538 Hannah Steele gave evidence that she witnessed CAPT KV calling CPL Turner on the phone, in front of Steven Turner, after and berated him over the phone with “lots of F’s” and “really inappropriate language”, and that CPL Turner “hated” CAPT KV after this.539 She acknowledged that she could not hear the full conversation, but could hear that there was an “aggressive person on the other end”, and all she could remember were “lots of F’s and that was it”, and that Ian was becoming “upset” as a result of the conversation.540
CAPT KV stated that this conversation did not happen. He stated he would never have berated or had that kind of conversation with a member.541
Steven Turner gave a further statement with detail about the conversation with CAPT KV, including that CAPT KV was swearing and shouting at CPL Turner.542 CAPT KV put on a responsive statement denying that this had occurred.543 Submissions regarding the phone call between CAPT KV and Steven Turner Submissions of Counsel Assisting
During the final tranche of hearing days, then-Senior Counsel Assisting made an oral submission that neither Steven Turner nor CAPT KV needed to be recalled to deal with the evidence as to what happened, noting they both gave evidence about it and made their position clear in that evidence. It remains the position of Counsel Assisting that it was not necessary to recall either CAPT KV or Steven Turner. It is submitted, however, that having regard to all the evidence, a finding about what happened can be made.
The evidence is relevant as it relates to the therapeutic relationship that CPL Turner had with CAPT KV, who was his clinical case coordinator. That being said, it should 537 Tab 50 (ADF Medical Records) at 29.
538 Tab 8 (Statement of Hannah Steele) at 3 [14].
542 Exhibit 49 (Statement of Steven Turner dated 11 August 2022) at 5-6.
543 Exhibit 60 (Supplementary Statement of CAPT KV dated 16 December 2022).
be clear that the submission of Counsel Assisting is not that this interaction had any causative effect on CPL Turner’s declining mental health. It is simply relevant as evidence of the relationship between him and one of his treating clinicians.
Submissions of Mr and Mrs Turner
Mr and Mrs Turner submit that the delay between the service of the brief and the provision of Steven Turner’s statement can be explained by Mr Turner’s service-related PTSD issues which “resurged” following CPL Turner’s death and that it was not until later when he was well enough to engage with the coronial proceedings that he realised that CAPT KV had denied that the abusive phone call had ever occurred.545 On this point, Counsel Assisting cautions that the submission is passed on instructions rather than evidence before the Inquest and should, therefore, not form the basis of a finding.546
In relation to the text message between CAPT KV and Steven Turner and the Commonwealth’s position that “one text message does not define a relationship”, Mr and Mrs Turner refer to other contemporaneous records that support a finding that CPL Turner did not view CAPT KV positively.547
Furthermore, they strongly support Counsel Assisting’s submission that the phone call with CPL Turner in fact occurred given that CAPT KV was unable to respond to over 544 Exhibit 57 (WhatsApp and SMS messages) at 3119.
545 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [58(a)].
546 Submissions in reply of Counsel Assisting dated 22 August 2024 at [107].
547 Tab 50 at 81; Tab 56 at 59; Tab 18 at 28-29.
50 questions during the Inquest because of an inability to recall events and the fact that he only vaguely remembered CPL Turner’s escape (the same night as the alleged phone call). They also agree that neither Hannah Steele nor Steven Turner had a motive to be untruthful about the existence of the call.548 Submissions of the Commonwealth
The Commonwealth submits that Counsel Assisting’s invitation to prefer the evidence of Steven Turner to that of CAPT KV “effectively” seeks a finding that CAPT KV lied to the Court. Accordingly, it is submitted that the rules of procedural fairness required CAPT KV to be recalled to give oral evidence for it to be put to him that he “lied” in his statement. Aside from procedural fairness, it is submitted that such a finding is unnecessary and insufficiently supported by the evidence in any event; the Commonwealth sets out in detail the evidence that it submits weighs against such a finding.549 Submissions in reply of Counsel Assisting
Counsel Assisting considers that the Commonwealth’s objection on procedural fairness grounds ought to be rejected.550 The question as to whether this conversation occurred was put to CAPT KV multiple times551 and he denied it multiple times, including in a further statement given in circumstances where he was on notice that Steven Turner had made a statement alleging that the conversation did occur. The suggestion of the Commonwealth appears to be that the dictates of procedural fairness required CAPT KV to be recalled in order for Counsel Assisting to say “I put to you that you are lying”, and so, presumably, he could repeat what he said in oral evidence “I am telling the truth”552 and what he said in his statement “This statement is true”.553 Counsel Assisting highlights that the rules of procedural fairness are concerned to avoid practical injustice.554
On that basis, Counsel Assisting notes that practical and substantive fairness was afforded to CAPT KV: the allegation was put to him, and when a further statement was prepared by Steven Turner making the same allegation, CAPT KV had the opportunity (of which he availed himself) to put on a written statement addressing that allegation.
548 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [59]-[62].
549 Submissions of the Commonwealth dated 7 June 2024 at [531]-[545], [548].
550 Submissions in reply of Counsel Assisting dated 22 August 2024 at [229]-[231].
553 Exhibit 60 at [1].
554 Re: Minister for Immigration and Multicultural and Indigenous Affairs; Ex parte Lam (2003) 214 CLR 1; [2003] HCA 6 at [37]- [38].
That is sufficient to reject the suggestion by the Commonwealth that CAPT KV was not on notice that an adverse finding might be made in this regard.
Consideration
I do not accept that there is procedural unfairness in deciding this issue. I am aware of the differing accounts given by CAPT KV, Steven Turner, and Hannah Steele on this issue. CAPT KV was well aware of the allegation that he berated CPL Turner on the telephone at a time when CPL Turner was particularly vulnerable. CAPT KV strenuously denied the conversation, although he had significant memory deficits about other events which occurred around that time.
I have considered the matter carefully and prefer the evidence of Steven Turner and Hannah Steele on this issue. I accept the reasons for the delay in Steven Turner providing his account. His version is largely corroborated by the evidence of Hannah Steele. I also accept that Steven Turner’s account does not seem to be out of keeping with other contemporaneous evidence about the relationship between CAPT KV and CPL Turner.
Returning to the evidence, CAPT MH stated that he went to the house with LCPL DL and met Mr Cardinaels outside the apartment. He said that he and LCPL DL “managed to talk Ian into admitting himself into the facility” and that Mr Cardinaels took CPL Turner and Steven Turner to the hospital where he checked himself in.555
CAPT MH stated in his ROI that on 23 April 2017, he went to visit CPL Turner and CAPT KV was there, and CPL Turner was “highly agitated” and didn’t want to talk to CAPT KV, and it got to the point where CAPT MH stated “get the fuck out of the room” 555 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 28.
because “you’re not helping”.556 CPL Turner stated to CPL TJ that he had an altercation with the CO on 23 April 2017.557
He Is currently admitted to the Liverpool PECC unit, and will require transfer to your facility.” The provisional diagnosis was stated to be: “Suicidal attempt by polypharmacy”
Hannah Steele’s evidence was to the effect that CPL Turner disliked being at SJoGH and that his program was being updated “without his input”.559
COL MF stated in his ROI that he went out to discuss his care with the health team, but that CPL Turner had stated that “he did not want to see the chain of command”.560 Dr Malik stated that CPL Turner did not want the content of his consults to be released to the ADF and that he was very distrustful of the ADF.561
On 25 May 2017, CPL Turner was discharged from SJoGH. The discharge summary recorded that CPL Turner did not want an extension of his stay and agreed to follow up as an outpatient. It recorded that he was “unfit for duties, considering medical discharge”.562 It appears that Dr Malik was under the impression, from CPL Turner, that Patricia Turner would be staying with him after he was discharged.563 That impression was incorrect and Dr Malik confirmed in his oral evidence that he was relying on what CPL Turner said to him but that, in any event, his mother being there would not have “cure[d] anything” and he could still have avoided her and isolated himself.564 556 Tab 18 (IGADF ROI with CAPT MH on 5 June 2018) at 29.
557 Exhibit 57 (WhatsApp and SMS messages) at 2729.
558 20/10/20 at T118.28-50.
559 Tab 8 (Statement of Hannah Steele) at 3 [16].
560 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 22.
561 Tab 112 (Statement of Dr Malik) at 4 [26].
562 Tab 56 (St John of God Records) at 43.
563 Tab 112 (Statement of Dr Malik) at 17 [110].
(h) The rehabilitation plan
There was some evidence in the Inquest about CPL Turner’s “rehabilitation plan” during the course of 2017. Hannah Steele stated in her statement that during this time all she knew CPL Turner was doing was “going to the gym and drinking at the Moore Park View Hotel”.565 In her oral evidence, she said that CPL Turner had voiced to her that he did not have an engaging rehab plan: “It was, like guitar, gym, coffee with friends” and he felt he “could have actually been doing something a little more valuable with the skills and knowledge he had”.566
The Rehabilitation Plan produced to the Inquest by APM, the external rehabilitation provider used by the ADF, identified little more by way of activities than the gym and medical appointments.567 Mr Cardinaels was asked about this, noting the evidence was that at least up until 10 July 2017, CPL Turner’s apparent “goal” was to return to work. He could not recall any return-to-work program which was put in place for CPL Turner.568
Ultimately, the evidence before the Inquest left the distinct impression that there was no real plan put in place, when CPL Turner was released from hospital on each occasion, as to what he would be doing each day or how he would be working towards a situation where he either returned to work as a Commando, returned to work in the ADF in a different capacity, engaged in some further study, or discharged and transitioned to civilian life. As Professor McFarlane emphasised in his oral evidence, this was “critical”: CPL Turner had a lot of capacity and if he was no longer deployable, that should not have been considered to be the end of his military career. He emphasised: “it’s about then (sic) how you transition that person into roles and for the ADF to identify roles to which people can be transferred, where they can maintain their respect, they retain their membership of their units”.569
(i) June to July 2017
On 19 June 2017, CPL Turner undertook a trip to the Gold Coast for around 5 days to attend a memorial for CPL Baird.570
On 28 June 2017, CPL Turner obtained his assistance dog, Lucky.571 565 Tab 8 (Statement of Hannah Steele) at 4 [20].
566 19/10/20 at T34.19-23.
567 Exhibit 34 at 146 (Rehabilitation Schedule for 3 to 7 July 2017).
570 Tab 50 (ADF Medical Records) at 67.
571 Tab 50 (ADF Medical Records) at 66.
On 28 June 2017, Mr Cardinaels emailed Carmel Poulter, the APM Rehabilitation consultant, copying CAPT KV, with the subject line “Ian daily program update” setting out a weekly schedule for CPL Turner, in the following terms:572
It appears that around 2 July 2017, CPL TJ and CPL Turner commenced a break in their relationship.573 CPL TJ stated in her ROI that she said to CPL Turner “I just need a break”, she had told him that they needed to “take some space but it was just like with that it was kind of more to motivate him to be like get healthy”, and that they were still catching up regularly.574
On 4 July 2017, CPL Turner attended an appointment with Dr Jessica Swain, psychiatrist.575
On 6 July 2017, CPL Turner reported to Dr Hale that he was struggling and overwhelmed and reported an incident where he had punched a patron of a pub for allegedly assaulting his companion dog.576
On 7 July 2017, a welfare board was conducted. The minutes suggest it was attended by (inter alia) COL MF, WO1 EL, WO2 MM, CAPT SW and CAPT KV.577 However, notes taken indicate that at least Dr Hale and Mr Cardinaels were also present.
572 Exhibit 31, Tranche 5 at 21.
573 See Exhibit 57 (WhatsApp and SMS messages) at 1861.
574 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 26-27.
575 Tab 50 (ADF Medical records) at 16.
576 Tab 50 (ADF Medical records) at 15.
577 Tab 38 (Welfare Board Minutes) at 16.
Dr Hale submits that he was not, in fact, present at the UWB, noting that the minutes indicate that the medical officer present was “CAPT SW”578 and that the references to what it is noted he said in the “other stakeholder comments” are attributable to either CAPT SW, Dr Reppas, or CAPT KV.579 In support of this submission, Dr Hale refers to the evidence that this welfare board was an Individual Welfare Board (IWB) (where two officers and a NCO were listed as present) and not a UWB (where those two officers and NCO were not listed in attendance).580
Counsel Assisting submits that the references to Dr Hale’s opinion under the “other stakeholder comments” and the reference to Dr Hale responding to a question from the CO who “rang in” further supports a finding that Dr Hale was present at the UWB.581
On the face of the minutes document, I accept it is more likely than not that Dr Hale was present.
The notes indicate that COL MF was unhappy that the overdose or the dissociative episode which CPL Turner had was not reported to him earlier. The notes report that the CO “wants a way forward”, he “wants the mbr to parade at work every day and his plan/program needs to be gripped up”, he wanted a “rolling roster for the next 72 h for contact with the mbr when he is not parading at HPW”, CPL Turner was to be on a “directed rehab plan and not an agreed plan”, and the CO “needs to know immediately if he misses an apt”. It also appears that a proposal for CPL Turner to go on leave to his family was discussed but that it was considered that he would “not benefit going on leave to his family given that there is a tendency to drink with his brothers”.582 COL MF apparently “acknowledge[d] issues with family” and said that “before any leave given an assessment will need to be made before leave is approved”.583 CAPT KV later sent an email to COL MF setting out the names of individuals who were going to spend the weekend with CPL Turner and advising that he had spoken to the Padre and the Padre was going to tell CPL TJ not to contact CPL Turner.584
CPL TJ’s evidence was that she recalled being told not to speak to CPL Turner because the Padre said it was “the best for Ian” and that she agreed but did not 578 Tab 38 (Welfare Board Minutes) at 16.
579 Submissions of Dr Hale dated 31 May 2024 at [21].
580 Submissions of Dr Hale dated 31 May 2024 at [22].
581 Submissions in reply of Counsel Assisting dated 22 August 2024 at [133]-[134].
582 Tab 38 (Welfare Board Minutes) at 18.
583 Tab 38 (Welfare Board Minutes) at 20.
584 Tab 50 (ADF medical records) at 62.
ultimately comply with what the Padre had said, and still contacted CPL Turner when he contacted her.585
On 7 July 2017, CAPT KV sent an email to Dr Swain reporting that “there has been a turn of events with Ian and new information that came to us only last night and this morning. Ian admitted to OD on prescribed medication and drinking heavily over the weekend, which explains the loss of memory”. It recorded that “we have a safety plan in place for the next 72 hours and a more controlling rehab plan for the next month” and that CPL Turner would have a “battle buddy with him at all times over the next 72 hours”.
On 10 July 2017, Dr Malik wrote to Dr Hale stating that “Ian was reviewed today and he reports he has curtailed use by self…his flashbacks and nightmares remain and he feels helpless…he is unfit for work of any kind and I will recommend a medical discharge”. The report further recommended that CPL Turner “not to drive in the morning if he feels sedated from the previous night medications” and that “[w]ork itself has become a trigger and he relives traumas when he is exposed to it. I will recommend that until he is discharged from army for him to attend doctor’s appointments on base after 10am”.586
Dr Malik’s evidence was to the effect that CPL Turner disclosed to Dr Malik that he had been drinking. Dr Malik indicated that he stated that he would prefer that CPL Turner be admitted to hospital, but CPL Turner declined.587 CPL Turner had also stated to Dr Malik that attending work had caused him to be triggered by seeing uniformed people. Dr Malik stated that he wrote the letter because he wanted the ADF to “engage him a bit different … give him, you know, time to attend”.588 He was asked why he did not contact Dr Hale to put into place a protective structure around this trigger and Dr Malik indicated that he “wrote a letter” and “that’s up to them”.589
Dr Malik’s last interaction with CPL Turner was on 10 July 2017. His evidence was that CPL Turner gave him (Dr Malik) no reason to think he was suicidal – he had engaged with him on the Friday (7 July) and Monday (10 July) and he said he was not suicidal.590
On 10 July 2017, medical notes made by Dr Hale record that “given current risk level, member is to be directed for inpatient care to ensure safety”, that “refusal to enter 585 12/08/21 39.27-42.
586 Tab 112 (Statement of Dr Malik) at 20.
inpatient service to be grounds for DFDA action”, and that “failure to remain within an inpatient facility to be grounds for DFDA action”. It also stated that a “contract” was to be written up “detailing all aspects of the members agreed upon plan” with the “consequences of failing to meet required taskings” being “DFDA action”.
COL MF stated in his ROI that everybody [i.e., in 2CDO] “100 per cent was committed to” providing care for CPL Turner through welfare boards, arrangements for picquets, and trying to track him down when he left in-patient care. COL MF stated “it became apparent quite quickly that he was not fulfilling his side of the bargain”. As a result, a decision was made by COL MF that “he is to report at the unit…he is to do everything through the unit because what he agreed to as part of his, in effect, his rehab and welfare plan, he was not living up to”.591 COL MF stated that he “really got the sense that the manipulation of the system was starting to kick in again”.592 WO1 EL stated that during the start of July, leadership was getting “feedback from the staff that Ian was missing appointments” and “wordage of Ian being belligerent to medical staff and chains of command”, so “we had to realign the rehab plan again” and “this time we made it that Ian had to parade daily at Holsworthy Barracks to HPW”.593
COL MF stated that there were allegations made by Joanna Turner “that Ian was involved with criminal elements, outlaw motorcycle groups, drugs and potentially, in effect, you know, hitman type roles”.594 COL MF also said he was concerned about the involvement of Hannah Steele, who he alleged was “on the scene providing…advice” contrary to CPL Turner’s rehabilitation plan, and so, “pretty much, the reins were sort of pulled right in…and then he subsequently was successful in a suicide attempt shortly thereafter”.595
COL MF accepted he did not consider discussing with Dr Malik, who was providing care to CPL Turner, whether his direction to “grip up” CPL Turner’s plan would be positive or negative for CPL Turner at that time.596 It is also notable that Dr Hale’s evidence was that treating CPL Turner’s medical issues as a disciplinary issue would have been “counterproductive” in terms of his therapeutic treatment. That evidence was given in relation to directing CPL Turner to enter inpatient treatment.597 Dr Hale accepted that it was possible that a mandatory direction that CPL Turner comply with 591 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 27.
592 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 27.
593 Tab 23 (IGADF ROI with WO1 EL on 15 August 2018) at 25-27.
594 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 27-28.
595 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 29.
his rehabilitation was potentially counterproductive.598 CAPT KV indicated that he was not in favour of using discipline to make sure that CPL Turner stayed safe and that using discipline was not his idea, but rather the CO’s.599
On 11 July 2017, Dr Hale and CAPT KV exchanged emails about plans for CPL Turner’s future, having regard to the letter from Dr Malik that he was no longer fit for duty and should proceed to a discharge. It was noted that Dr Hale considered an extended transition of two years would be suitable which would give CPL Turner the time to develop his research/academic skills and remain supported medically and psychologically.600 12 to 15 July 2017
On 12 July 2017, CPL Turner was reviewed by the unit medical officer along with CAPT KV.601 The entry in the medical records log records that “Dr Reppas’ recommendations” were discussed and that CPL Turner stated that he did not want to go back into an inpatient facility and would self-discharge if directed to go there. An “Alcohol Relapse Prevention Plan” that CPL Turner “would be happy to comply with” was discussed involving “random PST each week”, “random alcohol breath tests each week”, and that if “exposed to a stressor … he is to engage in a stress coping strategy”.
The notes record that CPL Turner agreed to a “Safety plan” in the following terms: “- call his ex-girlfriend or a work mate if he has thoughts of suicide or self-harm
avoid alcohol
continue with prescribed medication
attend medical appointments (new schedule starting Monday 17 Jul: psychiatrist Mondays (at SJOG), psychologist Tuesdays and Thursdays (Sydney), MHP Psych Wednesdays and MO Fridays at Tobruk HC)
engage in regular enjoyable activities - PT twice a day and walking his dog with friends or his ex-girlfriend twice a day
regular contact with his supervisor (by phone or in person at Tobruk Lines)”
CAPT KV’s evidence was that this was the safety plan for the weekend of 15-16 July.602 His evidence was that there was no plan for CPL Turner to have a “battle buddy” over the weekend of 15-16 July because he wanted to treat CPL Turner like an adult.603
On 14 July 2017, CPL Turner suffered a back injury at the gym. He consulted with Dr Hale, who noted that he was in such pain that he was unable to sit and was visibly
600 Exhibit 4 at 302-303.
601 Tab 50 (ADF medical records) at 59-60.
distressed. He was prescribed pain medication and other muscular treatments.604 Dr Hale also gave evidence that treating CPL Turner’s severe pain was essential for his mental wellbeing as his pain was another stressor and his ability to go to the gym was a “key component of his health care plan and his welfare plan”.605
Over the period from 2 July to 14 July 2017, CPL Turner continued to engage in significant bombardment of CPL TJ via messages, imploring her to get back together with him and accusing her of various misdeeds including cheating on him or generally not caring about him. She continued to reiterate that CPL Turner needed to focus on getting better for himself before they could recommence a relationship but offered a significant amount of support for him via messages through this time. He subsequently got upset about a photo of CPL TJ which she had posted on social media. She deleted that photo. CPL Turner accused CPL TJ again of cheating on him and then ceased messaging her.606
On Saturday 15 July 2017, Mr Cardinaels attended CPL Turner’s unit but could not obtain access to the unit. Using a ladder, he obtained access to the apartment and located CPL Turner deceased, cold and stiff sitting on the couch.607 Ambulance officers and police arrived and CPL Turner was pronounced deceased by ambulance officers.608
Toxicology reports indicated that CPL Turner had toxic quantities of Amitriptyline and Paracetamol and potentially lethal quantities of codeine and Nortriptyline in his system, as well as a number of other drugs.609
Next to empty boxes of medication was a notebook containing six suicide notes addressed to various people.610
I am satisfied to the requisite standard that in all the circumstances including recent suicidal ideation, a prior recent suicide attempt and the notes which were found at the scene that CPL Turner intended to end his life. No party submitted that I should consider an accidental overdose.
604 Tab 50 (ADF medical records) at 59. See also 23/10/20 T403-404.
606 Exhibit 57 (WhatsApp and SMS messages) at 1953-1954.
607 Tab 15 (IGADF ROI with SGT MC on 5 June 2018) at 15-17.
608 Tab 1 (Report of Death to the Coroner) at 3. See also Statement of Tim Giblett (Tab 5) at 2 [7].
609 Tab 3 (Limited Autopsy Report for the Coroner) at 4. See also Tab 4 (Toxicology Report).
610 Tab 5 (Statement of Tim Giblett) at 3 [8].
Other factual issues
(a) The relationship between Andrea Cantwell and Matthew Cardinaels Submissions of Counsel Assisting
Consideration
(b) After action review, IGADF Report, and other institutional self-reflections Submissions of Counsel Assisting
612 Exhibit 40 (Statement of Andrea Cantwell dated 31 August 2022) at 1.
613 Exhibit 40 (Statement of Andrea Cantwell dated 31 August 2022) at 6.
614 Exhibit 31, Tranche 3 at 181-184.
BRIG GD on 22 October 2017 and a number of recommendations were made.616 Those recommendations were as follows:
On 9 February 2018, a memorandum titled “Joint Capabilities Group Joint Health Command: Health File Review CPL IJ Turner” was signed by SE Sharkey, which attached the minutes of the AAR Review and the AAR Recommendations Status.617
On 2 October 2020, the AGS wrote to the Crown Solicitor’s Office identifying the steps which had been taken by the ADF in response to recommendations arising from the joint AAR. In relation to recommendation (a), a full-time ADF psychiatrist is now employed at HQ Joint Health Unit Central, which manages ADF health centres and clinics in the Sydney metro area including Holsworthy Health Centre and Tobruk Clinic.
616 Tab 36 (Outcome of Health File Review resulting from the death of CPL TI) at 5-9.
617 Tab 36 (Outcome of Health File Review resulting from the death of CPL TI).
A full time ADF senior medical officer is also now based at Holsworthy Health Centre.
It was decided that the development and operation of inpatient specialist psychiatric treatment facilities was beyond the capacity and remit of Joint Health Command and the ADF.618 The AGS also pointed to various policies which addressed the recommendations and stated that Commander Special Forces welfare boards have been held on two occasions since CPL Turner’s death, once in 2018 and once in 2019.619
On 28 November 2022, the AGS wrote again in relation to the recommendations which had been further assessed since the AGS’ previous letter of 2 October 2020. The AGS provided a number of further policy documents. Of note was an update to the Military Personnel Manual to provide that commanders should consider conducting IWBs for members who are the accused, complainant, or key witness in any disciplinary matter.620 It was also noted that in late October 2020, a Joint Transition Authority was established within the ADF to support ADF members and their families during the transition from military to civilian life.621
On 7 April 2019, the IGADF published a report of the Inquiry into CPL Turner’s death.
On 29 April 2019, the IGADF published a report into Military Justice Issues concerning CPL Turner.
Neither the AAR nor the IGADF report identified a number of the issues which have been canvassed in the Inquest, including the appropriateness or otherwise of the medical clearance granted to CPL Turner to deploy to Iraq in 2016. The AAR did not investigate the issue of the clearance granted to CPL Turner in 2016 at all. The IGADF report dealt with the medical clearance in relatively short order, concluding, based apparently on the evidence of MAJ AF, that “it was more detrimental to CPL Turner’s mental health to leave him behind than allow him to deploy”.622 This conclusion was seemingly reached without asking any mental health professional about the reliability of CPL Turner’s performance in the workplace as an indicator of PTSD or the risk of recurrence of PTSD if CPL Turner deployed. Similarly, the IGADF report noted the effect of the disciplinary proceedings on CPL Turner’s mental health, as well as his move from B Company to C Company, but did not investigate whether support was provided to CPL Turner in respect of his mental health through this period. It does not 618 Tab 119 (Letter from AGS to CSO dated 2 October 2020) at 2.
619 Tab 119 (Letter from AGS to CSO dated 2 October 2020) at 4.
620 Exhibit 62 (Letter from AGS to CSO dated 28 November 2022) at 5.
621 Exhibit 62 (Letter from AGS to CSO dated 28 November 2022) at 6.
622 Tab 13 (IGADF Report) at 6.
appear that the IGADF Inquiry involved the gathering of relevant contemporaneous documents to verify the matters which were stated by witnesses in their ROIs.
Ultimately, it is not clear that either of these investigations were designed to engage in any particularly critical process of self-reflection by the ADF on how CPL Turner’s declining mental health was managed by the ADF throughout 2013 to 2017.
The consequence of this was that there was no contemporaneous assessment by those in positions of responsibility within the ADF to the adequacy of their response, how it could have improved, or how additional steps may have assisted in the circumstances. Such questions were, thus, necessarily being considered for the first time in the context of the Inquest after the passage of considerable time, with knowledge that criticisms may well be made (given that letters of sufficient interest were served on the ADF and ultimately on individual members) and in the context of public scrutiny from outside the organisation itself.
MAJ AF was asked in his record of interview with the IGADF, as were other interviewees, what he considered to be the cause of CPL Turner’s decision to take his own life. He listed the charge and demotion, the transfer to C Company which took him “out of his intimate support network” and the embarrassment associated with that, and his lack of relationships outside the workplace.623 MAJ AF concluded that “he had every opportunity to turn it around. He had every opportunity thrown at him, given to him. There’s a point where, I think, the organisation didn’t fail him but, for lack of a better term, and this is harsh, he failed the organisation”.624 MAJ AF was given the opportunity to recant this in his oral evidence but chose not to do so.625
The evidence of MAJ AF, as well as the outcome of the two reviews conducted by the ADF into CPL Turner’s death, is relevant to the culture within CPL Turner’s Chain of Command, and the effect this had on the ADF’s ability to properly manage his mental health. I accept Counsel Assisting’s submission that it demonstrates a serious lack of awareness of the severity and impact of his PTSD, the failure to recognise its severity throughout 2015 and 2016, and an unwillingness to recognise the system failures which led CPL Turner to experience such a serious decline in his mental health by the start of 2017.
623 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 36-37.
624 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 37.
Submissions of the Commonwealth
The Commonwealth submits that a review and critique of the IGADF report would be beyond the statutory jurisdiction of this Inquest and any adverse findings about that report or its processes would be a denial of procedural fairness.626 Further, it is submitted that to the extent the IGADF report is criticised for not covering certain matters, regard should be had to its particular statutory mandate and its limited reach by contrast to this Inquest.627 The Commonwealth raises similar objections with respect to the AAR process.628 To the extent that both reviews were said to be relevant to the culture within CPL Turner’s Chain of Command, the Commonwealth submits that this proposition should be rejected and is a procedurally unfair proposed finding.629 Consideration
I accept that it is not my place to conduct a detailed critique of the IGADF report or the AAR process. Nevertheless, the report and evidence pertaining to the AAR process are extremely useful in understanding the culture within CPL Turner’s Chain of Command and indeed the broader Army at the time of his mental health decline. In my view, the evidence establishes a serious lack of awareness of the severity and impact of CPL Turner’s PTSD. There is a failure to understand and grapple with the way in which ADF decisions were impacting on his mental health over a long period. I accept Counsel Assisting’s submissions on this issue.
There is no procedural unfairness to recognise, using evidence obtained from the IGADF report or the AAR process, amongst other evidence, that there was an inability to understand what was required for a truly therapeutic approach to CPL Turner’s mental health management. While Dr Hale accepted that treating CPL Turner’s medical issues as disciplinary issues would be “counterproductive”, in my view a disciplinary approach infected CPL Turner’s management right up to and even after his death.
COL MF wanted to “pull the reins in” and believed that CPL Turner was not “fulfilling his side of the bargain.” He feared that CPL Turner was “manipulating the system”.
Even more telling was MAJ AF’s shocking pronouncement in his record of interview that CPL Turner “failed the organisation” with his decision to take his own life. It was revealing that he took this firm view of what had occurred. MAJ AF’s understanding of 626 Submissions of the Commonwealth dated 7 June 2024 at [803]-[806].
627 Submissions of the Commonwealth dated 7 June 2024 at [807]-[808].
628 Submissions of the Commonwealth dated 7 June 2024 at [812]-[814] 629 Submissions of the Commonwealth dated 7 June 2024 at [818].
CPL Turner’s suicide appeared to remain within a strictly disciplinary framework, where the fault lay squarely with CPL Turner. When asked to identify why CPL Turner failed the ADF, he answered “suicide is unacceptable. Killing yourself is an unacceptable course of action and Ian should not have done it.”630 While MAJ AF’s lack of insight and compassion was particularly striking, his inability to properly consider the possibility of systems failures within the ADF was in line with some others who also gave evidence. Indeed, the IGDAF report and the AAR process demonstrate aspects of a culture that supports an officer such as MAJ AF to hold the harmful views he did.
The inquest revealed the ongoing need to destigmatise PTSD and mental health issues in the ADF. This evidence from a senior officer indicates the size of the task ahead. It was clear to me that there was intransigent thinking at all levels of the organisation.
(c) Relationship with Hannah Steele Submissions of Counsel Assisting
CPL Turner’s relationship with Hannah Steele became the subject of focus in reviews after his death which ultimately proved to be entirely misplaced. Ms Steele worked for the Vietnam Veterans, Peacekeepers and Peacemakers Association (VVPPA). She first met CPL Turner sometime in 2013. She became close friends with him in late 2016 when he moved into the building across from hers. In 2017, Ms Steele would meet up with CPL Turner for coffee after the gym and talk about life. She had a sexual relationship with CPL Turner on two occasions in 2017, one in January which was how they became close, and once during a period when he had not been in hospital for a few weeks (noting she was not clear on the timing).631 Ms Steele’s evidence to the Inquest demonstrated that she was a friend to CPL Turner throughout 2017 and attempted to assist him as such, including by visiting him in hospital and obtaining a service dog to keep him company.632
In February 2018, the ADF wrote a letter to Ms Steele’s employer informing them that she had acted outside her bounds as an advocate for CPL Turner.633 Ms Steele’s employer replied to the ADF making clear that she was not CPL Turner’s advocate634 and ultimately the ADF apologised for the false claims which had been made about 630 5/8/21 T45.44 to T46.17.
631 19/10/20 at T50.5-15.
632 Tab 8 (Statement of Hannah Steele).
633 Tab 9 (Letter from TL Smart AM, Air Vice-Marshal to Mr Frank Cole, NSW State President of the VVPPA (NSW Branch) dated 17 January 2018).
634 Tab 9 (Letter from Mr Frank Cole, NSW State President of the VVPPA (NSW Branch) to TL Smart AM, Air Vice-Marshal, dated 6 February 2018) at 5-6. See also Tab 8 (Statement of Hannah Steele) at 5 [28].
Ms Steele to her employer.635 Counsel Assisting submits that it is plainly regrettable that Ms Steele was subjected to this treatment from the ADF in circumstances where, as she stated, “I was just his friend”.636 Counsel Assisting considers that the evidence does not provide any basis for finding that Ms Steele interfered with CPL Turner’s treatment during 2017.
Submissions of the Commonwealth
The Commonwealth submits that a finding should not be made that Hannah Steele was “just his [CPL Turner’s] friend” and that, in fact, their relationship was such that it “added to the entangled complexity of [CPL Turner’s] life”.637 Submissions in reply of Counsel Assisting
Counsel Assisting notes that the Commonwealth’s characterisation omits the express references to the pair being “close friends” and having “had a sexual relationship” in the same paragraph. Beyond that, Counsel Assisting considers it is not apparent what the Commonwealth seeks to add in its submission other than eschewing the attribution of any blame to Ms Steele. Counsel Assisting considers there to be no basis for any finding that Ms Steele interfered with CPL Turner’s treatment during 2017 as had previously been asserted by the ADF in 2018.638 Consideration
I reject the Commonwealth’s submission that CPL Turner’s relationship with Hannah Steele “added to the entangled complexity” of CPL Turner’s life. I have seen no evidence that their friendship interfered with his treatment during 2017. Without that I reject the apparent implication that her contact with CPL Turner was somehow problematic.
(d) CPL Turner’s identity as a commando and part of B Company, 2CDO Submissions of Counsel Assisting
636 Tab 8 (Statement of Hannah Steele) at 5 [28].
637 Submissions of the Commonwealth dated 7 June 2024 at [819].
638 Submissions in reply of Counsel Assisting dated 22 August 2024 at [243].
connected to the army and his position in the regiment. He considered himself to be vital to the company…almost his identity was B Company…And that was good and bad”.639
Padre MP spoke more generally, giving an example of another individual who he had found attempting to commit suicide, and said “it came down to the fact that he couldn’t, you know, he couldn’t be what he wanted to be and it meant so much to him, it was so much engrained in his identity that he didn’t want to live if he couldn’t be a commando”.640 He stated that “they’ve got a motto commando for life and that’s real, it’s like, you know, they live by this stuff”.641
LCPCL DL stated that he remembered seeing CPL Turner when he was in a coma and he had a “whole sleeve of his arm tattooed in a dedication to our company…I remember just looking at it and thinking that’s how much this meant to you and it was taken away from you”.642 LTCOL SW stated in his ROI that when he spoke to CPL Turner in hospital after his second suicide attempt, “what came out in the discussion was that the only thing that had kept him tethered was his work, and you know being operationally employed was the thing that – you know he’s high functioning in that environment”.643
Christine Turner recounted a message during her IGADF ROI where CPL Turner stated that “I’m in a position where every single piece of my identity of how I view myself in this world has been taken from me. I was a husband and a father. I was the most senior team commander in all of [SOCOMD]. Now I’m dad one out of four weekends. I’m a 2IC in a different company and there is no more war to be fought”.644
Mr Cardinaels, for example, who had spent some 18 years in the unit, indicated that it was “not the case at all” that inevitably for all commandos there would come a time where they were not sufficiently fit to continue to undertake that role.645 This was at odds with the expert evidence (discussed below) which suggested that there was a limited number of deployments it was expected a soldier could undergo. Mr Cardinaels indicated that work had “started” in educating Commandos who were in training as to the need to be a “multi-dimensional human being”, to have “interests outside work”, 639 Tab 16 (IGADF ROI with MAJ AF on 24 July 2018) at 6.
640 Tab 19 (IGADF ROI with Padre MP on 18 September 2018) at 29.
641 Tab 19 (IGADF ROI with Padre MP on 18 September 2018) at 30.
642 Tab 21 (IGADF ROI with LCPL DL on 14 August 2018) at 10.
643 Tab 22 (IGADF ROI with LTCOL SW on 11 December 2018) at 14.
644 Tab 34 (IGADF ROI with Christine Turner on 21 August 2018) at 14.
and to have an “understanding of how you thrive and readjust to life in the community after your time”.646 Consideration
(a) Dr Olav Nielssen
Dr Nielssen was engaged by Counsel Assisting and he provided two reports to the Inquest. Dr Nielssen is a psychiatrist working in private practice. He has clinical professorial appointments at the University of Sydney and Macquarie University, works in the homeless sector at Matthew Talbot Hospital and consults for an online treatment service for anxiety and depression, which includes a PTSD course.647
In his first report, Dr Nielssen stated that, in his opinion, CPL Turner’s service and events arising from his service were a significant factor contributing to his death. He stated that PTSD is associated with an increased propensity to drink alcohol because of the temporary reduction in arousal and anxiety provided by alcohol. He further stated that CPL Turner’s prosecution, demotion, and transfer over the cock-carding incident was “likely to have had a detrimental effect for a person who had reached his level of service and was very attached to his immediate unit and is also likely to have contributed to the development of a depressive illness.”648
Dr Nielssen’s main criticism of CPL Turner’s care from 2014 to 2017 was allowing his return to active service after the identification of PTSD, as “further exposure to trauma would be expected to re-trigger the condition”. He disagreed with the view reached in the Clinical Perspective Document that a further tour of duty might help CPL Turner’s recovery, considering it was not consistent with medical advice.649 He stated that CPL
648 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 10.
649 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 10.
Turner’s redeployment to the Middle East after having been diagnosed with PTSD was “probably not in Mr Turner’s best interest, as any further trauma could trigger the recurrence of the disorder”.650
Dr Nielssen considered that CPL Turner received intensive intervention during his time managed under the HPW with regular reviews by various health professionals.651
Dr Nielssen noted that ADF policies included the requirement for regular mental health reviews and the removal of access to weapons and ammunition to members deemed to be at risk of committing suicide. Dr Nielssen noted that CPL Turner had the “obvious disincentive of losing the possibility of further rotations by raising serious mental health concerns”.652
Dr Nielssen considered it was difficult to assess the extent of the impact of the disciplinary proceedings on CPL Turner but stated “criminal proceedings of any kind are distressing”.653 He considered that his redeployment to C Company was likely to have had a “significant detrimental effect for a person of Mr Turner’s personality and background”.654
Dr Nielssen considered whether other factors arising during CPL Turner’s service contributed to his death and referred to the possibility of the use of anabolic steroids and cocaine which carried the risk of more severe depression.
In his supplementary report, Dr Nielssen stated he did not consider that the specific details of traumatic events needed to be known to a psychiatrist in order to diagnose and treat combat-related PTSD. His view was that revisiting the details of trauma can “exacerbate rather than relieve symptoms”.655
In relation to possible recommendations, Dr Nielssen stated:656 i. it seems inadvisable to return people diagnosed with service-related PTSD to active service because of the risk of further experiences adding to existing trauma; 650 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 15.
651 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 11.
652 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 11.
653 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 11.
654 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 12.
655 Supplementary Report of Dr Nielssen dated 3 July 2021 (Exhibit 9) at 4.
656 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 13-14.
ii. the military should consider a cap on the number of tours in which members are exposed to real danger, both as a matter of fairness and to reduce the liability for PTSD in elite troops subjected to constant rotation; iii. improved pastoral care of very exposed members of the ADF when they leave the military; iv. the supervision of substance use, given the ready availability of “on the spot and hair testing”.
(b) Dr Matthew Large
Dr Large was engaged by Dr Sringeri and provided three reports to the Inquest. Dr Large is a psychiatrist. He is the senior psychiatrist at the Prince of Wales Hospital, where he was engaged in work primarily in an Emergency Department and Emergency Psychiatrist Care Centre. He is also the Clinical Director of the Eastern Suburbs Mental Health Service and the conjoint professor in psychiatry and the University of New South Wales.657
In his first report, Dr Large stated that at the time of CPL Turner’s death he had a number of psychiatric conditions, “the most prominent of which was a substance use disorder, best characterised as a severe alcohol use disorder”.658 He stated that CPL Turner had also suffered from PTSD after being exposed to combat trauma, a depressive condition (which he considered was “secondary to his alcohol use”, and some symptoms of adult or residual ADHD (but which were equally likely to be due to alcohol use disorder or trauma related symptoms).659 Dr Large considered that it was likely there was “something of a vicious cycle of causality between PTSD and alcohol use” and that a “direct connection between his ADF service and alcohol use is probable”.660
Dr Large considered that the relative importance of these conditions was hard to assess but accepted there was a temporal relationship between his combat stress, PTSD symptoms, and increased drinking but that his alcohol use contributed to the severity of his PTSD.661
Dr Large stated that “in the most general terms suicide is quite unpredictable”, that suicide events are “not well explained by suicide risk factors even among people with
658 Report of Dr Large dated 28 September 2020 (Tab 109) at 47.
659 Report of Dr Large dated 28 September 2020 (Tab 109) at 47-48.
660 Report of Dr Large dated 28 September 2020 (Tab 109) at 49.
661 Report of Dr Large dated 28 September 2020 (Tab 109) at 48.
a significant history of suicidal behaviour”, and that CPL Turner’s suicide was “not unexpected given his presentation but could not have been reasonably anticipated over any clinically relevant time frame”.662
Dr Large was asked whether it was clinically appropriate in 2014 and 2015 for Dr Sringeri to determine CPL Turner was “fit for duty”. Dr Large explained that the “main role of an external treating psychiatrist” other than providing treatment “was to inform the ADF of [CPL Turner’s] clinical state”. He stated that “decisions about suitability for military duty are complex and go beyond a treating psychiatrist’s views”.663 Notwithstanding that view, he stated that Dr Sringeri was “within peer acceptable practice” in his view that CPL Turner was “fit for duty” and that a “slightly separate question was whether his return to work and possibly active duty was likely to be good or bad for [CPL Turner’s] mental health” but that he had “no strong grounds to question this conclusion by people that knew him”.664
Dr Large was also asked about Dr Sringeri having cleared CPL Turner as fit for duty on 13 July 2016 (in relation to the deployment on OP OKRA). It should be noted that Dr Large reviewed the notes of Dr Sringeri in which it is reported that CPL Turner stated “next deployment only involves training Iraqi soldiers and didn’t involve any combat” and “his duties, limited to training Iraqi soldiers only”.665 He stated that although it “is not really the role of a psychiatrist to be decision maker in matters related to fitness for military service, Dr Sringeri clearly considered the impact of [CPL Turner’s] condition on his ability to perform non-combat duties and concluded that [CPL Turner] was capable of this non-combat role”, and that “most psychiatrists would conclude that there were grounds to consider [CPL Turner] fit for this form of deployment”.666
Dr Large was asked about the role of a psychiatrist as a decision-maker in relation to whether an ADF member is fit for duty. His opinion was that the role of the psychiatrist is to provide information about the psychiatric state of the ADF member in order to assist the ADF to make decisions about fitness to return to duties. He stated that “it was quite reasonable for Dr Sringeri to express the view that [CPL Turner] was fit for deployment and that he would be capable of performing his duties” but that “the final question of whether he was cleared for deployment was not ultimately one that lay with Dr Sringeri”.667 662 Report of Dr Large dated 28 September 2020 (Tab 109) at 48.
663 Report of Dr Large dated 28 September 2020 (Tab 109) at 50.
664 Report of Dr Large dated 28 September 2020 (Tab 109) at 50.
665 Tab 111 (Statement of Dr Sringeri dated 25 September 2020) at 90.
666 Report of Dr Large dated 28 September 2020 (Tab 109) at 50.
667 Report of Dr Large dated 28 September 2020 (Tab 109) at 51.
(c) Dr Malcolm Hopwood
Dr Hopwood was engaged by the ADF and provided three reports to the Inquest. Dr Hopwood is a psychiatrist and a professor of psychiatry at the University of Melbourne.669
In his first report, Dr Hopwood considered that it appeared from Joanna Turner’s evidence that CPL Turner had begun to develop symptoms of PTSD before his clinical presentation (those could have been for a year “and possibly longer”) and that it was not uncommon for earlier stages of illness to be first evidence to those close to the affected individual.670 Dr Hopwood considered that the treatment CPL Turner received for his mental health difficulties in 2014 and again in 2017 were of the standard he expected and that he could not identify any specific interventions that would have been guaranteed to prevent his suicide.671
Dr Hopwood considered that it was “clear that the trauma that led to [CPL Turner’s] development of PTSD was related to his service in the ADF” and that the disability associated with his mental health difficulties also clearly complicated the latter stages of his career and may have contributed to his disciplinary issues and subsequent company transfer. Dr Hopwood considered that these events were significant stressors because of the pride which CPL Turner placed in his military career.672
Dr Hopwood considered an “important question” relates to whether CPL Turner’s mental health had improved as much as perceived between 2014 and 2016, or whether some degree of ongoing impairment was disguised by inadequate review or by any attempt on the part of CPL Turner to minimise symptoms and that this was a “difficult question to answer based on document review”.673 668 Supplementary Report of Dr Large dated 16 July 2021 (Exhibit 8) at 4.
670 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 4-5.
671 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 7.
672 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 7-8.
673 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 8.
Dr Hopwood considered that it was clear there was a potential tension between the desire of a soldier to pursue a valued military career and the discussion of any career related mental health issues. He considered it was impossible to completely eradicate this tension but that “hopefully all involved in the care of someone such as [CPL Turner] are aware of the tension”.674
He stated that it was likely that CPL Turner’s disciplinary proceedings and redeployment to C Company were “significant additional blows” and that they may have added to his sense of demoralisation and depression. He also commented that the loss of rank seemed a particularly strong punishment.675
Dr Hopwood stated that it was important to acknowledge that the very nature of military service “particularly deployment in a conflict zone is inherently potentially traumatic”.676 He also stated that there is an “indisputable body of evidence that suggest that prior trauma and/or PTSD increase the risk of the development of PTSD with subsequent trauma exposure”. He further noted that whilst the “intent of deployment may not appear inherently traumatic” (referring to the 2016 OP OKRA deployment), it must be difficult to guarantee this given the unpredictability of such a zone and the individual nature of what is or isn’t traumatic”.677
In his supplementary report, Dr Hopwood explained the term “combat related PTSD”, noting it is usually used to refer to PTSD resulting from an individual’s experience in a military conflict zone.678 He stated the symptoms of combat-related PTSD are essentially identical to those of civilian trauma-related PTSD. He explained that there is a common conception amongst mental health professionals that combat-related PTSD may be different in three main respects to civilian-related PTSD:679 i. First, it arises from circumstances that involve events challenging the normal human moral boundaries, which creates a higher risk of PTSD and can create challenges in its management. He noted that if the events that led to PTSD are associated with moral ambiguity or shame/guilt, it is likely that performing exposure-based psychotherapy may be more challenging.
ii. Second, the occurrence of combat-related PTSD is within a specifically military culture with its associated issues of pride in service, and complex issues 674 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 8.
675 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 9.
676 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 10.
677 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 11.
678 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 3.
679 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 3-4.
around the cessation of a military career and that the presence of such systemic issues can complicate presentation and delay treatment.
iii. Third, there is a limited body of evidence suggesting specifically that combat related PTSD may respond less well to treatment than civilian PTSD.
Dr Hopwood further stated that the functional impacts of PTSD are diverse and can result in social withdrawal and the disruption of normal interpersonal relationships. He stated that it was also associated with irritability and may be associated with aggressive behaviour and impulsivity. He also stated that PTSD can contribute to the risk of violent behaviour. He noted that substance abuse can increase the risk of criminal or anti-social behaviour.680
In relation to exposure-based therapy, Dr Hopwood’s evidence was that most treatment guidelines would recommend that co-morbid problems such as depression or active substance abuse need to be brought under control before exposure-based therapy is commenced. He explained that for some individuals, exposure-based therapies remained an overwhelming prospect.681
Dr Hopwood stated that individuals with even severe PTSD can hide or minimise their symptoms, but that the ability to do so is influenced by the severity of PTSD.682
In relation to the disclosure of traumatic events as part of treatment, Dr Hopwood stated that in his experience treating current and former members of the ADF, it was “quite clear that effective treatment will generally require a discussion of all relevant traumatic events”. He stated that on treating combat-related PTSD, there are traumatic issues that have great sensitivity including in the sense of being security-classified. He stated it “is indeed clinically unhelpful” when this occurs as it interferes with effective care and, although it can sometimes be informally handled, “on other occasions it is insurmountable and unhelpful”.683
Dr Hopwood further stated that current clinical guidelines indicate that “evidencebased psychotherapy” is the most common treatment of choice for PTSD and that the guidelines recommend three forms of psychotherapy, being Cognitive Behavioural Therapy (CBT), Cognitive Processing Therapy (CPT), and Eye Movement Desensitisation Reprocessing (EMDR). A key component of each of those therapies 680 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 4-5.
681 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 6.
682 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 6.
683 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 8.
was an “exposure to and reworking of the traumatic memories, which are seen as central to the symptomatology of PTSD”.684
In his further supplementary report, Dr Hopwood stated that he agreed with Dr Nielssen that the most salient issue in CPL Turner’s treatment was the decision to allow him to return to active service after he was identified as suffering from PTSD.685 Dr Hopwood noted Dr Large’s comments in relation to the significance of CPL Turner’s alcohol use disorder. He stated that there was a considerable body of evidence supporting the close relationship between alcohol misuse and symptoms of PTSD and that in CPL Turner’s case there was evidence from Joanna Turner that his alcohol use escalated significantly at the same time as the development of his PTSD symptoms. He also concurred with Dr Large’s opinion on the role of a psychiatrist in decisions about deployment.686
Dr Hopwood considered that decisions in relation to deployment required clinical input and also adequate expertise in military mental health and independence from specific unit-based concerns.687
Dr Hopwood further agreed with Dr Dinnen’s views (discussed further below) about the issues involved in private psychiatrists effectively communicating to health services within the ADF, and the difficulties involved in the lack of psychiatrists involved in the
(d) Dr Anthony Dinnen
Dr Dinnen is a psychiatrist in private practice. He had consulted in the past with St Vincent’s Hospital and DVA.690
685 Further Supplementary Report of Dr Hopwood dated 26 July 2021 (Exhibit 6) at 2.
686 Further Supplementary Report of Dr Hopwood dated 26 July 2021 (Exhibit 6) at 2.
687 Further Supplementary Report of Dr Hopwood dated 26 July 2021 (Exhibit 6) at 2.
688 Further Supplementary Report of Dr Hopwood dated 26 July 2021 (Exhibit 6) at 3.
689 Further Supplementary Report of Dr Hopwood dated 26 July 2021 (Exhibit 6) at 3.
so has an adverse effect on status, deployment and promotion” and that the more determined an ADF member is to pursue their career, the less likely they are to raise issues of mental health.691 Dr Dinnen stated that the “only change” he would like to see in military health is for psychiatrists to be full time employees of the military and to be given total and full responsibility for managing patient assessment and care, with psychologists as ancillary. He considered that as an “outside consultant” he was aware his recommendations carried less weight than psychologists who are “on base”.692
(e) Professor Alexander McFarlane
Professor McFarlane was engaged by Counsel Assisting and provided one report to the Inquest dated 15 July 2021. Professor McFarlane is an Emeritus Professor of Psychiatry at the University of Adelaide, and a Professorial fellow at Phoenix Australia, having previously been the Director of the Centre for Traumatic Stress Studies and head of the Department of Psychiatry at the University of Adelaide.696 He had a lengthy history of service in the ADF as a member of the RAAF specialist reserves, as a specialist adviser to the DVA and as a senior investigator in the Deployment Health Surveillance Program.697
In his report, Professor McFarlane was asked about the impact of CPL Turner’s service within the ADF on his mental health. His evidence was that it was unlikely that any single traumatic exposure in the course of CPL Turner’s deployments was the cause of his chronic PTSD, but that it was the “cumulative exposure throughout his deployment”.698 He referred to a number of studies in which he had been involved of ADF personnel since 2000. Professor McFarlane then stated that there were various 691 Report of Dr Dinnen dated 17 September 2020 (Tab 110A).
692 Report of Dr Dinnen dated 17 September 2020 (Tab 110A) at 11.
693 Supplementary Report of Dr Dinnen dated 26 July 2021 (Exhibit 7) at 2.
694 Supplementary Report of Dr Dinnen dated 26 July 2021 (Exhibit 7) at 7.
695 Supplementary Report of Dr Dinnen dated 26 July 2021 (Exhibit 7) at 7.
696 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 80.
697 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 77; 07/02/23 T6.
698 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 55.
reports detailing CPL Turner’s increasing development of symptomatology on his RtAPS and POPS screens and that no accumulative tracking of the trajectory existed in the material. He noted that it is recognised there is a delayed onset of symptoms in ADF members and that maximal distress related to combat exposure does not occur in the immediate post-deployment period. He noted an absence of material about how to map and manage the emerging risk to CPL Turner throughout his career.699 In particular, he noted that there was little by way of follow up in the context of him returning early from deployment in 2015. In his view, one of the reasons for the POPS screen is the recognition that there is frequently an escalation of symptoms in the period following the individual’s return from deployment and that CPL Turner was an individual who should have received and been directed to undergo more regular follow up.700
Professor McFarlane also noted that there was no consideration of CPL Turner’s progressive decline over a long period in the assessment of risks to CPL Turner from future deployments. He stated that CPL Turner’s symptoms around 2013 as reported by Joanna Turner were indicative that he was suffering from PTSD.701 He noted, for example, that the AAR report had set out CPL Turner’s major sources of distress as “being estranged from his wife”, “disciplinary proceedings and its consequence”, “his current relationship”, and “PTSD symptoms that were labile”. In Professor McFarlane’s view, this tended to confuse cause and effect because the probability was that CPL Turner’s marital issues and disciplinary proceedings were “secondary manifestations of his underlying post-traumatic stress disorder”.702
In relation to the cock-carding incident and disciplinary proceedings, Professor McFarlane noted that reckless and risk-taking behaviour was a symptom of PTSD. He considered that an important question was whether the known history of CPL Turner’s PTSD, depression, and alcohol abuse was taken into account when moving him from B Company to C Company. He stated that the loss of supports to an individual who is considered to be unwell has predictable consequences. He also considered that an important question arose as to whether there was adequate consideration around whether his mental health was reflected in his behaviour in the cock-carding incident.703 699 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 63.
700 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 33.
701 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 11.
702 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 34.
703 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 13.
In his view, further exposure had the potential to reinforce earlier traumatic memories, and dealing with incidents such as the human remains of the US pilot were likely to have played a significant role in the exacerbation of his condition.705
In relation to whether CPL Turner was “fit for duty” at the time of the 2016 deployment, Professor McFarlane emphasised that the question is not “simply whether an individual can perform their duties”, noting many people can perform their duties while suffering with a psychiatric illness”. Rather, the “critical question to be considered is the consequences for an individual of an exacerbation of their condition” and that it was also critical to assess the risks they would behave in a less than optimal way while deployed (including acting outside the rules of engagement, or other risk-taking behaviour).706
In relation to the issue of domestic violence perpetrated by CPL Turner on Joanna Turner, Professor McFarlane stated that these are “core aspects” of PTSD and that these matters were the consequence and markers of his declining mental health which should have alerted Command and clinicians to his predicament, noting that his marital difficulties and the domestic violence were issues that were known to the ADF.707
In relation to CPL Turner’s alcohol abuse, Professor McFarlane considered that given this was an issue which was identified by the ADF, it should have been dealt with aggressively in terms of his underlying symptoms, rather than just have been considered a “drinking behaviour”. He stated that CPL Turner was clearly an individual at substantial risk of a future exacerbation of his condition. Professor McFarlane noted that alcohol abuse frequently initially manifests as a form of self-medication in individuals with PTSD.708 704 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 18.
705 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 20.
706 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 43.
707 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 64.
708 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 18-19.
He likened this to players in the AFL pursuing an education while playing football, to ensure they have a career to move onto at the end of their professional sporting life.710 Professor McFarlane’s opinion was that the policies and procedures of the ADF do not take into account a long-term strategy for preparing individuals for transition. Rather, when an individual is “broken”, they tend to be discharged. This did not allow, in his opinion, a soldier such as CPL Turner to consider alternative career paths within the ADF so as to sustain their service and capacity to remain within the workforce.711
His opinion was that individuals within the ADF who were responsible for CPL Turner’s career management did not assist him properly to appraise the risks to his mental health or assign him to realistic roles that would have allowed him to continue serving other than as a commando. Professor McFarlane noted that CPL Turner had a great deal of combat experience that would have been of assistance in many domains.712
In relation to the adequacy of mental health treatment provided to CPL Turner, Professor McFarlane considered that this needed to be considered in the context of the “system of care” available to CPL Turner. He considered there were a number of issues with rehabilitation and the mental health programs at 2CDO (from his own research into that unit conducted in 2017) namely:713 i. a lack of experience in the clinicians involved in the care, including the risk of junior clinicians being overawed by the culture and identity of special forces members; ii. the adequacy of clinical governance and quality assurance; iii. the workforce having little awareness of research programs and critical information emerging from the research and risks of ongoing combat exposures, a lack of trust between special forces soldiers and the health 709 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 65.
710 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 68.
711 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 70.
712 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 69.
713 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 66-67.
practitioners, and a lack of understanding of the issues within Command of the accumulating risks to deploying personnel; iv. the lack of security clearances for practitioners, and the need to go outside the ADF for psychiatric help with clinicians with whom soldiers could not adequately communicate; v. health practitioners outside the military not having sufficient knowledge of the ADF and issues of veterans’ mental health because there are unique assessment skills required by clinicians in those settings; and vi. the concern within special forces by 2017 of the potential investigation and prosecution of war crimes.
The issue is whether the subsyndromal symptoms and the prior cumulative trauma exposure “do or do not pose a significant foreseeable risk to the individual’s mental health”.714 He stated that there was no evidence that this perspective was undertaken or considered in CPL Turner's management. He considered this to be of particular importance following CPL Turner’s admission in 2014 and the assessments made about the risk to him of future deployments. Professor McFarlane stated “in my opinion this was ill advised on many accounts”.715 Professor McFarlane stated he was perplexed by Dr Sringeri’s assessment reports about CPL Turner’s recovery in 2014, particularly because there was no discussion about the risk of CPL Turner having ceased his medication.716
Professor McFarlane considered that a core element of PTSD is the re-experiencing of traumatic events that have led to the disorder. The disclosure of these events and the details are important aspects of treatment, in particular in exposure-based treatments. He considered that not being able to disclose information for reasons of security classification was an important impediment to receiving effective treatment.
714 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 65-67.
715 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 67.
716 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 67-68.
His opinion was that a critical aspect of exposure based treatments is an exploration of all aspects of the traumatic memory. If an individual is specifically quarantining or withholding information, this disclosure may well be a critical issue to the necessary reprocessing of traumatic memories. He considered this was likely to decrease the effectiveness of psychological interventions.717 Professor McFarlane referred specifically to Dr Malik’s evidence to the effective of “there are some secretive missions, so I mean, I don’t know how much…He was involved in some secretive mission from the army which I wasn’t aware of”.718 He stated that this highlighted a barrier that existed because Dr Malik did not have security clearances.719 In his opinion, it is not possible to effectively treat a veteran unless their traumatic exposure can be fully explored.720
Professor McFarlane noted that he had been sufficiently concerned about this issue for some time and had raised it in various forums, including by writing to the Attorney General during his time on a committee of the Australian Medical Association. He stated that if there is a perceived issue by the patient in a clinical setting in relation to the security risk, they are unlikely to fully disclose matters to the clinician. He considered that in the setting of CPL Turner’s case, this would have impacted upon his willingness to engage with treating clinicians if there were reasons for him to have concerns about disclosure. In his view, this was an impediment to effective exposurebased psychological interventions.721
Professor McFarlane also stated that the interfaces between the various health systems which were involved in CPL Turner’s treatment meant that there were inevitably discontinuities.722
In his opinion, once an individual has demonstrated suicidal thinking, there is a considerable risk to that individual if they are further exposed to a combat environment on deployment. This was particularly the case, in his opinion, when they had been diagnosed with PTSD.723
In relation to Joanna Turner, including the domestic violence that she suffered, his evidence was that it was critical an individual with PTSD be treated in the context of their family relationships. He noted that spouses and family members will often have 717 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 73.
719 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 46.
720 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 48.
721 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 73.
722 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 68.
723 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 69.
particular insights into the individual’s difficulties and the impact on their family. He considered that these were matters that the ADF should take into account when considering future deployment.724 He described domestic violence as a “major indicator of the probability of psychiatric disorder in a soldier”.725
He considered it to be critical that the ADF have a way of supporting such transitions in a manner that assists and maintains an individual status and self-esteem. He considered that such considerations were not taken into account in the context of his deployment in 2016, when dealing with the charges against him, and when he was redeployed to C Company (noting CPL Turner considered this to be further punishment for the disciplinary proceedings). He stated that, in summary, the medical services available to CPL Turner were not fit for purpose.726
Professor McFarlane considered that there was a critical disincentive for CPL Turner to disclose his mental health difficulties by reason of the medical employment category that downgrades our soldiers’ ability to be accepted on deployments. He noted that commandos are extremely committed to being part of the fighting group and minimise their psychological distress so as to ensure they remain identified as part of their company. He also noted the financial incentives to remain in the deployment cycle.727 Professor McFarlane noted he is concerned about the capacity of Special Forces soldiers to manipulate the opinion and behaviour of health professionals undertaking their care.728
Professor McFarlane noted the heavy burden which has been placed on Special Forces soldiers in the context of the duration of a conflict in the Middle East area of operations. He considered that Command had failed to implement a strategy or plan to assist individuals when the cost of deployment had become excessive. He also noted that soldiers, and particularly commandos, have an unusual capacity to minimise or deny their own suffering and physical welfare.729
In relation to the approach of the clinicians (and other experts) Professor McFarlane noted that in his view, it was important to state that the management of CPL Turner’s mental health from 2016 onwards presented a very difficult clinical challenge. He stated that his social alienation and increasing nihilism were the consequences of his lengthy career in the ADF and its impact on his mental health. He considered this 724 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 69.
725 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 24.
726 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 70.
727 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 70.
728 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 30.
729 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 70.
situation would have been extremely challenging and difficult for any clinician to treat and effectively manage. He was at pains to point out that the differences of opinion he expressed were with the aim of identifying systemic and overarching issues that needed to be addressed.730 His main areas of concern with CPL Turner’s treatment by external consultants were identified as follows: i. In relation to Dr Sringeri, Dr Sringeri’s involvement in CPL Turner’s cessation of medication in 2015 so that he would be fit to undertake active duties in the ADF. Professor McFarlane noted it would have been possible to apply for a medical waiver that would have allowed continued prescription of medication.
He also noted the importance of antidepressant medication in relapse prevention.731 Dr Sringeri’s assessment of CPL Turner in 2014 and 2015 of having “PTSD in remission” in circumstances where there was a risk of subsyndromal symptoms and relapse on further trauma exposure.732 He also noted the difficult situation Dr Sringeri faced by being the person identified by the Court in 2015 as having legal responsibility to notify breaches of his treatment plan. In Professor McFarlane’s view, this would have impacted CPL Turner’s openness in his consultations.733 ii. In relation to Dr Large, Professor McFarlane noted that if decisions about suitability for military duty were outside Dr Sringeri’s role then that should have been stated in his report to the ADF. He did not consider that Dr Sringeri had adequately set out the limits of his opinions as to suitability for duty in his reports to the ADF.734 iii. In relation to each of Dr Sringeri and Dr Malik, regarding the focus of each of those psychiatrists in prescribing medication as against psychotherapy, he stated he did not accept that a psychiatrist is not doing psychotherapy even if it is “at a minimum, supportive psychotherapy”.735
731 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 50.
732 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 50.
733 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 53.
734 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 42.
735 Report of Professor McFarlane dated 15 July 2021 (Exhibit 12) at 52.
An independent review be conducted into the Inquiry conducted by the IGADF and Joint Health Command into CPL Turner’s death. This inquiry should ascertain what documents were or were not reviewed and what opinions were sought in regards to the quality of care provided to him.
Arising from these findings a set of recommendations should be made about how to improve the quality of the reviews and audits conducted within the IGADF and Joint Health Command and their overarching clinical governance.
Systematic steps be put in place to map the longitudinal history of an ADF soldier’s deployments, including their RtAPS and POP screens data in conjunction with their reported psychiatric diagnoses and treatment provided.
An actuarial risk analysis be conducted within Joint Health Command of the optimal rotation cycle and number of deployments that can be undertaken by combat personnel without posing an undue risk to their mental health and to identify steps that can be undertaken to prolong their life and service in a combat environment.
In the event of a Commando or soldier being deployed following treatment for post traumatic stress disorder, an independent clinical assessment be made by a psychiatrist who is not directly involved in the individual’s treatment, This is to protect the relationship between the clinician and the patient as being the gatekeeper to operational duties, which in turn can disrupt the disclosure of information.
Security clearances should be put in place for all clinicians treating Special Forces operators because of the potential security concerns within the patient’s mind when disclosing information.
An integrated system of care to be put in place where the psychiatrist and other clinicians used by the ADF are not simply chosen by location but by specialist expertise demonstrated in the domains of military and veterans’ psychiatry. This necessitates adequate training and experience be provided in these domains.
That families be actively engaged in the treatment program to provide them with support so as to ensure that all of the domains of the veteran’s presentation are being addressed.
In the context of an ADF member having threatened or having attempted suicide there should be an independent needs-based assessment followed by interventions to meet the patient’s needs and reduce exposure to the known risk factors. These include: i) Evidence-based treatment ii) Relationship counselling iii) Psychosocial support
An overview of the risk of suicide in ADF personnel should be made on the basis of the presence of a history of past attempts and/or ideation, a history of major depressive disorder and/or posttraumatic stress disorder, physical health difficulties and a history of traumatic stress exposures. The design of such an assessment should be done as is recommended by the Productivity Commission, which requires the more extensive use of data and a greater focus on outcomes.
The care of veterans should be oversighted with clinical measures. If there is a failure of improvement, a second opinion should be obtained, and a step-to-care model implemented. This should include novel and emerging treatments such as intravenous ketamine, which has been shown to have a significant impact on mood disturbance and suicidality.
There should be an increase in the number of uniform psychiatrists in the ADF with specialist training with trauma-related psychiatry in military and veterans’ psychiatry. The barriers to employing such psychiatrists should be identified and overcome.
Assuming that CPL Turner’s death is indicative of wider problems within the ADF, there should be ongoing monitoring of suicidality and suicidal risk and ADF personnel should (sic) be conducted as part of a continued health surveillance program.
A system of step care for PTSD to be established by the ADF to address treatment resistance, i.e. limited or non-response to first line evidence-based interventions.
This should use a staged model of care for PTSD and other disorders. A method of ensuring early review by senior consultants be established to assist in the
management of high-risk patients (Mcfarlane, A.C, Bryant R, PTSD: the need to use emerging knowledge to improve systems of care and clinical practice in Australia, Australas Psychiatry, 2017;25:329-331).
Finally, there have been various inquiries conducted into the issues of suicide and selfharm by current and former ADF personnel, which include:
National Mental Health Commission report of 28th March 2017;
Foreign Affairs, Defence, Trade and Reference Committee Report “the constant battle: suicide by veterans” August 2017;
Productivity Commission Inquiry Report “A better way to support veterans” No. 93, 27th June 2019;
The Inquiry into Transition by the Australian Defence Force (ADF Joint Standing Committee on Foreign Affairs, Defence and Trade) of April 2019 (to be reviewed).
Against the background of these inquiries, further recommendations could include the following:
To review and critique what information and research has been conducted into the suicide and suicidality of ADF personnel and veterans and its relationship to their mental health and the adequacy of treatment service to provide high standard care.
To enquire whether information about mental health and suicidality of ADF personnel and veterans has been optimally utilised. In the light of these findings to make recommendations about what research and quality assurance data could assist in identifying how the risk of suicide could be minimised and what changes in the system of health care are required.
To identify the barriers of the implementations of future, current and previous recommendations about implementing suicide prevention programs and improvements to mental health services. To make recommendations about how to address these barriers to implementation.
To make recommendations for how to optimally oversight the provision of mental health care by the ADF and DVA moving forward so as to ensure findings and recommendations that emerge about the causes of suicide and poor mental health can be appropriately implemented and operationalised.
These recommendations are broad matters that should have informed the care that was provided to CPL Turner and the risk of his death by suicide.”736
(f) The expert conclave
The nature of PTSD
seen in individuals with single traumatic episodes and PTSD which is uncomplicated by other disorders.737
Dr Hopwood’s evidence was that the prognosis for a person with a diagnosis of PTSD is highly variable but decreases with length of time having the disorder and the development of co-morbidities. He stated that a return to what is ostensibly a normal level of functioning is possible for individuals who achieve remission, but that those persons can still have a relapse of the condition most likely in association with other stressful life events or specific reminders of their trauma. Dr Hopwood stated that in relation to CPL Turner it is reasonable to state that if his PTSD had gone into remission prior to his 2016 deployment, it would have been appropriate to take into consideration the risk of relapse with this deployment.738
Dr Hopwood explained in relation to the concept “subsyndromal symptoms” that these are symptoms that do not meet the threshold criteria for a diagnosis of PTSD.739
It should be noted that Dr Sringeri was also asked about the nature of PTSD and its treatment. Dr Sringeri’s evidence was that PTSD is “treatable” but rather than being curable per se, people can “function at normal level” with “minimum symptoms”, but they will always be more vulnerable as a population. He considered that combatinduced PTSD made a person more vulnerable to future PTSD from combat-related circumstances.740 His view was that psychological treatment was the mainstay for treatment of PTSD and that exposure therapy, CPT, and EMDR have good evidence in the management of PTSD.741 The interaction of PTSD, alcohol, and major depressive disorder
Professor McFarlane’s evidence was that alcohol abuse is a recognised co-morbidity of PTSD. He stated that there is a well-established literature base demonstrating that alcohol misuse is a “consequence and a complication of PTSD”.742 He explained that alcohol abuse might be something that alerts family or social networks to the fact that a person may in fact be suffering from a psychiatric disorder.743 In terms of alcohol abuse and the experience of PTSD, he considered that the evidence pointed to alcohol in fact mitigating the symptoms of PTSD because of anxiolytic effects of alcohol.
However, when alcohol is consumed excessively, that creates a secondary set of 737 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 5-6.
738 Supplementary Report of Dr Hopwood dated 8 July 2021 (Exhibit 5) at 6.
behavioural problems and difficulties (albeit not necessary worsening the condition of PTSD).744 Dr Dinnen agreed with Professor McFarlane.745
Dr Large’s opinion was that alcohol is only anxiolytic when it is being drunk, and that in alcohol withdrawal, anxiety is a prominent feature. He was also of the view that alcohol use can predispose a person to PTSD.746 Dr Nielssen agreed with Dr Large.747 Dr Dinnen did not agree that alcohol use can lead to PTSD, but considered it was a prodromal sign, that is, an indication that the person is coping with their psychiatric symptoms in an unhealthy way.748 Dr Hopwood did not consider there was an established base in the literature demonstrating that alcohol abuse alone would predispose an individual to developing PTSD, other than by increasing the risk of being involved in a traumatic incident.749 Professor McFarlane did not agree that alcohol abuse was something that would predispose an individual to developing PTSD (aside from the risk that people who abuse alcohol are more likely to be involved in accidents and therefore trauma exposure).750
Dr Large explained his opinion on this might differ from that of Professor McFarlane because he worked almost solely with in-patients, so none of the patients he sees are currently drinking alcohol (rather, they are admitted and the hospitalisation would withdraw those individuals from substances). He stated that his view that alcohol use is associated with an increased severity in PTSD symptoms was “probably heavily informed by seeing people with post-traumatic stress disorder withdraw from alcohol”, not by seeing people who have PTSD and are continuing to drink alcohol.751
Dr Large, Dr Nielssen, and Dr Hopwood agreed that CPL Turner’s alcohol abuse was likely responsive to his symptoms of PTSD in the period 2013 to 2017, and itself contributed to the severity of his PTSD.752 Dr Dinnen disagreed and considered that the ongoing use of alcohol had an ongoing anxiolytic effect, so would not worsen PTSD. He stated that in his view, CPL Turner’s alcohol use in 2013 to 2017 was not “anything other than a reflection of his disturbance”, but rather was a form of “selfmedication”.753 Dr Hopwood clarified that alcohol abuse was likely to lessen the prospects of engaging with treatment and have an impact on other areas of a person’s
life and those things were unlikely to help with PTSD: he stated “the presence of a significant alcohol use disorder is likely to make the overall situation with PTSD worse, even if indirectly”.754
In respect of CPL Turner specifically, Professor McFarlane considered that it was “very important to separate the symptoms of his post-traumatic stress disorder from the alcohol use disorder, because alcohol use disorder creates its own difficulties independent of PTSD”.755 In his view, CPL Turner’s alcohol use disorder was not what made his PTSD worse, but rather it was his continued trauma exposure and continued deployment. He acknowledged that “his alcohol use certainly didn’t help”.756 The interaction of PTSD with domestic violence
Dr Hopwood considered there was an association of PTSD in veterans with domestic violence, but that this was an issue that “was long hidden and not discussed and researched well”.757 He also indicated that he had seen patterns where a person with PTSD, in response to their fear, will attempt to control the behaviours of their family, and can be expressed forcefully and might amount to “coercive control”.758 He also accepted that domestic violence might raise a red flag that PTSD is more active than is otherwise apparent.759
Professor McFarlane considered that domestic violence is a red flag for PTSD and other psychiatric disorders.760 He noted a study which he had done of the fire service in South Australia revealed that a person’s dysfunction associated with their PTSD symptoms was most apparent in their domestic environment: so they would be difficult to deal with and manage in their home environments, but be capable of functioning in their work environments. He considered that domestic violence is of particular significance because it may well “be the place where somebody’s difficulties first become manifest”.761 In his view, the mere fact of the AVO having been sought in 2015 was a red flag which ought to have been taken into account in July 2016 when the decision to deploy CPL Turner was made.762
Dr Large accepted that domestic violence was a red flag for many things, including PTSD. However, he emphasised that the “XY chromosome and alcohol on a
population basis” were the causes of controlling and violent behaviour, that domestic violence is a huge societal problem, and that PTSD is not “the prominent cause of it”.763
Dr Dinnen considered that PTSD was a potent cause of domestic friction but that the cases where there is actual domestic violence were “not frequent” and usually there were other factors involved.764 The risks of further deployments in the context of PTSD
Professor McFarlane explained research which had been done by way of tests of neural function on Special Forces soldiers and other members of the ADF and explained that one of the effects of prolonged deployments which had been shown was a diminished ability of target detection, as instead what happens is “they react to everything” and lose the ability to discriminate.765
Professor McFarlane emphasised in his oral evidence that CPL Turner had a heavy load of deployments and exposure to trauma. Professor McFarlane emphasised that it has been recognised in the psychiatric literature that there are limits of the period over which you can deploy people and that after a point further combat exposure places an unacceptable hazard to military personnel.766 CPL Turner’s symptoms in 2015 and 2016
The experts were taken to a number of documents in relation to CPL Turner’s mental state spanning the period from February 2015 to November 2015.767 Dr Hopwood’s evidence was that CPL Turner had symptoms of PTSD late in 2015.768 Professor McFarlane agreed with this and indicated that the matters written in the VVCS records from CPL Turner’s attendance in November 2015 indicated he was suffering from significant symptoms.769 Dr Large accepted that it could not be said CPL Turner had no symptoms of PTSD over the period of 2015 leading into 2016 and that it could not be assumed that the reason CPL Turner declined further treatment was because he was managing.770 In his view, the starting point was that, accepting CPL Turner had PTSD in 2014, it was fairly unlikely that his symptoms would remain resolved over long
periods of time.771 Dr Nielssen considered CPL Turner had symptoms throughout 2015 and had understated them.772
In relation to self-reporting symptoms, Dr Hopwood accepted that there were limits to self-reporting and that one of them is if the reporting occurs in the context of employment in a career which is valued. In relation to how an interviewer could ascertain if a person had or did not have symptoms, Dr Hopwood accepted that there was no perfection in the skill of seeking out symptoms and it was possible for someone to conceal their symptoms.773
In relation to whether a doctor could attempt to obtain a corroborative history from other people, Dr Hopwood indicated this was not always straightforward and could be destructive to any future therapeutic relationship.774 He accepted that information such as that which Joanna Turner had — that CPL Turner was suffering from nightmares and flashbacks in 2015 — would have indicated that CPL Turner had symptoms of PTSD.775 Professor McFarlane considered that corroborative evidence was extremely valuable but recognised that the issues of consent are complex.776
Professor McFarlane indicated that underreporting is an endemic issue in the Special Forces community and that there was a major probability of CPL Turner underreporting his symptoms in 2015 and 2016.777 He considered it significant that he did not find in the health records a record of the information which Joanna Turner had provided to BRIG Langford or information which she had been providing to Selena Clancy or the Chaplain (Padre). He further considered that the records around CPL Turner’s return from deployment in 2015 were “remarkably naïve”, in that there ought to have been evidence of inquiries into the welfare of Joanna Turner and her children, as this may have led to exploration of CPL Turner’s own difficulties.778 Professor McFarlane considered that there was a substantial body of evidence in the health records which demonstrated residual or recurrent PTSD symptoms throughout 2016, and that “it’s not to be critical of the individual health practitioners and I think, they have to, you know, deal with this in a clinical context” but rather “it’s the failure of anybody to actually
take an oversight of these records and I think that’s a particularly important issue when it came to the decision to re-deploy him".779 The 2016 clearance to deploy on OP OKRA
Professor McFarlane’s opinion was that based on CPL Turner’s presentation in 2014, the probability of him being fit to deploy in 2016 was low, but it was necessary to give him the benefit of the doubt and assess him.780 In doing that assessment, it would have been important to consider all of the information available in the health record.781
In his view, it was very naïve to think that being deployed would be good for CPL Turner’s mental health. He recognised that it might have been a further trauma for CPL Turner if he could not deploy with his teammates. However, he considered this was a matter that had to be managed with soldiers and that managing a transition out of a deployment cycle is something that did not happen for CPL Turner.782 In his view, it was incorrect to consider that it was better for CPL Turner’s mental health to deploy than to not deploy.783 He referred specifically to the assumption that being in Iraq might be good for CPL Turner because he would get away from alcohol and stated that, in his view, CPL Turner “needed a lot more going into an environment with an abstinence of alcohol and a detox facility probably would have been a better idea than thinking that…Iraq was going to be a detox deployment”.784
In relation to Dr Sringeri’s 13 July 2016 letter, Professor McFarlane considered that Dr Sringeri was in an “invidious position” because he did not have access to all of the information in the ADF health records. He considered that Dr Sringeri’s opinion was at risk of underestimating his difficulties. In his view, this was one of the problems with the ADF outsourcing aspects of clinical care because Dr Sringeri would not have understood the complexity of the issues involved, in particular in taking account of CPL Turner’s prior exposures and the nature of the activities on those deployments, as well as the secretive nature of the activities he might be involved in on the Iraq deployment in 2016.785
Professor McFarlane considered that it was not the role of an individual psychiatrist to make a recommendation about whether or not an ADF member was fit to deploy.786 In
his view, a civilian psychiatrist can provide valuable information about what they know about the patient’s condition, but that it was the role of the military to undertake the specific risk analysis based on whether the person should or should not deploy.787
Professor McFarlane’s view was that, assuming the entry in the brief of evidence which records the referral request from the ADF to Dr Sringeri on 11 July 2016 was the full referral letter, he considered it was manifestly inadequate.788 He explained that it ought to have had a specific set of facts, including things that Dr Sringeri might not know (even as CPL Turner’s treating clinician), which were contained in the ADF medical records.789 He was asked whether a civilian psychiatrist can reach a view about fitness to deploy. His answer was firmly to the effect that a civilian psychiatrist can provide information, but that information should be fed into the military system for determining waivers. In his view, “if we are to make the system better…getting these sorts of things right is absolutely critical” and it was important to have psychiatrists actually employed in the military.790 In his view, the decision on whether to deploy CPL Turner was not “about his fitness to deploy” but rather the medical employment classifications in the ADF and also about the “risk of reinjury and the recognition of the long-term costs and consequences to personnel” and that these issues were not addressed in the referral letter to Dr Sringeri.791
Dr Large’s opinion was that fitness to deploy is not solely the province of psychiatry. In his view, a psychiatrist asked to give a view about whether or not CPL Turner was fit to deploy in 2016 should have known about what was going to be required of the solider on the deployment: but that “probabilistic decisions about that sort of thing are, you know, they’re up to the armed forces and up to the individual as much as the psychiatrist”.792 In his view, the use of the term “very low” in the context of risk of relapse as at July 2016 was problematic because CPL Turner was always at risk of relapse and probabilistic statements are difficult to interpret, and that CPL Turner was not likely to ever be at a “low risk” of relapse, even in civilian life.793 In his view, it would have been possible for a psychiatrist to form a view that the psychiatric harm would be greater to CPL Turner by not deploying than deploying.794 Dr Large explained under cross-examination by Senior Counsel for the ADF that “fitness” seems to contain at least two elements, one being capacity and the other being risk. In his view, it was very
clear that CPL Turner had the capacity to deploy but as to risk, “we really allow patients to carry their own risk”.795
Dr Nielssen’s opinion was that CPL Turner was “perfectly fit” but that “even without hindsight bias I would say that it wouldn’t do him any good, that accumulative effects of multiple deployments and the cumulative traumas greatly increase the probability of enduring psychological harm”.796 In his view, the risk of further trauma would simply increase the probability of a disabling PTSD in the longer term.797 In his view, there was a reasonable view that another deployment may have been better for his mental health than not deploying.798 He later clarified that “it wouldn’t have done him any good, but whether he was fit from a military point of view and whether there was a possibility that going on the deployment might have made him feel better, both those views were available”.799 He considered that CPL Turner was at a real risk of relapse if deployed in 2016.800 He stated that it was not accurate to say that CPL Turner’s chances of recurrence of PTSD were very low.801
Dr Nielssen appeared to draw a distinction between the concept of being fit to perform duties and whether performing those duties carried a risk of harm to the individual. He considered it important to consider the perspective of who was doing the assessment: “if you’re doing the assessment on behalf of the army to try and fill the roster of people deployed, well, obviously, you say well, you’ll do a good job and he’s a really good soldier. If you’re worrying about him and the effect on him and its likely effect, then that’s a different story” and you would say “this could be bad for you…you should think about going to do something a bit quieter and don’t expose yourself anymore to this sort of danger”.802 He explained that in his view, CPL Turner was fit to deploy but “the customer is always right…and it was his wishes that were respected, his clear wishes that he wanted to be deployed”.803
Dr Dinnen indicated that CPL Turner’s symptoms as contained in the ADF medical records for the period of 2015 should have been taken into account in the decision of whether or not CPL Turner should have been deployed in 2016.804 Dr Dinnen’s view was that he was “fit for deployment” and that, as a psychiatrist, his first responsibility
was “to the interests of the person we’re looking after” and that CPL Turner would have been “convincing to me that he was capable of doing it”. However, he would have said to him “this is not good for you. You’ve been damaged enough. Do you really want to do this”.805 Again, Dr Dinnen (like Dr Nielssen) appeared to draw a distinction between CPL Turner being fit to deploy (that is, capable of doing his job) and the risk to him of that deployment.806 He stated that he would have told him about the risks of deployment and said in his report “I’m concerned about the consequences of this deployment, but he considers himself fit” and that “he’ll need careful monitoring when he returns”.807 In his view, the chances of recurrence of PTSD on deployment were not very low and he would have advised him that deployment was likely to make things worse if he had seen him.808
psychiatrist is to advise of the risks and consequences from a psychiatric perspective and then to indicate the question of deployment is one for the ADF.815
Dr Hopwood did not consider there was a reasonably available view that it would be better for CPL Turner’s mental health to deploy in July 2016 than to not deploy.816 The disciplinary proceedings
Dr Nielssen did not consider there was a direct relationship between PTSD and susceptibility to risk-taking behaviour and impulsivity.817 Dr Dinnen stated he was aware of literature demonstrating an increased risk of violence in traumatised veterans in America.818 However, he agreed with Dr Nielssen that for most people who have been traumatised, they are more vigilant, more cautious, and less impulsive.819 In his view, the relationship between PTSD and violence or unlawful behaviour is complicated and that one reaction to trauma is anger and a desire to seek vengeance, which is not really a “factor of PTSD so much as a response to traumatic events which they’ve witnessed”.820
Dr Hopwood considered there was an association of impulsivity and risk-taking behaviour in individuals with PTSD. He distinguished this from a person avoiding specific reminders of their trauma, but considered that impulsive behaviour, including irritability, was a “very real and prominent feature for some people in their PTSD”.821 In his view, a person who had no symptoms of PTSD but a past history of PTSD would still be at risk of a recrudescence of symptoms and a recrudescence of the impulsivity associated with that.822 Further, if a person still had symptoms (even subsyndromal symptoms), it would be more likely the person was at risk of acting impulsively.823
Dr Dinnen’s view was that having had PTSD, CPL Turner was at an increased risk of anger and irritability in 2016 and it would have increased his emotional response.824
Professor McFarlane’s evidence was that there is a clear link between PTSD and the propensity for people to do things that are completely out of character.825 He explained that part of PTSD is “numbing, where people feel dead”, and so they will “do things
that make them feel alive again”.826 Dr Large accepted there was a relationship between impulsivity and exposure to trauma.827 Use of steroids
Professor McFarlane’s evidence was that the use of steroids can have “significant psychotropic effects”, “increase people’s aggressiveness”, and “increase their disinhibition”.828 He considered the effects of steroid use on symptoms of PTSD is “really unclear”, but that the drugs had “other adverse effects on his mental state”.829 He noted that there was an important question about CPL Turner’s motivation for steroid abuse, noting that it commenced after he had experienced significant trauma and may have been motivated by a sense of seeking revenge, by increasing his physical strength and endurance in the battlefield.830
Dr Hopwood was not sure about whether PTSD could have caused CPL Turner to engage in steroid use and noted that, in his experience of treating ADF special forces, he had met other members who used anabolic steroids, so he found it difficult to be certain about the relationship between PTSD and steroid use.831 Use of other drugs
Dr Hopwood considered that there was a potential link between CPL Turner’s use of cocaine and his PTSD, referring to the euphoriant effects of cocaine.832 He also noted that use of illicit drugs which are difficult to discuss made treatment difficult because a person may not disclose that use and it can make developing a trusting and effective therapeutic relationship difficult.833
(g) Professor Naren Gunja
834 Exhibit 64.
Procedural fairness
The Commonwealth’s submissions complain that evidence was not led during the course of the Inquest from individuals “who would have been able to shed light on relevant events”835 and that, as such, there are now “consequences for the findings, comments and recommendations that [I am] now in a position to make.”836 Particular findings and comments were thereafter identified as not being open to me on this basis.837 Submissions
Counsel Assisting has provided submissions on this issue.838 Counsel Assisting notes that objections of this nature call for attention to two specific considerations: i. identification of the precise subject to whom procedural fairness is said to be owed; and ii. identification of the content of the obligation owed to that subject.
In the coronial context, the subject to whom the obligation is owed is one against whom an adverse finding or comment may be made. Such a person is entitled to be heard against the making of such a finding.839 It follows that a “coroner is not bound to observe the rules of natural justice in relation to each and every person who may be referred to during the course of the inquiry. Such an obligation arises only when an adverse finding against the person in question is contemplated.”840 The ability of a witness or evidence to “shed light” on a subject matter is, in and of itself, insufficient to give rise to an obligation of procedural fairness to that witness.
835 Submissions of the Commonwealth dated 7 June 2024 at [30].
836 Submissions of the Commonwealth dated 7 June 2024 at [31].
837 See, e.g., Submissions of the Commonwealth dated 7 June 2024 [111], [125(a)], [153], [158], [171], [176(d)], [185], [191], [215], [221], [236], [245], [474], [484]-[485], [546], [639], [665], [722], [732], [795], [804], [818].
838 Submissions in reply of Counsel Assisting dated 22 August 2024 at [3]-[14].
839 Annetts v McCann [1990] HCA 57; 170 CLR 596 at [7]-[9] (Mason CJ, Deane and McHugh JJ).
840 R v Somes; ex parte Woods [1998] ACTSC 160 at [27] (Crispin J) (emphasis added).
The content of the obligation extends only to the ability of the subject of a proposed adverse finding or comment to be heard on that topic – it is not a plenary “right to make submissions on the general subject matter of the inquest.”841
Counsel Assisting contends that the obligation does not arise in a vacuum. Rather, it is to be balanced against the obligation on a coroner to appropriately confine the scope of the inquiry to meet its “primary duty”842 in s 81 of the Coroners Act 2009 (NSW) (Coroners Act), lest a coroner “be constantly torn between the need to contain the scope of the inquiry and the need to ensure that all interested parties were treated fairly.”843
Counsel Assisting points out that, as the Commonwealth accepts,844 the purpose of the inquiry is not “to conduct a wide-ranging inquiry akin to that of a Royal Commission”845 and it is “important that extraneous factors do not get in the way of that primary duty”.846 To that end, a coroner, through the exercise of “proper discretion and commonsense”,847 is entitled to limit the ambit of the inquiry and have regard to “the importance of keeping the inquiry within reasonable bounds and expense”.848 If potential evidence that Counsel Assisting might have called has “no reasonable likelihood of influencing the outcome” of the inquiry, there is no obligation to procure that evidence even if it is potentially relevant to the subject matter of the inquiry.849 Counsel Assisting considers that such considerations are to be borne in mind when determining the degree to which I am required to hear further evidence on a particular issue in order to satisfy obligations of procedural fairness.
Viewing the Commonwealth’s submissions in the context of the above principles, Counsel Assisting makes the following observations.
First, to the extent an adverse comment or finding is sought in Counsel Assisting’s submissions, the subject of that comment or finding has been relevantly identified in those submissions. In this respect, a distinction needs to be drawn between the conduct of an individual within an organisation and the conduct of an organisation as a whole. While it is accepted that an organisation acts through individuals, an adverse finding as to a deficiency in the conduct of an individual in the performance of their role 841 Annetts v McCann [1990] HCA 57; 170 CLR 596 at [9] (Mason CJ, Deane and McHugh JJ).
842 Submissions of the Commonwealth dated 7 June 2024 at [21].
843 See R v Doogan; ex parte Lucas-Smith [2005] ACTSC 74; 158 ACTR 1 at [28] (Higgins CJ, Crispin and Bennett JJ).
844 Submissions of the Commonwealth dated 7 June 2024 at [18], [22].
845 R v Doogan; ex parte Lucas-Smith [2005] ACTSC 74; 158 ACTR 1 at [28] (Higgins CJ, Crispin and Bennett JJ).
846 Commissioner of Police v Attorney General for New South Wales [2022] NSWSC 595 at [99] (Wright J)).
847 Conway v Jerram, Magistrate and NSW State Coroner [2011] NSWCA 319 at [48] (Young JA).
848 Gallagher v The Coroners Court of the Australian Capital Territory [2022] ACTSC 160; 370 FLR 115 at [30] (McCallum CJ).
849 Doomadgee v Clements [2006] QSC 357; 2 Qd R 351 at [52] (Muir J); Inquest into the death of Kumanjayi Walker (Ruling No 7) [2023] NTLC 11 at [4]-[5] (Judge Armitage).
within the organisation is different in terms to an adverse finding that an organisation as a whole acted in a deficient manner. Accordingly, to submit that an adverse finding cannot be made against an individual and therefore “through them the ADF”850 risks eliding the intended subject of the proposed comment or finding.
An example of the importance of focussing on the correct subject of the finding or comment is illustrative. The Commonwealth submits that because evidence was not led from “medical personnel involved in the RtAPS/POPS screenings conducted between 2008-2013”, adverse findings or comments cannot be made against the “the relevant personnel (and, through them the ADF)”.851 This is apparently responsive852 to Counsel Assisting’s submission that there “were early warning signs” in these screenings that CPL Turner “was experiencing significant trauma and was slowly developing the symptoms of PTSD”.853 Counsel Assisting notes that, when that submission is read in context,854 the relevant finding is that during this period it appeared the ADF did not have “in place any longitudinal method of identifying individuals who were at particular risk of deterioration in their mental health”. Clearly, these paragraphs do not identify a particular deficiency in the care provided by the medical personnel involved in any particular RtAPS/POPS screening per se. Rather, they focus on an identified systemic issue in the ADF. It is not necessary that such a deficiency is identified “through” the conduct of any particular individual as the Commonwealth submits.
Second, it is submitted that to the extent that I would make a comment or finding as to the institutional response of the ADF, the discharge of the obligation of procedural fairness to the ADF does not require that Counsel Assisting call all available witnesses who might “shed light” or give evidence relevant to a particular topic. It is submitted that unless a coroner formed the view that there was a reasonable likelihood, based on the evidence that has been adduced, that the evidence of an uncalled witness could influence the outcome of a proposed finding, a coroner is entitled to limit the ambit of the inquiry and proceed in the absence of that evidence. Counsel Assisting submits that a coroner is not obliged to hear from each and every individual involved in an organisational process in order to form a view about the adequacy of that organisational process. Such an obligation would render the coronial process unworkable and would bespeak the “wide-ranging inquiry” or “discursive 850 See e.g. Submissions of the Commonwealth dated 7 June 2024 at [102], [171], [191], [484].
851 Submissions of the Commonwealth dated 7 June 2024 at [111].
852 Submissions of the Commonwealth dated 7 June 2024 at [102].
853 Submissions of Counsel Assisting dated 2 November 2023 at [443].
854 Submissions of Counsel Assisting dated 2 November 2023 at [444].
investigation”855 that is eschewed in the coronial context. It also pays insufficient regard to the extensive documentary evidence in this case.
Counsel Assisting notes that each of the interested parties have been given the opportunity to provide lengthy and detailed submissions in reply to issues raised during the Inquest, and at the very latest in submissions of Counsel Assisting provided to the parties some seven months before responsive submissions being filed.
856 Submissions of the Commonwealth dated 7 June 2024 at [24]-[27], [33].
857 Commissioner of Police v Attorney General for New South Wales [2022] NSWSC 595 at [83] (Wright J).
858 Onuma v The Coroner's Court of South Australia [2011] SASC 218; 111 SASR 382 at [98] (Kelly J).
859 Commissioner of Police v Coroners Court of South Australia [2020] SASCFC 64; 138 SASR 535 at [78] (Kourakis CJ; Parker and Hughes JJ) (citing Musumeci v Attorney General of NSW [2003] NSWCA 77; 57 NSWLR 193).
860 Musumeci v Attorney General of NSW [2003] NSWCA 77; 57 NSWLR 193 at [113] (Ipp JA, Beazley JA agreeing).
861 See e.g. Onuma v The Coroner's Court of South Australia [2011] SASC 218; 111 SASR 382 at [97] (Kelly J).
862 Commissioner of Police v Coroners Court of South Australia [2020] SASCFC 64; 138 SASR 535 at [83]-[84] (Kourakis CJ; Parker and Hughes JJ); Mead v Mulligan [2013] WASC 460 at [80(f)] (Kenneth Martin J).
863 See e.g. CS [93], [532].
adverse finding may be made has been raised in the course of doing so, Counsel Assisting is not obliged to recall such a witness to put each possible conclusion that the coroner might draw from their evidence to them.
Consideration
This would place an onerous burden on the Court and make coronial proceedings unworkable. I pause to say that I am unaware of any request from the Commonwealth to call a witness which was refused.
Hindsight bias
The Commonwealth and some of the interested parties have referred to the concept of “hindsight bias” and criticise the approach of Counsel Assisting in both the conduct of the Inquest and written submissions.865 Submissions
Counsel Assisting has provided submissions addressing these criticisms.866 864 Coroners Act NSW (2009) s 58.
865 See, e.g., Submissions of the Commonwealth dated 7 June at [56]-[57]; Submissions in reply of GPCAPT Ross dated 22 July 2024 at [17]; Submissions in reply of Dr Hale dated 19 July 2024 at [6]; Submissions of CAPT MH dated 7 June 2024 at [3].
866 Submissions in reply of Counsel Assisting dated 22 August 2024 at [15]-[20].
The Commonwealth refers to certain case law867 that is concerned with actions in negligence, the purpose and outcome of which are to attribute responsibility in the form of tortious liability to a particular person. Counsel Assisting submits that avoiding hindsight bias in that context ensures that reasonably acting defendants are not unfairly subjected to adverse liability judgments, the role of a coroner is not to attribute liability or blame for a death to any person or organisation.868
In submissions in reply, Counsel Assisting submits that “the Coroner should be astute to avoid hindsight bias in judging the actions of any particular person or organisation in the process of making a finding which results in adverse criticism of their conduct, at the time their conduct was engaged in.”869 It is submitted that a finding of that kind would be unfair for essentially the same reasons as hindsight bias is to be eschewed in the context of actions in negligence. It is not the case that a coroner is required to approach the findings to be made as if the coronial process is not one that is obviously being conduct with the benefit of hindsight. Rather, a coroner looks back at what happened in respect of a particular death with the benefit of all the facts available to them and determine what findings should be made about manner and cause and what recommendations (if any) should be made arising out of the death of a person.870
Counsel Assisting submits that it would be artificial, and pointless, to attempt to approach the Inquest and the findings as if they were not what they plainly are: a retrospective analysis of the manner and cause of a death, with a view to making recommendations as to the future to address the matters arising from those findings as to manner and cause of death. They note it would deprive the coronial process of much of its utility if an inquest were confined to assessing all the facts from the perspective of those individuals involved at the relevant time, because it would deprive the coroner of the ability to formulate sensible recommendations or generate learnings from the tragic circumstances with which this jurisdiction is concerned.
In this respect, Counsel Assisting refers to the comments of State Coroner Barnes in the Inquest into the deaths arising from the Lindt Café Siege (2017), in which his Honour stated at [25]: “relying on the benefits of hindsight is understandable but unnecessary. The inquest compiled a more complete picture of the events of 15 – 16 December than was available to any individual at the time. The insight this knowledge afforded can be applied to the benefit of police and the public. Such use of hindsight is fair and proper.
867 Rosenberg v Percival (2001) 205 CLR 434 at [16] and Tapp v Australian Bushmen’s Campdraft & Rodeo Association Limited (2022) 273 CLR 454 at [60].
868 Submissions in reply of Counsel Assisting dated 22 August 2024 at [15].
869 Submissions in reply of Counsel Assisting dated 22 August 2024 at [16].
870 See Abernethy et al, Waller’s Coronial Law and Practice in New South Wales (4th ed, 2010) at [I.124]-[I.125],
Using hindsight to criticise individuals by reference to things that they did not know and could not reasonably have been expected to know would be unfair. That has not been done in this report.”
However, in performing the role set out in ss. 81 and 82 of the Act, it is accepted that a Coroner must judge the appropriateness of steps taken or not taken by an involved person or organisation against the information that was available to that individual or organisation at the time, and not, as has been pointed out in submissions, through the prism of the tragic outcome of the case. Indeed, coronial inquests routinely examine whether, armed with the knowledge available to the relevant individual or organisation at the time, a party could have or should have acted differently in the particular circumstances that presented themselves. This is, in my view, entirely appropriate, and indeed a fundamental aspect of the coronial jurisdiction.”
Counsel Assisting submits that any finding involving the criticism of a person or organisation’s conduct of a particular matter is not to be infected with hindsight bias in order to ensure it is not an unfair criticism. Counsel Assisting further submits that, with the benefit of all of the hindsight that the coronial inquest brings, findings as to the appropriateness or otherwise of the conduct of persons or organisations and recommendations in respect of future conduct of persons or organisations involved in the Inquest should be made. It is submitted that such a finding is not unfair and can acknowledge the contemporaneous limitations upon those involved in those decisions having regard to what they knew at the time they engaged in relevant conduct.871 Consideration
In my view, criticisms of the approach taken by Counsel Assisting on this issue are misplaced and demonstrate a conceptual misunderstanding of the work of a coronial court. There is no doubt that the Inquest was able to compile a more complete picture of the events leading up to CPL Turner’s death than would have been available to any single individual at the time. This is the strength of the kind of review which can occur in this Court. It allows a coroner to have a broad overall understanding of events which can be particularly useful in identifying the true circumstances of a death, any systemic issues that may arise, and the possible need for recommendations. It does not mean that particular individuals are thereby judged as though they too had the benefit of this overview at the time they were making relevant decisions.
871 Submissions in reply of Counsel Assisting dated 22 August 2024 at [20].
Conclusions of other inquiries and foreseeability Submissions Submissions of Mr and Mrs Turner
Submissions of Counsel Assisting
Counsel Assisting submits that insofar as the submission suggests that publicly available material would be used as a basis of an adverse finding, I am limited to the evidence that was adduced during the Inquest.873 They consider that any aspects of the Dunt Report not contained in or adopted by Professor McFarlane ought not be relied upon in my findings.874 I accept that submission.
Mr and Mrs Turner also refer to other reports and inquiries referred to by Professor McFarlane in his report, including the report “Suicidality in the Australian Defence Force: results from the 2010 ADF Mental Health Prevalence and Wellbeing Dataset” of May 2012 (which made a number of observations pertinent to the risk factors identified in CPL Turner’s suicide), the report McFarlane and Bryant. Predicted trajectories of morbidity for the Australian Defence Force 23rd May 2013, and an extensive research program conducted as the part of the Deployment Health Surveillance Program examining members of 2CDO prior to 2010 to 2011. Mr and Mrs Turner contend that, as a result of these other investigations, the ADF was “forewarned of risk factors” and that “the ADF were left wanting in handling the known risks”.875 872 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [4]-[13].
873 Submissions in reply of Counsel Assisting dated 22 August 2024 at [95].
874 Submissions in reply of Counsel Assisting dated 22 August 2024 at [96].
875 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [19].
Counsel Assisting notes that a recognition that deployment to a conflict zone was “inherently potentially traumatic” was a feature of the evidence in the Inquest from both ADF members876 and the experts.877 In this sense, they agree that there was a degree of foreseeability in relation to the risk of deterioration in the mental health of a member with a known diagnosis of PTSD who was to be deployed to a combat zone. However, Counsel Assisting more particularly relies on the specific knowledge the ADF had in relation to CPL Turner’s condition in support of a conclusion that his deployment was “inherently risky”.878 Consideration
In my view, there was ample evidence before the Court from the experts to ground a finding that there was a degree of foreseeability in relation to the risk of deterioration in the mental health of a member with a known diagnosis of PTSD who was to be deployed to a combat zone. The question that needs to be answered is why did the ADF not understand the level of risk involved. It is a question to which I will return.
A list of issues to be considered at the Inquest was initially prepared and circulated to the parties on 23 July 2020 before the commencement of the first tranche of hearing days on proceedings on 19 October 2020. As a result of evidence arising during the first two tranches of hearing days, an updated list of issues was circulated on 10 August
The issues identified in that list were as follows: Issue 1: The cause of CPL Turner’s death; Issue 2: The impact of CPL Turner’s service in the ADF upon his mental health and his death in the context of his personality type and interpersonal relationships; Issue 3: The adequacy of the ADF’s response to CPL Turner’s mental health issues in particular from 2014 to July 2017 and whether CPL Turner’s declining mental health was appropriately managed by the ADF in general and in particular by the Human Performance Wing at Holsworthy; Issue 4: Whether there was any disincentive to CPL Turner raising mental health issues or seeking mental health treatment by reason of ADF policies or procedures; 876 Submissions of Counsel Assisting dated 2 November 2023 at [104]-[105].
877 Submissions of Counsel Assisting dated 2 November 2023 at [362].
878 Submissions in reply of Counsel Assisting dated 22 August 2024 at [97].
Issue 5: The extent to which the investigation and laying of charges arising from an incident involving a pornographic playing card affected CPL Turner’s mental health, the extent to which CPL Turner’s mental health history was taken into account in this process and whether adequate support was provided in these circumstances; Issue 6: The extent to which, if any, that CPL Turner’s redeployment in early 2017 to Charlie Company affected his mental health and whether adequate support was provided in these circumstances; Issue 7: Whether lack of communication and/or cooperation between prescribing doctors played a part in CPL Turner’s death by enabling him to obtain more prescription medication than intended and/or by undermining his mental health care and treatment and the adequacy of the healthcare provided to CPL Turner during 2017; Issue 8: The circumstances by which CPL Turner came to have significant supplies of medication available to him at the time of his death; Issue 9: Whether any electronic or other material was removed (other than by the NSW Police Force) from CPL Turner’s premises after his death, and if so, the present location of that material and the reasons for its removal; Issue 10: Whether CPL Turner was made aware of allegations made against him in late June 2017 and reported to ADFIS and the NSWPF, and if so, the circumstances in which he was made aware, his response, and the impact (if any) on his mental health issues; Issue 11: Whether any other factors arising during CPL Turner’s service contributed to his death; and Issue 12: Whether any recommendations should be made arising from the circumstances of CPL Turner’s death.
Issue 1 – The cause of CPL Turner’s death Evidence
The evidence relevant to this issue is set out in the chronology above. In addition to that evidence, it is noted that the Amended Death Certificate issued on 28 March 2018 records CPL Turner’s cause of death as “(1) Multi-Drug Toxicity”.879 Submissions Submissions of Counsel Assisting
Counsel Assisting submits that on the whole of the evidence before the Inquest, it is plain enough that CPL Turner’s mental state in the lead up to his death was affected by his relationship difficulties with CPL TJ, including the matters the subject of CPL TJ’s confidential statement, the breakdown of his marriage with Joanna Turner, the concerns he had about access to his children, and the concerns he had about his treatment by the ADF during and after the 2016 Iraq deployment. It is submitted that it is plain enough that there was a multifactorial set of circumstances that led to CPL Turner’s death by suicide.880 Submissions of Mr and Mrs Turner
Mr and Mrs Turner have requested that the death certificate registered on the NSW Register of Births, Deaths and Marriages be amended to state that the cause of death and duration of last illness include “multi-drug toxicity, hours” and “post-traumatic stress disorder, years”.881 Submissions of the Commonwealth
The Commonwealth accepts that CPL Turner was suffering from PTSD, alcohol use disorder, and major depression at the time of his death and that these issues and CPL Turner’s death “were causally related to his service in the ADF”.882
The Commonwealth notes that both DVA and the IGADF had made findings linking CPL Turner’s death with his service within the ADF.883 879 Tab 56 (St John of God Hospital medical records) at 16.
880 29/08/22 at T8-9.
881 Submissions of Mr and Mrs Turner dated 28 January 2024 at [13]-[14].
882 Submissions of the Commonwealth dated 7 June 2024 at [28].
883 Submissions of the Commonwealth dated 7 June 2024 at [3].
Submissions in reply
Consideration
Issue 2 - The impact of CPL Turner’s service in the ADF upon his mental health and his death in the context of his personality type and interpersonal relationships Evidence
Submissions Submissions of Counsel Assisting
Counsel Assisting refers to the fact that CPL Turner completed a heavy load of deployments to Afghanistan and to my comment during the course of the expert conclave that “[a]s a country, we had asked him to do a very great deal”.888
Those repeated deployments had a cumulative negative effect on his mental health and the worsening of his PTSD. There were early warning signs, by way of CPL Turner’s RtAPS and POPS screenings, which revealed that he was experiencing significant trauma and was slowly developing the symptoms of PTSD. This was particularly the case in relation to the POPS screenings following the 2011-2012 Afghanistan Deployment, after which CPL Turner reported significant alcohol use and a number of other symptoms of PTSD including restlessness, hyper-alertness, flashbacks, and nightmares.
Counsel Assisting further submits that it does not appear that the ADF had in place any longitudinal method of identifying individuals who were at particular risk of deterioration in their mental health.
Submissions of Mr and Mrs Turner
889 Submissions of Mr and Mrs Turner dated 28 January 2024 at [21].
890 Submissions of Mr and Mrs Turner dated 28 January 2024 at [22].
891 Submissions of Mr and Mrs Turner dated 28 January 2024 at [33].
892 Submissions of Mr and Mrs Turner dated 28 January 2024 at [36].
893 Submissions of Mr and Mrs Turner dated 28 January 2024 at [36].
Mr and Mrs Turner further submit that the evidence indicates that PTSD was a root cause of the breakdown of CPL Turner’s interpersonal relationships, notably those with Joanna Turner and CPL TJ.894 Mr and Mrs Turner would like to see a clear finding that there was a strong correlation between incidents of domestic violence and CPL Turner’s PTSD.895 Submissions of the Commonwealth
The ADF accepts that CPL Turner’s PTSD emerged in the period after his enlistment in the ADF in 2000, most notably in the period 2007-2013, during which CPL Turner was deployed to Afghanistan on four occasions. CPL Turner experienced a number of distressing incidents during these deployments, including the loss of several friends/colleagues which were “doubtlessly sufficient to cause the development of PTSD”. As Counsel Assisting observes, the signs/symptoms of PTSD developed slowly across a number of years. The turning point came in 2013; including him “being withdrawn, quick to anger [and] drinking a significant amount”. Joanna Turner also dated the commencement of CPL Turner’s steroid use to this time.896
The ADF accepts Counsel Assisting’s submission that “[t]here were early warning signs, by way of CPL Turner’s RtAPS and POPS screenings [in the pre-2014] period, which revealed that he was experiencing significant trauma and was slowly developing the symptoms of PTSD”.897 Submissions in reply
Counsel Assisting supports a finding that there was a causative relationship between CPL Turner’s PTSD and the domestic violence to which Joanna Turner was subjected.898 In support of this, Counsel Assisting points to Joanna Turner’s evidence of it not being in CPL Turner’s nature to be violent towards her and the children, the first time of violence towards her was in 2005 after he had returned from Iraq, and that acts of violence towards her son were not consistent with CPL Turner’s behaviour pre2012.899 However, Counsel Assisting does not support a finding that attributes PTSD as the sole and/or ongoing exclusive cause of domestic violence throughout the relevant period (referring to the evidence regarding CPL Turner’s alcohol consumption 894 Submissions of Mr and Mrs Turner dated 28 January 2024 at [46].
895 Submissions of Mr and Mrs Turner dated 28 January 2024 at [48].
896 Submissions of the Commonwealth dated 7 June 2024 at [99].
897 Submissions of the Commonwealth dated 7 June 2024 at [102].
898 Submissions in reply of Counsel Assisting dated 22 August 2024 at [46].
899 Tab 6 (Statement of Joanna Turner dated 6 January 2018) at 1; Tab 32 (IGADF evidence of Joanna Turner) at 34; 19/10/2020 T52.24 and T71.42.
associated with his bouts of violence900 and the lack of consensus amongst the experts as to whether PTSD was a frequently recognised cause of domestic violence (despite raising a “red flag” for PTSD) (as summarised at [480] to [483] above)).
Consideration
I accept Counsel Assisting’s submission that CPL Turner’s mental decline in the months preceding his death was directly attributable to the PTSD he suffered as a result of his service in the ADF. In my view, it is an inescapable conclusion which arises directly from the evidence. I note Dr Malik’s opinion that CPL Turner’s was “one of the worst cases of PTSD” he had seen. The condition arose from repeated deployments and significant ongoing trauma. While there were warning signs recorded in CPL Turner’s RtAPS and POPS screenings, the ADF had no adequate longitudinal method in place to properly identify his deterioration over a period of years.
I accept Mr and Mrs Turner’s submissions that the burden placed on the 2CDO impacted CPL Turner’s ability to take annual leave, attend therapy, and re-integrate into family life. In my view, it is likely that the pervasive culture of the regiment also affected CPL Turner’s ability or willingness to reach out for help. I note that CPL TJ gave evidence that it is a “common perception amongst the differs at the regiment” that the Human Performance Wing (HPW), where CPL Turner was eventually placed, was a designation for “broken people.”901 Joanna Turner gave similar evidence as to the perception of the HPW being a place for “broken” ADF members and Mr Cardinaels also spoke of ADF members not wanting to be perceived as “weak” if they admit to having PTSD.902
There is no doubt that CPL Turner’s use of alcohol was problematic. Professor McFarlane drew my attention to a well-established literature base demonstrating that alcohol use is both a “consequence and complication of PTSD.” I accept that view.
Professor Large had a slightly different approach suggesting that alcohol use might also pre-dispose one to PTSD, an opinion which was contested by some of the other experts. Having carefully considered the expert evidence, it remains difficult for me to precisely unpack the complex interrelation of CPL Turner’s substance abuse and his PTSD. However, there is a clear correlation between the two. It is significant that there 900 19/10/20 T52.22; Tab 7 (Supplementary statement of Joanna Turner) at 2; Tab 32 (IGADF evidence of Joanna Turner) at 20.
902 Tab 7 (Supplementary statement of Joanna Turner dated 15 August 2018) at [33]; Tab 15 (ROI with Mr Cardinaels on 5 June 2018) at 21.
is evidence suggesting that CPL Turner’s use of alcohol or drugs does not appear to have been problematic prior to his ADF service.
Her evidence is clear that prior to his first deployment to Iraq, CPL Turner had not subjected her or the children to acts of violence.
Most of the experts accepted that domestic violence was a significant red flag for PTSD, among other conditions. It troubled me greatly that the evidence disclosed a complete failure on the part of the ADF to adequately deal with this issue. Even when the ADF was aware of the AVO and police involvement, there was a failure to properly consider the issue or to identify it as a “red flag” for CPL Turner or a safety issue for an ADF family. Joanna Turner’s efforts to advise BRIG Langford were ignored (a point to which I will return). She went in good faith to get some assistance, while at the same time trying to save her husband’s career. In my view, she was treated appallingly by the ADF. Again and again the violence that CPL Turner was inflicting was described as “marital difficulties.” Euphemisms were used to excuse and disguise what was really going on as CPL Turner’s mental health deteriorated. Joanna Turner was ignored and at times vilified.
Dr Hopwood, who had a significant history of working with veterans, spoke of the issue of domestic violence in ADF families as one which was “long hidden and not discussed or researched well”. This must stop and it is an issue to which I will return.
Issue 3 – The adequacy of the ADF’s response to CPL Turner’s mental health issues in particular from 2014 to July 2017 and whether CPL Turner’s declining mental health was appropriately managed by the ADF in general and in particular by the Human Performance Wing at Holsworthy Adequacy of ADF’s response prior to 2014
Submissions of the Commonwealth
2007-2008”.903 The Commonwealth also submits that “alcohol abuse is not necessarily a sign/symptom of PTSD; it may simply be a sign/symptom of alcohol use disorder.”904 This, it is submitted, may have informed how personnel may have responded to CPL Turner’s presentation and whether or not they could have recognised the development of PTSD in the context of pre-existing alcohol abuse.905 In this context, the Commonwealth submits that domestic violence may also have been perceived as being indicative of alcohol abuse rather than PTSD.906
As noted above at [557], the ADF accepts Counsel Assisting’s submission that “[t]here were early warning signs, by way of CPL Turner’s RtAPS and POPS screenings [in the pre-2014 period], which revealed that he was experienced significant trauma and was slowly developing symptoms of PTSD”. However, it is submitted that no finding or comment should be made to the effect that relevant medical personnel (and, through them, the ADF) did not respond adequately to these RtAPS and POPS screenings.907 In support of that submission, the Commonwealth notes the following: i. there is no suggestion that the symptoms disclosed in the screenings crossed the threshold for non-consensual mandatory reporting to the Chain of Command; ii. the approach taken by the psychologists who conducted the screenings to manage CPL Turner’s symptoms “within” the ADF’s medical system was not inappropriate; iii. there is every likelihood that CPL Turner was concealing or downplaying his symptoms to the psychologists; iv. while the psychologists perceived that CPL Turner would benefit from further psychological interventions, CPL Turner refused treatment; and v. statements were not obtained from the medical personnel involved in the screenings conducted between 2008-2013.
In relation to MAJ NB and the 2009 screenings, the Commonwealth notes908 that MAJ NB did in fact refer CPL Turner to CAPT KH for “an RtAPS follow-up” and that CAPT 903 Submissions of the Commonwealth dated 7 June 2024 at [100].
904 Submissions of the Commonwealth dated 7 June 2024 at [91].
905 Submissions of the Commonwealth dated 7 June 2024 at [90]-[93].
906 Submissions of the Commonwealth dated 7 June 2024 at [95]-[96].
907 Submissions of the Commonwealth dated 7 June 2024 at [102]-[112].
908 Submissions of the Commonwealth dated 7 June 2024 at [112].
KH decided to take the opportunity to conduct a POPS because of the “timeframe for follow-up and [CPL Turner’s] upcoming commitments on courses”.909
The Commonwealth also submits that it is unnecessary for me to address the evidence of Joanna Turner and Padre MP concerning the wrongdoing of the ADF during the 2013 Afghanistan Deployment (summarised at [23]-[31] above) on the basis that it is “too unconnected to manner and cause of death” or, in the alternative, that no finding should be made that the events described actually occurred.910 Submissions of Mr and Mrs Turner
Mr and Mrs Turner note Dr Dinnen’s and Professor Hopwood’s views that CPL Turner had PTSD prior to 2014 and submit that the ADF failed to identify mental health disorders or engage in meaningful early intervention, which resulted in CPL Turner’s continued deployments and made his recovery more unlikely. They identify a lack of training with respect to PTSD resulting in a failure by the ADF to provide CPL Turner with adequate mental health support, including a delay in his diagnosis. They also submit that the use of a “civilian PTSD checklist” was indicative of a lack of experience with ADF members who are exposed to prolonged combat operations and that a military-focused checklist may be more appropriate.911
In relation to CPL Turner’s PTSD Checklist – Civilian (PCL-C) score of 51 on the 1 July 2009 RtAPS screening tool, CPL Turner’s parents contend that the ADF’s response to the screening was “totally inadequate” and that the ADF breached its own policy that requires that a person with such a score be “appropriately referred for assistance” given that no additional assessment, referral, or support was provided until a POPS two months later. They are also critical of MAJ NB’s failure to act when the PTSD screening identified a high level of symptoms and CPL Turner was, at that point, wanting help. They contend that had there been any follow up after the RtAPS screening, CPL Turner could have been referred for psychological assistance during his six weeks leave.912
As for the POPS conducted on 12 September 2009, Mr and Mrs Turner’s view is that the assessment of CPL Turner’s symptoms as being attributed to ADHD was improper, noting a lack of reference in the POPS to the previous PCL-C score or high symptom levels recorded in the RtAPS. They believe that the lack of clinical assessment at this 909 Tab 48 (ADF medical records – Psychological file) at 35, 42-3.
910 Submissions of the Commonwealth dated 7 June 2024 at [113]-[114].
911 Submissions of Mr and Mrs Turner dated 28 January 2024 at [50]-[55].
912 Submissions of Mr and Mrs Turner dated 28 January 2024 at [56]-[61].
time was a missed opportunity to properly diagnose CPL Turner’s symptoms. They are also critical about the conversation between CAPT DW and Mr Sakar regarding the incompatibility of severe ADHD requiring Ritalin with deployment, which resulted in no further action being taken in relation to CPL Turner. They infer that CAPT KH did not properly assess the screening results from MAJ NB and there was a lack of assessment following a conclusion of ADHD.913
Mr and Mrs Turner further submit that the RtAPS conducted on 31 January 2012 and the POPS screening on 28 August 2012 were inadequate. By the time of the latter, CPL Turner was reluctant to engage in psychological support and he continued to be deployed. At this time, the ADF was aware of other ADF members who had served alongside CPL Turner being discharged for combat-related PTSD.914
Mr and Mrs Turner also consider that the RtAPS conducted on 10 July 2013 and 16 October 2013 failed CPL Turner. In relation to the former, they contend that CPL Turner’s admission of excessive alcohol consumption, the interpersonal conflict with Joanna, and his minimisation of his symptoms despite having just lost his friend in traumatic circumstances should have triggered an immediate referral for assessment and intervention. As for the latter, they note that although CAPT KH concluded that CPL Turner presented with moderate levels of PTSD symptomatology, CAPT KH recommended that no further action be taken due to CPL Turner’s resistance to engage and denial of current difficulties. Mr and Mrs Turner consider that CPL Turner’s unwillingness to engage with psychologists or other mental health clinicians at this time was an irrelevant consideration in deciding whether intervention was to occur. They believe that if a member is identified as having PTSD and they decline treatment, the member should not be deployable.915
In relation to the Commonwealth’s submission above about CPL Turner’s alcohol abuse in the 2007-2008 period, Mr and Mrs Turner note that Joanna Turner’s evidence referred to by the Commonwealth is more appropriately construed as CPL Turner’s consumption of alcohol being a response to his trauma memories, with his consumption of alcohol increasing over time. They note that Joanna Turner did not state that excessive alcohol use was present in the relationship prior to the first Afghanistan deployment in 2007-2008.916 Mr and Mrs Turner also submit that the 913 Submissions of Mr and Mrs Turner dated 28 January 2024 at [62]-[64].
914 Submissions of Mr and Mrs Turner dated 28 January 2024 at [65]-[66].
915 Submissions of Mr and Mrs Turner dated 28 January 2024 at [67]-[71].
916 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [27].
increase in drinking and emergence of CPL Turner’s alcohol abuse correlates with his exposure to various traumatic experiences throughout his service with the ADF.917 Submissions in reply of Counsel Assisting
Counsel Assisting notes that Chapter 7 of Part 10 of the Defence Health Manual (DHM) states that the PCL-C is used in RtAPS and POPS questionnaires “because at this stage only a very small proportion” of the ADF “are involved in prolonged combat operations”.918 While the DHM does identify the availability of a separate checklist (PCL-Military), which inferentially would be more appropriate for those who are exposed to prolonged combat operations, the differences between the checklists are described as being “very small”.919 Counsel Assisting considers that given the adequacy of the PCL-C, PCL-Military, or some other checklist, was not a key focus of expert evidence, it would be difficult to conclude that the use of the PCL-C was deficient. Ultimately, the use of a different checklist based on self-reporting may suffer from the same vice of being subject to the member’s tendency to downplay symptoms which can be guarded against with longitudinal management of conditions and the appointment of single points of coordination – being a system of the kind recommended below at [1217].920
Counsel Assisting notes that the findings sought below at [583]-[591], [639]-[645], and [664] concern institutional and systemic responses to the detection, reporting, intervention, monitoring, and support provided by the ADF where “warning signs” are disclosed in psychological screening tests. Counsel Assisting’s position is that it is not necessary to make adverse findings concerning the standard of care exercised by the particular professional referred to by Mr and Mrs Turner.921
In relation to the Commonwealth’s objection to a finding being made about the 2013 Afghanistan Deployment, Counsel Assisting considers that the matters raised above at [23]-[31] are sufficiently relevant to the scope of the Inquest and form part of the narrative of CPL Turner reporting having experienced a number of traumatic events during the 2013 Afghanistan Deployment and the effect those had on his mental health.
Counsel Assisting considers that if those events are construed in that sense, it would be unnecessary for a specific finding to be made about the actual occurrence of the events or about the persons involved in any such events (given that the relevance is 917 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [28]-[31].
918 Tab 84 at 12.
919 Tab 84 at 11.
920 Submissions in reply of Counsel Assisting dated 22 August 2024 at [53].
921 Submissions in reply of Counsel Assisting dated 22 August 2024 at [56.2].
only in the fact that CPL Turner reported such events and their consequences on his mental health, including to members of the ADF).922
As for the Commonwealth’s contention that no finding should be made about relevant medical personnel not responding adequately to the RtAPS and POPS screenings pre2014, Counsel Assisting notes that no adverse finding is sought against the individuals who carried out those processes. Rather, the point proffered at [551] is made clear at [552], which relates to the absence of any longitudinal method of identifying persons at particular risk of deterioration, which is a systemic issue and not a matter of individual deficiency of any person.923
Lastly, in relation to Mr and Mrs Turner’s submission on Joanna Turner’s evidence on the topic of alcohol abuse prior to the 2007-2008 deployment, Counsel Assisting notes that the evidence suggests that she observed an increased consumption of alcohol at times when CPL Turner was struggling to sleep or was vocalising traumatic memories.924 In circumstances where Joanna Turner and CPL Turner had been in a relationship since 2002, Counsel Assisting considers the submission made by the Commonwealth on this point above was open. However, the critical aspect of Joanna Turner’s evidence was the increase of alcohol abuse over time in line with continued deployments and continued worsening of PTSD symptoms. In that respect, Counsel Assisting refers to the parts of the chronology at [15]-[80] above concerning CPL Turner’s alcohol abuse.925 Consideration
Having carefully considered the evidence in relation to the ADF’s response to CPL Turner’s mental health prior to 2014, I find that there were missed opportunities which resulted in there being no meaningful early intervention. While I make no adverse findings against the individuals involved in the RtAPS and POPS screenings prior to 2014, it is clear the system did not identify early red flags or provide an adequate longitudinal mechanism for identifying people who were at risk of deterioration. I accept Mr and Mrs Turner’s submission that a lack of institutional understanding about the nature of PTSD impacted CPL Turner’s mental state prior to 2014 and resulted in his condition becoming entrenched.
922 Submissions in reply of Counsel Assisting dated 22 August 2024 at [188].
923 Submissions in reply of Counsel Assisting dated 22 August 2024 at [191].
925 Submissions in reply of Counsel Assisting dated 22 August 2024 at [98]-[100].
Adequacy of ADF’s response in 2014
Counsel Assisting’s submissions
It is noted that it appears that this violence was known to members of the ADF as early as 2013 but not recognised as a possible symptom of PTSD, nor were any interventions put in place.
Rather, the interventions occurred because CPL Turner’s mental health affected the ADF in two negative ways: first, the ADF was notified of the AVO obtained by the NSW Police on behalf of Joanna Turner, and second, CPL Turner’s colleagues considered his drinking on a course in Singleton was becoming so excessive that they discussed it with the unit psychologist. (The Commonwealth accepts that CPL Turner’s mental health issues came to the attention of the ADF Chain of Command at this time.)927
Once the domestic violence became apparent, it again does not appear that there were any longitudinal systems in place which recognised the domestic violence as a possible incidence of PTSD symptoms and put in place mitigations around that risk.
Joanna Turner went to significant lengths to attempt to bring CPL Turner’s worsening PTSD to the attention of the leadership of the ADF. She took the extraordinary step of penning a letter to the then-CO of 2CDO, BRIG Langford, raising concerns about the level of support that had been provided to her and clearly setting out her view that the domestic violence she was experiencing was attributable to CPL Turner’s mental health as a result of his service. Counsel Assisting considers that the evidence as to the response of the ADF to this letter was concerning as it does not appear that any formal steps were undertaken to ensure that Joanna Turner’s concerns were recorded, followed up on, and formed part of the ADF’s ongoing treatment of CPL Turner’s mental health.
The conditional release plan
927 Submissions of the Commonwealth dated 7 June 2024 at [127].
that Dr Sringeri, who was responsible for supervising his treatment and reporting to the Local Court in respect of compliance and breaches, understood the serious nature of the undertaking which he had given to the Local Court. During the period, CPL Turner appeared to have unilaterally ceased taking medication. That was not a matter that received any particular focus in Dr Sringeri’s treatment notes during that period.
Dr Sringeri himself acknowledged that this was a “breach in some sense”. CPL Turner appeared to have breached the plan in two ways: first, by unilaterally ceasing antidepressant medication and, second, by failing to continue with psychiatric reviews for a period of 12 months.
It is also submitted that there was inadequate monitoring by Dr Sringeri in respect of his compliance with the plan during the period of 12 months following May 2014 when the conditional release order was made.
There was little by way of evidence that demonstrated the ADF had a system in place to check and ensure compliance with the conditions of that plan as it concerned CPL Turner’s treatment within the ADF health system and via referral to Dr Sringeri.
Although the ADF did not have formal responsibility under the conditional release plan, plainly enough the only psychotherapy with a clinical psychologist which CPL Turner was receiving was through the ADF. That meant the ADF also had a role to play in checking compliance with the conditions of the order. It is submitted that there was inadequate monitoring by the ADF of CPL Turner’s compliance with the conditions of his conditional release plan. It is further submitted that the ADF had knowledge of CPL Turner’s non-compliance with the orders associated with his conditional release and failed to take any action in response. Counsel Assisting notes that so much is clear from the fact that the ADF received from Dr Sringeri the reports which indicated CPL Turner was ceasing medication and then ceasing psychiatric review.
condition was improving. According to Counsel Assisting, the evidence of Joanna Turner suggests that his condition was not improving, at all, and that CPL Turner continued to perpetrate domestic violence upon Joanna Turner and the children in the lead up to the 2015 Iraq Deployment. Counsel Assisting considers that it is all the more concerning because Joanna Turner had specifically approached the ADF (and the CO of 2CDO) in respect of her concerns about CPL Turner, and a follow up of that approach would have likely revealed to the ADF that the picture which CPL Turner was presenting about his mental health was not accurate. It is submitted that there was a failure by the ADF in this regard, which meant that CPL Turner was able to present himself throughout 2014 and into 2015 as having effectively been “cured” of his PTSD.
As the expert evidence demonstrated, the likelihood of that being the case was very low. Counsel Assisting states that there should have been a significantly greater level of circumspection and probing into CPL Turner’s apparently quick return to solid mental health throughout this period.
Submissions of Mr and Mrs Turner
Mr and Mrs Turner consider that the lack of education and experience across all levels of personnel responsible for responding to and managing CPL Turner’s mental health resulted in repeated missed opportunities to provide assessment, therapeutic intervention, support, and adequate care after the diagnosis of PTSD in 2014. Their view is that the ADF breached the Army Standing Instruction (Personnel) in failing to rehabilitate CPL Turner after the PTSD diagnosis in 2014. They also refer to the chapter “Management of Post-Traumatic Stress Disorder and Acute Stress Disorder in the Australian Defence Force for Primary Care Providers” (which states that members “are to be referred” to the ADF Rehabilitation Program) in the DHM and submit that the ADF breached its policy by not referring CPL Turner to the program upon his discharge.928
Furthermore, they contend that the decision of BRIG Langford to fully employ CPL Turner two weeks before his discharge from hospital breached ADF policy and demonstrated a lack of care for CPL Turner’s personal health and wellbeing.929 Submissions of Joanna Turner
In relation to her letter of 11 June 2014, Joanna Turner submits that “checking in with me on occasion by one person is not acceptable as an appropriate response” and that 928 Submissions of Mr and Mrs Turner dated 28 January 2024 at [72]-[75].
929 Submissions of Mr and Mrs Turner dated 28 January 2024 at [75].
CPL Turner did not face accountability. She submits that it was not sufficient for the ADF to rely on “other sources of information, including what others saw with their own eyes” in the context of claims of domestic violence, including the fact that CPL Turner may have otherwise presented as performing acceptably in the workplace.930 Submissions of the Commonwealth
Looking at the evidence as a whole, and with the benefit of hindsight, the ADF accepts that there is force in Counsel Assisting’s ultimate submission about the ADF’s response to CPL Turner’s mental health issues in 2014, namely that: “there should have been a significantly greater level of circumspection and probing into CPL Turner’s apparently quick return to solid mental health throughout this period”. This is not to say that the ADF ignored CPL Turner’s mental health issues: to the contrary, the Commonwealth submits that the ADF made a concerted, good faith effort over the course of 2014 to ensure that CPL Turner returned to full mental health, including by referring him to a very experienced external health practitioner, and by engaging the services of ADF personnel with relevant subject matter expertise. The problem, in retrospect, might best be described as a failure on the part of the ADF to “connect the dots”; that is, to draw together the constellation of issues facing CPL Turner and his family and appreciate their significance as a whole.931
The Commonwealth notes that CPL Turner had spent six weeks at SSPH in April-May 2014 where he “remained fully engaged in his health and welfare” and that Dr Sringeri observed “remarkable” improvement in PTSD symptoms upon discharge. The Commonwealth submits that with the benefit of hindsight, questions might now be asked about whether the treatment at this time “was as effective as it appeared at the time”.932
The Commonwealth also points out that CPL Turner’s unilateral decision to cease taking his antidepressant medication in mid-2014 was a matter known to Dr Sringeri and he did not raise concerns with the ADF. The Commonwealth submits that Dr Sringeri’s observations of “progressive improvement” in PTSD symptoms throughout 2014, and his reports to the ADF consistent with those observations, meant “the ADF was well entitled to proceed on the basis that CPL Turner’s rehabilitation was going extremely well”.933 930 Submissions in reply of Joanna Turner at 4.
931 Submissions of the Commonwealth dated 7 June 2024 at [117].
932 Submissions of the Commonwealth dated 7 June 2024 at [130]-[134] (emphasis in original).
933 Submissions of the Commonwealth dated 7 June 2024 at [140]-[145].
ii. “Connecting the dots” is much easier for a person who has access to all relevant or potentially relevant information. However, at the relevant times, no single individual or group of individuals within the ADF had anything like the access to the information before this Inquest. For this reason, Counsel Assisting’s tendency to refer to “the ADF” as an entity makes little sense – the analysis must be granular.
iii. To the extent that there was a failure to “connect the dots”, that points to a need for better training, including with respect to the speed and efficacy of PTSD treatment; the capacity of people with mental health issues to conceal signs/symptoms and continue performing well in the workplace; and the complex interrelationship(s) between PTSD, abuse of alcohol/drugs, and domestic violence.
iv. An important part of the ADF’s response was “delivered” by CAPT SG, who was involved in CPL Turner’s treatment and care on a regular basis from at least late March/early April 2014 to December 2014. CAPT SG was not asked to provide a witness statement or called to give evidence, with the result that there is a gap in the evidence. That also has procedural fairness implications in respect of any proposed adverse findings or comments in respect of CAPT SG (and, through him, the ADF). The Commonwealth also submits that CAPT SG’s treatment of CPL Turner was appropriate and that he was entitled not to second guess the observations made by Dr Sringeri in this period regarding CPL Turner’s progress.935 v. Another part of the ADF’s response was “delivered” by MAJ Clancy, whose role in 2014 is not referred to in Counsel Assisting’s submissions.
935 Submissions of the Commonwealth dated 7 June 2024 at [154]-[157].
of responding to Joanna Turner’s letter was delegated to MAJ Clancy, the Padre, and the Adjutant.936 Initial interventions in response to CPL Turner’s mental health issues
Counsel Assisting submits that the ADF initiated interventions in response to the mental health issues that came to the attention of the ADF Chain of Command in 2014 only “because” they “affected” the ADF in “negative” ways. It is submitted by the Commonwealth that the submission unfairly implies that CPL Turner’s mental health issues were known to relevant operational personnel prior to April 2014, but were not active because they had no impact on the ADF given that the evidence does not support any such conclusion.937
While early warning signs of mental health issues had been observed by the medical personnel who conducted the RtAPS and POPS screenings in the pre-2014 period, there is no evidence that these matters were reported to operational personnel or that they could have been consistently with applicable ADF policy. To the extent that Joanna Turner raised mental health issues with ADF members prior to April 2014, it would seem that the persons she approached were various chaplains both inside and outside 2CDO. It is contended that the evidence does not permit the making of clear findings about how these chaplains responded and there is no evidence that they were reported to operational personnel (or at least operational personnel with rank and authority to deal with them).938
The Commonwealth submits that the evidence relating to the events of early April 2014 establishes that the ADF responded swiftly and appropriately once the issues came to its attention.939 The conditional release plan
The Commonwealth submits that findings should not be made that the ADF inadequately monitored the conditional release plan imposed by the Local Court on 3 June 2014 and that the ADF failed to respond to known non-compliance with that plan.
In support of this submission, the Commonwealth notes that the evidence: i. does not establish that the ADF had knowledge of the orders or the terms of the treatment plan referred to in the orders; 936 Submissions of the Commonwealth dated 7 June 2024 at [176(c)-(d)] and [184].
937 Submissions of the Commonwealth dated 7 June 2024 at [128].
938 Submissions of the Commonwealth dated 7 June 2024 at [128].
939 Submissions of the Commonwealth dated 7 June 2024 at [129].
ii. indicates that the relevant ADF personnel may not have regarded CPL Turner as being in breach of the orders and/or plan (assuming they had a copy of them) and may have regarded CPL Turner as acting consistently with Dr Sringeri’s advice; iii. the orders did not impose any responsibility on the ADF to monitor compliance with the orders and/or plan; and iv. the ADF member who was “presumably responsible” for monitoring CPL Turner’s compliance with the orders and treatment plan was CAPT SG (who was not called to give evidence).940
The Commonwealth notes that if it was the case that relevant personnel were not aware of the terms of the orders, then “that was most unfortunate”. It is further noted that current procedures are now designed to ensure the ADF is aware of “any civil charges” and the basis on which such charges are disposed of by the courts.941 The response to Joanna Turner’s letter of 11 June 2014
The Commonwealth disagrees with Counsel Assisting’s submission that there were inadequate “concrete” or “formal” steps taken from Joanna Turner’s letter of 11 June 2014 in that it considers the submission does not reflect the evidence.
The Commonwealth notes942 that the fact that the letter was taken seriously by the ADF is reflected in the evidence that: i. BRIG Langford “quickly” arranged to have a meeting with her which was an “unusual” step to take for someone in his position;943 ii. Joanna Turner conceded that she presented things in a “positive context” to BRIG Langford which led him to believe the discussion was positive and constructive;944 iii. BRIG Langford delegated the ADF’s response to appropriately trained subordinates;945 and 940 Submissions of the Commonwealth dated 7 June 2024 at [165]-[171].
941 Submissions of the Commonwealth dated 7 June 2024 at [127].
942 Submissions of the Commonwealth dated 7 June 2024 at [176].
iv. MAJ Clancy was in regular contact with Joanna Turner in 2014-2015946 (and Joanna Turner accepted that MAJ Clancy “was doing the best she could”).947
Further, the Commonwealth notes that the ADF was receiving separate and competing information about CPL Turner’s condition at this time from other sources948 and that the ADF’s response was also, to an extent, “a product of [its] times” in relation to the (lack of) discourse surrounding domestic violence in the broader community.949 Dr Sringeri’s report of 27 October 2014
The Commonwealth refers to the report of Dr Sringeri dated 27 October 2014, which lists “Post Traumatic Stress Disorder in remission” and “Alcohol Dependence Syndrome in remission” as diagnoses and recommendations as “Psychoeducation. In my opinion Ian is well and stable. In my opinion Ian is cleared to attend all duties from a psychiatric point. He does not require any psychiatric follow up for next 12 months and I am happy to review him if required.”950 The Commonwealth contends that in his statement dated 5 August 2021 (Exhibit 15), Dr Sringeri sought to distance himself from the plain meaning of the words “Ian is cleared to attend all duties from a psychiatric point” on the basis that he did not have (and could not be expected to have) any knowledge of the “occupation hazards” of his patients.951
The Commonwealth is also critical of the email posed by those assisting to Dr Sringeri’s representatives on 11 August 2021 about his recommendation that “Ian is cleared to attend all duties from a psychiatric point” (specifically, whether he intended this to mean that CPL Turner was cleared to deploy in a combat zone) and the response from Dr Sringeri (Exhibit 19) that he did not intend to imply or suggest that he had cleared CPL Turner to deploy in a combat zone. The Commonwealth considers this to be problematic not only because the question raised was inappropriately leading, but also because the response was not made on oath or affirmation. The question of Dr Sringeri’s subjective intention is irrelevant and the appropriate question is what the report would objectively convey to the reasonable reader.952
It is submitted that given Dr Sringeri effectively ended his treatment of CPL Turner in October 2014 with a report to the ADF that stated that CPL Turner’s PTSD and alcohol dependence syndrome were “in remission”, he was “well and stable”, he was “cleared
948 Submissions of the Commonwealth dated 7 June 2024 at [175].
949 Submissions of the Commonwealth dated 7 June 2024 at [177].
950 Tab 47 (ADF medical records – part 2) at 16-17.
951 Submissions of the Commonwealth dated 22 June 2024 at [146].
952 Submissions of the Commonwealth dated 22 June 2024 at [149].
to attend all duties from a psychiatric point [of view] and he did “not require any psychiatric follow up” over the next 12 months, the ADF was well entitled to proceed on the basis that CPL Turner’s rehabilitation had gone extremely well.953 Submissions of Dr Sringeri The conditional release plan
Dr Sringeri disputes Counsel Assisting’s submissions in relation to his role in the treatment of CPL Turner following the orders made by the Local Court of NSW on 3 June 2014. Dr Sringeri notes that two different orders were made, one under the Crimes Act 1914 (Cth) and the other under the MH(FP) Act. While the former stipulated a period of 12 months, the latter did not specify any time period and this gave rise to a degree of ambiguity as to the length of the treatment plan. Dr Sringeri submits that there is no recommendation for a twelve-month period of medications; rather, the medication is recommended to be taken as prescribed.954
While Dr Sringeri stated there was a “breach in some sense” of the undertaking, Dr Sringeri’s evidence was that CPL Turner volunteered to him that he had ceased taking medication which was in the process of being reduced in the context of a plan to cease that medication.955
Dr Sringeri further submits that the twelve-month recommendation related to 12 months of psychotherapy which was managed by the psychologist within the ADF. Had there been non-compliance with that recommendation, it was not reported to him by CPL Turner of the ADF.956
Dr Sringeri submits that there was no evidence adduced to show that Dr Sringeri was provided with a copy of the orders by CPL Turner, the ADF, or the Local Court. Rather, his evidence was that he did not receive a copy of the orders and did not know the Court would make the recommendation. Dr Sringeri contends that Counsel Assisting’s submissions on this point above at [586]-[589] are procedurally unfair and that the facts do not support the making of a finding as submitted at [589] as he was unaware he had not complied with the undertaking he had volunteered.957 953 Submissions of the Commonwealth dated 22 June 2024 at [150].
954 Submissions of Dr Sringeri dated 24 April 2024 at [36]-[40].
955 Submissions of Dr Sringeri dated 24 April 2024 at [45].
956 Submissions of Dr Sringeri dated 24 April 2024 at [42], [44].
957 Submissions of Dr Sringeri dated 24 April 2024 at [42]-[43], [47]-[48].
Dr Sringeri’s report of 27 October 2014
Dr Sringeri objects to the Commonwealth’s contention summarised above at [608]- [609].958 In his statement of 5 August 2021 (Exhibit 15) he was not distancing himself from his opinion expressed in the 27 October 2014 report; rather, he was endorsing what his opinion was at the time. Dr Sringeri considers that the Commonwealth’s criticism fails to appreciate the context in which the statement was given (namely, accepting some aspects and responding to other aspects of Professor McFarlane’s criticisms959 about Dr Sringeri’s “admitted lack of knowledge” of the ADF, such as whether he had sufficient knowledge about the occupational hazards).960
Dr Sringeri also contends that any issues the Commonwealth (or GPCAPT Ross) wanted to raise in relation to the report ought to have been done in open court and that accepting those submissions without giving Dr Sringeri the opportunity to give evidence to rebut them would be procedurally unfair.961
Dr Sringeri suggests that the Commonwealth’s submission about the statement dated 5 August 2021 is made “without acknowledgement that the only information that Dr Sringeri had was the referral letter from the ADF dated 4 April 2014, the information provided to him by CPL Turner, in addition to the observations he had made over the course of providing treatment and care to [CPL] Turner during his hospital admission in April 2014 and the follow up reviews after discharge in 2014, the two reviews in 2015, and the review on 13 July 2016”. Similarly, there is no acknowledgement in the Commonwealth’s submissions that the opinion expressed in the 27 October 2014 letter was within the context that related to a time when CPL Turner was not being deployed and CPL Turner informed Dr Sringeri that he was keen to join his team for the purpose of training.962
Dr Sringeri also rejects the Commonwealth’s criticisms of the answers he gave in the 11 August 2021 response (Exhibit 19) and submits that such criticisms operate as “an utter denial of procedural fairness or lack of opportunity to be afforded to Dr Sringeri to respond to such criticisms through the giving of evidence” (noting he was not called to give evidence about this).963 958 Submissions of the Commonwealth dated 7 June 2024 at [146].
959 Exhibit 12 at 38-42.
960 Submissions in reply of Dr Sringeri dated 22 July 2024 at [26]-[35], [44].
961 Submissions in reply of Dr Sringeri dated 22 July 2024 at [43].
962 Submissions in reply of Dr Sringeri dated 22 July 2024 at [35].
963 Submissions in reply of Dr Sringeri dated 22 July 2024 at [24].
Submissions in reply of Counsel Assisting
Counsel Assisting notes that the chapter of the DHM referred to in Mr and Mrs Turner’s submissions (above at [592]) is not in evidence and that without a complete picture of the referral process (including whether acceptance into the ADF Rehabilitation Program is mandatory), the single statement that members “are to be referred” does not provide a sufficient basis to conclude that, on the facts of this matter and on a complete picture of ADF policy, that such a policy was breached.964
Counsel Assisting does not seek a finding that Dr Sringeri sought to “distance himself” from the meaning of the words in his letter of 27 October 2014 and it is submitted that Dr Sringeri’s letter was inadequate for the reasons outlined below at [673].965 The conditional release plan
In view of Dr Sringeri’s submissions (as summarised above at [611]-[614]), Counsel Assisting accepts that the evidence does not enable positive findings that Dr Sringeri was provided with a copy of the form of orders made by the Local Court, that Dr Sringeri was aware CPL Turner had not acted in compliance with the terms of the conditional release order, or that Dr Sringeri did not report that fact back to the Local Court.
However, it is submitted that it is open for a finding to be made that Dr Sringeri was aware CPL Turner was non-compliant with what Dr Sringeri had proposed and undertaken to the Court as being an appropriate treatment plan for CPL Turner.966
As for the Commonwealth’s submission that the ADF did not have knowledge of the terms of the court orders or the treatment plan, Counsel Assisting submits967 that the evidence suggests that not only were the court proceedings being monitored by the ADF, but the disposition under s 32 of the MH(FP) Act was in fact anticipated. CAPT SG noted the anticipated court proceedings in his clinical notes of 30 April 2014 and 26 May 2014,968 in the former explicitly recording that “Ian has legal representation sorted and will pursue a section 32”.969 Then, on 5 June 2014, CAPT SG recorded “Court proceedings for the AVO conducted with positive outcome”.970
This monitoring by CAPT SG is consistent with expectations of other witnesses who gave evidence. MAJ AM gave evidence that he would have expected the outcome to 964 Submissions in reply of Counsel Assisting dated 22 August 2024 at [57].
965 Submissions in reply of Counsel Assisting dated 22 August 2024 at [172].
966 Submissions in reply of Counsel Assisting dated 22 August 2024 at [165]-[167].
967 Submissions in reply of Counsel Assisting dated 22 August 2024 at [195]-[200].
968 Tab 49 (ADF unit medical records) at 535.
969 Tab 49 (ADF unit medical records) at 543.
970 Tab 47 (ADF central medical records – part 2) at 92.
appear on CPL Turner’s medical file.971 BRIG Langford gave evidence that, at least with respect to convictions, at the relevant time “there was a mandatory reporting obligation” and “I would be aware of it, as a general rule.”972 He also accepted the court proceedings were brought to his attention in Joanna Turner’s letter.973
Even if it were to be accepted that the ADF was not aware of the outcome of the criminal charge, BRIG Langford accepted that this should have been brought to his attention.974 Relevantly in this context, it is noted that Joanna Turner submitted in reply submissions that the Commonwealth, having been aware of the criminal charge, had an obligation to “document and respond effectively” to the orders made, and, either the ADF failed in responding to what they were aware of, or, failed by not ensuring they were sufficiently aware.975
As for the Commonwealth’s submission that the terms of the order were ambiguous such that ADF personal may not have regarded CPL Turner as being in breach, Counsel Assisting notes that the absence of action taken does not support the positive inference that the ADF formed a view there was no breach. Rather, the clearer conclusion to be drawn is that the ADF simply did not sufficiently engage with requirements under the order at all.
The response to Joanna Turner’s letter of 11 June 2014
975 Submissions in reply of Joanna Turner at 4.
978 Submissions in reply of Counsel Assisting dated 22 August 2024 at [201].
In relation to the Commonwealth’s objection to any adverse finding about the care provided by CAPT SG, Counsel Assisting notes that none of the references to CAPT SG at [47]-[49], [53], or [55] seek an adverse finding about CAPT SG’s conduct and that the only relevant findings with respect to the period of CAPT SG’s care is summarised above at [590]-[591], which concerns the lack of monitoring by the ADF of CPL Turner’s compliance with the conditional release plan. Contrary to the Commonwealth’s submission that no finding can be made about the conduct of the ADF because the conduct of the ADF was apparently in the hands of CAPT SG, there is no implied or express submission that it was CAPT SG who was responsible for monitoring CPL Turner’s compliance with the conditional release plan. Counsel Assisting submits that the evidence did not reveal that the ADF had any particular role to play in ensuring compliance with the conditions of the conditional release plan and ought to have, which is a submission relating to the ADF’s systems. As the Commonwealth submits, the ADF’s current policy framework which has been reviewed since 2014 is designed to ensure that it is aware of civil charges brought against members and the basis on which any such charges are disposed of, including any conditions.981 Consideration
There were a variety of events occurring in 2014 which should have signalled to the ADF that CPL Turner’s mental health was becoming a significant issue. The ADF failed to recognise his excessive drinking (as evidenced during the Singleton course) and his 979 Submissions in reply of Counsel Assisting dated 22 August 2024 at [203]-[204].
981 Submissions in reply of Counsel Assisting dated 22 August 2024 at [192]-[193].
ongoing violence (as evidenced by the need for police to apply for an ADVO and commence criminal proceedings) as potential red flags for PTSD.
The Commonwealth submissions on this issue were somewhat confusing. On the one hand, it accepted “that there should have been a significantly greater level of circumspection and probing into CPL Turner’s apparently quick return to solid mental health throughout this period”; in retrospect describing it as a “failure to connect the dots.”
On the other hand, there is a reluctance to take responsibility for the failure of the systems which allowed those tasked with managing CPL Turner to see the significance of critical events. In the Commonwealth’s submission, it “makes little sense to generalise or describe the ADF as an “entity” because at the relevant time no “single individual or group of individuals within the ADF had anything like the access to the information before this inquest.” There is just no substance to the contention. As I have already stated, the Court is well aware that it possesses information gathered from a variety of sources, well after the event. That does not absolve the ADF from its corporate responsibility. The Court has been careful not to generalise, but there remains a need to analyse the institutional response.
I have already recorded that, in my view, Joanna Turner’s attempt get help and advise the ADF of her concerns about her husband’s mental state were poorly managed.
There is no evidence that her concerns were formally recorded or factored into the ADF’s mental health treatment response to CPL Turner. The criticism is directed towards the apparent lack of an adequate system which would have ensured the information Joanna Turner provided was understood and acted upon.
In my view, the ADF response to CPL Turner’s court appearance and conditional release was also wholly inadequate.
I was disappointed by the Commonwealth’s submissions on this issue. Among other things, it submitted that there was no evidence that the ADF had knowledge of the orders or terms of the conditional release and had no responsibility to monitor compliance. It is perfectly clear that the court proceedings were well known in the 2CDO. As I have already outlined above at [44], character references were provided on 2CDO letterhead, an ADF member attended proceedings with CPL Turner, and one of the conditions of the final discharge involved the provision of counselling with CAPT SG. The issue was also brought specifically to BRIG Langford’s attention by Joanna
Turner. To suggest that it has not been established that the ADF had knowledge of the orders or an obligation to monitor compliance is to miss the point entirely.
I do not accept that senior members of 2CDO were unaware of the proceedings. If they were unaware of the terms of the conditional release, that constitutes either a disturbing lack of curiosity or a complete disregard for civilian court proceedings affecting a member of the ADF. Whichever it was, in my view the failure to take seriously the outcome of the Local Court proceedings represents a significant missed opportunity in CPL Turner’s health management.
One of the conditions of CPL Turner’s discharge was compliance with a mental health plan for 12 months. Dr Sringeri ceased treating CPL Turner after five months which he recognised as a “breach in some sense”. I accept the submission put by his representatives that Dr Sringeri was entitled to put weight on the fact that an ADF psychologist was also managing CPL Turner. After Dr Sringeri ceased treatment, he also informed the ADF that he was happy to review CPL Turner if required. While I accept that he may not have seen the final orders, in my view he nevertheless had a duty to find out what they were. It is quite apparent that nobody took the Local Court orders seriously.
Dr Sringeri’s report of 27 October 2014 stated that CPL Turner’s PTSD and alcohol dependence syndrome were “in remission” and that he was “well and stable.” While it is now apparent that CPL Turner was not always open with his treating doctors, I accept that at the time the ADF were entitled to place some weight on his opinion.
Adequacy of ADF’s response in 2015
Counsel Assisting’s submissions
for safety, and that when he did return, his violence and alcohol intake increased dramatically.
Counsel Assisting notes that there was no system in place, seemingly, for this to be recognised and dealt with by the ADF. This is particularly concerning because Joanna Turner was not someone who was unknown to the ADF or who had demonstrated a complete unwillingness to discuss her domestic issues with the ADF. There did not appear to be a system, however, whereby what CPL Turner reported to the ADF (that he was coming home because of Joanna Turner’s mental health) was verified with Joanna Turner or investigated any further. Counsel Assisting submits that this appears to reflect a lack of a longitudinal approach whereby CPL Turner’s entire history was taken into account at the time of his early RTA. Doing so may well have raised a red flag, noting that CPL Turner had been hospitalised for PTSD only the previous year.
It is also concerning that the domestic violence continued throughout 2015 and was reported to MAJ Clancy but that this information did not appear to be clearly fed into CPL Turner’s mental health treatment within the ADF or his health records more generally. There did not appear to be any prominence or significance afforded to her role in decision-making within the ADF.
BRIG Langford’s evidence was to the effect that the information reported to MAJ Clancy as to harm suffered by her in September 2015 was not brought to his attention.
This was around the time that BRIG Langford signed a waiver for CPL Turner to deploy to Malaysia. He accepted that it should have been brought to his attention, and that it would have influenced his decision as to whether or not CPL Turner should have been given a medical waiver to deploy to Malaysia. 983 He also accepted that inquiries should have been made of Joanna Turner from 2014 onwards for the purpose of informing decisions about CPL Turner’s deployment.984 Counsel Assisting’s view is that this lack of enquiry by BRIG Langford as to the current status of CPL Turner’s domestic circumstances is especially egregious given his personal knowledge of the domestic violence and CPL Turner’s mental health issues, resulting from the letter he received from Joanna Turner and the subsequent meeting he had with her in June the previous year.
i. Speaking after CPL Turner’s death in his ROI with the IGADF, WO2 DP stated that CPL Turner was “struggling to cope with the fact that he would not see those children. The wife was willing to have visitations to the daughter. But from what I understand, the son was never allowed to go and see Ian or spend any time with Ian, which wasn’t nice for him”.985 ii. BRIG Langford’s evidence was that he understood, since CPL Turner’s death, that there was a “sense from Ian’s perspective that Joanna was not inclined to help him in his career…in his view, that she was essentially trying to damage him”, and CPL Turner had requested that no-one in his unit was to contact Joanna Turner or discuss his family affairs with her.986
Counsel Assisting submits that given that CPL Turner had been charged by police, had an AVO imposed, and had been hospitalised for PTSD only a year prior, it is difficult to discern why Joanna Turner’s concerns in 2015 were not given significantly more prominence in decision-making about CPL Turner throughout 2015 and leading into 2016, and why the ADF and particularly, the CO, were willing to take CPL Turner’s information about CPL Turner at face value.
Ultimately, this was information which nearly all the decision-makers around CPL Turner’s medical clearance in 2016 indicated they would have liked to have known.
The difficulty is that the violence which Joanna Turner was experiencing (albeit an underreported form of it) was known to the ADF, was not taken seriously, and was not recorded in such a way that enabled it to be taken into account in treatment and deployment decisions.
Submissions of Mr and Mrs Turner Referral to an addiction medicine specialist
986 Tab 24 (IGADF ROI with WO2 DP dated 5 July 2018) at 8.
987 Submissions of Mr and Mrs Turner dated 28 January 2024 at [86].
Submissions of the Commonwealth Deployment to Iraq in January 2015
In relation to CPL Turner’s deployment to Iraq in January 2015, the Commonwealth submits there was no evidence to suggest any potentially traumatic events in this period and that the decision to deploy was made in the context of Dr Sringeri having concluded that CPL Turner’s alcohol dependence and PTSD was “in remission”.988 Referral to an addiction medicine specialist
The Commonwealth points out that CAPT KH discussed the potential referral to an addiction medicine specialist with Dr Sringeri who verbally advised that there was “no need for a referral to an addiction specialist”.989 The AVO in June 2015
In relation to the AVO against CPL Turner that police had applied for on 29 June 2015, the Commonwealth submits that BRIG Langford sought a ‘two pronged’ response to this event, namely psychological counselling and support for CPL Turner and support for Joanna Turner. The Commonwealth points to evidence that counselling with CAPT KH that subsequently occurred and evidence of overtures made to Joanna Turner,990 particularly by MAJ Clancy.991 The Commonwealth further notes that while CAPT KH concluded that CPL Turner was not suffering from a relapse from PTSD, CAPT KH referred CPL Turner to Dr Sringeri who reported CPL was “in remission”.992 BRIG Langford
The Commonwealth also objects to Counsel Assisting’s criticism that BRIG Langford did not personally make enquiries of Joanna Turner. It contends that, as a matter of procedural fairness, it was necessary to put to BRIG Langford that this was “egregious”.993 CAPT KH and the Early Return to Australia (ERTA)
The Commonwealth also objects994 to any proposed adverse finding about the role of CAPT KH, including whether the ADF, through CAPT KH, failed to respond to the 988Submissions of the Commonwealth dated 7 June 2024 at [184]-[186].
989 Submissions of the Commonwealth dated 7 June 2024 at [242].
990 Submissions of the Commonwealth dated 7 June 2024 at [202]-[210].
991 Submissions of the Commonwealth dated 7 June 2024 at [237]-[239].
992 Submissions of the Commonwealth dated 7 June 2024 at [212]-[213].
993 Submissions of the Commonwealth dated 7 June 2024 at [217].
994 Submissions of the Commonwealth dated 7 June 2024 at [180], [181], [195], [215], [221]-[236] and [249].
domestic violence issues that arose in June/July 2015 (including the AVO) as CAPT KH was not called to give evidence. The Commonwealth submits that the documentary evidence suggests CAPT KH gave CPL Turner an appropriate standard of care in this period and actively considered the prospect of PTSD symptoms.995 It is noted the expert evidence “did not speak with one voice” regarding the presence of PTSD symptoms in 2015.996 The Commonwealth’s objection directs attention to Counsel Assisting’s submission on the fact that in 2015 the violence directed towards Joanna Turner did not form part of the ADF’s decision-making in relation to deployment and the submissions that focus on the lack of a system in place for the allegations being made by Joanna Turner to be recognised and dealt with by the ADF and the absence of a longitudinal approach to CPL Turner’s history which could be taken into account in deployment decisions.
The Commonwealth raises a similar objection in relation to findings about the ERTA in 2015 and those people involved in it.997 The Commonwealth submits that there was a system in place for scrutinising the reasons for the ERTA and supporting Joanna Turner and CPL Turner, namely the RtAPS process and support provided by MAJ Clancy and Padre MP.998 Reported incident of domestic violence in September 2015
In relation to the incident of reported domestic violence on 17 September 2015, the Commonwealth submits that the reasons why the Subsequent Incident Report “understated” or “minimised” the incident were unknown and cannot be the subject of findings. It is submitted that Counsel Assisting’s criticism of the underreporting is affected by hindsight bias but bespeaks the need for better training about PTSD, its relationship to substance abuse and domestic violence, and training on reporting obligations by ADF personnel.999 Submissions in reply of Counsel Assisting Referral to an addiction medicine specialist
Counsel Assisting does not support a finding that the proposal to refer CPL Turner to an addiction medicine specialist was “not actioned” given that CAPT KH apparently 995 Submissions of the Commonwealth dated 7 June 2024 at [222]-[225].
996 Submissions of the Commonwealth dated 7 June 2024 at [227]-[231].
997 Submissions of the Commonwealth dated 7 June 2024 at [191]-[194] and [196].
998 Submissions of the Commonwealth dated 7 June 2024 at [192].
999 Submissions of the Commonwealth dated 7 June 2024 at [244]-[246].
took advice from, and deferred to the view of, CPL Turner’s long-term treating psychiatrist.1000 CAPT KH and the ERTA
Counsel Assisting also does not seek any adverse finding against CAPT KH.1001 As the Commonwealth accepts, it is possible “there was a failure on the part of the ADF to ‘connect the dots’” in this period.1002 The suggestion that it was necessary to call CAPT KH to fill some evidentiary gap should be rejected, because there is no real possibility that her presence could influence the outcome of a proposed finding as to the absence of a system.
Similarly, in relation to the ERTA, Counsel Assisting does not seek a finding against any particular member of the ADF and it is submitted that it is not necessary for Counsel Assisting to call people to explain the absence of a process which plainly did not exist (and it does not seem to be contended that it did exist).1003 BRIG Langford
As for the Commonwealth’s issue with the criticism of BRIG Langford, Counsel Assisting considers the complaint to be based on a false premise.
Counsel Assisting notes that the submission regarding BRIG Langford’s evidence (above at [642]) does not suggest that any enquiry of Joanna Turner needed to be personally done, but rather the nature of his personal knowledge meant that such an enquiry ought to have been made (whether by BRIG Langford personally or at his instigation). The suggestion that it was necessary to put to BRIG Langford that this was “egregious” is without foundation, noting that procedural fairness does not require the adjective to be used to describe a criticism to be put to the witness. The suggestion that fairness required him to be recalled so his evidence could be given with the benefit of his own email1004 should similarly be rejected. Procedural fairness does not require a witness to have shown to them all the potentially helpful documents (in this case, their own documents) that emerge after they have given evidence and then have the questions re-asked.1005 1000 Submissions in reply of Counsel Assisting dated 22 August 2024 at [60].
1001 Submissions of Counsel Assisting dated 22 August 2024 at [206].
1002 Submissions of the Commonwealth dated 7 June 2024 at [181].
1003 Submissions of the Commonwealth dated 7 June 2024 at [192].
1004 Submissions of the Commonwealth dated 7 June 2024 at [217].
1005 Submissions of Counsel Assisting dated 22 August 2024 at [208].
Consideration
There was a continued escalation of domestic violence throughout 2015 and an ongoing lack of curiosity by those managing CPL Turner about it. When CPL Turner returned home early from Iraq ostensibly by reason of “Joanna Turner’s mental health”, it is apparent that no inquiries were made into the real circumstances of Joanna’s mental health or the impact of the decision to return on CPL Turner’s wellbeing. As Counsel Assisting has made clear, a simple phone call to Joanna Turner would have indicated her ongoing fear and contact with police. MAJ Clancy was well aware of what was occurring, but the information did not seem to get connected to CPL Turner’s health records or indeed make its way to BRIG Langford.
BRIG Langford told the Court that the information would have influenced his decision about whether or not CPL Turner should have been given a medical waiver to deploy to Malaysia. His lack of curiosity about what was really going on for CPL Turner is alarming given that he had met with Joanna Turner after her letter to him the previous year.
There are a number of really significant failures of the ADF to properly deal with the escalation of domestic violence. Firstly, there was an inadequate response to the AVO from June 2015 and then when domestic violence was reported in September 2015 it was minimised and understated.
I have considered whether CPL Turner should have been referred to an addiction medicine specialist as suggested by Dr Wallace in September 2015. In my view, it would have been an extremely valuable intervention. Nevertheless, I accept the Commonwealth’s submission that while CAPT KH discussed the issue with Dr Sringeri, she was advised that there was “no need”.
Adequacy of ADF’s response in 2016
Counsel Assisting’s submissions
from the VVCS in November 2015. It was also apparent that by the end of 2015 his mental health was seriously impaired.
The 2016 waiver/clearance decision
The Clinical Perspective Document
The only objective indicator of positive mental health appeared to have been his performance in the workplace throughout 2016. Counsel Assisting refers to the expert evidence, which demonstrates that this is an unreliable indicator of whether CPL Turner was experiencing symptoms of PTSD. What was then presented to GPCAPT Ross as a medical perspective was in fact MAJ AM having enacted the Command’s intent, which was to have the decision reversed under the guise of a document containing medically relevant information.
The brief drafted by MAJ AF
instructed to particularly monitor his mental health, to be on the lookout for signs of relapse, or given any instruction on how to deal with CPL Turner suffering a relapse.
Indeed, asking his team members to undertake this task in theatre would have been highly unrealistic. As the evidence of MAJ BJ demonstrated, the situation in Iraq was highly unpredictable and CPL Turner’s teammates were occupied with the task at hand. They appeared to have very little capacity, in the midst of their ordinary work, to perform the roles (in theory) assigned to them by the CO’s brief.
It is further submitted that the assertion put to GPCAPT Ross that the personnel best able to monitor, assess, and manage CPL Turner’s mental health were his regular team members was in itself a red flag that should have alerted him (GPCAPT Ross) to the fact that there was no realistic plan in place to monitor and support CPL Turner’s mental health should the medical clearance be granted. Counsel Assisting contends that it should have been obvious to GPCAPT Ross, as an experienced member of the ADF’s medical staff, that CPL Turner’s regular team members would not have had the qualifications and expertise to undertake such a task even if they had the time and the wherewithal to do so.
As for the “ready access to coalition medical support” including psychologists, it is very difficult to see how CPL Turner’s access could be described as “ready”. He was located in TQ where there were no available psychologists. MAJ AF’s evidence was that there was either a “psych team” or individual in AMAB (i.e. the UAE) but there was “none in Iraq”.1007 Although there was a hospital with American psychological staff at BDSC, MAJ AF’s evidence was that he could not imagine that CPL Turner would have accessed psychological support from coalition partner forces’ health services in Iraq.1008 He explained that this was because he considered CPL Turner would likely want to use the Australian system as compared to a coalition partner system for medical support.1009
In those circumstances, Counsel Assisting submits that CPL Turner’s access to psychological support could hardly be described as “ready”. Indeed, in a message to CPL TJ on 14 October 2016, CPL Turner himself stated “the more I think about it, the more I realise that they put me in a bad position. Putting me out here so isolated from everything. Even though it clearly states on my waiver that I need access to medical support”.1010
1010 Exhibit 57 (WhatsApp and SMS messages) at 1289.
ii. No-one involved in the authoring of that document, nor anyone to whom it was sent, took any steps to ensure that what was represented would be done by way of support for CPL Turner in Iraq was in fact done.
iii. The document was simply an advocacy piece to achieve a result: the reversal of GPCAPT Ross’ initial decision. It bore no connection to the reality which CPL Turner would face once he was actually deployed.
GPCAPT Ross’ decision to reverse the initial decision not to grant medical clearance
Dr Sringeri’s letter of 13 July 2016
problematic. In Counsel Assisting’s view, it is plainly open to be interpreted as Dr Sringeri clearing CPL Turner as fit to be deployed on OP OKRA. This is particularly the case in the context of the referral to Dr Sringeri which expressly asked: “I need your opinion about his deployment, is member fit to deploy?”. Counsel Assisting notes that it is very difficult to accept that the ADF should have interpreted Dr Sringeri’s letter in any other way than that Dr Sringeri was giving his opinion that CPL Turner was fit to deploy to Iraq. That is what a plain reading of the letter conveys and if Dr Sringeri had not intended that to be how the letter was read, he should have made this clear.
Indeed, the letter expressly stated that CPL Turner’s risk of relapse was “very low” in a context in which Dr Sringeri was asked for his opinion about deployment.
Other submissions about the waiver/clearance decision
the result that critical information about CPL Turner’s risk on deployment was missed in the decision-making process.
The way the evidence fell also revealed a significant degree of confusion about the extent to which it was appropriate for Command to be involved and the extent to which the medical clearance was a medical decision only, based on risks to CPL Turner, or if it could take into account the interests of the ADF in having CPL Turner deploy. It appeared that the Chain of Command conceived of GPCAPT Ross’ role as being medical only. GPCAPT Ross at some points considered that he was making a purely medical decision but at other points considered that he needed to take into account the interests of the ADF and the operational requirements of the military. Counsel Assisting submits that I would comfortably find there was a lack of clear understanding amongst the various individuals involved in this decision of what was to be taken into account and why.
Finally, in relation to MAJ AF’s evidence to the effect that he believed and continues to believe that deploying was in CPL Turner’s best interests, including in a medical sense (i.e. for his mental health), Counsel Assisting notes that the overwhelming inference from the evidence is that MAJ AF wanted CPL Turner to deploy for operational reasons and not because of any concern about his mental health. To the extent that he believed it was better for CPL Turner to deploy than to stay in Australia, Counsel Assisting submits that this opinion was naïve at best and wilfully blind to available medical information at worst. Counsel Assisting notes that MAJ AF does not have qualifications as a mental health professional and submit that his dogged persistence in his belief, even in the face of all of the evidence now available, that the deployment was good for CPL Turner is concerning in that it tends to suggest an inadequate understanding on the part of leaders in the ADF about the nature of PTSD, the risks of recurrence, the potential triggers, and the importance of taking all these into account in making decisions in the best interests of members.
The Iraq deployment
Contrary to what was represented to GPCAPT Ross in the Clinical Perspective Document, there was no actual mental health support put in place for CPL Turner to minimise the risks to him during that deployment. MAJ AF’s evidence was that this was limited to “routine engagement by the chain of command”. What is made express in that answer is that nothing out of the ordinary was done beyond the mental health and pastoral care that would be expected of the Chain of Command in respect of every member of the ADF.
The failure to put supports in place at the outset was exacerbated by the experiences which CPL Turner ultimately had during the deployment, including the disciplinary proceedings, the issuing of the NTSC, being informed of a move from B Company to C Company and the body recovery mission. It is submitted that the people around CPL Turner who were apparently looking after his mental health (MAJ BJ and CAPT MH) were inadequately placed to do so – they were not properly trained and were not in fact in a position to offer the support which CPL Turner needed. CPL TJ was left to deal alone with the brunt of CPL Turner’s mental health issues during that deployment.
Counsel Assisting considers that she was in a compromised position given her nascent relationship with CPL Turner and was inadequately equipped to manage the significant volatility she experienced from CPL Turner. She ought not to have been put in that position and it could have been avoided by the Chain of Command doing what it had represented it would do in CO’s brief.
The body recovery mission
Noting that it is difficult to know exactly what happened and what CPL Turner was involved in, Counsel Assisting believes that it is clear beyond doubt that something did happen and that CPL Turner was triggered into relapse by it. This tends to demonstrate how unpredictable deployment to a warzone can be and that there was an overreliance on the idea that because the deployment was simply “train, advise, and assist”, there was minimal risk of re-traumatisation.
who had a mental health diagnosis. In his view, those people would not come forward with symptoms if that was the potential outcome.1012
Counsel Assisting notes that whilst this was a valuable contribution from MAJ AM, the focus of his concerns tends to reveal a greater difficulty with the focus of the ADF throughout the Inquest on emphasising that just because a member has had PTSD does not mean they should not ever be deployed. Counsel Assisting submits that this was and remains a strawman. Rather, the question to be determined at the Inquest has been and remains the manner and cause of CPL Turner’s death and, in that regard, the appropriateness of the decision to deploy him on OP OKRA in 2016.
None of the shortcomings which have been identified with that decision say anything about whether a different member who has suffered PTSD in the past should be deployed. Counsel Assisting posits that the shortcomings identified in the evidence in this Inquest are all firmly grounded in the failure, both at the unit level and the J07 HQJOC level, to adequately consider the available information in relation to CPL Turner’s presentation, assess the risks associated with his personal situation, and respond appropriately in deployment and waiver/clearance decision-making.
Submissions of Mr and Mrs Turner The 2016 waiver/clearance decision
Mr and Mrs Turner submit that GPCAPT Ross’ reliance on MAJ AM “as a medical officer who had direct clinical knowledge” of CPL Turner was misplaced, noting that MAJ AM was not his treating physician. They also contend that MAJ AM did not have direct access to CPL Turner’s medical records when he prepared the Clinical Perspective Document and, rather, he wrote this document from a remote location (which impacted the availability of clinical records to him).1013 They consider that MAJ AM’s oral evidence supports a conclusion that he did not review CPL Turner’s medical records himself and, instead, he relied on a junior RMO to relay relevant information to him over the telephone.1014 CPL Turner’s parents submit this was less than satisfactory.
They also submit that given the Clinical Perspective Document was written outside of working hours, it would be reasonable to conclude that there was also no consultation
1013 Submissions of Mr and Mrs Turner dated 28 January 2024 at [162]-[173].
1014 Submissions of Mr and Mrs Turner dated 28 January 2024 at [169].
with any of CPL Turner’s treating clinicians (noting also that MAJ AM did not give evidence that he spoke with any clinicians).1015
CPL Turner’s parents contend that MAJ AM should not have titled his document “clinical perspective” because he was not a treating clinician. They consider that in light of the document’s title, it was understandable that GPCAPT Ross relied on that document as the professional opinion of MAJ AM, seemingly believing that MAJ AM had direct clinical knowledge of CPL Turner.1016 Submissions of the Commonwealth
With the benefit of hindsight, the ADF accepts that its operational personnel did not sufficiently understand, or they underestimated, the extent to which a person suffering from PTSD (or other mental health issues) can successfully conceal signs/symptoms and continue to perform at a legal level in the workplace. The ADF also accepts that further training about this matter is necessary. However, the Commonwealth notes that CPL Turner’s continued high performance was not irrelevant to the question of whether he was suitable for deployment in 2016, and certainly was not regarded as irrelevant.1017
Other matters which, at the time, pointed in favour of deployment are submitted to be: CPL Turner’s desire to be deployed; the fact he recently completed two training exercises (Exercise Night Tiger and Exercise Balikatan) which required predeployment health screening; the fact he was MEC J23 (and was in the process of being upgraded to J11); the nature of the mission being “train, advise and assist”; that there was a “no alcohol” direction; and “from the perspective of the operational personnel”, “CPL [Turner] had a history of positively engaging with mental health services”.1018 The understanding at the time of the adequacy of psychological services while on deployment and the ability of CPL Turner’s peers to monitor him (see below at [700]) are also relied upon in this respect.1019 As to the monitoring by peers, the Commonwealth accepts that in hindsight that strategy failed, largely due to the decision to post CPL Turner to TQ.1020 However, it is submitted that decisions concerning his movement were not made frivolously or without regard to CPL Turner’s welfare.1021 1015 Submissions of Mr and Mrs Turner dated 28 January 2024 at [169]-[170].
1016 Submissions of Mr and Mrs Turner dated 28 January 2024 at [172].
1017 Submissions of the Commonwealth dated 7 June 2024 at [79], [264].
1018 Submissions of the Commonwealth dated 7 June 2024 at [259]-[278].
1019 Submissions of the Commonwealth dated 7 June 2024 at [378]-[379].
1020 Submissions of the Commonwealth dated 7 June 2024 at [432].
1021 Submissions of the Commonwealth dated 7 June 2024 at [432]-[441].
The deployment decision
It notes that when the evidence is looked at as a whole and with the benefit of hindsight, there was an insufficiently clear understanding on the part of the 2CDO Chain of Command, ADF medical personnel, and Dr Sringeri about their respective “roles and responsibilities in the process of decision-making”, including the “scope and limitation[s]” of their tasks.1022 As a general submission, the Commonwealth observes that those involved in the medical clearance process did not have the benefit of hindsight and the time the Inquest has had to consider this decision and they were faced with a difficult decision (that included the decision to be made by MAJ AM),1023 for which there was not an obviously correct answer.1024
The Commonwealth also submits that Counsel Assisting ought to have had regard to the circumstances in which MAJ AM prepared the Clinical Perspective Document, that is: his physical location at Port Wakefield; the limited time in which he had to prepare the document; that he did not have “ready access” to his email or DeHS; his lack of access to CPL Turner’s medical records; and his inability to secure input from others.1025
The Commonwealth also submits that, in relation to the medical clearance process, “[i]n retrospect, the ADF accepts that the risk of relapse of CPL Turner’s PTSD should have been identified as higher than it was”.1026
The ADF also accepts its responsibility to ensure its medical personnel are sufficiently trained with respect to mental health issues (like PTSD) that may be expected to be present among ADF members.1027
The ADF considers it would be appropriate for it to consider reviewing its policy framework with respect to the making of deployment decisions for ADF members who have or have had a diagnosis of PTSD or another similar mental health condition, with a view to: i. consider implementing training programs “designed to ensure that operational personnel and medical personnel have a clear understanding of their roles and 1022 Submissions of the Commonwealth dated 7 June 2024 at [316].
1023 Submissions of the Commonwealth dated 7 June 2024 at [331]-[333].
1024 Submissions of the Commonwealth dated 7 June 2024 at [312]-[314].
1025 Submissions of the Commonwealth dated 7 June 2024 at [335]-[336].
1026 Submissions of the Commonwealth dated 7 June 2024 at [315].
1027 Submissions of the Commonwealth dated 7 June 2024 at [330].
responsibilities with respect to the making of deployment decisions for ADF members diagnoses with PTSD” or another similar mental health condition;1028 and ii. developing clear guidelines about (i) how such decisions should be made; (ii) the roles and responsibilities of operational personnel, medical personnel, and any external health practitioners in the making of such decisions; (iii) the information to which operational personnel, medical personnel, and any external health practitioners may and may not have access in making such decisions; and (iv) in the event that a decision to deploy is made, the development and implementation of risk mitigation strategies.1029
The Commonwealth considers that a review of this kind would be the best way of achieving the goals underlying Counsel Assisting’s recommendations (l), (m), and (n) (see below).1030
The Commonwealth also makes the following three key submissions in relation to the deployment decision: i. While the ADF accepts that there is evidence that there was a “failure of the system to operative effectively”, it considers there to be no “proper basis” for a finding that MAJ AF and MAJ AM “did not have regard to the interests of CPL Turner” or “decided to prioritise ADF’s operational interests over CPL Turner’s” in the 2016 deployment decision.1031 ii. No finding can be made that MAJ AM, when preparing the Clinical Perspective Document, simply “enacted the [chain of] command’s intent” with “almost no regard to the volume of evidence in the ADF health records”.1032 It is submitted that no findings should be made about the appropriate level of involvement by the Chain of Command given the absence of evidence on the topic.1033 iii. It is not open to find that the Clinical Perspective Document was the only document that GPCAPT Ross considered when making the second/reversal decision.1034 It is submitted that the brief to GPCAPT Ross also contained new 1028 Submissions of the Commonwealth dated 7 June 2024 at [318(b)].
1029 Submissions of the Commonwealth dated 7 June 2024 at [318(a)].
1030 Submissions of the Commonwealth dated 7 June 2024 at [318(a)].
1031 Submissions of the Commonwealth dated 7 June 2024 at [319].
1032 Submissions of the Commonwealth dated 7 June 2024 at [325].
1033 Submissions of the Commonwealth dated 7 June 2024 at [380(a)].
1034 Submissions of the Commonwealth dated 7 June 2024 at [381]-[384].
information in the sense of the Chain of Command’s perspective about mitigation strategies.1035
It is also noted that the ADF accepts that the fact that MAJ AM did not have a clearer understanding about how he was expected to balance his various roles and responsibilities, in particular, about “what was to be taken into account and why” as part of the medical clearance decision, is a failure on the part of the ADF to sufficiently delineate roles and responsibilities and offer training accordingly.1036 Dr Sringeri’s letter dated 13 July 2016
The ADF’s view is that there was nothing inappropriate or unreasonable about the fact that the ADF relied on Dr Sringeri’s letter and that a finding ought not be made that Dr Sringeri’s review fell short of an appropriate, peer accepted standard.1037 It is submitted that as part of GPCAPT Ross’ brief, its presence and content should have particular importance given Dr Sringeri’s expertise and existing clinical relationship with CPL Turner. 1038
It is further submitted the Dr Sringeri’s letter supported the conclusion that CPL Turner’s colleagues would be capable of monitoring CPL Turner’s mental health on deployment, a conclusion also supported by the proximity of those colleagues while on deployment and the fact that peers had raised concerns in the past.1039 Body recovery incident
The Commonwealth notes that the incident that appears to have triggered a relapse of PTSD during the 2016 deployment was the involvement in the body recovery incident, which in the period January to June 2016, would perhaps not have been regarded as an especially traumatic incident. With the benefit of hindsight, the ADF accepts that this view (to the extent held) was misplaced and that there is a need for better training about the risk of relapse of PTSD, including the range of potential causes of relapse.
However, to say that a more nuanced understanding of the risk of relapse of PTSD needs to be developed is not to say that there was anything inappropriate or unreasonable in the fact that the relevant operational personnel took into account the 1035 Submissions of the Commonwealth dated 7 June 2024 at [380(b)].
1036 Submissions of the Commonwealth dated 7 June 2024 at [327]-[328].
1037 Submissions of the Commonwealth dated 7 June 2024 at [374].
1038 Submissions of the Commonwealth dated 7 June 2024 at [363]-[371], [385].
1039 Submissions of the Commonwealth dated 7 June 2024 at [378].
nature of the deployment for which CPL Turner was being considered, or that they made relativistic or probabilistic decisions about the level of risk that it posed.1040
The Commonwealth submits that there is “no firm evidentiary basis for the proposition that CPL Turner’s mental health was in decline” prior to the body recovery which occurred in September 2016.1041 However, the ADF does accept that “the evidence indicates that the incident that appears to have triggered a relapse of CPL Turner’s PTSD during the 2016 deployment was his involvement in the body recovery, especially his involvement in the ramp ceremony associated with that recovery”.1042 Submissions of GPCAPT Ross The 2016 waiver/clearance decision
GPCAPT Ross embraces Mr and Mrs Turner’s submission in relation to the “title” of the Clinical Perspective Document (as noted at [688] above). However, in relation to Mr and Mrs Turner’s submission that his reliance on MAJ AM as a medical officer who had direct knowledge of CPL Turner was “misplaced”, GPCAPT Ross notes that his evidence1043 made it clear that he was not labouring under any misapprehension that MAJ AM was CPL Turner’s treating physician.1044
GPCAPT Ross submits that he was not ignorant of the information in CPL Turner’s medical records, nor did he act inconsistently with it; rather, he made his initial decision to refuse to grant the clearance “in reliance on” that information, which was the best and most complete information available to him at the time.1045
GPCAPT Ross contends that in assessing his decision to grant CPL Turner clearance to deploy, it is key to bear in mind the important role played in the MEC system (in that, as CPL Turner held a MEC J23 at the time, he was prima facie deployable on OP OKRA but was required to obtain medical clearance).1046
GPCAPT Ross submits that the finding advocated by Counsel Assisting concerning the “third point of failure” (set out at [671(iii)]) should be rejected, noting that it cannot reasonably be found that (a) GPCAPT Ross made his appeal/reversal decision on the 1040 Submissions of the Commonwealth dated 7 June 2024 at [84]-[89], [272].
1041 Submissions of the Commonwealth dated 7 June 2024 at [448].
1042 Submissions of the Commonwealth dated 7 June 2024 at [430].
1044 Submissions of GPCAPT Ross dated 5 June 2024 at [63].
1045 Submissions of GPCAPT Ross dated 5 June 2024 at [19].
1046 Submissions of GPCAPT Ross dated 5 June 2024 at [25]-[26].
Clinical Perspective Document alone and (b) GPCAPT Ross did not interrogate the medical records to test what was being put to him in that document.1047
GPCAPT Ross disagrees with any contention that he sought to assign responsibility to others for the medical clearance decision. He submits that he has at all times acknowledged and accepted that the decision first to refuse and subsequently grant the clearance was made by him (without meeting with CPL Turner).1048 He accepts that it was his decision to make and not Dr Sringeri’s.1049 He submits that he was entitled to rely on (and did in fact rely on) material provided by MAJ AM (the Clinical Perspective Document) and Dr Sringeri’s letter dated 13 July 2016 in making his appeal/reversal decision, which placed him in an invidious position in that the material “on its face addressed the matters that had caused him to make the Initial Decision and reject medical clearance, but which did not refer to limitations with that information that were apparently operating on the minds of those who drafted the documents”.1050
GPCAPT Ross submits that while MAJ AF accepted that the (draft) minute was intended to influence GPCAPT Ross to change his initial decision to refuse medical clearance and that COL MF accepted that he intended for the minute to influence GPCAPT Ross as to whether CPL Turner should be granted medical clearance, it does not follow that GPCAPT Ross was in fact influenced by any Command imperative in making the appeal/reversal decision.1051 Rather, his evidence was that it was not the fact that the RMO had provided information that caused him to change his decision – it was the substance of the information.1052
GPCAPT Ross also acknowledges that in making his appeal decision, he considered the availability of in-country psychological support in accordance with ADF risk assessment policy (noting that deployment carries an inherent risk of trauma). He submits that while the risk of trauma tragically came to pass, this does not in itself indicate any error in GPCAPT Ross’ risk assessment process nor in the decision to grant medical clearance to deploy.1053
GPCAPT Ross notes that as part of the risk assessment, he took into account the risk to the ADF of CPL Turner’s deployment, the medical support available to him in country, that he had recently deployed successfully, the potential risk in Iraq, the 1047 Submissions of GPCAPT Ross dated 5 June 2024 at [88].
1048 Submissions of GPCAPT Ross dated 5 June 2024 at [9], [46].
1049 Submissions in reply of GPCAPT Ross dated 22 July 2024 at [13].
1050 Submissions of GPCAPT Ross dated 5 June 2024 at [47]-[48].
1051 Submissions of GPCAPT Ross dated 5 June 2024 at [104]-[105].
1052 Submissions of GPCAPT Ross dated 5 June 2024 at [107].
1053 Submissions of GPCAPT Ross dated 5 June 2024 at [120]-[121].
matters outlined in the Clinical Perspective Document, and potentially “other factors”.
He acknowledged that there is no good way to determine who amongst those who have had PTSD and have redeployed are at higher or lower risk of the negative outcome coming to pass once deployed. He could not have been expected to anticipate and assess the particular chain of events that occurred on and following CPL Turner’s deployment.1054
GPCAPT Ross also notes that there is no counterfactual by which to assess how CPL Turner would have fared had he not been deployed in 2016 in that it is not possible to assess how his mental health might have been affected had he remained in Australia while his B Company colleagues deployed, nor what relationship issues and other stressors he might have experienced in the barracks environment during that time. In this sense, it was outside the scope of GPCAPT Ross’ role to assess the consequences of an individual not deploying.1055
Lastly, GPCAPT Ross states that there is no consensus medical opinion before the Inquest to invalidate the presumption on which his reversal decision rests; namely, that a person who has suffered from PTSD in the past but is now presenting as asymptomatic or minimally symptomatic is capable of deploying and is not as an unacceptably high risk of suffering recurrence of PTSD in doing so.1056 The role of Dr Sringeri and his letter of 13 July 2016
GPCAPT Ross submits that a finding should be made that one of the documents that was before him when he made the appeal/reversal decision and which he took into account was Dr Sringeri’s letter of 13 July 2016 and, furthermore, that he was entitled to rely on the opinion expressed in the letter as there was nothing on its face that would put GPCAPT Ross on notice as to any limitations or qualifications on those opinions.1057 He further submits that it would be “extremely difficult for him not to have accepted Dr Sringeri’s expert opinion as to CPL Turner’s psychiatric condition” given Dr Sringeri was a qualified psychiatrist, he was CPL Turner’s treating psychiatrist, and his opinions were addressed directly to the matters that had caused GPCAPT Ross to refuse clearance in his initial decision.1058 1054 Submissions of GPCAPT Ross dated 5 June 2024 at [122]-[125].
1055 Submissions of GPCAPT Ross dated 5 June 2024 at [118]-[119].
1056 Submissions of GPCAPT Ross dated 5 June 2024 at [108]-[117].
1057 Submissions of GPCAPT Ross dated 5 June 2024 at [67]-[71].
1058 Submissions of GPCAPT Ross dated 5 June 2024 at [73]; Submissions in reply of GPCAPT Ross dated 22 July 2024 at [16].
In support of this submission, GPCAPT Ross refers to the expert evidence on this point.1059 GPCAPT Ross also considers that he was entitled to assume that Dr Sringeri had made whatever enquiries necessary to satisfy himself as to the veracity of CPL Turner’s presentation, to consider the possibility he was underreporting his symptoms, and to report anything of significance in the letter. GPCAPT Ross considers that there is nothing on the face of Dr Sringeri’s letter to suggest that CPL Turner might have been downplaying his symptoms for fear of career repercussions or that CPL Turner’s objective was to obtain a letter that would permit him to deploy.1060
GPCAPT Ross notes that Dr Sringeri’s letter addressed the concerns he had at the time of making the initial medical clearance decision, namely CPL Turner’s discontinuation of his psychological treatment, suggesting he might have poor insight into his condition (Dr Sringeri considered he required no psychiatric follow-up and opined that CPL Turner “had good insight”); CPL Turner’s alcohol consumption (Dr Sringeri noted he “consumes alcohol only on the weekends and special occasions and monitors his alcohol intake”); CPL Turner was at “high risk of deterioration if deployed” (Dr Sringeri opined that the risk of his PTSD recurring was “very low”); and the risk of granting the medical clearance to deploy to a person with symptomatic PTSD (Dr Sringeri described CPL Turner as “symptom free”).1061
GPCAPT Ross also states that while Dr Sringeri gave evidence that he did not recall receiving the referral letter from Dr Aftab, the fact that it is contained in ADF records suggests that it was provided to him.1062
In relation to Dr Sringeri’s contention that the clearance was a matter for the ADF medical board and the Chains of Command (and not Dr Sringeri), GPCAPT Ross considers that Dr Sringeri should have known and accepted that the decision-makers in the ADF would rely on his opinion. GPCAPT Ross considers that a finding ought to be made that Dr Sringeri was aware that ADF personnel would be receiving his letter for the purposes of assessing whether CPL Turner was medically fit to deploy to Iraq and that they would read his opinion that CPL Turner was “cleared to attend all duties from a psychiatric point” as an opinion that he was psychiatrically fit to deploy.1063
Furthermore, GPCAPT Ross submits that there is nothing on the face of the letter of 13 July 2016 that conveys any limitation as to Dr Sringeri’s requirement to “determine
1060 Submissions of GPCAPT Ross dated 5 June 2024 at [76], [80].
1061 Submissions of GPCAPT Ross dated 5 June 2024 at [72].
1062 Submissions of GPCAPT Ross dated 5 June 2024 at [77].
1063 Submissions of GPCAPT Ross dated 5 June 2024 at [78].
whether a patient is well enough to be cleared to return to work to attend to duties”, nor that his opinion about CPL Turner being cleared to attend all duties from a psychiatric perspective “was not intended to imply or suggest that [he] cleared [CPL Turner] to deploy in a combat zone”.1064 GPCAPT Ross also refers to the evidence of the experts who support the view that opining as to fitness for duty was within the scope of Dr Sringeri’s role.1065 He further submits that while the decision as to medical clearance did not ultimately rest with Dr Sringeri, this did not relieve him of the obligation to ensure that the opinion as to psychiatric fitness he provided could be accepted on its face.
In respect of Counsel Assisting’s submission that it is difficult to accept that “the ADF should have interpreted Dr Sringeri’s letter in any other way than that Dr Sringeri was giving his opinion that CPL Turner was fit to deploy”, insofar as the reference to the ADF includes GPCAPT Ross, GPCAPT Ross emphasises that his evidence was that while he did not recall receiving the letter, this does not mean that he did not receive the letter, and that if he did receive the letter he would have taken it into account in making the appeal/reversal decision.1066
In respect of Dr Sringeri’s submission that his letter did not express any opinion that CPL Turner was “fit to deploy” (see below at [723]), GPCAPT Ross submits that Dr Sringeri must be taken to have understood the significance of him expressing the view that CPL Turner was “well and stable”, “cleared to attend all duties from a psychiatric point”, that his “chances of recurrence of his PTSD symptoms [were] very low”, and that his “risk of self and harm to others [were] also very low”. GPCAPT Ross considers it is not plausible to relieve Dr Sringeri of responsibility for the opinion he did express simply because the decision to deploy CPL Turner was ultimately not his to make and because he did not use the phrase “fit to deploy” in the letter. Rather, if Dr Sringeri did not intend the person who would make that decision to take those statements at face value and to rely on them in making that decision, then his letter should have made that clear.1067 1064 Submissions of GPCAPT Ross dated 5 June 2024 at [79]-[80].
1065 Exhibit 9 (Supplementary Report of Dr Nie lssen) at 3; Tab 109 (Report of Professor Large) at 1745-6, 1789-90; 07.02.23
1066 Submissions of CPCAPT Ross dated 5 June 2024 at [90]-[91].
1067 Submissions in reply of GPCAPT Ross dated 22 July 2024 at [14]-[15].
Submissions of Dr Sringeri Dr Sringeri’s letter dated 13 July 2016
In relation to his letter dated 13 July 2016, Dr Sringeri objects to Counsel Assisting’s use of adjectives such as “grossly” inadequate, “highly” problematic, and “highly inadequate”. Dr Sringeri submits the language used is inflammatory and the adjectives are unsupported by expert evidence and are inconsistent with the purpose of an inquest, which is not to apportion blame or guilt.1068
Dr Sringeri does not dispute that the experts all expressed a similar opinion in respect of his assessment of risk recurrence of CPL Turner’s PTSD symptoms as being “very low”. Dr Sringeri submits that, impliedly, he accepted the expert evidence that the use of the words “very low” risk was problematic. He was invited to put on a statement responding to the expert evidence on that point and did not do so.1069
Despite the expert evidence in relation to the words “very low”, it is noted that there was no actual criticism made by the experts that that terminology was “inappropriate” or that it was “highly” or “grossly” inadequate language to use in order to convey “the risks of deployment on further relapse, and the limitations which he later stated were implicit in his own opinion”. Dr Sringeri’s view is that Counsel Assisting’s submissions do not address similar opinions expressed by Dr Large, Dr Nielssen, Dr Dinnen, and Professor Hopwood that, as at the date of 13 July 2016, it was an available view that CPL Turner was fit to deploy from a psychiatric perspective as his symptoms were mild.1070
Dr Sringeri further submits that it is unclear what evidence Counsel Assisting is referring to in the passage “the limitations which he later stated were implicit in his own opinion” above at [675]. Dr Sringeri notes that his opinion in his letter dated 13 July 2016 was “cleared for all duties” and that his opinion did not state CPL Turner “was ‘fit’ for deployment”. It is apparent from the letter that the opinion was expressly noted to be from his perspective as a psychiatrist. Despite that, Counsel Assisting at various times asked whether it was reasonable for a psychiatrist to use the language “fit to deploy” point of view, or whether a psychiatrist should refrain from any view as to fitness. As stated by Professor Hopwood, there is no universally agreed standard as to how psychiatrists express themselves.1071 1068 Submissions of Dr Sringeri dated 24 April 2024 at [4]-[8], [16].
1069 Submissions of Dr Sringeri dated 24 April 2024 at [9].
1070 Submissions of Dr Sringeri dated 24 April 2024 at [10]-[11].
1071 Submissions of Dr Sringeri dated 24 April 2024 at [17]-[18], [23]-[24].
Dr Sringeri submits that it is not necessary for a finding to be made on the language or terminology used in his letter dated 13 July 2016. Rather, a finding should be confined to the fact that Dr Sringeri’s opinion of a “very low” risk of recurrence of PTSD symptoms was not supported by the experts in their oral evidence.1072
Notwithstanding his decades of experience as a consultant psychiatrist, Dr Sringeri disagrees1073 with any contention that he had “expertise” in PTSD and alcohol use disorder (as at 2014). Dr Sringeri submits that his evidence was that “the number of patients he saw with combat-related PTSD were about 15-20, the number serving in the ADF were 2, (on the evidence when it was given, at that stage) and of the 15-20 combat-related patients, 50% suffered from PTSD”. Dr Sringeri also contends that any description of him being “well familiar”1074 with the general nature of the duties that CPL Turner performed as a member of 2CDO is “highly speculative” and not supported by the evidence.
Letter from Dr Sringeri’s representatives dated 11 August 2021 (Exhibit 19)
Dr Sringeri refers to questions posed by Counsel Assisting via email on 11 August 2021 in relation to whether: he considered the risks associated with deployment at the consult on 13 July 2016; and CPL Turner should be cleared for deployment. Dr Sringeri’s response (Exhibit 19) was that he did consider the risks associated with deployment (his notes reflected this) and that he undertook a PCL-M, which scored 10, indicating little or no symptoms. Dr Sringeri submits that clearance for deployment was not a matter for him, it was for the ADF medical board and the Chains of Command.1075
In relation to the Commonwealth’s complaints about the manner in which Exhibit 19 was tendered into evidence, Dr Sringeri notes that the manner in which was tendered resulted from the piecemeal production of material and the tender of pertinent, if not crucial material, after the evidence of significant factual witnesses.1076
Dr Sringeri submits that insofar as the Commonwealth alleges that prior to Counsel Assisting posing the questions to Dr Sringeri which led to the response which became Exhibit 19, those assisting advised Dr Sringeri’s solicitors that his letter dated 13 July 2016 “did exist”, that allegation ought to be rejected. Dr Sringeri seeks leave to tender 1072 Submissions of Dr Sringeri dated 24 April 2024 at [27].
1073 Submissions in reply of Dr Sringer dated 22 July 2024 at [55]-[60].
1074 Submissions of the Commonwealth dated 7 June 2024 at [370].
1075 Submissions of Dr Sringeri dated 24 April 2024 at [14]; Exhibit 19 at 1.
1076 Submissions in reply of Dr Sringeri dated 22 July 2024 at [9]-[14].
an email chain from those assisting in December 2021 for the purpose of dispelling this allegation.1077
Dr Sringeri highlights that there is no reference to a referral being provided by CPL Turner or to Dr Sringeri being in receipt of a referral from the ADF and that during the consultation there was a discussion about CPT Turner wanting to go on deployment and needing psychiatric clearance. CPL Turner advised the deployment was training Iraqi soldiers and did not involve combat.1081 1077 Submissions in reply of Dr Sringeri dated 22 July 2024 at [65]-[71]. Dr Sringeri also requested that the Commonwealth’s submission be redacted.
1078 Submissions in reply of Dr Sringeri dated 22 July 2024 at [9]-[25].
1079 Submissions of the Commonwealth dated 7 June 2024 at [147]-[148].
1080 Tab 50 at 9.
1081 Submissions of Dr Sringeri dated 24 April 2024 at [19]-[20], [22].
Dr Sringeri disagrees with GPCAPT Ross’ submission that “the fact [the referral] is contained in the ADF records suggests [the referral from Dr Ahmed] was provided to him” in that what is within the ADF records is the summary referring to the purported referral – not the actual referral.1082
Dr Sringeri notes that his letter of 13 July 2016 must be considered in light of what was known to Dr Sringeri when he assessed CPL Turner that day and that even if he had been in receipt of the referral letter from Dr Ahmed (which he denies), that letter was devoid of any relevant information regarding CPL Turner’s medical records.1083 Role in determining clearance for deployment
Dr Sringeri contends that Counsel Assisting’s submission that Dr Sringeri “sought to shift responsibility back on the ADF” in the context of who was responsible to determine whether CPL Turner was fit for deployment is “somewhat unfair” on the basis that “this was not his evidence”. Rather, Dr Sringeri’s response to a question about whether his reports may be relevant to a decision made about CPL Turner’s medical classification or fitness to deploy was that “I may help them, but it is just our advice-medical advice as a civilian doctor”. In this sense, Dr Sringeri reiterates that the clearance was not for him to decide, as it was a matter for the ADF medical board and the Chains of Command. This accords with the evidence of Professor McFarlane that “it isn’t the individual psychiatrist’s role to make that recommendation”.1084
Dr Sringeri submits that, in the circumstances, the inclusion of Dr Sringeri as “one or amongst one of” the decision-makers determining a medical clearance for deployment ought to be resisted as (i) the words of “fit to deploy” or “fitness for deployment” were never scribed in his letter dated 13 July 2016;1085 (ii) his opinion was open to be accepted or rejected by the ADF; and (iii) where GPCAPT Ross did hold such concerns as to whether CPL Turner should deploy (given he was prima facie “deployable”), it was open to GPCAPT Ross to discuss the matter with Dr Wallace or to ring Dr Sringeri.1086
In response to GPCAPT Ross’ submission that Dr Sringeri was attempting to distance himself from the opinion expressed in the 13 July 2016 letter and that GPCAPT Ross was entitled to fully rely upon the letter, Dr Sringeri’s view1087 is that the submission is 1082 Submissions in reply of Dr Sringeri dated 22 July 2024 at [63]-[64].
1083 Submissions in reply of Dr Sringeri dated 22 July 2024 at [52].
1084 Submissions of Dr Sringeri dated 24 April 2024 at [28]-[29], [33]-[34].
1085 Submissions of Dr Sringeri dated 24 April 2024 at [35].
1086 Submissions in reply of Dr Sringeri dated 22 July 2024 at [53].
1087 Submissions in reply of Dr Sringeri dated 22 July 2024 at [51]-[54].
unsupported by the evidence and ought to be rejected. Rather, Dr Sringeri contends that GPCAPT Ross fails to acknowledge the clear and apparent inconsistencies between what is contained with the ADF medical records and the information about the clinical review that Dr Sringeri sets out in the 13 July 2016 letter. In this regard, he refers to the evidence of Professor McFarlane (who indicated that he would have expected GPCAPT Ross to have carefully looked at the other documentation within the ADF medical records, not take Dr Sringeri’s report on “face value”, and scrutinise the other documents and not view Dr Sringeri’s report in isolation)1088 and Professor Hopwood (who said that GPCAPT Ross could rely upon the report “as much as any psychiatric assessment of a single session is reliably” and that assuming Dr Sringeri was competent would not “obviate the responsibility to acknowledge the limits of that assessment, as knowledge that a single assessment may not always tell the whole picture”).
Dr Sringeri submits1089 that it would be procedurally unfair to accept the Commonwealth’s and GPCAPT Ross’ submissions that parts of Exhibit 15 are an attempt by Dr Sringeri to limit, qualify, or distance himself from his 13 July 2016 letter, merely upon the same grounds that the opinion as expressed in the 27 October 2014 letter is the same opinion expressed in the 13 July 2016 letter.1090
Dr Sringeri also notes that his oral evidence that it was not the role of the individual psychiatrist to make a recommendation (as to fitness to deploy) was consistent with the evidence of Professor McFarlane’s evidence that “we have a medical practitioner who is not really asking or writing an appropriate letter to a psychiatrist outside of the military, knowing the limitations of that persons’ capacity, knowing-and not probably really understanding the specific information that needs to be required to actually fully answer that question”.1091
Dr Sringeri also points out that Professor McFarlane saw the 13 July 2016 letter as a “red flag” in the context of the “woefully inadequate” referral letter dated 11 July 2016 (which it was assumed Dr Sringeri was in receipt of) which was not an appropriate referral letter “to a psychiatrist outside of the military, knowing the limitations of that persons capacity, knowing and not probably really understanding the specific information that needs to be required to actually fully answer the question”.1092
1089 Submissions in reply of Dr Sringeri dated 22 July 2024 at [40].
1090 Submissions in reply of Dr Sringeri dated 22 July 2024 at [45]..
1092 Submissions in reply of Dr Sringeri dated 22 July 2024 at [50].
Submissions of CAPT MH
Submissions in reply of Counsel Assisting Dr Sringeri’s letter dated 13 July 2016
In relation to Dr Sringeri’s submissions concerning the description of his use of the words “very low risk” in his letter of 13 July 2016, Counsel Assisting submits that while it is correct that it is not a coroner’s role to apportion blame, it is important to recognise that “this does not mean that the coroner’s findings concerning manner and cause of death…will not contain matters which may reflect adversely on particular persons”.1096 Dr Sringeri appears to accept that it is open to make a finding that the use of the words “very low risk” was “problematic”.1097
As to the complaint that no expert used the adjectival language about which Dr Sringeri complains, Counsel Assisting notes that the term “highly problematic” is directed to the language used in the 13 July 2016 letter in the context of what Dr Sringeri said about it, which was that he was not stating that CPL Turner was cleared for deployment to Iraq (being the “limitations which he later said were implicit in his own opinion”). What is conveyed on a plain reading of the letter, in the context in which it was given, is a matter for the tribunal of fact and not a matter for expert opinion.1098
As to Dr Sringeri’s submission that no expert contended that using the language of “very low risk” was “inappropriate” in order to convey the risks of deployment on further relapse, Counsel Assisting notes that this is, in fact, contradicted by the expert evidence. Counsel Assisting raises two matters in respect of this submission: 1093 Submissions of CAPT MH dated 7 June 2024 at [23]-[29].
1095 Exhibit 57 at 209-451.
1096 Abernathy et al., Waller’s Coronial Law and Practice in New South Wales (4th ed, 2010) at [1.86].
1097 Submissions in reply of Counsel Assisting dated 22 August 2024 at [154].
1098 Submissions in reply of Counsel Assisting dated 22 August 2024 at [155].
i. First, Dr Sringeri’s submission that the question posed during the course of expert evidence did not address whether the words “very low risk” was inappropriate to be used as a descriptor of the risk of recurrence should be rejected. The question posed was whether “there was an available view that there was a low risk of relapse of Corporal Turner’s PTSD during that deployment”. If there was not an available view that there was a low risk of recurrence of CPL Turner’s PTSD, then it follows that describing that risk as “very low” is appropriate.
ii. Second, the answers given to that question were that: “the term ‘very low’ is problematic”, it was a stretch to consider that there was a risk of recurrence that was “very low”, and that CPL Turner was a person who “is never going to be at a very low risk” (Professor Large);1099 it would not be accurate to say that the risk of recurrence of PTSD symptoms was very low (Professor Nielssen);1100 and it was not an available view that the risk was low and instead the “likelihood is very high” (Professor Hopwood).1101
In these circumstances, Counsel Assisting submits that it is open to make a finding that the use of the language “very low risk” was inadequate language to convey the risks to CPL Turner to relapse.1102
As to the complaint about no expert using the language of “highly” or “grossly”, Counsel Assisting notes that the expert opinion establishes that the language “very low risk” was problematic and my function includes assessing the degree of deficiency in light of all the evidence and that, accordingly, the findings proposed above at [673] to [675] are open to be made.1103 The procurement of the letter dated 13 July 2016
In response to Dr Sringeri’s objection above at [731] regarding the “procurement” of his letter, Counsel Assisting notes1104 that the language of “procured” was not intended to suggest that the ADF had, or had not, provided a referral letter to Dr Sringeri.
Counsel Assisting accepts that the evidence does not permit a positive finding as to
1102 Submissions in reply of Counsel Assisting dated 22 August 2024 at [156].
1103 Submissions in reply of Counsel Assisting dated 22 August 2024 at [157].
1104 Submissions in reply of Counsel Assisting dated 22 August 2024 at [158].
whether the referral letter was provided to Dr Sringeri (noting that a letter in the nature of an “External Service Provider Request” dated 11 July 2017 is in evidence).1105
This is not intended to mean that the letter was not “procured” in the sense that the reason CPL Turner went to obtain it from Dr Sringeri was because the ADF required it, and Dr Sringeri was aware that CPL Turner was obtaining the letter because the ADF required it. That is clear from the “External Provider Request”, which indicated that Dr Ahmed had sought to obtain an opinion from Dr Sringeri.1106 Counsel Assisting does not submit that a finding can be made that Dr Sringeri was actually provided with this referral request – Counsel Assisting only seeks a finding from it supporting the finding as to why CPL Turner was approaching Dr Sringeri for a letter.1107 Counsel Assisting notes that it is Dr Sringeri’s own evidence that this is what precisely what CPL Turner told Dr Sringeri when he presented to him on 13 July 2016.1108 That the point of the letter was to express an opinion to the ADF about CPL Turner is also clear from the face of the letter, which is addressed to MAJ AM (the Senior Medical Officer at Tobruk Clinic).1109
Lastly, Counsel Assisting believes that it is beside the point whether a referral letter was provided or not to Dr Sringeri and the absence of such a letter does not preclude a finding that the letter was in response to the ADF procuring an opinion about CPL Turner’s fitness to deploy. Dr Sringeri’s own evidence is that this was the context in which CPL Turner attended his clinic on 13 July 2016 and he accepts that there is no dispute that the opinion expressed in the letter was “available to be interpreted by the ADF and GPCAPT Ross as being fit to deploy from a psychiatric perspective”. Counsel Assisting considers that this finding is open to be made.1110 The letter from Dr Sringeri’s representatives dated 11 August 2021 (Exhibit 19)
As for Dr Sringeri’s issues regarding the procedural history in relation to the tender of the 13 July 2016 letter and Exhibit 19, Counsel Assisting notes that the Exhibit 19 letter was tendered into evidence without objection.1111 Counsel Assisting also notes that the complaint made by the Commonwealth1112 that Dr Sringeri’s subjective intention in 1105 Tab 116 at 12-13.
1106 Tab 116 at 12.
1107 Submissions in reply of Counsel Assisting dated 22 August 2024 at [159].
1108 Tab 111 at 90; 22/10/2020 T15.25, T325.44-49; Exhibit 19.
1109 Exhibit 26.
1110 Submissions in reply of Counsel Assisting dated 22 August 2024 at [161].
1112 Submissions of the Commonwealth dated 7 June 2024 at [149].
writing the report is irrelevant is to be viewed in light of the absence of any objection to its tender at the time.1113
To the extent that the Commonwealth is submitting that Counsel Assisting has not tendered relevant evidence, Counsel Assisting contends this should be rejected as base speculation given that the Commonwealth submits in the first place that “the ADF does not know”. In those circumstances, Counsel Assisting does not consider there to be a basis to grant leave to tender the further evidence proposed by Dr Sringeri nor does the evidence give rise to the level of significance warranting redaction from the Commonwealth’s submissions.1114 Roles in determining clearance for deployment
In relation to Dr Sringeri’s objection to being considered as “one or amongst one of” the decision-makers regarding CPL Turner’s medical clearance (see above at [735]), Counsel Assisting considers the objection to be misconceived. Counsel Assisting’s original submission is to the effect Dr Sringeri was part of a decision-making process and not a decision-maker. Further, it is submitted submit that there were not clear roles and responsibilities assigned as between the ADF and Dr Sringeri within that decisionmaking process.1115
Counsel Assisting also notes that whilst it is clear that Dr Sringeri considered that “clearance for deployment was not a matter for me, it was a matter for the ADF medical board and the chains of command”, it is apparent that Dr Sringeri was speaking in the context of a final clearance decision – that is a different question from whether he was a person involved in a process and it is clear from the evidence that he was a person so involved.1116 1113 Submissions in reply of Counsel Assisting dated 22 August 2024 at [170].
1114 Submissions in reply of Counsel Assisting dated 22 August 2024 at [173]-[174].
1115 Submissions in reply of Counsel Assisting dated 22 August 2024 at [163]].
1116 Submissions in reply of Counsel Assisting dated 22 August 2024 at [164].
Deployment decision
ii. The basis for a finding that MAJ AM, when preparing the Clinical Perspective Document, “enacted the [chain of] command’s intent” with “almost no regard to the volume of evidence in the ADF health records”.is established by the evidence summarised above at [114]-[151]. In addition, Counsel Assisting draws attention to the aspects of MAJ AM’s evidence where it is accepted that in preparing the document he was selecting the “positive information” to “restore balance”.1118 His evidence was clear that he was not relying himself on the full ADF health records but instead intended to “trigger the J07 to have a comprehensive review” of the records; he asserted he had “absolute trust” that GPCAPT Ross would do so, but nevertheless did not ask him to do so.1119 iii. No finding should be made that GPCAPT Ross also had regard to the CO brief which provided the letter from Dr Sringeri of 13 July 2016.
Body recovery incident
1120 Tab 49 at 56.
Consideration
I accept Counsel Assisting’s submissions that by the end of 2015 it was apparent that CPL Turner’s mental health was seriously impaired and that by 2016 he had not engaged in appropriate mental health treatment. The objective evidence is that in November 2015, despite reporting significant PTSD symptoms to a counsellor from the VVCS, he declined treatment.
The Court heard a significant amount of evidence about the 2016 clearance decision, which was at times incorrectly referred to as ‘the waiver.” In my view, it is a critical factor influencing the trajectory of CPL Turner’s decline.
I accept Counsel Assisting’s submission on this issue. Firstly, it is established that MAJ AM’s Clinical Perspective Document was a one-sided presentation compiled by a medical practitioner who had never seen CPL Turner in a clinical setting for the sole purpose of influencing the decision. It was neither accurate nor considered. It did not take into account material in the ADF records which indicated CPL Turner’s ongoing struggles and his refusal to undertake treatment. MAJ AM told the Court that he did not review the medical records himself, instead relying on a junior officer to relay the information over the telephone. I agree with Mr and Mrs Turner that this was unsatisfactory.
Secondly, I accept that the brief which was signed by COL MF, but drafted by MAJ AF, was inaccurate and misleading. In my view, the evidence establishes that MAJ AF prioritised operational considerations over an independent review of CPL Turner’s mental health. Specifically, the assertion that “the personnel best able to monitor, asses [sic] and manage his mental health are his regular team members, who he will be deployed with” was a hollow statement and, as we have seen, entirely without substance or merit. There was just no evidence that CPL Turner’s team was given any advice or support about how to monitor, assess, or manage CPL Turner’s mental health symptoms if they emerged. It was an empty statement. The situation in Iraq was unpredictable and GPCAPT Ross should have understood that more would be required. There was in fact no realistic plan in place to support CPL Turner should his mental health deteriorate. Given there were no available psychologists in TQ, I accept Counsel Assisting’s submission that to describe his access to psychological services as “ready” was inaccurate. The brief was prepared for the purpose of persuading GPCAPT Ross to overturn his decision and no person took responsibility for ensuring that what was represented would actually occur. I accept the submission that it was simply a piece of advocacy. The Commonwealth accepts that with hindsight the
strategy of “peer monitoring” failed. In my view, it was both ill-informed and reckless.
Further, I was particularly concerned that MAJ AF gave evidence that he continues to believe that deploying was in CPL Turner’s best interests, even with the benefit of hindsight. In my view, his adherence to this position demonstrates a complete lack of insight, inadequate understanding of PTSD, and an ongoing inability to reflect usefully on factors which contributed ultimately to CPL Turner’s death.
Having said that, I accept he was entitled to rely to some degree on Dr Sringeri’s opinion but not to defer to him. Unfortunately, Dr Sringeri’s letter was in certain respects inadequate for the purpose it was used for.
Fourthly, I am critical of Dr Sringeri’s letter of 13 July 2016 and the use it was put to by the Chain of Command. Each of the experts agreed that to describe the risk of recurrence of PTSD symptoms as “very low” was problematic. I note that in hindsight Dr Sringeri appeared to accept this.
In my view, Dr Sringeri’s opinion that CPL Turner was “cleared to attend all duties from a psychiatric point” was open to broad interpretation and therefore dangerous. While I understand that Dr Sringeri contends he was not attempting to convey a view that CPL Turner was cleared for a specific deployment to Iraq, which he understood was a matter for the ADF medical board and the Chain of Command, I do not accept, despite taking into account his submissions, that he could have been unaware of the way his letter would be used.
The Commonwealth accepts that in retrospect the risk of relapse of CPL Turner’s PTSD should have been recognised as higher than it was.
Fifthly, I accept Counsel Assisting’s submission that everyone involved in the decisionmaking process in relation to the 2016 medical clearance appeared to abrogate responsibility. In my view, Counsel Assisting sums it up accurately: “the Chain of Command sought to shift responsibility to Dr Sringeri and GPCAPT Ross; Dr Sringeri
did not consider it was his role to decide whether CPL Turner was fit for deployment at all and sought to shift responsibility back on the ADF; and GPCAPT Ross relied heavily on the documents provided by MAJ AM, which included Dr Sringeri’s opinion.1121 In some respects, it appears that Dr Sringeri was relying on the ADF and the ADF was, in turn, relying on Dr Sringeri, and neither had a clear understanding of the role of the other in making decisions about deployment.”
The lack of clarity in relation to individual roles and responsibilities caused me considerable concern, as did the significant degree of confusion about the extent to which it was appropriate for Command to be involved and the extent to which the medical clearance decision was a medical decision only, based on medical risks. The Commonwealth appeared to accept the need for clearer guidelines about how these decisions are made. It is an issue to which I will return.
Sixthly, once CPL Turner was deployed, according to MAJ AF nothing out of the ordinary was done to monitor or support his mental health. I accept Counsel Assisting’s submission that ultimately the brunt of support fell to CPL TJ. Others such as MAJ BJ and CAPT MH who offered support were, like CPL TJ, untrained and just doing the best they could under difficult circumstances. I accept the contemporaneous WhatsApp messages, phone calls, and emails show they were genuinely trying to provide personal support to CPL Turner. That was important but what was also required was skilled professional assistance.
Lastly, the body recovery mission issue took up more court time than it should have.
The Commonwealth’s initial questioning on the issue appeared to suggest it may be a figment of CPL Turner’s mind. It was not and at least some ADF witnesses knew that at all times. In my view, the way the issue unfolded was most unfortunate. I am concerned that it was not approached with honesty and transparency. There is a clear mechanism for the making of public interest immunity claims and it does not involve witnesses such as MAJ AF withholding information or presenting a partial and misleading account. Nevertheless, while I am ultimately unable to say exactly what happened, I am able to make firm findings that CPL Turner had some involvement in a body recovery and that it triggered a relapse of his PTSD. The whole incident demonstrates the unpredictable nature of deployment in a warzone and the 1121 In submissions in reply, Counsel Assisting note that the point, as against GPCAPT Ross, is directed to the degree to which he relied on others to make the (medical) assessments which formed the basis of his decision, a matter which GPCAPT Ross himself contends he was entitled to do: Submissions in reply of Counsel Assisting dated 22 August 2024 at [176].
overreliance on the idea that a mission to “train, advise and assist” would present minimal risk to someone in CPL Turner’s position.
Adequacy of ADF’s response in 2017 (up until 15 July 2017)
Counsel Assisting’s submissions
Counsel Assisting submits1122 that CPL Turner’s mental health continued to deteriorate over the course of 2017. There are two issues in this regard.
The first is that the ADF (in particular, COL MF) appeared to have had limited to no regard to the impact of the move from B Company to C Company on CPL Turner’s mental health. Counsel Assisting considers that this was a decision made with regard to capability, not individual needs. While that is not per se wrong or objectionable, if the decision was so important to capability that no other option could have been pursued, there was plainly enough an obvious need to put a significant amount of mental health support around CPL Turner at the time the decision was made. It is submitted that the potential impact was obvious: BRIG Langford, who was not the CO at the time, accepted that it would have been humiliating for CPL Turner to be demoted and taken out of the Sergeants’ Mess against his will.1123 He acknowledged that B Company would have been important in terms of a support network to him.1124
Counsel Assisting states that it is clear that the transfer was made without any real weight being given to his mental health, nor were any supports put in place once the decision was made and when he returned to Australia and was placed in C Company.
It is difficult to know if this would have made a difference to the tragic outcome.
1122 Submissions of Counsel Assisting dated 2 November 2023 at [482]-[484].
The Human Performance Wing (HPW)
Counsel Assisting notes1125 that, physically speaking, the HPW was located at Holsworthy, in a building that is on a central breezeway and connected to where A Company and B Company were located. It was located within the 2CDO.1126 CPL Turner was placed under the care of Mr Cardinaels in the HPW after his first suicide attempt in early March 2017 and remained there until his death.
Mr Cardinaels was the “leader” of the HPW from around 2015 to at least 2018.1127 He described the purpose of the HPW as being to “provide mentoring management of the wounded injured (sic) in a culturally relevant space and it was a by commando for commando area”.1128 Mr Cardinaels stated in his ROI that it was intended to be a “multidisciplinary approach” involving clinicians, and “having an informed environment where we do best by the member and try and service all their needs”.1129
The views of other former members of 2CDO were that if a person suffered a mental illness, they would be removed from active duty.1130 Eddie Robertson described it as a “general feeling amongst the ranks that if you were having mental health issues it would affect your career opportunities and also have you sidelined for future deployments with your Team/Platoon/Company”.1131
Mr Cardinaels struggled to articulate in oral evidence what the HPW was aiming to achieve with CPL Turner.1132 It was not clear that there was one person who had responsibility for CPL Turner’s overall care during his time with the HPW. Mr Cardinaels was not aware, but imagined “it would be someone”, possibly the rehab coordinator and possibly the RMO.1133
Mr Cardinaels’ evidence was that during his time as part of the HPW, there was no formal evaluation or audit of its processes.1134 His evidence as to his own qualifications to manage the HPW were limited to being “well read” and having an interest in rehabilitation.1135 He was not a psychologist and had no psychiatric training.1136 1125 Submissions of Counsel Assisting dated 2 November 2023 at [485]-[490].
1127 Tab 15 (IGADF ROI with SGT MC on 5 June 2018) at 3; 02/08/21 T10-11.
1128 Tab 15 (IGADF ROI with SGT MC on 5 June 2018) at 3.
1129 Tab 15 (IGADF ROI with SGT MC on 5 June 2018) at 6.
1130 See Tab 10 (Damien Thomlinson); Tab 12 (Eddie Robertson), both of whom deployed with CPL Turner as part of 2CDO.
1131 Tab 12 (Eddie Robertson).
1132 See generally 02/08/21 T19-36.
The evidence during the period that CPL Turner was placed in the HPW tended to suggest that it was not helpful for CPL Turner’s mental health. He appeared to be isolated from his regular teammates and had little sense of purpose or direction. As Professor McFarlane emphasised, a critical issue for CPL Turner was his “sense for the future and his social engagement”. CPL TJ’s evidence reflected this also: she stated that having the PhD was CPL Turner’s hope for a refresh, and once it was “scrapped” he was “very different man”.1137
Counsel Assisting submits that it was critical for CPL Turner’s ongoing wellbeing that he had a clear plan to transition into a role in the ADF where he could remain useful, or outside of the ADF into further study or employment. It was not clear that the HPW provided him with a clear direction to achieve either of those outcomes.1138 The PhD proposal
Counsel Assisting highlights1139 that it is clear that at some point in time, a proposal that CPL Turner undertake a PhD (possibly as part of a secondment to another organisation) was made and was rejected out of hand by COL MF. Whether or not it was rejected only because of the outplacement component (as per the evidence given by COL MF), it is clear that no real consideration was given to assisting CPL Turner to transition into studying in some other way. If COL MF intended only to reject the outplacement aspect of the PhD proposal, it is clear that this was not clearly communicated to CPL Turner who perceived that his proposal to study had simply been rejected. Counsel Assisting submits that more consideration ought to have been given to supporting a study placement or assisting CPL Turner to study in some other way – the outright rejection appeared to have been significantly unhelpful for his ongoing recovery.
Joanna Turner also noted that if CPL Turner “had thought that [the PhD] was possible in the future, it could [have] assisted him”.1140 The fragmented nature of the care provided to CPL Turner
Counsel Assisting considers1141 that the evidence in relation to CPL Turner’s care during 2017 revealed that it was fragmented in a way that was unlikely to be helpful. It 1137 Exhibit 10 (Supplementary statement of CPL TJ dated 20 July 2021) at 3.
1138 See, eg, Tab 50 (ADF Medical Records) at 16 which records a query from Dr Swain to the ADF on 5 July 2017 asking “what is happening with Ian from a MEC/rehab perspective … Ian states he believes he will be medically separated, but no one has directly addressed it with him as yet”.
1139 Submissions of Counsel Assisting dated 2 November 2023 at [491].
1140 Submissions of Joanna Turner dated 17 January 2024 at [6].
1141 Submissions of Counsel Assisting dated 2 November 2023 at [492]-[495].
appears Ms Cantwell took over as clinical case coordinator in March 2017. She referred CPL Turner to Dr Swain, an external psychologist based in Sydney CBD, on the basis that Dr Swain had knowledge of the ADF, the background to deal with CPL Turner’s complex psychological needs, and the capacity to treat CPL Turner “at the appropriate frequency and intensity, consistent with his needs”.1142 Ms Cantwell then ceased as CPL Turner’s clinical case coordinator at the end of March 2017 and CAPT KV took over.1143 CAPT KV then appears to have been the clinical case coordinator from this time until CPL’s death.1144
There were numerous individuals involved in CPL Turner’s care throughout 2017: including Dr Hale, Dr Reppas, Dr Toma, Dr Ahmed, Andrea Cantwell and then CAPT KV, Dr Swain, Drs Malik and Sringeri, the rehabilitation coordinator Carmel Poulter (who was employed by an external consultant to the ADF) pursuant to a referral made by the ADF on 31 March 2017, Greg Frost (the ADF rehabilitation coordinator who made the referral to Carmel Poulter), and Mr Cardinaels and the HPW.
Dr Nielssen’s evidence was that “if anything, Mr Turner’s care by so many professionals might have been perceived as intrusive by a person who disclosed having little trust in the ADF hierarchy”.1145
In addition to this risk, Counsel Assisting notes that the distinct impression which the overall evidence left was that there was a lack of clear responsibility for the care of CPL Turner. His care during 2017 was highly fragmented across different ADF medical professionals, external consultants, and other individuals such as Mr Cardinaels who did not have mental health training or expertise. Although it is clear that there were a great number of people who were trying to assist CPL Turner throughout this period, the fact of fragmentation and the many different consultants, many of whom were outside the ADF, was likely to have contributed to difficulties in caring for CPL Turner throughout his period of significant decline in 2017.
Submissions of Mr and Mrs Turner
1143 Exhibit 40 (Statement of Andrea Cantwell dated 31 August 2022) at 5.
1145 Tab 108 (Report of Dr Nielssen dated 12 August 2020) at 11.
care” by the ADF psychologists who assessed his risk of harm and stability and failed to provide any treatment. They contend that 2CDO, CAPT KV, BH, and COL MF collectively had a responsibility to ensure than CPL Turner received timely and appropriate psychological support, intervention, and treatment.1146
Mr and Mrs Turner also submit that CPL Turner found the welfare board meeting in May 2017 to be “confronting and overwhelming”.1147
CPL Turner’s parents also note that the 2CDO clinicians should have viewed CPL Turner’s absconding in the context of distressing PTSD symptoms rather than impulsive acts requiring disciplinary action.1148
Furthermore, Mr and Mrs Turner posit that while the 2CDO was dealing with a heavy load of members requiring support in 2017, COL MF failed to effectively manage the coordination of support services and he did not seek assistance outside of 2CDO (either through his Chain of Command or CPL Turner’s psychiatrist or psychologist), which was in breach of ADF policy.1149 The Human Performance Wing
CPL Turner’s parents express concern about how CPL Turner was treated within the HPW, where he was assigned following his first overdose. Their concerns include that the HPW was for physically wounded ADF members (and not for members with psychological illnesses), there was a limited handover, the HPW Manager (Mr Cardinaels) did not have any formal qualifications in dealing with persons with psychological illnesses, Mr Cardinaels was not (but should have been) directly involved in CPL Turner’s clinical assessments or welfare boards, and that the 2CDO medical officers and psychologists had limited training and experience with PTSD. Mr and Mrs Turner also disagree with Mr Cardinaels’ evidence that the HPW was “best practice” in terms of dealing with complex medical cases on the basis that “without clinical knowledge, one simply cannot know what one does not know”. They also consider that soldier-led recovery models may be appropriate for physically injured soldiers, but that is not suitable in the case of members suffering from psychological illnesses (who require fully trained and experienced clinicians).1150 1146 Submissions of Mr and Mrs Turner dated 28 January 2024 at [76]-[78].
1147 Submissions of Mr and Mrs Turner dated 28 January 2024 at [89].
1148 Submissions of Mr and Mrs Turner dated 28 January 2024 at [93].
1149 Submissions of Mr and Mrs Turner dated 28 January 2024 at [104]-[105].
1150 Submissions of Mr and Mrs Turner dated 28 January 2024 at [186]-[195].
The PhD proposal
Mr and Mrs Turner contend that when COL MF decided that he would not support CPL Turner’s proposed PhD, COL MF failed to take into consideration the years of CPL Turner’s service, his performance appraisals which repeatedly found him fit for representational duty, and MAJ AF’s assessment of CPL Turner in 2016 as “the number one team commander”. They also contend that there is no evidence that COL MF sought any clinical opinion as to CPL Turner’s fitness to undertake the PhD or how the request should be handled such that any negative response would not further impact his mental health in an adverse manner.1151
They also agree with Professor McFarlane’s views that the possibility of doing a PhD should have raised issues as to what steps could have been put in place to assist him to transition from 2CDO or the ADF and that ADF members need to be informed that there is a limited period of time in which their mental health and physical capacity can be sustained in intense combat roles (which should be systematically addressed by Command by offering transitioning pathways that sustain members’ morale and identity).1152 Submissions of the Commonwealth
The Commonwealth notes that the submissions of Counsel Assisting omitted many relevant details from the chronology of events in early 2017. In its submissions, the Commonwealth sets out1153 a number of further interactions between CPL Turner and medical personnel and steps taken by those personnel in response to his worsening condition. It is submitted that at no point until 2 March 2017 did the reported symptoms “cross the threshold for non-consensual mandatory reporting to the ADF chain of command”.1154
With respect to the text messages exchanged between CPL Turner and CPL TJ between 4 and 6 March 2017 which included references to suicide, the Commonwealth observes that CPL Turner had previously threatened suicide in his relationship as a means of coercive control and that there was no evidence to suggest that the ADF was aware of the breakdown of that relationship that occurred between 4 and 6 March 2017.1155 1151 Submissions of Mr and Mrs Turner dated 28 January 2024 at [196]-[207].
1152 Submissions of Mr and Mrs Turner dated 28 January 2024 at [205]-[207].
1153 Submissions of the Commonwealth dated 7 June 2024 at [478]-[483].
1154 Submissions of the Commonwealth dated 7 June 2024 at [481].
1155 Submissions of the Commonwealth dated 7 June 2024 at [486]-[496].
The Commonwealth further submits that insufficient focus was given by Counsel Assisting to CPL Turner’s admission to SSPH in March 2017 and that the evidentiary gap affected the ability to obtain a clear and complete picture of CPL Turner’s mental health in this period and the ADF’s response to his first suicide attempt.1156 The Commonwealth sets out a detailed chronology of this period in its submissions.1157
The Commonwealth notes that CPL Turner met with CAPT McLean on five occasions in this period and that the evidence suggests that CPL Turner may not have been in a position to engage in more intensive therapy even if that had been considered by CAPT McLean.1158 The Human Performance Wing and the rehabilitation plan
The Commonwealth considers that none of Counsel Assisting’s criticisms of the HPW (summarised above at [772]-[778]) should be accepted.1159 Reasons in support of the Commonwealth’s position include:1160 i. Counsel Assisting made oral submissions on 6 September 2022 that the Inquest would not investigate the HPW; ii. the criticisms of the HPW do not explain the connection to the way in which CPL Turner was treated within the HPW; iii. the submissions do not appreciate that CPL Turner was in the HPW for a short period of time; iv. evidence was not obtained from those involved in the rehabilitation plan which would give rise to procedural unfairness if they were to be criticised; v. the criticism of the plan in that it was insufficiently “engaging” and/or left CPL Turner with too much free time does not comport with the evidence of Hannah Steele;1161 vi. the characterisation of the rehabilitation plan as identifying “little more by way of activities than the gym and medical appointments” over-simplifies the factual circumstances in which the plan was developed; 1156 Submissions of the Commonwealth dated 7 June 2024 at [498]-[502].
1157 Submissions of the Commonwealth dated 7 June 2024 at [503]-[513].
1158 Submissions of the Commonwealth dated 7 June 2024 at [639]-[640].
1159 Submissions of the Commonwealth dated 7 June 2024 at [641].
1160 Submissions of the Commonwealth dated 7 June 2024 at [641]-[662].
vii. the submissions ignore the reality of CPL Turner’s physical and mental limitations/capacities in June-July 2017; viii. the submissions ignore the fact that CPL Turner was involved in all decisions regarding his non-medical activities, including which activities he did and how much he did on each day (although he was not always happy about the plan); ix. CPL Turner had conversations with personnel at the HPW about what he would be working towards at the HPW; x. it was a matter for CPL Turner as to whether he provided health information to Mr Cardinaels; and xi. the suggestion that “evidence during the period that CPL Turner was placed in the HPW tended to suggest that it was not helpful for CPL Turner’s mental health…[h]e appeared to be isolated from his regular teammates and had little sense of purpose or direction” is made without any reference to the evidence said to support it.
The PhD proposal
In relation to the PhD, the Commonwealth considers that Counsel Assisting’s submission that BRIG MF “rejected out of hand” the PhD proposal cannot be accepted (on the basis that CPL TJ’s evidence about this is unreliable and is contrary to other evidence)1162 and that the PhD proposal was given “no air time” or was “outright” rejected is not supported by the evidence and would be a procedurally unfair finding.1163
The Commonwealth submits that as at January 2017 the evidence suggests CPL Turner’s proposal was to undertake a secondment and, while doing so, work towards a PhD (which may not be supported by the Chain of Command).1164 Thereafter, and after BRIG MF indicated he was not supportive of the secondment, that CPL Turner continued to raise the idea of the PhD is submitted to be inconsistent with the suggestion that BRIG MF had rejected the idea “outright”.1165
The Commonwealth notes that prior to 6 March 2017, all that CPL Turner raised was an idea of a secondment to an organisation such as ASPI or the Department of Prime Minister and Cabinet, together with a PhD, which, given his recent disciplinary action, 1162 Submissions of the Commonwealth dated 7 June 2024 at [769].
1163 Submissions of the Commonwealth dated 7 June 2024 at [735], [770].
1164 Submissions of the Commonwealth dated 7 June 2024 at [737]-[745].
1165 Submissions of the Commonwealth dated 7 June 2024 at [746]-[754].
the Chain of Command “understandably” did not support. There had also not been a formal application for the further study. The Commonwealth also notes that after the first suicide attempt, the idea of further study was “always seen as a protective factor and there is no evidence that it was ever rejected”.1166
The Commonwealth submits that it would be procedurally unfair to accept the evidence of Hannah Steele regarding the discussion of the proposal at the 26 May 2017 IWB.1167 Further, it is submitted that the account of CPL TJ on this issue was confused and inconsistent.1168
Rather, the Commonwealth notes that there had to be realistic expectations placed around what were protective factors and what were achievable outcomes and the idea of a PhD was never taken off the table (as seen from Dr Hale’s email of 11 July 2017).1169
The Commonwealth also refers to Joanna Turner’s evidence that CPL Turner was not in a fit state to study, noting that with “his mental ill health at that time, it would have been challenging for him to take on a fulltime study role or something as high pressure as a PhD”.1170 The period of 30 March to 11 April 2017
The Commonwealth notes that this period was mainly consumed with (i) a resumption of serious interpersonal conflict between CPL Turner and CPL TJ and (ii) attempts made by the medical and rehabilitation personnel to “step up” an outpatient treatment and rehabilitation for CPL Turner.1171
The Commonwealth submits that regard must be had to the lengthy fight via text message between CPL Turner and CPL TJ on the morning of 11 April 2017, 1166 Submissions of the Commonwealth dated 7 June 2024 at [770(b)].
1167 Submissions of the Commonwealth dated 7 June 2024 at [759].
1168 Submissions of the Commonwealth dated 7 June 2024 at [765]-[768].
1169 Submissions of the Commonwealth dated 7 June 2024 at [764], [770]-[775].
1173 Submissions of the Commonwealth dated 7 June 2024 at [515(c)].
when considering the manner and cause of CPL Turner’s death.1174 The period of 11 April to 25 May 2017
The Commonwealth submits that Counsel Assisting did not advert to the efforts of the ADF to provide care for CPL Turner during the period between 11 and 21 April 2017 when CPL was admitted to St Vincent’s Hospital following a second suicide attempt. It is submitted that no adverse finding could be made against the ADF for this period.1175
For the period between 21 and 27 April 2017, the Commonwealth invites a finding that CPL Turner’s reason for absconding from the SSPH on 21 April 2017 was immediately caused by the fight over text message with CPL TJ that day (and her expressed views about the hospital) and that the ADF cannot be criticised for concluding that the best course was to attempt to persuade CPL Turner to accept voluntary inpatient admission at this time.1176
With respect to the period between 27 April and 25 May 2017, the Commonwealth notes there was little evidence adduced regarding CPL Turner’s admission to SJoGH and to the efforts of the ADF to support him at this time. It is submitted that no adverse finding ought to be made against the ADF or any its personnel for this period.1177 The period of 25 May to 14 July 2017
In its submissions,1178 the Commonwealth sets out a detailed chronology of events which highlight the following matters: i. in the week between 22 May and 28 May 2017, meetings (including IWBs) were held to discuss CPL Turner’s condition, attempts were made to keep him admitted at SJoGH, and meetings/assessments took place between CPL Turner and Dr Hale, Ms Poulter, and Mr Cardinaels;1179 ii. in the week between 29 May and 4 June 2017, there were hostile communications between CPL Turner and Joanna Turner, meetings/assessments between CPL Turner and CAPT McLean, Dr Hale, Ms 1174 Submissions of the Commonwealth dated 7 June 2024 at [518]-[519].
1175 Submissions of the Commonwealth dated 7 June 2024 at [520]-[521].
1176 Submissions of the Commonwealth dated 7 June 2024 at [524]-[527].
1177 Submissions of the Commonwealth dated 7 June 2024 at [551].
1178 Submissions of the Commonwealth dated 7 June 2024 at [557]-[620].
1179 Submissions of the Commonwealth dated 7 June 2024 at [557]-[562].
Poulter, and Dr Malik, and evidence of the relationship breakdown between CPL Turner and CPL TJ;1180 iii. in the week between 5 June to 11 June 2017, there were meetings/assessments between CPL Turner and CAPT McLean, Dr Hale, CAPT KV, Dr Malik (who prescribed prazosin), and Ms Poulter, communications suggesting Joanna Turner would not let CPL Turner see his daughter in this period, further relationship volatility between CPL Turner and CPL TJ, and a bout of drinking during a commemoration of CPL Baird;1181 iv. in the week between 12 June and 18 June 2017, there were meetings (including an IWB) held to discuss CPL Turner’s progress, meetings/assessments between CPL Turner and Dr Hale, Carmel Poulter, CAPT McLean, and CAPT KV, and communications between CPL Turner and CPL TJ about issues CPL Turner was having with Joanna Turner (including finances and access to his daughter);1182 v. in the week between 19 June and 25 June 2017, there were meetings/assessments between CPL Turner and Dr Siddiqi and CAPT KV (including by phone when CPL Turner was on the Gold Coast between 21 and 26 June 2017);1183 vi. in the week between 26 June and 2 July 2017, there were meetings/assessments held between CPL Turner and CAPT KV, Mr Cardinaels, and Ms Poulter, further acrimonious correspondence between CPL Turner and Joanna Turner, and a breakdown in the relationship between CPL Turner and CPL TJ;1184 vii. in the week between 3 July and 9 July 2017, there were meetings/assessments between CPL Turner and Ms Poulter, CAPT KV, Dr Hale, Dr Malik, and Dr Swain (including what was reported as a ‘dissociative episode’ on 1-2 July), an IWB held on 7 July 2017, the further relationship breakdown between CPL Turner and CPL TJ, an altercation CPL Turner had at a pub, and the time spent with CPL Turner by members of 2CDO over the weekend of 8-9 July 2017;1185 and 1180 Submissions of the Commonwealth dated 7 June 2024 at [563]-[569].
1181 Submissions of the Commonwealth dated 7 June 2024 at [570]-[576].
1182 Submissions of the Commonwealth dated 7 June 2024 at [577]-[581].
1183 Submissions of the Commonwealth dated 7 June 2024 at [582]-[587].
1184 Submissions of the Commonwealth dated 7 June 2024 at [588]-[595].
1185 Submissions of the Commonwealth dated 7 June 2024 at [596]-[610].
viii. in the week of 10 July 2017 until CPL Turner’s death, there were meetings/assessments between CPL Turner and Mr Cardinaels, Ms Poulter, Dr Hale, Dr Malik, and Dr Swain, the decision that CPL Turner be directed to inpatient care, CPL Turner’s desire for a discharge, and ongoing communication between CPL Turner and CPL TJ.1186
The Commonwealth submits that it is necessary to consider the above chronology in order to assess the adequacy of the ADF’s response in this period and the submissions concerning fragmentation of care (see below).1187 The Commonwealth notes that by the first two weeks of July 2017, the ADF was confronted with a difficult situation in which CPL Turner had suffered memory loss following a dissociative episode or overdose, was drinking excessively, had missed appointments, and was increasingly volatile.1188 The fragmented nature of the care provided to CPL Turner
The Commonwealth submits that any conclusion that “fragmentation” of CPL Turner’s care was likely to have been detrimental to his care is not supported by the evidence and should not be accepted for various reasons. These include:1189 i. the term “fragmentation” is not defined nor is there any identification of what difficulties in caring for CPL Turner arose from such fragmentation; ii. no evidence was obtained from various treatment providers who treated CPL Turner in 2017 on the question of any fragmentation; iii. there were periods in late 2016 to 2017 where CPL Turner was either on postdeployment leave or an inpatient which resulted in some necessary fragmentation in his treatment; iv. the evidence in the Inquest, such as of CAPT KV1190 and Dr Hale,1191 was that CPL Turner required longer inpatient admissions and a further admission in July 2017 (which CPL Turner refused); v. CPL Turner was suffering from a number of physical and psychological issues in 2017; 1186 Submissions of the Commonwealth dated 7 June 2024 at [611]-[620].
1187 Submissions of the Commonwealth dated 7 June 2024 at [554]-[555].
1188 Submissions of the Commonwealth dated 7 June 2024 at [666]/.
1189 Submissions of the Commonwealth dated 7 June 2024 at [621]-[638].
vi. the “numerous individuals” involved in CPL Turner’s care in 2017 all had different roles to play in his treatment; vii. Dr Ahmed and Dr Toma played only an administrative role in his treatment; treatment providers are entitled to take leaves of absences or otherwise attend to their personal lives; viii. the treatment providers took “extraordinary efforts” to communicate with each other; treatment providers went out of their way to touch base with CPL Turner if he missed an appointment; and ix. CPL TJ’s text messages suggested that medical personnel were not always being informed of the true extent of CPL Turner’s issues.
Submissions of CPL TJ
CPL TJ refers to the instance in February 2017, two weeks prior to the first suicide attempt, where she reported CPL Turner’s significant deterioration in mental health to MAJ MP (who told her he would raise the issue with the CO and the RSM and was informed that the Chain of Command had his condition and welfare “under control”) and also reporting her concern to the Chain of Command that CPL Turner was not getting the help he needed from SSPH. CPL TJ submits that despite these reports, it appears that nothing substantive was done by the Chain of Command to address her concerns.1193
CPL TJ submits that she and others “went well above and beyond what could be expected of anyone in their position in terms of providing support for” CPL Turner and that the ADF response “lacked appropriate engagement”.1194 1192 Submissions of the Commonwealth dated 7 June 2024 at [635].
1193 Submissions of CPL TJ dated 7 June 2024 at [36]-[37].
1194 Submissions of CPL TJ dated 7 June 2024 at [38].
The PhD proposal
CPL TJ submits that the decision regarding his PhD reinforced CPL Turner’s perception that he was being abandoned and not supported and compounded his lonely view of his own position and role (after in fairly rapid succession being disciplined, publicly demoted, and removed from his home unit). CPL TJ considers that the Chain of Command’s approach in rejecting the application was “deeply insensitive” to CPL Turner’s plans for his future and they were indifferent to the consequences that such a decision may have on CPL Turner. She submits that even though the proposal was supported by the head of the High-Performance Wing, the CO appears to have rejected the proposal for no more than speculative reasons and did so admitting that he did not have regard to any mental health consequences that might flow from his decision.1195 Submissions of Dr Hale
Dr Hale submits that, in light of Dr Nielssen’s evidence,1196 the nature of the care provided to CPL Turner is to be described as “multifactorial or complex” rather than “fragmented”.1197
Dr Hale further submits that insofar as it is suggested that Dr Hale’s email to Dr Wallace on 14 July 2017 was deficient or that he ought to have referred CPL Turner to Dr Wallace sooner, such a suggestion should be rejected given that it was not put to Dr Hale during the inquest.1198
Dr Hale also states that in relation to the Commonwealth’s submissions about his note of 11 April 2017, soon after seeing Dr Hale on 3 April 2017, CPL Turner was assessed by Dr Swain and CAPT KV shortly thereafter. Dr Hale objects to any adverse finding about the note given that he was not called to give evidence about the 3 April 2017 attendance.1199
Dr Hale also notes that, contrary to the Commonwealth’s submissions, on 14 June 2017, CAPT McLean advised CAPT KV1200 (not Dr Hale, as he was on leave) that she was particularly concerned about CPL Turner’s increased alcohol intake.1201 1195 Submissions of CPL TJ dated 7 June 2024 at [40]-[48].
1196 Tab 108 (Dr Olav Nielssen) at 9-14; T405.14-19 1197 Submissions of Dr Hale dated 31 May 2024 at [24]-[26].
1198 Submissions of Dr Hale dated 31 May 2024 at [40].
1199 Submissions in reply of Dr Hale dated 19 July 2024 at [3].
1200 Exhibit 4 at 235-236.
1201 Submissions in reply of Dr Hale dated 19 July 2024 at [4].
Dr Hale also objects to any criticism being aimed at the email of 16:14 to BRIG MF on 11 July 2017, which contained the recommendation that CPL Turner be directed to inpatient care given that the recommendation was not put to Dr Hale during his evidence.1202
In relation to Mr and Mrs Turner’s submission about there being a “fundamental lack of clinical understanding of [CPL Turner’s] mental health struggles in 2017, and this created a negative attitude toward him, which likely compounded his feelings of agitation and alienation toward the chain of command”,1203 Dr Hale rejects the submission insofar as it is intended to be a criticism of his care and treatment of CPL Turner (noting that this was not put to him at the Inquest).1204 The PhD proposal
In relation to Joanna Turner’s submission that CPL Turner’s “illness decline and death was preventable” and that the need for CPL Turner to have “support in the development of his sense of self separate to his identity as a soldier”,1205 Dr Hale submits that he assisted in that regard by indicating he would make a submission in support of a MEC that would allow CPL Turner to study.1206 Submissions in reply of Counsel Assisting
In relation to the appropriateness of the nature of the care that was provided to CPL Turner in the 39 days following CPL Turner’s discharge from SJoGH, Counsel Assisting does not consider that any adverse finding should be made on the appropriateness of the care provided by CAPT McLean. However, the position in relation to the “fragmented” nature of CPL Turner’s care during this period is maintained.1207
Counsel Assisting also does not seek an adverse findings flagged by Dr Hale above at [817]-[819].1208 The general substance of whether or not a direction to CPL Turner to comply with treatment – including whether such directions were counterproductive – was the subject of other questions to Dr Hale (albeit not by reference to this specific email).1209 1202 Submissions in reply of Dr Hale dated 19 July 2024 at [4].
1203 Submissions of Mr and Mrs Turner dated 28 January 2024 at [90].
1204 Submissions of Dr Hale dated 31 May 2024 at [41].
1205 Submissions of Joanna Turner dated 17 January 2024 at [7].
1206 Submissions of Dr Hale dated 31 May 2024 at [45].
1207 Submissions in reply of Counsel Assisting dated 22 August 2024 at [59].
1208 Submissions in reply of Counsel Assisting dated 22 August 2024 at [138.1].
1209 23/10/2020 T410.41-412.4; Submissions in reply of Counsel Assisting dated 22 August 2024 at [138.3].
The Human Performance Wing
Counsel Assisting submits that in relation to SGT MC’s evidence which did not mention the word “ill” when noting the HPW had been set up for the “wounded and injured”, significant weight should not be placed on this omission given that evidence was provided by other witnesses.1210
In relation to the objection made by the Commonwealth that the criticism of the HPW appears irrelevant to the manner and cause of death in circumstances where it was previously stated by Counsel Assisting on 6 September 2022 that the role of the Inquest was not to investigate HPW “more broadly”, Counsel Assisting’s position1211 in relation to the relevance of the HPW is clear when understood in its context:1212 “Your Honour, there is a concern that the role of this inquest is not to investigate the Human Performance Wing more broadly. There are clearly issues relating very specifically to Corporal Turner and the way in which he was treated within the Human Performance Wing…”
Counsel Assisting’s initial submissions on the HPW clearly concern CPL Turner’s treatment within the HPW and to the extent there are broader assessments regarding qualifications of its staff or its overall purpose, they are made in the context of assessing the appropriateness of that venue for CPL Turner at that time. No finding or comment is sought in which would traverse what was accepted by Counsel Assisting on 6 September 2022.1213 The fragmented nature of the care provided to CPL Turner
In response to the Commonwealth’s objection to Counsel Assisting’s submission that there was a “fragmentation of care”, Counsel Assisting indicates that the fragmentation of CPL Turner’s care prevented the fulsome disclosure of information between practitioners, prevented communication between practitioners, prevented input from external practitioners in welfare boards, prevented consistent oversight of prescription of medication, and may have been seen to be intrusive for someone in CPL Turner’s position. Those matters are apparent from the evidence as previously summarised and it is submitted that it is not additionally necessary for there to be expert opinion to make such a finding.1214 1210 Submissions in reply of Counsel Assisting dated 22 August 2024 at [50], referring to 1/9/22 T31.36; T31.47; T41.9; 9/9/22
1211 Submissions in reply of Counsel Assisting dated 22 August 2024 at [226].
1213 Submissions in reply of Counsel Assisting dated 22 August 2024 at [227].
1214 Submissions in reply of Counsel Assisting dated 22 August 2024 at [223].
In relation to the Commonwealth’s explanations as to why fragmentation of CPL Turner’s care occurred, Counsel Assisting submits that the evidence does not grapple with the impact of the fragmentation which was the focus of Counsel Assisting’s initial submissions on this point to which the Commonwealth objects. It is submitted that while it may be unavoidable that CPL Turner had to be seen by several practitioners, it is the degree to which that fragmentation occurred and the lack of wholistic coordination and oversight of CPL Turner’s care which gave rise to the issues.1215
Lastly, contrary to the Commonwealth’s submission at [811] above, it is not Counsel Assisting’s position that fragmentation could only be remedied by management by a “single person”.1216 Consideration
It is perfectly clear that CPL Turner’s mental health deteriorated rapidly throughout the first half of 2017. The move from B Company to C Company was done in a manner which lacked attention to the potential risks for CPL Turner. Whether or not the demotion and move were necessary is not for me to judge. However, it is clear that a significant amount of mental health support would have been required. BRIG Langford accepted the steps taken would have been humiliating. In my view, the potential impact is obvious.
Unfortunately, even when CPL TJ communicated her concerns to the Padre, there is no evidence that this was fed up the Chain of Command. Nevertheless, she continued to try and support CPL Turner and for that she should be commended.
The ADF placed reliance on the fact that CPL Turner would be managed by the HPW after his first suicide attempt in early March 2017. This unit, located within the 2CDO, was described as being set up “to provide mentoring management of the wounded injured (sic) in a culturally relevant space and it was a by commando for commando area.” Mr Cardinaels was the “leader” of the HPW from around 2015 to 2018. I had the opportunity to hear from him during the inquest. It was less than impressive.
His own qualifications for running such a unit were being “well read”, talking to others in the field, and having an interest in rehabilitation. He had no psychological or psychiatric training. I make no finding on the operation of the HPW more broadly but, in my view, Mr Cardinaels struggled to articulate what the HPW was trying to achieve for CPL Turner. He appeared to have no idea who was case managing CPL Turner’s 1215 Submissions in reply of Counsel Assisting dated 22 August 2024 at [223].
1216 Submissions in reply of Counsel Assisting dated 22 August 2024 at [224].
rehabilitation. In my view, the reliance the ADF placed on CPL Turner’s placement with the HPW was entirely misplaced. What was required was coordinated and professional support, not amateurish mentoring in a space which was “culturally relevant” to commandos.
In my view, there is no question that COL MF’s rejection of the PhD proposal was not sensitively handled and had very serious repercussions. Whether it was rejected or “not supported because of the outplacement component” is not a matter I will comment on. What is clear is that the proposal was one of the few things that gave CPL Turner hope at that point in his life. The fact that it was “taken off the table” at that time was unnecessary and robbed him of his dream of finding a suitable and respectful transition. I accept CPL TJ’s submission that this decision reinforced CPL Turner’s perception that he had been publicly abandoned.
I have taken into account the specific matters raised by the Commonwealth both in relation to other stresses that were affecting CPL Turner during this time that the ADF had no control over (for example, issues occurring in his relationship with CPL TJ) as well as steps the ADF took to provide care (including around the time he was admitted to St Vincent’s Hospital) but it does not change my mind that his care was always largely reactive. It is not that the ADF did nothing, it is that a coordinated plan was lacking. I have considered and do not accept the submission that the IWB procedure was helpful at this time.
I accept that by this stage CPL Turner’s health would have been difficult to manage.
During the first two weeks of July he had suffered a dissociative episode or overdose, was drinking excessively, had missed appointments, and was increasingly volatile. I have considered the Commonwealth’s detailed submissions which suggest that the notion of “fragmented care” should not be accepted. I am not persuaded by those submissions and, in my view, the care was both fragmented and reactive.
exacerbated by the fragmentation of his care. It is possible that individual practitioners honestly believed he was being managed elsewhere.
Adequacy of the ADF’s response in the period from 15 to 17 July 2017
Submissions of Counsel Assisting
Counsel Assisting submits1217 that in the period of 15 to 17 July 2017 there was a great deal of confusion amongst various witnesses about whether CPL Turner was intended to have a “battle buddy”, that is, someone with him 24/7, over that weekend. It ultimately transpired that he was not, and the safety plan involved him calling CPL TJ or a work mate if he had thoughts of suicide, avoiding alcohol, and following medical advice.
It also appears that immediately prior to this period, there were moves on the part of the ADF to use the disciplinary system in order to force CPL Turner to comply with treatment. Counsel Assisting posits that it was inappropriate to do so in the absence of any medical advice (from any person involved in the specific treatment of CPL Turner’s mental health (i.e., his treating psychologist or psychiatrist))1218 suggesting that this would be helpful. It is submitted that given that aspects of the ADF’s disciplinary system had been a significant cause in CPL Turner’s declining mental health and relapse, it ought to have been plainly obvious to the Chain of Command that using discipline to force treatment compliance might be counterproductive and to seek expert medical advice on the utility of it. Ultimately, this did not seem to assist CPL Turner in his recovery and was more likely to have been unhelpful to his recovery.
Counsel Assisting concludes that it appears that little could have been done to assist CPL Turner in his final few days, noting that the failures in treatment all occurred at an early stage. By mid-2017 he was in a critical condition and it is not clear what specific intervention at this stage might have avoided the tragic outcome.
Submissions of the Commonwealth
1218 Submissions in reply of Counsel Assisting dated 22 August 2024 at [228].
health facility, it would be procedurally unfair to make any adverse findings or comment about Dr Reppas’ advice or the ADF’s consideration of it.1219 Submissions in reply of the Counsel Assisting
Counsel Assisting does not seek an adverse finding against Dr Reppas.1220 Consideration
I accept Counsel Assisting’s submission that there was confusion in the days leading up to CPL Turner’s death about whether he should have someone with him 24/7. This is regrettable.
I was concerned that in the days leading up to his death there appears to have been consideration on the part of the ADF to use the disciplinary system to order CPL Turner to comply with treatment. In my view, even just taking into account CPL Turner’s recent response to the ADF disciplinary system, the potential approach was entirely misconceived. I do not raise the issue to suggest criticism of any particular individual but rather to highlight the apparent underestimation of CPL Turner’s ability at this juncture to respond rationally to ADF direction or punishment. In my view, it shows a failure to understand how critical things had become. A punitive approach was not required at this point.
Other matters raised in connection with Issue 3
(a) Clinical case management by the ADF throughout the period of 2014-2017 Submissions of Mr and Mrs Turner
1220 Submissions in reply of Counsel Assisting dated 22 August 2024 at [228].
1221 Submissions of Mr and Mrs Turner dated 28 January 2024 at [81]-[85]
example, 2CDO MO and psychologists believed they were CPL Turner’s clinical case managers), which impacted CPL Turner’s confidence in 2CDO’s ability to manage his clinical condition. They consider that, as per ADF policy, CPL Turner should have had a MO as his designated clinical case manager from the time of his discharge in 2014.
Furthermore, CAPT KV should not have assumed the role of clinical case manager as he was not a “medical officer”.1222
1223 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [54].
1224 Submissions of the Commonwealth dated 7 June 2024 at [280]-[283].
1225 Submissions of the Commonwealth dated 7 June 2024 at [241(a)].
1226 Submissions of the Commonwealth dated 7 June 2024 at [176(c)].
1227 Submissions of the Commonwealth dated 7 June 2024 at [241(c)].
vi. Joanna Turner reported that following the September 2015 domestic dispute, her Platoon Sergeant sat down with 2CDO and raised concerns about what was happening and CPL Turner’s mental state. 1228
Mr and Mrs Turner submit that if, notwithstanding the above, it is accepted that the Chain of Command did not know about the domestic violence, then that reflects a serious breakdown in the welfare processes at 2CDO at the time.1229
In response to any suggestion that the ADF was unaware of CPL Turner’s mental health issues at the time of the decision to move him to C Company in 2016, CPL Turner’s parents note:1230 i. the 2CDO Chain of Command actively participated in appealing the initial decision of GPCAPT Ross that CPL Turner was not fit to deploy due to mental health concerns; ii. CPL Turner was still being reviewed by the 2CDO UWBs whilst deployed; iii. CPL Turner had been involved in the disciplinary proceedings and the 2CDO Chain of Command knew of the demotion and move to C Company;1231 iv. BRIG MF gave evidence that the move to C Company would have caused some form of embarrassment;1232
They also note1233 that during 2017, the Chain of Command did not appreciate how unwell CPL Turner was before his first suicide attempt, despite the evidence of CPL TJ1234 and Padre MP.1235
Mr and Mrs Turner submit1236 that questions should be asked of the ADF as to why it was that medical and operational personnel were inadequately trained to recognise symptoms of PTSD and respond to CPL Turner’s PTSD given that the Commonwealth made the following concessions about the available body of knowledge the ADF had access to: 1228 Tab 7 at 4.
1229 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [53(a)].
1230 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [53(i)].
1233 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [53(j)].
1234 Tab 27 at 28.
1236 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [23(a)].
i. treatment of PTSD and the difficulties in treating PTSD that have existed for years;1237 ii. even if asymptomatic, “response rates for exposure-based therapy ‘remain modest’”;1238 iii. highest rates of remission are generally seen where the affected person has experienced a single traumatic episode and where PTSD is not complicated by comorbid conditions;1239 iv. “even those who return to normal function do…still have a risk of relapse of the condition, most likely in association with other stressful life events or specific reminder of their trauma”;1240 v. the ability of some PTSD sufferers to be “able to continue performing at a high level in the workplace”;1241 vi. the ability of some PTSD sufferers to “successfully conceal signs/symptoms and continue to perform at a high level in the workplace”;1242 vii. “abuse of alcohol and other drugs might be a sign/symptoms of PTSD”;1243 “domestic violence and coercive controlling behaviour might be a sign/symptom of PTSD”;1244 and viii. “reporting obligations of ADF personnel, both in respect of mental health issues and domestic violence”.1245
1238 Submissions of the Commonwealth dated 7 June 2024 at [86].
1239 Submissions of the Commonwealth dated 7 June 2024 at [86].
1240 Submissions of the Commonwealth dated 7 June 2024 at [86].
1241 Submissions of the Commonwealth dated 7 June 2024 at [139], [264].
1242 Submissions of the Commonwealth dated 7 June 2024 at [87], [264].
1243 Submissions of the Commonwealth dated 7 June 2024 at [87], [211].
1244 Submissions of the Commonwealth dated 7 June 2024 at [87, [94], [182(c)], [211], [495].
1245 Submissions of the Commonwealth dated 7 June 2024 at [182(c)].
1246 Submissions of Mr and Mrs Turner dated 28 January 2024 at [179]-[185].
Submissions of the Commonwealth
Submissions of GPCAPT Ross
GPCAPT Ross contends that no finding should be made in accordance with the Commonwealth’s concessions noted above at [855] that the operational and medical personnel who dealt with CPL Turner in 2014-2017 were not sufficiently trained in recognising and managing the symptoms of PTSD.1249
In my view, it is an important concession and one that is not aimed at any particular individual.
Submissions of Counsel Assisting
Counsel Assisting does not seek any finding in respect of GPCAPT Ross as raised above at [857].1250
In relation to the submission above at [848], Counsel Assisting notes that CAPT KV assumed the clinical case manager role on or around 31 March 2017 at the request of CPL Turner.1251 The policy on which Mr and Mrs Turner rely for indicating breach is the “Management of Post-Traumatic Stress Disorder and Acute Stress Disorder in the Australian Defence Force for Primary Care Providers”, in which “Mental Health Professional” is defined to include (1) medical officers, (2) nursing officers, (3) psychologists and (4) social workers.1252 Mr and Mrs Turner refer to the obligation for a “non-medical” mental health professional to refer a member suspected of having PTSD to a medical officer for further assessment. Counsel Assisting disagrees with Mr and Mrs Turner’s suggestion that CAPT KV was a “non-medical” professional (noting 1247 Submissions of the Commonwealth dated 7 June 2024 at [85].
1248 Submissions of the Commonwealth dated 7 June 2024 at [90], [94], [211].
1249 Submissions in reply of GPCAPT Ross dated 22 July 2024 at [5]-[8].
1250 Submissions in reply of Counsel Assisting dated 22 August 2024 at [182].
1251 Exhibit 40 at [31]; 10/08/2021 T70.19.
1252 Tab 84 at 2.
he is a psychologist with clinical training), noting that there is an insufficient basis to make a finding that there was a breach of this policy.1253 Consideration
As noted, I accept Mr and Mrs Turner’s general submission that CPL Turner should have been identified as having had subsyndromal PTSD at an earlier time. To later suggest he was “cured” indicates a superficial understanding of the nature of the condition. I accept their submission that there should be better education regarding sub-syndrome PTSD, PTSD symptomology, and stronger reviews of health files review policy.
I do not accept their specific contention that there was a breach of policy because CAPT KV was not a “medical officer.” I accept Counsel Assisting’s submissions on this issue.
(b) The role of the padre Submissions of Counsel Assisting
Counsel Assisting notes1254 that the role of the padre in providing mental health support emerged as an issue in the provision of mental health support to CPL Turner by the ADF. Padre MP was the padre (or “chaplain”) at 2CDO from 2015 to 2017.1255 By training, Padre MP is a Baptist Minister.1256 The role of the padre in providing mental health support was described by Padre MP as being “to provide pastoral care and support and walk alongside those who are hurting, definitely those who have got some mental health issues” but that “we are not decision makers” and do not provide “direct mental health support”.1257 He described this “walking alongside” as being “when someone’s struggling I’ll walk alongside them, be with them, I’m not leaving them, I’m not making any managerial or leadership decisions” but rather “It’s purely just support at a lateral point. With whatever they’re going through, I’m with them.”1258
Padre MP did not have significant training in mental health. His evidence was that he had attended a two day “mental health first aid course” which teaches “initially awareness of someone who is struggling with mental health”. He stated it was “done 1253 Submissions in reply of Counsel Assisting dated 22 August 2024 at [71]-[73].
1254 Submissions of Counsel Assisting dated 2 November 2023 at [499]-[503].
at a very lay level”.1259 This course included suicide prevention training.1260 He had not received training in alcohol abuse or PTSD but was aware of the symptoms of PTSD.1261 He explained that his role was not to manage mental health disorders, but rather to “walk with a member to get the mental health…get them to the right provider” but not to make decisions or manage, just to “support”.1262
The evidence in the Inquest revealed that the Padre was relied on to a significant extent to assist CPL Turner. For example, BRIG Langford’s evidence was that part of improving the ability for members of the ADF to obtain mental health support was by “strengthening our capacity to offer alternative pathways for members”, including through the Padre.1263
It was also apparent that the Padre was providing a level of support to Joanna Turner and was aware of some of the issues which Joanna Turner was facing in the home.1264 CPL TJ’s evidence was that she also took her concerns about CPL Turner’s mental health in early 2017 to the Padre.1265 The Padre was also flown to AMAB around the time of the disciplinary proceedings to provide support to the members who were being investigated.1266 However, it also appeared that there was very little interaction between mental health and medical professionals and the Padre. For example, MAJ AM stated that he did not remember talking to the Padre about CPL Turner around the time of the 2016 medical clearance,1267 and neither MAJ AF nor COL MF spoke to the Padre around the time of making that decision in relation to his views about CPL Turner’s mental health (notwithstanding it would appear he had relevant information about the difficulties Joanna Turner was facing in the home at that time).1268 Similarly, the Padre did not appear to have been involved in welfare boards, notwithstanding he was a person providing pastoral support to CPL Turner (noting the obviously blurred line between pastoral support and mental health support).
Professor McFarlane noted that chaplains faced difficulties when placed in roles where they were expected to manage mental health disorders in the ADF without necessary expertise and training. He considered that Padre MP’s role as an intermediary was fraught with complexities.1269 He noted that the relationship between the chaplain who
1266 Tab 19 (IGADF ROI with Padre MP on 18 September 2018) at 1-2.
1269 Exhibit 12 at 21.
had been a personal friend of CPL Turner highlighted the complexity in the role of the Padre in taking issues further up the Chain of Command to ensure optimal interventions occur. Professor McFarlane noted that at times, “service personnel see their interactions with the chaplain as being provided mental health care and therefore do not take further steps to receive appropriate treatment”.1270
The evidence revealed that, at various times, the Padre was relied upon as a person who could provide mental health support to CPL Turner and to Joanna Turner in the context of CPL Turner’s declining mental health. There was little by way of formal records of these interactions. However, Counsel Assisting highlights that there is a real question as to the role of the padre in providing mental health support in circumstances where those interactions did not appear to ultimately be communicated or taken into account in medical decision-making or decision-making around whether CPL Turner should be deployed. Counsel Assisting notes that these questions provide a basis to make a finding that this role is inadequately scoped or defined and a recommendation to review the role of a padre in providing mental health support.
Counsel Assisting does not seek an adverse finding about the Padre’s conduct in receiving information from Joanna Turner. It is submitted that there is nothing to suggest the Padre did so for any other reason than attempting to obtain a wholistic view of CPL Turner’s circumstances in order to support CPL Turner (as was his role).
In the same way, the Padre liaised with CPL TJ in relation to CPL Turner’s care. This is particularly relevant in the context of the ADF having been aware of issues of domestic violence and having had a history of at least some engagement with Joanna Turner through MAJ Clancy. Counsel Assisting accepts that the Padre carried out substantial engagement with CPL Turner without formal mental health qualifications and in circumstances where CPL Turner’s condition did not appear to ultimately be communicated or taken into account in medical and operational decision-making.1271 Submissions of the Commonwealth
1270 Exhibit 12 at 24.
1271 Submissions in reply of Counsel Assisting dated 22 August 2024 at [68]-[70].
1272 Submissions of the Commonwealth dated 2 June 2024 at [668].
Submissions of Mr and Mrs Turner
Mr and Mrs Turner submit that, at the time CPL Turner notified the ADF that he had separated from Joanna Turner, the Chain of Command should have had no further interaction with her in relation to his care and management. In particular, Mr and Mrs Turner are critical of the Padre’s role of acting as a conduit of information between CPL Turner and Joanna Turner, which they submit gave rise to a “very real risk” that the Padre would have been given inaccurate information which would then have been fed into the Chain of Command.1273 Submissions in reply of Counsel Assisting
Counsel Assisting considers that it is not clear whether Mr and Mrs Turner’s submission is intended to assert the identified “risk” in fact led to inaccurate information impacting CPL Turner’s care.1274 Consideration
I found Professor McFarlane’s evidence about the difficulties chaplains face when they are expected to assist in managing mental health disorders compelling. They do so without proper training or expertise. Specifically, Professor McFarlane identified the intermediary role Padre MP played at times was one which was fraught with complexities. He was a personal friend of CPL Turner’s and he was also relied upon by Joanna Turner. There appeared to be no clarity around when information given to him was or should have been sent up the Chain of Command. Both Counsel Assisting and Counsel for Mr and Mrs Turner, for different reasons, identified issues with the Padre’s undefined role and responsibilities.
The Commonwealth considered I had no basis to make a finding about the scope of the role of the padre without having had access to the various policies and guidelines which exist. I agree it would be improper for me to make a finding that Padre MP did not act in accordance with his duties. I have no intention to do that.
Nevertheless, the reliance on the Padre to assist the Chain of Command in the management of CPL Turner’s mental health, something he had no qualifications to attend to, was in my view misplaced. There was also a reliance by some on the Padre to feed information back to the Chain of Command. This was always fraught with difficulty given the conflicting loyalties involved.
1273 Submissions of Mr and Mrs Turner dated 28 January 2024 at [97]-[98].
1274 Submissions in reply of Counsel Assisting dated 22 August 2024 at [67].
(c) Coercive control Submissions of the Commonwealth
The Commonwealth submits that no finding should be made that ADF personnel can or should have recognised CPL Turner’s behaviour as “coercive controlling behaviour” or interpreted any such behaviour above as a sign or symptom of PTSD (referring to Counsel Assisting’s summary of the facts at [26], [91], [260], [327], and [480]). The Commonwealth posits that “coercive control” is a relatively new concept in the fields of medicine, social sciences, and law and none of the experts in the Inquest (who are not even experts in coercive controlling behaviour) gave evidence about such behaviour.1275 Submissions in reply of Counsel Assisting
Counsel Assisting emphasises that the submissions above at [583]-[586] make the point that domestic violence was known to the ADF but not recognised as a symptom of PTSD. The indicia of what might now be described as “coercive controlling behaviour” did not occur in a vacuum or in a form unrecognisable even ten years ago as a form of domestic violence. When CPL Turner was charged in 2014, the offences and facts showed indicia of what might now be described as coercively controlling behaviour in the form of actual criminal charges: stalking and menacing use of a carriage service. It is accepted by Counsel Assisting that members of the ADF could not have been expected to recognise the indicia of coercive control as a discrete phenomenon, however, this misses the point that such indicia which occurred in the context of what conduct amount to domestic violence, however described.1276 Consideration
I am perfectly comfortable in describing some of the behaviour which took place as “coercive controlling behaviour.” While it is true that the term is now better understood, it has been used to describe behaviour which has been recognised by psychologists as domestic violence for many years.
1275 Submissions of the Commonwealth dated 7 June 2024 at [97].
1276 Submissions in reply of Counsel Assisting dated 22 August 2024 at [190].
(d) Welfare board meetings Submissions of Mr and Mrs Turner
In relation to the welfare boards, it is submitted that there were “blurred lines of responsibility” in the communications and there should be ADF policy about who is responsible for providing the member with details of the proceeding and the outcome of welfare boards. They state that because CPL Turner was not present or represented at every welfare board meeting or even informed of the outcome of these meetings, he did not fully understand his predicament and the welfare boards lacked insight into CPL Turner’s condition and treatment. They also believe that ADF policy DIG PERS 16-24 Mental Health was breached by not having CPL Turner in attendance at every welfare board meeting.1277 Submissions of Counsel Assisting
Counsel Assisting considers that the evidence is insufficiently clear to base a finding that ADF policy was breached by not having CPL Turner in attendance at welfare board meetings. There is evidence that CPL Turner attended IWBs (where his attendance was required) and other times he did not.1278 Where it was permissible under ADF policy for a member to have a nominated representative on the IWB, his absence does not in and of itself suggest a lack of representation. Without identification of which IWB CPL Turner did not attend and what information was not provided to him, it is submitted that no useful conclusion can be drawn about any particular causative influence on his supervision or treatment. 1279 Consideration
(e) Shifting of blame to CPL Turner Submissions of Mr and Mrs Turner
1278 Tab 38 (Welfare Board Minutes) at 13, 16.
1279 Submissions in reply of Counsel Assisting dated 22 August 2024 at [64].
1280 Submissions of the Commonwealth dated 7 June 2024 at [74]-[83], [125], [135], [151], [158], [182], [195], [214], [226], [232], [241], [282], [329], [374].
understood in the context of the known stigma in the ADF of mental illness as being a barrier to members seeking care.1281
They also submit1282 that the Commonwealth’s submissions regarding CPL Turner’s intimate relationships are condescending and judgmental in that they refer to selective texts that label CPL Turner as being “aggressive”, “demeaning”, “self-piteous”, and “ostensibly loving and caring”,1283 which fails to properly acknowledge the expert evidence regarding CPL Turner’s intimate relationships.1284 They also note that the text messages referred to by the Commonwealth are written by someone suffering from severe PTSD (and that insofar as the Commonwealth contends that the text messages depict the behaviour of someone who is not suffering from a significant illness, such a contention should be rejected).1285 Submissions of Counsel Assisting
In relation to Mr and Mrs Turner’s submission that the Commonwealth appear to be shifting blame to CPL Turner for not being forthcoming with his symptoms, Counsel Assisting acknowledges the expert evidence concerning the difficulties arising from underreporting of symptoms (summarised above at [486]-[489]) and notes that Counsel Assisting’s recommendations in relation to this Inquest (discussed below) promote longitudinal management of ADF members’ mental health, training on the recognition of PTSD, and alternative career paths within and outside the ADF (career advancement being a consideration which may impact upon a member’s willingness to disclose).1286
In relation to Mr and Mrs Turner’s complaint about the Commonwealth’s submissions seeking to shift blame or focus to CPL Turner’s intimate relationships, Counsel Assisting refers to the evidence (as summarised above at [199]) regarding the interaction between PTSD, alcohol abuse and relationship breakdowns and domestic violence.1287
As for Mr and Mrs Turner’s submission that a finding ought to be made that from 2014 onwards, the 2CDO Chain of Command knew of CPL Turner’s mental health condition, Counsel Assisting emphasises that it is not merely an awareness of diagnosis that is relevant for such a finding, but the awareness of the deteriorating status of that 1281 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [49]-[51].
1282 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [52(b)].
1283 Submissions of the Commonwealth dated 7 June 2024 at [488].
1284 07/02/2023 T40.1-25, T41.5; Exhibit 12 at 6, 11.
1285 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [48].
1286 Submissions in reply of Counsel Assisting dated 22 August 2024 at [103].
1287 Submissions in reply of Counsel Assisting dated 22 August 2024 at [104].
diagnosis over time, and, to the extent certain information or events were not conveyed up the Chain of Command, it is the absence of systemic oversight and management of the diagnoses that is particularly relevant.1288 Consideration
It is necessary to be very careful when describing CPL Turner’s under-reporting of PTSD symptoms. I accept Mr and Mrs Turner’s submission that this behaviour must be viewed in context. I accept that there was considerable stigma surrounding having a mental illness in the ADF. It must also be remembered that he had a genuine desire to serve his country at all costs.
CPL Turner was very unwell and that is reflected in his behaviour and in his relationships.
Issue 4 – Whether there was any disincentive to CPL Turner raising mental health issues or seeking mental health treatment by reason of ADF policies or procedures Submissions Submissions of Counsel Assisting
Counsel Assisting1289 submits that BRIG Langford’s evidence was that during 20142015, the time he was the CO of 2CDO, there was an attempt to destigmatise members seeking help for mental health and that he tried to make it clear to members that there was a process where members could seek mental health support with a view to returning to active service when they were fit to serve.1290 This attitude appears to have continued under the command of COL MF who said in his ROI for the IGADF that “…to be honest, at that point, [CPL Turner] was almost a good news story… organisationally as well, to display that just because you did put your hand up and say you had an issue, it wasn’t a one-way ticket to medical discharge.”1291 This answer was given in the context of questions about the granting of the medical clearance for CPL Turner’s deployment on OP OKRA in 2016.
Ms Cantwell, clinical psychologist, formed the view during her treatment of CPL Turner that he was “willing to put on a ‘brave face’ and deny certain aspects of his presentation despite clinical symptoms and/r reports that would indicate otherwise”. She stated she was “acutely aware of this tendency of Mr Turner’s through my experience working 1288 Submissions in reply of Counsel Assisting dated 22 August 2024 at [105].
1289 Submissions of Counsel Assisting dated 2 November 2023 at [504]-[517].
1291 Tab 17 (IGADF ROI with COL MF on 22 August 2018) at 9.
with ADF members for several years prior” and that her experience was “that this was a common feature of ADF members, particularly members of the SF (Special Forces)”.1292
Dr Malik gave evidence that he felt CPL Turner was being open and honest with him when he had consultations with him.1293 Dr Malik explained that doctors have tools to try and cross-check whether the information a patient is giving is accurate: by checking their history and then checking their hands to see if the patient’s hands are sweating which can demonstrate hyperarousal, and to consider whether the patient has a change in their physical appearance when they talk about trauma.1294 However, he accepted that there were limitations to a doctor’s ability to know whether a patient is being truthful and that, ultimately, “you have to trust the patient… otherwise you risk breaking the therapeutic lines.”1295
Dr Malik was asked about an email which Patricia Turner had written to Dr Malik on 1 May 2017 in relation to CPL Turner’s treatment, at the end of which she had stated: “He is well known for being able to answer all tests as to being completely well, when it has been proven not to be the case”.1296 He stated that “I had to engage him really well…knowing this doesn’t mean that I can tell him that and he’s going to open up.
That breaks our relationship because he thinks I’m, you know, working against him”.
Dr Malik stated that CPL Turner gave him no reason to think that CPL Turner was lying, having stayed in the inpatient facility for four weeks, attending appointments and reviews, and that “you rely on what you see and you try to engage the patient rather than trying to question or interrogate them”.1297
Dr Sringeri was adamant in his oral evidence that CPL Turner was honest with him.1298
The experts generally agreed that it is possible for an individual to hide symptoms of PTSD. If someone is acutely unwell, it may be more difficult for them to hide symptoms.
In general, the experts agreed that it was important for maintaining a therapeutic relationship that clinicians are not overly sceptical of what their clients are telling them and that it was necessary to rely on what the patient was saying.1299 1292 Exhibit 40 (Statement of Andrea Cantwell dated 31 August 2022) at 3.
1296 Tab 56 (St John of God records) at 170.
1299 See 08/02/23 T25-27, 89-90.
Counsel Assisting notes that, ironically, the attitude of those in command that mental health issues should be destigmatised, provided an incentive for them to seek a review of the decision to not grant a medical clearance to CPL Turner without adequately investigating the risks to CPL Turner’s health in doing so.
Counsel Assisting does not submit that mental health issues should prevent a serving member of the ADF from being deployed. The demands of service as a commando are extreme and it is obviously important that commandos are sufficiently mentally fit to undertake their duties. However, a way has to be found for soldiers to raise issues relating to their mental health as soon as they arise without the fear that their ongoing career in the military will be immediately compromised. Rather than creating an incentive to hide their symptoms, the aim should be for ADF members to raise concerns and engage in treatment so they can return to good mental health.
Counsel Assisting notes that this objective is made difficult to achieve by the failure of Command to create alternative and attractive career paths for members whose identity and sense of purpose is inherently linked to their service as an active combat soldier.
It is submitted that consideration should be given to the creation of alternative career paths for Special Forces soldiers either after a fixed period of deployment to combat zones or after they had developed mental health issues that meant further combat deployments were of risk to their health. This is reflected in the recommendations proposed by Counsel Assisting below.
Security clearances
Another issue that arose in the Inquest was whether CPL Turner was able to disclose information about the activities in which he was involved to his treating doctors or whether he was limited in what he could disclose because that information was security classified. Dr Malik stated that CPL Turner was not able to talk about some matters because of security classifications.1300
Dr Malik’s opinion was that he did not need to engage in specifics and that, in any event, CPL Turner was not ready at the time he was engaging him to engage in discussions about traumatic events.1301 However, he acknowledged that “maybe later
down the track when you want to engage them in exposure therapy”, access to security classified information could be useful.1302
Dr Sringeri’s evidence was that he had experienced a situation where a person who was a serving member had said to Dr Sringeri that he could not talk about particular matters because it is “classified or secret”.1303
The experts were asked about this issue in the expert conclave. Dr Large, Dr Nielssen, Dr Hopwood, and Professor McFarlane agreed with the proposition that there may be difficulties in providing diagnoses and treatment to members of the military and particularly Special Forces soldiers where the member cannot provide security classified information to the clinician.1304 Dr Dinnen disagreed; however, his opinion focussed on whether the examination of a person indicated the presence of a serious psychiatric disorder as compared to the ability to engage in effective treatment.1305
It is submitted that the issue of security classified information does present a barrier to the effective treatment of members with PTSD.
Submissions of Mr and Mrs Turner
Mr and Mrs Turner submit that the obvious disincentive for members disclosing that they are struggling mentally is that it can seriously limit a career.1306 They contend that the only remedy to this is for the ADF to formulate alternative career pathways that lead from combat roles to other ADF roles once a member suffers traumatic injuries such as PTSD.1307
In the case of CPL Turner, Mr and Mrs Turner consider that he did not want to show any weakness or let his regiment down by openly admitting that his PTSD was not fully under control and that he was not coping. They consider that CPL Turner was used as a “good news story” in that he was deployed after being treated for PTSD.1308 Submissions of Dr Sringeri
Dr Sringeri objects to the proposed finding that the issue of security classified information “does” present a barrier to the effective treatment of members with PTSD
1306 Submissions of Mr and Mrs Turner dated 28 January 2024 at [110].
1307 Submissions of Mr and Mrs Turner dated 28 January 2024 at [110]-[111].
1308 Submissions of Mr and Mrs Turner dated 28 January 2024 at [114]-[115].
on the basis that the language of “does” may be “a bit strong” and that the evidence supports a finding that the issue “may” present a barrier to effective treatment.1309 Submissions in reply of Counsel Assisting
Counsel Assisting submits that it was not intended to suggest that the issue of security classified information would prevent the effective treatment of members in all cases and there is no issue with a finding being expressed in terms of “may” to avoid any such implication.1310 Consideration
I accept that there were clear disincentives for CPL Turner to raise the full extent of his mental health difficulties. It would have had an immediate impact on his career as a commando. He would not have been deployed. Without stronger pathways for alternative careers supported by the ADF, this kind of reluctance will remain the case.
This is an issue to which I will return.
In my view, it is likely that the fact CPL Turner was regarded as “a good news story” made honesty even more difficult. Unfortunately, his intelligence (and his superior’s complete lack of curiosity) appears to have made it possible for him to conceal the extent of his injury from the Chain of Command for an extended period.
I also accept the weight of the expert evidence that there may be a particular problem for Special Forces soldiers in relation to diagnosis and treatment where members cannot talk openly about classified operations.
Issue 5 – The extent to which the investigation and laying of charges arising from an incident involving a pornographic playing card affected CPL Turner’s mental health, the extent to which CPL Turner’s mental health history was taken into account in this process and whether adequate support was provided in these circumstances.
Evidence
1309 Submissions of Dr Sringeri dated 24 April 2024 at [49]-[51].
1310 Submissions in reply of Counsel Assisting dated 22 August 2024 at [168].
Submissions Submissions of Counsel Assisting
Counsel Assisting submits1311 that CPL Turner’s mental health was not taken into account during the disciplinary proceedings because it was not put to the summary authority. BRIG Langford accepted that if a person had PTSD, one would expect it to be put to the summary authority as part of their plea in mitigation.1312 CAPT MH’s evidence was that CPL Turner did not instruct him to put his mental health issues before the summary authority.1313 It is not ultimately clear why this happened: it may have been because CPL Turner was concerned about the effect on his career of formally raising his mental health problems is such a forum or it may have been because he did not expect the outcome of the hearing to be as severe as it was.
It is clear, however, that little to no regard was had for CPL Turner’s mental health in the process of the disciplinary proceedings and in its aftermath, and no specific mental health support was put in place for him when he returned to Iraq. Instead, he returned to TQ in a relatively isolated role and was left to deal with the further consequences of the disciplinary proceedings, namely the NTSC and the move from B Company to C Company, which were clearly likely to compound his distress.
Counsel Assisting submits that the failure to put in place mental health support in these circumstances is all the more stark when regard is had to the basis on which it was represented to GPCAPT Ross that the risk of CPL Turner deploying was low, because of his apparently “ready” access to psychologists and assessment and management of his mental health by his regular team members. As MAJ AF’s evidence revealed, he simply was not tracking the significant decline in CPL Turner’s mental health during this time. This cannot be attributed to CPL Turner’s determination to hide it because he revealed it to two superior officers, who ultimately did little with that information by way of substantive steps to mitigate the harm to CPL Turner.
Counsel Assisting submits that it is not my role to review the disciplinary proceedings themselves or the punishment which was imposed. However, it is submitted that it is open to make a finding that CPL Turner’s mental health was severely compromised as a result of those proceedings and by the subsequent failure to support him. In particular, MAJ AF, who had been involved in preparing the brief to GPCAPT Ross to justify the granting of a medical clearance to CPL Turner, should have been aware of 1311 Submissions of Counsel Assisting dated 2 November 2023 at [518]-[519].
1313 Exhibit 13 (letter from CAPT MH dated 31 July 2021) at 1.
the likely effect of the disciplinary proceedings on CPL Turner’s mental health and done more to monitor and support him.
Submissions of Mr and Mrs Turner
Mr and Mrs Turner take no issue with the proposition that it not the role of this Court to review the disciplinary proceedings. Rather, the issue is the “importance of the offer of an amnesty and its subsequently withdrawal which significantly impacted [CPL Turner’s] mental health”.1314 They submit that the ADF seems unwilling to acknowledge the full impact of the disciplinary proceedings on CPL Turner’s mental health and that any suggestion that the disciplinary proceedings were “an amusing sideshow” for CPL Turner should be emphatically rejected. They also reject the assertion that the “cockcard” was pornographic in nature.1315
Mr and Mrs Turner submit that the cock-carding matter was mismanaged by the Chain of Command and that it had devastating effects on CPL Turner’s mental health in that he felt betrayed and abandoned, which caused him to have an intense mistrust of his Chain of Command. They consider that CPL Turner’s mental health was not taken into account in the investigation, the process of laying charges, the hearing or sentencing, the reduction in rank, or his return to Australia (when he was removed from B Company).1316
Mr and Mrs Turner refer to the ADF Policy DIG PERS 16-24, which states that all ADF commanders have a duty to their subordinates to protect mental health and submit that the ADF failed to discharge this responsibility to CPL Turner.1317
In terms of the punishment of the reduction of rank, CPL Turner’s parents consider this was “harsh” and “unjust”, particularly in circumstances where CPL Turner and others believed that an amnesty was offered.1318
Mr and Mrs Turner are also critical of the legal advice that CPL Turner received in relation to the disciplinary proceedings. They are critical of the fact that his Defending Officer had not been a Defending Officer in any previous summary proceedings; he had also participated in the cock-carding practice; he was a witness to the incident; and he was also involved in the investigation.1319 They are also critical of the substance of the advice provided by MAJ JG about not petitioning the outcome of the disciplinary 1314 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [32].
1315 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [33].
1316 Submissions of Mr and Mrs Turner dated 28 January 2024 at [116]-[119].
1317 Submissions of Mr and Mrs Turner dated 28 January 2024 at [130].
1318 Submissions of Mr and Mrs Turner dated 28 January 2024 at [116]-[119].
1319 Submissions of Mr and Mrs Turner dated 28 January 2024 at [124].
proceedings (in particular, advice that he should “keep quiet” and “hope for luck”), as well the impropriety of MAJ JG providing such advice given she was not acting for CPL Turner in the disciplinary proceedings.1320 As a result of receiving MAJ JG’s advice, Mr and Mrs Turner believe that CPL Turner would have felt targeted by the ADF, disempowered, and that he was being used as a scape goat.
The Austin Report
Mr and Mrs Turner refer to the CJTF 633 Inquiry Officer Inquiry report dated 6 October 2016 (Austin Report),1321 which noted that: there was a broad acceptance and tolerance within 2CDO Regt of the practice of cock-carding dating back over five years and the Company leadership team did not take appropriate action to stop the practice; MAJ AF was aware of the practice within his sub-unit and had been cock-carded himself and took no action to stop the practice; CAPT MH was aware of the practice within his platoon, had been cock-carded himself, and had participated in the cockcarding practice and had not taken action to stop the practice; the person who placed a card in passports never came forwarded. The Austin Report also recommended that no administrative action be taken against CPL Turner and that MAJ AF and CAPT MH be formally counselled for failing to act earlier to stamp out the practice within 2CDO Regt.1322
The Austin Report was only mentioned in the IGADF report into the circumstances of CPL Turner’s death1323 in a footnote. The IGADF Inquiry Report on Military Justice Issues Concerning Corporal Turner1324 also fails to mention the Austin Report other than in footnotes. Mr and Mrs Turner submit that the IGADF reports failed to properly consider the Austin Report into the disciplinary proceedings and in the impact those proceedings had in the lead up to CPL Turner’s death.1325 They are also critical of the fact that the ADF did not produce the IGADF reports in their entirety, as the Austin Report was not provided along with the reports.1326
Further to the above, Mr and Mrs Turner are critical of the fact that the Austin Report (without annexures) was provided to the parties in the Inquest in October 2022 in response to subpoenas issued in December 2021 and March 2022. They submit that the Austin Report did not fall within the ambit of the documents mistakenly excluded 1320 Submissions of Mr and Mrs Turner dated 28 January 2024 at [125]-[127].
1321 Exhibit 31, Tranche 11, 47-82.
1322 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [36].
1323 Tab 13 (IGADF Report).
1324 Tab 125 (IGADF Inquiry Report on Military Justice Issues).
1325 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [38] 1326 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 [40].
from production in relation to the 2019 subpoena (see above at [128]-[133]) and ought to have been produced in its entirety given it was a “highly relevant” report regarding the common practice of “cock-carding” within the 2CDO Regt and the significant implications regarding CPL Turner’s representation at the disciplinary proceedings.1327 Submissions of CAPT MH
Submissions of CPL TJ
1328 Submissions of CAPT MH dated 7 June 2024 at [13]-[22].
iii. to CPL Turner’s mind, the outcome of the proceedings was the catalyst for the Chain of Command in taking the step of removing CPL Turner from B Company (which represented a further form of punishment) and transferring him to C Company.1330 Submissions of the Commonwealth
The Commonwealth submits that it would be a breach of procedural fairness to make the adverse finding against MAJ JG proffered by Mr and Mrs Turner.1331 Counsel Assisting accepts that submission.1332 The disciplinary proceedings
The Commonwealth submits that, in addition to the matters raised by Counsel Assisting, the following four matters1333 are relevant to the question of why CPL Turner’s health was not raised during the disciplinary proceedings.
Firstly, there is a gap in the evidence given CAPT MH, WO2, and CAPT Lippis did not provide evidence on this point.
Second, Counsel Assisting’s explanations for CPL Turner not raising his mental health issues (either because he was concerned about the effect of doing so on his career or because he did not expect the outcome of the hearing to be as severe as it was) are speculative and are not supported by the evidence (i.e., the possibility of a demotion was canvassed prior to the disciplinary hearing).1334
Third, CAPT MH’s claims of not having known about CPL Turner’s mental health issues during the disciplinary hearings, provided in Exhibits 13 and 66, are undermined by the documentary records,1335 CAPT MH's IGADF interview,1336 the text messages,1337 and his acknowledgement that his recollection of events was affected by the passage of time.1338
Fourth, both CAPT MH and CPL Turner were aware that the “personal background” and “health” were matters that could be put to the summary authority. The 1330 Submissions of CPL TJ dated 7 June 2024 at [12]-[19].
1331 Submission of the Commonwealth dated 7 June 2024 at [406].
1332 Submissions in reply of Counsel Assisting dated 22 August 2024 at [83].
1333 Submissions of the Commonwealth dated 7 June 2024 at [397]-[406].
1334 Tab 24 (ROI of WO2 DP) at 24.
1335 Exhibit 31 at 3.
1336 Tab 18 (ROI of CAPT MH) at 14, 23-26.
1337 Exhibit 57 at 209-451, 990.
1338 Exhibit 66 at [iii].
Commonwealth submits that no finding should be made to the effect that CPL Turner was improperly or inadequately advised by CAPT MH, WO2 DP, or CAPT Lippis or that he received “questionable legal representation at the disciplinary proceedings”.1339 Impact of the disciplinary proceedings
Submissions in reply of Counsel Assisting The Austin Report
In relation to Mr and Mrs Turner’s criticism that the IGADF and/or AAR processes did not contain references to the Austin Report or “background knowledge regarding suicide and risk associated with multiple deployments”.1344 Counsel Assisting does not consider it a necessary part of my role to assess the substance and content of these processes or comment on how those bodies performed as against their mandates.1345
Insofar as Mr and Mrs Turner submit that the ADF “must be held accountable” for failing to produce both IGADF reports in their entirety, Counsel Assisting notes that they have not articulated what prejudice the delay in the production caused, nor did they raise 1339 Submissions of the Commonwealth dated 7 June 2024 at [406].
1340 Submissions of the Commonwealth dated 7 June 2024 at [419].
1341 Submissions of the Commonwealth dated 7 June 2024 at [419].
1342 Submissions of the Commonwealth dated 7 June 2024 at [420]-[425].
1343 Tab 109 (Report of Dr Matthew Large) at 49; Tab 108 (Report of Dr Olav Nielssen) at 11; Tab 110 (Report of Dr Malcolm Hopwood) at 9.
1344 Submissions in reply of Mr and Mrs Turner dated 24 July 2024 at [36]-[47].
1345 Submissions in reply of Counsel Assisting dated 22 August 2024 at [102.1].
this matter at an earlier stage to afford the Commonwealth an opportunity to respond.1346
Counsel Assisting considers that the proposed findings submitted by CPL TJ above at [925] are appropriate and consistent with Counsel Assisting’s submissions save for (ii), in relation to which Counsel Assisting notes that “it is not the role of the Coroner to review the disciplinary proceedings themselves or the punishment which was imposed”.1347 The disciplinary proceedings
Counsel Assisting points out that the Commonwealth’s submissions on this point seek a conclusion about CPL Turner’s state of mind, which is unknowable absent a contemporaneous record. On that basis, Counsel Assisting concludes (as per [912] above) that any exact reasons the information was withheld is “unclear” and, accordingly, no particular positive finding in that respect is sought.1348
Counsel Assisting considers that the matters raised by the Commonwealth as to CAPT MH not knowing about CPL Turner’s mental health condition do not provide a compelling basis to reject what are clear and unequivocal statements by CAPT MH to the Court that he was unaware of the mental health issues at the time of the summary proceedings. Further, the reliance on statements made by CAPT MH after CPL Turner’s death to the effect that he was aware that CPL Turner’s mental health issues pre-dated the 2016 deployment do nothing to establish that CAPT MH was aware of this at the time of the summary proceedings.1349
Finally, Counsel Assisting opines that it is not clear why, if CAPT MH knew about the mental health condition during both the summary and NTSC processes (as the Commonwealth suggests), CAPT MH would raise it only in the latter context. (It is also not apparent on what basis the Commonwealth submits that the two processes “overlapped”1350 in circumstances where the disciplinary decision was delivered on 16 August 2016 but the NTSC response was sent on 19 August 2016). Counsel Assisting contends that the obvious explanation is that he received those instructions after the disciplinary decision was delivered.1351 1346 Submissions in reply of Counsel Assisting dated 22 August 2024 at [102.2].
1347 Submissions in reply of Counsel Assisting dated 22 August 2024 at [147].
1348 Submissions in reply of Counsel Assisting dated 22 August 2024 at [232].
1349 Submissions in reply of Counsel Assisting dated 22 August 2024 at [233]-[234].
1350 Submissions of the Commonwealth dated 7 June 2024 at [403(d)].
1351 Submissions in reply of Counsel Assisting dated 22 August 2024 at [235].
Impact of the disciplinary proceedings
Counsel Assisting does not identify the disciplinary proceedings as a singular causative factor of CPL Turner’s PTSD symptoms in this period nor does Counsel Assisting identify this matter as causing a “relapse” given that it is apparent CPL Turner was suffering from symptoms of PTSD prior to the proceedings when they deteriorated further after those proceedings.1352 For the reasons outlined above at [198]-[235], Counsel Assisting submits that CPL Turner’s mental health was “severely compromised” by the proceedings in the sense of expediting the deterioration.1353 Consideration
Having carefully considered all the submissions on the impact of the investigation and laying of charges over the “cock card” incident, I have no trouble in finding that it severely compromised CPL Turner’s mental health. I accept that there were a number of factors involved. The offer of some kind of amnesty, which was later withdrawn, left him feeling understandably angry and betrayed. The public impact of his demotion while still on operations and his later transfer to C Company affected him greatly. All this occurred without, it seems, sufficient thought being given by the Chain of Command to the likely effect this would have on CPL Turner’s pre-existing condition.
MAJ AF’s evidence makes it abundantly clear that he was not tracking CPL Turner’s mental health during this period. In my view, it should have been obvious that mental health assessment and perhaps ongoing mental health support was required.
1352 Submissions of Counsel Assisting dated 2 November 2023 at [90]-[98].
1353 Submissions in reply of Counsel Assisting dated 22 August 2024 at [236].
Issue 6 – The move from B Company to C Company Evidence
Submissions Submissions of Counsel Assisting
Counsel Assisting’s submissions on this Issue are generally dealt with in the submissions as summarised above at [769]. Counsel Assisting notes that it is apparent that the move from B Company to C Company had a significant negative impact on CPL Turner and that little or no support was put in place for him in circumstances where the negative effect on his mental health was entirely foreseeable.1354 Submissions of the Commonwealth
The Commonwealth contends that Counsel Assisting’s submissions that (i) the transfer decision was based “solely” on the effective delivery of “capability” (i.e., solely on military/operational considerations), (ii) the transfer decision was made without regard to CPL Turner’s interests or individual needs and no mental health support was put in place at the time the decision was made or implemented, and (iii) the transfer decision had a “significant negative” impact on CPL Turner, should not be accepted, at least without significant qualifications.1355
In support of this position, the Commonwealth makes a number of submissions.1356 Firstly, the Commonwealth posits that the evidence indicates that the transfer decision was well considered and was readily defensible from a military and organisational/administrative perspective, noting that BRIG MF explained1357 that the reasons for the transfer included operational requirements/role that B Company was scheduled to perform in 2017 (namely, complex and dangerous training), CPL Turner’s personal situation/role that C Company was scheduled to perform in 2017 (namely, supporting educational courses), the management of CPL Turner’s “influence” following from his demotion (which was consistent with MAJ AF’s1358 and SGT NA’s1359 1354 Submissions of Counsel Assisting dated 2 November 2023 at [520].
1355 Submissions of the Commonwealth dated 7 June 2024 at [672].
1356 Submissions of the Commonwealth dated 7 June 2024 at [673]-[733].
1357 21/10/2020 T240 to T244; 22/10/2020 T252; Tab 17 (ROI of COL MF) at 14-18.
1358 Tab 16 (ROI of MAJ AF) at 28; 04/08/2021 T55.15-49.
1359 Tab 14 (ROI of SGT NA) at 14.
evidence), and “other movements/transfers” within the regiment (which was supported by evidence from others such as MAJ AF and BRIG Langford).1360
Second, the Commonwealth points out that no evidence was provided by WO1 EL (who had input into the decision-making process and the most senior noncommissioned officer in the regiment) on the transfer decision, noting that his answers to the questions in the interview with the IGADF were generally consistent with BRIG MF’s evidence.1361
Third, the Commonwealth highlights that CPL Turner’s “interests” and “individual needs” were among a number of considerations that needed to be taken into account, with others including military/operational matters and the interests and individual needs of other members of 2CDO and, accordingly, there was nothing illogical, inappropriate, or unreasonable about BRIG MF placing emphasis on the safety of other members of B Company in the context of the dangerous training scheduled for 2017 as a primary consideration.1362
Fourth, the Commonwealth indicates that at the time of the decision, BRIG MF and MAJ AF did not know all of the information that we know now about CPL Turner’s mental state in October 2016 (although BRIG MF was aware of the potential for the transfer to be perceived by CPL Transfer as a further punishment for his disciplinary offence1363 and MAJ AF agreed that CPL Turner was “angry and annoyed” at the time of the decision).1364
Fifth, the Commonwealth notes that BRIG MF disagreed with Counsel Assisting’s suggestions that the move to C Company would be “highly traumatic” for CPL Turner (although he acknowledged it was “likely to have some form of embarrassment”) and that moving CPL Turner would remove him from his social supports.1365 MAJ AF also considered that the move would not have “dislocate[d] him from his support network”.1366
Sixth, the Commonwealth considers that the evidence indicates that the Chain of Command within B Company gave careful consideration to the question of who would 1360 21/10/2020 T240 to T244; 22/10/2020 T252; Tab 17 (ROI of COL MF) at 14-18.
1361 Tab 23 (ROI of WO1 EL).
1362 Submissions of the Commonwealth dated 7 June 2024 at [697].
tell CPL Turner about the transfer decision and who would be present at TQ to support him at the time he was told.1367
Seventh, the Commonwealth submits that the text messages from CPL Turner indicate he was aware that the Chain of Command considered the transfer to C Company would offer him “a break” because of its work schedule for 2017 and his transfer was one of a number of transfers occurring across the regime in 2017.1368
Eighth, the Commonwealth posits that most of CPL TJ’s evidence summarised above at [288]-[293] was wrong, noting that it is clear from the text messages and emails that CPL Turner knew of the transfer on 9 October 2016 and there were conversations between CPL Turner, MAJ AF, WO2 DP, and MAJ BJ about the transfer.
Ninth, the Commonwealth notes that there is a “real question whether CPL Turner was deeply affected by the transfer decision at the time that it was made…or whether it subsequently took on more significance as 2017 progressed.” The Commonwealth notes that the text messages and the discharge email demonstrate that after being told about his transfer, CPL Turner was upset and angry; however, the text messages also demonstrate that CPL Turner then calmed down and came to accept the transfer decision, even if he was still not happy about it. Being angry and resentful about the decision is, in the Commonwealth’s view, not clear evidence that the decision, as a standalone event, had an impact on CPL Turner’s mental health.1369
Lastly, the ADF accepts that the evidence indicates that once CPL Turner’s mental health deteriorated as a result of other matters, his perception of the transfer decision became one of the factors which contributed to the decline in his mental health.1370 Submissions of Mr and Mrs Turner
Mr and Mrs Turner contend that the Chain of Command should have had a reasonable understanding of what might happen from a mental health perspective if CPL Turner was moved from B Company, particularly in light of the length of time he had spent in B Company and the comments CPL Turner made in his response to the NTSC.1371 They are of the view that COL MF gave little, if any, consideration to the impact of 1367 Submissions of the Commonwealth dated 7 June 2024 at [710].
1368 Submissions of the Commonwealth dated 7 June 2024 at [721].
1369 Submissions of the Commonwealth dated 7 June 2024 at [729].
1370 Submissions of the Commonwealth dated 7 June 2024 at [730].
1371 Submissions of Mr and Mrs Turner dated 28 January 2024 at [133]-[134].
removal from B Company on CPL Turner’s mental health despite being aware that this would have had a detrimental impact on his mental health.1372
Mr and Mrs Turner are of the view that the impact of CPL Turner’s removal from B Company was “unsurprisingly significant” in that he felt betrayed, isolated, embarrassed, angry, and it affected his sense of self-worth and identity.1373
In response to the Commonwealth’s submission that there is no evidence that the transfer decision was made to punish CPL Turner (see above at [945]), Mr and Mrs Turner refer1374 to: MAJ AF’s email stating “I will protect and support this Coy with everything I have mate, and this Coy’s valuable resource is its people…Any forthright member of this Coy will have my support at all times, unless…you betray the Coy or Rgt”1375 (which they submit highlight that the Company comes first and people second); RSM WO1 EL, who was involved in the transfer decision, said “COL MF was obviously very distressed about the reputational damage that had been caused not only to B company but 2 Commando Regiment, Special Operations Command and the whole of Army”;1376 and MAJ AF’s opinion on the transfer decision was that “going to C was also the RSM’s way of saying ‘grow up. Grow a regimental experience’”.1377
Mr and Mrs Turner disagree with the Commonwealth’s submission that there is “evidence establishing that one of the reasons for the transfer was to give CPL Turner more time and space to focus on his personal life/personal stressors. Further, to the extent that mental health was not taken into account, this really reflects the state of knowledge that the relevant decision-makers had at the time they made the decision”.1378 Rather, they submit1379 that the claim that the Chain of Command did know of CPL Turner’s mental health challenges are undermined by MAJ AF’s evidence1380 and that if CPL Turner’s mental health was truly given serious consideration, a position in a non-combat role would have been considered (there is no evidence to suggest that any other option was considered other than the one that BRIG MF knew or should have known1381 would embarrass CPL Turner). They also consider that the Commonwealth’s submission on this point is contradicted by the 1372 Submissions of Mr and Mrs Turner dated 28 January 2024 at [136].
1373 Submissions of Mr and Mrs Turner dated 28 January 2024 at [138].
1374 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [55].
1375 Submissions of the Commonwealth dated 7 June 2024 at [413(d)].
1376 Tab 23 (ROI of WO1 EL) at 16.
1377 Tab 16 (ROI of MAJ AF) at 30.
1378 Submissions of the Commonwealth dated 7 June 2024 at [673(b)].
1379 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [55(d)].
1380 Tab 16 (ROI of MAJ AF) at 30.
further submission that “ADF agrees…CPL Turner viewed the transfer as a form of further punishment for the card incident”.1382 Submissions of CPL TJ
CPL TJ does not accept BRIG Langford’s evidence that the move from B Company to C Company was something that “occurred routinely” or was “common practice”.
CPL TJ posits that having regard to CPL Turner’s strong connection and commitment to B Company, CPL Turner was left feeling “humiliated” after his move to C Company and this should have been perfectly obvious to the Chain of Command. CPL TJ considers that the Chain of Command either were so uncaring as to CPL Turner’s welfare that they did not turn their minds to how CPL Turner might react to the move to C Company or did turn their mind to his reaction and accepted that notwithstanding that the move would more than likely have had a profoundly negative impact on CPL Turner, they chose to accept that risk and proceed anyway.1383
CPL TJ agrees with Counsel Assisting in that the decision to move CPL Turner to C Company was, at least in CPL Turner’s mind, “just a continuation of the punishments flowing from the ‘cock-carding incident’”.1384
CPL TJ submits that it was reasonable for CPL Turner to view the transfer as being directly connected to the outcome of the disciplinary proceedings, that the transfer to C Company was at the very least “imprudent” where there was a lack of any prior consultation about the decision and the decision to move him was made while he was on deployment, and that it was “manifestly careless” for the Chain of Command to make the decision to move him to C Company knowing the importance of B Company to CPL Turner1385 and the foreseeability of the risk to his mental health presented by such a move.
Submissions in reply of Counsel Assisting
1382 Submissions of the Commonwealth dated 7 June 2024 at [727].
1383 Submissions of CPL TJ dated 7 June 2024 at [20]-[28].
1384 Submissions of CPL TJ dated 7 June 2024 at [29].
1385 Submissions of CPL TJ dated 7 June 2024 at [30].
1386 Submissions in reply of Counsel Assisting dated 22 August 2024 at [106].
Counsel Assisting emphasises that it was CPL Turner’s mental health that was outweighed by operational considerations (as noted above at [280] and [769]). The high point of the evidence that CPL Turner’s mental health played any material role in the decision would seem to be a statement by COL MF that he considered the move would provide CPL Turner with “a bit more time to focus on his issues, including his medical issues”.1387 When this is considered against his explicit acceptance that he did not turn his mind to the potential adverse impacts of the transfer on CPL Turner’s mental health (in CPL Turner’s potential perception of it being further punishment)1388 and against the balance of the evidence summarised on this topic above, Counsel Assisting considers that the conclusion that “[a]t base, the decision was made with “capability” at the front of mind, not the interests of CPL Turner” is plainly open.1389 Consideration
In my view, it is beyond question that the move from B Company to C Company had a significant negative impact on CPL Turner. He experienced it as humiliating and as a punishment. I accept that it was a decision made primarily on the basis of the effective delivery of “capability”. In my view, the evidence establishes that the Chain of Command was primarily concerned about the potential of CPL Turner’s “influence” following his demotion.
I accept that there are also indications that the decision was made without regard for CPL Turner’s mental health. MAJ AF, for example, spoke of supporting company members unless they “betray the company.” He appeared angry at the reputational damage CPL Turner had brought to the company. He spoke of the transfer decision as the RSM’s way of saying “grow up. Grow a regimental experience.” I am unable to find that teaching CPL Turner a lesson did not influence his thinking.
Issue 7 – Lack of communication and/or cooperation between prescribing doctors Submissions Submissions of Counsel Assisting
1389 Submissions in reply of Counsel Assisting dated 22 August 2024 at [238].
1390 Submissions of Counsel Assisting dated 2 November 2023 at [521]-[524].
be most significant in relation to psychiatrists. For example, Dr Sringeri gave evidence that he did not receive clinical information from Holsworthy Health Centre or from the ADF in relation to CPL Turner, and that his identification of CPL Turner’s clinical presentation was based on his own clinical assessment.1391 He accepted that it would have assisted him in getting an accurate picture of CPL Turner’s presentation and history if he had been provided information by Holsworthy Health Centre or the
Dr Hale’s evidence was that the only direct contact he had with Dr Malik was while CPL Turner was an inpatient, and he did not recall discussing CPL Turner’s care with any external psychiatrist after he was discharged on 25 May 2017. Similarly, Dr Hale gave evidence that, with the benefit of hindsight, there would have been benefit in providing Dr Malik with information about CPL Turner’s presentation and symptoms to ensure that he had the fullest possible picture of CPL Turner in the period after 25 May 2017.1393
Dr Hale also gave evidence that it was not standard practice to have external specialists present (or ring in) at welfare boards, and that he did not think he had ever been to a welfare board where that had happened.1394
Counsel Assisting submits that I would comfortably find that difficulties arose in the treatment of CPL Turner’s mental health by reason of a lack of coordination between his various prescribing doctors.
Submissions of Dr Hale
Dr Hale submits that his level of care for CPL Turner is not only demonstrated by the contents of his thorough medical records, but also the “extensive and fulsome communication” by Dr Hale to others in 2CDO and to outside care providers.1395
Dr Hale submits that “there is no evidence of any lack of cooperation between the prescribing doctors” and/or that difficulties did not arise in the treatment of CPL Turner’s mental health “by reason of a lack of ‘coordination’ between the prescribing doctors.”1396 In support of this, Dr Hale refers to the evidence of Dr Nielssen that the absence of PBS records suggested that the medications were dispensed by ADF suppliers; all the prescriptions should have been visible to the ADF prescribing doctors;
1395 Submissions of Dr Hale dated 31 May 2024 at [7]-[8].
1396 Submissions of Dr Hale dated 31 May 2024 at [30]-[31], referring to Exhibit 4.
and while there was a risk of stockpiling his medication, Dr Nielssen did not consider there to be a lack of communication, cooperation, or coordination between prescribing doctors.1397 Submissions in reply
Counsel Assisting considers that to the extent there is a conceptual difference between cooperation and coordination, the latter is to be understood as an aspect of the former and, thus, the prescribing doctors could not have been cooperating if they were not coordinating.1398
To the extent that Dr Hale’s reference to Dr Nielssen’s evidence is used to support the presence of coordination and/or cooperation, Counsel Assisting notes that (a) this does not appear to be supported by the evidence of Dr Malik;1399 (b) if a non-ADF practitioner prescribed medication after a referral from the ADF, this would not appear on the ADF’s Defence eHealth System (DeHS);1400 (c) Dr Hale did not necessarily agree that all previous prescriptions from ADF practitioners were visible on the DeHS system;1401 and (d) Dr Malik gave evidence that he agreed it would be highly desirable for him to have had direct liaison with Dr Hale about medication.1402
In those circumstances, Counsel Assisting considers that the strength of the example used by Dr Hale to demonstrate cooperation and/or coordination is undermined.1403 Consideration
I am satisfied that the evidence reveals a lack of coordination and information exchange by doctors involved in CPL Turner’s care.
Issue 8 - The circumstances by which CPL Turner came to have significant supplies of medication available to him at the time of his death.
Submissions Submissions of Counsel Assisting
1398 Submissions in reply of Counsel Assisting dated 22 August 2024 at [135].
1400 Tab 117 at [6].
1403 Submissions in reply of Counsel Assisting dated 22 August 2024 at [135].
1404 Submissions of Counsel Assisting dated 2 November 2023 at [525]-[537].
TJ provided to the IGADF a photo she had taken of prescription medication after CPL Turner’s second overdose.1405 The police investigation of CPL Turner’s apartment after his death similarly demonstrates significant quantities of prescription medication were available to him at the time of his death.1406
Hannah Steele gave evidence that she had raised a concern about the supply of medication that CPL Turner had available to him to Mr Cardinaels and Kristy Watson (who was CPL Turner’s DVA advocate) but that nothing was done about it. CPL Turner was told that she had spoken to the ADF about the medication, and this “basically just crumbled his trust with me” and he was not honest about what was going on after that.1407 Mr Cardinaels did not recall having a conversation about this to Hannah Steele, or with CPL Turner about what Hannah Steele had said.1408
There was also evidence that the availability of prescription medication to CPL Turner was an issue of concern identified by both the medical practitioners involved in his care and the Chain of Command, and that steps were taken to ameliorate the risk of him accumulating large amounts.1409
Counsel Assisting submits that the evidence in the Inquest fell in such a way that it is not necessary to delve into the detail of the supplies of medication available to CPL Turner during 2017. Although he may have had access to more medication than he actually needed, the evidence suggests that this was not a matter which contributed in any material way to CPL Turner’s death. Notwithstanding the fact that CPL Turner’s suicide was caused by his overdose on prescription (and other) medication, the significant supplies of medication he had available to him could have just as easily been accumulated by his failure to take his prescribed medication over time. It is submitted that the superficial attraction of linking the possible over-supply of medication as a direct cause of CPL Turner’s death should be resisted.
Counsel Assisting considers that the evidence in the Inquest suggests that: (a) if CPL Turner did not have access to prescription medication at the time of his death, he would have easily had access to other medication by which he could suicide; (b) there would have been risks to CPL Turner’s health in attempting to limit his access to prescription medication during 2017, and particularly around July 2017 in that it might have destroyed his trust in Dr Malik, caused him to disengage from treatment, or put him in 1405 Tab 27 (IGADF ROI with CPL TJ on 14 August 2018) at 38-39.
1406 Tab 5 (Statement of Senior Constable Tim Giblett) at 2-3.
1409 See, e.g., Exhibit 4 (Email communications produced by Dr Hale) at 97.
danger of not having access to medication he needed; and (c) even if CPL Turner’s access to medication had been limited in some way, he could have relatively easily stockpiled that limited supply of medication without detection, achieving the same result of ultimately having a large supply available to him. These conclusions arise predominantly from the evidence of Dr Malik.
Dr Malik’s evidence was that he did not impose limitations on CPL Turner’s access to medication around June/July 2017, because he was getting better and he “didn’t have any concern”. Dr Malik also noted that even if he gave CPL Turner a weekly supply, he could stockpile every week’s supply. He considered this would have irritated CPL Turner and would not have “prevented anything” and he could have very easily “stockpiled daily supply, weekly supply”.1410
Dr Malik gave evidence that the “commonest cause of overdose is Panadol”, and if CPL Turner had wanted to, he could have got “40 tablets from Woolworths, that’s enough”. In his view, the more one tried to “control” CPL Turner’s behaviour in relation to prescription medication, it was “not useful because there’s many other ways he could have hurt himself”. He explained:1411 “If his plan was overdosing, he could have gone to any pharmacy and bought enough Panadol; more than 12 grams is almost fatal, less than 40 tablets. In Woolworths or Chemist Warehouse you can get 100 tablets; so you know, that's the risk, but it's not just the medication I give him; there are other means he could have done it. So the more you push on that side with him, the more you would have pushed him away.
That's what my assessment was. As you can see, obviously, I did a risk assessment, and if he's denying any - there's no reason for me to mistrust him and put him on a schedule, and all of that.”
Dr Malik was unshaken in his conviction, broadly speaking, that it was important for him to treat CPL Turner in relation to the symptoms with which he was presenting, that it was important not to undermine CPL Turner’s trust in him by limiting access to medications and that, ultimately, limiting CPL Turner’s access to medications would not have “worked” in the sense of preventing the risk of suicide because he could have either stockpiled daily, or weekly supplies, or he could have simply used Panadol, other chemicals or other methods to suicide.1412
Dr Malik’s evidence in this regard went broadly unchallenged. Dr Nielssen’s evidence was that dispensing medications daily or with a maximum of three days’ supply did not guarantee that medication would be taken as prescribed, nor prevented CPL Turner
1412 See generally 20/10/20 T134.
from stockpiling medication.1413 Dr Hopwood’s evidence was to the effect that it was clear that all prescribers were acting in a reasonable fashion to assist CPL Turner and that the risk of stockpiling was difficult to avoid.1414 Dr Dinnen’s evidence was that “not to prescribe medication” would have been “more negligent” and that if a person is determined to suicide, they will “find the means one way or another”.1415
Submissions of the Commonwealth
The Commonwealth submits that there was a significant question as to how CPL Turner came to have significant supplies of medication available to him at the time of his death. However, it is submitted that the ADF made extensive efforts to ensure only small amounts were dispensed to CPL Turner (accepting it could not control dispensers outside its own medical system). The Commonwealth agrees with Counsel Assisting’s submissions that I would not be in a position to make any findings about this topic.1416 Submissions of Mr and Mrs Turner
Mr and Mrs Turner submit that the evidence shows that CPL Turner used prescription medication to overdose and did not doctor shop.1417 Their view is that despite Dr Hale’s assessment that only 20% of the medication CPL Turner used to overdose was from legitimate sources and the rest was sourced via other means, all the medication used to overdose was medication prescribed by Dr Hale and Dr Sringeri.1418
Mr and Mrs Turner support the recommendation in the ADF After-Action Report to “amend defence policy to ensure that ADF members being managed with restricted access to prescription medication” and to “have this clearly articulated to all health 1413 Report of Dr Nielssen dated 12 August 2020 (Tab 108) at 12-13.
1414 Report of Dr Hopwood dated 12 October 2020 (Tab 110) at 9.
1415 Report of Dr Dinnen dated 17 September 2020 (Tab 110A) at 10.
1416 Submissions of the Commonwealth dated 7 June 2024 at [669]-[670].
1417 Submissions of Mr and Mrs Turner dated 28 January 2024 at [142], [146]; Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [52(a)-(b)].
1418 Submissions of Mr and Mrs Turner dated 28 January 2024 at [147].
providers including the requirement that no external prescriptions are to be provided to the member”.1419 Submissions of Dr Hale
Dr Hale submits that he was at pains to strike a balance between limiting CPL Turner’s opportunity to hoard medication and ensuring that he had sufficient medication to alleviate his physical and mental suffering.1420 He notes that the risk assessment regarding CPL Turner’s medication is best exemplified in his decision to limit the medication CPL Turner could access, namely a three day supply and a four day supply per week.1421
Dr Hale objects to any suggestion that he was dispensing too much medication, noting the referrals to CPL Turner’s psychologist and psychiatrist and that he was not questioned about whether he was dispensing too much medication and/or ought to have referred CPL Turner to Dr Wallace sooner.1422 Submissions in reply
Counsel Assisting considers that there would be insufficient evidence to make a finding that CPL Turner “doctor shopped” in order to stockpile medication1423 and that findings ought not be made in relation to the impact of supplies of prescription medication available to CPL Turner at the time of his death.1424 Consideration
There is no evidence of “doctor shopping” or that any doctor involved in CPL Turner’s care prescribed recklessly. I accept the submission that CPL Turner could at any time have obtained over the counter medication which he could have used to kill himself.
Indeed, he could have got a private prescription from a local doctor which would not have been visible on PBS records or known to his treating doctors.
1419 Submissions of Mr and Mrs Turner dated 28 January 2024 at [140].
1420 Submissions of Dr Hale dated 31 May 2024 at [34]-[36].
1421 Submissions of Dr Hale dated 31 May 2024 at [35].
1422 Submissions of Dr Hale dated 31 May 2024 at [40].
1423 Submissions in reply of Counsel Assisting dated 22 August 2024 at [86].
1424 Submissions in reply of Counsel Assisting dated 22 August 2024 at [136].
Issue 9 – The removal of items from CPL Turner’s premises after his death (sanitisation) Evidence
The issue of “sanitisation” originally arose by reason of a concern on the part of CPL Turner’s family that either a USB or a laptop, or both, were removed from CPL Turner’s apartment after his death. CPL TJ’s evidence was that he did have a laptop and hard drive at home.1425 Steven Turner gave a statement in which he stated that CPL Turner had a laptop which had videos, including video of footage taken from a helmet camera.1426 CPL Turner also sent text messages demonstrating he had a computer as late as 7 June 2017.1427 The whereabouts of his laptop and any hard drive/thumb drive are presently unknown.
A PowerPoint which it appears was presented at the AAR conducted on 21 August 2017 was in evidence in the Inquest and contained the following statement:1428 “Sanitisation of the site will be required post CIVPOL investigation requirements before family enter the scene
Are we traumatising our people?
Should we establish a national protocol with Police?”
The evidence in the Inquest suggested that the term “sanitisation” had a number of different meanings in usage in the ADF. It could mean, in operational circumstances, the cleaning of an area to ensure intelligence is not left behind, and it could also mean in the context of a suicide, the removal of “suicide paraphernalia” so as to minimise harm that a family might experience on returning to the scene of the member’s suicide.1429 BRIG MF’s evidence was that the use of “sanitisation” in the PowerPoint had the meaning of tidying/cleaning of a scene of a suicide of an ADF member by the ADF after police had released the scene.1430
Evidence was given from Person 1 in relation to this matter. His evidence was ultimately that he had a recollection of “sanitisation” being mentioned on one occasion in a meeting at 3:30pm on the day of CPL Turner’s death, that he recalled someone talking about “operational security” and a “thumb drive”,1431 but that he had no recollection of anything that suggested there had been sanitisation of CPL Turner’s
1426 Exhibit 49 (Statement of Steven Turner dated 11 August 2022) at [20].
1427 Exhibit 57 (WhatsApp and SMS Messages) at 3095.
1428 Exhibit 31 (Tranche 1) at 172. See also Exhibit 65 (Supplementary Statement of BRIG MF dated 22 December 2022) at [25].
1429 Exhibit 65 (Supplementary Statement of BRIG MF dated 22 December 2022) at [12]. See also 09/09/22 T50.47-50 (Cardinaels).
1430 Exhibit 65 (Supplementary Statement of BRIG MF dated 22 December 2022) at [26].
apartment.1432 His evidence in relation to the use of the term “sanitisation” in the AAR PowerPoint was that he was using the term “sanitisation” in a broader sense – to remove potentially sensitive items from a location.1433
Person 1 recalled that he had sent an email to BRIG GD raising his concerns about “sanitisation”. The email which was ultimately produced by the ADF did not refer to sanitisation.1434 It referred, rather, to a “series of issues and incidents since arrival at 2 Cdo Regt” and described the “basic issue is what I perceive to be ongoing and sustained marginalisation, unacceptable behaviour, harassment, bullying and intimidation”.1435
Person 1 also gave evidence he had raised concerns about sanitisation with LTCOL EB.1436 LTCOL EB’s evidence was that she had not had a conversation to that effect with Person 1.1437
BRIG GD gave oral evidence in the Inquest. BRIG GD was the Commander of SOCMD as at April 2018. He referred to an email which he sent to Person 1 following a meeting in person at Holsworthy in which he described the issues discussed at that meeting.
His oral evidence was that he was confident the email described the “crux of the conversation” although it was ultimately unclear from his oral evidence whether he had an independent recollection of the meeting or not.1438 The email which was sent referred to “some issues in relation to the cultural [sic] of 2 CDO, particularly regarding the treatment of support staff compared to CDO qualified folk, and that the HPW, and SGT Cardinaels in particular, has been one of the main areas of concern that has led you to feel like you and other staff filling supporting roles are being isolated from the unit”. It recorded that Person 1 did not want any specific instances of unacceptable behaviour investigated further. It also recorded that “considerable work” had been done on the issue about “HPW being an entity unto itself” and that LTCOL NB had invested “quite a lot of time in addressing how that entity is managed across the Command”.1439
1434 Exhibit 61 (Documents produced by ADF on 3 November 2022).
1435 Exhibit 61 (Documents produced by the ADF on 3 November 2022) at 33.
1439 Exhibit 61 (Documents produced by the ADF on 3 November 2022) at 32.
the ADF seeking to ensure that security classified items were properly dealt with in the aftermath of the death of a special forces member.1440
Mr Cardinaels’ evidence was that he did not see a laptop or USB stick at CPL Turner’s apartment after his death. Mr Cardinaels rejected the proposition that he took steps to sanitise CPL Turner’s apartment in the sense of seeking to find and remove anything that he saw that might contain confidential or security-classified information.1441
COL MF was also asked about the issue of sanitisation. His only association with that term in the context of CPL Turner’s death was in cleaning up the apartment after it was handed back by the NSW Police Force and he had never heard a suggestion that a thumb drive had been removed from CPL Turner’s house.1442
A number of members of the ADF gave evidence broadly to the effect that they would not be concerned that CPL Turner would have had security classified or sensitive information on his computer or at home, simply because members were not permitted to take classified material home. For example, COL MF’s evidence was that it is not expected that members are taking classified information home, and that “one of the key things of the job is maintaining, you know, operational security”.1443 LTCOL EB was asked, for example, whether in the era of mobile phones there would be a practice to find out what sensitive information a deceased member of the ADF might have in their home.1444 Her evidence was that “any imagery we would capture on a personal device, it requires clearance by our security officer before it can, in fact, be retained.
Even if it’s just a photograph”.1445 Submissions Submissions of Counsel Assisting
1446 Submissions of Counsel Assisting dated 2 November 2023 at [549]-[551].
in his oral evidence that there were concerns around written information in CPL Turner’s diary.1447 Similarly, the Commonwealth made claims for public interest immunity over material contained in CPL Turner’s personal phone, and although images in that phone were redacted, it is readily apparent from the time at which those images were taken that a number of images were taken by CPL Turner whilst he was deployed in Iraq. It is a matter of reality in this proceeding, and obvious logic, that a member of the ADF may have material in their personal possession which might contain matters which are security classified or sensitive. It is difficult to comprehend why this risk was not one which any member of the ADF was willing to accept the obvious existence of.
As regards the issue of sanitisation of CPL Turner’s apartment, it is submitted that there is insufficient information before the Inquest to form a positive conclusion that any member of the ADF removed CPL Turner’s property from his apartment after his death. It is submitted that, in those circumstances, no finding in respect of this matter should be made.
Counsel Assisting submits that, nevertheless, it is of significant concern that the Inquest has been unable to determine the present whereabouts of CPL Turner’s laptop computer, in circumstances where the evidence demonstrates that he had such a device and members of the NSW Police Force and the ADF were present in his apartment after his death. It is submitted that this issue goes to the proper exercise of my function in investigating this death under the Coroners Act.
Submissions of Mr and Mrs Turner
Mr and Mrs Turner allege that a personal computer, USB hard drive(s), thumb drives, and a black book were “removed” following CPL Turner’s death.1448 While they are sceptical about whether Defence were involved in the removal of the missing items, they accept that it is beyond the scope of this Inquest to reach any concluded view on this aspect.1449
Mr Turner is adamant that he did not collect the black book from police and, rather, a person claiming to be him attended police to collect the book on 27 July 2017. He submits that evidence of him being in Tasmania on the date supports that conclusion.1450
1448 Submissions of Mr and Mrs Turner dated 28 January 2024 at [148].
1449 Submissions of Mr and Mrs Turner dated 28 January 2024 at [155].
1450 Submissions of Mr and Mrs Turner dated 28 January 2024 at [153].
Submissions of the Commonwealth
The Commonwealth advances various submissions on this Issue. First, in relation to Counsel Assisting’s submission about the purported lack of concern within the ADF that members might have classified material at home, the Commonwealth notes that diary notes are “distinctly different” to the removal of documents and electronic material and that handwritten notes are “difficult for the ADF to control” and that it “must be recalled that CPL Turner was very mentally unwell and his actions cannot be said to reflect the norm of what might be expected of a member who is acting rationally”. 1451
Second, the Commonwealth submits that it is not possible to base any submission on risk on the redacted photos as they are not in evidence and that merely because a photo was taken in Iraq does not mean it is security classified information.1452 Moreover, it is submitted that a concern that classified information may have been held on CPL Turner’s devices would not necessarily arise as one is entitled to assume ADF members are law abiding.1453
Third, it is submitted that in circumstances where there is no evidence and where the only witness who was asked about the laptop was Mr Cardinaels, it would be procedurally unfair to make a finding or comment consistent with [1008] above.1454
Fourth, the Commonwealth contends that there is “no evidence” CPL Turner was still in possession of his laptop, hard drive, or a USB just prior to his death.1455 The Commonwealth agrees with Counsel Assisting that no findings or comments should be made on this issue.1456 Submissions in reply of Counsel Assisting
Counsel Assisting considers that Mr Turner’s theory concerning the removal of the “black book” is without an evidentiary basis and ought to be disregarded.1457
Counsel Assisting submits that there is insufficient information to make a positive conclusion that any member of the ADF removed CPL Turner’s apartment after his death.1458 1451 Submissions of the Commonwealth dated 7 June 2024 at [778].
1452 Submissions of the Commonwealth dated 7 June 2024 at [779].
1453 Submissions of the Commonwealth dated 7 June 2024 at [780]-[783].
1454 Submissions of the Commonwealth dated 7 June 2024 [795].
1455 Submissions of the Commonwealth dated 7 June 2024 at [786]-[794].
1456 Submissions of the Commonwealth dated 7 June 2024 at [784].
1457 Submissions in reply of Counsel Assisting dated 22 August 2024 at [87].
1458 Submissions in reply of Counsel Assisting dated 22 August 2024 at [89].
In addition, it is not apparent why the mere fact of keeping a diary is connected to his mental illness or why there might be a reduced risk that a diary would contain classified material for someone who was not mentally unwell.1459
On the second point, Counsel Assisting notes1460 that while certain photos in evidence were redacted, their context (that is, beyond the mere fact they were taken in Iraq) does highlight the risk emphasised above at [1006]. For example, text messages accompanying photos sent by CPL Turner to another ADF member on 10 November 2016 indicate he was identifying a particular member of the Iraqi Hostage Recovery Team that CPL Turner was training at that time.1461 It is submitted that even if the subject matter were not sensitive, clearly the ability to take such photos underscores the risk referred to in Counsel Assisting’s original submission.
In relation to the third submission, Counsel Assisting considers1462 that the objection seems to be on the basis of the use of the language “where … the evidence demonstrates that he had such a device and members of the NSW Police Force and the ADF were present in his apartment after his death”. While the concern of the Commonwealth appears to be that the comment is intended to some way cast any aspersion on members of the ADF or the NSW Police Force, Counsel Assisting notes that it does not. The point of noting the circumstances is that notwithstanding that this scene of death was relatively well secured (as compared, for example, to inquests involving deaths where bodies are not recovered for weeks or months), some of CPL Turner’s personal items have been unable to be located. That is why it is of “concern”, as compared to a situation where it might be readily explicable that items would go missing with the passage of time at an unattended scene of death.
As for the fourth point, Counsel Assisting contends1463 that it is open to find, on the basis of the evidence as to CPL Turner’s possession of such items (and an absence of evidence as to their disposal), that he remained in possession of them at the time of his death.
1459 Submissions in reply of Counsel Assisting dated 22 August 2024 at [239].
1460 Submissions in reply of Counsel Assisting dated 22 August 2024 at [240].
1461 Exhibit 57 at 51-52.
1462 Submissions in reply of Counsel Assisting dated 22 August 2024 at [241].
1463 Submissions in reply of Counsel Assisting dated 22 August 2024 at [242].
Consideration
I find the evidence given by ADF witnesses about the possibility that CPL Turner may have had sensitive information in his home very troubling. It did not appear to me to be altogether frank. As Counsel Assisting carefully set out, large portions of CPL Turner’s diary and material (including images) on his mobile telephone were the subject of public interest immunity claims. The suggestion that there would have been no concern because members were “not allowed” to have security classified information at home is entirely implausible.
CPL Turner’s death occurred at a time when the existence of combat head-cam footage was already well known in the public arena. Steven Turner’s statement also referred to it,1464 as did Mr Cardinaels in his evidence.1465 I would be surprised if CPL Turner’s superiors, knowing his combat history, would not have given consideration to the possibility that CPL Turner held information or at least images which could attract a security rating. My concerns were exacerbated by the misleading way MAJ AF dealt with other issues, such as the body recovery issue, which he believed (or had been advised) should not be revealed in court.
The issue of whether “sanitisation” (meaning the removal of restricted information or images) was ever discussed at a formal meeting was explored. Ultimately, while I am of the view that Person 1 was trying to honestly assist the Inquest, his recollection could not be relied upon to make firm findings on this Issue.
I remained very troubled by the fact that CPL Turner’s laptop could not be found. In my view, there is strong evidence that he had one at the relevant time. While I accept its apparent disappearance may go beyond the proper exercise of my coronial function, I remain disturbed by the complete lack of a plausible explanation of its whereabouts given the scene was supposedly controlled by NSW Police and then the ADF from an early time.
1464 Exhibit 49.
Issue 10 – Allegations made in late June 2017 reported to ADF and NSWPF Submissions Submissions of Counsel Assisting
Counsel Assisting submits1466 that on or around 22 May 2017, an allegation was reported to the ADF that an “unknown former member” of the ADF had used his Defence issued mobile telephone to procure prohibited substances (anabolic steroids) from an interpreter, including trenbolone acetate, clenbuterol and oxandrolone.1467 A document dated 26 May 2017 reports that the individual “most likely associated” with the handset was CPL Turner. It was noted that CPL Turner had “ongoing issues since his deployment”, which led to him attempting suicide. The writer sought the “support” of the person he/she was writing to (which appears to be the CO of Task Group 632) that “the ADFIS investigation and any follow up is treated with due sensitivity given the circumstances”.1468
It does not appear from the evidence in the Inquest that CPL Turner was made aware of this allegation prior to his death.1469 It therefore does not appear to have had an impact on the manner and cause of his death. Counsel Assisting submits that no finding should be made in relation to this issue.
Submissions of the Commonwealth
Issue 11 – Whether any other factors arising during CPL Turner’s service contributed to his death
(a) The ADF’s reliance on CPL TJ Submissions of Counsel Assisting
1467 Tab 42 (Conduct & Disciplinary records) at 63, 75.
1468 Tab 42 (Conduct & Disciplinary Records) at 60-63.
1469 See Exhibit 63 (Letter from AGS to CSO dated 15 December 2022).
1470 Submissions of the Commonwealth dated 7 June 2024 at [798].
1471 Submissions of Counsel Assisting dated 2 November 2023 at [554]-[555].
25 years old in 2017, had never been in a situation of the volatility she experienced with CPL Turner, and had no training in what was going on.1472 Counsel Assisting considers that it was evident from the messages between CPL TJ and CPL Turner which ultimately came to be in evidence that she also suffered significantly throughout the period she was involved with CPL Turner by reason of his poor mental health. It was also apparent from those messages that CPL TJ provided a significant level of support to CPL Turner throughout his severe decline in mental health, and her support likely had the effect of prolonging CPL Turner’s life. Counsel Assisting submits that it should be recognised that she was a victim of the circumstances that engulfed her partner and will have to live with the trauma of those events for the rest of her life.
Submissions of CPL TJ
In addition to agreeing with Counsel Assisting’s submissions regarding her relationship with CPL Turner during and following the deployments, CPL TJ submits that the support she provided to CPL Turner extended to the periods of their return from deployment, which came at significant personal cost to her.1473 Submissions of the Commonwealth
The Commonwealth submits that no finding in line with Counsel Assisting’s submission above at [1029] is available.1474 The Commonwealth refers to the ADF’s lack of knowledge as to the extent of the abusive behaviour from CPL Turner towards CPL TJ, that the ADF became more interventionist over time, and that CPL TJ was receiving support from an ADF psychologist during this time and was “in regular contact” with Padre MP.1475 Submissions in reply of Counsel Assisting
Counsel Assisting notes1476 that the submission that the ADF was giving CPL TJ adequate support and ensuring appropriate intervention in the circumstances is difficult to reconcile with the evidence that CPL TJ raised concerns in February 2017 about CPL Turner’s mental health (to which she received no response from the CO and RSM),1477 and that even after CPL Turner’s first suicide attempt in March 2017 “both the CO and RSM” contacted CPL TJ “regularly after that to find out what was going on
1473 Submissions of CPL TJ dated 7 June 2024 at [50]-[52].
1474 Submissions of the Commonwealth dated 7 June 2024 at [820].
1475 Submissions of the Commonwealth dated 7 June 2024 at [821]-[828].
1476 Submissions in reply of Counsel Assisting dated 22 August 2024 at [244].
1477 Submissions of Counsel Assisting dated 2 November 2023 at [250].
with [CPL Turner].”1478 Further, it is submitted that the ADF’s reliance on CPL TJ having seen an ADF psychologist does little to counter the clear evidence from CPL TJ herself that “I’ve never been so close to someone who was so sick and I hadn’t had any training in what was going on”.1479 Importantly, in response to the question as to whether “anybody” had offered her support given that she was “so close to another member who had indicated to you he had suicidal feelings”, CPL TJ’s answer was unequivocally “not until after”.1480 Consideration
I have no hesitation in accepting Counsel Assisting’s submissions on this issue. It is apparent that the ADF relied on CPL TJ to provide support to CPL Turner. I accept the evidence that she was frequently contacted about “what was going on” after CPL Turner’s first suicide attempt in March 2017. I accept CPL TJ as a witness of truth and believe her account that she was not offered support “until after” CPL Turner’s death.
She was 25 years of age and facing problems of her own. In my view, she was treated poorly. While I accept that the ADF did not know the internal details of her relationship with CPL Turner, given what they knew of his mental state, supports should have been put in place.
(b) The ADF’s treatment of Joanna Turner Submissions of Counsel Assisting
1478 12/08/2021 T30.4-9. See also Exhibit 10 at [4(d)].
Consideration
Joanna Turner was treated poorly by the ADF when she tried to raise concerns about her husband’s mental health at an early stage. She was vilified, disrespected, and at times ignored. While she hid some of the traumatic events which occurred in her home to protect her husband, she was nevertheless characterised as a vengeful woman. In my view, nothing could be further from the truth.
At some point, she realised that to protect her children she must leave her marriage, but it is very clear to me that she had also felt great love for CPL Turner, despite the changes in his behaviour she witnessed as his PTSD and substance issues took hold.
Final Issue: The production of documents by the ADF Submissions of Counsel Assisting
Counsel Assisting notes that the production of documents by the ADF in this matter was an issue of considerable concern. During the first two tranches of the Inquest, a document of critical importance being the letter from Dr Sringeri to MAJ AM dated 13 July 2016 clearing CPL Turner to attend all duties, was not able to be located.
On 12 November 2021, the AGS wrote to the Solicitor Assisting and indicated that following questioning during the August 2021 hearings and in the context of work being undertaken in response to the Royal Commission into Defence and Veteran Suicide (the Royal Commission), the Department of Defence was “continuing to review its records to determine whether it holds any additional, relevant material that may assist the Coroner”.1481
The letter from Dr Sringeri to MAJ AM was subsequently located (seemingly as a result of that further review) and provided to the solicitor assisting on 3 December 2021. At that time, the ADF indicated that it was still searching and reviewing various repositories and its best estimate was that this search and review process would not be completed until March 2022. The ADF was asked to, and did, provide an explanation of why this material was not produced in response to a subpoena issued on 30 October 2019. It explained that when searching for relevant material, the Department of Defence interpreted the subpoena as requiring production of records relating to CPL Turner held on “Objective”, Defence’s official document management 1481 Exhibit 23 (Letter from AGS to the CSO dated 12 November 2021).
system and other systems such as the Defence eHealth system.1482 Emails are not automatically saved on Objective and if a person had not manually saved an email (noting that only a small number of relevant emails were apparently saved on Objective when the first subpoena was answered in 2019)), then it would not have been produced.1483
It would plainly enough be beyond the knowledge of those framing the subpoena to be able to specify specific internal ADF systems. No objection was taken to the scope of the subpoena at the time and no clarification sought as to the nature of the material required to be produced. When production was made, no comment was included about assumptions made by the ADF about the scope of the call being limited in any way.
For the sake of clarification, a further subpoena was served on the ADF on 15 December 2021 with an extended return date of 1 April 2022. This return date was set after consultation with the AGS about a realistic timeframe for the production of the material. The material that was subsequently produced was provided in a number of tranches, the first of which was not delivered to the Court until nearly three weeks after the return date of 1 April 2022. A further 12 tranches were received (13 in total) with the last one being made available on 9 December 2022: more than eight months after the return date of the new subpoena and over three years after the issue of the initial subpoena. In total, a further 1834 pages of material was produced, all of which arguably fell within the scope of the original subpoena.
During the course of questioning of Person 1 on 1 September 2022, further documents which were relevant to the issues in the Inquest were put to Person 1 by Senior Counsel for the ADF. These documents had not previously been produced in response to the two subpoenas issued to the ADF but were later provided in a further tranche of documents produced by the ADF.1484 Counsel Assisting notes that this is a matter of significant concern in respect of the compliance by the ADF with the subpoenas served on it.
Given the ongoing disclosure by those representing the ADF that further relevant material might be available, it is submitted that I cannot be confident that all the 1482 Exhibit 29 (Statement of COL Melanie Cochbain dated 10 December 2021) 4-5.
1483 Exhibit 29 (Statement of COL Melanie Cochbain dated 10 December 2021) at 5-6.
material falling within the scope of the two subpoenas has been produced and put into evidence.
Consideration
The convoluted process gave me no confidence that all relevant documents were eventually produced. From my perspective, the process was made unnecessarily difficult and took an inordinate amount of time. At the conclusion of proceedings, it appeared to me that either the ADF’s capacity to manage its own documents was severely compromised or there was a concerning lack of appetite on behalf of those in charge of searching for documents to take this Court’s requests seriously. Neither option is attractive.
Section 82 of the Coroners Act confers on a coroner the power to make recommendations that he or she may consider necessary or desirable in relation to any matter connected with the death with which the inquest is concerned.
Counsel Assisting proposes 18 recommendations addressed to the Chief of the Defence Force for consideration to be given to various matters. Mr and Mrs Turner, Joanna Turner, CPL TJ, CAPT MH, and GPCAPT Ross have also proposed a number of recommendations. Recommendations proposed by Counsel Assisting and the interested parties are set out below, together with a consideration of them.
Counsel Assisting’s proposed recommendations Proposed recommendation (a)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to introducing a systematic process for mapping the history of an ADF member’s deployments, their RtAPS and POPS screens data, and other reported psychiatric diagnoses and treatment, that forms part of the member’s health record and including systems to record and action such notifications and to ensure that they are taken into account in decisions relating to deployment.1485 Submissions
The ADF supports this recommendation on the basis that any consideration of this issue would need to take account of legal, ethical, and policy restrictions concerning patient privacy/confidentiality and the sharing of ADF members’ health information.1486
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to this recommendation and, accordingly, Counsel Assisting maintains this recommendation in its current form.1493 Consideration
I note the recommendation arises directly out of the evidence before me and I make the recommendation in its suggested form.
1485 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
1486 Submissions of the Commonwealth dated 7 June 2024 at p.1.
1487 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1488 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1489 Submissions of Dr Hale dated 31 May 2024 at [38].
1490 Submissions of GPCAPT Ross dated 5 June 2024 1491 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1492 Submissions of CPL TJ dated 7 June 2024 at [53].
1493 Submissions in reply of Counsel Assisting dated 22 August 2024.
Proposed recommendation (b)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to the inclusion of a mandatory annual training for all Special Forces members in recognising the symptoms of and managing PTSD.1494 Submissions
Mr and Mrs Turner accept this recommendation but propose a modification for mandatory annual training to also focus on destigmatising the symptoms of PTSD.1495
The ADF supports a recommendation to this effect, including the Turner family’s suggestion that the recommendation be modified to read “including a mandatory annual training for all Special Forces members in recognising and destigmatising the symptoms of and managing PTSD”. The ADF agrees that the evidence in this Inquest establishes a need to give consideration to its PTSD/mental health training programs.1496
The Commonwealth refers to its submissions regarding mental health training and the reduction of stigma, where it has identified some particular issues (arising from the evidence) that could be addressed in revised training programs, including the speed and efficacy of PTSD treatment; the capacity of people with mental health issues to conceal signs/symptoms and continue performing well in the workplace; and the complex interrelationship(s) between PTSD, abuse of alcohol/drugs, and domestic violence.1497
1495 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1496 Submissions of the Commonwealth dated 7 June 2024 1.
1497Submissions of the Commonwealth dated 7 June 2024 at [84]-[89].
1498 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1499 Submissions of Dr Hale dated 31 May 2024 at [38].
1500 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1501 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1502 Submissions of CPL TJ dated 7 June 2024 at [53].
In submissions in reply, the ADF states that it would not oppose an amendment to the recommendation by adding “which appropriately includes simulations of real-life scenarios and recommendations about methods of decision making” to the end of the recommendation.1503
In submissions in reply, Counsel Assisting notes that the amendments to the recommendation proposed by Mr and Mrs Turner and the ADF are supported and the recommendation is otherwise maintained.1504 Consideration
There is a strong evidentiary basis for the recommendation. In my view, it is important to additionally refer specifically to training which focusses on destigmatising the symptoms of PTSD and I make the recommendation in its amended form.
Proposed recommendation (c)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to establishing a system by which psychological distress in the home environment can be communicated to an ADF member’s unit by family members, including systems to record and action such notifications and to ensure that they are taken into account in decisions relating to deployment.1505 Submissions
The ADF does not oppose a recommendation to this effect but notes that there are already various methods in place which allow a family member to obtain support for psychological distress in the home environment. These methods include: the 24/7 Defence Member and Family Support (DMFS) Helpline, which includes advice and support in instances of family and domestic violence; 24/7 Military Police contacts; the Sexual Misconduct Prevention and Response Office (SEMPRO); All hours support; 1800 IMSICK; and 24/7 chaplaincy support. However, while DMFS can request welfare checks in response to a notification of distress and then report to the Chain of Command about the outcome of a welfare check, the ADF accepts that these methods are not primarily directed towards the communication of psychological distress in the home environment to the Chain of Command for the purposes of informing decisions by the Chain of Command about deployment. While the issues surrounding the establishment of such a communication system are likely to be very complex, it is noted 1503 Submissions in reply of the Commonwealth dated 22 July 2024 at 2.
1504 Submissions in reply of Counsel Assisting dated 22 August 2024 at [42],[143].
1505 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
that the ADF does not oppose a recommendation to the effect that these issues be considered.1506
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to the recommendation and, accordingly, it is maintained.1513 Consideration
I note that there is no objection to the proposed recommendation which, in my view, arises directly from the evidence. I make the recommendation.
Proposed recommendation (d)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to providing opportunities for ADF families to be notified of and involved in treatment programs provided to ADF members for PTSD and other combat-related psychological conditions.1514 Submissions
The ADF supports a recommendation to this effect. While the ADF’s health services have an occupational focus, the ADF acknowledges that involving family in treatment programs is an important part of member-centric healthcare and rehabilitation. The ADF has existing policies about engaging families in members’ health services. It also has resources to support family involvement, including guidance about family engagement in health services for members and health personnel and a family 1506 Submissions of the Commonwealth dated 7 June 2024 at 13.
1507 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1508 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1509 Submissions of Dr Hale dated 31 May 2024 at [38].
1510 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1511 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1512 Submissions of CPL TJ dated 7 June 2024 at [53].
1513 Counsel Assisting submissions in reply dated 22 August 2024 at Annexure A.
1514 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
engagement in health care course for health personnel. The ADF notes that any consideration of this issue would need to take account of legal, ethical, and policy restrictions concerning patient privacy/confidentiality and the sharing of ADF members’ health information. Furthermore, member consent is required for disclosure of health information to family and cannot be implied. Consent is not enduring and should be obtained for each engagement with family.1515
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to this recommendation and, accordingly, it is maintained in its present form.1522 Consideration
I note that no objection was taken to the recommendation. I make the recommendation which arises directly from the evidence before me.
Proposed recommendation (e)
1516 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1517 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1518 Submissions of Dr Hale dated 31 May 2024 at [38].
1519 Submissions of GPCAPT Ross dated 5 June 2024 at [126].
1520 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1521 Submissions of CPL TJ dated 7 June 2024 at [53].
1522 Counsel Assisting submissions in reply dated 22 August 2024 at [79].
1523 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
Submissions
Mr and Mrs Turner support this recommendation and propose a modification to include after “study plans” the words “or transitional plans to non-combat roles within the ADF or employment roles outside the ADF.”1524
The ADF supports a recommendation to this effect, including the Turner family’s suggestion. The ADF notes that decisions relating to, inter alia, deployment and change of company are necessarily multifactorial. Various military, operational, resourcing, organisational, and administrative matters also need to be considered when making such decisions. The ADF also notes that any consideration of this issue would need to take account of legal, ethical, and policy restrictions concerning patient privacy/confidentiality and the sharing of ADF members’ health information.1525
Consideration
Proposed recommendation (f)
1525 Submissions of the Commonwealth dated 7 June 2024 at 14.
1526 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1527 Submissions of Dr Hale dated 31 May 2024 at [38].
1528 Submissions of GPCAPT Ross dated 5 June 2024 at [126].
1529 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1530 Submissions of CPL TJ dated 7 June 2024 at [53].
1531 Submissions in reply of Counsel Assisting dated 22 August 2024 at [79].
1532 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
Submissions
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to this recommendation and, accordingly, it is maintained in its present form.1540 Consideration
I note there was no objection. I make the recommendation which arises directly from the evidence before me.
Proposed recommendation (g)
1534 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1535 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1536 Submissions of Dr Hale dated 31 May 2024 at [38].
1537 Submissions of GPCAPT Ross dated 5 June 2024 at [126].
1538 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1539 Submissions of CPL TJ dated 7 June 2024 at [53].
1540 Counsel Assisting submissions in reply dated 22 August 2024 at Annexure A.
1541 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
Submissions
Proposed recommendation (h)
1543 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1544 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1545 Submissions of Dr Hale dated 31 May 2024 at [38].
1546 Submissions of GPCAPT Ross dated 5 June 2024 at [126].
1547 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1548 Submissions of CPL TJ dated 7 June 2024 at [53].
1549 Counsel Assisting submissions in reply dated 22 August 2024 at Annexure A.
i. specialist training in military and veterans’ psychiatry; and ii. security clearances at a level consistent with the clearances of the ADF members who are being treated by them.1550 Submissions
ii. The ADF does not assess or determine whether a person is eligible and suitable to hold a security clearance. This is an independent process, conducted by the Australian Government Security Vetting Agency (AGSVA). It involves AGSVA considering an applicant’s integrity, maturity, trustworthiness, honesty, resilience, tolerance, and loyalty and conducting prescribed minimum personal security checks. While the process undertaken depends upon the level of clearance being applied for (with higher clearance levels requiring a more onerous vetting process), the process can be time-consuming and resource-intensive. The process is also intrusive for the applicant, which may affect the number of psychiatrists who are willing to undertake it.
iii. There would be significant practical impediments to conducting psychiatric and/or psychological treatment involving the communication of security classified information. For example, treatment sessions would need to be held in secure facilities; case notes and information would need to be stored on secure systems and may not be able to be stored electronically; and any security classified information disclosed during a treatment session would not be able to be disclosed to another clinician who did not hold an appropriate security clearance, potentially causing coordination/fragmentation issues.1551
1551 Submissions of the Commonwealth dated 7 June 2024 at 15.
1552 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to this recommendation and, accordingly, it is maintained in its present form.1558 Consideration
Notwithstanding the resourcing issues raised by the ADF, I make the recommendation.
Proposed recommendation (i)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to ensuring that enlisted psychologists and contracted psychologists have security clearances at a level consistent with the clearances of the ADF members who are being treated by them.1559 Submissions
The ADF supports a recommendation to this effect. The ADF notes that it already employs or engages ADF uniformed, Australian Public Service, and contracted psychologists who hold different levels of security clearances. The ADF also repeats the observations made in relation to proposed recommendation (h).1560
1554 Submissions of Dr Hale dated 31 May 2024 at [38].
1555 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1556 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1557 Submissions of CPL TJ dated 7 June 2024 at [53].
1558 Counsel Assisting submissions in reply dated 22 August 2024 at Annexure A.
1559 Submissions of Counsel Assisting dated 2 November 2023 at pp 167-169.
1560 Submissions of the Commonwealth dated 7 June 2024 at 16.
1561 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1562 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1563 Submissions of Dr Hale dated 31 May 2024 at [38].
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to this recommendation and, accordingly, it is maintained in its present form.1567 Consideration
Notwithstanding the resourcing issues raised by the ADF, I make the recommendation.
Proposed recommendation (j)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to establishing systems and a culture of transition from Special Forces, including providing adequate support for transitions: i. to non-combat roles within the ADF; and ii. to employment roles outside the ADF.1568 Submissions
The ADF does not oppose a recommendation to this effect. However, the ADF notes that issues concerning discharge/separation/transition were not a particular focus during this Inquest and were the subject of only limited evidence. The ADF notes that it already has systems/mechanisms which provide considerable support to transitioning members, including: transition training; transition centres; employment assistance; financial support; and health centre support.1569
1565 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1566 Submissions of CPL TJ dated 7 June 2024 at [53].
1567 Counsel Assisting submissions in reply dated 22 August 2024 at Annexure A.
1568 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
1569 Submissions of the Commonwealth dated 7 June 2024 at 16.
1570 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1571 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1572 Submissions of Dr Hale dated 31 May 2024 at [38].
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to this recommendation and, accordingly, it is maintained in its present form.1576 Consideration
In my view, there was sufficient evidence before me to consider the issues raised. I make the recommendation.
Proposed recommendation (k)
1574 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1575 Submissions of CPL TJ dated 7 June 2024 at [53].
1576 Counsel Assisting submissions in reply dated 22 August 2024 at Annexure.
1577 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
1578 Submissions of the Commonwealth dated 7 June 2024 at 16.
1579 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1580 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1581 Submissions of Dr Hale dated 31 May 2024 at [38].
1582 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1583 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1584 Submissions of CPL TJ dated 7 June 2024 at [53].
In submissions in reply, Counsel Assisting notes that no objection is taken by the interested parties to this recommendation and, accordingly, it is maintained in its present form.1585 Consideration
I accept this recommendation arises directly from the evidence before me. I make the recommendation.
Proposed recommendation (l)
PTSD: i. an independent clinical assessment be made by a psychiatrist not involved in the individual’s treatment or Chain of Command; and ii. a risk analysis be undertaken based on a review of the history referred to in recommendation (a) above; and iii. the ADF introduce clear guidelines indicating the factors which are to be taken into account in a decision whether the member should be permitted to deploy, including whether capability requirements are intended to have any influence on that decision (and if so, in what way).1586 Submissions
1586 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
1587 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1588 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1589 Submissions of Dr Hale dated 31 May 2024 at [38].
1590 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1591 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1592 Submissions of CPL TJ dated 7 June 2024 at [53].
The ADF’s view is that proposed recommendations (l), (m) and (n) raise closely related issues which should be considered together. While the ADF supports the intent behind the proposed recommendations, it does not support them in their current form. The ADF considers the more appropriate course would be for a recommendation that “it give consideration to reviewing its policy framework with respect to the making of deployment decisions for ADF members who have or have had a diagnosis of PTSD or another similar mental health condition, with a view to developing clear guidelines about:
How such decisions should be made (including whether and how they can be “appealed”);
The roles and responsibilities of operational personnel, medical personnel and any external health practitioners in the making of such decisions;
The information to which operational personnel, medical personnel and any external health practitioners may and may not have access in making such decisions; and
In the event that a decision to deploy is made, the development and implementation of risk mitigation strategies.”
The ADF also notes that any review would need to take account of legal, ethical, and policy restrictions concerning patient privacy/confidentiality and the sharing of ADF members’ health information. In proposing a less prescriptive and more holistic recommendation, the ADF is conscious of the work of the Royal Commission and the need to avoid “universalising” from one case.1593
Joanna Turner agrees with the ADF’s alternative and proposes that the ADF policy should require a trained mental health professional to be the primary decision maker; noting that her view is that medical officers do not always have comprehensive mental health training and are therefore not well positioned to be the clinical lead in relation to such issues.1594
Counsel Assisting does not oppose the ADF’s alternative recommendation, subject to the consideration of matters raised by GPCAPT Ross and Mr and Mrs Turner in relation to proposed recommendations (l), (m), and (n).1595 1593 Submissions of the Commonwealth dated 7 June 2024 at 16.
1594 Submissions in reply of Joanna Turner 15 July 2024 at [1(a)].
1595 Submissions in reply of Counsel Assisting dated 22 August 2024 at [246.1].
Consideration
Proposed recommendation (m)
GPCAPT Ross indicates that this recommendation would introduce “potentially significant logistical impediments” and that in order to be “suitably qualified” for the role it would be necessary for the health professional to have military experience and there are few such health professionals. He also notes that requests for medical clearance are often submitted close to the dates of deployment (meaning that independent review may not be feasible).1601
Mr and Mrs Turner accept this recommendation but propose a modification that the recommendation also “provides that formal procedures are to be instigated regarding the process of appealing a negative medical clearance and how that appeal is reviewed”.1602 1596 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
1597 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1598 Submissions of Dr Hale dated 31 May 2024 at [38].
1599 Submissions of CPL TJ dated 7 June 2024 at [53].
1600 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1601 Submissions of GPCAPT Ross dated 5 June 2024 at [127(a)].
1602 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208(a)].
The ADF refers to its response to recommendation (l) above and notes that subparagraph (1) in [1169] incorporates Mr and Mrs Turner’s suggestion that “appeal” processes be considered as part of any review.1603
Joanna Turner disagrees with the ADF that an independent review cannot be undertaken prior to issuing a clearance/waiver. She considers that it would be reasonable for either a member of a regional JHC senior mental health team or otherwise the ADF Second Opinion Clinic to review and provide comment on any such decision. This would enable an independent review to be considered and documented, whilst maintaining confidentiality/privacy. She notes that all such documentation for these situations should require sign off by two levels of assessment (i.e., mental health professional carrying out the review and the senior or second opinion clinician reviewing the assessment).1604
Counsel Assisting is supportive of the proposed modification proposed by Mr and Mrs Turner1605 and does not oppose the ADF’s alternative recommendation, subject to the consideration of matters raised by GPCAPT Ross and Mr and Mrs Turner in relation to recommendations (l), (m), and (n).1606 Consideration
Having considered the submissions made on this issue, I accept the general approach of the Commonwealth and intend to deal with recommendations (l), (m) and (n) together.
Proposed recommendation (n)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to requiring that when an independent review as per (m) above results in a clearance being granted, that:
the risks to the individual resulting from the clearance being granted are clearly identified and documented along with detailed reasons why the need to deploy the individual outweighs the risks involved;
a detailed plan to mitigate the identified risks to the individual is documented and signed off by the relevant medical and command personnel; and 1603 Submissions of the Commonwealth dated 7 June 2024 at 17.
1604 Submissions in reply of Joanna Turner at [1(b)].
1605 Submissions in reply of Counsel Assisting dated 22 August 2024 at [76.1].
1606 Submissions in reply of Counsel Assisting dated 22 August 2024 at [246.1].
Mr and Mrs Turner propose that the recommendation be modified to include “4. a plan of action to be formulated as part of the mitigation plan should the condition for which the ADF member received a clearance begin to deteriorate.”1613
GPCAPT Ross considers that this recommendation confuses the medical clearance process with the command waiver process and that an “acceptable alternative” to this recommendation would be that any ADF member with a history of PTSD be dealt with separately from the medical clearance process such that there is no possibility that the member be medically cleared to deploy and would require a command waiver.
However, GPCAPT Ross does not support such an alternative because, in his professional opinion, an ADF member with PTSD could be cleared to deploy.1614
1608 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1609 Submissions of CPL TJ dated 7 June 2024 at [53].
1610 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1611 Submissions of Dr Hale dated 31 May 2024 at [38].
1612 Submissions of the Commonwealth dated 7 June 2024 at 18.
1613 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208(b)].
1614 Submissions of GPCAPT Ross dated 5 June 2024 at [127(b)-(f)].
1615 Submissions in reply of Counsel Assisting dated 22 August 2024 at [181].
Ross’ proposed alternative to recommendation (n), noting that he himself does not support it.1616 Consideration
Proposed recommendation (o)
1617 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
Submissions
The ADF does not support a recommendation to this effect, as it believes it does not take account of legal, ethical, and policy restrictions concerning patient privacy and confidentiality and the sharing of ADF member’s health information. The ADF notes that a RtAPS or POPS that identifies PTSD symptoms cannot be notified to the member’s Chain of Command unless the member consents or the medical/health professional reasonably believes that the disclosure is necessary to lessen or prevent an imminent serious threat to the life, health, or safety of any individual or to public health and safety.1624
Joanna Turner agrees with the ADF’s position raising concerns about confidentiality and resulting underreporting and she proposes that there be training directed to those administering such screenings to lead to better outcomes.1625
Counsel Assisting maintains this recommendation in its present form.1626 Consideration
I understand the need to protect the therapeutic relationship and to promote honesty in RtAPS and POPS procedures. Nevertheless, it would be of benefit for the Chain of Command to know when a member is experiencing severe symptoms of PTSD. It appears to me that there could be consideration of developing a system where a simple alert is issued (without detailed personal confidences being revealed) when severe symptoms are disclosed and permission to advise the Chain of Command is not 1618 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1619 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1620 Submissions of Dr Hale dated 31 May 2024 at [38].
1621 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1622 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1623 Submissions of CPL TJ dated 7 June 2024 at [53].
1624 Submissions of the Commonwealth dated 7 June 2024 at 18.
1625 Submissions in reply of Joanna Turner at [1(c)].
1626 Submissions in reply of Counsel Assisting dated 22 August 2024 at [246.2].
forthcoming. Clearly, this would necessitate working through issues of confidentiality and privacy.
Proposed recommendation (p)
Counsel Assisting proposes that the Chief of the Defence Force give consideration to the implementation of training programs for ADF members in command roles in relation to PTSD, including the identification of PTSD symptoms and the appropriate management of soldiers experiencing PTSD.1627 Submissions
The ADF supports a recommendation to this effect and repeats the observations made in relation to proposed recommendation (b).1628
1628 Submissions of the Commonwealth dated 7 June 2024 at 18.
1629 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1630 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1631 Submissions of Dr Hale dated 31 May 2024 at [38].
1632 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1633 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1634 Submissions of CPL TJ dated 7 June 2024 at [53].
1635 Counsel Assisting submissions in reply dated 22 August 2024 at Annexure A.
Consideration
Proposed recommendation (q)
Counsel Assisting proposes that a review be conducted of the management of soldiers suffering from mental health conditions in 2CDO in consideration of:
best clinical practice;
longitudinal management of conditions and treatments; and the appointment of a single point of coordination and responsibility for the overall treatment of the individual.1636 Submissions
1637 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1638 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1639 Submissions of Dr Hale dated 31 May 2024 at [38].
1640 Submissions of GPCAPT Ross dated. 5 June 2024 at [126].
1641 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
1642 Submissions of CPL TJ dated 7 June 2024 at [53].
1643 Submissions of the Commonwealth dated 7 June 2024 at 19.
Counsel Assisting maintains that the recommendation is clear in its terms and arises directly from the issues raised regarding the management of CPL Turner and his mental health.1644 Consideration
The evidence indicated that members of the 2CDO undertook a considerable combat load, which places them at clear risk of mental health consequences. That fact should be uncontroverted. It is apparent that members suffering mental health conditions deserve best clinical practice and that their management is evidence-based and wellcoordinated.
I was surprised that the ADF could not understand the recommendation, perhaps on further reflection its purport will be clear. After listening to the evidence of Mr Cardinaels and others, I was not convinced that at the time CPL Turner was being managed that his condition was handled appropriately and in accordance with best practice. Should the review find that much has changed, little further work will need to be done.
Proposed recommendation (r)
1645 Submissions of Counsel Assisting dated 2 November 2023 at 167-169.
1646 Submissions of Mr and Mrs Turner dated 28 January 2024 at [208].
1647 Submissions of Dr Sringeri dated 24 April 2024 at [2].
1648 Submissions of Dr Hale dated 31 May 2024 at [38].
1649 Submissions of GPCAPT Ross dated 5 June 2024 at [126].
1650 Submissions of CAPT MH dated 7 June 2024 at [6], [46].
The ADF does not support a recommendation to this effect and notes that policy documents/guidelines relating to the role of the padre (which exist and which have been updated since 2017) were never requested by those assisting or the subject of a subpoena/order for production. The ADF is of the view that there is no appropriate evidence base to support the need for this recommendation.1652
Joanna Turner agrees “that Padres need to have very established boundaries defining and identifying what constitutes pastoral response and what presentations require mental health professional assessment” and that the recommendation should not be limited to 2CDO.1653
Counsel Assisting maintains this recommendation in its present form and notes that, if made, it should be confined to 2CDO in light of the scope of the evidence adduced in the Inquest.1654 Consideration
I do not accept that I need old and updated policies about the padre to make this recommendation. In my view, it arises clearly from the evidence in this Inquest. I identified a variety of potential issues relating to the padre’s role. The boundaries around the padre’s involvement were not well-defined. A padre needs an ability to identify the difference between a pastoral care role and a treatment role which requires psychological or social work experience. A number of times during the Inquest a witness would advise the Court that they had “told the padre” about something, but it was rarely clear what obligation the padre had to share or withhold that information.
I understand that the padre’s role pre-dates an army with professional mental health services. It is a role that requires review, perhaps throughout the whole Army but given the evidence in this Inquest I make it only with regard to the 2CDO.
Mr and Mrs Turner’s proposed recommendations Proposed recommendation (a)
1652 Submissions of the Commonwealth dated 7 June 2024 at 19.
1653 Submissions in reply of Joanna Turner at [1(d)].
1654 Counsel Assisting submissions in reply dated 22 August 2024 at [246.3].
establishing a system for mapping the history of an ADF members leave entitlements, the leave taken, and lapsing/lapsed leave and to ensure that they are considered in decisions relating to deployments.1655 Submissions
Counsel Assisting supports this recommendation, noting that it would complement Counsel Assisting’s proposed recommendation (a) and (k).1657 It is submitted that if those recommendations are accepted, Mr and Mrs Turner’s recommendation would not pose a significant additional burden on the ADF. CPL Turner was deployed for a substantial period of time between 2007 and 2016 and the expert evidence emphasised the “inherently potentially traumatic” nature of service, the “accumulative effects of multiple deployments and the cumulative traumas greatly increase the probability of enduring psychological harm”, and the impact of “cumulative exposure” to traumatic incidents.1658 Consideration
In my view, this is a useful recommendation and I intend to make it.
Proposed recommendation (b)
1655 Submissions of Mr and Mrs Turner dated 28 January 2024 at [37], [209].
1656 Submissions of the Commonwealth dated 7 June 2024 at 19-20.
1657 Submissions in reply of Counsel Assisting dated 22 August 2024 at [36].
1658 Tab 110 at 10; 7/2/2023 T71.1; 8/2/23 T46.19.
1659 Submissions of Mr and Mrs Turner dated 28 January 2024 at [37] and [209].
1660 Submissions of the Commonwealth dated 7 June 2024 at 20.
1661 Counsel Assisting submissions in reply dated 22 August 2024 at [36].
Proposed recommendation (c)
Mr and Mrs Turner contend that education for ADF families and significant others of ADF members regarding PTSD should be made available and there ought to be appropriate services available to assist family members deal with the effects of combat related PTSD. Accordingly, Mr and Mrs Turner propose the establishment of systems to provide:
Education for ADF families and significant others of ADF members in recognising the symptoms of PTSD (including subsyndromal PTSD) and other combat related psychological conditions;
Suitable services to assist ADF family members and significant others of ADF members to deal with the impact of the symptoms of the PTSD and / other combat related psychological conditions; and
Suitable services to ADF family members and significant others of an ADF member who suicide from PTSD and/or other combat related psychological conditions during service.1662 Submissions
The ADF is of the view that issues of this kind were being explored by the Royal Commission and that the Royal Commission was the more appropriate forum for consideration of this issue.1663
Joanna Turner considers that this issue “could be addressed”, however, she notes that the recommendation places undue responsibility on family members and that, in CPL Turner’s case, focus regarding education should have been on “command and treating medical professionals” in their recognition of “family dysfunction” and on the relevant ADF member “so they maintain primary responsibility”.1664
Counsel Assisting does not consider recommendations (c)(1) and (c)(2) to be appropriate given recommendations need to be “in relation to any matter connected with the death” (s 82 of the Coroners Act) and the evidence did not suggest CPL Turner’s death in any way arose from a lack of recognition of symptoms by his partner or family. Rather, Counsel Assisting posits that the concerns canvassed by this 1662 Submissions of Mr and Mrs Turner dated 28 January 2024 at [45]-[46] and [209].
1663 Submissions of the Commonwealth dated 7 June 2024 at 20.
1664 Submissions of Joanna Turner in reply at [2(a)].
recommendation are more appropriately addressed in Counsel Assisting’s proposed recommendations (c) and (d).1665
Counsel Assisting does not consider there to be a sufficient evidentiary basis for recommendation (c)(3).1666 Consideration
While I have considerable sympathy for ADF families and the significant others of members, I accept Counsel Assisting’s submission that matters raised may go beyond scope and may not arise directly from the evidence before me. I decline to make the recommendation and note that the issue was considered by the Royal Commission.
Proposed recommendation (d)
Mr and Mrs Turner suggest that the correlation between incidents of domestic violence and PTSD should be the subject of greater research and analysis (as it is an important part of looking after the family of ADF members suffering from PTSD). In a similar vein, they recommend that the ADF give “greater consideration” to the impact of vicarious trauma on intimate partners and children of ADF members and, in turn, their ability to support the ADF member. They also contend that it would be useful to have a study that investigates the decompensation of members with PTSD on or around the dates of the traumas experienced by the members. 1667 Submissions
The ADF notes that the interrelationship(s) between PTSD, abuse of alcohol/drugs, and domestic violence/coercive control are complex.1668
Joanna Turner emphasises the need to maintain focus on the perpetrator of domestic violence and to ensure such behaviour is not used to excuse the behaviour.1669
Counsel Assisting supports the recommendation in relation to the decompensation study, noting the evidence of Dr Hopwood was that this issue was not “researched well”.1670 1665 Submissions in reply of Counsel Assisting dated 22 August 2024 at [41].
1666 Submissions of Counsel Assisting dated 22 August 2024 at [43].
1667 Submissions of Mr and Mrs Turner dated 28 January 2024 at [45], [48] and [209].
1668 Submissions of the Commonwealth dated 7 June 2024 at 20.
1669 Submissions in reply of Joanna Turner at [2(b)].
1670 Submissions in reply of Counsel Assisting dated 22 August 2024 at [49].
Consideration
Given the differences of emphasis that emerged in the expert conclave in relation to the relationship between PTSD and domestic violence, I accept that it is worthy of study. Accepting a link between domestic violence and PTSD does not excuse violent behaviour or fail to recognise the harm wrought on family members. The breakdown of CPL Turner’s family unit due to domestic violence certainly contributed to the mental health decline which ended ultimately in his death, so the connection to my coronial purpose is established. I also accept that it would be useful to have some empirical evidence about the reported decompensation of members which appears to occur around trauma dates.
In my view, both areas are worthy of study. I will make the recommendations.
Proposed recommendation (e)
ADF policy should adapt to ensure members returning from combat operations have available both appropriate and timely mental health assessments and ongoing interventions as required.1671 Submissions
The ADF relies on its submissions1672 (summarised above at [567]-[568]) concerning RtAPS and POPS screenings and referrals from such screenings.1673
Counsel Assisting refers to the submissions above concerning Issue 31674 and emphasises that there were early warning signs, by way of CPL Turner’s RtAPS and POPS screenings, and that it does not appear that the ADF had in place any longitudinal method of identifying individuals who were at particular risk of deterioration in their mental health.1675 Counsel Assisting considers that the gravamen sought to be addressed by Mr and Mrs Turner’s recommendations regarding psychological screening are addressed by existing recommendations proposed by Counsel 1671 Submissions of Mr and Mrs Turner dated 28 January 2024 at [61] and [209].
1672 Submissions of the Commonwealth dated 7 June 2024 at [101]-[112].
1673 Submissions of the Commonwealth dated 7 June 2024 at 20.
1674Submissions in reply of Counsel Assisting dated 22 August 2024 at [56].
1675 Submissions in reply of Counsel Assisting dated 22 August 2024 at [56.1]-[56.5].
Assisting, namely recommendations (a), (o), and (q). To the extent that Mr and Mrs Turner’s recommendations are not otherwise covered by those proposed by Counsel Assisting, Counsel Assisting is supportive of the recommendations.1676 Consideration
Proposed recommendation (f)
Mr and Mrs Turner propose that it be mandated that all psychologists conducting the RtAPS and POPS: i. consider previous psychological screening results to ensure that they have a complete picture when carrying out individual assessments; and ii. be trained to ensure they understand and appreciate the importance of their role in identifying and responding appropriately to combat trauma; and iii. undertake the assessment in an environment that allows the member to fully participate in the assessment.1677 Submissions
The ADF relies on its submissions1678 (summarised above at [567]-[568]) concerning RtAPS and POPS screenings and referrals from such screenings.1679
Counsel Assisting’s position on this recommendation is summarised at [1263] above.1680 Consideration
I accept Counsel Assisting’s submission that these matters may be covered by recommendations already made. Nevertheless, given the important role psychologists play in undertaking the RtAPS and POPS screenings, I am satisfied that making the recommendation may have some merit.
1676 Submissions in reply of Counsel Assisting dated 22 August 2024 at [56.4]-[56.5].
1677 Submissions of Mr and Mrs Turner dated 28 January 2024 at [64], [69]-[71] and [209].
1678 Submissions of the Commonwealth dated 7 June 2024 at [101]-[112].
1679 Submissions of the Commonwealth dated 7 June 2024 at 21.
1680 Submissions in reply of Counsel Assisting dated 22 August 2024 at [56.1].
Proposed recommendation (g)
Mr and Mrs Turner consider that there should be better education regarding subsyndromal PTSD and an independent review should be undertaken of health files and a policy developed to guide future reviews in similar situations.1681 Submissions
The ADF supports a recommendation concerning training/education about PTSD and refers to its proposed amendments to Counsel Assisting’s proposed recommendations
(b) and (p).1682
(p) in this regard.1683 Consideration
Proposed recommendation (h)
Mr and Mrs Turner would like the ADF to consider that where ADF members are discharging on medical grounds for combat-acquired PTSD that it should be seen as a red flag for others within the unit and should trigger suitable interventions where necessary.1684 Submissions
The ADF does not support a recommendation to this effect on the basis that this issue was not the subject of appropriate evidence in this Inquest.1685
Counsel Assisting’s position on this recommendation is summarised at [1263] above.
Counsel Assisting supports this recommendation.1686 1681 Submissions of Mr and Mrs Turner dated 28 January 2024 at [209].
1682 Submissions of the Commonwealth dated 7 June 2024 at 21.
1683 Submissions in reply of Counsel Assisting dated 22 August 2024 at [93.1] and Annexure A.
1684 Submissions of Mr and Mrs Turner dated 28 January 2024 at [66] and [209].
1685 Submissions of the Commonwealth dated 7 June 2024 at 20.
1686 Submissions in reply of Counsel Assisting dated 22 August 2024 at [56.5].
Consideration
Proposed recommendation (i)
Mr and Mrs Turner contend that in complex cases, clinical subject matter experts should be engaged to guide and support the Chain of Command in IWBs in relation to their responsibilities to ensure effective care for the mental health and well-being of members in their Chain of Command.1687 Submissions
The ADF does not support a recommendation to this effect given that the evidence in this Inquest establishes that welfare boards were attended by appropriate medical and health personnel.1688
Joanna Turner agrees with the ADF and does not support the recommendation, noting that relevant personnel on the boards are suitably qualified and adding further to the boards would create complexity.1689
Counsel Assisting does not support this recommendation on the basis that suitable medical professionals are already attendees.1690 Consideration
I have considered the recommendation and am concerned that introducing a new role at the IWB may complicate rather than improve care. I have decided not to make the recommendation in that form.
Proposed recommendation (j)
1688 Submissions of the Commonwealth dated 7 June 2024 at 20.
1689 Submissions in reply of Joanna Turner at [2(c)].
1690 Submissions in reply of Counsel Assisting dated 22 August 2024 at [65].
that there should be specialised clinical oversight in managing and making decisions regarding the suitability of activities, duties, and clinical intervention for members in CPL Turner’s situation.1691 Submissions
The ADF does not support a recommendation to this effect, which appears to propose a total review of the entirety of the ADF’s policy framework in relation to mental health issues. It considers that the Royal Commission was the appropriate forum for recommendations of this kind.1692
Joanna Turner does not support this recommendation on the basis that she does not consider CPL Turner’s case should be used to “inform such broad statements”.1693
Counsel Assisting is supportive of this recommendation. Contrary to the ADF’s position, Counsel Assisting considers that if a matter properly arises for recommendation under s 82(1) of the Coroners Act, a coroner is entitled to make a recommendation and should not decline to do so based on supposition of what might occur in another forum such as the Royal Commission. Counsel Assisting considers that the recommendation is not as broad as the ADF appears to characterise it (it being focussed on a subset of “complex psychiatric cases” and a consideration of how additional resources and oversight might occur for such cases).1694 Consideration
I can readily see the benefit of reviewing policies and practices governing the way complex psychiatric cases are managed. The evidence in this case demonstrates that there are opportunities to provide clarity about when additional or alternative support is available. There was limited or no clinical oversight regarding the suitability of the activities, duties, and clinical intervention provided. As we have seen, care was fragmented.
In my view, the recommendation arises directly out of the evidence I heard and I intend to make it.
1691 Submissions of Mr and Mrs Turner dated 28 January 2024 at [185] and [209].
1692 Submissions of the Commonwealth dated 7 June 2024 at 21-22.
1693 Submissions in reply of Joanna Turner at [2(d)].
1694 Submissions in reply of Counsel Assisting dated 22 August 2024 at [92].
Proposed recommendation (k)
Mr and Mrs Turner request that the ADF consider how the Chain of Command above the unit level be informed of the complexity of certain challenging cases and what their response will be to ensure adequate resources are made available to the unit for proper care.1695 Submissions
The ADF does not support a recommendation to this effect on the basis that this issue was not the subject of appropriate evidence at the Inquest.1696
Counsel Assisting supports this recommendation on the same basis as [1285] above.1697 Consideration
I accept that this recommendation touches on matters that were not the subject of direct evidence. I decline making the recommendation.
Proposed recommendation (l)
Mr and Mrs Turner propose that the ADF’s policy, Army Standing Instruction (Personnel) Part 8 Chapter 8: Delivery of Support to Wounded, Injured and Ill Members in the Australian Army (ASI(P) Part 8 Chapter 8) dated November 2021, be amended to include the following:
If the member is physically unable to attend the WB meeting, the policy is to stipulate who is responsible for providing the member with details of the proceeding and the outcome;
A process of referral in circumstances where the WB is not witnessing an expected trajectory of improvement in the member’s condition, the Chain of Command can escalate the matter for additional resource support, including additional clinical input for a higher level of care;
Implementing recommendation (d) arising from a Joint After- Action Review conducted by Special Operations Command and Joint Health Command 195 that Director Garrison Operations be included in quarterly Commander Special 1695 Submissions of Mr and Mrs Turner dated 28 January 2024 at [209].
1696 Submissions of the Commonwealth dated 7 June 2024 at 22.
1697 Submissions in reply of Counsel Assisting dated 22 August 2024 at [91]-[92].
Forces Welfare Board to ensure that complex cases have the adequate resources at the unit level to deliver appropriate care; and
Proposed recommendation (m)
Mr and Mrs Turner contend that the ADF needs to formulate alternative career pathways that transition from combat roles to other ADF roles or roles outside the ADF once a member suffers traumatic injuries such as PTSD. It should not be a situation where an occupationally acquired mental health illness means no further gainful employment.1701 Submissions
The ADF considers that Counsel Assisting’s proposed recommendation (j), which it does not oppose, sufficiently addresses this matter.1702
Counsel Assisting takes the same view as the ADF on this recommendation.1703 Consideration
I accept the submissions of Counsel Assisting and the ADF on this matter. The issue is an important one but I am confident it is covered by Counsel Assisting’s recommendation (j). I decline to make the recommendation in this form.
1698 Submissions of Mr and Mrs Turner dated 28 January 2024 at [209].
1699 Submissions of the Commonwealth dated 7 June 2024 at 22.
1700 Submissions in reply of Counsel Assisting dated 22 August 2024 at [66].
1701 Submissions of Mr and Mrs Turner dated 28 January 2024 at [209].
1702 Submissions of the Commonwealth dated 7 June 2024 at 23.
1703 Submissions in reply of Counsel Assisting dated 22 August 2024 at [81].
Proposed recommendation (n)
Mr and Mrs Turner would like to see clearer policy around the management of deceased members personal effects. They contend that there should be some greater transparency such that while recognising the need for the ADF to protect sensitive material, possessions should not be removed and left unaccounted regardless of content.1704 Submissions
The ADF does not support a recommendation to this effect. The ADF’s view is that in light of the ultimate evidence on this issue, it is doubtful that I would have jurisdiction to make a recommendation to this effect under s 82(1) of the Coroners Act. In any event, it is noted that the ADF has existing clear policy addressing the management of deceased members’ personal effects, including the Defence Incident Scene Initial Action and Preservation Manual1705 and the Casualty Manual Chapter 6: Management of Effects for Defence Members Declared Deceased, Missing, Incapacitated or Captured (which replaced the Defence Casualty and Bereavement Support Manual Chapter 6: Disposal of effects for Defence Members Declared Deceased, Missing, Incapacitated or Captured)1706 A Second Edition of the Defence Incident Scene Initial Action and Preservation Manual was released in November 2023.1707
Counsel Assisting agrees with the position proffered by the Commonwealth, noting that there is an insufficient evidentiary basis for the recommendation.1708 Consideration
While I understand Mr and Mrs Turner’s concerns, I accept that at the conclusion of evidence I was unable to establish what happened to CPL Turner’s missing property.
Given that no breach of established policy or wrongdoing was identified, I accept that this recommendation may be beyond scope. I decline to make the recommendation.
Proposed recommendation (o)
1705 Exhibit 59 at 1.
1706 Exhibit 59 at 19.
1707 Submissions of the Commonwealth dated 7 June 2024 at 23.
1708 Submissions in reply of Counsel Assisting dated 22 August 2024 at [89].
individual. The role and responsibilities of a medical officer need to be clearly defined to ensure that a proper and unbiased perspective is provided.1709 Submissions
The ADF repeats its response to Counsel Assisting’s proposed recommendations (l), (m), and (n).1710
Counsel Assisting considers that the recommendation is likely to be unnecessary if Counsel Assisting’s recommendations (m) and (n) are modified in the manner suggested by Mr and Mrs Turner.1711 Consideration
I agree with Counsel Assisting’s submission that the recommendation is adequately addressed by other recommendations I intend to make.
Proposed recommendation (p)
Mr and Mrs Turner suggest that the ADF should clearly delineate the difference between a medical clearance and a command waiver and ensure that all documentation including policies and forms used in the process reflect that delineation.1712 Submissions
The ADF repeats its response to Counsel Assisting’s proposed recommendations (l),(m), and (n).1713 On the point of the distinction between command waivers and medical clearances, the ADF observes that “[w]hile the processes are distinct, they are not hermetically sealed. The Chain of Command may have input into the medical clearance process and health practitioners may give medical advice during the command waiver process”.1714
Counsel Assisting considers that the ADF’s submission on this recommendation underscores the need for clarity in this context notwithstanding the conceptual distinction between medical clearances and command waivers. Counsel Assisting supports this recommendation.1715 1709 Submissions of Mr and Mrs Turner dated 28 January 2024 at [173] and [209].
1710 Submissions of the Commonwealth dated 7 June 2024 at 23.
1711 Submissions in reply of Counsel Assisting dated 22 August 2024 at [76].
1712 Submissions of Mr and Mrs Turner dated 28 January 2024 at [178] and [209].
1713 Submissions of the Commonwealth dated 7 June 2024 at 23.
1714 Submissions of the Commonwealth dated 7 June 2024 at [300].
1715 Submissions in reply of Counsel Assisting dated 22 August 2024 at [78].
Consideration
As I have already stated, there was significant confusion during the Inquest about the precise relationship between a command waiver and medical clearance demonstrated by senior officers and medical staff. Every time a clear distinction was drawn, there was further evidence indicating the distinction was not so clear. The Commonwealth’s response to this recommendation proposal concerns me and I accept Counsel Assisting’s submission that the lack of clarity on the distinction between the two concepts increases rather than reduces the need for the recommendation.
I intend to make the recommendation which, in my view, highlights an important issue which arises directly from the evidence in this matter. If the delineation is already clear, the work involved will not be onerous.
Proposed recommendation (q)
Mr and Mrs Turner suggest that the Australian Government and the ADF “review the decisions that result in a few select ADF units undertaking the main combat” in Afghanistan.1716 Submissions
The ADF’s view is that this recommendation is beyond the scope of s 82(1) of the Coroners Act.1717
Counsel Assisting adopts the same view as the ADF in relation to this recommendation.1718 Consideration
This proposed recommendation raises a very significant issue, however, I accept it is beyond the scope of s 82 of the Coroners Act.
Proposed recommendation (r)
1717 Submissions of the Commonwealth dated 7 June 2024 at 24.
1718 Submissions in reply of Counsel Assisting dated 22 August 2024 at [93.2].
1719 Submissions of Mr and Mrs Turner dated 28 January 2024 at [209].
Submissions
The ADF does not support a recommendation to this effect on the basis that it was not subject to appropriate evidence in the Inquest.1720
Counsel Assisting supports this recommendation and considers that this is a relevant ancillary consideration to the consideration of ADF members’ schedules of deployments and periods of leave taken and that CPL Turner’s transition into the home environment following deployment was a matter which was the subject of evidence in the Inquest.1721 Consideration
In my view, the proposed recommendation raises an important issue for research consideration. The evidence reflected the difficulty involved in CPL Turner’s transitions home. The ADF would be well served by research that examined this issue.
I am comfortable the proposed recommendation arises from the evidence and I intend to make it.
Proposed recommendation (s)
Mr and Mrs Turner propose that the ADF give consideration as to how they might facilitate members having supervised visits with their children if there are Family Court proceedings in progress and access to their children is problematic, particularly in the context of mental health issues related to service.1722 Submissions
The ADF does not support this recommendation on the basis that it is not within the ambit of s 82(1) of the Coroners Act.1723
Joanna Turner does not support the recommendation and considers that this is a matter for the Family Court.1724
Counsel Assisting agrees with the ADF’s conclusion on this recommendation and, accordingly, does not support the recommendation.1725 1720 Submissions of the Commonwealth dated 7 June 2024 at 24.
1721 Submissions of Counsel Assisting dated 2 November 2023 at [62]-[65].
1722 Submissions of Mr and Mrs Turner dated 28 January 2024 at [209].
1723 Submissions of the Commonwealth dated 7 June 2024 at 24.
1724 Submissions in reply of Joanna Turner at [2(e)].
1725 Submissions in reply of Counsel Assisting dated 22 August 2024 at [93.4].
Consideration
Recommendations proposed by Joanna Turner Proposed recommendation 1
Joanna Turner proposes that external health providers should not assess or comment on the employability or deployability of ADF members. She also notes that “a Command referral PM008 should [have] been requested and a military psychiatrist and/or psychologist complete a comprehensive file review and in person assessment”.1726 Submissions
The ADF repeats its responses to Counsel Assisting’s proposed recommendations (l), (m), and (n) in relation.1727
As to the first aspect of the recommendation/submission, Counsel Assisting does not agree that the evidence would support such a recommendation. Rather, as has been emphasised in relation to Dr Sringeri’s letter of 13 July 2016, flaws arose in the predeployment process from a lack of clarity as to the nature of the opinion being sought from Dr Sringeri, the information on which that opinion was based, how that opinion was expressed and what it conveyed to the reader, and where the responsibility lay for the final determination of fitness to deploy. The fact that Dr Sringeri was an external practitioner did not, in and of itself, contribute to the flawed process.1728
As to the second aspect of the recommendation/submission, the substance of it is adopted by Counsel Assisting’s recommendations (l), (m), and (n).1729
Counsel Assisting does not support a recommendation that external health providers should not be involved in assessments of employability or deployability. Counsel Assisting notes there is no evidentiary basis for this arising from this Inquest. In respect of a pre-deployment assessment, Counsel Assisting does not oppose such a recommendation, but considers the substance of Joanna Turner’s proposal is 1726 Submissions of Joanna Turner dated 17 January 2024 at [1].
1727 Submissions of the Commonwealth dated 7 June 2024 at 16-18, 24.
1728 Submissions in reply of Counsel Assisting dated 22 August 2024 at [111].
1729 Submissions in reply of Counsel Assisting dated 22 August 2024 at [112].
adequately adopted by Counsel Assisting’s proposed recommendations (l), (m), and (n).1730 Consideration
Proposed recommendation 2
Joanna Turner proposes that Special Operations units should only employ of a MAJ or above rank, as this would ensure that the psychologist has both the experience in profession and rank to understand complex cases, which are more likely in high tempo units.1731 Submissions
The ADF does not support a recommendation to this effect and notes that, as discussed in its response to Counsel Assisting’s proposed recommendations (g), (h) and (i), the ADF is currently facing significant workforce/recruitment challenges, including in relation to medical and health personnel. The ADF is of the view that requiring psychologists to have the rank of Major or above would “greatly exacerbate” those challenges.1732
Joanna Turner submits that “workforce issues” ought not outweigh considerations of “[q]uality of care” and that CPL Turner’s quality of care declined when under the care of psychologists with the rank of Captain.1733
Counsel Assisting does not support this recommendation, noting that mere rank does not (and need not) necessarily correlate to quality of care nor the assertiveness with which it can be provided.1734 1730 Submissions in reply of Counsel Assisting dated 22 August 2024 at [110]-[111].
1731 Submissions of Joanna Turner dated 17 January 2024 at [2].
1732 Submissions of the Commonwealth dated 7 June 2024 at 25.
1733 Submissions in reply of Joanna Turner at [3(a)].
1734 Submissions in reply of Counsel Assisting dated 22 August 2024 at [114].
Consideration
Proposed recommendation 3
Joanna Turner encourages the ADF to consider education for units, in particular male dominated units, regarding the ethical and moral treatment of women. Joanna Turner submits that greater emphasis ought to have been placed by the ADF on “[p]rotecting the family unit” for a member suffering from ill mental health as the family provides a “secure base of support”.1735 Submissions
The ADF does not oppose a recommendation to this effect, noting that significant work has already been done (and is ongoing) in relation to family and domestic violence policies and procedures.1736
Counsel Assisting does not oppose a recommendation to this effect and notes that Counsel Assisting’s proposed recommendation (c) is directly relevant to the concern raised in this recommendation.1737 Consideration
In my view, this is an important recommendation that arises directly from the evidence before me. The need for education in this area is revealed by the ADF’s treatment of Joanna Turner and the frequent failure to recognise and name the family violence which was occurring. Her concerns were frequently ignored and using euphemisms such as “marital issues” were used to describe what was in fact family violence. The Court also had the opportunity to read personal texts from a number of ADF members.
This strengthened my concern about a culture which devalued women.
1735 Submissions of Joanna Turner dated 17 January 2024 at [3].
1736 Submissions of the Commonwealth dated 7 June 2024 at 25.
1737 Submissions in reply of Counsel Assisting dated 22 August 2024 at [116]-[117].
Proposed recommendation 4
Noting the duty of care owed by the ADF to her family in relation to the reports made of family violence and dangerous consumption of substances in the family home, Joanna Turner submits that the ADF should be required to follow risk of harm reporting protocols (i.e., reporting to Family and Community Services).1738 Joanna Turner asserts there was a breach of relevant legal reporting obligations in CPL Turner’s case.1739 Submissions
The ADF does not support a recommendation to this effect, as it has existing reporting requirements in place for reporting family and domestic violence and other matters.
Some of those reporting requirements are outlined in documents included in Exhibit 38 of the ADF’s submissions, including A Commanders and Managers Guide to Responding to Family and Domestic Violence, which takes into account relevant internal and external reporting requirements, and privacy and confidentiality laws.1740
While no finding is sought that the ADF breached “child protection laws” (as asserted by Joanna Turner), Counsel Assisting refers to the evidence concerning how the ADF responded internally to reports of domestic violence, how it monitored and engaged with Joanna Turner following direct reports to the ADF of domestic violence, and how it monitored the external criminal proceedings that related to domestic violence.1741 Consideration
Proposed recommendation 5
1739 Submissions in reply of Joanna Turner at [3(b)].
1740 Submissions of the Commonwealth dated 7 June 2024 at 25.
1741 Submissions in reply of Counsel Assisting dated 22 August 2024 at [119].
documentation.1742Joanna Turner proposes that changes to a member’s will and removal of family remembers from PMKeyS should not occur “without command approval” (noting that the changes made to CPL Turner’s will and the removal of herself and her son from his PMKeyS were done without CPL Turner needing to provide any documentation).1743 Submissions
The ADF does not support such a recommendation on the basis that it was not the subject of appropriate evidence at the Inquest.1744
In her reply submissions, Joanna Turner presses the necessity of a review of this process.1745
Counsel Assisting does not support this recommendation as it is not considered appropriate (or indeed lawful) for a member of the ADF to be subject to “command approval” prior to changes being made to their will. It is not accepted by Counsel Assisting that a mere change to a serving member’s will or amendment to PMKeyS would of itself give rise to particular concern so as to warrant a recommendation of the breadth proposed by Joanna Turner.1746 Consideration
I consider this issue, while clearly important to Joanna Turner, as beyond my purview.
Recommendations proposed by GPCAPT Ross Proposed recommendation 1
GPCAPT Ross proposes that the Joint Health Command investigate whether the ADF should retain or revise its policy that an ADF member who has a history of PTSD, irrespective of whether that person is symptomatic or asymptomatic, is capable of being deployed to a combat or combat-related role.1747 Submissions
The ADF supports the intent behind this recommendation but does not support the recommendation in its present form. The ADF considers that the more appropriate 1742 Submissions of Joanna Turner dated 17 January 2024 at [5].
1743 Submissions of Joanna Turner dated 17 January 2024 at [5].
1744 Submissions of the Commonwealth dated 7 June 2024 at 25.
1745 Submissions in reply of Joanna Turner at [3(e)].
1746 Submissions in reply of Counsel Assisting dated 22 August 2024 at [120]-[121].
1747 Submissions of GPCAPT Ross dated 5 June 2024 at 127-(h)].
course would be for this issue to be addressed in the context of any evidence-based review that the ADF decides to conduct pursuant to Counsel Assisting’s proposed recommendation (k). This would ensure that any change in ADF policy that might ultimately be considered/made would have a sound basis in existing and emerging psychiatric, psychological, and medical evidence.1748
Counsel Assisting does not support this recommendation on the basis that this recommendation would be adequately covered by Counsel Assisting’s proposed recommendations (l), (m), and (n) (or the Commonwealth’s alternative).1749 Consideration
I consider the issue raised by this proposed recommendation is adequately covered by recommendations I have already made. I decline to make it.
Recommendations proposed by CAPT MH Proposed recommendation 1
The ADF considers that Counsel Assisting’s recommendation (b) sufficiently addresses this matter and (as noted above) further indicates that it would not oppose an amendment to (b) to include at the end of the current recommendation the words “which appropriately includes simulations of real-life scenarios and recommendations about methods of decision-making”.1752
Counsel Assisting supports the intent of CAPT MH’s recommendation but considers that it is adequately addressed by Counsel Assisting’s recommendation (b) (as modified by the Commonwealth’s proposed modification).1753 1748 Submissions in reply of the Commonwealth dated 22 July 2024 at 2.
1749 Submissions in reply of Counsel Assisting dated 22 August 2024 at [180].
1750 Submissions of CAPT MH dated 7 June 2024 at [46]-[48].
1751 Submissions in reply of Mr and Mrs Turner dated 22 July 2024 at [2].
1752 Submissions in reply of the Commonwealth dated 22 July 2024 at 2.
1753 Submissions in reply of Counsel Assisting dated 22 August 2024 at [142]-[143].
Consideration
Recommendations proposed by CPL TJ Proposed recommendations 1, 2, and 3
The ADF opposes these recommendations on the grounds that there are already medical/psychological systems in place for ADF members and the public at large and the suggested EAP raises legal, ethical, and policy restrictions concerning patient privacy and confidentiality in relation to the sharing of ADF member’s health information. The Commonwealth also submits that the proposed service would be beyond the capacity and remit of Joint Health Command and the ADF more broadly. It is also noted that the benefit for members in the current approach is that it “avoid[s] concerns about fragmentation/coordination of care and to ensure that operational personnel have access to information that they “need to know”.1756
Counsel Assisting does not support the system as proposed by CPL TJ, particularly as it relates to ADF members on the basis that the proposed “non-ADF system” may have the effect of undermining the longitudinal management and organisational 1754 Submissions of CPLT TJ dated 7 June 2024 at [54].
1755 Submissions in reply of Mr and Mrs Turner dated 22 July at [2].
1756 Submissions in reply of the Commonwealth dated 22 July 2024 at 3-4.
oversight of members’ mental health to which many of Counsel Assisting’s recommendations are directed.1757 Consideration
Place of death He died at 206/18 Amelia Street, Waterloo, NSW.
Cause of death He died of multi-drug toxicity. The antecedent cause was combat-related Post Traumatic Stress Disorder (PTSD).
Manner of death His death was intentionally self-inflicted in the context of combat-related PTSD.
Recommendations
For the reasons stated above and pursuant to s 82 of the Coroners Act, I recommend that the Chief of the Defence Force give consideration to:
Introducing a systematic process for mapping the history of an ADF member’s deployments, their RtAPS and POPS screens data, and other reported psychiatric 1757 Submissions in reply of Counsel Assisting dated 22 August 2024 at [150].
diagnoses and treatment, that forms part of a member’s health record and including systems to record and action such notifications and to ensure that they are taken into account in decisions relating to deployment.
Including a mandatory annual training for all Special Forces members in recognising and destigmatising the symptoms of and managing PTSD, which appropriately includes simulations of real-life scenarios and recommendations about methods of decision-making.
Establishing a system by which psychological distress in the home environment can be communicated to an ADF member’s unit by family members including systems to record and action such notifications and to ensure that they are taken into account in decisions relating to deployment.
Providing opportunities for ADF families to be notified of and involved in treatment programs provided to ADF members for PTSD and other combat-related psychological conditions.
Making it a requirement that the impact upon mental health be taken into account in decisions relating to deployment, change of company, or support of members’ study plans or transitional plans to non-combat roles within the ADF or employment roles outside the ADF.
Implementing a requirement for psychological screening and support to be automatically offered to ADF members who are undergoing disciplinary proceedings.
Providing psychological screening and support whilst on deployment to ADF members who have previously been diagnosed with PTSD.
Employing enlisted ADF psychiatrists with: i. specialist training in military and veterans’ psychiatry; and ii. security clearances at a level consistent with the clearances of the ADF members who are being treated by them.
Ensuring that enlisted psychologists and contracted psychologists have security clearances at a level consistent with the clearances of the ADF members who are being treated by them.
Establishing systems and a culture of transition from Special Forces, including providing adequate support for transitions: i. to non-combat roles within the ADF; and ii. to employment roles outside the ADF.
Undertaking an evidence-based review as to whether and how the ADF should limit the number of combat deployments upon which an ADF member can deploy during their career before being required to transition to non-combat roles.
Reviewing the ADF policy framework with respect to the making of deployment decisions for ADF members who have or have had a diagnosis of PTSD or another similar mental health condition, with a view to developing clear guidelines and procedures about: i. How such decisions should be made (including whether and how they can be “appealed”); ii. The roles and responsibilities of operational personnel, medical personnel and any external health practitioners in the making of such decisions; iii. The information to which operational personnel, medical personnel and any external health practitioners may and may not have access in making such decisions; and iv. In the event that a decision to deploy is made, the development and implementation of risk mitigation strategies (a plan of action should also be formulated as part of the mitigation plan/strategy in the event the condition for which the ADF member received a clearance or waiver begins to deteriorate).
Promptly notifying the Chain of Command by issuing a simple alert where an RtAPS or POPS reveals severe PTSD symptoms and permission to advise the Chain of Command is not forthcoming..
Implementing training programs for ADF members in command roles in relation to PTSD, including the identification of PTSD symptoms and the appropriate management of soldiers experiencing PTSD.
Reviewing the management of soldiers suffering from mental health conditions in 2CDO in consideration of: i. best clinical practice; ii. longitudinal management of conditions and treatments; and iii. the appointment of a single point of coordination and responsibility for the overall treatment of the individual.
Reviewing the role of the padre in relation to the identification, treatment, and management of soldiers with mental health conditions in 2CDO.
Implementing a system whereby the ADF formally track the time members deploy by establishing a system for mapping the history of an ADF members leave entitlements, the leave taken, and lapsing/lapsed leave and to ensure that they are considered in decisions relating to deployments.
Undertaking a study of the effects of repeated deployments on a member’s home and family life.
Conducting greater research and analysis on the correlation between incidents of domestic violence and PTSD and considering the impact of vicarious trauma on intimate partners and children of ADF members and, in turn, their ability to support the ADF member, which could include undertaking a study that investigates the decompensation of members with PTSD on or around the dates of the traumas experienced by the members.
Requiring all ADF psychologists conducting the RtAPS and POPS to: i. consider previous psychological screening results to ensure that they have a complete picture when carrying out individual assessments; ii. be trained to ensure they understand and appreciate the importance of their role in identifying and responding appropriately to combat trauma; and iii. undertake the assessment in an environment that allows the member to fully participate in the assessment.
Providing better education regarding subsyndromal PTSD and undertaking an independent review of health files and developing a policy to guide future reviews in similar situations.
Implementing a system whereby where ADF members are discharging on medical grounds for combat-acquired PTSD, it should be seen as a red flag for others within the unit and should trigger suitable interventions where necessary.
Reviewing ADF policies and practices in managing complex psychiatric cases, including clarity on where additional support and when referral to alternative service providers can be requested and ensuring that there is specialised clinical oversight in managing and making decisions regarding the suitability of activities, duties, and clinical intervention for members in CPL Turner’s situation.
Amending the ADF’s policy, Army Standing Instruction (Personnel) Part 8 Chapter 8: Delivery of Support to Wounded, Injured and Ill Members in the Australian Army (ASI(P) Part 8 Chapter 8) dated November 2021, by including the following: i. If the member is physically unable to attend the welfare board meeting, the policy is to stipulate who is responsible for providing the member with details of the proceeding and the outcome; ii. A process of referral in circumstances where the welfare board is not witnessing an expected trajectory of improvement in the member’s condition, the Chain of Command can escalate the matter for additional resource support, including additional clinical input for a higher level of care; iii. Implementing recommendation (d) arising from a Joint After-Action Review conducted by Special Operations Command and Joint Health Command 195 that Director Garrison Operations be included in quarterly Commander Special Forces Welfare Board to ensure that complex cases have the adequate resources at the unit level to deliver appropriate care; and iv. Coordination of services..
Clearly delineating the difference between a medical clearance and a command waiver and ensure that all documentation including policies and forms used in the process reflect that delineation.
Undertaking research regarding the value of a transition period between a member being on operations and returning to a domestic environment and the time required to make such a transition.
Providing education for units, in particular male dominated units, regarding the ethical and moral treatment of women and placing greater emphasis on “[p]rotecting the family unit” for a member suffering from ill mental health.
I am aware the inquest process has been extremely painful for Joanna Turner and her children, for CPL Turner’s parents and siblings, for CPL TJ, and for members of the ADF and others who loved and respected CPL Turner. Their commitment to these difficult proceedings was clearly motivated by a desire to shine a light on the systems and procedures which failed him. I know they hope there will be changes to ADF policies and procedures that may protect others from future harm.
CPL Turner was unwell for an extended period. His behaviour must be understood in that context. In my view, a greater institutional understanding of PTSD might have protected not just CPL Turner, but also those around him. I intend to send a copy of these Findings to the Chief of the Defence Force and to the Minister for Defence. The ADF must understand and grapple with the real effects of PTSD at the highest levels of the organisation.
I acknowledge the particular pain those close to CPL Turner experienced when searingly personal details of his and their lives were revealed and discussed in open court. It was a high price to pay. I accept that they endured it in the hope that the Inquest could support change within the ADF. Their ongoing participation in the inquest has protected the integrity of the proceedings and their contribution to the recommendation process has been meaningful and appreciated.
It is necessary to say something about the effect of the quite considerable delays in these proceedings. I am sure it extended the suffering of those involved. It is regrettable and while there were many factors involved, the inadequate resourcing of this Court cannot be ignored. I am sorry that CPL Turner’s brother Steven is not present with us today and I offer his family my sincere condolences for their profound loss.
I wish to thank the assisting team for their very great assistance in this matter. Their deep commitment to these proceedings was extraordinary. I thank Kristina Stern SC (now Justice Stern SC) and her able junior counsels Madeleine Ellicott and Naomi Wootton. When Kristina Stern SC was elevated to the bench, a huge task fell to Ms Wootton. I am especially grateful to her. I would also like to thank Edward McGinness for stepping in to assist Ms Wootton at the conclusion of these proceedings. I have
also been assisted by a number of solicitors in the conduct of this inquest. Paul Armstrong’s commitment in the preparation and conduct of these proceedings was unparalleled and I specifically thank him. James Prindiville of the CSO has assisted in this final stage with his usual skill and tenacity.
It is important to say that CPL Turner was so much more than an example of PTSD we can learn from. He was clearly a charismatic, intelligent, and much loved man. He was a highly respected soldier who served this country to the best of his ability. He was loyal to his fellow commandos and he expected much from the soldiers he led. His life is not defined by the chaos and pain that resulted from his poorly managed PTSD and related substance use. Inquest proceedings are not about blame or liability. We conduct them to find clarity about what occurred and to consider change where change is needed. As a community we must learn something from CPL Turner’s journey from optimistic recruitment to the ADF to his final terrible despair. I trust that the recommendations that have arisen from the evidence in these proceedings will be given careful consideration by the ADF.
Finally, once again I offer my personal condolences to those who loved CPL Turner. I am so sorry for your profound loss.
Magistrate Harriet Grahame Deputy State Coroner NSW Coroners Court, Lidcombe 19 December 2024
ANNEXURE A: DRAMATIS PERSONNAE ADF PERSONNEL (with pseudonyms) Pseudonym Role Relevant Period for the Inquest MAJ AF (also referred Officer Commanding, B Coy, 2CDO 2016 - 2017 to as LTCOL AF) MAJ AM (also referred Senior Regimental Medical Officer at 2 CDO. Was Jan 2014 – Dec to as LTCOL AM) involved with obtaining a medical waiver for CPL 2016 Turner to be deployed to Iraq in 2016.
Captain in Bravo Coy, 2 CDO. Undertook two
MAJ BJ overseas deployments and one domestic deployment Nov 2013 - 2017 as Junior Platoon Commander with CPL Turner.
MAJ CM Executive officer at 2CDO at the time of CPL Turner’s Jul 2017 death LCPL DL Deployed in CPL Turner’s team to Afghanistan and 2012 – 2015 Iraq.
WO2 DP Company Sergeant Major of Bravo Coy, 2 CDO. 2018 WO1 EL Jan 2016 - Jan Regimental Sergeant Major of 2 CDO.
2018 BRIG GD Commander Special Forces at Special Operations Headquarters. Met with Person 1 re concerns about April 2018 Human Performance Wing.
LTCOL GG 2CDO member, Acting CO of 2CDO 2014-2015 COL HM (also referred Presided over proceedings against CPL Turner for the Jul 2016 to as BRIG HM) cock card incident.
Platoon commander in Bravo Coy, 2 CDO around
MAJ JP 2010-2012 and the XO of SOTG in 2015. Wrote a 2010 - 2015 reference for CPL Turner for his Local Court appearance on 3 April 2014.
Team commander within Bravo Coy, 2 CDO from 2008
CPL JW to 2017. Deployed with CPL Turner to Afghanistan 2008-2017 and Iraq.
COL KS Special operations headquarters chief of staff.
Advised BRIG GD in relation to the issues raised by April/May 2018
COL L Commanding Officer SOER. Jun 2016 Special operations headquarters chief legal officer.
LTCOL LS Advised BRIG GD in relation to the issues raised by April/May 2018
COL MF (also referred Commanding Officer, 2 CDO 2016 - 2017 to as BRIG MF)
CAPT MH (also referred Platoon Commander of R Platoon, B Coy, 2 CDO. 2016 - 2017 to as MAJ MH) Personnel officer who attended Welfare Board held on WO2 MM Jul 2017 7 July 2017.
MP (also referred to as Padre MP, Chaplain MP Padre of 2 CDO. 2016 - 2017 and MAJ MP) SGT NA Section Commander, B Coy, 2 CDO 2015-2018 LTCOL NJ Commanding Officer of OP OKRA. Jun 2016 CSM of B Coy, 2 CDO. Served provisional AVO on
WO2 NW Apr 2014 CPL Turner whilst on a course at Singleton.
Personnel Officer for 2 CDO. Emailed and Feb 2017 to Sep PERSON 1 subsequently met with BRIG GD re concerns about 2018 Human Performance Wing.
LCPL RG A friend of CPL Turner’s Around 2017 Friend of CPL Turner who collected him from home in
CPL SM November 2013 after he had returned drunk from the 2013 memorial service for Cameron Baird.
CO of Bravo Coy, 2 CDO. Wrote a reference for CPL Turner which was tendered at his disciplinary hearing 2008-2009
LTCOL SW into the cock card incident.
Deployed to Iraq with CPL Turner in 2016 and CPL TJ (also referred to 2016-2017 commenced a relationship with him.
as SGT TJ) ADF PERSONNEL (named) Name Role Relevant Period Close friend of CPL Turner who died on 22 June 2013,
CPL CAMERON Oruzgan, Afghanistan. Posthumously awarded the 2013
Leader of the Human Performance Wing, 2 CDO.
SGT MATTHEW Responsible for CPL Turner’s rehabilitation and found 2016 - 2017
CARDINAELS CPL Turner’s body.
MAJ SELENA CLANCY (also referred 2CDO welfare officer. Family liaison officer allocated to 2014 – Oct 2015 to as SELENA Joanna Turner.
BRIG LANGFORD (also referred to as COL CO, 2 CDO. 2014 - 2015 Langford and BRIG IL) CAPT ZOE LIPPIS Legal Officer at AMAB 2016 Ex-commando who knew CPL Turner well.
EDDIE ROBERTSON Responded to a set of questions posed by Mike - Turner.
Friend of CPL Turner who lost both his legs when his
PTE DAMIEN vehicle was struck by an IED on 3 April 2009. CPL 2009
THOMLINSON Turner witnessed the injury and applied first aid.
Close friend of CPL Turner who died during a building PTE LUKE WORSLEY clearance operation in Afghanistan on 23 November 2007 2007 ADF PERSONNEL (medical) Role Relevant Period Name/Pseudonym Clinical Psychologist at Tobruk Lines Regimental Aid
ANDREA CANTWELL Post (designated health facility for Special Forces Mar 2017 personnel stationed at Holsworthy) who treated CPL Turner in March 2017.
Full time GP with ADF from January 2013 to present.
GP at Holsworthy barracks from 2014 – 2017.
DR BRENDAN HALE Provided treatment to CPL Turner following his return 2014 - 2017 from deployment in Iraq from approximately 31 January 2017 to the time of death.
Unit psychologist at 2 CDO. Took over psychological CAPT KV (also referred care of CPL Turner from Andrea Cantwell in March 2016 and 2017 to as MAJ KV) 2017.
Was copied on MAJ AM’s submission in support of MAJ LK Jun 2016 grant of medical clearance.
CAPT KH Psychologist at 2CDO. 2015 CAPT McLEAN ADF psychologist 2017 DR MM (also referred to GP at the Tobruk Clinic at Holsworthy. 2014 as LTCOL MM) GP at Tobruk Clinic. Supported CPL Turner’s DR PA application for medical waiver to attend promotion 2014 course in August 2014.
DR REPPAS Unit medical officer. Jul 2017 GPCAPT ROSS J07 HQJOC. Jun 2016
CAPT SG 2 CDO psychologist. April/May 2014 CAPT SW Medical officer at 2CDO. 2016 - 2017 DR DUNCAN ADF psychiatrist in 2015; spoke to CAPT KH about September 2015 WALLACE CPL Turner/Joanna Turner in September 2015
NON-ADF MEDICAL PERSONNEL Name Role Relevant Period Visiting psychiatric medical officer at St John of God Apr 2017 – Jul Hospital, Richmond. Treated CPL Turner from 24 April 2017
DR MALIK 2017 when he was admitted to the St John of God Hospital CARMEL POULTER Rehabilitation consultant engaged by the ADF 2017 Consultant psychiatrist at the Sydney Southwest Apr 2014 – Apr Private Hospital. Treated CPL Turner for PTSD, 2017
DR SRINGERI alcohol dependence, etc. from April 2014 until April 2017.
DR JESSICA SWAIN External psychologist engaged by the ADF 2017
FAMILY MEMBERS Name/Pseudonym Relationship Joanna Turner CPL Turner’s wife XS CPL Turner’s stepson ET CPL Turner’s daughter Mike Turner CPL Turner’s father Pat Turner CPL Turner’s mother Christine Turner CPL Turner’s sister Karen Hossain CPL Turner’s sister Lisa Hammond CPL Turner’s sister Steven Turner CPL Turner’s brother (now deceased)
OTHER INDIVIDUALS Name Relationship Hannah Steele Friend of CPL Turner.
ANNEXURE B: DEFINED TERMS / ACRONYMS LOCATIONS (overseas) Term/Acronym Meaning AMAB Al Minhad Air Base, military installation in the United Arab Emirates TQ At-Taqaddum military airbase in Iraq BDSC Baghdad Diplomatic Support Centre LOCATIONS (in Australia) Term/Acronym Meaning TLHC Tobruk Lines Health Centre
ADF ORGANISATIONAL TERMS ADF Australian Defence Force SOCOMD Special Operations Command SOTG Special Operations Task Group HQJOC Headquarters Joint Operations Command 2CDO 2nd Commando Regiment B Coy Bravo Company, one of four infantry companies making up 2 CDO C Coy Charlie Company, one of four infantry companies making up 2 CDO SOER Special Operations Engineer Regiment JHC Joint Health Command IGADF Inspector General Australian Defence Force ADFIS Australian Defence Force Investigative Service
ADF RANKS / POSITIONS CO Commanding Officer - Commands a battalion or equivalent and is ranked as a Lieutenant-Colonel.
OC Officer Commanding - usually a Major who commands a sub-unit of a battalion (or equivalent) such as a Company.
J07 HQJOC Director Health, Headquarters Joint Operations Command.
RMO Regimental Medical Officer.
XO Executive Officer.
NCO Non-commissioned Officer (e.g. Corporal, Sergeant, Warrant Officer).
RSM Regimental Sergeant Major (most senior NCO role in a Battalion).
CSM Company Sergeant major (most senior NCO role in a Company).
BRIG Brigadier COL Colonel LTCOL Lieutenant Colonel MAJ Major GPCAPT Group Captain (RAAF Rank)
CAPT Captain LT Lieutenant WO1 Warrant Officer 1 WO2 Warrant Officer 2 SGT Sergeant CPL Corporal LCPL Lance Corporal PTE Private
OTHER TERMINOLOGY AAR After Action Review COC Chain of Command Defence Force Discipline Act 1982
DFDA DVA Department of Veterans’ Affairs HRT Hostage Recovery Team – specific to OP OKRA NTSC Notice to Show Cause OP SLIPPER Operation Slipper was the ADF contribution to the war in Afghanistan.
OP OKRA Operation Okra was the ADF contribution to the international coalition against the Islamic State in Iraq and Syria RtAPS Return to Australia Psychology Screen POPS Post-Operational Psychological Screening ROI Record of Interview SSPH Sydney Southwest Private Hospital
A 58-year-old man with a 20-year history of chronic depression killed his 15-year-old son before taking his own life. Critical clinical failures included: incomplete handover of medical records when a new GP took over th…
Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…
This coronial finding examines the deaths of six people stabbed by Joel Cauchi at Westfield Bondi Junction on 13 April 2024. Key clinical lessons centre on mental health management: Cauchi had treatment-resistant schizop…
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