Inquest into the deaths of Lynette Thompson and Alan Fletcher

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Lynette Helen Thompson and Alan Leslie Fletcher Hearing dates: 25-26 March 2025, Dubbo Local Court; 31 October and 3 November, Lidcombe Coroners Court Date of findings: 9 December 2025 Place of findings: Dubbo Local Court Findings of: Magistrate R Hosking, Deputy State Coroner Catchwords: Manner of death; murder-suicide; domestic violence; police protection; bail drug offences; homicide; intentional self-inflicted death; ADVO application; thermal injuries.

File number: 2020/332599 and 2020/319608 Representation: Counsel Assisting the Inquest: Andrew Wong of Counsel and Sarah Crellin, Solicitor Advocate, instructed by Amber Boatman and Charlotte Ward, NSW Crown Solicitors Office Commissioner of Police, NSWPF and Senior Constable Luke Robinson: Kim Burke of Counsel instructed by Stuart Robinson, the Office of General Counsel Kyle Thompson: Hayden McDuff, Solicitor Advocate, Legal Aid Commission Inspector Michael Smith: Darian Nagle of Counsel instructed by Casey Young, Police Association of

NSW CULTURAL WARNING Aboriginal and Torres Strait Islander readers are advised that these findings may contain the name of a deceased Aboriginal or Torres Strait Islander person. Readers are warned that there may be words and descriptions that may be culturally distressing.

Findings: Identity of deceased: Lynette Helen Thompson Date of death: 21 November 2020 Place of death: Royal North Shore Hospital, St Leonards NSW Cause of death: Thermal injuries (extensive burns) and complications thereof Manner of death: Homicide by a known person Identity of deceased: Alan Leslie Fletcher Date of death: 9 November 2020 Place of death: Dubbo Hospital, Dubbo NSW Cause of death: Neck compression Manner of death: Intentionally self-inflicted.

Recommendations: That the Commissioner of NSW Police consider: 1 amending the Domestic and Family Violence Standard Operating Procedures 2018 at page 112 under the heading ‘The Test for a Senior Police Officer’ by adding a third paragraph that states: The failure to identify a primary aggressor is not a proper basis for a senior officer to refuse an application for a provisional ADVO where it is suspected or believed that both parties have committed an offence and both parties are in need of protection.

2 amending the process by which provisional ADVO applications are refused electronically on the WebCOPS system, by allowing senior officers, at the time of refusal, to include a narrative on the system that clearly sets out the specific reasons why an ADVO application has been refused.

Publication orders: In accordance with s 75(5) of the Act, an order was made permitting the publication of a report of the proceedings.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

Contents Whether there is a sufficient causal connection between Issues 2(a) and (b) to enable findings Issue 2(a): The adequacy of the steps taken by NSW Police in considering the appropriateness Issue 2(b): The adequacy of the steps taken by NSW Police in respect of the ADVO applications Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

INTRODUCTION 1 Section 81(1) of the Coroners Act 2009 (NSW) (the Act) requires that when an inquest is held, the coroner must record in writing their findings as to various aspects of the death.

2 In accordance with s 75(5) of the Act, I make an order permitting the publication of a report of the proceedings as I find it is desirable in the public interest to do so.

3 These are the findings of an inquest into the circumstances of the deaths of Lynette Helen Thompson and Alan Leslie Fletcher.

4 With respect to Lynette, the inquest was mandatory pursuant to s 27(1)(a) of the Act as, on the material before me, it appeared that Lynette’s death may have been as a result of homicide. While an inquest into Alan’s death was not mandatory, as will be seen, they are so intrinsically connected that it was appropriate to proceed to a joint inquest in respect of the deaths of Lynette and Alan.

5 Lynette, a First Nations woman, was born on 24 November 1962 and Alan was born on 4 May 1961. Lynette and Alan had been in a domestic relationship for approximately 40 years and share 6 adult children. The relationship included a reported history of domestic violence.

6 Lynette and Alan’s children remember happier times. Their parents always took the kids to football and made sure they played their best game. Lynette liked to sing and listen to music. The couple were loved and are missed by their children, grandchildren and their friends in Wellington.

7 Lynette and Alan died from events which took place on 8 November 2020. At that time, Lynette and Alan were residing at 59 Curtis Street, Wellington NSW

2820. This is a home they purchased in 2003.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

8 At about 3.28pm on 8 November 2020, Benjamin Day saw a person we now know to be Lynette, on fire near the toilet blocks in Kennard Park, Wellington.

He grabbed a fire extinguisher and drove his van into the park and extinguished the fire surrounding Lynette. Lynette was taken to Wellington Hospital before being transferred to Royal North Shore Hospital for further treatment. Lynette suffered burns to over 72% of her body, inhalation injuries, multiple organ failure and was placed on life support. Lynette died on 21 November 2020 at 1.34am.

9 At about 3.55pm, Phillip Dowd of 61 Curtis Street, saw Alan hanging by a blue and yellow coloured rope from a tree in the backyard of 59 Curtis Street. Alan was transported to Wellington Hospital and then transferred to Dubbo Hospital where he remained until he died on 9 November 2020.

The role of the coroner 10 Pursuant to section 81 of the Act, a coroner holding an inquest concerning the suspected death of a person must make findings as to whether the person has died and if so, the date and place of the person’s death, and the cause and manner of their death.

11 In addition, the coroner may make recommendations in relation to matters which have the capacity to improve public health and safety in the future, arising out of the death in question.

The issues examined at the inquest 12 The issues examined at the inquest follow.

(1) The statutory findings: the identity of each deceased, and the date, place, manner and cause of death. In particular, the manner of Lynette’s death.

(2) The actions of NSW Police in the lead up to Lynette and Alan’s deaths, in particular: Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

(a) the adequacy of the steps taken by NSW Police in considering the appropriateness of bail addresses.

(b) the ADVO1 applications relating to Lynette and Alan in October 2019.

(3) Whether it is necessary or desirable to make any recommendations in relation to any matter connected to either death.

The evidence 13 Tendered to the court was a four volume2 brief of evidence compiled by Detective Senior Constable Armour3 and supplemented by the Assisting team.

14 In addition, at the inquest the court received evidence from: (1) Benjamin Day, lay witness (2) Sergeant Michael Smith, NSWPF (3) Senior Constable Melissa Mertens, NSWPF (4) Constable Luke Robinson, NSWPF (5) Inspector Michael Smith, NSWPF (6) Superintendent Danielle Emerton, NSWPF.

15 While I am unable to refer specifically to all the available material in detail in my reasons, it has been comprehensively reviewed and assessed.

1 Apprehended Domestic Violence Order 2 Including the supplementary volume tendered in the course of the second tranche of the hearing.

3 The officer in charge of the coronial investigation.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

Findings 16 As will be seen, the conclusions I have reached, follow.

(1) I find the approach adopted by Smith in this case and his evidence as to his views surrounding cross-ADVOs fails to take into account:

(a) the realities of domestic violence including that in some relationships, violence can be perpetrated by both parties and there can be incidents of aggression by both parties; and

(b) it is not always possible in the immediate aftermath of an incident of domestic violence for police to determine who is the primary aggressor and who is the victim. To rule out cross-ADVOs in these circumstances leaves both parties unprotected.

(2) I find that the approach adopted by Smith, both in his interpretation of the SOPs in so far as they relate to cross-ADVOS, and in his rejection of the ADVO applications without further enquiries being made, was inappropriate and inadequate. Further enquiries could have been made by using the resubmit function; reviewing the COPs Event and Alan and Lynette’s domestic violence history; or by contacting Robinson.

(3) I am not suggesting that if the ADVO's had been approved Lynette and Alan would not have died. There are many uncertainties including:

(a) even if made, the ADVOs applications did not provide for a ‘no contact’ order or an order preventing Lynette and Alan from residing together.

(b) even if made, they may not have remained in place a year later.

(c) Lynette applied for her own ADVO when the police initiated ADVOs were refused4. This application was ultimately 4 On 16 October 2019, Lynette made an application for an ADVO (see E141896402 COPS Event).

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

withdrawn/dismissed when Lynette failed to appear at court on 22 October 2019. The ADVO initiated for Lynette by the NSWPF may have met the same fate if she failed to attend the hearing.

17 I make the recommendation that follows.

(1) That the Commissioner of NSW Police consider:

(a) amending the Domestic and Family Violence Standard Operating Procedures 2018 at page 112 under the heading ‘The Test for a Senior Police Officer’ by adding a third paragraph that states: The failure to identify a primary aggressor is not a proper basis for a senior officer to refuse an application for a provisional ADVO where it is suspected or believed that both parties have committed an offence and both parties are in need of protection.

(b) amending the process by which provisional ADVO applications are refused electronically on the WebCOPS system, by allowing senior officers, at the time of refusal, to include a narrative on the system that clearly sets out the specific reasons why an ADVO application has been refused.

AUTOPSY Lynette 18 An external examination of Lynette was performed by Dr Sairita Maistry assisted by Deborah Sayers, on 25 November 2020. Dr Maistry opined that Lynette died from thermal injuries and the complications thereof.

19 Dr Maistry found extensive full thickness burns to approximately 72% of the total body surface.

Alan 20 An external examination of Alan was performed by Dr Benjamin Harding, supervised by Dr Leah Clifton, on 12 November 2020.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

21 Doctors Harding and Clifton opined that the direct cause of death was neck compression due to hanging.

22 In the course of the examination, the doctors noted features of fire-related injury with singeing of facial hair, eyebrows and the frontal anterior aspect in the hairy scalp with singeing of hair on the dorsal aspect of the forearms. There was a region of superficial thermal injury (burn) present on the dorsal aspect of the right upper arm extending to the right elbow.

BACKGROUND 23 Much of the facts of this matter are not in dispute and I am grateful for the observations by my instructing solicitor and submissions by Counsel Assisting from which I have drawn extensively and in relation to non-contentious issues, directly at times, in these findings.

History of domestic violence 24 Police records indicate a reported history of domestic violence as between Lynette and Alan. A summary follows.

(1) E900000036379: 20 February 1992 – an AVO5 was made listing Lynette as the person in need of protection (PINOP) and Alan as the defendant.

(2) E23418787: 18 September 2004 – the couple had a verbal argument after Alan disclosed he had an affair with Lynette’s sister-in-law. Alan was listed as the PINOP while Lynette was listed as the defendant.

(3) E85581394 - 26 October 2004 – the couple had a verbal argument about Alan’s infidelity with Lynette’s sister-in-law. Lynette was listed as the PINOP while Alan was listed as the defendant.

5 Apprehended Domestic Violence Order Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

(4) E58991230 - 31 December 2015 – the couple had a verbal argument about Lynette’s suspicions that Alan had been sleeping with a neighbour.

Alan was listed as the PINOP while Lynette was listed as the defendant.

(5) E74977784 - 13 October 2019 - report of common assault – Alan reported being punched to the face by Lynette and Lynette complained that Alan had slapped her on the face. Both were named as complainants/defendants. Police initiated two provisional cross ADVOs.

Both were refused by Smith.

(6) E141896402 - 16 October 2019 - Non-urgent ADVO application made by Lynette. Lynette was listed as the PINOP while Alan was listed as the defendant. This was dismissed by the Magistrate when Lynette did not attend court.

Granting of bail 25 In 2019, police were investigating a suspected drug dealing enterprise in the Wellington area6 (Strike Force Pinnacle). The investigation led to the execution of 16 search warrants and the arrest of Lynette, Alan and five of their children.

26 Lynette was charged with: (1) owner/occupier knowingly allowing house to be used as drug premises (2) organises/conducts/assists drug premises (3) possess prohibited drug (4) goods in custody – suspected stolen (5) participate in criminal group.

6 Strike Force Pinnacle Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

27 Alan was charged with: (1) supply prohibited plant (2) goods in Custody – suspected stolen (3) deal with proceeds of crime (4) owner/occupier knowingly allowing house to be used as drug premises (5) participate in criminal group.

28 Lynette and Alan were originally bail refused in the Local Court. They were ultimately released on bail by the Supreme Court, Lynette on 24 August 2020 and Alan on 7 October 2020. As will be discussed below, significantly given the history of domestic violence, Lynette and Alan were both bailed to 33 Montefiores Street, Montefiores.

Events of 8 November 2020 29 Witness accounts and CCTV footage provides a clear chronology of the movements of Lynette and Alan in the lead-up to the events that caused their deaths. A summary of the CCTV footage shows:

TIME DESCRIPTION Approx. Snr Const. Hannelly saw Lynette and Alan’s vehicles parked side by 3:00pm side at the low-level bridge near the Macquarie River. They were both sitting in Lynette’s vehicle.

3:16:43pm Alan’s vehicle traveled south on Nanima Crescent, through the roundabout at Warne Street and Lee Street/Nanima Crescent.

3:18:00pm Lynette’s vehicle traveled along Nanima Crescent, through the roundabout at Warne Street and Lee Street/Nanima Crescent, 1 minute and 11 seconds behind Alan’s vehicle.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

3:17:41pm Alan turned right onto Showground Road in the direction of Pioneer Park.

3:18:56pm Lynette drove on Showground Road in the direction of Pioneer Park, 55 seconds behind Alan’s vehicle.

Approx. Hannelly was walking through Pioneer Park and saw Alan and 3:19pm Lynette drive into Pioneer Park and come to a stop parking side by side.

Hannelly saw Alan get out of his vehicle and walk to the driver’s side of Lynette’s vehicle. She saw Alan wave his arms and point at Lynette. This lasted no more than 2 minutes and she saw Alan return to his vehicle before quickly driving away. She saw Lynette’s vehicle follow soon after.

3:21:11pm Alan drove towards Wellington CBD through the roundabout at Showground Road and Maughan Street and past Wellington Police Station.

3:21:37pm Alan continued through the roundabout outside McDonalds and continued along Maughan Street.

3:21:40pm Lynette drove through the roundabout at Showground Road and Maughan Street.

3:22:16pm Lynette drove through the roundabout outside McDonalds, 39 seconds behind Alan’s vehicle.

3:22:34pm Brianna (Alan and Lynette’s daughter in law) and Lyn Meizer drive through the roundabout outside McDonalds, 18 seconds behind Lynette.

3:23:01pm Alan turned left on Simpson Street and through the gates at Kennard Park.

3:23:41pm Lynette drove towards the gates at Kennard Park.

3:23:51pm Brianna and Lynn Meizer traveled along Simpson Street. Alan drove into Kennard Park, while Lynette pulled over and stopped at the side of the road and was met shortly thereafter by the Meizers.

The Meizers parked their vehicle alongside Lynette’s vehicle.

Brianna told police that she had a conversation with Lynette, asking her for money to put on Bradley Thompson’s prison account. Lynette told her she did not have money but asked if the children wanted hot Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

chips. Brianna’s child exited the vehicle and took hot chips from Lynette before returning to Brianna’s vehicle.

3:25:51pm Lynette entered Kennard Park in her vehicle, 2 minutes after Alan.

3:28:21pm Alan drove out of Kennard Park, some 4 ½ minutes after entering and 2 ½ minutes after Lynette had entered.

ISSUES The statutory findings Lynette 30 Simon Searles, Det. Leading Snr. Const. prepared a statement dated 25 November 2020 following his analysis of the left palm of the deceased and opined that the deceased was Lynette. I accept his opinion that the identity of the person burned in the fire on 8 November 2020 was Lynette.

31 I am satisfied on the evidence adduced that Lynette died at 11.34am on 21 November 2020 at the Royal North Shore Hospital from thermal injuries (extensive burns) and the complications thereof.

Manner of death 32 The manner of Lynette’s death was a matter in issue in the inquest. There were two possible scenarios: (1) that Lynette was set alight by Alan, or (2) that Lynette set herself alight.

33 The fire was investigated by Senior Cst. Mertens. As to the cause and point of origin of the fire, Snr. Cst. Mertens concluded that Alan squirted petrol using a drink bottle onto Lynette while she was seated in the driver’s seat and then lit the fire with a cigarette lighter. Her conclusions were based on the evidence that follows.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

(1) The drink bottle found in Alan’s car with petrol in it and no other identifiable ignition source in or around the vehicle.

(2) Cigarette lighters found in Alan’s pocket.

(3) The extent of damage to the vehicle inside the cabin and the minimal damage to the outside.

(4) The extent of Lynette’s injuries to her upper limbs, her chest and the front of her torso as well as her clothes.

(5) Minimal damage found on items in the boot of the vehicle.

(6) Thermal injuries (to his right arm and singed hair) on Alan placing him close to a fire.

34 Counsel Assisting submitted that the circumstances and evidence outlined below supports the contention that Alan set Lynette alight.

(1) The absence of evidence (including a suicide note) that at the time of the incident, Lynette was expressing any suicidal ideation notwithstanding that she was on bail for serious drug related offences.

(2) Fire as a method is unlikely to be adopted in an intentional death scenario.

(3) Day stated that he thought Lynette was trying to extinguish the flames with her hands. He specifically said in his statement, ‘…the woman was running and appeared to be trying to put herself out. She was clearly trying to put herself out with her hands’. While in no way definitive, it could point against her death being intentionally self-inflicted.

(4) Brianna Meizer reported that when she spoke to Lynette just prior to the fire she appeared fine and did not look angry, upset or stressed. If Lynette was intending suicide or self-harm at that moment, it seems Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

unlikely she would have chatted to Meizer and offered food to her children.

(5) If Lynette and Alan had agreed to self-harm close in time to each other, it seems unlikely they would choose to self-harm in separate locations or that they would intend that Lynette would self-harm in a such a public place and for Alan to leave her and commit suicide at a different location.

(6) Lynette was only in Kennard Park with Alan for some 2 ½ minutes. The fact they were with each other for such a short time is not consistent with a mutual decision to suicide. Rather the very quick timing of the events, is more consistent with Alan lighting Lynette on fire and making a quick getaway before he could be apprehended.

(7) Alan's autopsy report noted that he had a thermal injury on his right arm, as well as singeing of the hair on the frontal region, eyebrows, facial hair and dorsal aspect of the forearms.

(8) Paramedic Kuiper reported that Alan had singed facial hair and he could smell burnt hair.

(9) Prior to Alan committing suicide, he attended 7 Palmer Street and gave Meizer around $1000 in cash which smelt like burnt rubber which is consistent with Alan being close to Lynette when she was set alight only minutes earlier.

(10) If Alan had singed hair, a thermal injury on his right arm and had money that smelt like burnt rubber - this suggests he was present when Lynette was on fire. If this is the case, if he didn't start the fire or intend to cause her harm - it is odd that the evidence does not show him taking any steps to assist in extinguishing the flames or calling for help.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

(11) At 9:25pm on the night of 8 November 2020, Alan’s vehicle was seized.

Within it was a 1 litre Powerade bottle that was mostly full of a liquid later confirmed to be petrol.

(12) Notes written by Alan before his death, are supportive of the fact that he acted alone, in particular his note to their son Nathan: To Nathan, Im very sorry for what iv done but she left me no choice.

(13) Of more significance is that the letter appears to be a farewell note where he tells Nathan he will leave everything for him to sort out even if he has to sell their belongings. He ends the note saying: So just cremate us both together don't go to big expense on our funeral and make sure our ashes are mixed together as I love her so much.

Those words support the fact that Alan knew Lynette was dead and gives context to his apology described above.

(14) Lynette’s notes to Alan from prison appear to point to the breakdown of their relationship, as opposed to an agreement between the two to commit suicide:

(a) In a letter dated 19 July (no year), Lynette expressed her anger towards Alan and blamed him for her being in prison. She referred to abuse on his part and that he would terrorise and stalk her. One part of the letter is supportive of the fact a murder-suicide took place, she wrote: It never mattered to you if you couldn't have me, you made sure nobody could.

(15) For 18 months prior to her death, Lynette was seeing John Stanley, also known as Buck Stanley. This suggests that Lynette was focused on a new relationship.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

(16) Messages on Lynette’s phone appear to show her communicating with two people that she had an intimate relationship with. This points to Lynette moving away from Alan and this could provide a basis for Alan’s jealousy and provide a motive for setting Lynette alight7.

(17) Lesley Kelly said that Alan had attended her home four days before 8 November 2020 and told her that he was taking Lynette on a beautiful holiday but would not say where and would only say ‘it's beautiful where we're going’ and ‘we're going to a beautiful place’. She said he said the holiday would be within the week or maybe sooner. Kelly formed the view, after finding out what happened, that Alan’s reference to a beautiful holiday was a reference to heaven. This evidence is significant as Alan had provided a specific timeframe and there is no evidence that he had prepared or later prepared any other holiday or trip away.

(18) Robert Smith, a friend of Alan and Lynette, recalled that on 8 November 2020, Alan attended his home in Wellington and told him that ‘he was finding it a bit hard because she (Lynette) went Crown witness against the family because of the drug raids earlier this year’. If Alan was concerned about Lynette becoming a Crown witness, this could provide a separate motive as to why he may have wanted to harm her.

35 There is also, some evidence which could suggest that Alan was not the perpetrator. This includes: (1) When police investigated the backyard of 59 Curtis Street (the location where Alan hung himself), they saw two small patches on the ground where something had been burnt. Investigators believed clothes had been burnt no more than a few days prior and initial testing showed the presence of petrol. If Alan was responsible for starting a fire in the backyard of 59 Curtis Street on the day of his death, this could explain why he had 2 lighters, the petrol in his car and the singeing of his hair.

7 Though the evidence also suggested that Lynette and Alan were in an open relationship.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

(2) Lynette obtained petrol from Robert Smith on 8 November 2020 which she said was for her lawn mower. The petrol was provided in a jerry can.

(3) There was no evidence suggesting that Alan’s clothes smelt of petrol.

(4) Day’s evidence was that Lynette said something to him which he believes was consistent with ‘I tried to light something’. He did not resile from that evidence on cross examination.

36 Having considered all of the evidence, I find that Alan poured petrol on Lynette via a drink bottle through the car window and then, using a lighter, set her alight.

In reaching that finding, I consider that: (1) the collection of petrol by Lynette is most likely a coincidence (2) while I found Day to be an honest witness, in his evidence, as to what he thought Lynette said, he described her as being difficult to understand, the situation was stressful and it is highly possible that he misheard.

Alan 37 Alan was identified by his niece.

38 I am satisfied on the evidence adduced that Alan died at 2.20am on 9 November 2020 at Dubbo Hospital from neck compression due to hanging.

39 In relation to manner of death, the evidence must be sufficiently clear and cogent to allow for a conclusion to be reached in relation to intention. The evidentiary standard to be applied to a coronial finding of intentional taking of one’s own life is the Briginshaw standard (Briginshaw v Briginshaw 60 GLR 336).

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

40 Given the nature of death by hanging and the circumstances leading up to Alan’s death, I am satisfied to the required standard that his death was intentionally self-inflicted.

Whether there is a sufficient causal connection between Issues 2(a) and (b) to enable findings and recommendations to be made 41 It was submitted on behalf of the Commissioner, NSWPF that the evidence did not establish a sufficient connection between issues 2(a) and (b) to enable findings or recommendations to be made pursuant to ss 81(1) and 82(1) of the Act.

42 As will be seen, I do not conclude that failures or inadequacies identified in the evidence relevant to these issues caused the deaths. However, the relationship between Alan and Lynette at the time of their death is fundamental to any discussion as to manner of death. I cannot say that Alan or Lynette would be alive if not for the fact that they were bailed to the same address. The precise impact of that fact will remain unknown. However, it is a factor relevant to the relationship at the time of death.

43 Similarly, I cannot say that the missed opportunity for an ADVO to be in place as between Alan and Lynette, particularly for the protection of Lynette, caused or contributed to her death. However, if one had been in place it could have had an effect on their relationship and it may have impacted their deaths.

44 In my view, the power to make recommendations pursuant to s 82 is not limited to the making of recommendations which would prevent the recurrence of a similar death. This is in contrast to s 57A(2) of the Coroners Act 2006 (NZ) which limits recommendations ‘only for the purpose of reducing the chance of further deaths occurring in circumstances similar to those in which the death occurred’.

45 In Commissioner of Police, NSW Police Force v Attorney-General of NSW [2025] NSWSC 1119, the Commissioner made an application asserting that the Coroner lacked jurisdiction to inquire into certain matters including the dealings Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

the deceased had with the NSW Police Force, prior to her death in the period between 9 and 14 December 2022.

46 McHugh JA at [67] found that s 82(1) was not confined by reference to s 81(1) of the Act and also stated that: (1) The fact the power under s 82(1) is discretionary and extends to recommendations the Coroner considers desirable, suggests a degree of flexibility that is inconsistent with a narrow test.

(2) The words used to identify the relationship between the ‘matter’ and the ‘death’ are not ‘any matter causing the death’, but ‘any matter connected with the death’. The ordinary meaning of that language is capable of capturing subjects extending beyond the March v Stramare common sense test of causation and there was nothing in the text suggesting those words should be given a narrower legal meaning.

(3) The very general language used in s 82(2) is not subject to a causal limitation.

47 It is important to keep in mind that I am not inquiring into the general role played by NSW Police officers in respect of the imposition of provisional ADVOs and/or the setting of bail conditions. Rather, the inquiry is specifically into the role played by NSW Police in respect of these issues, in the context of Lynette and Alan’s deaths. I find that the causal connection between issues 2(a) and 2(b) are sufficiently connected with the deaths of Alan and Lynette to allow findings and recommendations to be made in relation to the evidence adduced.

Issue 2(a): The adequacy of the steps taken by NSW Police in considering the appropriateness of bail address 48 On 27 May 2020, a search warrant was executed at Lynette and Alan’s address. During a search that took place over two days, police located 1.4 kg gold, electronic scales, a money counter, numerous mobile telephones, ammunition, cannabis, 13.1 grams white crystal substance and a total of Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

$306,485.00 in Australian currency (including cash located in a safe buried under a concrete shed slab).

49 On 9 June 2020, Alan was arrested and bail refused in the Local Court and on n 12 June 2020 Lynette was arrested and bail refused in the Local Court.

50 On 24 August 2020 Lynette made a successful release application in the Supreme Court. Lynette was to live at 33 Montefiores Street in Wellington, which was the home of Doreen Saunders and Eugene Spicer.

51 On 7 October 2020, Alan also had a successful release application before the Supreme Court 7 October 2020. He was bailed to the same address8.

52 During Alan's application for bail, the presiding Judge was not advised that Lynette had been granted bail some 6 weeks earlier to live at the same address.

The presiding Judge was made aware that family members were co-accused.

At one point he asked Alan’s solicitor about the fact that the proposed bail conditions would allow Alan to have contact with his children who were also coaccused. Alan’s solicitor submitted: His main wish is to be able to communicate with his partner Lyn Thompson, with whom he has been with for some 40 years. But certainly, if your Honour does not wish to extend that to the children.

53 No submissions were made as to any history of domestic violence, or any concerns about domestic violence. It was a condition of his bail that Alan was not to communicate, by any means except through his lawyer, with any of his co-accused, except Lynette.

54 Eugene Spicer confirmed that when Alan and Lynette were granted bail, they both lived at his home but in separate rooms. He did not witness any arguments or violence during this period.

8 A letter in support by Eugene Spicer was provided to the Court.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

55 A question in the inquest was whether the NSWPF (and in particular the officers involved in Strike Force Pinnacle) were on notice as to any specific reason why Lynette and Alan should not be bailed to the same address.

56 In his statement dated 3 March 2025, Det. Snr. Baker indicated that the officers involved in Strike Force Pinnacle were not aware of any history of domestic violence between Lynette and Alan. He did know that they were separated but that they had been residing together.

57 The issue is whether the officers in Strike Force Pinnacle should have taken steps to prevent Lynette and Alan residing with each other.

58 It was submitted by Counsel Assisting that Strike Force Pinnacle officers were not in a position to take steps to prevent Lynette and Alan being bailed to same address given: (1) At the time of Alan’s arrest, they had been residing together and there was no ADVO in place preventing them from doing so.

(2) There was no evidence that Lynette objected to him being bailed to the same address.

(3) Even if they had been aware of a history of domestic violence, there was no evidence that domestic violence was a consideration relevant to the determination of bail for those charges.

59 Alternatively, if an ADVO had been in existence at the time Alan sought bail to the same address, it is likely this would have been flagged as an issue preventing the parties being bailed to the same address.

Issue 2(b): The adequacy of the steps taken by NSW Police in respect of the ADVO applications relating to Lynette and Alan on 13 October 2019 60 On 13 October 2019, the NSWPF were called to an incident between Lynette and Alan, where each made allegations of assault against the other. Lynette Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

said Alan had slapped her in the face, whereas Alan told police Lynette had punched him in the face. Both provided signed statements to that effect.

61 The COPS Event noted that there were no visible marks on Alan's face and while there was a small red mark on Lynette's face, police were not sure if the mark was due to an assault or a blemish, as the other side of her face was also red. No charges were laid as police formed the view, as stated in the COPS Event, that there was: insufficient evidence as to who assaulted who and conflicting version of events.

Therefore, there is insufficient evidence to take action.

62 Robinson did apply for an ADVO for both Lynette and Alan. These applications were rejected by Smith. Robinson said in his first statement, that he could not recall why the ADVOs were rejected. In his third statement dated 30 June 2025, he said at that after he submitted the ADVOs to Smith he had a conversation with Smith where Smith said words to the effect of ‘We don't do cross-ADVOs9’.

63 Smith could not recall any conversation with Robinson where he said that, however it was clear from his evidence that he did not believe as a general practice that cross-ADVOs were appropriate. When Smith first gave evidence in March 2025, he stated: Our domestic and family violence SOPs10 at the time states that we are not to take out cross-applications…. I would be acting against our SOPs to have approved both applications.

64 When he was asked, what would be an acceptable circumstance, where he might envisage a cross-ADVO being appropriate, he said that this was hard to answer and in almost 25 years of policing he had never applied for them and never suggested for people to apply for them and never approved one.

9 Cross over meaning 2 ADVO’s naming each individual as defendant on one and person in need of protection on the other.

10 References to the ‘SOPs’ in this inquest are referring to The Domestic and Family Violence Standard Operating Procedures 2018.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

65 Superintendent Emerton’s evidence was that if she were reviewing the applications submitted by Robinson, it is likely that she would have approved them. She did not consider their approval would be inconsistent with the SOPs.

66 Emerton stated that one of the safeguards in place to ensure an ADVO application is determined on its merits and not rejected because the form is inadequate or incomplete is the ‘functionality’ within the WebCOPS system.

67 She went on to say that if a senior officer believes an application requires rework, they can resubmit the application within the WebCOPS system to the applicant officer. If a decision is made to resubmit, the senior officer must make personal contact with the applicant officer to discuss the resubmit requirements.

Emerton stated in evidence that when an application is resubmitted to the applicant officer, the senior officer can include a narrative setting out in more detail what further information is required to improve the application.

Senior Constable Robinson 68 As at October 2019, Robinson had around three years' experience and minimal experience in domestic violence matters. He was previously posted in the city and didn't really deal with domestic violence regularly until he started at Wellington.

69 At the scene he rang a supervisor as he understood this to be in line with the SOPs. It appears he spoke to the Dubbo Supervisor, Barnes.

70 Robinson applied for cross-ADVOs as he believed that both Lynette and Alan needed protection, as each made an allegation of assault against the other.

71 He believed that after the ADVOs were rejected, he had a conversation with Smith. At the time he was not aware you could amend and resubmit an ADVO but now knows this can be done. This is the only time he has had an application for an ADVO rejected.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

72 In his evidence, Robinson indicated that if the same thing happened again, he would seek further advice from a senior officer or a Domestic Violence Liaison Officer.

73 Robinson also acknowledged that the submitted applications did not include a reference to ‘his fears in relation to each party’, any ‘fears expressed by Lynette and Alan’ and any ‘history of reports or previous domestic violence incidents’.

He agreed these matters should have been included. He also acknowledged that an application could have been made for an ADVO to the court.

74 As he gave evidence he indicated if he had an application rejected now he would question it whereas at the time, as a junior officer, he accepted it.

75 Significantly, Emerton’s evidence was that if the application were before her, it is likely she would have granted it. She did not criticise the applications on the basis that they were cross-ADVOs. She also gave evidence as to the ‘resubmit’ function which, in this instance, would have allowed Robinson to remedy the inadequacies in his applications and explain why he considered cross applications to be appropriate.

Inspector Smith 76 Rather than utilising the ‘resubmit’ function, Smith rejected the applications and identified the reason (from a drop down menu) as ‘No reasonable grounds.’ This provided no assistance to Robinson, a junior officer, as to what was missing from his application.

77 Smith said that he rejected the application as the application did not include ‘fears expressed by the victim and by the police’ and he was not aware Lynette had provided a statement and would have expected information about prior history of domestic incidents. All of these matters could have been easily clarified either through the ‘resubmit’ function or a phone call to Robinson.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

78 The difficulty is when Smith rejected both applications - there was no scope for him to include in the computer system, a narrative as to what he believed was missing from the application.

79 It makes no sense that there is scope to include a narrative when a senior officer asks the applicant officer to ‘resubmit’ but cannot include a narrative when rejecting an application. Where a senior officer and an applicant officer are talking and where an applicant officer has resubmitted an application and it is refused, there may be no need to include any narrative as it may be abundantly clear why an application has been refused. The ability to include a narrative is important in cases such as the present case - where there is a lack of communication and a junior officer has no idea why his ADVO application has been refused and he has not been asked to resubmit it.

80 In his evidence, Smith said: (1) he refused the applications as the SOPs said, ‘we are not to take out cross-applications’ and that when police attended they're to ‘nominate or identify one of the parties is what they call the primary aggressor….there should have been, you know, in my eyes, it should have been the case that one party was identified as the primary aggressor and action taken with that person as the defendant.’ (2) he would be acting against the SOPs if he approved both applications.

(3) one thing he really looks at is fears - fears expressed by both the victim and by the police as well. In the present case, there was no expression of fear that would warrant approving an AVO application.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

(4) he would not look at the COPS Event about the narrative as he would trust the officers to put anything relevant in the ADVO application as he can be doing 6 or 7 applications back to back11.

(5) he did not find that where Alan complained Lynette had punched him this warranted an ADVO. He also said that where Lynette alleged Alan slapped her, that this did not warrant an ADVO as there was insufficient evidence as to who assaulted who.

81 When it was put to Smith that there can be a possibility that there's two primary aggressors, as in both parties were actually aggressive to each other, he said, ‘There could be two people being aggressive, but one would have to be the primary. You can't have two being the primary.’ 82 When asked if he would have taken any further steps to investigate if he was making the same decision today, Smith said: Hard to say…I expect an investigation has already been done. I'm not the actual investigator…Sometimes I might say to somebody, You need to go and do a bit more work or, I want to know a bit more about this or that. …if I do decline an application which does happen regularly, I do give the officer feedback as to why it's been declined and - because it might be the case because they're 90% there, they just need to add a little bit more in the application and I'd be happy with it, but you know, I do give the officer feedback, yeah, as to why it's been declined.

83 When asked if he recalled speaking to Robinson about the applications he said it was his general practice to speak to the officer, but in this case, he believes he did not see the application for 4 or 5 days. This is not reflected in the documentary evidence however I accept with the passage of time he has no real recollection.

84 The SOPs were put to Smith where it was suggested that cross-ADVOs were generally not recommended but in certain circumstances it was an unavoidable outcome. When he was asked if the present case was one of those unavoidable 11 Though the evidence did not support that 6 or 7 applications were before him when he considered the subject applications.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

outcomes, he said ‘no’ and when asked why, he said, police ‘need to investigate what happened and make an unpopular choice/identify who is the victim/offender in the situation’.

85 Inspector Smith was asked if his position was that where there is a couple in a relationship where both have made allegations of assault an ADVO should not be imposed, he said ‘Correct’ and when asked why, he said, ‘We need to identify who is the victim and who was the offender, something has to have happened first. Something has to - there is a chronology’.

86 Smith said when he refuses an application, his general practice would be to review the application and go through issues and speak to the applicant officer and see what can be done to address those issues.

87 I find the approach adopted by Smith in this case and his evidence as to his views surrounding cross-ADVOs fails to take into account: (1) the realities of domestic violence including that in some relationships, violence can be perpetrated by both parties and there can be incidents of aggression by both parties; and (2) it is not always possible in the immediate aftermath of an incident of domestic violence for police to determine who is the primary aggressor and who is the victim. To rule out cross-ADVOs in these circumstances leaves both parties unprotected.

88 I find that the approach adopted by Smith, both in his interpretation of the SOPs in so far as they relate to cross-ADVOS, and in his rejection of the ADVO applications without further enquiries being made, was inappropriate and inadequate. Further enquiries could have been made by using the resubmit function; reviewing the COPs Event and Alan and Lynette’s domestic violence history; or by contacting Robinson.

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

89 I am not suggesting that if the ADVO's had been approved Lynette and Alan would not have died. There are many uncertainties including: (1) even if made, the ADVOs applications did not provide for a ‘no contact’ order or an order preventing Lynette and Alan from residing together.

(2) even if made, they may not have remained in place a year later.

(3) Lynette applied for her own ADVO when the police initiated ADVOs were refused12. This application was ultimately withdrawn/dismissed when Lynette failed to appear at court on 22 October 2019. The ADVO initiated for Lynette by the NSWPF may have met the same fate if she failed to attend the hearing.

Is it necessary or desirable to make any recommendations?

90 As outlined above, I found that there were inadequacies in Smith’s approach to approving, or in fact rejecting, the ADVO applications lodged by Robinson approximately a year before the deaths of Alan and Lynette. This is the only issue in this inquest in which the potential for making recommendations arises.

Amending the SOPs 91 The issues identified related to both Smith’s interpretation of the SOPs and in his rejection of the applications without further enquiries being made.

92 In relation to the SOPs, given Emerton formed the view that the applications made by Robinson could have (and perhaps would have) been granted if she were the senior officer, she did not consider the SOPs prohibited cross-ADVOs from being made in this context. However, equally there were no concessions made by Smith who, while acknowledging that his rejection of the ADVOs left Lynette and Alan unprotected, remained of the view that cross-ADVOs ought not have been made.

12 On 16 October 2019, Lynette made an application for an ADVO (see E141896402 COPS Event).

Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

93 Given these contrasting views, while the SOPs do not, to my mind (or that of Emerton) rule out the granting of cross-ADVOs, as they are currently worded, they allow for a very narrow interpretation by a senior police officer. In these circumstances a review of the terminology is appropriate.

The rejection process and the WebCOPS system 94 As outlined in detail above, when Robinson’s applications were rejected, he was not provided with any reasons for their rejection. He conceded that due to his inexperience, he did not make further enquiries, which he now would.

95 From a systems perspective, there was no allowance for Smith to provide reasons for the rejection outside of the cursory options of ‘Insufficient Information’, ‘Lack of Urgency’ or ‘No reasonable grounds’ of which Smith chose the latter.

96 Unlike the ‘resubmit’ function, when an application is rejected outright, there is currently no capability for the approvals officer to include a narrative. In this instance, the narrative could have included the Smith’s views that further investigations were required to identify the aggressor; the failure of Robinson to refer to any history (or lack thereof) of domestic violence or the failure to reference any fears held by him and the persons in need of protection. I consider this ‘gap’ in the system ought to be addressed.

Recommendations 97 For the reasons outlined, I make the recommendations that follow.

98 That the Commissioner of NSW Police consider: (1) amending the Domestic and Family Violence Standard Operating Procedures 2018 at page 112 under the heading ‘The Test for a Senior Police Officer’ by adding a third paragraph that states: The failure to identify a primary aggressor is not a proper basis for a senior officer to refuse an application for a provisional ADVO where it Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

is suspected or believed that both parties have committed an offence and both parties are in need of protection.

(2) amending the process by which provisional ADVO applications are refused electronically on the WebCOPS system, by allowing senior officers, at the time of refusal, to include a narrative on the system that clearly sets out the specific reasons why an ADVO application has been refused.

99 I note that these recommendations are supported by Lynette and Alan’s family and that there was no objection posed by the representatives of the Commissioner of the NSWPF.

CONCLUDING REMARKS 100 I will close by conveying to Lynette and Alan’s children and their families my sympathy for their loss.

101 I thank the Aboriginal Coronial Information and Support Program social worker, Nicolle Lowe for her invaluable work. The Court always relies on her great assistance and is grateful to receive it.

102 I thank the Assisting team for their outstanding support in the conduct of this Inquest.

103 I thank investigator Detective Senior Constable Armour for his work in conducting the investigation and compiling the brief of evidence.

FINDINGS REQUIRED BY S 81(1) Lynette Thompson Identity of deceased Lynette Helen Thompson Date of death 21 November 2020 Place of death Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher

Royal North Shore Hospital, St Leonards NSW Cause of death Thermal injuries (extensive burns) and complications thereof Manner of death: Homicide by a known person Alan Fletcher Identity of deceased Alan Leslie Fletcher Date of death 9 November 2020 Place of death Dubbo Hospital, Dubbo NSW Cause of death Neck compression Manner of death Intentionally self-inflicted.

I close this inquest.

Magistrate R Hosking Deputy State Coroner Lidcombe ********** Findings in the Inquest into the deaths of Lynette Helen Thompson and Alan Leslie Fletcher