Parsons, Anthony John

OFFICE OF THE STATE CORONER FINDING OF INQUEST CITATION: Inquest into the death of Anthony John Parsons TITLE OF COURT: Coroner’s Court JURISDICTION: Brisbane FILE NO(s): COR 2010/319 DELIVERED ON: 21 October 2011 DELIVERED AT: Brisbane HEARING DATE(s): 17 June 2011 and 27 July 2011 FINDINGS OF: Mr Michael Barnes, State Coroner CATCHWORDS: CORONERS: death in custody; siege

REPRESENTATION: Counsel Assisting: Mr Peter Johns Senior Constable Maurice Fatnowna & Senior Sergeant Mark Sweetnam: Mr Calvin Gnech (Office of the Police Union Solicitor) QPS Commissioner: Mr Wayne Kelly (QPS Solicitors Office)

Table of Contents

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 officials with responsibility for the justice system including the Attorney-General and the Minister for Police, Corrective Services and Emergency Services. These are my findings in relation to the death of Anthony John Parsons. They will be distributed in accordance with the requirements of the Act and posted on the website of the Office of the State Coroner.

Introduction Anthony Parsons was likely suffering an acute period of depression exacerbated by job loss, financial distress and relationship difficulties when, on the afternoon of 25 January 2010 he violently assaulted his wife and began destroying property at their residence in Moranbah. The house owned by Mr Parsons’ father in law, contained several guns and when his wife noticed him to be trying to access the safe in which they were kept she called the police and then took the decision to flee with the couples three young children.

The seriousness of the situation quickly became apparent to the police officers who had arrived at the scene when they heard gunshots from within the house. A siege situation developed and over the ensuing eight hours Mr Parsons remained within a cordon put in place by specialist police. On moving beyond that cordon and armed with a shotgun Mr Parsons was challenged by police. He promptly, and consistent with threats he had made in the previous hours to friends, media and police, raised the gun to his head and fired. He died a short time later. He was 35 years old.

These findings:-  establish the circumstances in which the fatal injuries were sustained;  confirm the identity of the deceased person, the time, place and medical cause of his death; and  consider whether the police officers involved in managing the siege situation acted appropriately, effectively and in accordance with the Queensland Police Service (QPS) policies and procedures then in force.

As this is an inquest and not a criminal or civil trial, these findings will not seek to lay blame or suggest anyone has been guilty of a criminal offence or is civilly liable for the death. As the death followed immediately a series of events involving police and the incident was investigated by other police officers, the findings also critique the quality of that investigation.

The investigation Findings of the inquest into the death of Antony John Parsons 1

The investigation was conducted by the QPS Ethical Standards Command (ESC) and a detailed report was prepared by Inspector Russell Halfpenny.

Initial investigations were conducted by two officers from the Moranbah CIB.

Detective Sergeant Michael Pownell, who had not been involved in the siege, advised senior staff on the appropriate areas to be sealed off. He organised for those areas to be photographed and forensically examined, with all objects at the scene itemised and mapped.

The Special Emergency Response Team (SERT) operatives involved were removed from the scene as soon as their role in providing medical assistance to Mr Parsons ceased. The weapons of the SERT operative who had challenged Mr Parsons shortly prior to his death were seized by his team leader and provided to investigators. All members of this team and a Moranbah dog squad officer, who was also involved in forming the ‘inner cordon’, underwent breath tests after the siege.

Inspector Halfpenny and another ESC officer Inspector Michael Day travelled to Moranbah on the morning of 26 January 2010. They attended the scene of the siege and over the following days conducted interviews with those involved in the siege. Those officers later made enquiries into the medical and psychiatric background of Mr Parsons and all relevant medical records were obtained. Statements were obtained from medical staff involved both in advising police during the siege, those who treated Mr Parsons after he had been shot and those involved in his earlier psychiatric treatment.

Tapes of the ‘000’ calls made by Mrs Parsons and the telephone calls made between Mr Parsons and police negotiators were seized. All negotiator logs, police notebooks and regulatory documents related to the siege were seized.

Interviews were conducted with a number of civilian witnesses including friends and a member of the media who had been in contact with Mr Parsons in the hours prior to his death.

An experienced QPS ballistics expert conducted a series of tests on the two weapons allegedly used by Mr Parsons as well as casings and projectiles found at the scene. Swabs were taken of Mr Parsons’ hands after he had been declared deceased so they could later be tested for gunshot residue.

Those swabs and other items at the scene were forensically tested. This included analysis of DNA that could be extracted from items found at the scene of the siege.

A post mortem examination was conducted on the body of Mr Parsons at the Rockhampton mortuary on 28 January 2010. In the course of that examination bodily fluid samples were taken and later toxicologically tested.

I am satisfied this matter has been thoroughly and professionally investigated and all sources of relevant information have been accessed and analysed. I commend Inspector Halfpenny for his efforts.

Findings of the inquest into the death of Antony John Parsons 2

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

Social history Anthony Parsons, known to family and friends as Anton, was born on 25 October 1974 in Emerald, Queensland.

He was married to Tracey Parsons in 1998.

At the time of his death Mr Parsons was residing at 112 McCool Street Moranbah, in a house owned by his father-in-law, with Tracey and his three children.

He is survived by his wife and three children.

Criminal History and mental health background It appears from the medical records tendered to the inquest that Mr Parsons had suffered from periods of clinical depression from at least 2002. At that time he was prescribed the anti-depressant medication, Effexor, which he continued to take up until 2008.

In 2002 Mr Parsons had been charged with arson for which he was later found guilty and imprisoned. After a period of separation he reconciled with his wife about 12 months after release from prison.

On 27 July 2008 Mr Parsons was involved in a single vehicle collision which he later indicated to doctors had constituted a suicide attempt. He was treated at Moranbah hospital and seen by mental health workers at that time including a psychiatrist. He expressed immediate regret for having attempted suicide and over the coming weeks and months denied ongoing suicidal ideation.

There is reference in the medical records to another, earlier suicide attempt and it is clear that despite his denials with regards to ongoing suicidal ideation that his illness remained very serious. It is not clear it was ever formally diagnosed.

Mr Parsons was prescribed another anti-depressant medication, Dothep, which he continued to take for a period of approximately four months before ceasing. Although he was reported to have engaged with the mental health team at Moranbah hospital very well in the initial weeks and months after his 2008 suicide attempt, that was no longer the case by November that year. A discharge record from the mental health service dated 1 December 2008 states that Mr Parsons, by that time, had not responded to a number of letters and telephone calls notifying him of appointments that had been scheduled for him. Problems clearly remained as reflected in notes taken by a clinical mental health nurse on 29 October 2008. On that date Mrs Parsons attended the appointment that had been scheduled for her husband and expressed Findings of the inquest into the death of Antony John Parsons 3

concern over his state of mind. She felt that his medication was not working and said he was using emotional blackmail to prevent her leaving the marriage; claiming that he would kill himself if she did. At that time it was noted that an appointment with a psychiatrist had been organised for 5 November 2008. There was, though, no further contact from Mr Parsons.

The ongoing relationship problems combined with a loss of employment (Mr Parsons last worked in November 2009) were possible triggers for a ‘low point’ throughout January 2010 that Mrs Parsons noticed was dragging on longer than was usually the case.

25 January 2010 The period of tension in the relationship throughout January came to a head early on the afternoon of 25 January 2010 when Mrs Parsons confronted her husband about what was upsetting him. She says he announced that he no longer wanted to be married but felt he had limited options due to financial worries. An argument developed during which Mr Parsons began packing his bags and Mrs Parsons offered to give him the money he needed to leave. She says that was the cue for Mr Parsons to punch her in the face. He then began smashing the computer, printer and television before going into her father’s bedroom where she knew the firearms safe was located.

This version of events given by Mrs Parsons to investigators is certainly consistent with the contents of a “000” call made by her during the course of these events in which she is clearly distressed and reports the assault. After warning police in the call that Mr Parsons could be attempting to access firearms she left the house with her three children and made her way along the street.

Police become involved Senior Constable Sue Zealey and Constable Terry Nickless were hailed down by Mrs Parsons outside the house at 114 McCool Street. The conversation that followed was taped and again reveals a contemporaneous version of events consistent with what Mrs Parsons later told police. The seriousness of the situation soon became apparent to the attending officers, if it was not already, when they heard via police communications that Mr Parsons was threatening to shoot himself and then heard a gunshot from within the house at 112 McCool Street. The officers evacuated Mrs Parsons and the children from the area and notified police communications of what had occurred. Mrs Parsons then reported to police that she had received a message on her mobile phone from Mr Parsons saying that he intended to kill himself.

The sudden escalation of the situation resulted in more police arriving at the scene including a dog squad officer and the officer in charge of Moranbah station, Sergeant John Muller, who acted as incident commander in the early stages. Over the following period police focussed their attention on evacuating other residents from the area.

Mr Parsons made two “000” calls during these initial stages. Despite it being he who made the calls he did not engage with the operator to any great Findings of the inquest into the death of Antony John Parsons 4

degree, seeming to be trying to determine what the police were doing at that point and stating his intention that he would not be coming out of the house alive.

A cordon was formed around the residence by those officers who had arrived, directed initially by Senior Constable Zealey and then by Sergeant Muller. A later message from Mr Parsons to police was to the effect that he could see the officers. It was clear he was becoming agitated by this and a decision was made to pull the cordon back. It was also decided subsequent to this message that it would be safer for any neighbour still in their houses to remain rather than for the evacuations to continue.

At the Mackay police station the Acting District Officer, Senior Sergeant (then Acting Inspector) Mark Sweetnam was briefed on the situation. He formed the opinion that an emergency declaration was necessary and instigated the process to have that put in place pursuant to the Public Safety Preservation Act. He appointed Detective Senior Constable Maurice Fatnowna, a trained negotiator, to act in that role and had him take charge of setting up a negotiation cell. He then travelled to Moranbah while receiving ongoing briefs from Senior Constable Fatnowna and Sergeant Muller as he was en route.

The siege Senior Sergeant Sweetnam gave evidence at the inquest that he was dissatisfied with the location of the forward command post when he arrived at the scene. As the incident commander he ordered that it be moved further away from the “stronghold”. Although he didn’t go as far as to say it was unsafe, the original position of the command post, as chosen by the more junior officers initially at the scene, was far from ideal. The range at which Mr Parsons later showed he was able to reach with the firearms available to him confirmed that the action taken by Senior Sergeant Sweetnam was wise.

Senior Sergeant Sweetnam also told the inquest he was concerned with the adequacy of the containment line (or cordon) that was in place on his arrival.

Taking advice from an ex-SERT officer stationed in his region, he assigned more experienced personnel to more appropriate positions in that forward line for the situation that was developing.

After many attempts, Sergeant Fatnowna made contact with Mr Parsons at 4:16pm. Initially his difficulty in making contact appears to be because Mr Parsons was making a series of calls to friends telling them, in effect, that he was in a siege situation and that he did not intend to come out of it alive.

Those people later made contact with police and this information appropriately found its way to Sergeant Fatnowna.

In a series of conversations with Mr Parsons, Sergeant Fatnowna maintained a focus, as he had been trained, on discussions of future events. It was apparent that Mr Parsons had convinced himself that the only two outcomes available to him were to die or be sent back to jail. He was adamant over the course of several hours that he had no intention of submitting to the latter.

Sergeant Fatnowna sought to convince Mr Parsons that jail was not an Findings of the inquest into the death of Antony John Parsons 5

inevitable outcome of surrender. Sergeant Fatnowna told the inquest that the nature of his discussions with Mr Parsons caused him to fear from an early stage that the threat of suicide was real.

Just after 5:30pm four shots were fired from the house. After Mr Parsons’ death, bullet holes believed to be caused by shots fired by Mr Parsons were found in a police vehicle parked more than 200m from the house.

At 6:18pm police were contacted by a member of the media who advised them that Mr Parsons had sent an email to Channel 7 in which he stated he had plans “not to come out alive”.

Over the course of the initial hours of the siege another police negotiator, Constable Marshall Roper compiled a profile of Mr Parsons by speaking to staff at Moranbah Hospital and with friends, family and neighbours. Mr Parsons’ father-in-law was interviewed in relation to the weapons and ammunition in the house. He confirmed that Mr Parsons had access to a .410 shotgun, a .22 rifle and a more powerful .243 rifle.

The SERT team arrived in Moranbah just after 7:00pm and travelled to the police station where they received a briefing. They then deployed to the inner cordon and were in place at 8:15pm, relieving the general duties officers who had remained there for a number of hours.

At 8:56pm Mr Parsons told Sergeant Fatnowna that he was going to come out of the house and shoot himself. This information was relayed to the scene. Mr Parsons did then emerged from the house, fired a round from his shotgun and then lay down on the road in front of the house. He remained there with the shotgun pointed towards his head for approximately 40 minutes before standing up and walking away from the house along Williams Street.

This caused Mr Parsons to quickly come to the boundary of the inner cordon.

As he did so he was challenged by a SERT officer concealed in a nearby house. The officer told Mr Parsons to drop his weapon and return to the house. After initially pointing the shotgun in the general direction of the SERT officer, Mr Parsons quickly placed it under his chin and fired. He immediately slumped to the ground.

The aftermath The Queensland Ambulance Service (QAS) had been called at around the time that Mr Parsons lay on the road with a gun to his head after making threats to kill himself. QAS records show that they received this call at 8:59pm. They were, therefore, on scene when the siege came to an end and paramedics immediately attended to Mr Parsons after he had been shot.

Resuscitation attempts were initially conducted by members of SERT. The first paramedic on the scene noted “4-5 officers around patient, CPR in progress”. The seriousness of the injury and the proximity of Moranbah hospital caused the paramedics to immediately transport Mr Parsons rather than attempt any further stabilisation and treatment at the scene. Medical Findings of the inquest into the death of Antony John Parsons 6

records from Moranbah hospital note that paramedics were continuing with resuscitation attempts at the time the ambulance arrived. A SERT officer remained in the ambulance to assist paramedics with chest compressions.

Administration of adrenaline and further resuscitation attempts at Moranbah hospital were in vain. Mr Parsons was declared deceased at 10:10pm by Dr Pieter Nieuwoudt, approximately fifteen minutes after arrival at the hospital.

The emergency declaration under the Public Safety Preservation Act was revoked at 10:00pm.

The body of Mr Parsons was formally identified by his brother-in-law, known to him for fifteen years.

The investigation findings All officers who underwent breath tests after the siege returned negative results.

Ballistics testing revealed unremarkable results with respect to matches between projectiles and casing found at the scene and the two weapons alleged to have been used by Mr Parsons. DNA located on the barrel of the 0.410 shotgun and in a pool of blood was matched with Mr Parsons. Samples taken from other parts of the gun were not sufficient for a DNA profile to be established.

Investigations’ regarding the guns showed that at the time they were licensed and properly stored with the bolts located separately to the rest of the assembly, which itself was secured in a safe. It is unknown how Mr Parsons obtained the keys and located the bolts.

The autopsy A post mortem examination on the body of Mr Parsons was conducted by Dr Nigel Buxton, an experienced forensic pathologist, at the Rockhampton mortuary on 28 January 2010.

Dr Buxton observed a close contact gunshot wound which he considered was consistent with the version given by police to him that it was self-inflicted through the use of a 0.410 inch calibre shotgun. Injuries to the jaw and brain reflected the passage of gases from a close range discharge. A mark on the chest was, in Dr Buxton’s opinion, consistent with a hot barrel having rested there leading to superficial burns. Dr Buxton subsequently issued an autopsy certificate listing the cause of death as: 1.(a) Gunshot wound to the head.

Toxicology testing of a blood sample taken at autopsy later revealed that no alcohol or drugs were present. There were no other findings relevant to the events leading to his death.

Findings of the inquest into the death of Antony John Parsons 7

Conclusions It is clear that Tracey Parsons and his mother had ongoing concerns about Mr Parsons mental health. However, I am satisfied there is no basis to review the care provided to Mr Parsons at Moranbah Hospital as there is no indication that mental health staff at that hospital, or elsewhere, were approached by Mr Parsons after he failed to attend his last appointment in October 2008.

I am satisfied that for the majority of the period in which a siege was underway that QPS officers acted professionally and appropriately. Where there was a deviation from the standards that might otherwise be expected, they were identified by Senior Sergeant Sweetnam and rectified promptly. I accept the evidence that all officers in the region have now been trained in incident command.

I am satisfied that the process adopted by Sergeant Fatnowna to engage with Mr Parsons was adequately researched and thought through. There was no basis in this case for police to have ‘stormed’ the house or taken any more interventionist approach. The tactic to give Mr Parsons every opportunity to surrender as long as he posed no threat to others was correct. Even when he breached the inner cordon he was appropriately given the opportunity to drop his weapon and return to the house rather than being told he was under arrest. That he chose that moment to take his own life is not a reflection on the adequacy or appropriateness of the approach adopted.

Police readily and appropriately gained access to information about Mr Parsons’ previous contact with the Moranbah hospital mental health team.

I find that all of the officers and other agencies involved in responding to the emergency created by Mr Parsons’ sudden and dangerous actions discharged their responsibilities effectively. The junior officers who initially formed the inner cordon particularly deserve commendation for their brave and professional actions.

Findings required by s45 I am required to find, as far as is possible, who the deceased person was, how he died, when and where he died and what caused his death. As a result of considering all of the material contained in the exhibits and the evidence given by the witnesses, the material parts of which I have summarised above, I am able to make the following findings.

Identity of the deceased - The deceased person was Anthony John Parsons How he died - He took his own life when he shot himself after a protracted stand off with police while suffering from mental illness.

Place of death - Mr Parsons died at Moranbah in Queensland.

Findings of the inquest into the death of Antony John Parsons 8

Date of death - He died on 25 January 2010 Cause of death - Mr Parsons died from a gunshot wound to head.

Concerns, 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 administration of justice or ways to prevent deaths from happening in similar circumstances in the future.

In this case I am satisfied that the management of the siege and negotiation with Mr Parsons was done satisfactorily and in accordance with relevant policies in place at the time. There is nothing before me to indicate that those policies or the practices adopted as a result are inadequate or inappropriate.

As I have concluded, the plan to contain Mr Parsons without pressuring him and to give him every opportunity to continue to negotiate was appropriate to the circumstances. There is nothing before me to indicate that any more could have been done by way of negotiating with Mr Parsons to achieve a better outcome.

Mention was made at the inquest of the time taken for SERT to arrive at the scene; a period in which local officers stationed in the inner cordon were exposed to an undoubtedly dangerous situation. Presently SERT teams are based in Brisbane and Cairns. Submissions were made that I should consider recommending that the QPS station a SERT team in central Queensland.

While that may have merit, I do not consider I have sufficient evidence on which to base such a recommendation.

I close the inquest.

Michael Barnes State Coroner Brisbane 21 October 2011 Findings of the inquest into the death of Antony John Parsons 9