Deceased
Liam Cooper Scorsese
Demographics
31y, male
Coroner
Ryan
Date of death
2018-02-25
Finding date
2021-05-28
Cause of death
Gunshot wounds to the neck and chest
AI-generated summary
Liam Scorsese, 31, died from gunshot wounds inflicted by police during a confrontation at his estranged partner's parents' home in Queensland. He had a history of violence, substance abuse (methamphetamine, cocaine), and untreated mental health issues including drug-induced paranoia. Despite repeated directions from his parole officer to obtain a mental health plan after release, he failed to engage. On the day of death, intoxicated and displaying paranoia, he attended the family home, became aggressive when asked to leave, and produced a knife when police arrived. Officers attempted de-escalation and deployed a Taser (ineffective), but he advanced toward them. The officer fired twice when Scorsese came within 2.5 metres. The coroner found the police response lawful and appropriate. Clinical lessons include: importance of mental health assessment on release from custody; need for better information-sharing between correctional and health services; and enhanced training for parole officers managing substance abuse and mental health comorbidity. Notably, the responding officer's body-worn camera failed to activate, limiting independent documentation of the incident.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Liam Cooper Scorsese TITLE OF COURT: Coroners Court
JURISDICTION: BRISBANE FILE NO(s): 2018/902 DELIVERED ON: 28 May 2021 DELIVERED AT: Brisbane HEARING DATE(s): 12 March 2020, 18-19 September 2020 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, police shooting, edged weapon, tasers, body-worn cameras, information sharing, mental health support for parolees.
REPRESENTATION: Counsel Assisting: Ms Sarah Lio-Willie Commissioner of Police: Mr Mark O’Brien (QPS Legal Unit) Constable Till and Constable Reed: Mr Troy Schmidt (Instructed by Gnech and Associates)
Family: Mr Angus Edwards (instructed by Ashkan Tai Lawyers) WMHHS, MSHHS, GCHHS: Ms Stephanie Gallagher Queensland Corrective Services: Ms Jesika Franco, Crown Law (instructed by QCS)
Contents
Introduction
Police were responding to a triple zero call from his partner’s mother. She had told police that he was aggressive and kicking in her doors and windows.
When police attended, Liam produced a knife and asked them to shoot him.
The police officers retreated backwards down the street, where Liam was ultimately fatally shot. An attempt to use a Taser had been unsuccessful. The events unfolded over a minute.
An investigation into the circumstances surrounding Liam’s death was conducted by Detective Sergeant Dylan Brook of the Ethical Standards Command, Internal Investigations Group. A coronial report was subsequently provided with various annexures, including witness statements, digital recordings, offender and medical records.
A post-mortem examination found Liam’s cause of death to be gunshot wounds to the neck and chest.
The inquest
• Mr Scorsese’s family
• Commissioner of Police
• Constable Till and Constable Reed
• West Moreton, Metro South and Gold Coast Hospital and Health Services
• Queensland Corrective Services
• Detective Sergeant Dylan Brook
• Madeleine Erasmus
• Peter Erasmus
• Kim Gehrke
• Chris Pennifold
• Stephen Joughin Findings of the inquest into the death of Liam Cooper Scorsese Page 4 of 36
• Constable Reed
• Constable Till
• Stephanie Marr, Case Manager, Queensland Corrective Services
• Sarah Hyde, Assistant Commissioner, Queensland Corrective Services
• The findings required by s. 45 (2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused his death.
• Whether the actions of attending police officers were appropriate in the circumstances.
• Current arrangements for the sharing of confidential information between Queensland Health and Queensland Corrective Services including whether these are sufficient on transition from prison to parole and remand in custody.
• Whether any changes to procedures and policies need to be made with respect to parolees accessing mental health plans or participating in relevant programs immediately after release from prison.
• Whether sufficient training and support is provided to probation and parole officers to identify and manage mental health risks for offenders under their supervision.
• What further can be done to ensure that offenders released on parole are provided with appropriate support for mental health concerns in the community?
• Consideration of the use of body worn cameras and associated QPS training.
The evidence Personal history
Liam was survived by his parents. His mother, Maree Maloney, and his father, Peter Schumacher, separated when he was a child. Liam was estranged from his father from the age of 11 years but reconnected with him at about the age of 21.
Ms Maloney said that her son had behavioural issues in relation to anger management as a teenager. She tried to address his behaviour with the assistance of counselling. From about the age of 14, he lived with extended family for 18 months. Despite these issues Liam continued to have a close relationship with his mother and maternal grandparents.
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Liam left school at 15 years and worked as a tradesman. Shortly before his 18th birthday, his grandfather died. Ms Maloney said that this affected him significantly and he became more involved in the party and drug scene.
Liam’s birth name was Liam Cooper Moloney. He changed his name to Scorsese to create a fresh start after a period in custody in 2013.
Criminal history
Liam had a criminal history in New South Wales commencing in 2005 when he was a juvenile. His criminal history consisted primarily of personal violence and property offences.
He had been sentenced to various orders including good behaviour bonds, community service orders, and suspended periods of imprisonment. His final offending in New South Wales was committed and finalised in 2010.
During his time in New South Wales, Liam was also the respondent on four different apprehended violence orders against family members, his partner and an alleged drug associate.
After Liam moved to the Gold Coast in 2010, his Queensland criminal history commenced. His offending consisted of personal violence, drug and Bail Act offences, including assault occasioning bodily harm, serious assault of a police officer and possession of dangerous drugs.
Liam was first incarcerated in Queensland in 2013, having spent 43 days in presentence custody for an offence of assault occasioning bodily harm. Liam was then released on parole. This was also his first contact with Queensland Probation and Parole. Liam’s most recent period of incarceration was from 1 August 2017. He was sentenced to 18 months imprisonment and was released on parole on 1 November 2017.
Liam was known to the QPS as an associate of Outlaw Motorcycle Gangs, the Finks and Comancheros. His relationship with the QPS was characterised by antagonism and this was reflected in his criminal history.
Engagement with Probation and Parole
iv. Report to and receive visits as directed by the chief executive or delegate; v. Notify the chief executive or delegate within 48 hours of any change of address or employment during the parole period; vi. Not commit an offence; vii. Comply with a condition requiring compliance with a direction by a corrective services officer, including a curfew or monitoring condition in accordance with Section 200A of the Corrective Services Act.
On the same date he was also issued with a Reasonable Direction to abstain from all illicit and prohibited drugs and to not leave Queensland without the permission of an authorised corrective services officer.
On 5 February 2018, the Parole Board Queensland formally amended Liam's Parole Order to include the following condition: viii. You must not in any way directly or indirectly contact or communicate or associate with members or associates of Criminal Organisations (for example, but not limited to, Outlaw Motorcycle Gangs).
After his release from custody, Liam was subject to an assessment period by Queensland Corrective Services (QCS) between 1 November and 7 December 2017.
The assessment identified that his criminogenic needs were substance abuse and peer relationships. His mental health was assessed as a noncriminogenic need and was to be monitored through his engagement with a GP and psychologist. He denied a history of self-harm or suicidal ideations and no information was available to suggest otherwise. At the time of his release he told his Case Manager, Stephanie Marr, that he had no contact with Ms Beytell. He also disclosed that he had committed the respective assault offences in the middle of a relationship breakdown with Ms Beytell.
A review of Liam’s QCS offender records identified numerous references to the management of his mental health. The first record from 6 November 2017 noted that he had attended a GP, Dr Abdur Alamigir, in Surfers Paradise to manage his anxiety and depression and was keen to return to sessions with Psychologist, Dr John Brownhill.
On 1 December 2017, Liam had failed to engage with a psychologist and was directed by Ms Marr to obtain an updated mental health plan (MHP) within two weeks.
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By 2 December 2017, he had not obtained a MHP and reported experiencing fluctuating moods. Ms Marr again directed him to obtain a MHP and referral to a psychologist before his next visit.
On 7 January 2018, Liam provided prescriptions from Dr Alamgir. This demonstrated to QCS that he was in contact with a health professional within weeks of his release from custody.1
On 15 January 2018, Ms Marr sent Liam a text message requesting he bring a copy of his MHP to his visit on 16 January 2018. Liam attended the QCS office on 16 January 2018 but had not obtained a MHP.
While he denied using illicit substances, Ms Marr noted he had a substantial increase in muscle mass. He initially denied using steroids but later in the appointment stated he was prescribed testosterone by his doctor to assist in hormone levels to manage his depression. He was then directed to attend the probation and parole office on 17 January 2018 to be provided with a social history and direction outlining the requirement to engage psychological intervention.
Between 19 and 22 January 2018, several text messages were sent between Ms Marr and Liam attempting to get him to attend probation and parole to collect a copy of his mental health documents. On 24 January 2018, he attended probation and parole and was issued with a social history to obtain a MHP. He was again directed to attend his GP and request a referral to a psychologist and to produce the MHP at his next visit.
Where a person is directed to obtain a mental health plan but is unwilling, the case manager can utilise management strategies such as motivational interviewing. Case managers work with offenders to navigate offender problems to build motivation for change. If the person is unwilling to obtain a MHP, their mental health would be monitored at each contact.2
After his admission to hospital following a drug overdose on 7 February 2018, Liam’s level of service was elevated to ‘intensive’, which resulted in an increase in testing frequency3 to at least one scheduled test every three months and recorded in the Dynamic Supervision Instrument (DSI) at his next contact. Probation and Parole did not initiate breach proceedings at the time of his overdose. This was communicated by Ms Marr to hospital staff, who asked that they reassure Liam he was not going to be breached.
On 15 February 2018, Ms Marr conducted a home visit with Liam. His MHP was discussed. He advised he had an appointment booked but he forgot to 1 Ex C2 2 Ex C1 3 Ex C2 Findings of the inquest into the death of Liam Cooper Scorsese Page 8 of 36
take his social history, so did not attend. He was again directed by Ms Marr to obtain a MHP. Following her visit Ms Marr sent Liam a message, “Hi Liam, please let me know when you've made an appointment to get you mental health care plan and referral to the psychologist. You can have your Dr fax it to me if that easier. Remember to use the support and resources around you, I'm sure you can get back on track!"
Despite his failure to comply with directions to obtain a MHP and his drug overdose, an application was not made for Liam’s parole to be suspended.
Ms Peta-Anne Clark, Regional Manager, South Coast Region,4 reviewed Ms Marr’s handling of Liam’s parole supervision. She considered that Ms Marr’s management was in accordance with the Operational Practice Guidelines (OPG), the outcomes of assessment, including the validated risk assessment tool for general re-offending, the QCS benchmark assessment tool and the QCS assigned level of service. She further took the view that Ms Marr was balancing the role to motivate and encourage him to engage in intervention and address his offending and compliance with his order conditions. This was inhibited by his failure to follow through.
In reviewing Liam’s background and behaviour under supervision it is apparent that he had a violent criminal history, ongoing mental health issues (albeit likely drug induced) and was not willing or was unable to engage his own mental health plan despite numerous requests from probation and parole. However, Ms Clark supported Ms Marr’s decision to not breach Liam particularly for the drug overdose as “appropriate”.
Mental Health History and Treatment
The first record of any mental health concerns was from Liam’s period of custody in 2012 in Queensland. On 5 October 2012, he completed a medical request stating, “I came off meds anti-depressants but I didn’t wean of them now I have no motivation, I’m depressed and feel very frustrated at the smallest tasks and I’m starting to get angry all the time. Can I see a doctor ASAP.”5 No further references to his mental health are noted on his offender profile during this period of incarceration.
On 22 December 2015, Liam had a consultation with a doctor at the Dee Why General Practice.6 It was noted that Liam had anxiety with some drug induced paranoia. He disclosed his use of ice, cocaine and heavy alcohol 4 Ex C2 5 Ex C3 6 Ex H4 Findings of the inquest into the death of Liam Cooper Scorsese Page 9 of 36
binges. He said it was never full blown mania, but some hypomania. He was referred to a psychiatrist, who he did not see.
The next time Liam sought treatment for his mental health was on 27 August 2016 at the Sundale Medical Practice in Southport. He attended six consultations with three different doctors between 27 August and 17 December 2016.
On 7 October 2016, he saw Consultant Psychiatrist Dr Yeung, in the company of Ms Beytell. He self-reported that he could become ‘psychotic and irritable’, and recognised a mood pattern when he was using drugs. He denied any psychiatric admissions but believed he would have been admitted to a psychiatric hospital if someone had assessed him.
Dr Yeung commented that Liam did not have insight into his problem. He reassured Dr Yeung that he was seeking treatment to help his mental health and not simply to manage his court appearance. Dr Yeung noted that Liam required further psychoeducation and needed to address his drug and alcohol use. He was referred to a psychologist who specialised in drug and alcohol use. Liam did not attend the psychologist or Dr Yeung again.
On 14 October 2016, Liam attended a consultation with Dr Brownhill7, after being referred by his lawyer to provide a court report in relation to his assault offences. Dr Brownhill noted that Liam was reluctant to provide any substance misuse history and reported worry, progressing to panic, in the context of anticipating court and possible incarceration. Dr Brownhill did not diagnose him with a depressive episode as his symptoms were contextual.
Dr Brownhill thought Liam had an anti-social personality disorder. Liam attended a total of nine sessions with Dr Brownhill.
On 11 December 2016, Liam stabbed himself and was admitted to hospital, after binging alcohol and cocaine. He self-reported that he became paranoid when on drugs and believed everyone was against him. Ms Beytell told the consulting psychiatrist that Liam purposely drove into another vehicle in another attempt to end his life.
During this consultation, Ms Beytell denied any violence in the relationship.
Liam was unable to be assessed on a collateral self-harm attempt in the context of his drug intoxication and it was noted he would need further psychiatric and risk assessment.8
his mental state and risks. Liam displayed signs of paranoia and impulsivity while in the ICU. As the drugs cleared his system it was noted that it would be beneficial for a short mental health admission to monitor any residual psychotic symptoms.9
On 14 December 2016, Liam voiced no thoughts of self-harm and denied any suicidal ideation, claiming he was unsure why he stabbed himself. He was regretful, showing good insight into the detrimental effect alcohol and drugs were having on his life and was motivated to engage in a treatment plan and follow-up with mental health and AODS. Liam admitted lacking selfcontrol, having a long history of harmful use of alcohol and drugs and impulsivity under the influence of substances. However, he had not attempted suicide previously.10 He was subsequently discharged from hospital.
During an appointment with hospital social workers he reported that he would engage with a psychologist in January 2017.11 There are no records of him following through this plan. His Medicare history indicates that Liam attended various GPs eight times between December 2016 and August 2017.
The next time Liam’s mental health was recorded in records was upon his reception to custody on 1 August 2017. He then denied any history of suicide attempts or self-harm and stated he had never been treated for depression.12
According to his QCS offender records, he reported a psychiatric history but did not meet the criteria for a Prisoner Mental Health Service (PMHS) referral. Overall, his mental status presented as unremarkable at the time of his reception.13
On 12 September 2017, Liam asked to speak with a psychologist. He was offered a brief intervention.14 On 24 September 2017, he was reviewed due to mental health concerns. He disclosed that he found it difficult to stay calm and can “snap easily” over small things. He reported ongoing issues with anger management and impulsivity but denied suicide or self-harm ideation.
He was temporarily unable to work until a PMHS review could be conducted.
9 Ex E2, p4 10 Ex E2, p5 11 Ex E2, p18 12 Ex C8, p29 13 Ex C4, p29 14 Ex C4, p35 Findings of the inquest into the death of Liam Cooper Scorsese Page 11 of 36
On 7 February 2018, Liam overdosed on the drug GHB/fantasy. He underwent a psychiatric review on 8 and 9 February 2018. The clinical notes from 8 February 2018 indicate that the overdose was intentional. Liam failed to measure the GHB and passed out after consuming it.
The clinical notes from 9 February 2018 are identical but the overdose was unintentional. On that date, he denied any suicidal ideation. He indicated he had plans to see a psychologist and asked about seeking the help of AODS in the community. It was determined that there was no basis to detain Liam in hospital and he was subsequently discharged. The last time Liam saw a doctor was on 13 February 2018.
While there was no formal diagnosis of any mental health condition, Liam was prescribed medication for anxiety and depression. Liam failed to engage, or continue engagement, with mental health professionals and the information probation and parole and other QCS staff relied on was his selfreporting of mental health concerns or symptoms. It is also clear from the various health practitioners he spoke to, that Liam had insight that his paranoia was the result of the consumption of illicit substances.
Relationship with Ms Beytell
Liam had been in a relationship with Chireez Beytell since March 2014. It appeared to have been a tumultuous relationship, and they had separated several times throughout the nearly four years they were together. At the time of his death they were engaged but estranged.
Ms Beytell stated that about eight months to a year into their relationship, Liam started to suffer from paranoia. She described this as schizophrenia,15 and he started making lots of threats and accusations. He accused her of being a police informant, tracking his mobile phone and sleeping with other people. He had also threatened to come after her and kill her. Ms Beytell said that Liam would behave this way when he was taking drugs. He would not act that way when he was sober. She said that he “just switched” after taking drugs. Liam also appeared to recognise this, as he self-reported to several doctors.
Ms Beytell told police that there were instances of violence during their relationship but was reluctant to disclose the particulars. It appears that both her family and Liam’s family were unaware of the violence in their relationship.
15 There was no formal diagnosis of schizophrenia.
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Ms Beytell confirmed two incidents where Liam had assaulted her. The first occurred in Sydney before Christmas 2015, Liam used drugs and became very paranoid and “raged” out of control and bashed her unconscious. When she regained consciousness, Liam was kicking her in the stomach. Ms Beytell was left with bruising to her face and arms. She did not report the assault because he did not want anyone to know.
The second incident she disclosed occurred in 2016 at Broadbeach. She was sitting in his car when he pulled a jacket over her head, held it down and punched her in the face and over the head with his fist.
A temporary domestic violence order naming Liam as the respondent and Ms Beytell as the aggrieved was made on 15 December 2016. The QPS applied for the order on her behalf. A formal protection order was granted on 19 January 2017, to be in force for two years. The only condition was that Liam was to be of good behaviour towards Ms Beytell and not commit domestic violence against her.
On 16 February 2018, Ms Beytell and her brother joined Liam at a Sunshine Coast resort for his birthday. On the night of his birthday, 17 February 2018, Liam used drugs and displayed signs of paranoia. He again made accusations against Ms Beytell while he was in possession of a knife.
Ms Beytell and her brother left the Sunshine Coast at about 8.00am on 18 February 2018. Ms Beytell went to the unit she shared with Liam at Broadbeach, packed her belongings and returned to her family home at Wakerley. This was the last time she saw Liam until the day of his death.
Significant events leading up to Mr Scorsese’s death Bus driver assault16
The bus driver asked if they were going to be much longer. In response, Liam “king hit” the driver and punched him in the face. The bus driver went back onto the bus and Liam pulled him out of the bus and threw him on the ground, and kicked him while he was on the ground. This CCTV footage was circulated by mainstream media and made news headlines around Queensland.
16 Exhibits B63, I53 and I61.
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Self-inflicted stab wounds and assault on QAS and QPS17
On 11 December 2016, Liam drove to an address in Broadbeach Waters looking for his partner Ms Beytell. They were separated at the time. He appeared to be under the influence of drugs and alcohol and was emotionally unstable. He told Ms Beytell that no one loved him, and that life was a struggle. He then picked up a knife from the kitchen and stabbed himself 3 to 5 times in the chest.
Liam left the house and Ms Beytell called QAS and police. Liam got in his car and drove it approximately 20 metres down the road and crashed into a parked vehicle. He walked back to the residence Ms Beytell was at and was met by QAS and received treatment.
While preparing Liam for transport to the hospital, he pushed QAS officers out of the way and jumped off the gurney. He then removed all IV lines and dressings the QAS had put on him, causing him to bleed. He then became violent towards QPS officers, throwing punches at police before being restrained and placed into the ambulance.
During this assault, Liam was captured on BWC saying to police, “fuck you, you fucking dog, go on hit me again you fucking dog, go on fucking kill me, kill me you fucking dog, do it do it, just fucking kill me.”
This incident was captured by a television station on the Gold Coast and received significant media attention. Liam’s mother, Ms Moloney, described these incidents as being troubling and embarrassing for Liam. That he expressed great shame for his actions, particularly because they were broadcast through mainstream media outlets.
Traffic intercept18
On 22 February 2018, Liam was captured on BWC during a traffic intercept by general duties police officers at Cavill Avenue, Surfers Paradise. During the interaction, Liam was compliant, cooperative and apologetic to police for the traffic offence. When asked by police if he had been keeping out of trouble and for how long, he replied, “I’ve been a good boy, about four months now. I say it’s a long time but if you ask me missus she doesn’t really agree.” Hit and run 17 Ex I63 18 Ex I59 Findings of the inquest into the death of Liam Cooper Scorsese Page 14 of 36
On 23 February 2018, Liam’s vehicle was involved in a hit and run. The driver, was an associate of his who was the passenger in his vehicle during the traffic intercept the previous night. The associate was seen crashing Liam’s vehicle into a parked vehicle on River Crescent, and went in and out of Liam’s unit saying they were not home.19 Events leading up to the death
On 25 February 2018, Chireez Beytell was asleep in her brother’s room at her parent’s home at Wakerley. Ms Beytell’s parents Madelene and Petrus Erasmus, and her two brothers, Paul and Shaun, were also present.
At 4.39am, Liam sent the following text message to Ms Beytell: “For wat it's worth prob nothin I'm sorry I treated u like shit n did wrong by u I will always love u plz take care x”.
At approximately 7.30am, Liam called Ms Beytell’s mobile phone.20 He sounded paranoid, claiming there were listening devices in his house and accused her of being a police informant.
Liam said words to the effect of, “I’m going to come and get you; you wait. If I don’t get you, I will get someone you love but I’m going to get you.” Ms Beytell believed that Liam was threatening to kill her, and she attempted to placate him, telling him that she had not spoken to the police.
Liam responded “you’re a piece of shit, you wait I’m going to come and get you, you don’t want to see me face to face, I’m going to come and get you, see what happens.”
At about 9.30am, Liam attended the home looking for Ms Beytell. Mrs Erasmus allowed him in. He walked straight to the bedroom. He asked Ms Beytell to speak to him outside and she complied.
Once outside, Liam’s behaviour became erratic. He accused Ms Beytell of having an affair with his friend while Liam was in jail and hospital. He also questioned if “the guy” was in the house.
Mrs Erasmus intervened and told him she would not lie to him and there was no one in her house. After Liam continued to scream and shout at Ms Beytell, Mrs Erasmus pulled her into the house and locked the front screen door.
Liam told Mrs Erasmus to open the door. She refused and told him to leave.
19 Ex B71 20 This phone call does not appear on Liam’s mobile phone records. It appears he was using a second phone to contact Ms Beytell.
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He then proceeded to kick the door, and walked around the house and kicked other doors and windows to gain entry to the house.
At 9.49am, Mrs Erasmus called ‘000’ and asked for police to attend to remove Liam. Mr Erasmus informed him that QPS were on their way and Liam said words to the effect of “I don’t care, they’re not going to take me, I’ll show them.” After he kicked various entry points to the house, he walked to the concrete mailbox on the front lawn, took off his shirt and sat down.
Mrs Erasmus told the inquest that she had known Liam for four years and had not known him to be violent or aggressive. She had never been told by Chireez that she feared him.
Similarly, Mr Erasmus said that he had not seen Liam angry previously. After Liam was locked outside and demanding to see his daughter, he told him to go away or the police would be called. Mr Erasmus said that he did not see the police arrive but saw Liam running to his left. After he heard two gun shots he went outside and saw Liam on the road and a neighbour assisting with CPR.
Police attendance
At 9.54am Constables Damon Till and Michelle Reed arrived on scene and booked off with Police Communications. They parked on the road, in line with the lawn separating the driveways of 7 and 9 Goulburn Street.
Mrs Erasmus remained on the phone with ‘000’ until police arrived. As police arrived on scene, Liam produced a black handled, kitchen steak knife from a pocket in his shorts.
Constable Till was the driver of the police vehicle and was the closest officer to Liam. When Constable Till got out of the vehicle, Liam held the knife in his right hand and shouted at the officers, “come on, come on then fucking cops”.
Constable Till gave Liam continued directions to get down on the ground but he refused, instead advancing towards the officers, with the knife in his hand and walking towards them in an aggressive manner. At this point Constable Reed had drawn her firearm. She said that Liam was 4-5 metres from her at that time.
The officers responded by walking backwards down Goulburn Street to create distance between themselves and Liam. Once outside 7 Goulburn Street, Constable Till produced his taser and told Liam to “get on the ground, get on the ground, this is a taser”. Liam replied, “go on fucking shoot me then, shoot me, go on”.
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Liam then moved towards the police vehicle and kicked it. He then faced Constable Till, with the knife still in his hand and walked towards him.
Constable Till attempted to activate his body worn camera (BWC), dropped the Taser on the ground and produced his firearm. Liam continued to walk towards Constable Till at a steady pace. Both Constables continued to walk backwards down Goulburn Street. Constable Till was directly in front of Liam, while Constable Reed was on the left side of the road parallel to them.
During this time Liam continued to yell, “come on, come on, fucking shoot me, just kill me.”
Although both Constables continued to direct Liam to stop and get down on the ground, he did not comply. As the officers reached the end of the street Liam increased his pace and approached him, closing the distance between himself and Constable Till to approximately 2.5 metres.
Constable Reed told the inquest that as the distance between Liam and Constable Till shortened she saw him move from a position where his arms were held wide to a lunge at Constable Till. She said that Constable Till said to Liam ‘I don’t want to shoot you, don’t make me do this’.
Fearing he would be stabbed by Liam, Constable Till shot him. This caused Liam’s right side to recoil momentarily. Constable Reed said that Liam continued to proceed towards Constable Till after the first shot. Constable Till fired a second shot, resulting in Liam stumbling and falling to the ground near 3 Goulburn Street. The distance travelled from the Erasmus’ home to the scene of the shooting was 62.3 metres.
Constable Till told the inquest that he considered it was necessary to shoot Liam in order to stop the threat. He believed that he was going to be stabbed by Liam. This was consistent with his training in relation to the use of force in response to a threat with an edged weapon.
When police arrived and Liam produced the knife, Mrs Erasmus relayed to the ‘000’ operator21, ‘oh he’s got a knife, he’s going to stab someone sir, oh fuck he’s got a knife he’s stabbing somebody, he’s got a knife on him and 21 Ex I41 at 7.28 minutes Findings of the inquest into the death of Liam Cooper Scorsese Page 17 of 36
he’s run up to your people with a knife… oh I’ve heard the shots now sir, I think they’ve shot him.’ This recording of Mrs Erasmus indicates how quickly the incident occurred.
Civilian witnesses
Liam was waving his arms, but she was not sure what was in his hands.
After she moved her family to the rear of her home she went back to the street and saw that the police had moved down the hill towards 1 Goulburn Street.
Ms Gehrke asked the police if they wanted her to call anyone and this offer was declined. She said that as the police officers had their guns drawn, she decided to go back inside her home. She then heard two gun shots and went back outside to see if anyone had been injured.
Ms Gehrke said that she was a nurse and helped police with resuscitation efforts until the QAS arrived. She observed a knife in the gutter adjacent to Liam’s legs.
Chris Pennifold said that he was jogging along Moss Road for exercise on the day of Liam’s death. He stopped at the intersection of Moss Road and Watervale Parade, where he had a clear view of the incident. He said that he was around 50 metres away from the shooting. He said that he heard shots and he yelled “no, no”. Prior to that he could hear Liam saying, “shoot me” but the police officers were silent.
After the incident he resumed running and compiled notes in relation to the incident two hours later. He said he could not see anything in Liam’s hands from his vantage point. He said that Liam did not make any lunges towards police. The closest officer was six metres away. Mr Pennifold’s notes indicated: Whilst shouting at the Police Officer the victim was stepping towards the Police Officer in front of him but not quickly and not waving anything, he had both of his arms held spread from his sides whilst shouting "Go on shoot me!" The Police Officer was stepping backwards/sideways in sync with the movements of the victim therefore maintaining a significant distance apart Findings of the inquest into the death of Liam Cooper Scorsese Page 18 of 36
I did not see the victim holding or waving any gun or any other form of weapon at the officers.
I did not see the victim make any lunges towards either of the two Police Officers. Both were sufficiently far away from the victim for even the slightest attempt to be deemed a threat.
Mr Pennifold told the inquest that he thought the police officers should have adopted a containment strategy until backup arrived. A police vehicle arrived 10-20 seconds later. Mr Pennifold said that Liam did not appear to be an immediate threat and he was unarmed. However, he was also not able to identify if Liam had tattoos. Mr Pennifold accepted he could not say for certain if Liam had anything in his hand and that he only briefly observed the interaction.
India Brock described herself as a close friend of Liam who had known him since 2011. He arrived at her home on the night of 24 February 2018. He told her that he wanted to go to Brisbane to see a male and gave her directions to Goulburn Street. She stopped at the end of the street and he told her to wait near the park at the bottom of the street.
Ms Brock said Ms Brock said that Liam had a swig of rum and walked up Goulburn Street. He was gone for a short time. He then came back to the car and they left. After they departed, he said that he wanted to go back so she turned around and parked near the intersection of Goulburn Street and Mossvale Drive. She said that she could see clearly up the street. She saw the police arrive and then saw them walking down the street backwards.
Liam was walking towards the police saying, “shoot me”. Mr Brock did not see Liam holding anything in his hands. She heard the police officers yelling at him. She was yelling at Liam to get into her car.
Although not displayed in call records, Ms Brock said that she had called Liam at the time of the shooting in a panic. She did not see the police attempt to taser Liam and denied seeing a knife in his possession at any time. She said that just before he was shot, Liam was two paces away from the police officer closest to him. Liam had his hands out and his palms forward. His shirt was off, and he said “shoot me” twice.
Stephen Joughin lived on Mossvale Drive adjacent to the intersection with Goulbourn Street. Mr Joughin was on the street waiting for landscape supplies to be delivered when he saw a police vehicle drive past. His daughter was playing on her scooter. He said that one minute later he could hear police yelling ‘get down, put it down’. The yelling became louder. He then heard Liam yelling ‘just shoot me’. Mr Joughin saw the two police officers walking backwards down the hill. He was standing in his driveway when he heard two gun shots. The police were 5-6 metres from Liam at that Findings of the inquest into the death of Liam Cooper Scorsese Page 19 of 36
time. He said that he heard the male officer say to the female officer "What was I supposed to do? He had a knife".
QAS response
At 9.56am Constable Reed made a radio transmission advising that Liam had been shot and requested QAS code 1. At the same time the District Duty Officer (‘DDO’) Senior Sergeant Les Hutton arrived on scene. Tactical first aid was applied, and CPR commenced with the assistance of a neighbour, a registered nurse, until QAS arrived. Mr Erasmus also ran towards the officers and provided them with his shirt, as directed, and the officers used it to apply pressure to stem the flow of blood from the wounds.
At 10.00am, advanced care paramedics Macbeth and Potent were the first QAS unit on scene. They assessed Liam’s heart rhythm and found he had pulseless electrical activity (PEA). They provided him with initial resuscitative care. While treating Liam another QAS unit arrived on scene with advanced care paramedics Turnbull and Watson.
At this time they were given a direction by Dr Stephen Rashford, Medical Director for QAS, to transport Liam to the Princess Alexandra Hospital (‘PAH’) and that he, a critical care paramedic (‘CCP’) and the high acuity response unit (‘HARU’) would meet them en route.22 Dr Rashford considered that Liam’s injuries and the cause of them had an extremely high (near 100%) mortality rate,23 and the only chance of survival was to arrest the bleeding point. Any intervention was time critical.
Dr Rashford, the HARU and CCP intercepted the ambulance transporting Liam at a bus stop along Manly Road. By this time Liam’s electrical rhythm was approximately 50 per minute. Dr Rashford elected to remove Liam from the ambulance to perform a clam shell thoracotomy.24
The HARU officer assisted Dr Rashford and performed a finer thoracostomy on the right side of Liam’s chest.25 Dr Rashford noted a large right haemothorax with apparent complex injury involving the superior mediastinum that was still bleeding. He applied direct pressure and wedged trauma combines into the area. There was limited non-coordinated cardiac activity present and internal cardiac massage was commenced. Once this was completed, a blood transfusion was initiated.26 Along with the resuscitation, the heart signs indicated an improved blood volume.
22 Ex D9 - Dr Rashford was dispatched at 10.03am and responded at 10.04am.
23 Ex D9 24 Ex D9 - A clam shell thoracotomy is a horizontal incision across the anterior chest, allowing access to all the contents of the chest cavity to provide life-saving basic surgical intervention.
25 Ex D9; Ex D8 26 Ex D8 Findings of the inquest into the death of Liam Cooper Scorsese Page 20 of 36
The heart was visible with no signs of mechanical activity. There was no evidence of cardiac tamponade, and no visible signs of ongoing blood loss.
In consultation with the team assembled, including an emergency physician, consultant surgeon, and Dr Rashford, it was decided that in the absence of signs of life for such a prolonged period, despite maximal resuscitative efforts, ongoing resuscitation would be futile. Liam was declared life extinct at 10.51am.27
Dr Powrie considered, based on his clinical assessment, information provided by Dr Rashford and in the QAS electronic ambulance report form, that Liam exsanguinated from gunshot words to the neck and chest, despite the maximal resuscitative efforts provided by Dr Rashford and QAS paramedics.28 Autopsy results
An external and full internal examination was performed by Dr Rebecca Williams on 26 February 2018 at Queensland Health Forensic and Scientific Services (‘QHFSS’). A toxicology test, CT scan and review of the Queensland Ambulance Service medical records were also conducted. CT scans showed two gunshot wounds, entering in the right anterior neck and right anterior chest.
The external post-mortem examination showed signs of recent medical therapy, including a ‘clamshell’ thoracotomy incision. There were two gunshot wounds, one in the right anterior neck (A) and the other in the right anterior chest (B). Both wounds had the appearance of distant entry wounds.
There were no features to suggest a contact or near contact entry-type wound.
appearance to the first wound associated with the taser barb were identified.
The taser barb was not considered to have contributed to Liam’s death.
The full internal post-mortem examination showed no evidence of any significant natural disease that would have contributed to death.
Gunshot wound A in the neck, passed from left toward right, slightly downward and slightly backward for approximately 18cm. A deformed projectile was retrieved from the posterior right shoulder. This wound caused a small laceration in the trachea, as well as haemorrhage and damage to the skeletal muscles in the right side of the neck, upper torso and right shoulder.
No major blood vessels in this region were affected. It is considered significant to death as it would have caused escape of air into soft tissues, as well as blood loss.
Gunshot B in the right anterior chest, passed in a downward direction, from front to back, with no significant lateral deviation, for approximately 19cm in total. A deformed projectile was retrieved from the soft tissues of the posterior right chest wall. This wound caused comminuted fracture of the anterior right 2nd rib, large track through the right upper lung lobe and smaller wound in the right lower lung lobe, the comminuted fracture of the posterior right 7th and 8th ribs. This injury was associated with major haemorrhage in the right chest cavity. It would have been immediately life-threatening and is considered significant to death.
A toxicology test performed on samples of blood and urine revealed Liam had a mixture of substances in his system - a combination of stimulants, antidepressants, anti-anxiety agents, sleeping agent, anti-inflammatory and narcotic analgesic. Methylamphetamine and cocaine were detected at concentrations within a potentially fatal range, but these substances were not considered to have played any direct role in causing Liam’s death.
Dr Williams concluded that the cause of death was gunshot wounds to the neck and chest.
The investigation
The Queensland Police Service (QPS), Ethical Standards Command (ESC) Internal Investigations Group (IIG) investigated the death. A coronial report was prepared by Detective Sergeant Dylan Brook.
After the QAS arrived on scene and treated Liam, Constables Till and Reed were separated until officers from the Internal Investigations Group arrived.
An IIG investigation commenced immediately which included an individual video walk-through re-enactment with Constable Till and Constable Reed.
Police also obtained audio recorded statements from witnesses on Goulburn Street.
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Constable Reed was a first year constable under supervision within the South Brisbane District. She had been sworn into the QPS on 27 September
She had completed all requisite training, including active armed offender (AAO) and operational skills training.
Constable Till was sworn into the QPS on 12 December 2013. At the time of the incident he was a general duties officer working at the Wynnum police station. He was a qualified field training officer and was selected to work with and supervise First Year Constables. He had completed and was up to date with his requisite training, including active armed offender (AAO) and operational skills training. He had never discharged his QPS issued firearm in the line of duty before 25 February 2018.
Review of Till and Reed’s approach and responses
District Duty Officer Hutton responded and was assigned to back 9:50:29 am up Constables Reed and Till The operator provided all units the following information: 9:50:30 am “Ok details are a Liam Scorsese has attended kicking at the door, he’s off his head, because her daughter used to go out with him, informant stated the male has now run away POI has a DV order 29 Ex A5, p.30.
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with the daughter, he’s now back causing a disturbance, he’s kicking at things outside, informant’s very distressed.” Constable Reed acknowledged the information 9:50:31 am Operator provided further information: 9:51:08 am “the male is in the backyard of the house yelling at the daughter, this Liam’s got a few flags, from 2011 history of violence interstate, DNA, Corrections flags, will threaten police and attempt to intimidate saying you all work out of one station you will be easy to pick off one at a time, street checks, he will conceal drugs as well (inaudible) don’t place any trust in him… also known OMCG associate.” Constable Reed acknowledged the information 9:52:25 am Constable Reed booked off at job 9:54:03 am Operator broadcast: 9:54:18 am “just a description, brown shorts, no shirt, olive complexion, has a knife, SB442 this male has a knife” Operator made a second broadcast: 9:54:31 am “yeah SB442, that male has a knife…” Constable Reed cut across simultaneously.
Constable Reed: “SB 442 urgent, urgent, shots fired, number 3 Goulburn Street, QAS required” Operator: "SB 442 received shots fired has anyone been injured please" Constable Reed:" Shots fired person of interest down" Operator: "Is he conscious and breathing?
Constable Reed "breathing" Constable Reed "Code 1 for QAS" Operator: "Received that where about is the male?" Constable Reed: "On the ground outside 3 Goulburn Street Wakerley" Findings of the inquest into the death of Liam Cooper Scorsese Page 24 of 36
Operator: "Yeah received we're getting QAS code 1 outside 3 Goulburn Street" Senior Sergeant Hutton: "SB 160 off' 9:56:38 am "Yeah he's breathing VKR, we are just applying some tac med now" SB 160 "two gunshots to the throat, compressions are being 9:58:28 am administered".
SB 421 "Just commencing CPR at the moment” 9:59:49 am SB 160 "QAS on scene" 10:00:00 am
Effectiveness of the taser
Only one probe penetrated Liam. The second probe did not engage Liam, it had gone past him and struck a van parked in the driveway behind him, rendering the taser ineffective.
Constable Till told IIG investigators that he is aware that QPS officers are trained that if the person of interest is armed with a knife, then they are to use their firearms. Constable Till explained that he did not use his firearm but used the taser at this point because he did not consider he was in immediate danger, there was enough distance between him and Liam, and he hoped if he could successfully deploy the taser then it would cause Liam to drop the knife and fall to the ground and he would be able to detain him.
The IIG investigation concluded that Constable Till made a deliberate choice to utilise a less lethal option to resolve the situation, despite being faced with an armed person.
Situational use of force model Findings of the inquest into the death of Liam Cooper Scorsese Page 25 of 36
There are no official mandated behaviours listed as a benchmark that require police to undertake specific actions. The preferred organisational position is to equip officers with operational tools to assist them in a confrontational situation that may require the use of force, such as the Situational Use of Force Model.
In terms of tactical decision making relating to use of force matters, police are instructed to utilise the ‘Situational use of force model’ as a guide. The model assists the police officer to select the most appropriate option(s) to resolve an incident.
Officers are instructed that it is good policing to perform a continual threat assessment as to the level of risk, both real and potential. The categories are ‘high risk’ and ‘assessed risk’. Threat assessment requires continuous re-evaluation being mindful that threat levels rise and fall during use of force incidents.
Constable Reed explained that she did not discharge her firearm because she was at Liam’s side. She was aware they were on a suburban street; some neighbours were on the street and if she had discharged her firearm a bullet could have struck a house or other person nearby.
Constable Till explained that Liam had come within 2.5 metres of him, still holding the knife. He feared that he would get stabbed or his partner could be hurt and had no option left but to use his firearm.
Senior Sergeant Damien Hayden is the Officer in Charge (OIC) of the Operational Skills Section (OSS) within the QPS. He was engaged by IIG to provide an expert opinion on Constable Till’s use of the taser and whether his actions in all the circumstances were justified.
Senior Sergeant Hayden was of the view that the initial application of force to Liam by deploying a taser was a reasonable and proportionate response to his actions. Senior Sergeant Hayden stated that less lethal options are not intended to replace the use of lethal force, but, where appropriate may be deployed as a possible alternative to use of lethal force.
Senior Sergeant Hayden was of the view that due to the imminent threat of grievous bodily harm or death posed by Liam to Constable Till and Constable Reed, the decision to deploy lethal force and discharge their firearms at Liam was the most appropriate response to preserve their life.
Senior Sergeant Hayden further explained that if officers are required to discharge their firearms they are trained to aim for the “armpit hold”, to stop the threat. He stated that “shooting to injure or disable” is not practical or safe Findings of the inquest into the death of Liam Cooper Scorsese Page 26 of 36
and fraught with risk; and is unaware of any police jurisdiction in the world that promotes a “shoot to wound” policy.30 Body worn camera
Therefore, an essential pre-requisite to using BWCs is an Evidence.com account. To obtain an account, new users are required to undertake QPS approved training which is either the BWC on-line learning product (OLP) or face-to-face training delivered by the BWC Project Team or an Axon Super User. Constable Till did not receive face-to-face training and as such, was required to complete the OLP which was completed on 7 January 2018.
Constable Till wore his BWC on the right hand side of his utility belt. During his walk-through interview, he said he believed that he activated his BWC after discarding his taser. He believed he activated the BWC by pushing the event button repeatedly.
Constable Till confirmed that he completed the mandatory OLP training and had only received the BWC several days prior to the shooting. He had not much opportunity to familiarise himself with its use. When he received his BWC the training assisted him to update the preferences of the device by de-activating the indicator lights and the external volume for officer safety reasons. The lights can also assist in identifying if the device is recording or not.
A full audit was completed of Constable Till’s BWC, and identified that Constable Till attempted to activate his camera as he described. The audit32 identified that Constable Till powered on the BWC at 09:54:16am and then pressed the event button four (4) separate times: 09:54:48 09:55:01 09:55:42 09:55:57 30 Ex B15 31 Ex B14. 18 BWCs were delivered to Wynnum Police Station on 16 January 2018, to be deployed operationally by the OIC of the station to officers who had completed the requisite training. Wynnum Station had an operational staffing level of 33 general duties officers.
32 Ex B80, p8 Findings of the inquest into the death of Liam Cooper Scorsese Page 27 of 36
A recording is ended by pressing and holding the event button for three seconds. Unless configured otherwise by the user, upon ending a recording the device emits a three second beep, vibrates for three seconds and LED status changes from red to green.
Care and treatment provided to Mr Scorsese
Constable Reed and Till and the neighbour Ms Gehkre alternated in performing CPR until QAS arrived on scene.
IIG investigation findings
Till employing lethal force discharging his service firearm, to avoid grievous bodily harm or lethal assault from Liam.
Constable Till tried to use non-lethal tactics but Liam did not comply with direction and was within 2.5 metres of Constable Till before he deployed his firearm.
When Constable Till was asked why he didn't use deadly force sooner he stated: "Because I've got to live with it, and I was trying to give him every opportunity to drop the knife, like he was being really threatening and things like that but um, but walking down you know I've got to live with it, and at one point when he just got too close, I was like it's either me or you, so that's when I shot him".
The findings of the investigation concluded that Constable Till’s actions on the day were lawful, authorised and justified in the circumstances surrounding this critical incident.
Findings required by s. 45
As a result of considering all the material, I make the following findings: Identity of the deceased Liam Cooper Scorsese How he died Liam died after he attended the home of his partner’s parents under the influence of methylamphetamine and cocaine. After being asked to leave the property he attempted to forcibly gain access to the residence. His partner’s mother called police. After police attended at the residence, Liam walked towards them with a knife as they retreated backwards down the street on foot. An attempt to use a Taser to incapacitate Liam was unsuccessful. He was within 2.5m of police when shot by an officer acting in the course of his duties. The officer reasonably feared that Liam would kill him or cause grievous bodily harm.
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Place of death Princess Alexandra Hospital, Woolloongabba Queensland 4102 Australia Date of death 25 February 2018 Cause of death Gunshot wounds to the neck and chest Conclusions on issues Whether the actions of attending police officers were appropriate in the circumstances.
Liam attended the Erasmus residence at Goulburn Street, Wakerley shortly after 9.30 am on 25 February 2018 without warning to Ms Beytell and her family. After he was asked to leave, he behaved aggressively outside the home, kicking at doors and windows. Mrs Erasmus called triple zero. She identified that Liam was the person outside her home, that he had been in jail and used to go out with her daughter. Ms Erasmus was audibly distressed and told the operator: Please, please, please send someone to my house urgently. I’m very scared.
Constables Till and Reed were tasked to urgently attend at the property. I accept that shortly after police arrived, they observed Liam with a knife in his hand. Liam yelled at the police to shoot him. They directed him to drop the knife and get onto the ground. Liam did not comply with these directions and advanced towards the officers with a knife. This exchange was repeated as the officers retreated backwards down Goulburn Street. Constable Till had deployed his Taser but this was ineffective as only one of the barbs had attached to Liam.
Constables Till and Reed produced their firearms and continued walking backwards down the street at a steady pace, at the same time as directing Liam to drop the knife. He continued to respond with words to the effect of ‘just shoot me’. As the police officers approached the end of Goulburn Street towards its junction with Mossvale Drive, Liam increased his pace and closed the distance between himself and Constable Till to approximately 2.5 metres.
While there was contention about whether Liam lunged at Constable Till with the knife in his hand, I accept that he did not lunge at Constable Till or make a striking motion at him. However, I am satisfied that he was still holding the knife in his hand when he was shot.
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I accept that Constable Till feared that he would be stabbed when he shot Liam. Liam recoiled momentarily, and then Constable Till fired a second shot, resulting in Liam falling to the ground. I also accept that if Liam had not been shot, he would likely have proceeded to attack Constable Till with the knife, and would have inflicted grievous bodily harm.
I also accept the evidence of Detective Sergeant Brook that the use of a Taser was not the appropriate use of force option in the circumstances, given the manner Liam was approaching with the knife and his close proximity to Constable Till at the time of the shooting.
The ESC investigation concluded that there was no misconduct displayed by any of the officers involved and further concluded that no disciplinary proceedings were required. I agree with those conclusions.
Liam was given ample opportunity to comply with the directions by the police.
He advanced towards them over more than 60 metres as they continued to give him directions that would have resolved the situation without lethal use of force.
The accounts given by the police officers are generally consistent with the evidence of the civilian witnesses who lived on Goulburn Street. I am unable to place significant weight on the evidence of Ms Brock. She did not make herself known to police until two and a half years after Liam’s death. She had obtained information about the incident online prior to giving her statement to police. I consider that her recollection of the events was not as reliable as those who provided their statements contemporaneously. While she may have been in the vicinity, none of the other witnesses supported her assertion that she was at the scene of the shooting.
The actions of the attending police officers were consistent with their training that a safe distance for a person armed with a knife was seven to ten metres prior to drawing their firearm.34 Liam came within two and a half metres of Constable Till. Constable Till was questioned by investigators why he didn’t use lethal force sooner, and he told them: I have to live with it, and I was trying to give him every opportunity to drop the knife. Like, he was being really threatening and things like that.
But walking down, you know, I’ve got to live with it. And at one point he just got too close, and it was, like, it’s either me or you, and that’s when I shot him.
34 A mandatory minimum distance rule for officers who encounter knife-armed offenders is no longer recommended.
Findings of the inquest into the death of Liam Cooper Scorsese Page 31 of 36
I also accept Detective Sergeant Brook’s evidence that the first aid treatment provided by the officers was appropriate, having regard to the scope of their first aid training.
Submissions from Liam’s family focussed on the contrast between the interviews of police and civilian witnesses by the Ethical Standards Command investigators. It was asserted that the police witnesses’ answers were facilitated by the investigators, rather than being questioned as a suspect might be. It was submitted that the questions were designed to elicit only one answer, which was the desired answer. The following examples were provided from the interview of Constable Till by Detective Sergeant Brook: So what do you think at this point in time? You’ve tasered him, it’s been ineffective, he’s still walking towards you.
… Okay. What’s your understanding of the use of force model in relation to a person armed with a knife? What are our options?
… So to your recollection, you fired the first shot and you’ve seen him stumble, but he stayed upright; is that correct?
….
Yeah, okay. So did you believe that he still posed a threat at that stage?
Is that correct?
It was submitted on behalf of the family that the problem with police investigating police is that they ‘may have a natural affinity for one another and may be open to allegations of being non-partisan’. It was submitted that in the absence of independent evidence such as body worn camera footage, this can lead “at least to suspicion and uncertainty and, on the other end of the spectrum, to conspiracy theories”. In this instance, that uncertainty could have been avoided by the proper compliance by Constable Till with the requirements expected of him in the use of his power as a police officer by activating his body worn camera.
Acknowledging that community confidence in the independent investigation of police related deaths is a matter of significant public interest, I have recently recommended that that the Queensland Government consider whether to commission an independent review of the current arrangements for the investigation of police related deaths on behalf of the coroner and the Findings of the inquest into the death of Liam Cooper Scorsese Page 32 of 36
oversight of those investigations.35 That recommendation is under consideration.
Use of body worn cameras and associated QPS training.
It was clear that Constable Till did not correctly activate his body-worn camera to record the events on the 25 February 2018. He had completed an online learning product on 7 January 2018. He was then assigned a camera on 6 February 2018, and at that time he had not completed any in-person training.
The audit trail showed he first updated the camera on 21 February 2018, which is consistent with his evidence of only having used the camera for about three shifts prior to this incident. Constable Till also explained that the body-worn camera was still new to him, and he was not familiar with arming it and then activating the record function. I accept that Constable Till’s incorrect activation of the camera was not intentional. It was a product of his inexperience and lack of personal training. The audit trail of his use reflected that at no time had he correctly activated the recording function.
The rollout of body-worn cameras across the Queensland Police Service was implemented as a standalone project in 2016. Cameras were initially rolled out at that time to frontline officers. A further rollout was completed in 2017 of Axon Body cameras. This was the same model used by Constable Till, and is the same model used by officers today.
Since 2018, Queensland Police recruits are now trained in person with the use of body-worn cameras. The activation of the body-worn camera was included as a theoretical assessment item in the dynamic interactive scenario training which commenced in the 2018-2019 financial year. This assessment has since been included in the annual operational skills training.
I accept that it is not practical to have cameras recording for an entire shift.
The answer provided was that it is possible but not practical, for many reasons, including battery life, the cost of data storage, and the delay in data transfer.
This can automatically activate all body-worn cameras within a 10-metre range but the QPS has not purchased this option.
35 Inquest into the death of Cindy Leigh Miller, 22 January 2021.
Findings of the inquest into the death of Liam Cooper Scorsese Page 33 of 36
Unfortunately, in this situation, Constable Till had not had the practical training or experience to activate his camera in a high-stress use-of-force situation. Given the current state of the technology, the activation of bodyworn cameras relies on user operation to activate them in accordance with the respective QPS manuals.
Recommendation 1 I recommend that the Queensland Police Service consider the viability of purchasing the Bluetooth enabled feature for Axon body-worn cameras.
Recommendation 2 I recommend that the Queensland Police Service use the capabilities of the Axon and Evidence.com platform to conduct random audits to ensure officer compliance with policies relating to the use of body-worn cameras.
Information sharing between Queensland Health and Queensland Corrective Services, parolee access to mental health plans and support, and training for probation and parole officers in identifying mental health risks.
Detective Sergeant Brook’s report contained recommendations that Queensland Corrective Services consider the ways in which sharing of prisoner's mental health information from prison to parole is enhanced; and that consideration be given to developing and co-ordinating delivery of annual mental health training for case officers with options for alternative mental health referrals to assist with reintegration.
While Liam was not formally diagnosed with a mental health condition, he self-reported that he had drug-induced psychosis and experienced episodes of anxiety and depression. After he was released on parole, he continually denied any suicidal ideation and denied the use of illicit substances. During his last period in custody in 2017, he did not meet the criteria for a Prisoner Mental Health Service referral, and his mental health presented as unremarkable.
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When he was released to parole in November 2017, he denied any suicidal ideation, and his mental health was assessed as a non-criminogenic need, to be monitored through his engagement with a GP and a psychologist.
While Liam initially saw his GP and was prescribed medication for anxiety, he failed to obtain a mental health plan as directed on at least seven occasions by Ms Marr, his parole officer. She also provided him with help in obtaining a mental health plan.
At the time of his drug overdose on 7 February 2018, he was assessed as having no mental health barriers to being discharged from hospital and his level of service in the community was elevated to intensive.
Ms Marr subsequently conducted a home visit and sent Liam several followup text messages for him to obtain his mental health plan. Liam did not engage his own mental health plan, despite the numerous requests and support offered by Ms Marr.
A review was conducted of Ms Marr’s management of Liam and the decision to not formally breach him after his drug overdose and failure to obtain his mental health plan. Ultimately, her management was deemed to be appropriate. I accept that conclusion.
Assistant Commissioner Hyde’s evidence was that Community Corrections officers constantly balance punitive and therapeutic approaches to the management of persons on parole. She agreed that a punitive approach to Liam’s technical breach was not appropriate in the circumstances.
I accept that Liam’s mental health concerns were just one of the risk factors identified by QCS. The others were substance abuse, contact with criminal associates, domestic violence and gambling.
Assistant Commissioner Hyde also gave evidence of the level of training in place for Community Corrections Officers. She identified a vast number of changes that are being adopted and implemented within Queensland Corrective Services to train officers about managing persons with mental health concerns, including the engagement of a number of health experts that can also be relied upon as external resources and at the same time provide case officers with the appropriate support and resources as well.36 Griffith University has been engaged to deliver a best-practice curriculum involving specialised training in managing mentally ill and substance-abusing clients, advanced forensic mental health, and understanding alcohol and other drugs.
36 Following the Queensland Parole System review Findings of the inquest into the death of Liam Cooper Scorsese Page 35 of 36
Terry Ryan State Coroner Brisbane Findings of the inquest into the death of Liam Cooper Scorsese Page 36 of 36
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