Partridge, Phillip Bruce

OFFICE OF THE STATE CORONER FINDING OF INQUEST CITATION: Inquest into the death of Phillip Bruce

PARTRIDGE TITLE OF COURT: Coroner’s Court JURISDICTION: State FILE NO(s): COR-2151/04(9) DELIVERED ON: 22 December 2005 DELIVERED AT: Brisbane HEARING DATE(s): 6 December 2005 FINDINGS OF: Mr Michael Barnes, State Coroner CATCHWORDS: CORONERS: Inquest, police siege, suicide, mental health etc ….

REPRESENTATION: Counsel: Counsel Assisting the State Coroner: Detective Inspector Gil Aspinall Queensland Police Service Commissioner: Ms Amanda Clarke Findings of the inquest into the death of Phillip Bruce Partridge Page 1 of 13

The Coroners Act 2003 provides in s45 that when an inquest is held into a death in custody, the coroner’s written findings must be given to the family of the person who died, each of the persons or organizations granted leave to appear at the inquest and to various specified officials with responsibility for the justice system. These are my findings in relation to the death of Phillip Bruce Partridge. They will be distributed in accordance with the requirements of the Act.

Introduction Phillip Bruce Partridge was 37 years of age when he was involved in a siege with police officers at his home at Lot 85 Boonah-Rathdowney Road, Boonah for approximately 36 hours until its conclusion on Wednesday 1 September

2004. When police finally entered Phillip’s premises, he was found dead with stab wounds to his abdomen.

These findings seek to explain how that occurred.

The Coroner’s jurisdiction Before turning to the evidence, I will say something about the nature of the coronial jurisdiction.

The basis of the jurisdiction Because when he died, Mr Partridge was trying to avoid being put into custody by the police, his death was a “death in custody”1 within the terms of the Act and so it was reported to the State Coroner for investigation and inquest.2 The scope of the Coroner’s inquiry and findings A coroner has jurisdiction to inquire into the cause and the circumstances of a reportable death. If possible, he/she is required to find:- (cid:121) whether the death in fact happened (cid:121) the identity of the deceased; (cid:121) when, where and how the death occurred; and (cid:121) what caused the person to die.

There has been considerable litigation concerning the extent of a coroner’s jurisdiction to inquire into the circumstances of a death. The authorities clearly establish that the scope of an inquest goes beyond merely establishing the medical cause of death but as there is no contention around that issue in this case I need not seek to examine those authorities here with a view to settling that question. I will, however, say something about the general nature of inquests.

1 See s10 2 s8(3) defines “reportable death” to include deaths in custody and s7(2) requires that such deaths be reported to the state corners or deputy state coroner. S27 requires an inquest be held in relation to all deaths in custody Findings of the inquest into the death of Phillip Bruce Partridge Page 2 of 13

An inquest is not a trial between opposing parties but an inquiry into the death.

In a leading English case it was described in this way:- It is an inquisitorial process, a process of investigation quite unlike a criminal trial where the prosecutor accuses and the accused defends… The function of an inquest is to seek out and record as many of the facts concerning the death as the public interest requires. 3 The focus is on discovering what happened, not on ascribing guilt, attributing blame or apportioning liability. The purpose is to inform the family and the public of how the death occurred with a view to reducing the likelihood of similar deaths. As a result, the Act authorises a coroner to make preventive recommendations concerning public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in future4. However, a coroner must not include in the findings or any comments or recommendations statements that a person is or maybe guilty of an offence or civilly liable for something.5 The admissibility of evidence and the standard of proof Proceedings in a coroner’s court are not bound by the rules of evidence because s37 of the Act provides that the court “may inform itself in any way it considers appropriate”. That doesn’t mean that any and every piece of information, however unreliable, will be admitted into evidence and acted upon.

However, it does give a coroner greater scope to receive information that may not be admissible in other proceedings and to have regard to its provenance when determining what weight should be given to the information.

This flexibility has been explained as a consequence of an inquest being a factfinding exercise rather than a means of apportioning guilt: an inquiry rather than a trial.6 A coroner should apply the civil standard of proof, namely the balance of probabilities, but the approach referred to as the Brigenshaw sliding scale is applicable.7 This means that the more significant the issue to be determined, the more serious an allegation or the more inherently unlikely an occurrence, the clearer and more persuasive the evidence needed for the trier of fact to be sufficiently satisfied that it has been proven to the civil standard.8 It is also clear that a coroner is obliged to comply with the rules of natural justice and to act judicially.9 This means that no findings adverse to the interest of any party may be made without that party first being given a right to 3 R v South London Coroner; ex parte Thompson (1982) 126 S.J. 625 4 s46 5 s45(5) and 46(3) 6 R v South London Coroner; ex parte Thompson per Lord Lane CJ, (1982) 126 S.J. 625 7 Anderson v Blashki [1993] 2 VR 89 at 96 per Gobbo J 8 Briginshaw v Briginshaw (1938) 60 CLR 336 at 361 per Sir Owen Dixon J 9 Harmsworth v State Coroner [1989] VR 989 at 994 and see a useful discussion of the issue in Freckelton I., “Inquest Law” in The inquest handbook, Selby H., Federation Press, 1998 at Findings of the inquest into the death of Phillip Bruce Partridge Page 3 of 13

be heard in opposition to that finding. As Annetts v McCann10 makes clear that includes being given an opportunity to make submissions against findings that might be damaging to the reputation of any individual or organisation.

The investigation Once the paramedics who attended the scene established that Mr Partridge was dead, Inspector Brett Schafferius was directed to conduct a “death in custody” coronial investigation. This investigation was overviewed by the Ethical Standards Command, of the Queensland Police Service (QPS). The Crime and Misconduct Commission also overviewed the investigation into Mr Partridge’s death.

The scene was photographed and forensically examined. All relevant witnesses were interviewed and statements obtained. On 2 September 2004, an autopsy was conducted by Dr Guy Lampe, a Forensic Pathologist from the John Tonge Centre.

I am satisfied that the investigation was competent and thorough.

The Inquest An inquest was held in Brisbane on 6 December 2005. Detective Inspector Aspinall was appointed to assist me. Leave to appear was granted to the Commissioner of the Queensland Police Service. Mr Partridge’s family advised through their solicitors that they did not wish to attend and had no matters they wished raised at the inquest. A copy of the evidence and the proposed submissions were provided to the solicitor representing the family prior to the inquest All of the statements, records of interview, medical records and photographs were tendered.

I determined that the evidence contained in them was sufficient to enable me to make the findings required by the Act and that there was no other purpose which would warrant any witnesses being called to give oral evidence. The family indicated that they did not wish to challenge or examine any of the witnesses’ versions as contained in the documents which had been tendered.

The evidence I turn now to the evidence. Of course I cannot even summarise all of the information contained in the exhibits but I consider it appropriate to record in these reasons the evidence I believe is necessary to understand the findings I have made.

Background The deceased’s family consisted of his brother, Andrew James Partridge, his mother, Helen Phyllis Partridge and his father, Bruce James Partridge. The 10 (1990) 65 ALJR 167 at 168 Findings of the inquest into the death of Phillip Bruce Partridge Page 4 of 13

deceased’s father Bruce Partridge died on 22 January 2000 at the Ipswich Hospital. Prior to his death, Bruce Partridge resided with Phillip at the Boonah property After his father’s death, Phillip continued to live at the property and would divide his time between the property and his mother’s address on the Gold Coast.

According to his family, Phillip began acting strangely after his father’s death in 2000. In September 2001, he suffered a psychotic episode and was detained under the provisions of the Mental Health Act. He remained in a mental health facility until 6 December 2001. While there the deceased was prescribed Zyprexa and he apparently continued taking this medication until mid January 2002. According to his brother Andrew, the deceased cut back using his medication gradually and then totally stopped taking it. Phillip indicated to his brother that the medication made him drowsy and he could not do the things he enjoyed.

In August 2004, Phillip attended the Gold Coast as was usual. Andrew indicates that Phillip was behaving strangely. Examples of this were that when Andrew would speak to the deceased it would take him 30 seconds to respond and on one occasion when they went for a drive, Phillip was laughing to himself. It appeared to Andrew that the deceased was in a ‘world of his own’. One night, Andrew found Phillip sitting in the kitchen/dining area in the dark staring at a blank wall. When asked if he was all right, Phillip indicated that he was.

The deceased’s mother and Andrew attempted to get Phillip to again take his medication, however he declined to comply.

On 20th August 2004, Helen Partridge contacted local police and requested they attend Phillip’s residence for the purpose of checking on his welfare.

Upon attending Phillip’s property at Boonah, Senior Constable Kirkham explained the purpose of police visiting and Phillip indicated that he was camping away from home to sort out some problems he was having. He indicated however that everything was now ‘fine’. He also indicated that he had been having problems sleeping, however he had taken some sleeping tablets and was now resting better.

Phillip was informed that his mother had attended and left a mobile phone and food for the deceased. He was advised that his mother loved him and was worried because she had not heard from him. Phillip indicated that his mother was ‘great’ and that ‘she looked out for him’.

Phillip advised that he did not feel like hurting himself, and that catching up on some sleep had made the world of difference to him.

Phillip’s bedroom was observed to be neat and tidy. Several hunting knives, camping equipment and rock-climbing equipment were observed in the residence.

Senior Constable Kirkham advised that Phillip appeared at ease and did not display signs of instability or suicidal tendencies. He left and telephoned Phillips’s mother Helen to advise her of what had occurred. Helen indicated that Phillip had telephoned her and everything was now “fine”.

Findings of the inquest into the death of Phillip Bruce Partridge Page 5 of 13

The events of Sunday 29 August 2004 On Sunday 29th August 2004, Phillip was supposed to telephone his mother, however he did not. As a result, at 8.00am on Tuesday 31st August 2004, the deceased’s brother Andrew and their mother Helen travelled to Phillip’s residence at Boonah.

The front gate was locked so Andrew jumped over the fence and walked up to the house. Andrew called out to Phillip to let him know that he was there.

Phillip came out of the house and met Andrew and asked him what he was doing there.

Andrew informed Phillip that they were there to visit him. Andrew also mentioned that their mother had left messages for him. Phillip appeared shocked and asked in surprise if their mother was with Andrew.

Andrew asked Phillip to get the keys so that he could let them drive the car up to the house. Phillip then suggested they did not just go home as everything was all right.

Andrew advised that he and their mother had travelled to the property from the Gold Coast and they really wanted to see him. Phillip then went to look for the keys. Andrew went to go into the house and at this time Phillip turned around and told Andrew not to go inside. Phillip located a set of keys and gave them to Andrew.

Andrew saw that Phillip’s television was on the “burn pile” and that it had been smashed. He also saw two fridges had been taken out of the residence, and it appeared to him, that they were to also go onto the burn pile. He also saw the Phillip’s Harley Davidson motorcycle outside.

Andrew asked Phillip to let them in, however Phillip was not responding to this. Andrew coaxed Phillip to follow him, which he did but Phillip kept telling him to go home. When they reached the front of the house, Phillip stopped and was insistent that Andrew tell their mother that everything was fine and that they were to go home.

By this time, Andrew had asked Phillip 4 or 5 times to let them in, and he thought that the safest thing to do was to head back to his mother’s location.

Andrew was aware that Phillip suffered from a mental illness and believed he was back in a destructive cycle.

Andrew and his mother decided that they would have to get Phillip to hospital due to his condition. As a result, a decision was made to ring the Boonah Police to get assistance. Andrew spoke to Sergeant Peter Boyce, the Officer in Charge of Boonah Police Division, and advised him of the situation.

Initial police attendance at residence A short time later Sergeant Boyce and Senior Constable Anthony O’Meara from Boonah Police attended the location. They were in police uniform and Findings of the inquest into the death of Phillip Bruce Partridge Page 6 of 13

driving a marked police car. The police vehicle travelled ahead of the Partridge’s vehicle as they drove up the driveway and both parked near the residence.

For approximately 3 to 5 minutes, all were knocking on the door and calling out but getting no response. Phillip eventually answered from inside. Sergeant Boyce asked him to open the door. All four persons were near the front door.

Sergeant Boyce and Helen Partridge were closest to the doorway.

Phillip unlocked the front door. Sergeant Boyce pushed the door open slightly and saw Phillip standing at the door. Sergeant Boyce said “It’s Peter Boyce from the police here mate”. He observed that Phillip was holding something, so Sergeant Boyce said “Put it down”. Phillip refused. Sergeant Boyce said, “What have you got, hang on, he’s got a crossbow”. Phillip has then said “It’s not”. Boyce said, “What have you got in your hand mate”. Phillip replied however, Boyce was distracted by Mrs Partridge, who was trying to gain entry to the house.

Sergeant Boyce pushed Mrs Partridge back and said “Out of the way mum”.

Sergeant Boyce again said, “Phil, just put it down thanks mate”. Phillip replied, however Sergeant Boyce could not understand what he said.

Sergeant Boyce said, “Put it down, I’m not here to hurt you, I’m here just to talk to you. We want to know if you’re OK”. At about this time Senior Constable O’Meara ushered Mrs Partridge and Andrew Partridge away, whilst Sergeant Boyce continued trying to engage Phillip in conversation.

After about a minute of conversation Sergeant Boyce asked Senior Constable O’Meara to request a Police Negotiator. Sergeant Boyce then attempted to continue his conversation with Phillip, however Phillip failed to respond.

Sergeant Boyce asked Phillip to move around into the light so that he could see him and then told him he was going to push the door open further. Phillip did not respond to his conversation. Senior Constable O’Meara covered the front door with his firearm drawn whilst Sergeant Boyce pushed the door open. Senior Constable O’Meara was unable to see Phillip.

Sergeant Boyce then entered the residence and continued to try and engage Phillip in conversation Sergeant Boyce kept asking questions of Phillip trying to locate him in the residence. Phillip did not answer or engage in any conversation. Sergeant Boyce requested Senior Constable O’Meara to have an ambulance attend the location. Sergeant Boyce asked Senior Constable O’Meara to obtain a torch because although it was daytime the curtains on the windows made it very difficult to see inside the house.

Sergeant Boyce then advised Phillip that other police would be coming to assist. Phillip responded and engaged in conversation. Sergeant Boyce identified that Phillip was in the northern side of the room that he was standing in. Phillip advised that he wasn’t going to negotiate. Sergeant Boyce asked Findings of the inquest into the death of Phillip Bruce Partridge Page 7 of 13

him questions in relation to his television. Sergeant Boyce continued to engage Phillip in conversation and sensed that he was becoming agitated.

Sergeant Boyce changed the subject and asked Phillip how long he had lived at the location. Sergeant Boyce stated that it was a great location. When Sergeant Boyce said this, he heard the sound of moving bed springs.

Sergeant Boyce focused on the doorway leading to the rear room at the rear north-western corner of the room he was standing in.

Phillip appeared standing side on with the crossbow raised in front of him. It appeared to Sergeant Boyce that Phillip was aiming the bow at him. Sergeant Boyce spontaneously turned and rushed away. He heard the front door close behind him as he left.

Commencement of the siege situation The officers then advised Ipswich Police Communications Centre of the situation. Sergeant Boyce and Senior Constable O’Meara then moved back to the police vehicle and donned their bullet-proof vests with the view to containing Phillip in the premises until other police arrived on scene.

Sergeant Boyce and Senior Constable O’Meara continued to contain and secure Phillip in the premises and requested that the next police crew to arrive were to obtain the layout of the residence and any contact telephone numbers from the family. Sergeant Boyce also requested that Senior Constable Kirkham, who had previous dealings with Phillip, be contacted to ascertain any information that may be of assistance in the present situation.

As additional police arrived, they were deployed to secure and contain Phillip in the premises.

A request was made for the Special Emergency Response Team (S.E.R.T.) to be placed on standby.

The incident was then conducted as a “siege situation”. Police in charge of the scene considered the situation called for Phillip to be isolated and contained in the premises. Negotiators were then called in to endeavour to diffuse the situation. Police Negotiators and SERT arrived at the scene. The situation was evaluated and tactics were identified.

An Emergency Situation was declared pursuant to Section 5(3) of the Public Safety Preservation Act at 1.21 pm. The area of the Emergency existed at "Lot 85 Boonah Rathdowney Road via Boonah 1 km radius of the Residence Dwelling House and airspace to 1 Km above the house". The incident was identified as "involving a weapon that may cause injury or distress to any person".

At 2.38pm further attempts at negotiation commenced and continued over the duration of the siege situation.

From this time onwards until the conclusion of the siege, police utilised a number of tactics in an attempt to diffuse the situation including requesting Findings of the inquest into the death of Phillip Bruce Partridge Page 8 of 13

psychiatrists to attend the scene with the view to assisting with the negotiation process; using a remote controlled ‘echidna’ to open a roller door to the premises and the playing of tape recordings of both Helen and Andrew Partridge via the loudspeaker system to Phillip.

Numerous attempts were made by both telephone and a loud-speaker system to contact Phillip. Information was received that Phillip was friendly with a neighbour, Mr. Richard Collier. Arrangements were then made to secure an audio-recorded message from this person to try to assist with diffusing the situation. None of these actions elicited an observable response from Phillip.

Events of Wednesday 1 September 2004 On the morning of Wednesday 1 September the Police Commanders on site reaffirmed the objective of the operation was to engage Phillip in conversation in order to negotiate a peaceful conclusion to the incident.

At 8.25am, Phillip came out of his residence and walked to the barbed wire fence, which was some 15 meters away from the residence. He was smoking a cigarette and wearing a sombrero with a hood. He then walked back into the house. It was unknown if he had any weapons concealed and the cloak.

Phillip was then observed making minor repairs to the roller door.

At 11.00am, two mental health professionals from the Ipswich Mental Health facility, Dr. Drew Richardson and Ms Paula van Epenhuysen attended the scene and provided professional advice as to Phillip’s mental state. It was confirmed that Phillip was suffering from schizophrenia.

At 12.00pm, Phillip exited the residence for two short periods of time, however did not move far enough to enable police to attempt to intercept him.

Doctor Richardson determined that as Phillip had previously been prescribed “Zyprexa” it was appropriate to provide this drug to him. It was thought that it may sedate and relax him. This issue and the consequences were discussed with the police and Phillip’s family.

A strip of six (6) ten (10) milligram “Zyprexa” tablets were placed near the roller door entrance. A short time later, Phillip walked out of the roller door, picked up the medication, turned around and walked back inside the dwelling.

Phillip did not acknowledge the presence of police at that time.

When back inside the residence, Phillip walked through the residence to the northern side of it and gave the ‘thumbs up’ sign to police.

Various attempts were made to again make contact with Phillip, however he did not respond.

At 5.25pm, an armoured police vehicle with the “karaoke device” drove around the residence and continued with attempts to gain acknowledgement from Phillip. This proved unsuccessful.

Findings of the inquest into the death of Phillip Bruce Partridge Page 9 of 13

At 6.10pm, the lights police had brought to rhe scene were illuminated.

At 7.22pm police observed torchlight through a window on the northern side of the premises; however no physical sighting of Phillip was made.

At 9.25pm, the lights at the residence were turned off and turned back on at 9.53pm.

At 10.00pm, a plan utilising a pole camera was implemented, which involved looking into the area near the roller door with a camera on a pole. Whilst this was being undertaken, SERT personnel removed curtains from the window on the southern side of the premises. Phillip was not seen via the pole camera.

It was then decided to break down the front door of the premises to view inside to ascertain the welfare of Phillip.

At 10.28pm, the SERT specialist police team moved towards the residence.

At 10.29pm, the front door of the premises was breeched and the police immediately observed Phillip’s legs a short distance inside of the front door. It appeared that he was lying down behind a couch, which was hard up against the front wall of the house, next to the front door. The couch obscured Phillip’s body from his knees up.

Police called, “Police don’t move, show me your hands’. No response was received and the police officer stepped into the doorway to view Phillip’s entire body and to view his hands.

As a police officer stepped into the room he observed Phillip lying on his right hand side, face down with a large hunting style knife in his right hand. The blade of the knife was pointing towards his feet, which was in the direction of the police officer.

The officer was concerned for his welfare and the welfare of the other police.

He says he considered the situational ‘use of force’ model and, as a result, deployed his Taser Gun to Phillip to remove any potential threat. Upon deployment, the probes of the Taser Gun struck Phillip in the left hip area.No response was seen from him.

The police officer lent forward and stepped onto Phillip’s hand and removed the knife. The police officer then rolled Phillip onto his back and checked for vital signs of life, however none were located. A small amount of blood was seen on the front of Phillip’s shirt in the stomach area.

Paramedics were immediately called and attended the scene. The police officer observed that rigor mortis had not set into Phillip’s body. Paramedics attended at 10.32pm and determined that Mr Partridge was dead.

Findings of the inquest into the death of Phillip Bruce Partridge Page 10 of 13

Autopsy results His body was taken to the John Tonge Centre where, at the conclusion of the autopsy examination, Forensic Pathologist, Doctor Guy Lampe advised that, in his opinion, Phillip died as a result of two separate stab wounds to his abdomen. The larger knife located in Phillip’s hand appeared to have been used for the more superior wound and the pocket-knife, which was also located at the scene, for the lesser wound.

Dr. Lampe advised that the stab wounds had resulted in massive bleeding into the abdominal cavity, which caused the death.

Dr. Lampe stated that given the wound angles and locations, they are quite consistent with self-infliction.

Dr. Lampe was also of the view that Phillip was deceased at the time the police used the Taser Gun on him. He was of the view that the use of the Taser Gun played no part in Phillip’s death.

Issue of the drug Zyprexa Doctor Leslie Griffiths, Forensic Medical Officer of the Clinical Forensic Medicine Unit has provided professional opinion concerning the drug “Zyprexa”, which was supplied to Phillip during the siege situation Zyprexa is the trade name for one of the newer anti-psychotic drugs known as olanzapine, which is a mood stabiliser. It is commonly used for persons suffering from schizophrenia.

After studying the available literature, Dr. Griffiths determined that the level of the olanzapine in Phillip’s post-mortem serum fell within the toxic and potentially lethal range. He determined that he could not exclude altogether the possibility that Phillip experienced some toxic effects after the ingestion of the olanzapine.

However, Dr. Griffiths concluded that there does not appear to be a scientifically validated method of determining a true ante-mortem blood concentration from post-mortem levels, which could be spuriously high.

Dr Griffiths was of the opinion that Phillip would have had a theoretical level of about 80ng/ml of olanzapine after ingesting 6 tablets of 10mgm each and, that if this was before death ensued from another cause, this level of olanzapine falls below the scientifically reported examples of death due to olanzapine alone.

It is also noted that in his Autopsy Report, Dr Lampe reports that, in his view, the level of the drug “olanzapine” in Phillip’s system at post-mortem was slightly above the therapeutic range, but well short of the fatal level.

How Mr Partridge died Findings of the inquest into the death of Phillip Bruce Partridge Page 11 of 13

The following aspects of the matter support the conclusion that Mr Partridge intentionally caused his own death:-

• the history of bizarre behaviour and schizophrenia;

• the destruction by Mr Partridge of his property

• his unusual behaviour prior to and during the siege situation;

• the diagnosis by Dr. Richardson that during the siege situation Mr Partridge was suffering from a schizophrenic episode

• evidence that he was alone in his residence surrounded by police when he was found deceased;

• the autopsy evidence indicating injuries consistent with self-inflicted stab wounds; and

• an absence of evidence of any third party involvement.

Findings required by s45 I am required to find, as far as is possible, the medical cause of death, who the deceased person was and when, where and how he came by his death. I have already dealt with this last aspect of the matter, the manner of the death. As a result of considering all of the material contained in the exhibits, I am able to make the following findings in relation to the other aspects of the matter.

Identity of the deceased – The deceased person was Phillip Bruce Partridge Place of death – He died at Lot 85 Boonah-Rathdowney Road, Boonah, Queensland.

Date of death – Mr Partridge died on 1 September 2004 Cause of death – He died from self-inflicted stab wounds to his abdomen.

Comments and recommendations Section 46, in so far as it is relevant to this matter, provides that a coroner may comment on anything connected with a death that relates to public health or safety, the administratio of justice or ways to prevent deaths from happening in similar circumstances in the future.

I find that none of the police officers caused or contributed to the death and that nothing could have been done to save Mr Partridge when police finally gained entry to the house.

After considering the available evidence, I am of the view that the police involved in this incident rightly determined to attempt to resolve the situation by containing and negotiating with Mr Partridge. However, unfortunately due Findings of the inquest into the death of Phillip Bruce Partridge Page 12 of 13

to his mental state, this was unable to be achieved and Mr Partridge died from self-inflicted stab wounds to his abdomen.

I do not consider police could reasonably have handled the matter in any other way and that had they simply left the property in all likelihood the result would have been the same with an attendant risk that harm could have come to anyone else who happened upon the scene. I consider the police officer involved acted admirably in their attempts to secure the welfare of Mr Partridge.

Michael Barnes State Coroner Brisbane 22 December 2005 Findings of the inquest into the death of Phillip Bruce Partridge Page 13 of 13