Deceased
Colin Neil Amatto
Demographics
40y, male
Coroner
Decision ofDeputy State Coroner Forbes
Date of death
2019-03-01
Finding date
2025-04-16
Cause of death
septic complications from injuries received from multiple dog bites sustained on 24 January 2019
AI-generated summary
Colin Amatto, a 40-year-old Yuin man, died from septic complications following a devastating dog attack with over 80 bite wounds. Critical clinical lesson: the same dog (Boof, a Staffordshire Bull Terrier) had attacked another person severely 18 months earlier but was not declared dangerous or menacing due to legal ambiguities about 'provocation' and inadequate inter-agency coordination. The prior attack was a missed opportunity for protection. Clinical recommendations: regulatory regime reform needed including clearer statutory definitions, improved seizure powers for council officers, enhanced dangerous/menacing dog declaration thresholds, and public education about dog ownership risks—particularly regarding muscular breeds. The coroner emphasised that stricter dog ownership regulation is warranted to prevent similar fatal attacks.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
Inquest:
| Hearing dates:
| Date of final submissions |
| by the parties:
Date of findings
| Place. of findings:
Findings of:
| Catchwords:
| File number:
Representation:
Gareviere Court of NSW, idcombe
CGE Cine Gua 0 oS
Inquest into the death of Colin Neil Amiatko
4-5 and 11-12 March 2024
10 March 2025
| 16 Apri 2025
Deputy state Coroner Carmel Forbes
CORONIAL LAW - Dog aifack= Examination of the Companion
Animals Act 1998 regulatory regime - Recommendations for regulatory changes
2019/68724
Dr D Kell SC with Mr C McGorey, Counsel Assisting, instructed
_ by Ms R Campbell and Ms Y Edgell, NSW Crown Solicitor’s | Office
| Ms K Edwards SC, instructed by Mr A Avery, for Penrith City
Council
Mr C Zoppo, solicitor, Sparke Helmore, for Blacktown City Council
Mr L Chapman, instructed by B Moroney and R Garrett, Moray & Agnew Lawyers, for the Office of Local Government
_ Ms S Love, instructed by J Pereira, Wotton Kearney, for the
Commissioner, NSW Police Force
Non-publication order:
i | i
| Findings: | ij {
Orders for non-publication have been made in this Inquest.
The Orders may be found on the Registry file.
| find that Colin Neil Amatto died on 1 March 2019 at
Westmead Hospital NSW. | am satisfied the cause of his death
eh ae
was septic complications from injuries he received from
multiple dog bites he sustained in his own home on}
24 January 2019. The dogs were known to him and ordinarily
were kept at his residence.
Recommendations:
_ | recommend to the Minister for Local Government and the
| recommend to the Chief Executive of the OLG and the NSW
Commissioner of Police:
developing a model or overarching memorandum of
understanding (MOU), which can be adopted and
utilised for councils and Police Area Commands or
Police Districts regarding the coordination of responses
(including investigation and enforcement), and
formalising of roles and responsibilities of Police and
councils, with respect to dog attack incidents.
training package for council rangers in NSW that are
expected to respond to reports of dog attacks on ;
people or other dogs and of dog escapes.
notices, court outcomes, warnings issued, suspected
contraventions).
amendment of s 16 of the CA Act to delete subsection
The Minister and the OLG consider a | (2)(b). | !
i
The Minister and the OLG consider possible amendment of s 18 of the CA Act to broaden the scope |
for exercise of that power.
The Minister and the OLG examine the appropriateness | of the statutory thresholds and framing of the | provisions in the CA Act for the issuance of notices to
declare a dog a menacing or dangerous dog.
The Minister and the OLG examine the possible
amendment of the CA Act to include an additional
stand-alone offence of a dog attack causing serious
harm or death to a person.
The Minister and OLG consider the possible amendment of the CA Act to confer upon police officers the power to make dangerous and menacing dog :
declarations.
| The Minister and the OLG examine the possible | amendment of the CA Act to introduce a provision | empowering an authorised officer to direct an owner or person in control of a dog to secure the dog with a
muzzle and / or lead for a specified period.
The Minister and the OLG review, or continue to review,
the appropriateness of the rehoming provisions of the
CA Act regarding dogs involved in serious or fatal
attacks.
The Minister and the OLG investigate, or continue to investigate, facilitating reasonable access to DNA
testing in NSW to assist in breed identification of dogs.
The Minister and the OLG examine, in consultation with councils, the development and implementation of a
Statewide public awareness and education campaign to
educate dog owners and the community generally
about the risks posed by dogs and how safely to interact |
with them.
The Minister and the OLG, in consultation with councils | and other stakeholders, consider introducing a licensing | requirement for dog ownership, which may involve | particular licence conditions calibrated for particular ; breeds of dogs and with applicants being required to :
undergo education with respect to safety and risk |
management.
i
The Minister and the OLG examine the adequacy of the |
maximum penalties for the offences provided by ss 12A,
13, 14, 16 and 17 of the CA Act.
The Minister and the OLG review the adequacy of the penalties for non-compliance with registration and identification requirements for dogs in the CA Act and
the Regulation.
| recommend to the Chief Executive Officer of Penrith City
{ Council:
The Council continue to review its standard operating
procedures concerning responding to dog attack |
incidents and the training provided to authorised |
officers as regards the exercise of statutory powers ‘
under the CA Act, including the making of declarations,
| and with a view to ensuring proper coordination of responsibilities if the NSW Police Force is also involved
i in responding to a dog attack incident.
t recommend to the Commissioner, NSW Police Force:
Force’s standard operating procedures, and the training | ; i provided to officers, regarding responses to suspected : dog attacks, the statutory powers available to police
under the CA Act, and in ensuring proper coordination
of responsibilities between Police and councils in
respect of a dog attack incident.
Lee een renee it
Table of Contents
INTRODUCTION COLIN AMATO... ccc eeeseeseesenesereceecuseesesenenseceveesdanseseaaseseesusasiesaeenaeadeeceasanessserseeesesnetesisererenieenenes 9 THE DOGS... ceecccceseeceeesseneneeenneensecesseeseeaeseeeensasecasesesaeaneanecaaesaeeeasesadseenseeeseseesseaeesaeeecsueeaeenineesnaaesiaeces 10 Expert Opinion... cece cece reece cre ceeceseeeaescceeeeeceecaneenseccensesansesaneaseeseesraseeseneasiececeneareees 10 identification/registration HIStory... eects ceeeee eee ceeeececeeneesenseseneesaeceeceaseeesineeteneatneeaeenee 10 ATTACK ON MR AMATTO uu... cccccccccssecscesenececneneesssssuedeerestuaesendseesaanstdetesesestasseneresessesecsenterenseeeeet 1 23 JANUALY 2019... eects cceseneeeeeaesstesesresenseesesvepcaseeeseesiselennesantsaqeeesenavstesesaseeasreseeieaeteten 11 24 SAMUATY 2019... eee cneeeeneeeeceeeseeeeceseeceasnecenscsaeseeseesasueseseansesaeescatsesieeeecsestenesseeaeeecieensieees 12 Mr Amatto’s treatment... cece cceeccseenseeceteenersesseeesescesseesessecaeenesseneeeenesaseeetsesaceressesasessavenseneea 46 REGULATORY REGIME FOR OWNERSHIP AND CONTROL OF DOGS... eeeenereceeeeeeneees 20 ReQistration oo... cee ee eee cece ceeececeeecceeeeseceeeecaeeseeessseeseecasequeeeeeseaesceessecaraesaeeeereereneereamuesareas 21 Provisions for COMtrol ANd SCIZULC osc ceeteeettecaseeetsecedereeescasetertecesesecsacaeneeeseteatareneeeeatenea 21 Restricted, dangerous And MENACING DOGS... cccsccsccsscsteessecseentesessesssecseseeeesersseaeesesseereneaee 23
Process for making a declaration Obligations on dog owner if declaration made.
Enclosure requirements «0.0.0... .cecececeeneereeeeteeees
Control requirements
ISSUES oo. eececceersenrseceeeereeneneeerensneeenasenesneeasenensesonsecess cease eu eensesesesonsesesceeaseaeeesenssceedsasteaeconseteeneeneaaeeas 27 Why did the Companion Animal Regulatory Regime not provide any protection from a further attack by Boof after the vicious attack on Mr Grant in 2017? oo... cccccccescseesseeessseaeesenseceees 27
Did the investigating authorities have the power to seize Boof after the attack on Mr Grant
UI QO17? a ceecccceceeeetenertecseteeeasecaseceeeecsseeecasssceeeeaeeneessceeenessdaasesseaeaeeeeecaeeecasseaaseesineateasescaeistes 29
Why was Boof not declared a dangerous or menacing animal after the attack on
Mr Grant? ... 31 What is the incidence of serious injury from dog attacks in NSW7...
Breeds involved itt AtlaCk So. cecceccccse sce cteeeceeeeesenaaeeneeeaenesedieceeeaeceeeaseeaseseuerscseetsesseneaee 36
Dog attack hospital AUMISSIONS .00....ec ce esc t ec teeeteetteeee cree ceecueneesanesaeseeeeneeteeesesensteensenenes 38
Other reports /HCPAture voc cccecccccscsesesescssccssecssssecesesseseseerscscascesuscsesesseseessteesussessesseeesvaseree 38
Limitation of the restricted dog ProviSiONs 0.0.0... ccc cseessctsceceesssesseeersesnsetaseseeeesstersassesesesreee 42
Licensing Regime for Dog Owners oo... cece cccseecccccceeneceescaneeneseeacsecacaceseuecieeeanesiestacieietesseees
On 24 January 2019, Mr Amatto (40 years of age) was attacked by two dogs that he lived with at Tregear (Tregear Residence), both Staffordshire Bull Terriers. He suffered
severe injuries, with more than 80 bite wounds to his neck, torso, limbs and face.
the intensive care team ceased life support, and he was pronounced deceased.
was put in place after that attack.
medical cause of the death and the circumstances surrounding the death.
safety issues arising out of the death in question.
prevention of a similar death, as Mr Amatto’s , in the future.
Mr Amatto was a proud Yuin man. He came from a big family, he was one of the youngest of 24 first cousins and he had over 200 close family members, who were all
impacted by his death.
Mr Amatto’s sister, described him as funny, charismatic, proud, with a big heart and a wicked sense of humour. He always had a good story to tell. Mr Amatto was excellent at sports, making the focal papers when he was young, with his batting abilities in
cricket.
Family meant so much to Mr Amatto. His sister explained that their family have so many happy memories of him that fill their spirits and make them Jaugh. She has relied on
those memories to help her through the trauma of losing him.
She informed the court that while he was in hospital for the five weeks after the dog attack and fighting for his life, that his family came in droves, coming to see him as often as they could, from near and far. She drove to the hospital every day of those 5 weeks, in the hope that there might be a positive turn in his health. Not only was he attacked with over 80 lacerations to his limbs and torso, his legs were stripped so he had hardly any skin left, the dogs took part of his nose and his ears. She made the difficult decision to amputate his arm to try and save his life, however, unfortunately, this measure was not successful. She then, along with other family members, made the gut-wrenching
final decision to let him be at peace.
Mr Amatto’s father and stepmother could not attend this inquest as they are still
suffering and coming to terms with their loss.
Many of the family members have developed a dog phobia and find it scary just walking down the street knowing what dogs are capable of, regardless of when their owners tell
them that the dog is friendly.
The Amatto family are hoping that changes can be made that will prevent any other family suffering the trauma they have, and are, experiencing. They are particularly
concerned as to why one of the dogs wasn’t put down two years earlier when it had
severely attacked another person. They cannot understand that missed opportunity
that may have ultimately saved Mr Amatto’s life.
Boof was a white and brindled male (desexed) dog, aged about 7 years. At the time of the attack on Mr Amatto, Boof weighed about 30 to 35kg. He was described variously as a “Pit Bull” or, as an American Staffordshire Terrier. At the time of microchipping, and in later registration, Boof’s breed was recorded as a Staffordshire Bull Terrier. He had been bought online (from Gumtree) when he was a pup and had been advertised for
sale as an American Staffordshire Terrier.
Hope was a brown and white female dog, aged 13 years. At the time of the attack on
Mr Amatto, Hope weighed about 25kg. Her owner described her as a Staffy-cross.
At the time of microchipping, Hope’s breed was recorded as a Staffordshire Bull Terrier.
According to their owner, both Boof and Hope were loving dogs.
Baby was an older female English Staffy, aged about 17 years. Baby was not very mobile and, although present in the Tregear Residence, was not involved in the attack on
Mr Amatto.
Expert Opinion
Professor Paul McGreevy, of the Sydney School of Veterinary Science at the University of Sydney, examined photographs of Boof and Hope. He confirmed that Boof and Hope
were both Staffordshire Bull Terriers.
Identification/registration history
Boof was microchipped on 30 August 2012. The following information was recorded at
that time:
(i) Breed: Bull Terrier (Staffordshire).
(ii) Type: male (desexed) that “white and brindle” coloured.
24,
(iii) Date of birth: 2 May 2012.
Boof was about 6 years old at the date of the attack on Mr Amatto in January 2019.
On 1 August 2017, Boof was registered on the Companion Animal Register (CAR) as
residing at 29 Walker Street, Werrington (Werrington Residence).
Hope was microchipped on 15 March 2014. The following information was recorded at
that time:
(i) Breed: Bull Terrier (Staffordshire).
(ii) Type: female - “brown and white” colour.
(iii) Date of birth: 1 January 1999.
Hope was never registered.
The perimeter of the residence’s yard was fenced, and the back yard was separated from the front.
According to Mr Murray and Ms Graham, Mr Amatto got along well with the dogs. He looked after them when they were away. He also played and wrestled with Boof, and the dogs would sleep with him at night.t The dogs were allowed inside the house ona regular basis.
23 January 2019
two daughters, then aged 15 years and 10 years of age, stayed overnight at the Tregear
Residence while visiting Mr Amatto.
1Ex 1 Vol 1 Tab 10
Ms Casperson and Mr Amatto were previously in a relationship, from about 1995 to
with her two children.
Ms Casperson, and her daughters, arrived at the residence at about 5:00 pm on Wednesday, 23 January 2019. At that time, Boof and Hope, were put in the backyard by Mr Murray. Mr Murray later told Police he did this because the dogs were “funny with
new people” .*
About an hour or so later, Mr Murray let the dogs back inside the house — so that, “they
[the dogs] could meet the people [the visitors] and... get used to them and all of that”?
According to Mr Murray, Hope growled under its breath at Ms Casperson occasionally,’ but there were otherwise no issues or anything to cause alarm, and “the dogs were fine
with them.”>
Ms Graham said that once the dogs were brought in from outside “[t]here wasn’t any problems there at all’,® everything was fine that night,” and none of the dogs seemed
to have any issues with anyone in the house.®
That evening, either one or both dogs slept on the bed that Ms Casperson’s two
daughters were using.
24 January 2019
The next morning, Thursday 24 January 2019, Mr Amatto left to go to work, while
Ms Casperson and her two girls stayed at the house with Mr Murray and Ms Graham.
At about 11:00 am, Mr Murray, Ms Graham (and their baby daughter) went to a doctor’s
appointment, leaving Ms Casperson and her daughters alone at the residence.
2x 1 Vol 1 Tab 10
3 Ex 1 Vol 1 Tab 10
*Ex 1 Vol 1 Tab 10 pp 11-12, and 13.
Sex 1 Vol 1 Tab 10p 11.
® Ex 1 Vol 1 Tab 11, p15.
7Ex1Vol 1 Tab 11, p15.
8 Ex 1 Vol 1 Tab 11, p16.
About 40 minutes after Mr Murray and Ms Graham left for the doctor’s appointment,
Mr Amatto came back from work.
Ms Graham said that, before they left to go to the doctor’s appointment, she put the
(two) dogs outside.
Mr Murray agreed and said that before he and Ms Graham left to go to the doctor’s he saw Ms Graham put Boof and Hope outside. Mr Murray also said that, out of habit, he double checked the security door (the back door) was shut by giving it a push and a pull
to ensure it was secure.
Ms Casperson said that the dogs were left inside the house.
Either way, after Mr Murray and Ms Graham left the residence to go to the doctor’s
appointment:
(i) At some point, Mr Amatto arrived home from work.
(ii) At some point, all 3 dogs were in the house, together with Mr Amatto, Ms Casperson and her two children. Either the two younger dogs, Boof and Hope, were already in the house or, by some means, they had got back inside the house,
possibly when Mr Amatto came home.
(iii) At about 1:00 pm, inside the house, one of the two dogs bit Ms Casperson’s daughter on her abdomen and back causing her to scream. Her daughter later
received treatment at hospital for that injury.
(iv) Ms Casperson tried to help her daughter and was herself bitten on her right
forearm. She also later received treatment at hospital for that injury.
(v) Mr Amatto then intervened to try to help and Ms Casperson and her daughter.
(vi) Ms Casperson and her daughters managed to leave the house via the front door,
which shut behind them (and locked), with Mr Amatto inside.
(vil) Boofthen savagely attacked Mr Amatto. Hope joined in the attack. It was an attack
of extreme ferocity.
(viii) Shortly before 1:00 pm, Mr Murray and Ms Graham arrived back at the residence.
Mr Murray and Ms Graham left their child in their car and entered the residence
through the front door with their key. They saw blood on the lounge room floor
and smeared on the walls. The kitchen door was shut with blood on it.
(ix) The dogs were in the hallway covered in blood and they secured them in the bathroom. Ms Graham said that the dogs were “just covered” in blood and “their
eyes were really big.”®
(x) They found Mr Amatto on the kitchen floor, covered in blood, barely conscious.
Mr Amatto stated, “! can’t breathe” and then lost consciousness.
Emergency response
49,
At about 12:58 pm, the NSW Ambulance Service were called to the residence.
At about 1:04 pm, paramedics arrived. Mr Amatto was in cardiac arrest with multiple lacerations to his entire body. Paramedics commenced cardiopulmonary resuscitation.
Mr Amatto suffered cardiac arrest several more times but was revived by paramedics.
At about 1:10 pm, Senior Constable Kumar and Constable Horne arrived. They saw Ms Casperson with a bloodied towel wrapped around her arm and her daughter with
an abdominal injury.
Mr Amatto was transported to Westmead Hospital by Care Flight.
The RSPCA was called to the scene and the dogs were sedated. Mr Murray provided
consent authorising them to be surrendered and later destroyed.
Boof and Hope were euthanised the next day.
Ms Casperson and her daughters were taken to Westmead Children’s Hospital by
ambulance.
Paramedics observed a large bite wound the size of a fist on Ms Casperson’s daughter’s left flank with multiple punctures evident. Ms Casperson was also injured, having been
bitten on her right forearm.
2 —x 1 Vol 1 Tab 11 p 21.
Mr Amatto’s treatment
$1.
Mr Amatto arrived at Westmead Hospital at about 2:26 pm.
He had suffered very extensive injuries. Treating doctors estimated he had over 80 wounds with multiple bite wounds over his body, neck, torso and limbs, and extensive
facial wounds.
Mr Amatto underwent a transfusion and was taken urgently to surgery. He was admitted as an intensive care patient for the next 36 days and underwent multiple
surgeries.
In her post-mortem report, the forensic pathologist, Dr Irvine, noted;
‘Over the course of the 36 day hospitalisation he developed persistent multiorgan failure in the context of septic shock. Acute kidney injury was multifactorial including sepsis, hypovolaemia and rhabdomyolysis (muscle breakdown because of crush injury). He had ischaemic hepatitis, coagulopathy, and gastrointestinal bleeding because of ischaemic colitis. A tracheostomy was created because of prolonged ventilator dependence. The deceased underwent multiple surgical interventions. His left arm was
amputated on 31 January 2019...
Ultimately he developed persistent fungal wound infections, cavitating fungal lesions in his lungs (causing pneumothoraxes, or lung collapse) and possible lesions in his brain. On 1 March 2019 he began to bleed from his lower gastrointestinal tract, likely related to ischaemic colitis. Following discussion with his family regarding his condition and the likelihood of further complications, the decision was made to afford him palliative care. He was pronounced fife extinct on 1 March 2019 at 8:04 pm (on the 36 hospital day).’7°
EX 1 Vol 1 Tab 4
Mr Amatto pronounced deceased on 1 March 2019
On Monday, 24 July 2017, about 18 months prior to this fatal attack on Mr Amatto, there was an earlier attack on a person by the dog Boof.
The victim of the attack was a property agent, Barry Grant, who was then 65 years old.
The attack occurred at 29 Walker Street, Werrington (Werrington Residence), which was a rented property where Mr Murray and Ms Graham lived (with their dogs) prior to moving to the Tregear Residence. The Werrington Residence fell within the local government area (LGA) of Penrith City Council. Mr Amatto was not living with Mr Murray and Ms Graham at that time.
Mr Grant attended the Werrington Residence, without an appointment, in his capacity as a property agent, for the landlord, to try to speak with the tenants. The property at 29 Walker Street, Werrington was a two-story residence, with one set of tenants living on the ground floor, and a second set of tenants living on the upstairs level.
Mr Grant knocked on the front door of the property, which was the entrance to the upstairs levei, but there was no answer.
Mr Grant went to the wooden gate at the front of the property. This was the entrance to the downstairs level. On Mr Grant’s account, the wooden gate was not locked and upon knocking on it, it swung backwards (towards the rear of the property).
A brown dog appeared, which appeared to be friendly and which Mr Grant bent down
to pat. A second dog, which Mr Grant described to Police as appearing to be a “white
Pit-bull”,14 and which was in fact Boof, ran towards Mr Grant, jumped at him and
attacked him.
The dog latched on to his left arm, pulled its head from side to side and pulled Mr Grant
backwards. The dog also bit his leg, thigh, and stomach.
Mr Grant yelled out for help and struggled to try to get away. He was able to pick up a
broom from the front porch and tried to fend off the dog with it.
A brave 15-year-old boy from a neighbouring property, Mr Delton Monti, heard Mr Grant screaming for help and saw Mr Grant being attacked. Mr Monti ran to assist Mr Grant. He picked up a small plastic chair from the front part of the property and used it to fend off the attacking dog. | commend the actions of Mr Monti which may well
have saved Mr Grant’s life.
Following the attack, Mr Grant was taken by ambulance to Nepean Hospital for surgery on his arms and where he remained for 4 days. He then spent several weeks receiving
outpatient treatment for his injuries.
Medical records obtained as part of the coronial investigation indicate that Mr Grant suffered bite wounds and lacerations to his left and right forearms and hands, abrasions
to his abdomen and a puncture wound to his left thigh.??
NSW Police attended the scene and spoke with Mr Grant {while he was in the ambulance, and then later in hospital) and also spoke with Mr Murray, the owner of the
dogs.
The COPS record stated:
“At 15:00 pm Police attended the address of 22 Railway Street, Werrington and spoke to the VIC who was in the rear of the Ambulance vehicle at the time. Police checked on the welfare of the VIC before obtaining his particulars. Police also to the resident of the address who had helped free the VIC [Delton Monti]. Police were informed that the dog had gone back to
where it comes from while pointing out the double storey home in the
4 Ex 1 Vol 3 Tab 61 2 Ex 1 Vol 3 Tab 65
adjacent street. The VIC was conveyed to Nepean District Hospital for further
assessment.
Police contacted the dog catcher [the Council] to attend the location.
Police attended the address of 29 Walker Street, Werrington and spoke to the downstairs occupant who is the owner of the dog [Mr] MURRAY.
MURRAY informed Police that the dog was in the rear yard secured. Police spoke to the OWNER obtaining his particulars. OWNER informed Police that he has owned the dog throughout its entire four-year existence and that he has never done anything like this. The owner told Police that he was not expecting the VIC to attend his address and that there was no appointment
made.
The OWNER further told Police that he had only just gone out with his partner and young child for a short time locking his wooden gate before leaving. The OWNER arrived home around 30 minutes later and opened the wooden gate using his key, in opening the gate he had observed a set of car keys as well as a folder containing several documents situated on the ground by the gate.
The OWNER later observed what appeared to be droplets of blood on the gate. A short time later Danielle from Animal Services [the Council] attended the location and spoke with Police as well as the owner. The OWNER had agreed to walk "BOOF" out to the rear of the caged ute where the dog was safely secured before being taken to Hawkesbury Animal Services [the pound] where he will be caged and housed. With consent of the occupant, Police looked over the rear yard of the owner observing the owner's other two dogs. After looking along the side colourbond fence police were satisfied that the yard is well secured. The OWNER appeared shocked and apologetic further telling Police that his dog has never attacked anybody in the past, questioning why the agent had opened his gate. Photographs of the yard and
side gate obtained.”?
3 Ex 1 Val3 Tab 62
NSW Police and Penrith City Council
offences under the Companion Animals Act or otherwise.
that, in effect, the Council could provide:
“Assistance in relation to details of The Companion Animals Act 1998 and any other requests police may have for possible action, orders, etc... | said that I’m led to believe that the dog may have been defending his property and therefore this may not be an offence / attack matter that we are dealing
with.”
the dog Baof back to the owner. A COPS system entry states:
“On Thursday the 27 July 2017, police were contacted by Animal Services Officer, Amanda Burns from Penrith City Council in relation to the release of the dog. While speaking with Amanda Burns, she advised police that as the victim entered the rear yard without the consent or knowledge of the owner, the dog was an "animal in defence of property", and as such no offences
were committed.
Police have provided Amanda Burns consent to release the animal to its
owner. Event to be finalised...
History:
On Monday the 24th of July 2017, a male American Staffy attacked a male in the rear yard of 29 Walker Street, Werrington. This attack resulted in the male sustaining bite injuries to both arms which have required hospital
treatment. As a result, police attended the premises and with the assistance
“Ex 1 Vol 1 Tab 49
of an animal services officer, seized the dog. Since this date the dog has been held at Hawkesbury Animal Services. The dog has been held at this location until police could determine the circumstances of the incident and whether
action was required against the behaviour of the dog.
Current Situation
Police investigations to date have identified that the victim of this dog attack entered the rear yard of the premise without the consent or knowledge of the owner. As a result, it is the view of police that the dog was an “animal in defence of property", as it was on its own land. As a result, it has been determined that no offence has been committed. The dog can now be
returned to its owner with no further police action anticipated.”
registered on the CAR.15
principally to the local government councils within their respective LGAs.
compliance with its requirements by imposing criminal sanctions for non-compliance.
1S CA Act, s 64(4) (an unregistered animal that is required to be registered cannot be claimed until an
application for registration has been properly made and any registration fee has been paid).
Registration
Part 9 of the CA Act provides for the creation and operation of the Register of
Companion Animals (CAR).
Owners must ensure that, from the time that a “companion animal” (which, relevantly, includes a dog) is 12 weeks old, it is “identified”: s 8(1). By reference to the Regulation {cl 5), the dog is to be identified by a microchip. Identification information includes “the type of animal (dog or cat), and the breed of the animal” (cl 8(g), Regulation). The owner
of a dog can be guilty of an offence if the dog is not so identified: s 8(3).
Owners must also ensure that a companion animal is registered s9. This is a step separate from the identification requirement referred to above. The information recorded for a dog is to include its breed: s 80(1)(g). Registration of dogs can be undertaken at a relevant Local Government administration building or online through
the NSW Pet Registry.
Provisions for control and seizure
Sections 12 to 28 of the CA Act set out provisions dealing with the responsibilities for
control of dogs. A limited power of seizure is provided bys 18.
Section 18 relevantly provides as follows: “18 Dog that has attacked or bitten may be secured or seized
(1) If a dog attacks or bites any person or animal (except vermin) otherwise than in the circumstances referred to in section 16(2), an authorised officer may, at any time within 72 hours after the attack or bite—
(a) secure the dog on property that the officer has reason to believe is occupied by the dog’s owner, or
(b}) seize the dog.
(2} Any other person may seize the dog if the dog is on property owned
or occupied by the person.
(3) If the dog is on property that an authorised officer has reason to believe is occupied by the dog’s owner, the officer may seize the dog
only if the officer is satisfied that—
(a) the dog cannot be kept adequately secured on that property,
or
(b) the dog cannot be kept under the effective control of some
competent person while it is on that property, or
(c) the owner of the dog has repeatedly failed to keep the dog secured on that property or under the effective control of a competent person while it is on that property (regardless of whether the dog is secured or under effective control at the
relevant time).
(6) This section applies whether or not any injury is caused to a
person or animal by the dog’s attack or bite.”
(1) If a dog rushes at, attacks, bites, harasses or chases any person ...
whether or not any injury is caused to the person ...—
(a) the owner of the dog, or
(b) if the owner is not present at the time of the offence and another person who is of or above the age of 16 years is in charge of the dog
at that time—that other person, is guilty of an offence.
Maximum penalty—
(a) 100 penalty units except in the case of a dangerous, menacing or
restricted dog, or
(b) 400 penalty units in the case of a dangerous, menacing or
restricted dog.
(2) It is not an offence under this section if the incident occurred—
(a) as a result of the dog being teased, mistreated, attacked or
otherwise provoked, or
(b) as a result of the person or animal trespassing on the property on
which the dog was being kept, or
(c) as a result of the dog acting in reasonable defence of a person or
property, or...”
Restricted, dangerous and menacing dogs
The CA Act contains additional provisions, including restrictions, relating to dogs that fall within the statutory definitions of “restricted dog”, “dangerous dog” and
“menacing dog”.
The magnitude of requirements for these categories descends from restricted to menacing, with the former having the most restrictive obligations and the latter the least restrictive. This reflects the legislature’s view of the respective dangers of each
category of dog.
A “restricted dog” includes specific breeds (including American pit bull terriers or pit bull terriers), a dog declared to be a restricted dog, or any breed, kind or description
prescribed by the Regulation: s 55{1}.
An American Staffordshire Terrier is not a “restricted dog” under the CA Act.
Process for making a declaration
A dog relevantly becomes a dangerous dog or menacing dog upon the making of a declaration to that effect (s 5(1)), which can occur only after notice of an intention to make such a declaration has been served on the dog owner and consideration has been given to any objections made, within 7 days, by the dog owner: ss 34({1) and (1A}, 35 and 37.
intention and make a declaration.
“34 Authorised officer may declare dog to be dangerous dog or menacing
dog
(1) An authorised officer of a council may declare a dog to be a
dangerous dog if the authorised officer is satisfied that—
(a) the dog is dangerous, or
(1A) An authorised officer of a council may declare a dog to be a
menacing dog if the authorised officer is satisfied that—
(a) the dog is menacing, or
(2) A declaration can be made on the officer’s own initiative or on the
written application of a police officer or any other person.”
“dangerous dog” and “menacing dog” as follows: “33 Meaning of “dangerous” (1) For the purposes of this Act, a dog is dangerous if it—
(a) has, without provocation, attacked or killed a person or
animal (other than vermin), or
(b} has, without provocation, repeatedly threatened to attack or
repeatedly chased a person or animal (other than vermin), ...”
And:
“33A Meaning of “menacing” and “menacing breed or kind of dog” (1) For the purposes of this Act, a dog is menacing if it—
(a) has displayed unreasonable aggression towards a person or
animal (other than vermin), or
(b) has, without provocation, attacked a person or animal (other
than vermin) but without causing serious injury or death.
(2) The regulations may declare a breed or kind of dog to be a menacing breed or kind of dog.
Obligations on dog owner if declaration made
dangerous dogs or menacing dogs. Owners must obtain annual permits for a dog that
is, or has been declared to be, a dangerous dog. A permit is not required for a dog
declared to be a menacing dog.
(i) the enclosure; and
(ii) the control of dangerous and menacing dogs, along with the selling and
acceptance of ownership of such dogs.
+6 The term “serious injury”, referred to in s 33A(1), is defined, non-exhaustively, ins 33A(4), Note also that
5 33A(2) provides that the regulations may dectare a breed or a kind of dog to be a menacing breed or kind of
dog. The power to make that regulation is subject to s 33A(3). No such regulation has been issued to date.
Enclosure requirements
Regarding the enclosure requirement:
(ii)
Dangerous dog: While on the property at which it is ordinarily kept, a dangerous dog must be kept in an enclosure that meets the requirements prescribed by the
Regulation: s 51(1).1”
Menacing dog: While on the property at which it is ordinarily kept, and while it is not under the effective control of a person aged 18 years or above, a menacing
dog must be enclosed to prevent a child accessing it: s 51(1A).1®
Clause 32 of the Regulation specifies requirements for the enclosures on properties for
dangerous dogs (but not for menacing dogs). These include that the enclosure must:
(iii)
(iv)
(v) (vi)
(vii) (viii)
be fully enclosed, constructed and maintained so the dog cannot dig under or
escape from it;
be constructed so a person cannot have access to it without the assistance of an
occupier of the property who is above the age of 18 years; be designed to prevent children having access to the enclosure;
not be positioned on the property such that people are required to pass through
it to gain access to other parts of the property; have a minimum height of 1.8 metres and a minimum width of 1.8 metres;
have wails, a fixed covering and a (self-enclosing} gate constructed of brick, timber, iron, or similar solid material or material that otherwise meets the
specified requirements, as well as a floor constructed of sealed concrete.
A person is prohibited from owning a dangerous dog unless a certificate of compliance
is in force for the enclosure in which the dog is required to be kept under s 51(1){a):
s 58H(1).
Y CA Act, 5 51(1). The owner of the dog must obtain a certificate of compliance in relation to the prescribed enclosure: 5 58H.
38 CA Act, s 51(1A). The CA Act does not require that a menacing dog enclosure satisfy the certification requirements applicable for restricted or dangerous dogs.
Control requirements
(i} | Dangerous dog: Whenever outside its enclosure, a dangerous dog must be under the effective control of a competent person by specified means (chain, cord or leash) and muzzled: ss 51(1) and 56. This requirement applies even when the dog
is within the property at which it ordinarily resides if it is outside its enclosure.
(ii) | Menacing dog: Whenever a menacing dog is outside the property at which it is ordinarily kept it must be under the effective control of a competent person by specified means and muzzled. This requirement does not apply when the dog is
within the property at which it ordinarily resides s 51(1A).
to seize a dangerous dog or menacing dog: (s 52).
Why did the Companion Animal Regulatory Regime not provide any protection from a
further attack by Boof after the vicious attack on Mr Grant in 2017?
Was the attack on Mr Grant appropriately investigated?
offering assistance.
with the operation and enforcement of the CA Act that council officers have.
104,
The Council officers gave evidence that there had been frustration on their behalf in instances when Police commenced a dog attack investigation and then passed, or attempted to pass, the investigation on to the Council. With respect to the attack on Mr Grant there were timing issues with Police being on duty and the speed in which information was coming back to the Council, particularly when they were concerned about whether the seizure of the dog was authorised and whether or not they were to
make a declaration in relation to the dog.
Penrith City Council has informed this inquest that a more formal understanding is being put in place between the Council and the local Palice. At present there are Memoranda of Understanding between Police Area Commands and two Local Councils in relation to the CA Act in NSW. One with Sutherland Shire Council and one with Campbelltown City Council. The Police are of the opinion that it would be more practical and pragmatic to enter into an overarching or model Memorandum of Understanding with the OLG. That document could then be implemented by all focal councils and Police districts
throughout NSW.
| propose to recommend that the OLG and the Commissioner of Police consider developing a model or overarching Memorandum of Understanding, which can be adopted and utilised for councils and Police Area Commands or Police Districts, regarding the coordination of responses, including investigation and enforcement, and the formalising of roles and responsibilities of Police and councils with respect to dog
attack incidents.
The CAR records information regarding the history of a dog including penalty notices, outcomes, warnings issued and suspected contraventions. Council officers do not have ready access to the CAR in the field. The information may inform an officer’s decision and actions in response to an event, such as a dog attack or escape, including assessments of the competence of an owner to keep his or her dog under effective control and to take appropriate measures to secure the dog within the property at
which it is ordinarily kept.
The Penrith City Council officer informed this Court that this was a significant limitation of the CAR and emphasised that the CAR should include accessible histories of
regulatory actions against an owner and also adverse interactions, or penalty notice and
court outcomes, in relation to CA Act offences. | propose to recommend that the OLG review and update the functionality of the CAR to enable councils readily to access the
regulatory history of dog owners.
| also propose to recommend to the Chief Executive Officer of Penrith City Council that the Council continue to review its standing operating procedures concerning responding to dog attack incidents and the training provided to authorised officers as regards the exercise of statutory powers under the CA Act, including the making of declarations, with a view to ensuring proper coordination of responsibilities if the NSW
Police Force is also involved in responding to a dog attack incident.
Did the investigating authorities have the power to seize Boof after the attack an Mr Grant in
2017?
Mr Grant described in his evidence that as he knocked on the wooden gate at the Werrington Residence it swung open and he took a step into the property and patted a first dog before he was then pulled further into the property in the attack by Boof. It is not in dispute that his actions of entering the property in that manner in the circumstances of attending the property without any prior arrangement amounted to a
trespass at law.!9
After the attack, Police arrived at the scene and requested the Penrith City Council to send an Animal Services Officer (ASO) to seize Boof while Police investigated the matter further. The ASO took Boof to the pound. She believed she was exercising a power of seizure under s 18(1) of the CA Act. She also believed that the Police were going to
investigate the attack.
Penrith City Council became concerned as to whether there had been a lawful basis for seizing Boof. It was thought that in the circumstances of s 16 (2)(b) CA Act (person trespassing) or s 16(2)(c} CA Act (dog acting in reasonable defence of property) that the
seizure powers in s 18 (1) CA Act might have been precluded.
19 For a discussion on the legal principles of trespass in the circumstance see Counsel Assisiting’s Closing Submissions dated 11 December 2024 pp 32-37
As a result of that concern, the owner, Mr Murray, was not required to pay the impound
fees when Boof was released from the pound on 28 July 2017.
The steps taken by Police and, principally, Penrith City Council to arrange for the dog Boof to be seized, while a Police investigation took place, arose in circumstances where the full factual position was still emerging. The dog had attacked Mr Grant with extreme ferocity, causing significant injuries. There was an understandable concern, on the part of Police (and, in turn, the Council) that an apparently vicious dog be seized and
removed, in the interests of public safety, while the matter was investigated.
. That said, the concerns held by Penrith City Council as to whether the seizure was lawful
were justified. On the information obtained from Police at the scene, it appeared that the victim of the attack had, or may have, entered the rear of the property without
permission.
The power conferred by s 18 is exercisable only in limited circumstances and is
significantly constrained by its reference to s 16(2).
Council officers who respond to a suspected dog attack should have the clear authority to seize the dog. They may have incomplete information about the circumstances of the attack and related matters. They may have little information of the manner in which the dog was secured or controlled by its owner and how effective such arrangements might be in the future. They also may have little information on the history of the dog or the dog owner including as to their past compliance with the obligations under the CA Act and Regulation and any other information relevant to an assessment of their
competence and reliability.
The interests of public safety may be undermined if a general power of seizure and impounding, at least as an interim measure, is not readily available to an authorised
officer and which makes appropriate allowance for such difficulties.
[t is in the interests of both clarity and public safety in there being a clearly conferred power of seizure under the CA Act to permit an authorised council officer to seize and impound a dog, at least for an interim period while investigations are undertaken, and
which does not have the existing restriction imposed by the connection to s 16(2).
| propose to recommend that there be an amendment to s 16(2}(b) CA Act. That section
applies irrespective of the severity of the attack and even if the entry of a person on a property where the dog is being kept is momentary. The section affects the seizure power ins 18 CA Act. I propose to recommend an amendment to s 18 CA Act to broaden the scope for the exercise of the power to seize a dog so that council officers and/or
police officers may seize a dog while an investigation into an attack is undertaken.
| propose to make a recommendation to the NSW Commissioner of Police that the Commissioner consider reviewing the NSW Police Force’s standard operating procedures, and the training provided to officers, regarding responses to suspected dog attacks, the statutory powers available to police under their CA Act and ensuring proper coordination of responsibilities between Police and councils in respect of a dog attack
incident. | note that the Commissioner of NSW Police supports this recommendation.
Why was Boof not declared a dangerous or menacing animal after the attack on Mr Grant?
119,
The process for making a dangerous dog or menacing dog declaration, and the consequences of so doing, is described in paragraphs [86]-[96] above. The key criteria, in the definitions of dangerous dog and menacing dog, are contained in ss 33 and 33A
of the CA Act, as set out at [89] above.
Under the CA Act the Council is the entity empowered to make a dangerous or
menacing dog declaration.
After the 2017 attack on Mr Grant, Penrith City Council did not take any steps towards making a dangerous dog or menacing dog declaration with respect to Boof. The Council gave evidence that because the matter involved an investigation being conducted by Police that the Council was waiting on information from Police and notification of an outcome from the Police investigation. The Council gave evidence that, because of their concern about the seizure of Boof, there was some urgency in the Council finding out what Police had determined in terms of whether there was an offence on the property and whether the Counci! would therefore be commencing some action for a dangerous or menacing dog declaration, or whether the dog was to
be returned to its owner.
On 27 July 2017 the Police determined that no offence had been committed by Boof and that he could be returned to his owner. Consequently, the Council arranged for
the dog to be returned to its owner.
A dog can only be declared a dangerous dog if it has “without provocation” attacked a person (s33({1)(a)). The CA Act does not define the term “provocation” or the expression “without provocation”. It is arguable that the presence of a person in the rear of a property who is a trespasser at law may constitute provocation for a dog that attacks that person. The Council officer gave evidence that she certainly considered a person entering the property without consent would amount to provocation of a dog,
even if all the person did was to greet and pat it.
A dog. can only be declared a menacing dog if it has displayed unreasonable aggression towards a person, or without provocation attacks a person. The concept of unreasonable aggression is not straightforward. The Council officer was of the opinion that Boof’s actions did not amount to unreasonable aggression. That an attack in the property in which a dog is normally kept upon a trespasser does not amount to
unreasonable aggression.
Even if Boof had been declared a menacing dog it is unlikely that any of the enclosure or control requirements obligations placed on the owner would have operated in such
a way to protect Mr Amatto.
The provisions of the CA Act were not able to protect Mr Amatto from Boof despite
the vicious attack on Mr Grant.
The OLG should examine the appropriateness and framing of the terms “without provocation” and “unreasonable aggression” and “acting in reasonable defence or person or property”. Furthermore, consideration of whether the CA Act should make clear whether any trespass, even momentary trespass, should be taken to constitute
provocation or to involve a dog acting in reasonable defence of a personal property.
| propose to make a recommendation to the Minister for Local Government and the OLG that the appropriateness of the statutory thresholds and framing of the provisions in the CA Act for the issuance of notices to declare a dog a menacing oar
dangerous dog be reviewed.
129,
| also propose to recommend that the CA Act include an additional standalone offence of a dog attack causing serious harm or death to a person. The penalties should include, at the least, control and enclosure obligations on the owner including in their
own home.
The CA Act does not confer power on a police officer to declare a dog dangerous or menacing. | propose to recommend that upon the review of the CA Act that consideration be given to confer upon police officers the power to make dangerous and menacing dog declarations. | note that the Commissioner of NSW Police is of the opinion that authorised officers of council are more appropriately trained and resourced to make such declarations. However, it appears incongruous that Police may be involved in investigating a serious dog attack incident including in determining what enforcement action should be taken under the CA Act and yet have no power to
make a declaration which may well be appropriate in the interest of public safety.
The CA Act does not provide statutory power to permit an authorised officer to make a direction to the owner of a dog to secure the dog with a muzzle or lead (whether in public or while the dog is in the property at which it is ordinarily kept). It is in the interest of public safety for authorised officers to have such a power. The circumstances in which a risk to public safety from a dog may arise are wide, varied and impossible to predict in advance. The contemplated power is particularly significant while further investigations and potential processes are undertaken, or pending other measures being implemented such as securing a faulty gate or hole in
a property fence from which a dog may be able to escape.
| propose to recommend that the CA Act be amended to include a provision empowering an authorised officer to direct an owner or person in control of a dog to
secure the dog with a muzzle and or lead for a specified period.
What is the incidence of serious injury from dog attacks in NSW?
The matters being considered by this Court, both at the present inquest hearing and in other inquest matters involving fatal dog attacks, reveal a concerning number of
fatal dog attacks in NSW between 2009 and 2023, namely:
Date of the fatal attack
Matter
Key facts
January 2009
Burke Inquest
Deceased: child (3 years old).
Location of attack: residential home of friends of the deceased's parents. The deceased and her sibling (14 months old) were visiting (being minded by their parents’ friends). The dogs ordinarily lived at that home.
Breed of dogs (4 dogs suspected to be involved in attack): breed of dogs not specified in findings (at least 3 of the 5 dogs at the home described to be Bull Mastiff-Cross-Rhodesian Ridgebacks?°).
March 2018
Jones Inquest2+
Deceased: infant (13 months old).
Location of attack: residential home of a family member (grandmother). The attack occurred when the deceased, and her parents, were visiting the family member’s home.
Breed of dog (1 dog): Rottweiler.
Registration status: dog not registered (was microchipped).
Known history to council (before fatal attack): no known prior attacks on animals or people.
May 2019
OReilly
Inquest
Deceased: adult female (72 years old).
Location of attack: residential home at which the deceased lived with the dog and her husband.
Breed of dog: registered as American Staffordshire Terrier,
Registration status: registered (and microchipped).
Known history to council (before fatal attack}: no known history of attacks or aggression.
70 See https://www.smh.com.au/national/frenzied-dogs-killed-ruby-lea-inquest-20110920- Ikjdy.html#.
4 The holding of an inquest into the death of IK was dispensed with on 19 September 2018
June 2019
Smith
Inquest
Deceased: adult male (50 years of age).
Location of attack: inside the residential home at which the deceased ordinarily lived. The dog belonged to the deceased’s flat mate and ordinarily lived there.
Breed of dog: registered as a Staffordshire cross.
Registration status: registered (and microchipped).
Known history to council (before fatal attack): no known history of attacks or aggression.?2
March 2020
Holland
Inquest
Deceased: adult female (90 years of age).
Location of attack: public beach after the 3 dogs left their property unaccompanied. Before and after the fatal attack, the dogs attacked four other people, including the deceased’s adult daughter and a 79-yearold female friend of the deceased causing serious injuries.
Breed of dogs (3 dogs): crossbreed of multiple breeds which included Staffordshire Bull Terrier (not restricted breed).
Registration status: none of the 3 dogs registered (only one microchipped).
Known history to council (before fatal attack): several notices and penalty notices issued for non-registration of dogs. One report of an unprovoked attack ona person living near to the dogs’ home about one week before the fatal attack.
July 2021
MJ (nquest
Deceased: infant (5 weeks old).
Location of attack: family home (where the dog ordinarily lived).
Breed of dog (1 dog): American Staffordshire Terrier (not restricted breed).
Registration status: registered (and microchipped).
Known history to council (before fatal attack): one report of suspected attack on another dog about one month before fatal attack.
22 The holding of an inquest into the death of SG was dispensed with on 25 February 2020
November Pollard Deceased: child (2 years old).
2022 Inquest
Location of attack: motel accommodation at which the child, sibling and mother were temporarily staying and where the dogs ordinarily lived (owned by motel operator).
Breed of dogs (2 dogs): Rottweiler (primary attacker) and Australian cattle dog (crossbreed).
Registration status: neither dog registered (only one dog microchipped).
Known history to council (before fatal attack): no known history of attacks or aggression against people for either dog.
Feb 2023 RM Inquest | Deceased: infant (5 weeks old).
Location of attack: residential home of a family member (not the deceased’s home). The attack occurred when the deceased, and her parents, went to a family gathering at the family member's home.
Breed of dogs (2 dogs): Rottweilers.
Registration status: both dogs registered (and microchipped).
Known history to council (before fatal attack): no known history of attacks or aggression for either dog.
Breeds involved in attacks
local government matters.”
?3 See OLG website: https://www.olg.nsw.gov.au/.
2021, while Rottweilers were also involved in a relatively high number of attacks:**
2rd , | soze | 16783 | i \ Number of attacking dogs in NSW by breed per year | \ | Top 20 attacking dog breeds in NSW) [oe mp “ 18 | | _ ~ _ zeae | zo20 | zorsee | 2018 | Total | | American Staffordshire Terrier i 413 | 677, 806 | 483 029: {2 | Bull Terrier (Staffordshire) | 2100 | 4350397 33501377 LL | Australian Cattle Dog | 138 232 i 212 j 205 i 787 | : ; | German Shepherd Dog | 115 j 204 : 202 ; 189 710 : : | Bull Terrier (Staffordshire) — Cross Breed 60 i 135 : M6 | 120 : 431 ottweiler 58 1280 2d | 1096 ustralian Kelpie rs ee : ( ?
merican Staffordshire Terrier—Cross Breed | 939 | S95 | | 8 astiff ~ Cross Breed 2 | 82; Sse Border Collie . |. 56 ' 99 os | 8m | Siberian Husky 50 1 7? : 76 | 76 (279 Labrador Retriever 44 6 | sz fm Australian Kelpie — Cross Breed od 49 : 27 i 60 ! 52 | 188 | : Bull Terrier <n C Buil Mastiff sO rr 16 Australian Cattle Dog ~ Cross Breed 35 i is : $9 | 51 : 1600: . | Mastiff 5 3% SE ts ; \ Boxer Se © = Bull Mastiff ~ Cross Breed : 0 ee ee ee | Jack Russell Terrier ; 0 nr 330 a2
*01/01/2021-36/06/2021 **The 2019 July-September data is not publicly available
be removed from the home, impounded and possibly destroyed.
4 A caveat with respect to this data is the potential inaccuracy with breed identification in particular cases, given the difficulties in accurate identification based on features and/or the unreliability arising from selfreports of owners. Nor do these statistics provide figures for the number of attacks relative to the total number of dogs of the particular breed type.
25 Ex 3 at [47]
Dog attack hospital admissions
and New Zealand Journal of Public Health (2017), relevantly state:2°
“This study has identified a number of patterns in the statistical data for dog bite injuries in contemporary Australia. On average each year between 2001 and 2013, 2601 persons required hospitalisation for dog bite injuries in Australia at an annual rate of 12.39 per 100,000. The highest incidence density was for infants and children aged 0-4 years and the next highest
was for 5-9 year olds.” (emphasis added)
Children’s Hospital”,?’ relevantly found that:
(i) Some 628 patients presented to SCH with dog bites during the study period
(seemingly 10 years);
(ii) of those persons, 273 (43.5%) patients received treatment in the Emergency Department only with the remaining 355 (56.5%) patients admitted for further
treatment; (iii) the average patient age was 5.69 years; (iv) facial and other head and neck injuries were most common (64.4%); and
(v) the mean clinical cost per dog bite injury was $2,968.
Other reports / literature
the AVA stated (citations omitted):78
6 Ex 13 Vol 3 Tab 26
27 Ex 13 Vol 3 Tab 27 8 Ex 3 Annexure D
“Most scientific studies report that children are more likely to be bitten by dogs than adults. In their 2001 paper, ‘A community approach to dog bite prevention —- AVMA Task Force on Canine Aggression and Human—Canine
interactions’, Beaver et al noted that:
‘Children are the most common victims of serious dog bites. Seventy per cent of fatal dog attacks (Sacks et al 2000) and more than half of bite wounds requiring medical attention involve children.’ (Beaver et al
In a review of United States research into victims of dog bites, Overall and Love
found that: . Most dog bites affect children under 15 years of age.
e 60-75% of those bitten are under 20 years of age, and most are 5-
9 year olds.
e After 1 year of age, the incidence increases through to ages 5-
° Children are bitten 2-3 times more frequently than would be
expected on the basis of their population proportion.
. 45% of 3,200 children 4-18 years of age reported being bitten
during their lifetime.
. Children are at least three times more likely to experience a bite
needing medical attention than are adults.
An extensive telephone-based survey of 1184 families in Belgium revealed a 2.2% annual prevalence of dog bites to children, and research from Indiana, USA mirrored these findings. Far less than 50% of bites were reported to
medical or legal authorities (Kahn et al 2004).
The number of dog bite cases presented to hospital emergency departments was about one quarter of those caused by road accidents and one-third of those caused by burns received at home. Of the dag bite cases, 65% of
patients were bitten at home and 35% in public. In 86% of the home bites
and 31% of the public bites, the bite was determined to result mainly from the child’s or adult’s behaviour. Bites at home occurred when there was no
adult supervision (Kahn et al 2003).
Figures like these are from medical reporting sources and reflect the likelihood of a bite being reported. Children are generally shorter, weaker and have poorer judgement than adults. They also actively interact with dogs differently to adults, so are more likely to be bitten on the face and head causing complex, serious, and disfiguring injuries. However, children typically require significantly shorter periods of hospitalisation than do adults
(Ozanne-Smith et al 2001). Beaver (2001) concisely summarises the findings:
‘Children’s natural behaviours, including running, yelling, grabbing, hitting, quick and darting movements, and maintaining eye contact, put them at risk for dog bite injuries. Proximity of a child’s face to the
dog also increases the risk that facial injuries will occur.’”
Increased risk of attack by dog that has previously attacked a person or animal
Professor McGreevy relevantly stated (at {2.1]):
“There are no peer-reviewed reports on this possibility, not least because the ethics of establishing a definitive empirical study of this sort would be unacceptable. However, in my opinion, if a dog is involved in an attack onan animal or person, that dog is thereafter at increased risk of attacking a person or animal in future. This likelihood reflects the proximate increase in arousal of the dog after its first attack and what it is likely to learn from the
encounter,
Dogs have the dental weaponry to inflict severe wounds and to kill members
22 Ex 13 Vol 2 Tab 18
of their own social group, let alone strangers. So, the costs of combat can be significant. In general, they avoid conflict and their ability to keep the peace
is remarkable.
However, under extreme conditions in nature and under manufactured conditions in the fighting pit, they may cross the threshold into combat. They may be motivated to show agonistic responses (i.e., defence or aggression) to push away a fear-eliciting threat or defend their resources (e.g., food, territory or offspring). After crossing the threshold into conflict, they may
either die from the encounter or survive and learn from it.
The dog that survives physical combat will either be emboldened and learn to cross the threshold more readily to guard resources or be more fearful, as a result of the encounter, and therefore more highly motivated to remove
threats. Either way, it is generally at increased risk of attacking in future.”
The Companion Animals Amendment (Rehoming Animals) Bill 2022 {NSW) places restrictions on councils’ powers to euthanise a dog that has been seized following a serious attack. Section s64B is added to the CA ACT and states that a council cannot
destroy a seized or surrendered animal without:
(i) giving written notice to at least two rehoming organisations that an animal is available for rehoming and will remain available for at least seven days from the
day the notice is given; and
(ii) taking reasonable steps to advertise on a web page or through a social media
platform than an animal is available for rehoming.
Subsection 3 states that if a rehoming organisation gives the council written notice it can rehome an animal the council must not destroy the animal and arrange for
collection of the animal.
This could allow the rehoming of dogs that are not suitable. Based on the available expert evidence it is important that councils are vested with a discretionary power to euthanise a dog that has been seized following a serious or fatal attack against a person.
| propose to make a recommendation to the Minister for Local Government and the
OLG that the appropriateness of s 64B (1) and (3) of the CA Act, regarding dogs involved
in serious or fatal attacks, is reviewed.
Limitation of the restricted dog provisions
The restricted dog provisions of the CA Act are focused on the breed of the dog and not a specific event. However, the protection afforded by this part of the regime depends,
inter alia, on:
(i) | The breeder, supplier, and / or owner accurately identifying that the dog is one of
the breeds identified in s 55(1) and complying with the applicable restrictions.
(ii) The authorised identifier accurately identifying the breed at the time of microchipping.
(iii) If the dog comes to the attention of a council but has not yet been identified as a restricted breed, the dog’s breed then being accurately recognised such as
potentially to enable a restricted dog declaration to be made.
(iv) If a subsequent dispute follows over the breed, the approved breed assessor
accurately identifying the dog’s breed.
However, difficulties may arise:
(i) in accurately identifying whether a dog is an American Pit Bull Terrier or pit bull
terrier, or a crossbreed thereof; and/or
(ii) in accurately distinguishing American Pit Bull terriers or pit bull terriers (which are restricted breeds) from American Staffordshire Terriers and Staffordshire Buil
Terriers (which are not restricted breeds).
The difficulties with correct breed identification provide a significant impediment to the
efficacy of the restricted dog provisions of the CA Act.
If a restricted dog is not accurately identified, its owner will not be made subject to the obligations that the legistature considers are necessary for such animals in the interests
of community safety.
and the availability of DNA testing, | propose to recommend that the minister and the OLG facilitate reasonable access to DNA testing in NSW to assist in breed identification
of dogs.
Importance of public education and awareness campaigns
Public education and awareness campaigns have an important role to play in protecting
the community from dog attacks. This is particularly so given:
(i) | The vast ownership of dogs in the community.
(ii) | The prevalence of dog attacks, which sometimes cause significant injury and even
death.
(iii) The importance of dog owners being educated as to the significant risks posed by dogs, including particular breeds, and the responsibilities of dog owners in terms of ensuring their dog is effectively controlled and secured to minimise the risk of
an attack, both in the home and in public.
(iv) The limitations of the protections provided by the restricted, dangerous and
menacing dog provisions in the CA Act (outlined above).
The Australian Veterinary Association (AVA) Dangerous Dogs report noted studies showing that well designed and appropriately targeted programs to educate children and parents about behaviours around dogs have been effective. The AVA recommended that a proportion of dog registration fees be directed to education, with specific recommendations regarding training parents about protecting small children
from dogs and about safe behaviour of children around dogs.°°
In a Law Society Journal article titled “Dog attacks inquest prompts debate over laws and public education”, the Manager of Animal Rehoming for Blacktown City Council is
quoted as stating that there is “an urgent need for a statewide campaign — similar to
30 Ex 3 Annexure D
151,
the sunscreen campaign designed to win over sceptics — that targets dog owners who
don’t understand why, or do not want to desex, register and train their dogs” 31
Typically, individual councils provide their own education campaigns around dog
ownership.
In an institutional statement dated 16 February 2024, the OLG described its
involvement in education programs. Without being exhaustive, this has included:22
(i)
(ii)
(iit)
(iv)
(vi)
(vii)
Since 2011, OLG’s implementation with councils of a Statewide responsible pet ownership and dog safety education program known as the Responsible Pet
Ownership Education Program (RPO).
The RPO is the most direct intervention the OLG is involved with in terms of
education to owners, families and the wider community about animal safety.
The RPO involves trained staff (“Pet Educators”) attending schools and preschools throughout NSW (as of February 2024 the RPO had conducted 13,537 visits to primary / pre-schools and provided 23,628 education sessions to 914,055
children).
In 2013, the OLG launched an online learning tool for children’s education
(Kindergarten to Year 2) around responsible pet ownership and dog safety.
In October 2023, the OLG contacted al! councils in NSW and offered to attend companion animal or pet related events run by respective councils to provide information, brochures and advice around responsible pet ownership and
promote community engagement.
As of February 2024, the OLG was reviewing the scope of the RPO and was said to
be committed to improving the content of its website.
The Minister for Local Government has committed to a review of the companion animals legislative framework, which will include considering recommendations from the dog attack coronial inquests and recent parliamentary inquiries into
pounds and veterinary services.
Tab 13 Vol 3 Tab 31, p 3 32 Ex 3 at [15]-[36] pp 2-4.
154,
Increased consideration could be given to whether such programs are likely to be more effective if they are coordinated by a central executive body, such as the OLG, rather than the bulk of such programs being individually provided by councils. Potential
benefits from such a focus would include:
(i) better resourcing, with greater economies of scale as opposed to individual
councils each engaging in their own education programs;
(ii) potentially greater reach across NSW, particularly from a Statewide advertising
campaign like that utilised in South Australia;?? and (iii) and more consistent messaging.
in any Statewide public awareness campaign, consideration could be given to informing
the public about matters including:
(i) the severity of injuries that dogs can inflict, particularly dogs of muscular builds like American Staffordshire Terriers, Staffordshire Bull Terriers and Rottweilers (or
crossbreeds thereof};
(ii) that in some cases serious or fatal injuries are inflicted on infants and children,
although adults are also at risk;
(ii) that serious and fatal dog attacks have been inflicted on people with whom the
dog ordinarily lives or whom the dog already knows; and
(iv) that dogs that have committed fatal attacks have had no known history of past aggression or attacks on animals or people (and that the presence of such past aggression is not necessarily a reliable indicator of whether a dog may attack a
person).
| propose to make a recommendation that the Minister and the OLG examine, in consultation with councils, the development and implementation of a Statewide public awareness and education campaign to educate dog owners and the community generally about the risks posed by dogs, in particular some dog breeds, and how to
safely interact with them.
33 See https://dogandcatboard.com.au/gooddogsbaddays.
Licensing Regime for Dog Owners
The existing regulatory regime under the CA Act and the Regulation requires that all dogs be identified (microchipped) and registered on the CAR. The regulatory regime does not require satisfaction of a dog owner’s fitness or capacity to comply with
regulatory requirements before registration of the dog takes place.
The CA Act does provide that, in the case of a dangerous dog, an annua! permit is required to own the dog (s 11C) and, in the case of a restricted dog {including one
declared as such), an annual permit is required to own the dog (ss 11D and 56(1)(i)).
As for the issuance of permits, the Departmental Chief Executive may, upon receipt of an application for a permit, carry out any investigations and inquiries that the Departmental Chief Executive considers necessary to enable the proper consideration of the application: s 111(4). A permit may be subject to any condition prescribed by the Regulation, or any condition imposed by the Departmental Chief Executive: s 11K. By
s 11N, the Regulation may make provision regarding the grounds for refusal of permits.
Part 4 (cll 26-28) of the Regulation concerns annual permits. Part 4 does not specify criterion for eligibility to hold a permit {e.g., fitness / competence) or specify the
matters to be considered in granting or refusing an application for a permit.
Whatever potential protection the permit requirement for dangerous and restricted dogs might be thought to offer in terms of public safety, such protection is necessarily limited by virtue of the fact that, in the case of a dangerous dog, a dog will be declared dangerous only if an event or incident occurs. It is possible a dog that commits a serious or fatal attack may have no known history of aggression or attacks and not be subject to a dangerous dog declaration. Further, in the case of a restricted dog, breeds such as the American Staffordshire Terrier and Rottweiler are not captured by the provisions.
There may also be dogs that are not accurately identified as to their breed type and
thus not the subject of action under provisions dealing with restricted dogs.
Outside of the permits required for the ownership of a dangerous or restricted dog, the
regulatory regime does not require people to be licensed to own or possess a dog.
The licensing regime for firearm possession and use reflects the significant dangers that firearms pose (e.g., to cause fatal injuries). It also reflects the risks posed when firearms
are not secured and used responsibly by fit and competent persons.
Even if it be accepted that dog ownership does not pose the same level of risk as firearm ownership, the possession of dogs can pose considerable risks to children and vulnerable adults, especially if the dog owner has inadequate awareness of the risks and does not put effective measures in place to minimise such risks, such as by securing
and controlling their dog.
Material supportive of a regime that would require owners to be educated in responsible dog ownership and to demonstrate some level of competency has formed part of the evidence in the dog attack inquests. This includes the opinion of Dr Emetia Cull, an experienced veterinarian, to the effect that dog owners ought to be licensed so as to ensure that persons are competent and have training on how to deal with specific issues with animals. This would assist to ensure their animals are not put in situations of risk. Training would also assist owners to pre-empt a circumstance when their dog may be uncomfortable, and which could lead to aggressive behaviour. Training around the risks of permitting a child to have unsupervised exposure to a dog would also be
beneficial.24
In the Victorian Inquiry, Professor Coleman of the Animal Welfare Science Centre told
the inquiry:
“Lam of the view that pet owners, but particularly dog owners ... should be licensed. So it is not the dog that is licensed, it is the owner that is licensed, and | think to get that there should be some sort of, even if it is fairly rudimentary, hurdle to pay. We do it for drivers licences. We have no difficulty in having somebody go up to the desk, answer 20 questions and get
their licence. Why not do that for companion animats?”35
in its final report, the Victorian Inquiry touched on the possibility of “Licensing of
owners or mandatory education in responsible ownership” (Chapter 7 at [7.7]).252
34 Ex 13 Vol 2 Tab 20 % Ex 13 Vol 1 Tab 3, p 265
Ultimately, the Victorian Inquiry did not make recommendations in favour of such a
proposal, stating:
“The Committee considers that these powers, combined with education campaigns and an effective suite of measures to combat irresponsible owners, are a more practical option than owner licensing. Incentives such as reduced registration fees may also be an effective way of encouraging owners to undertake
training for themselves and their dogs.”
There are powerful considerations in favour of a person being required to be licensed to own a dog, particularly to own a breed of dog that is known to have killed people.
The continuing instances of serious and fatal attacks by dogs in NSW justifies examination of such a proposal. | propose to make a recommendation that the Minister for Local Government and the OLG consider the issue of introducing a licence requirement for dog ownership, which may involve particular licence conditions
calibrated for particular breeds of dogs.
The vicious attack on Mr Grant in 2017 was a red flag that Boof could be dangerous
and may go on to attack someone else.
Nothing in the companion animals regulatory regime offered any warnings or protection to persons who encountered Boof after that attack. At the very least, if Boof had been required to be kept in an enclosure, or otherwise muzzled when not in an enclosure, this may have impacted on the likelihood or nature of the fatal attack
on Mr Amatto.
The OLG has informed this inquest that it is committed to focusing closely on each of the recommendations arising from this inquest. The government has confirmed that it is committed to achieving a modern and outcomes based legislative framework, so that, as far as reasonably practicable, future tragedies can be avoided or at least
minimised.
tam of the opinion that any disadvantage of stricter regulation around dog ownership is outweighed by the possible prevention of a similar attack as the one Mr Amatto
suffered.
l express my sincere condolences to Mr Amatto’s family.
Finally, this inquest has been greatly assisted by the cooperative provision of information and statements by the Penrith City Council, the OLG and the Commissioner of Police. The proactive steps taken by Penrith City Council are commendable and | note that the council has sought and continues to seek to address the systemic issues involved in animal management and the companion animals’
regulatory regime.
| find that Colin Neil Amatto died on 1 March 2019 at Westmead Hospital NSW. | am satisfied
the cause of his death was septic complications from injuries he received from multiple dog
bites he sustained in his own home on 24 January 2019. The dogs were known to him and
ordinarily were kept at his residence.
| recommend to the Chief Executive of the OLG and the NSW Commissioner of Police:
The OLG and the Commissioner of Police consider developing a model or overarching memorandum of understanding (MOU), which can be adopted and utilised for councils and Police Area Commands or Police Districts regarding the coordination of responses (including investigation and enforcement), and formalising of roles and responsibilities
of Police and councils, with respect to dog attack incidents.
| recommend to the Minister for Local Government and the OLG:
The Minister and the OLG develop a standardised training package for council rangers
in NSW that are expected to respond to reports of dog attacks on people or other dogs
11,
and of dog escapes.
The Minister and the OLG further review and update the functionality of the CAR to enable councils readily to access the regulatory history of dog owners (penalty notices,
court outcomes, warnings issued, suspected contraventions).
The Minister and the OLG consider possible amendment of s 16 of the CA Act to delete subsection (2)(b).
The Minister and the OLG consider possible amendment of s 18 of the CA Act to broaden
the scope for exercise of that power.
The Minister and the OLG examine the appropriateness of the statutory thresholds and framing of the provisions in the CA Act for the issuance of notices to declare a dog a
menacing or dangerous dog.
The Minister and the OLG examine the possible amendment of the CA Act to include an additional stand-alone offence of a dog attack causing serious harm or death to a
person.
The Minister and OLG consider the possible amendment of the CA Act to confer upon
police officers the power to make dangerous and menacing dog declarations.
The Minister and the OLG examine the possible amendment of the CA Act to introduce a provision empowering an authorised officer to direct an owner or person in control
of a dog to secure the dog with a muzzle and / or lead for a specified period.
The Minister and the OLG review, or continue to review, the appropriateness of the
rehoming provisions of the CA Act regarding dogs involved in serious or fatal attacks.
The Minister and the OLG investigate, or continue to investigate, facilitating reasonable
access to DNA testing in NSW to assist in breed identification of dogs.
The Minister and the OLG examine, in consultation with councils, the development and implementation of a Statewide public awareness and education campaign to educate dog owners and the community generally about the risks posed by dogs and how safely
to interact with them.
The Minister and the OLG, in consultation with councils and other stakeholders,
consider introducing a licensing requirement for dog ownership, which may involve particular licence conditions calibrated for particular breeds of dogs and with applicants
being required to undergo education with respect to safety and risk management.
offences provided by ss 12A, 13, 14, 16 and 17 of the CA Act.
registration and identification requirements for dogs in the CA Act and the Regulation.
| recammend to the Chief Executive Officer of Penrith City Council:
NSW Police Force is also involved in responding to a dog attack incident.
| recommend to the Commissioner, NSW Police Force:
attack incident.
C Forbes Deputy State Coroner
16 April 2025
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